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Phacoemulsification and IOL Implantation in an Iris Coloboma Case
videoWe present a case of cataract extraction and intraocular lens implantation in an eye with a congenital iris coloboma.
Sinus Venosus ASD Repair
videoThis video demonstrates a sinus venosus ASD repair with the two patch repair technique. Authors: Emily Goodman; Brian Reemtsen, MD; Markus Renno, MD; Christian Eisenring, ACNP-BC; Lawrence Greiten, MD University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR Arkansas Children's Hospital, Little Rock, AR
Pulmonary Valve Replacement
videoThis video highlights a pulmonary valve replacement in a patient with Tetralogy of Fallot.
Complete Repair of Total Anomalous Venous Return
videoComplete repair of a total anomalous pulmonary venous return. Also shown is a primary closure of a patent foramen ovale and patent ductus arteriosus. The patient is placed on cardiopulmonary bypass (CPB) in the standard fashion. The patient is then crash cooled to 20 degrees celsius with ice placed on the head and administration of steroids. Antegrade cardioplegia is then administered. The large confluent vein (vertical vein) is dissected and an arteriotomy is made, a subsequent atriotomy is made in the left atrial appendage. A side to side anastomosis using polypropylene suture in a continuous running fashion. The right atrium is then opened and the patent foramen ovale is closed. The patient was warmed to a satisfactory temperature and once adequate hemostasis was achieved the vertical vein is ligated at its insertion into the innominate vein.
Sinus Venosus ASD Repair
videoThis video demonstrates a sinus venosus ASD repair with the two patch repair technique. Authors: Emily Goodman; Brian Reemtsen, MD; Markus Renno, MD; Christian Eisenring, ACNP-BC; Lawrence Greiten, MD University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR Arkansas Children's Hospital, Little Rock, AR
Minimally Invasive Radioguided Parathyroidectomy
videoMinimally Invasive Radioguided Parathyroidectomy Author: Joshua Hagood Performing surgeon/coauthor: Brendan C. Stack, Jr., M.D., FACS, FACE Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA Overview: Primary hyperparathyroidism is a disease caused by overproduction of parathyroid hormone (PTH). This condition is most commonly caused by a solitary, hyperfunctioning, adenoma among one of the four parathyroid glands. The hallmark finding of hyperparathyroidism is hypercalcemia which can manifest symptomatically as nephrolithiasis, diabetes insipidus, renal insufficiency, bone pathology, gastrointestinal symptoms, and neuropsychiatric disturbances (remembered as “Stones, Bones, Groans, and Psychiatric overtones”). Minimally invasive Radio guided Parathyroidectomy (MIRP) is a curative procedure for primary hyperparathyroidism that can use both radionuclide guidance and intraoperative PTH measurements to confirm the removal of the offending adenoma. Radionuclide guidance is performed via the injection of 99mTc-sestamibi, which is a radiomarker that sequesters within adenomatous/hypermetabolic parathyroid tissue. Intraoperatively, the amount of 99mTc-sestamibi within excised tissue can be measured with the use of a handheld gamma probe. Instrumentation: -Endotracheal Nerve Integrity Monitoring System (NIMS) -Gamma Probe -Intraoperative PTH assay equipment
Cranioplasty for Sagittal Craniosynostosis
videoCranioplasty with barrel stave osteotomies to treat sagittal suture craniosynostosis.
