Surgical Atlas of pediatric otolaryngology - part 8 ppt

594 Surgical Atlas of Pediatric Otolaryngology • The skin with the tract is dissected with scissors from the surrounding tissue down to the opening in the trachea. The tract is separated from the trachea with a knife (Figure 26–11). • Cartilage removal is generally unnecessary. If cartilage is removed, the amount should be minimal. • There are different techniques for closure of the fistula. Regardless of technique, subcutaneous emphysema must be prevented. ♦ A small tracheal opening can be left to close spontaneously. ♦ A larger tracheal opening can be closed primarily with 4-0 Vicryl sutures. • Strap muscles, subcutaneous tissues, and skin are closed loosely in layers with a drain beneath the strap muscles to prevent subcutaneous emphy- sema (Figure 26–12). • Alternatively, the incision may be left open and allowed to heal by sec- ondary intention. This minimizes the risk of subcutaneous emphysema with an acceptable cosmetic result. Postoperative Care • The patient is observed overnight in an intensive care unit, or a similar- ly supervised setting, for early detection and management of respiratory distress or subcutaneous emphysema. • The drain is removed after 24 hours. Complications • Subcutaneous emphysema • Pneumothorax • Respiratory distress 596 Surgical Atlas of Pediatric Otolaryngology BIBLIOGRAPHY Myers EN, Stool SE, Johnson JT. Tracheotomy. New York: Churchill Livingstone; 1985. Rothfield RE, Petruzzeli GJ, Stool SE. Neonatal tracheotomy tube modification. Otolaryngol Head Neck Surg 1990;103:133–134. Wetmore R. Tracheotomy. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngolo- gy. 3rd ed. Philadelphia (PA): WB Saunders; 1996. p.1425–40. CHAPTER 27 SURGERY OF THE LARYNX AND TRACHEA Greg R. Licameli, MD Gerald B. Healy, MD Surgical conditions of the pediatric airway may be classified as supraglottic, glottic, subglottic, or tracheal. Although these disorders are infrequent, surgery can be lifesaving or improve the quality of life. The most com- monly performed procedures in children are illustrated in this chapter and include the following: • Supraglottic procedures—endoscopic arytenoidectomy, open (external) arytenoidectomy, and supraglottoplasty • Glottic procedures—glottic web excision, posterior glottic stenosis repair, and laryngeal separation • Subglottic procedures—laryngeal decompression (cricoid split) with hyoid interposition, augmentation laryngoplasty with cartilage graft, and augmentation laryngoplasty with cartilage stent • Tracheal procedures—segmental tracheal resection, and cricotracheal resection ARYTENOIDECTOMY Bilateral vocal cord paralysis is a difficult and challenging problem (Figure 27–1 A). Arytenoidectomy offers an opportunity for decannulation in selected cases. Either an endoscopic or an open (or “external”) approach may be used. Airway enlargement at the glottic level often comes at the price of voice degradation, which must be appreciated fully by the patient and family prior to surgery. First described by Jackson in 1922, the procedure today is facilitated by the laser. Advantages over cold techniques include improved hemostasis and decreased tissue manipulation. Indications • Bilateral vocal cord paralysis in patients in whom spontaneous resolu- tion has not taken place within 18 months of onset • Chronic arytenoid dislocation with obstruction of the glottis • Inability to decannulate because of glottic obstruction 598 Surgical Atlas of Pediatric Otolaryngology Anesthetic Considerations • The procedure is performed under general anesthesia. ♦ If a tracheostomy is present, anesthesia is delivered through this port. ♦ If an endoscopic laser technique is employed, a noncombustible tra- cheostomy tube must be used. • Maximal muscle relaxation facilitates the procedure. • An intravenous line and pulse oximeter are placed. Preparation • The patient is positioned with the shoulders elevated and the neck hyperextended. • If an open procedure is used, the neck is prepared with Betadine solu- tion and is then draped. The incision area is infiltrated with 1:200,000 epinephrine (1 to 2 mL). • The eyes and face are protected if the laser is to be used. • 1:200,000 epinephrine solution (1 mL) is injected into the arytenoid area for hemostasis. Procedure No 1. Endoscopic arytenoidectomy • Arytenoidectomy may be performed endoscopically using a suspen- sion binocular laryngoscope and operating microscope. The CO 2 or KTP laser is extremely useful for the procedure. • A horizontal incision is made over the arytenoid cartilage with a laser or sickle knife (Figure 27–1 B). • The arytenoid is grasped with alligator forceps, and the perichondri- al attachments are separated with a laser or scissors (Figure 27–1 C). The arytenoid cartilage is removed. • The posterior one-third of the true vocal cord is resected to improve the glottic aperture (Figure 27–1 D). • The mucosal incision is sutured with 5-0 polyglactin 910. 