4 Gland Duct Ligation

Four Gland Duct Ligation with Botulinum Injections 


This video visualizes the four-duct ligation surgery for chronic sialorrhea. Sialorrhea is characterized by the improper spilling of saliva, most commonly due to poor muscle coordination1. Controlling oral secretions with the perioral muscles and the act of swallowing takes precise contraction from voluntary and reflex contractions. Sialorrhea is common in newborns and children up to 5 since they have not learned to coordinate these contractions yet1. The most common etiology of persistent, or new, sialorrhea is cerebral palsy, amyotrophic lateral sclerosis, seizures, cerebrovascular accidents, facial paralysis, and dental problems1.While many neurological conditions can predispose a child to sialorrhea, cerebral palsy is most common, comprising up to 10% of cases3.The side effects of untreated sialorrhea include increased risk of infections, dental caries, and interference with speech. Aspiration pneumonia is a serious consequence from pooling of saliva in the posterior pharynx3. Patients can also become malnourished due to trouble chewing, loss of fluids/electrolytes, and loss of protein2. Non-evasive measures such as oral motor therapy, behavior modification therapy via biofeedback, and drug therapy should be considered before proceeding to surgical treatment2. Surgical treatment is preferred when the patient is at risk for aspiration pneumonia3. One of the most common surgical procedures for sialorrhea is the four-gland duct ligation. While the four-gland duct ligation is low risk for complications, facial swelling, aspiration pneumonia, oxygen desaturation, and vomiting are potential complications. Out of these, facial swelling was the most common adverse event3. 


An appropriate surgical candidate was identified in the clinic and advised about the risks and benefits of the procedure. The patient was appropriately prepped and inducted under general anesthesia. An oral side bitter was placed to visualize the oral cavity. Stensen’s duct was identified on the left with army navy retraction. A lacrimal probe was used to maintain the duct opening and an alice retractor was used to hold the duct in place. The dissection was performed bluntly and with cautery. Care was taken to prevent injury to the duct and to provide clear exposure. The probe was removed, and the proximal portion of the duct was ligated with two oppositely placed 3.0 silk sutures. The mucosa was then closed with 4.0 chromic suture in a simple interrupted stitch. The same procedure was performed on the contralateral side. The focus was then turned to whartons duct. The oral side bitter was removed, and the tongue was retracted using an army navy. The right papilla was identified and retracted with a Geralds with teeth to maintain proper visualization of the duct. Blunt and cautery dissection was performed around the duct for proper exposure. Once down to the base of the duct, tonsil clamps were used to clamp just proximal to the gland to aid with suture ligation. Two oppositely placed 3.0 silk sutures were used to ligate the duct. The mucosa was closed with a 4.0 chromic stitch. The exact same procedure was performed on the left whartons duct. Once complete the oral cavity was irrigated and cleaned. Ultrasound was then brought into the field. Under direct visual guidance 1mg/kg of botulinum toxin was injected into the parotid and submandibular glands using the hockey shaped ultrasound probe. Having tolerated the procedure well, the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.  


There were no complications encountered before, during, or after the procedure. The patient was followed in clinic for 1 year and the patient’s care giver reported satisfactory reduction in sialorrhea.  


This video shows the steps of performing a 4-gland duct ligation with botulinum toxin injections. It is a commonly indicated procedure in children under 5 years of age for chronic sialorrhea refractory to other treatment options. While not first line therapy, this procedure should be heavily considered for due to post-operative success and care giver satisfaction.  