Laparoscopic Orchiopexy: Use of a Hitch Stitch
videoContributors: John Paddack (University of Arkansas for Medical Sciences) INTRODUCTION AND OBJECTIVES: The percutaneous hitch stitch, a commonly described technique for elevation of the ureteropelvic junction during laparoscopic pyeloplasty, allows for easier dissection and suturing. We have adapted this technique to laparoscopic orchiopexy. METHODS: The technique described was used for testicular retraction during three consecutive cases of right-sided intraabdominal testicle RESULTS: There were three cases of non palpable testicle, mean age 31 months (range 22-42). Testicles were all within 3 cm of internal ring on laparoscopy. In all cases, testicle was placed in subdartos pouch in single stage, without division of the spermatic vessels. There were no complications. CONCLUSIONS: The percutaneous hitch stitch is a simple modification to the traditional laparoscopic orchiopexy. It provides atraumatic retraction of the intraabdominal testicle and facilitates dissection of spermatic vessels from the posterior peritoneum. DOI: http://dx.doi.org/10.17797/n1nnrufxpt
Open Surgical Release of Stenosing Tenosynovitis (a.k.a. Trigger Finger)
videoContributors: James Kee In this video, we show the open surgical release of the A1 pulley to restore movement and alleviate triggering in a patient with stenosing tenosynovitis, or trigger finger. DOI #: https://doi.org/10.17797/punju11l92
Open Carpal Tunnel Release
videoContributors: Theresa O. Wyrick This video shows the open surgical release of the carpal tunnel for relief of compressive median neuropathy at the wrist or carpal tunnel syndrome (CTS). DOI: https://doi.org/10.17797/2ddezhnxdf
Fronto-Orbital Advancement and Cranial Vault Remodeling for Metopic Craniosynostosis
videoContributors:Michael Golinko, MD, MA, Eylem Ocal, MD and Kumar Patel, PA Premature metopic suture fusion is corrected using fronto-orbital advancement and cranial vault remodeling to open the fused suture and allow for adequate brain growth. DOI#: https://doi.org/10.17797/hg9xbuxoms
Mandibular Distraction for Micrognathia in a Neonate
videoIntroduction 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
Orbital Decompression through Conjuctival and Lynch Incisions
videoSurgical orbital decompression for proptosis secondary to Graves' Disease.
Upper Eyelid Blepharoplasty
videoIntroduction: Cosmetic Upper Blepharoplasty involves removing excess skin from the upper eyelid to enhance the appearance of the upper eyelids. Methods: Markings were made for the inferior incision on the upper eyelid between 8-10 mm above the upper lash line. Forceps are used to pinch the excess upper eyelid skin in the middle, nasal, and temporal, aspects of the upper eyelid. Markings are then made superiorly at the middle, nasal, and temporal points and are connected. Toothed forceps are used to pinch the excess upper eyelid skin, using the markings as a guide. Iris scissor is used to excise the pinched excess skin and the underlying orbicularis muscle. The skin between the two eyelids was closed. Conclusions: In our experience, cosmetic upper blepharoplasty is an efficient way to enhance the appearance of the eyes. By: Peyton Yee, Addison Yee Surgeon: Suzanne Yee, MD, FACS Dr. Suzanne Yee Cosmetic and Laser Surgery Center, Little Rock, AR, USA Recruited by: Gresham T Richter, MD
Laparoscopic Right Salpingo-oophorectomy in a patient at 17 weeks gestation
videoIntroduction: The prevalence of adnexal masses in pregnancy ranges from 0.05 to 2.4 percent and approximately 1 to 6 percent of these masses are malignant. Patients typically present on prenatal ultrasound asymptomatically but some can have abdominal and back pain as well. Concerns for the fetus and complications in pregnancy cause surgeries to be postponed until after delivery; however, some adnexal masses require evaluation for malignancy. We present a case of a 28-year-old female with a cystic adnexal mass that required laparoscopic salpingo-oophorectomy at 17 weeks gestation. Methods: After the patient was prepped and draped,the initial laparoscopic port was placed in the left upper quadrant, 3 cm below the costal margin and in the midclavicular line. This area, known as Palmer’s point, was chosen as the site for the initial port placement in order to avoid the gravid uterus. After intraperitoneal placement, the abdomen was insufflated with CO2 gas. Laparoscopic ports were placed at the umbilicus and in the right lower quadrant under direct visualization. The port placed at the umbilicus was an Applied Medical GelPOINT Advanced Access Platform. The entire abdominal and pelvic cavities were examined for any lesions. An initial washing was done to examine for malignant cells. The left ovary was examined and determined to be normal. The right ovary was noted to be enlarged, to approximately 10 cm, and was displaced into the posterior cul de sac. Next the infundibulopelvic ligament, broad ligament, ovarian vessels, and ureter are identified. The ureter, which is typically able to be identified at the pelvic brim where it crosses over the bifurcation of the iliac vessels and passes medially, was noted to be well below the plane of dissection. If the ureter is unable to be located trans-peritoneally, a peritoneal incision can be made parallel to the ovarian vessels and the ureter located retroperitoneally in the medial leaflet of the broad ligament. The right fallopian tube and right utero-ovarian ligament were transected using the Ligasure bipolar device. We evaluated for hemostasis of the pedicles. The right suspensory ligament of the ovary containing the ovarian vessels was then isolated and cauterized and transected using the Ligasure bipolar device. A laparoscopic retrieval bag was introduced through the GelPOINT advanced access platform, the specimen was placed in the bag, and then the bag was brought to the surface of the patient's abdomen. We were able to drain straw colored fluid from the cyst with the cyst contained safely within the bag. The remainder of the specimen was then able to be removed, contained within the bag. The patient’s abdomen was deflated and the ports were removed. The fascia at the umbilicus was closed with an 0 Vicryl (polyglactin) suture so as to avoid herniation at the site of the larger incision accommodating the GelPOINT. The rest of the ports were closed using subcuticular sutures. Discussion: Pathology revealed a mature cystic teratoma. The patient was discharged home on the same day of surgery with no complications. Fetal heart tones were within normal limits pre- and post-procedure. Laparoscopic surgery is a safe treatment for pregnant women with non-obstetrical surgical issues, including adnexal masses.
