Airway Evaluation Prior to Closure of Tracheo-Cutaneous Fistula

The patient is a five year old, ex 23 week preemie whom was successfully decannulated with the tracheotomy removed in the ICU eleven months prior. The child did not have any airway reconstruction. As the techniques around decannulation as well as closure of trachea-cuteanous fistula are varied and at times controversial, it would be most excellent to see video sequences of the various ways to decannulate. The patient underwent a direct laryngoscopy and bronchoscopy and closure of the tracheo-cutaenous fistula. He is brought to the operating room for closure of a tracheo-cutaneous fistula. Prior to closure of the fistula, the patient had an airway evaluation to ensure that the airway was safe. Note the distal secretions and otherwise normal airway evaluation. The method for the airway evaluation in the setting of a trachea-cutaenous fistula is to first ensure the patient has adequate ventilation and oxygenation. If necessary and a very large fistula, the fistula may need to be covered with gauze or a finger to allow gas exchange. The airway evaluation then proceeds with a laryngoscope to expose the larynx and an endoscopic camera via a bronchoscope is passed through the vocal folds to evaluate the airway. This video demonstrates that there is no mucosal opening where the trachea-cutaneous fistula would be expected to be found.


Coblation Adenoidectomy

Coblation (radiofrequency ablation) has become popular and the tool of choice for over half of Otolaryngologists. There has been legitimate concern about the ability to use the device for an adenoidectomy. This video shot using a mirror to examine the nasopharynx demonstrates the feasibility and ease of using the Coblation wand to perform an adenoidectomy. Note how easy the instrument can reach the posterior choanae and completely remove the adenoids safely. For the adenoidectomy, the surgeon can alternate between a setting of 9 ablate and 5 coagulation; both the ablation and coagulation modes are safe and beneficial when performing a coblation adenoidectomy.


Endoscopic Drainage of a Severe Subperiosteal Abscess – Less is More

An adolescent male presented with a few day history of right eye swelling, erythema, and edema. The eye swelling was determined to be a result of subperiosteal abscess of the medial orbit, as seen on imaging. The vision was progressively getting worse and the decision was made to urgently take the patient to the operating room. The surgical indications are at times controversial but include decreased range of motion of the eye as well as loss of vision/color discrimination. This patient only had markedly decreased range of motion of the eye. The patient was taken to the operating room; afrin pledgets were placed and the middle turbinate was medialized. At this time the edema and swelling of the ethmoid sinuses was evident. The traditional teaching is to remove the ethmoid air cells and open up the lamina papyrecea. For the past several years, the author has adopted a less is more approach – where the author opens up the ethmoid sinuses and exposes the lamina to allow the pus a route of egress. This video clearly epitomizes the less is more approach. The ethmoid cells have been opened up and there is a large route of egress for the pus which is under pressure. The video demonstrates that upon palpation of the right eye (the Stankiewicz maneuver), there is a massive amount of pus that drains out. The child recovered expeditiously. Endoscopic sinus surgery is an area where is there significant potential for errors and complications – especially inadvertent injury to the eye and brain. As such, the author believes that in some cases, a less is more approach ultimately benefits the patient.


Orbital Fat Intentional Exposed Endoscopically

The mystery of orbital fat should not be so intimidating. The surgical mantra for chronic rhinosinusitis is to not expose orbital fat, however in specific instances it is imperative to take down the lamina papyracea to expose the orbital fat. Instances where this would be necessary would be for infections, tumors, orbital decompression as well as others. Specifically in this case, we surgically opened the maxillary antrum and took down the anterior ethmoid air cells. From here, we dissected laterally to the lamina papyracea and opened up the lamina where the orbital fat is exposed. This video shows that when you compress on the orbit the orbital fat moves and is displaced towards the path of least resistance in this case the opened up lamina and hence the fat moves towards the ethmoid air cells (ie medial).


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