600 Surgical Atlas of Pediatric Otolaryngology No 2. Open-technique arytenoidectomy • If an open approach is employed, an external horizontal skin incision is made at the midlevel of the thyroid cartilage and is carried to the margins of the sternomastoid muscle (Figure 27–2 A). • The dissection is carried subcutaneously through the platysma, exposing the external hyoid muscles. The strap muscles are separated in the midline to expose the thyrohyoid membrane, the anterior aspect of the thyroid cartilage, and the cricothyroid membrane. • A vertical incision is made through the cricothyroid membrane and is carried up through the anterior thyroid cartilage in the midline. The thyroid laminae are retracted laterally (Figure 27–2 B). • A vertical incision is made through the epithelium anterior to the vocal process of the arytenoid. The vocal process is dissected free, and then the posterior cricoarytenoid, the lateral cricoarytenoid, and the thyroarytenoid muscles are cut. • The cricoarytenoid joint is transected, and the arytenoid is removed. The incision is closed with a 4-0 polyglactin 910 suture (Figure 27–2 C and D). • A mattress suture is placed above and below the vocal cord with a 2- 0 polyglactin 910 suture, then pulled through the thyroid lamina, and tied laterally. This lateralizes the vocal cord. • The thyroid cartilage is closed with a 2-0 polyglactin 910 suture. The wound is closed in layers over a drain. Postoperative Care • Wound care is undertaken twice a day. • Systemic antibiotics are employed for 7 to 10 days. • Meticulous tracheotomy care is encouraged. 602 Surgical Atlas of Pediatric Otolaryngology SUPRAGLOTTOPLASTY Congenital laryngeal stridor (laryngomalacia) is usually self-limited; how- ever, some patients have respiratory distress with associated symptoms severe enough to require surgery to improve ventilation. Indication • Severe laryngomalacia (Figure 27–3A) causing obstructive apnea, cyanosis, cor pulmonale, or failure to thrive Anesthetic Considerations • General anesthesia is employed in all cases. Combustion precautions are taken with the endotracheal tube if the laser is to be used. • An intravenous line and a pulse oximeter are placed. Preparation • The patient is positioned with the shoulders elevated and the neck hyperextended. • The eyes and face are protected if the laser is used. • Dexamethasone 1.5 mg/kg up to 20 mg is given in a single intravenous dose. • Antireflux therapy is begun prior to surgery. Procedure • Suspension microlaryngoscopy is employed with the CO 2 or KTP laser. • Excess mucosa over the cuneiform cartilages and arytenoids is vaporized (see Figures 27–3 A and B). • In severe obstruction (see Figure 27–3 A), division of the aryepiglottic folds is completed with the laser to release the epiglottis. • The mucosa may be trimmed from the lateral edges of the epiglottis, the aryepiglottic folds, and the arytenoids and corniculate cartilages (epiglottoplasty). • Unilateral surgery can be performed in selected patients. The risk of supraglottic stenosis may be less due to fewer demucosalized surfaces. The risk of postoperative aspiration also may be decreased. Postoperative Care • The patient is kept in a humidified atmosphere. • Systemic antibiotics are administered for 7 to 10 days. • Aggressive antireflux therapy helps to avoid healing difficulties. 604 Surgical Atlas of Pediatric Otolaryngology GLOTTIC WEB EXCISION Congenital webs are commonly located in the anterior one-half to two- thirds of the glottis. The lesion may be thick or thin and may extend into the subglottic space. Patients usually present with aphonia and demonstrate varying degrees of respiratory distress, depending on the amount of obstruction present. Webs occupying more than 50% of the glottis (Figure 27–4A) usually require treatment because of potential of airway compromise with a con- current upper respiratory tract infection. Thin webs may be lysed with a laser or microsurgical instruments, but thicker webs with subglottic exten- sion may require a tracheostomy. Indications • Glottic web occupying 50% or more of the glottic inlet • Glottic web causing respiratory distress or significant aphonia