After informed consent was obtained the patient was brought to the operating room and placed in the supine position. The correct patient and procedure were identified and a Time Out was performed. After induction of general anesthesia, patient was intubated transnasally from right nostril. The table was turned to 90 degree and head was extended. 2% xylocaine with 1:100,00 epinephrine was injected over the left side of the maxillary gingivolabial sulcus.
Patient was prepped and draped in usual fashion.
Approximately 3 cm long incision was made along the mucogingival junction on the left side preserving the gingiva at the dental margin. This went from just to the right of the central incisor and over to the left molar. Supraperiosteal dissection was performed till the desired vestibular depth using predominantly a 15 blade. The periosteum was intentionally incised towards the height of the sulcus to promote attachment of the mucosa and maintain a deep sulcus with healing.
In the process of obtaining adequate release towards the intended sulcus depth, a connection to the nasal cavity was noted where the fistula was previously repaired. Tissue manipulation was done around the left nasal fistulous tract to allow for closure and it was then sutured with 5-0 vicryl in intermittent fashion.
Leak test performed showed no leak. Another suture in figure 8 fashion was then also applied over the closure to ensure no leak.
The free cut mucosal edge of the lip tissue was then sutured to the depth of the vestibular sulcus using interrupted 4-0 monocryl sutures. The remaining raw periosteal surface was covered with a 2×2 cm piece of Neox 1K membrane and was secured with intermittent sutures with 4-0 monocryl. Hemostasis was great throughout requiring very little cautery..
A periopak was created that was also mixed with doxycycline powder and applied over the surgical site. Mouth was closed to reshape the Coepack dressing to remove excess material and to prevent chipping off while eating.
Having tolerated the procedure well the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.
We present in this video our innovative approach to mild to moderately sized perforations in the setting of chronic eustachian tube dysfunction with push through myringoplasty using tragal cartilage graft with primary T-tube. There was improvement in conductive hearing loss while allowing for stable middle ear ventilation with this technique.
This video demonstrates a myringoplasty procedure using Neox RT – a human birth tissue allograft – to repair a tympanic membrane perforation in a pediatric patient. Neox RT is indicated as a wound covering for dermal ulcers or defects, but it holds further utility for myringoplasty. Birth tissue contains growth factors that stimulate epithelialization, as well as extracellular proteins that furnish scaffolding material for wound repair. These properties make it a natural and appealing option to induce tympanic membrane regeneration and healing.
We employ a “sandwich” technique, in which pieces of the allograft are placed both medial and lateral to the perforation. Simple overlay and underlay techniques have been tried with success, but the allograft is packaged as a single piece that affords enough material to craft two smaller pieces. The simultaneous placement of medial and lateral grafts not only avoids waste but may increase success.
Both pieces are trimmed to be slightly larger than the perforation. After freshening the edges of the perforation with a Rosen pick and partially filling the middle ear with dry, absorbable gelatin sponge, trimmed pieces of allograft are inserted sequentially in underlay and overlay fashion to remain medial and lateral to the perforation. Both the underlay and overlay pieces cover the perforation and overlap the native tympanic membrane around the perforation. More absorbable sponge is then inserted lateral to the graft to hold it in place against the tympanic membrane. Finally, antibiotic drops and bacitracin ointment are placed in the canal.
This is a case of an 8 month old with a midline nasal mass present since birth. Preoperative physical exam and imaging was consistent with a nasal dermoid cyst with no evidence of intracranial extension.
The most common of the rare craniofacial clefts, Tessier’s No. 7 cleft is represented by a deficiency of tissue that may span from the oral commissure to the ear. (1) The repair of the cleft of the lip must include especial attention to restoring continuity of the orbicularis oris muscle as well the vermillion. This case is presented as an example of the repair of the Tessier 7 cleft lip deformity.
DOI #: http://dx.doi.org/10.17797/4h2edlts5zz
Contributors: Larry Hartzell
Repair of the bilateral cleft lip deformity can be challenging to the cleft and craniofacial surgeon. The goals of an acceptable repair must include precise continuity of the cupid’s bow, maximizing philtral length, and establishing a mucosa lined sulcus. We present an example of a repair of the bilateral incomplete lip as described by Millard.
DOI: http://dx.doi.org/10.17797/qefi9lqbam
Introduction
Patients with Pierre-Robin Sequence (PRS) suffer from micrognathia, glossoptosis, and upper airway obstruction, which is sometimes associated with cleft palate and feeding issues. To overcome these symptoms in our full-term male neonate patient with PRS, mandibular distraction osteogenesis was performed.
Methods
The patient was intubated after airway endoscopy. A submandibular incision was carried down to the mandible. A distractor was modified to fit the osteotomy site that we marked, and its pin was pulled through an infrauricular incision. Screws secured the plates and the osteotomy was performed. The mandible was distracted 1.8 mm daily for twelve days.
Results
During distraction, the patient worked with speech therapy. Eventually, he adequately fed orally. He showed no further glossoptosis or obstruction after distraction was completed.
Conclusion
In our experience, mandibular distraction is a successful way to avoid a surgical airway and promote oral feeding in children with PRS and obstructive symptoms.
By: Ravi W Sun, BE
Surgeons:
Megan M Gaffey, MD
Adam B Johnson, MD, PhD
Larry D Hartzell, MD
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
Recruited by: Gresham T Richter, MD
Velopharyngeal dysfunction (VPD) refers to the improper control of airflow through the nasopharynx. The term VPD denotes the clinical finding of incomplete velopharyngeal closure. Other terms used to describe VPD include velopharyngeal insufficiency, inadequacy and incompetence. However, the use of VPD has gained popularity over these terms as they may be used to infer a specific etiology of impaired velopharyngeal closure.1
Control of airflow through the nasopharynx is dependent on the simultaneous elevation of the soft palate and constriction of the lateral and posterior pharyngeal walls. Disruptions of this mechanism caused by structural, muscular or neurologic pathology of the palate or pharyngeal walls can result in VPD. VPD can result in a hypernasal voice with compensatory misarticulations, nasal emissions and aberrant facial movements during speech.2
The assessment of velopharyngeal function is best preformed by a multispecialty team evaluation including speech-language pathologists, prosthodontists, otolaryngologists and plastic surgeons. The initial diagnosis of VPD is typically made with voice and resonance evaluation conducted by a speech-language pathologist. To better characterize the patient’s VPD, video nasopharyngeal endoscopy or speech videofluoroscopy can be used to visualize the velopharyngeal mechanism during speech.
VPD may first be managed with speech-language therapy and removable prostheses. For those who are good surgical candidates and do not fully respond to speech-language therapy, surgical intervention may be pursued.
Surgical management of VPD is most commonly accomplished by pharyngeal flap procedures or sphincter pharyngoplasty. In this video, a superiorly based pharyngeal flap with a uvular mucosal lining flap was preformed for VPD in a five-year-old patient with 22q11 Deletion Syndrome and aberrantly medial internal carotid arteries.
This video shows a pediatric patient with Van der Woude syndrome. He has lip pits that are classic for this syndrome and his family desired surgical correction. This video outlines and shows the steps of the modified simple excision technique as well as discussing tips for a successful surgery.
This video outlines the steps taken for pre-operative markings that need to be made prior to performing unilateral cleft lip repair using the Fisher anatomic subunit approximation technique. The technique has been written about in detail by Dr. David Fisher in his article “Unilateral Cleft Lip Repair: An Anatomical Subunit Approximation Technique”. This video simply outlines the markings that are made prior to performing this technique, which are crucial for correctly carrying out the repair.