Lip Pit Excision
videoThis 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.
Ahmed® Glaucoma Valve for Treatment of Refractory Glaucoma
videoIntroduction Intraocular pressure is the single modifiable risk factor resulting in progression of various subtypes of glaucoma. Intraocular pressure control is often achieved with topical medications, outpatient laser procedures, or minimally-invasive glaucoma surgery (MIGS). This patient is a 63-year-old with traumatic glaucoma in the right eye with elevated intraocular pressure sub-optimally controlled despite maximum medical therapy (29 mmHg). His intraocular pressure must be controlled with incisional glaucoma surgery - in this case, with placement of an Ahmed Model FP7 glaucoma valve. An advantage of valved glaucoma shunts is lower risk of postoperative hypotony-related complications compared to non-valved glaucoma shunts. Methods The 10 and 12 o'clock meridians are marked with a marking pen to define the borders of the conjunctival peritomy. A limbal traction 6-0 Vicryl suture is placed superotemporally in the cornea at the limbus. The conjunctival peritomy is then completed using Westcott scissors along the predetermined marks. The peritomy is extended posteriorly with blunt dissection using Stevens tenotomy scissors. Wet field cautery is used to achieve hemostasis of the scleral bed. A Stevens tenotomy hook is used to identify the superior rectus muscle and a marking pen is used to mark its border. The Ahmed Model FP7 tube shunt is then introduced onto the surgical field. Balanced salt solution is injected into the tip of the tube using a 30-gauge cannula to ensure adequate patency of the valve. The Ahmed plate is then sutured to the sclera approximately 8 mm posterior to the limbus using 5-0 Nylon suture. A corneal paracentesis is made at the 8 o'clock position, and viscoelastic is injected to deepen the anterior chamber. A 23-gauge needle attached to the Healon syringe is then used to tunnel from a point 2.0 mm posterior to the limbus into the anterior chamber. The needle tract is anterior and parallel to the plane of the iris and the surgeon must ensure that the tube does not contact the iris or corneal endothelium after insertion. The implant tube is then laid flush with the cornea and shortened with Westcott scissors with an oblique cut, bevel up. Healon is injected as the needle is withdrawn. Non-toothed forceps are then used to insert the tube into the anterior chamber. A single 8-0 Vicryl suture is used to secure the tube to the underlying sclera. A corneal patch graft is cut to fit the site of tube implantation and secured with a single 8-0 Vicryl horizontal cross mattress suture. The conjunctival peritomy is then closed with a running 8-0 Vicryl suture on a BV needle. Anchoring sutures incorporating the conjunctiva and the episclera to firmly secure the corners of the peritomy to the limbus. A 9-0 Nylon suture is used to re-approximate the limbal conjunctiva. At the conclusion of the case, the eye is returned to a neutral position, the traction suture is removed, and satisfactory intraocular pressure is confirmed by palpation. Results No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and mild pain that decreased over the following week. Prednisolone acetate drops were applied six times daily to prevent inflammation and moxifloxacin drops were applied four times daily to prevent infection. At the three-month follow up, the eye was quiet and intraocular pressure was measured to be 9 mmHg. Conclusion Implantation of an Ahmed glaucoma tube shunt is a safe procedure that can effectively treat various subtypes of glaucoma with sub-optimally controlled intraocular pressure despite maximum medical therapy. Joseph W. Fong, MD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA JFong@uams.edu Ahmed A. Sallam, MD, PhD Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA ASallam@uams.edu Surgery was performed at University of Arkansas for Medical Sciences, Little Rock, AR, USA.
