Operative Techniques in Otolaryngology - Head and Neck Surgery最新文献

Posterior glottic stenosis (PGS) is usually caused by long-term intubation and can be very challenging to manage in particular if both cricoarytenoid joints (CAJ) are involved. Most surgical approaches are limited to enlarging the airway by resecting portions of the posterior commissure and glottis compromising on both, voice and respiratory function. In the following, we describe an endoscopic technique that can restore arytenoid mobility in a selected group of patients suffering from high-grade PGS. Patients must have intact CAJ facets and a normal joint space that is not replaced by fibrosis or bone to benefit from this procedure. When performing this procedure, the fibrotic tissue between the arytenoids and around both CAJ is ablated and both arytenoids are mobilized by performing CAJ capsulotomies to restore arytenoid mobility. A mucosal rotational advancement flap, raised from the postcricoid and medial pyriform sinus, is used to reconstruct the interarytenoid space and the posterior commissure.

Subglottic stenosis is a narrowing of the airway that has significant impact on patient breathing and quality of life. The majority of cases result from intubation, prior tracheostomy, or trauma but some instances still have no known etiology. Knowledge of the disease has increased substantially over recent decades with advances in basic science research and collaborative clinical studies. Treatment approaches typically range from endoscopic to open surgery, including innovative strategies to prevent restenosis. This article presents a review of subglottic stenosis, focused on understanding pathophysiology and treatment paradigms.

Subglottic stenosis (SGS) is a narrowing of the airway below the vocal cords that can lead to respiratory distress and in severe cases, airway obstruction. Endoscopic surgical management of SGS has been established as a safe and effective treatment option. The aim of this manuscript is to provide an overview of the current state of the art in endoscopic surgical management of SGS. Endoscopic management of SGS typically utilizes laser (CO₂ or Nd:YAG) or cold knife incision or wedge excision in combination with rigid or balloon dilation. Topical antifibrotic therapies and steroid injections are frequently employed intraoperatively. The choice of technique depends on the location and severity of the stenosis, and a multimodal approach is common. For patients with extensive stenosis or who have failed previous endoscopic treatments, open surgery may be necessary. Preoperative assessment of the airway is critical for identifying the extent of the stenosis and ensuring appropriate treatment planning. Postoperative care includes close monitoring for complications such as bleeding, infection, and airway edema and adjuvant medical therapies such as proton pump inhibitors, inhaled corticosteroids, and antibiotics are used frequently. In conclusion, endoscopic surgical management of SGS has become an important treatment option for patients with subglottic stenosis, and new techniques such as endoscopic resection with adjuvant medical therapy (ERMT) have been employed effectively in some patients. With proper patient selection, technique selection, and postoperative care, this approach can provide effective relief of symptoms and improve patient outcomes.

Serial Intralesional Steroid Injection (SILSI) has been gaining popularity among patients and physicians as a first-line treatment for idiopathic subglottic stenosis. Patients are followed by in-office and at-home spirometry to assess the peak inspiratory flow (PIF), peak expiratory flow (PEF) and the PEF% values, along with quality-of-life instruments such as the RAND36, EQ5D and the new subglottic stenosis-specific, iSGS6. The initial procedure can be performed in the operating room using balloons and cold instruments to remove the subglottic scarring with injection of triamcinolone acetate 40 mg/cc into the subglottis. Subsequent injections are performed in the awake-office setting at 3-week intervals until reaching a total of 6 injections (1 at surgery + 5 in-office). This single-surgeon experience with SILSI at Mass Eye and Ear now spans 13+ years, 95 patients and over 1,000 injections. A total of 58% (55/95) of patients have only required one SILSI Round (4 to 6 injections) while we have an overall success rate of 96% (91/95). A total of 95% of subjects (90/95) tolerated awake SILSI. The 52 patients with greater than 2 years of follow-up have an average follow-up of 68 months. As a group they started at a PEF% of 55% and ended their SILSI at a PEF% of 93%. Their most recent PEF% is 92% reflecting the lasting efficacy SILSI offers. As a group they underwent an average of 7 steroid injections and 1.6 surgeries resulting in an average of 36 months between interventions. A total of 29% of patients (15/52) in the Long-Term group have not had recurrences in the 53 months they have been followed. They have a group PEF% of 94% highlighting the durable SILSI effects allowing them to breath without restriction. SILSI is a safe and reliable method to treat airway stenosis that is rooted in many years of clinical success. These patients have excellent quality of life and can maintain a high level of breathing for much longer than those treated with balloon dilation (36 months vs. 12 months).