Jean-Paul Meningaud, Poramate Pitak-Arnnop, Luc Chikhani, Jacques-Charles Bertrand, Drooling of saliva: A review of the etiology and management options, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Volume 101, Issue 1,2006, Pages 48-57, ISSN 1079-2104 
Little, S.A., Kubba, H. and Hussain, S.S.M. (2009), An evidence-based approach to the child who drools saliva. Clinical Otolaryngology, 34: 236-239. https://doi-org.libproxy.uams.edu/10.1111/j.1749-4486.2009.01917.x 
Khan WU, Islam A, Fu A, et al. Four-Duct Ligation for the Treatment of Sialorrhea in Children. JAMA Otolaryngol Head Neck Surg. 2016;142(3):278–283. doi:10.1001/jamaoto.2015.3592

Arteriovenous Malformation (AVM) Resection


Introduction: Arteriovenous malformations (AVMs) are abnormal connections between arteries and veins that lack an intervening capillary network. The high flow of arterial blood directly into veins can lead to the weakening of venous walls, potentially resulting in life-threatening hemorrhages.The primary treatment modalities for cerebral arteriovenous malformations (AVMs) include surgical resection, endovascular embolization.

Case presentation: A 34-year-old female presented with a roughly 7×7 cm arteriovenous malformation (AVM) located in the right temporoparietal area. The AVM extended both superficially and deeply into the infratemporal fossa and laterally towards the orbit. Imaging revealed the presence of multiple large contributing vessels in the preauricular area. The patient underwent embolization with interventional radiology one day prior to the surgical procedure.

Methods: Markings were made along the right upper hairline after trimming and continued down the preauricular skin. A #15 blade was utilized to make incisions through the epidermis and dermis, reaching the subcutaneous tissues. The temporoparietal and temporal flap fascia were dissected and carefully raised. Once the AVM was detached from the surrounding temporalis muscle and the zygomatic bone, its feeder vessels were ligated near the tragal pointer using hemoclips to aid in future localization. Hemostasis was successfully achieved with bipolar cautery. The temporalis muscle and its adjacent fascia were sutured closed with vicryl suture. Closure of the deep dermal layer was accomplished with 4-0 PDS, and the skin was closed in a running subcutaneous fashion using 5-0 monocryl.

Conclusion : We present a successful surgical resection of Arteriovenous Malformation with a prior embolization by interventional radiologist


Coleman, Madison, MD,

Aryan D Shay ,MD

Gresham T Richter, MD, FACS

Conflicts of Interest: None

Funding: This research received no external funding

Department of Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Arkansas Children’s Hospital, Little Rock, AR, USA

Excision of a Dermoid Cyst

This video demonstrates the excision of a supraorbital dermoid cyst in a pediatric patient. This lesion was located just superior to the right lateral orbit.

Electromyography Endotracheal Tube in Thyroid Surgery

This video explains how electromyography endotracheal tubes work during thyroid surgery. Also known as, EMG ET tubes, these are a type of Intraoperative Neuromonitoring (IONM) which serve a big role preventing nerve injury by monitoring recurrent laryngeal nerve activity. Placement of the tube during intubation is important as the surface electrodes should be in contact with the vocal cords. Incorrect placement would render the tube ineffective and could cause damage to the nerve. Both, macintosh and video laryngoscopes can be used if there is poor visibility during intubation.

During surgery the tube may shift from its correct position for several reasons, primarily movement of the neck, so it’s important to check its correct placement throughout the duration of surgery. The tube itself has electrodes located at the tip. These electrodes come into contact with the vocal cords and detect electrical signals produced by the nerves. These signals are transmitted to a monitoring system which allows for continuous monitoring throughout the surgery. Once the EMG ET tube is properly placed, it can detect electrical signals produced by the nerve by using a stimulation probe. Whenever the nerve is stimulated surgeons and anesthesiologists can view the signals on a screen and listen to the sounds produced by pressing directly above the vocal cords.

The EMG signals are transmitted to a real-time monitoring system which helps surgeons view the signals on a screen and evaluate nerve integrity. During surgery this feedback helps surgeons adjust their technique to avoid nerve damage. Stimulation of the nerve creates a sinusoidal wave on the nerve integrity monitor along with an audible signal confirming its intactness. These waveforms, also known as electromyograms. In a normal resting state, should show very little electrical activity. The intensity can be seen by the amplitude of the wave. And the duration can provide information about the speed of muscle activation. A decrease or loss of EMG signals in response to nerve stimulation can indicate nerve damage or irritation.

