A 3 yo girl was referred to the ENT clinic after her PCP noticed an abnormal TM on the left.
She has a history of a 2 ear infections prior to presentation. She is asymptomatic, with no pain and no drainage from her TM. Her audiogram was normal. Her physical eventually revealed the presence of a relatively large keratin pearl on her TM, without obvious middle ear effusions. After a short period of observation the family decided to have it removed.
The case was performed endoscopically in a trans-canal approach. The lesion was dissected mainly with a straight pick. The fibrous layer underneath was found to be intact and no myringoplasty was necessary.
The patient was was seen again 2 months post-op and her TM was found to be normal with a normal audiogram.
Laryngomalacia is the most common laryngeal anomaly affecting newborns. Patient’s with severe disease should be considered for supraglottoplasty. It classically presents in a newborn with high-pitched inspiratory stridor that worsens with exertion, supine-positioning, and feeding. It is characterized by anatomic and physiologic abnormalities including shortened aryepiglottic (AE) folds, small, tightly curled epiglottis, redundant soft tissue overlying the cuneiform or accessory cartilages and reduced laryngeal tone. Any combination of these may present with laryngomalacia. Most cases are mild and resolve with observation or medical therapy.
Steps:
1. Laser precautions are taken to protect patient and personnel.
2. Spontaneous ventilation
3. Suspension laryngoscopy is performed with adequate visualization of the larynx.
4. The operating telescope or microscope is used for visualization. The CO2 laser is tested.
5. First, division of the AE folds is performed.
6. Next, redundant mucosa and tissue overlying the accessory cartilages is ablated.
Double Stage Laryngotracheal Reconstruction with Anterior and Posterior Rib Cartilage Graft.
The procedure shown in this video is an awake transcervical injection laryngoplasty via a thyrohyoid membrane approach.
Editor Recruited By: Michael M. Johns III, MD
DOI: http://dx.doi.org/10.17797/elckgrc4zg
The procedure shown in this video is a pediatric ansa to recurrent laryngeal nerve reinnervation. It is performed with a concurrent laryngeal electromyography and injection laryngoplasty.
Editor Recruited By: Sanjay Parikh, MD, FACS
DOI: http://dx.doi.org/10.17797/7jjbn56ca3
Contributor: Tyler McElwee
Choanal atresia describes the congenital narrowing of the back of the nasal cavity that causes difficulty breathing in neonate. Choanal atresia is often associated with CHARGE, Treacher Collins and Tessier Syndrome. It is a rare condition that occurs in 1:7000 live births, seen in females twice as often as males, and affects bilaterally in roughly 50% of cases. Bilateral choanal atresia is usually repaired in the newborn period. Unilateral CA repair is often deferred until age 2-3 years. Stent placement has become optional as stentless repair is gaining popularity because this technique decreases foreign body reaction in the nasopharynx which in term decreases granulation formation. Transnasal endoscopic choanal atresia repair is performed by opening the atresia bilaterally, drilling out pterygoid bone as needed, and removal of the posterior septum and vomer. Normal mucosa is preserved as much as possible by elevating a lateral based mucosal flap to prevent scarring and restenosis. Postoperatively, these patients are treated with antibiotic, reflux medications and steroid nasal drops; a second look procedure is planned 4-6 weeks postop for debridement and possible removal of granulation tissue & scar.
DOI: http://dx.doi.org/10.17797/9s5ty2f7yv
Editor Recruited By: Sanjay Parikh, MD, FACS
Contributor: Tyler McElwee
Congenital dacryocystocele describe the distended lacrimal sac in neonates with or without associated intranasal cyst. The prevalence is about 0.1% of infants with congenital nasolacrimal duct obstruction and a slight prevalence in female infants. It refers to cystic distention of the lacrimal sac as a consequence of the nasolacrimal drainage system obstruction. It typically presents as a bluish swelling inferomedial to the medial canthus in the neonates. Unilateral congenital dacryocystocele is more common but 12-25% of patients affected have bilateral lesions. Ultrasound, CT scan or MRI can be used for diagnosis. About half of the patient with acute dacryocystitis can be management with conservative management such as digital massage of lacrimal sac or in-office lacrimal duct probing. The other half of patients will require surgery under general anesthesia for removal of the dacryocystocele. Endoscopic excision of the intranasal cysts has been used successfully as a treatment option with Crawford stent placement. Post-operatively patients are treated empirically with antibiotics and nasal saline. No second look is usually planned unless patients develop significant nasal obstrctuion.
Editor Recruited By: Sanjay Parikh, MD, FACS
DOI: http://dx.doi.org/10.17797/16rnuq8n0y
Contributors: Deepak Mehta
This video depicts how to harvest a rib cartilage graft for use in pediatric laryngotracheal reconstruction for airway stenosis.
DOI# http://dx.doi.org/10.17797/oo77838cxt
Authors Recruited By: Deepak Metha
In this video, we demonstrate the set-up, port configuration, and key steps involved in performing a robotic-assisted retroperitoneoscopic partial nephrectomy.
DOI#: https://doi.org/10.17797/di559dgayo
History of airway stenosis, s/p laryngotracheal reconstruction. Developed restenosis, and balloon dilated three times.
In this video we describe our technique for airway stent insertion and its securing to the neck skin.
Balloon dilation of the airway expanded the airway to its appropriate size. After sizing, an 8mm modified Mehta laryngeal stent with rings (Hood Laboratories, Pembroke, Mass., USA)is inserted in the airway with laryngeal forceps. The scope is inserted into the stent to verify its position. Then a 2.0 prolene stitch is taken through the neck, trachea, stent, and taken out through the contralateral skin. This is performed under visualization with a 2.3mm endoscope through the stent. The needle is then re-inserted through the exit puncture and again taken out next to the entry puncture after passing through a subcutaneous tunnel, without re-entering the stent. A small skin incision is performed between the two prolene threads. Multiple knots are taken over an angiocath, which is then buried under the skin.
The stent is taken out 2-6 weeks after the procedure. A neck incision is performed, the angiocath is identified, the knot is cut and the stent is removed under the vision of the endoscope.
