Surgical Atlas of pediatric otolaryngology - part 6 ppt

420 Surgical Atlas of Pediatric Otolaryngology Preparation • A videotape of the nasopharynx during connected speech is viewed immediately before the operation to determine the level of attempted velopharyngeal closure. Anatomic landmarks are identified on the tape that can be used to locate this level in the patient. • The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure • A mouth gag is inserted, and the patient is placed into suspension. The posterior pharyngeal wall is visualized and palpated to identify any sig- nificant vessels in the operative field. • Red rubber catheters are placed transnasally and brought out through the mouth to symmetrically retract the soft palate. • Landmarks identified on the videotape that localize the exact site of nasopharyngeal escape are identified in the patient. • Proposed incision lines are infiltrated with 1% lidocaine with 1:100,000 units epinephrine to affect vasoconstriction. The incisions entail rectan- gular flaps encompassing each posterior tonsillar pillar. A horizontal incision is made connecting the medial limbs of the incisions at the level of velopharyngeal closure (Figure 18–9). • The soft palate may be split in the midline to facilitate visualization within the nasopharynx. • The mucosa is incised to the prevertebral fascia on the medial incisions. The palatopharyngeus muscle is incorporated into the flap. Lateral dis- section is limited in the area of the tonsil. • After making the transverse incision at the level of velopharyngeal clo- sure, the surrounding tissue is elevated superiorly to create a bed within which the flaps may be inset. Inferior dissection is avoided to prevent insetting the flaps below the level of velopharyngeal closure. • The base of each flap is undermined superiorly and laterally to effec- tively narrow the lateral velopharyngeal walls when the flaps are rotated medially. • The donor sites are closed with interrupted 3-0 Vicryl sutures. • The inferior edge of each flap is medially rotated and sewn to the later- al limit of the recipient horizontal incision of the opposite side (Figure 18–10). One flap will reside above the other. • If the palate was divided for improved exposure, it is closed in three lay- ers. Meticulous technique is necessary to minimize fistula formation. Postoperative Care • The patient is discharged after recovery from general anesthesia. • Perioperative oral antibiotics are prescribed for 1 week. • Postoperative neck pain is expected as the prevertebral fascia has been irritated. Figure 18–11 Y-V advancement flap to close a lateral port that is excessively wide. 422 Surgical Atlas of Pediatric Otolaryngology LATERAL PORT REVISION - NARROWING The goal of the operation is to create local advancement flaps to narrow the lateral ports. Indication • Continued VPI following placement of a pharyngeal flap through an incompetent lateral port Anesthetic Considerations and Preparation • General endotracheal anesthesia is required. • Preoperative nasopharyngoscopic evaluation during connected speech has identified the lateral ports that require revision. • The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure • A mouth gag is inserted, and the patient is placed into suspension. • Red rubber catheters are placed transnasally and brought out through the mouth to retract the soft palate symmetrically. • The posterior and lateral mucosa of the lateral velopharyngeal port are infiltrated with 1% lidocaine with 1:100,000 units epinephrine to affect vasoconstriction. • A Y-to-V advancement flap is created where the lateral margin of the port is advanced medially (Figure 18–11). The advancement is on the posterior lateral pharyngeal wall, extending into the nasopharynx, adja- cent to the pedicle of the flap. • Bilateral port procedures may be necessary. Velopharyngeal Insufficiency 423 Postoperative Care • The patient is discharged after recovery from general anesthesia. • Perioperative oral antibiotics are prescribed for 1 week. • Patients return for a postoperative check at 3 weeks. • Speech therapy begins 1 month postoperatively. • A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hyper- nasality or nasal emission is detected. Complications • VPI may persist if the advancement flaps did not effectively narrow the lateral ports. • Hyponasality or obstructive breathing may arise if lateral port stenosis occurs. 