Tongue Reduction (Partial Glossectomy) for Pediatric Macroglossia
videoThis video demonstrates how to perform a tongue reduction using a Y-V advancement technique for pediatric macroglossia.
Pre-operative marking for the Fisher technique in unilateral cleft lip repair
videoThis 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.
Partial Penectomy due to Penile Calciphylaxis
videoPartial penectomy is the surgical standard of care for invasive tumors of the mid to distal penis, but is utilized in cases of distal penile calciphylaxis due to pain. Partial Penectomy is advantageous compared to a total penectomy, as the patient is able to urinate in the standing position. A 51-year-old man on dialysis for end stage renal disease presented to the emergency department with pain that was increasing in severity for over a month at the glans of the penis. On examination, the glans of the penis was firm with gangrenous necrosis extending distal to the corona, and the urethral meatus was not identified due to the extensive scarring. A clinical diagnosis of penile calciphylaxis was determined and a Partial Penectomy was subsequently performed. Calciphylaxis is a rare life-threatening systemic disease in patients with end stage renal disease due to medial calcification and fibrosis of blood vessels leading to infection and gangrene. The prognosis for penile calciphylaxis tends to be poor with an overall mortality of 64% with a mean time to death of 2.5 months.
Non-fenestrated Extracardiac Fontan
videoThis video demonstrates a non-fenestrated extracardiac fontan. This is the final step in palliation of hypoplastic left heart syndrome. Authors: Ethan Chernivec; Chris Eisenring, ACNP-BC; Lawrence Greiten, MD; Brian Reemtsen, MD. Arkansas Children's Hospital, Department of Pediatric Cardiothoracic Surgery, Little Rock, AR University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR
Closure of a Large Secundum ASD
videoInstitution: University of Arkansas for Medical Sciences Authors: Thomas Heye - teheye@uams.edu Lawrence Greiten MD - lgreiten@uams.edu Christian Eisenring ACNP-BC - EisenringC@archildrens.org
Transannual Patch Repair of Tetralogy of Fallot
videoInstitution: University of Arkansas for Medical Sciences Authors: Thomas Heye - teheye@uams.edu Lawrence Greiten MD - lgreiten@uams.edu Christian Eisenring ACNP-BC -EisenringC@archildrens.org
Medial Orbital Dermoid Cyst Removal
videoDermoid cysts are the most common orbital tumor in childhood. It is a developmental benign choristoma, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes. It is lined by keratinized stratified squamous epithelium and expands slowly due to constant desquamation and dermal glandular elements. They are usually smooth, painless, mobile, or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis, or diplopia, depending on depth and extent1. Although lateral orbital dermoid cysts are common, medial orbital dermoid cysts are rare2. Our patient had a right medial orbital congenital dermoid cyst since birth. At the presentation, the patient was 2 years old. On CT, the cyst measured 5 mm at the upper lid/medial canthus of the right orbit with subtle bone remodeling. He had a mildly clogged tear duct on the left but was otherwise asymptomatic. The decision was made to surgically remove the dermoid cyst. In this video, we present a case of removal of a medial orbital dermoid cyst in a 2-year-old patient. An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance. A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control. A continuous Incision was made with a #15 blade on the skin. Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it. Extra care was made to protect the integrity and avoid the rupture of the cyst. After the entire cyst was freed from the surrounding tissue, it was carefully removed from its attachments to the periosteum using Westcott scissors. The incision was closed in a two-layer fashion. The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures. Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance. Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.
Nasal Dermoid Cyst Excision
videoThis 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.
A Pediatric Case of Levator Palpebrae Resection
videoIn this video, we present a case of levator palpebrae resection in an 8-year-old patient with right eye ptosis. In the pre-op photo, significant ptosis of the right eye can be appreciated. An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures. In this one-week post-op photo, the ptosis of his right eye was improved. Thank you for watching!