Thyroid Cyst Removal with Hemithyroidectomy

This video shows a thyroid cyst removal that resulted in a hemithyroidectomy. The patient is placed under general anesthesia and intubated using a mac video laryngoscope and an EMG endotracheal tube. The ET tube has 4 stainless steel wire electrodes which touch the vocal cords for monitoring during surgery. After video intubation electrode placement is verified by direct stimulation of the area.

The surgeon makes a curvilinear skin crease incision in the front of the neck, to minimize the visibility of a scar. Afterwards, subplatysmal flaps are elevated and the midline raphe is dissected exposing the sternohyoid muscle, which is retracted laterally, and the sternothyroid muscle that is dissected off the left thyroid gland.

The thyroid cyst is found superficial and dissected, keeping in mind that anything suspicious for the recurrent laryngeal nerve is stimulated prior to dissection. The cyst is ruptured and sent for frozen pathology. The results returned as thyroid, so the surgeon proceeded with a hemithyroidectomy. The superior and inferior parathyroids were identified and dissected free. Hemostasis was achieved with electrocautery and confirmed with Valsalva. Strap musculature platysma and skin are closed. And lastly, mastisol and steri-strips are placed perpendicular to the wound.

Branchial Cleft Cyst Excision

Branchial cleft cysts are a benign anomaly caused by incomplete obliteration of a primordial branchial cleft.  They typically appear in childhood or adolescence, but can appear at any age. They present as a non-tender, fluctuant mass following an upper respiratory infection, most commonly at the anterior border of the sternocleidomastoid muscle. These lesions are thought to originate during the 4th week of gestation when the branchial arches fail to fuse. The second branchial cleft is the most common site (95%) and cysts from in this distribution can affect cranial nerves VII, IX, and XII. 

Microdebrider Assisted Lingual Tonsillectomy

Microdebrider Assisted Lingual Tonsillectomy

Adrian Williamson, Michael Kubala MD, Adam Johnson MD PhD, Megan Gaffey MD, and Gresham Richter MD

The lingual tonsils are a collection of lymphoid tissue found on the base of the tongue. The lingual tonsils along with the adenoid, tubal tonsils, palatine tonsils make up Waldeyer’s tonsillar ring. Hypertrophy of the lingual tonsils contributes to obstructive sleep apnea and lingual tonsillectomy can alleviate this intermittent airway obstruction.1,2 Lingual tonsil hypertrophy can manifest more rarely with chronic infection or dysphagia. A lingual tonsil grading system has been purposed by Friedman et al 2015, which rates lingual tonsils between grade 0 and grade 4. Friedman et al define grade 0 as absent lingual tonsils and grade 4 lingual tonsils as lymphoid tissue covering the entire base of tongue and rising above the tip of the epiglottis in thickness.3

Lingual tonsillectomy has been approached by a variety of different surgical techniques including electrocautery, CO2 laser, cold ablation (coblation) and microdebridement.4-9 Transoral robotic surgery (TORS) has also been used to improve exposure of the tongue base to perform lingual tonsillectomy.10-13 At this time, there is not enough evidence to support that one of these techniques is superior.

Here, we describe the microdebrider assisted lingual tonsillectomy in an 8 year-old female with Down Syndrome. This patient was following in Arkansas Children’s Sleep Disorders Center and found to have persistent moderate obstructive sleep apnea despite previous adenoidectomy and palatine tonsillectomy. Unfortunately, she did not tolerate her continuous positive airway pressure (CPAP) device. The patient underwent polysomnography 2 months preoperatively which revealed an oxygen saturation nadir of 90%, an apnea-hypopnea index of 7.7, and an arousal index of 16.9. There was no evidence of central sleep apnea. The patient was referred to otolaryngology to evaluate for possible surgical management.