Anesthetic Considerations • General anesthesia is always required. • An intravenous line and a pulse oximeter are placed. • If possible a small-bore fire-retardant endotracheal tube is inserted and a short-acting paralytic agent is given to stop vocal cord activity. • Dexamethasone 1.5 mg/kg up to 20 mg is given in a single intravenous dose. • If a tracheostomy is present, a fire-retardant tube should be inserted. Preparation • The patient is positioned with the shoulders elevated and the neck hyperextended. • The eyes and face are protected if the laser is used. • Antireflux therapy is begun prior to surgery. Procedure • A microsurgical technique with or without the laser is employed. • Microscissors or a laser is used to divide the web along the free edge of one vocal cord (Figure 27–4 B). • Thin webs are easily lysed. • Thick webs with subglottic extension require stenting with a keel or endotracheal tube to keep the opposing raw surfaces separated. ♦ A keel (Boston Medical Products, Westborough, MA) is placed endo- scopically (Figure 27–4 C), but a tracheostomy is required to maintain the airway. ♦ Alternatively the patient is intubated nasally, and the tube is left in place to stent the glottis for several days after surgery. Postoperative Care • If a keel or endotracheal tube has been used, prophylactic antibiotics are given until the foreign object is removed. 606 Surgical Atlas of Pediatric Otolaryngology POSTERIOR GLOTTIC STENOSIS REPAIR The severity of posterior glottic stenosis varies from a thin web to a thick scar band. Management depends on the extent of the stenosis present. Thin webs may be divided with the CO 2 laser (described below), but severe scar- ring and arytenoid fixation require division of the scar and the posterior cricoid with cartilage augmentation (not described). Indication • Mild to moderate stenosis of the posterior glottis (Figure 27–5A) Anesthesia Considerations • General anesthesia is always required. • An intravenous line and a pulse oximeter are placed. • If possible a small-bore fire-retardant endotracheal tube is inserted and a short-acting paralytic agent is given to stop vocal cord activity. • Dexamethasone 1.5 mg/kg up to 20 mg is given in a single intravenous dose. • If a tracheostomy is present, a fire-retardant tube should be inserted. Preparation • The patient is positioned with the shoulders elevated and the neck hyperextended. • The eyes and face are protected if the laser is used. Procedure • Suspension microlaryngoscopy is employed with the CO 2 or KTP laser. • An inferiorly based posterior mucosal flap is created by carefully elevat- ing the laryngeal mucosa (see Figure 27–5 A). • Scar tissue is ablated, and the mucosal flap is replaced (Figure 27–5 B). Postoperative Care • Humidification is critical. • Antireflux therapy helps to avoid healing difficulties. • Avoidance of an endotracheal tube, if possible, helps to ensure flap survival. 608 Surgical Atlas of Pediatric Otolaryngology LARYNGEAL SEPARATION Indications • Life-threatening aspiration in patients with impaired laryngeal or pha- ryngeal function • A potential for reversal of the procedure exists if function improves. Anesthetic Considerations • General anesthesia is delivered via an endotracheal tube placed orally or through an existing tracheostomy site. • After the trachea is divided, flexible endotracheal RAE tube may be used to ventilate through the distal trachea. Preparation • The patient is positioned with the shoulders elevated and the neck hyperextended. • Care must be taken to palpate and mark the landmarks, including the thyroid cartilage, cricoid cartilage, and sternal notch. • A 0.5% lidocaine solution with 1:200,000 epinephrine is injected into the incision area for hemostasis. Procedure • A horizontal incision is made halfway between the cricoid and the suprasternal notch in the anterior neck. If a tracheostomy already exists, the incision is placed superior to the stoma. The stoma is excised sepa- rately from the trachea. • Superior and inferior subplatysmal flaps are created, and the strap mus- cles are separated and retracted in the midline (Figure 27–6A). • The trachea is exposed anteriorly, and the recurrent laryngeal nerves are identified and protected. • The trachea is transected at the third to fourth tracheal ring by beveling the incision superiorly (Figure 27–6 B). If a tracheostomy already exists, the incision starts at its inferior aspect. [...]