Posterior Pharyngeal Flap for Large Gap Velopharyngeal Insufficiency

Velopharyngeal insufficiency (VPI) is a speech disorder characterized by inability for the palate (velum) to contact the posterior pharyngeal wall resulting in nasal air escape and subsequent speech abnormalities. All but the mildest cases are treated surgically, with technique chosen based on the closure pattern and gap size reserving the pharyngeal flap for the most severely affected patients. We present a 6-year old female with developmental delay and VPI with large (~60%) coronal pattern velopharyngeal gap subsequently deemed a candidate for posterior pharyngeal flap.

Following Dingman mouthgag placement, the posterior wall is inspected and palpated ensuring no carotid medialization. The flap is designed and marked as wide and long as possible to reduce tension. Local injection wis performed. Using an angled needle tip Bovie, the flap was then elevated in the plane the prevertebral fascia to the level of the nasopharynx. The donor site is closed with simple interrupted 4.0 chromic sutures. The palatal mucosa is divided in a T-shaped fashion, without violating palatal musculature. The flap is inset with horizontal mattress sutures using 4.0 chromic. The nasal ports are inspected frequently to ensure adequate nasal airway patency. The palatal mucosa is reapproximated and any residual donor site closed.  The patient is observed overnight, discharged home post-operative day 1, maintained on a soft diet for two weeks and abstains from speech therapy for 4 weeks to allow healing. Follow up demonstrated excellent healing well and VPI resolution on repeat speech sample.

Selective Stapedial tendon and Tensor Tympani tenotomy for the treatment of Middle Ear Myoclonus in a pediatric patient

Objective tinnitus is a rare phenomenon whereby a patient perceives sound in the absence of external auditory stimuli, that is also observed by the examiner. Unlike subjective tinnitus which is thought to be somatosensory and usually difficult to cure, objective tinnitus is more likely to have an identifiable cause amenable to treatment. The differential for objective tinnitus includes aberrant vascular anatomy affecting the temporal bone, patulous eustachian tube function, and abnormal myoclonic activity of the palatal or middle ear muscles.1  

We present a 16-year-old female who presented for evaluation of objective tinnitus. On physical examination, an intermittent rhythmic clicking was identified. Visualization of both the tympanic membrane and palate during active audible tinnitus was observed and found to be normal. A hearing test was performed demonstrating normal hearing and speech thresholds as well as normal tympanogram. Acoustic reflex testing demonstrated absent decay in both ears and  spontaneous discharge for the right ear in response to both high and very low stimulus indicating abnormal stapedial and tensor tympani function. MRA demonstrated normal vascular anatomy and MRI was obtained demonstrating normal anatomy without lesions of the brainstem, cochleovestibular nerves, or ear or mastoid pathology. The patients was subsequently diagnosed with isolated middle ear myocolonus (MEM). Treatment options including medical versus surgical therapy were discussed as has previously been described. The patient ultimately elected for surgical tenotomy of the stapedial and tensor tympani tendons. Using endoscopic technique, a middle ear exploration was performed. Canal injection was performed with standard tympanomeatal flap elevation was assisted with epinephrine pledgets. The Annular ligament was identified and the middle ear was entered. Additional dissections was performed superiorly, and the chorda tympani nerve was identified and preserved. The stapedial tendon was visualized emanating from the pyramidal eminence to the posterior crus of the stapes. Balluci scissors were used to sharply incise the tendon and the remaining ends were reflected using a Rosen needle to prevent re-anastamosis. Additional dissection along the malleus was performed to gain access to the tensor tympani tendon. A 30 degree angled endoscope was utilized to visualize the tensor tympani tendon extending forward from the cochleariform process to the neck of the malleus. The angled 6400 Beaver blade was used to sharply incise the tendon, requiring multiple passess due to the thickness of the tendon. The sharply incised ends of both tendons were clearly visualized. The tympanomeatal flap was re draped and secured with gel foam packing. The patient was seen in follow up three weeks post operatively with a well healed ear drum, resolution of her objective tinnitus, normal hearing, and absent stapedial reflexes. The patient and mother were happy. Endoscopic stapedial and tensor tympani tenotomy is a feasible technique for isolated MEM in the pediatric population.

Endoscopic Nd:Yag and Bleomycin Injection for the management of a Hypopharyngeal Venous Malformation

Venous malformations (VM) are congenital lesions, frequently affecting the head and neck, with poor respect for tissue planes. Established treatments include observation, sclerotherapy, laser, and surgical resection.1  

Lesions affecting the upper airways present unique challenge due to frequent unresectability and difficult access/exposure for alternative standard treatments. We describe our approach of standard endoscopic airway techniques for the administration of advanced treatment modalities including simultaneous laser and sclerotherapy for an extensive airway VM.

Our patient is a 16-year-old female with an extensive multi-spatial VM with associated airway obstruction.  The patient suffered from severe obstructive sleep apnea (OSA) and continuous positive airway pressure (CPAP) dependence as a result of airway compression. Direct laryngoscopy and bronchoscopy demonstrated extensive venous staining and large vascular channels of the hypopharynx. Lumenis Nd:Yag laser (Yokneam, Israel) via 550 micron fiber was passed under telescopic visualization. Treatment via previously described “polka dot” technique was performed (15W, 0.5 pulse duration) with immediate tissue response. The largest vascular channel was accessed via 25-gauge butterfly needle. Immediate return of blood following lesion puncture confirmed intralesional placement. Reconstituted bleomycin (1 U/kg; max dose = 15 U per treatment) was injected and hemostasis achieved with afrin pledgets. The patient was intubated overnight. She was extubated the next morning and advanced to a regular diet, discharging post-operative day two. Post-operative flexible laryngoscopy demonstrated significant improvement in the treatment areas, and follow up sleep study demonstrated sleep apnea resolution with liberation of her CPAP therapy.

Transoral Incision and Drainage of a Massive Retropharyngeal Abscess Involving the Danger Space

Retropharyngeal (RP) abscesses are uncommon yet serious sequala of pediatric head and neck
infections. The RP space extends from the skull-base to the carina and is located between the
buccopharyngeal fascia, alar fascia, and the carotid sheaths. Immediately deep to this, anterior
to the prevertebral fascia, is the “danger space,” allowing infection to spread into the thorax
and mediastinum. We present the use of a transoral incision, and suction assisted evacuation
for managing a massive RPA with danger space extension.
Our patient, a 19 months-old previously healthy female, presented with 10 days of progressive
congestion, cough, and fever. Evaluation demonstrated a toxic stridorous child. Chest
radiograph demonstrated significant superior mediastinal widening. Subsequent contrasted CT
imaging demonstrated a large, rim-enhancing, RP fluid collection extending from the neck to
the carina with tracheoesophageal compression and mediastinitis. The patient was taken
urgently the OR for drainage. Following bronchoscopy and intubation, a mouth gag was used to
expose the RP. Parasagittal incision was made with immediate expression of high volume
purulent material. Hemostat dissection was performed to disrupt loculations and extrinsic neck
compression was used to evacuate the abscess. To access the deepest components, an eight
French tracheal suction catheter was passed to assist with decompression of the mediastinal
components until no further material could be evacuated. Copious irrigation was performed
and the incision was left open. The patient was kept intubated for 48 hours, before uneventful

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