Tetralogy of Fallot Repair
videoComplete repair of Tetralogy of Fallot with a transannular patch. The patient is placed on cardiopulmonary bypass in the standard fashion. An incision in made into the free wall of the right ventricle and the septal defect is exposed. A non-autologous CorMatrix patch is placed with prolene suture in a running fashion to repair the septal defect. An additional patch is used to repair the right ventricular outflow tract with a similar running suture. The patient was removed from cardiopulmonary bypass and extubated in the operating room.
Branchial Cleft Cyst Excision
videoBranchial 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.
Pediatric Lumbar Epidural Catheter Placement via the Landmark Technique.
videoThis video demonstrates an epidural catheter placement on a 2-year-old, 12kg male patient presenting for left hip osteotomy. His past medical history was remarkable for congenital heart defects, bilateral congenital hip dislocations, and a sacral dimple which is sometimes associated with neurologic spinal canal abnormalities. In this case, no neurologic anatomical abnormalities were demonstrated on the neonatal spine ultrasound. The patient was placed in a left lateral decubitus position. Using anatomical landmarks like Tuffier’s line or the intercristal line corresponding to L4-L5 level, the target level for needle placement was identified and marked. The patient’s skin was sterilized and draped under sterile conditions. An 18-gauge, 5 cm length Tuohy needle was used to encounter the epidural space. A general guideline for the depth to the epidural space from the skin is approximately 1mm/kg of body weight¹. Subsequently, a 20-gauge catheter was placed through the needle to a depth of 4.5 cm at the level of the skin. Negative aspiration of blood or CSF was confirmed. A test dose was calculated at 0.5 mcg/kg epinephrine or 0.1ml/kg of lidocaine 1.5% with epinephrine 1:200,000. In this case, a 1.2 mL test dose of lidocaine 1.5% with epinephrine 1:200,000 was given without any observed cardiovascular changes (e.g. ≥ 25% increase or decrease in T wave amplitude, HR increase ≥ 10 bpm, or SBP increase ≥ 15 mmHg)¹. Finally, the catheter was secured to the back of the patient. Parental consent was obtained for the publication of this video.
Thyroid Cyst Removal with Hemithyroidectomy
videoThis 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.
Excision of greater occipital nerves and 3rd occipital nerves
videoAbstract Introduction: Occipital headache is a common, costly and debilitating disease process.When traditional therapies such as medication management and physical therapy fail to provide relief, surgical interventions may be considered. This procedure involves the excision of the 3rd and both greater occipital nerves. Case presentation: 36 years old. female with history of chronic refractory occipital headaches involving both greater occipital nerves and 3rd occipital nerves who presented for resection of those nerves. Methods: A 10cm incision was marked on the posterior neck, positioned inferior to the occipital skull base. Subsequently, the incision was carefully extended through the subcutaneous tissue. By means of both blunt and sharp dissection through the posterior muscle fascia where it inserts into the skull base, the right greater occipital nerve was identified and dissected into the paravertebral muscles and several centimeter of the nerve was resected so it could not grow back together. A corresponding procedure was employed for the left greater occipital nerve, located approximately 3 cm from the midline, and excised using the same technique. Additionally, the third occipital nerves situated in the midline were excised to address the entirety of the issue. Following these procedures, the wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was diligently maintained throughout the surgical intervention using both monopolar and bipolar cautery. To alleviate postoperative discomfort, 0.5% Marcaine with epinephrine was carefully injected into the nerve areas. The fascia needs to be closed with strong sutures and the skin and subcutaneous tissue were closed in two layers. Conclusion :The excision of greater occipital nerves presents a viable option for the management of chronic occipital headaches when conservative treatments prove ineffective. This case report highlights the successful outcome of such a procedure in a 36-year-old female suffering from debilitating headaches Surgeons: Dang-Khoa Nguyen, MD James Y Suen,MD 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
Excision of supratrochlear and supraorbital nerves