... CO2 laser is used on low-power setting (3 to 6 watts of power, 0.01to 0.05-second pulse duration, and 25 0- m spot size) to cut across the base of the cyst • The CO2 laser is very effective for this type of excision because it provides a bloodless field for dissection (Figure 28 5C) Postoperative Care • See General Principles of Postoperative Care 6 48 Surgical Atlas of Pediatric Otolaryngology INTRACORDAL... left hand as most surgeons are right-hand- 640 Surgical Atlas of Pediatric Otolaryngology • • • • • ed and most of the endoscopic instruments are designed for right-hand application Some of the specialty laryngoscopes are specifically designed so the Venturi ventilation needle fits along the left side of the laryngoscope This unilateral design minimizes the width of the distal tip The scrub nurse is... some of the smaller flexible pediatric bronchoscopes, but limitations include the lack of concurrent ventilation and the caution that the fiber must extend far enough from the bronchoscope to prevent reflected energy from melting the tip of the bronchoscope NEODYMIUM-YTTRIUM-ALUMINUM-GARNET LASER The neodymium-yttrium-aluminum-garnet (Nd:YAG) laser operates at a wavelength of 1064 nm in the near-infrared... The major portion of the cyst wall is resected with the CO2 laser, attempting to remove greater than 50% • Once the top of the cyst has been resected, the CO2 laser may be used on slightly higher powers (8 to12 watts) in a defocused mode to ablate the lining of the cyst (Figure 28 4C) Postoperative Care • See General Principles of Postoperative Care 646 Surgical Atlas of Pediatric Otolaryngology VENTRICULAR... Laryngol 1976 ;85 :437–9 Zalzal GH Use of stents in laryngotracheal reconstruction in children: indications, technical considerations and complications Laryngoscope 1 988 ; 98: 849–54 Zalzal GH, Anon JB, Cotton RT Epiglottoplasty for the treatment of laryngomalacia Ann Otol Rhinol Laryngol 1 987 ;96:72–6 C H A P T E R 28 L ARYNGOTRACHEAL L ASER S URGERY Jay A Werkhaven, MD The use of lasers for pediatric laryngotracheal... months to assess for airway patency 632 Surgical Atlas of Pediatric Otolaryngology Stern Y, Gerber ME, Walner DL, Cotton RT Partial cricotracheal resection with primary anastomosis in the pediatric age group Ann Otol Rhinol Laryngol 1997;106 :89 1–6 Thornell WC Intralaryngeal approach of arytenoidectomy in bilateral abductor vocal cord paralysis Arch Otolaryngol 19 48; 47:505–12 Woodman DG, Pennington CL... The soft tissue is separated, and the hyoid, cricoid, trachea, and lower border of the thyroid cartilage are identified • The suprahyoid musculature is dissected off the hyoid between the lesser and greater cornua • An incision is made through the cricoid cartilage (and mucosa), the first two tracheal rings, and the lower one-third of the thyroid cartilage (Figure 27–7C) 614 Surgical Atlas of Pediatric. .. edema after the impact of the laser Occasionally, epinephrine on a neurosurgical pledget may be applied topically to control any excessive bleeding This technique is generally 642 Surgical Atlas of Pediatric Otolaryngology EPIGLOTTIC CYSTS Indications • Epiglottic cysts may be found along the laryngeal surface of the epiglottis or occasionally along the aryepiglottic fold (Figure 28 3A) The cysts vary... removed with external perichondrium left attached (Figure 27–8A) The interior (posterior) perichondrium is left in situ • The chest wound is closed with a 4-0 polyglactin 910 suture • A horizontal neck incision is made (Figure 27–8B) If a tracheostomy is in place, the stomal area should be included in this incision 6 18 Surgical Atlas of Pediatric Otolaryngology • The cricoid cartilage, thyroid cartilage,... anastomosed with a 3-0 or 4-0 polyglactin 910 suture, depending on patient’s age (Figure 27–10C) When placing the posterior sutures, the endotracheal tube is displaced laterally to facilitate access 626 Surgical Atlas of Pediatric Otolaryngology • The wound is copiously irrigated and is closed in layers over a drain Drainage should be kept in place for a minimum of 5 days because of the potential for . the lower one-third of the thyroid cartilage (Fig- ure 27–7 C). 614 Surgical Atlas of Pediatric Otolaryngology • Stay sutures are placed on both sides of the cricoid for emergency pur- poses (see. healing difficulties. 604 Surgical Atlas of Pediatric Otolaryngology GLOTTIC WEB EXCISION Congenital webs are commonly located in the anterior one-half to two- thirds of the glottis. The lesion. difficulties. • Avoidance of an endotracheal tube, if possible, helps to ensure flap survival. 6 08 Surgical Atlas of Pediatric Otolaryngology LARYNGEAL SEPARATION Indications • Life-threatening aspiration