Stenosis of the glottis, subglottis, and cervical trachea are challenging entities plagued by frequent recurrences of stenosis regardless of the site involved. Since the earliest airway surgeries, there have been attempts to create various devices to keep the reconstructed airway open. In the modern era, these are most commonly silicone stents, T tubes, and keels. Additional modifications of these procedures, including the new interarytenoid spring, and novel methods, like the use of a sutured silastic sheet to stage posterior glottic stenosis repair, have also been published. The success rates of these devices vary widely and study populations are small, but these devices play an important role in maintaining patency in both transcervical and endoscopic approaches to airway reconstruction.

Caring for patients who identify as transgender and gender diverse (TGD) requires a ground level understanding of proper patient communication, a framework for decision-making surrounding medical and surgical interventions, and an awareness of obstacles surrounding healthcare. The objective of this chapter is to highlight appropriate terminology and definitions, discuss the current standards of care for transgender health, raise awareness of the barriers to healthcare access facing the TGD population, and discuss basic facial anatomy and sexual dimorphisms. Gender incongruence occurs when birth-assigned sex and gender identity differ for an individual, and gender dysphoria is the distress felt in this state. Persons who experience gender dysphoria may seek gender-affirming hormone therapy or surgery. Access to care is not straightforward, and the current standards of care aim to provide a guideline for administration of hormones and surgery. In order to offer the highest level of care, surgeons should have a fundamental understanding of issues surrounding the TGD community combined with a robust comprehension of facial features characterizing gender.

Hair transplantation can play a complementary role in the spectrum of gender affirming procedures. Amongst the hair restoration procedures sought by transgender patients, female hairline feminization, beard and eyebrow transplantation, surgical hairline lowering, and body hair transplantation are the most popular. Hairline lowering, hairline feminization, and eyebrow and pubic hair transplantation can play roles for the male to female (MTF) transition patient while beard and body hair transplantation can play integral roles for the female to male (FTM) transitioning patient to create a more feminine or masculine appearance and to help conceal prior surgical scarring. This chapter will delineate the role hair restoration plays for the transitioning patient. The various surgical approaches and treatment paradigms will be detailed for the hair restoration surgeon.

Gender affirming rhinoplasty is integral to gender-affirming facial surgery, and while sharing some characteristics with cisgender rhinoplasty, there are particular considerations, goals, and techniques of which to be aware. This publication will share how these authors approach feminizing rhinoplasty along with standard operative techniques for select common feminizing interventions by subsite. Techniques will proceed from cephalic to caudal and are not exhaustive of the many possible surgical interventions that are useful in gender-affirming rhinoplasty. Ultimate choice of approach and technique are chosen to meet the individual goals of each patient.

Gender-affirming facial surgery (GFS) describes approaches and strategies to surgically feminize or masculinize the face. Although techniques for performing facial feminization surgery are widely described, surgical masculinization techniques are underreported. While hormone treatments typically accomplish adequate masculinization in most cases, nonsurgical therapy is not universally effective. Surgical masculinization may be undertaken after lack of efficacy of nonsurgical therapy. With a deep understanding of the volumetric differences of the male facial skeleton, facial masculinization surgery essentially follows an augmentative paradigm for the upper, middle, and lower thirds of the face. Herein, we describe operative techniques used for facial masculinization.