Given the severity of the patient’s symptoms and clinical appearance, a drug induced sleep state endoscopy with possible surgical intervention was planned. The drug induced sleep state endoscopy revealed grade IV lingual tonsil hypertrophy causing obstruction of the airway with collapse of the epiglottis to the posterior pharyngeal wall. A jaw thrust was found to relieve this displacement and airway obstruction. The turbinates and pharyngeal tonsils were not causing significant obstruction of the airway. At this time the decision was made to proceed with microdebrider assisted lingual tonsillectomy.

First, microlaryngoscopy and bronchoscopy were performed followed by orotracheal intubation using a Phillips 1 blade and a 0 degree Hopkins rod. Surgical exposure was achieved using suspension laryngoscopy with the Lindholm laryngoscope and the 0 degree Hopkins rod. 1% lidocaine with epinephrine is injected into the base of tongue for hemostatic control using a laryngeal needle under the guidance of the 0 degree Hopkins rod. 1.     The 4 mm Tricut Sinus Microdebrider blade was set to 5000 RPM and inserted between the laryngoscope and the lips to resect the lingual tonsils. Oxymetazoline-soaked pledgets were used periodically during resection to maintain hemostasis and proper visualization. A subtotal lingual tonsillectomy was completed with preservation of the fascia overlying the musculature at the base of tongue.

She was extubated following surgery and there were no postoperative complications. Four months after postoperatively the patient followed up at Arkansas Children’s Sleep Disorders Center and was found to have notable clinical improvement especially with her daytime symptoms. A postoperative polysomnography was not performed given the patient’s clinical improvement.

ND:YAG Laser Therapy of Tongue Venous Malformation

This is a visual representation of the treatment of a venous malformation within the substance of the tongue. The laser directly treats the venous malformation via selective photothermolysis while preventing injury to the tongue itself. Venous malformations infiltrate normal tissue as a birthmark but continue to grow with time and show no evidence of regression. Instead of excising the venous malformation with some of the tongue itself this is a way of controlling the lesion. As seen, the ND:YAG laser set at 25 Watts and 1.0 sec duration is used to shrink the venous malformation. The laser is fired in a polkadot fashion in order to prevent mucosal sloughing. The surface is relatively protected as the laser selective penetrates the VM.

DOI: http://dx.doi.org/10.17797/938qzyj3uh

Hemangioma Excision

Infantile hemangiomas are vascular tumors composed of proliferating endothelial cells. They uniquely undergo rapid expansion from birth to 6-8 months of age and subsequent slow dissolution over several years thereafter. Some hemangiomas are at risk of causing functional problems during their growth phase as seen in this upper eyebrow lesion obstructing the visual axis. Laser, surgical and medical treatment options are available for problematic hemangiomas. This patient was elected to undergo excision to completely remove the lesion and forego a long course of medical therapy (propranolol). Because of the their vascular nature, excision of hemangiomas requires careful planning and hemostasis. The hemangioma is marked in elliptical fashion along natural aesthetic facial lines along the brow. The inferior mark in incised first. Careful subdermal dissection is critical to completely excise to the hemangioma near the surface and find the appropriate plane. Control of bleeding is maintained by monopolar and bipolar electrocautery as well as dissecting the lesion from one side and alternating to the other. The plane of deep dissection is rarely below the subcutaneous layer thus protecting important nerves and vessels. Complete removal is possible. Closure is performed with dissolvable monocryl or PDS suture with dermabond superficially. A plastic eyeshield (blue) is placed at the beginning of case to protect the patient’s cornea during the procedure.

DOI: http://dx.doi.org/10.17797/zlvhux8afu

Endoscopic Excision of Concha Bullosa

Contributors: Gresham Richter

Here we present endoscopic excision of a concha bullosa (a pneumatized middle turbinate) that was causing obstruction in the left nasal cavity.  This particular patient failed medical management of his chronic sinusitis including antibiotic and steroid therapy. The concha bullosa was causing obstruction of the maxillary sinus ostium and deviation of the nasal septum. Resection of the concha bullosa was necessary in order to complete a functional endoscopic sinus surgery afterward and septoplasty (not shown).

DOI # 10.17797/pyzfxehca8

Author Recruited by: Gresham Ritcher

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