videoAbstract Introduction: Frontal headache is a common, costly and debilitating disease process.When treatments, including medication management and physical therapy, prove ineffective, surgical interventions become a viable consideration Among these interventions, the excision of supratrochlear and supraorbital nerves stands out as a potential therapeutic option. Case presentation: 24-year-old female with history of chronic frontal headaches who presents for resection of supraorbital and supratrochlear nerves. Methods: A 4 cm incision was carefully made along the right eyebrow. This incision extended through the subcutaneous tissue. Employing a combination of blunt and sharp dissection techniques, we successfully identified supratrochlear nerves, observing multiple branches emerging from the orbit. All branches were excised via scissors . Subsequently, we located the supraorbital nerve exiting through a foramen, just above the mid-orbital rim, and proceeded to excise it. The wound was thoroughly irrigated with normal saline to ensure cleanliness, and hemostasis was maintained throughout the procedure using both monopolar and bipolar cautery. Closure of the incision was executed in a layered fashion, employing 3-0 Monocryl and 5-0 Chromic sutures. To minimize postoperative discomfort, 0.5% Marcaine with epinephrine was injected into the nerve areas. Conclusion :The excision of the supraorbital and supratrochlear nerves offers a promising option for managing chronic frontal headaches when conventional treatments prove ineffective. This case report underscores the successful outcome of this procedure in a 24-year-old female who had been enduring debilitating headaches. Surgeons: Dang-Khoa Nguyen, MD James Y Suen,MD 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
Arteriovenous Malformation (AVM) Resection
videoAbstract 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 7x7 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 Surgeons: 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
Eagle Syndrome (Calcification of the Stylohyoid Ligament) Excision
videoAbstract Introduction: Eagle syndrome can affect many patients of any age, anywhere from 25 to 80 years old. The most common symptoms are ear and anterior superior neck pain underneath the angle of the jaw, tinnitus, some throat symptoms, and dizziness. There are two approaches that can be done for surgery, with our preference being for the intraoral approach. The pathophysiology is that the stylohyoid ligament becomes calcified and can cause pressure on blood vessels and nerves, causing variable symptoms. It is frequently undiagnosed causing patients to visit several physicians before correctly identifying the problem. A CT scan of the neck with or without contrast, can help identify the problem. Case presentation: A 39-year-old female with a history of ear and upper neck pain at the angle of the jaw. CT imaging showed calcification of the stylohyoid ligament. Surgery was recommended and a trans-oral approach was used. Methods: General anesthesia with muscle relaxation was used. A crow Davis or Dingman tractor was used to retract the endotracheal tube to allow exposure of the Oropharynx. Betadine was used to help sterilize the oropharynx. Palpation on each side is done to localize the calcified ligament and if present, the surgery is much easier to do. A 2.5 cm vertical incision is made in the anterior tonsillar pillar, being careful not to go too high on the soft palate because it can paralyze the soft palate causing significant reflux into the nasopharynx and nose, with speech and swallowing problems. The tonsil capsule and the medial pterygoid muscle are identified, and the dissection is between the two. The calcified ligament is usually about 2.5 cm deep to that area. It is in or under the fat pad in the prevertebral area. It may be difficult to find, and it is helpful if your finger is passed through the incision to palpate deeper to feel the bony process. The stylohyoid muscle and fat must be cleaned off the bone as high and low as can be dissected ideally using a combination of the monopolar and bipolar cautery. It is important to be careful in this area with the monopolar cautery because of the proximity to the internal carotid artery and jugular vein. Also, the vagus nerve can be injured. A Kerrison rongeur is used to fracture the bone superiorly. The ligament is connected at the inferior part which can be divided with the cautery. It is important to obtain good hemostasis using the bipolar cautery and saline irrigation. The wound is closed by sewing the tonsil capsule to the medial pterygoid muscle after which the mucosal incision is sewed. Preferably, vicryl sutures are used so that it will last approximately four weeks. Bupivacaine 0.5% can be injected around the surgical site to decrease postop pain. The surgery is done as an outpatient basis and the patient is given pain medication and antibiotics for significant throat pain lasting 7 to 10 days postop. Conclusion: The removal of the calcified Stylohyoid ligament via an intraoral approach, can be simple or very complicated, and must be done carefully by an experienced surgeon to avoid major complications. Most patients benefit significantly with relief of their symptoms and are very grateful. This case illustrates the surgical procedure that was easy to perform, but they are not all that easy. Surgeons: Siddharth Patel, MD James Y Suen, MD 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
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