424 Surgical Atlas of Pediatric Otolaryngology LATERAL PORT REVISION - ENLARGING A local advancement flap is used to open and reline the stenotic lateral port. Indication • Stenosis of the lateral port with obstructive respiration, hyponasality, or both Anesthetic Considerations and Preparation • General endotracheal anesthesia is required. • Preoperative nasopharyngoscopic evaluation during connected speech has identified the lateral ports that require revision. • The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure • A mouth gag is inserted, and the patient is placed into suspension. • An endotracheal tube is passed transnasally through the stenotic port. • A vertical incision of the soft palate in the midportion of the lateral port is made to release the stenosis (Figure 18–12). Mucosa from the nasal surface of the soft palate is advanced to cover the raw surface created by the incision. • If the resulting size of the port is inadequate, multiple incisions can be made to adequately open the ports. Postoperative Care • The patient is discharged after recovery from general anesthesia. • Perioperative oral antibiotics are not generally required. • Patients return for a postoperative check at 3 weeks. • Speech therapy begins 1 month postoperatively. • A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hyper- nasality or nasal emission is detected. Figure 18–12 Enlargement of a stenotic lateral port. Velopharyngeal Insufficiency 425 Complications • Hyponasality or obstructive breathing may occur if the lateral port stenosis persists or re-develops. • VPI may develop if the advancement flaps opened the lateral ports beyond that which could be closed by lateral wall movement. SURGICAL OUTCOMES Revision surgery for VPI is possible. It is important to investigate the rea- sons for the previous surgical failure so precautions can be taken to mini- mize their recurrence. Pharyngeal flaps can be raised a second time if 6-12 months are permitted to elapse. Unilateral sphincteroplasties may be per- formed in patients who fail to develop adequate lateral wall motion fol- lowing pharyngeal flap placement. Patients must have an objective evaluation 3-6 months following recon- structive procedures to assess their nasal resonance. Precise terminology is necessary to judge outcome; “normal” is not the same as “acceptable.” A family’s satisfaction with the results of surgery does not equate to normal or acceptable resonance. Without objective scrutiny of postoperative out- comes, improvement in surgical judgment cannot occur. Not all patients with continued hypernasality need revision surgery. Developmental delays, compensatory articulation errors, and underlying syndromes will affect speech outcomes. Creating the structural elements necessary for velopharyngeal closure is the essential goal of surgery. Collab- oration with speech pathologists is mandatory for maximal outcome. REFERENCES 1. Kummer AW, Curtis C, Wiggs M, et al. Comparison of velopharyngeal gap size in patients with hypernasality, hypernasality and nasal emission, or nasal turbulence (rustle) as the primary speech characteristic. Cleft Palate Craniofac J 1992;29:152–6. 2. Croft C, Shprintzen R, Rakoff S. Patterns of velopharyngeal valving in normal and cleft palate subjects: a multi-view videofluoroscopic and nasendoscopic study. Laryngoscope 1981;91:265–71. 3. Shprintzen R, Goldberg R, Lewin M, et al. A new syndrome involving cleft palate, cardiac anomalies, typical facies, and learning disabilities: velo-cardio-facial syndrome. Cleft Palate J 1978;15:56–62. 4. Hogan V. A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control (l.p.c.) pharyngeal flap. Cleft Palate J 1973;10:331–45. 5. Gray SD, Pinborough-Zimmerman J, Catten M. Posterior wall augmentation for treatment of velopharyngeal insufficiency. Otolaryngol Head Neck Surg 1999;121:107–12. 6. Smith J, McCabe B. Teflon injection in the nasopharynx to improve velopharyngeal closure. Ann Otol Rhinol Laryngol 1977;86:559–63. 7. Borgatti R, Tettamanti A, Piccinelli P. Brain injury in a healthy child one year after periureter- al injection of Teflon. Pediatrics 1996;98:290–1. 8. Jackson I, Silverton J. The sphincter pharyngoplasty as a secondary procedure in cleft palates. Plast Reconst Surg 1977;59:518–24. [...]... The VIM-Silverman (12-gauge) needle (Figure 20–1A) or the disposable TRU-Cut (14-gauge) needle (Figure 20–1B) may be used 2 The FNA technique uses much smaller 2 2- to 25-gauge needles from 1 1⁄2 to 3 1⁄2 inches in length, depending on the lesion depth (Figure 20–1C) An 1 8- to 20-gauge needle may be needed to aspirate cystic lesions containing thick mucoid material 444 Surgical Atlas of Pediatric Otolaryngology. .. first 48 hours Special Considerations • The floor of mouth may take 4 weeks to heal completely if closure of the anterior incision has been difficult • The result usually becomes apparent within 6 weeks 434 Surgical Atlas of Pediatric Otolaryngology • The anesthetic machine is at the foot of the operating table and to the left of the patient so that the surgical team has ample access to the patient’s... (Figure 20–13) The S-shape of the vertical component of the modified Conley incision also heals well with minimal contracture and comparatively good cosmesis • The incision is infiltrated with 1% lidocaine with 1:100,000 epinephrine for hemostasis Figure 20–13 Child draped in surgical position with modified Conley incision outlined 4 56 Surgical Atlas of Pediatric Otolaryngology Surgical exposure and... cutting–needle biopsy • A 1-2 mm skin incision is made with a No 11 scalpel blade prior to needle insertion (Figure 20–4) • The biopsy technique varies with the type of large-bore needle used; the TRU-Cut needle, for example, comes with its own specific instructions Figure 20–2 The patient is positioned so that the biopsy site is easily accessible to the surgeon 4 46 Surgical Atlas of Pediatric Otolaryngology. .. mass (Figure 20 6) Subcutaneous infiltration of 1% lidocaine with 1:100,000 epinephrine solution provides hemostasis • The skin, subcutaneous tissues, and platysma muscle are transected down to the level of the superficial layer of the deep cervical fascia (Figure 20–7) Detailed knowledge of the regional anatomy is necessary to avoid neurovascular injury 450 Surgical Atlas of Pediatric Otolaryngology. .. Considerations • Ranula formation occurs in 8% of patients having this procedure The parents, or other caregivers, need to be forewarned about this problem, and follow-up will be necessary for at least 1 year A B Figure 19 6 A, Pulling a catheter into the anterior incisional area B, Threading of the suture through the catheter 4 36 Surgical Atlas of Pediatric Otolaryngology PAROTID DUCT LIGATION Indications... include the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve (Figure 20– 16) Figure 20–14 Elevation of cervical flaps with identification of important superficial anatomical structures 458 Surgical Atlas of Pediatric Otolaryngology • Intimate knowledge of the fascial layers of the neck is mandatory in order to perform an adequate functional neck dissection (see also Chapter... mandibular branch of the facial nerve as reviewed in detail in Chapter 23  460 Surgical Atlas of Pediatric Otolaryngology • During removal of the level 5 lymph nodes within the posterolateral cervical compartment, care must be taken to identify and preserve the brachial plexus and the phrenic nerve The phrenic nerve should be identified along the anterior scalene muscle; this nerve is partially intraaponeurotic... forms a single layer anterior to the sternocleidomastoid muscle and meets its counterpart from the opposite side This layer is attached to the hyoid bone and is important because it divides the neck into the areas above 466 Surgical Atlas of Pediatric Otolaryngology (suprahyoid) and below (infrahyoid) The superior part of this fascia encloses the submandibular and parotid glands and forms the stylomandibular... (Figure 21–2) Both the anterior and posterior portions of this space originate at the base of the skull The anterior layer blends with the fascia of the esophagus in the superior mediastinum and is considered the posterior wall of the retropharyngeal space The posterior portion extends inferiorly to the coccyx  468 Surgical Atlas of Pediatric Otolaryngology SUBMANDIBULAR SPACE DRAINAGE The submandibular . been irritated. Figure 18–11 Y-V advancement flap to close a lateral port that is excessively wide. 422 Surgical Atlas of Pediatric Otolaryngology LATERAL PORT REVISION - NARROWING The goal of the operation. floor of mouth may take 4 weeks to heal completely if closure of the anterior incision has been difficult. • The result usually becomes apparent within 6 weeks. 434 Surgical Atlas of Pediatric Otolaryngology •. stenosis occurs. 424 Surgical Atlas of Pediatric Otolaryngology LATERAL PORT REVISION - ENLARGING A local advancement flap is used to open and reline the stenotic lateral port. Indication • Stenosis of the