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

Drug-induced sleep endoscopy (DISE) has become an essential diagnostic tool in children with persistent obstructive sleep apnea (OSA) after adenotonsillectomy or those at high risk of persistent OSA. Utilizing either propofol or dexmedetomidine intravenous sedation to model sleep in the operating room, a flexible laryngoscope is used to look for obstruction at each level of the airway. Several pediatric-specific DISE scoring systems have been published in an effort to provide a thorough and reproducible airway assessment. Although they all assign severity grades, the scoring systems differ depending on which anatomic subsites they include. DISE-directed surgery encompasses a set of procedures which target areas of airway obstruction identified during sleep endoscopy.

Pediatric obstructive sleep apnea (OSA) is characterized by upper airway collapse that results in poor, restless sleep, and daytime sequelae such as sleepiness and behavior problems. The primary treatment for pediatric OSA has traditionally been adenotonsillectomy (AT). However, rates of persistent OSA following AT can be as high as 50%. With the increased utilization of drug-induced sleep endoscopy in both surgically-naïve pediatric OSA patients and patients with persistent OSA after AT, the palate has been identified as a common site of collapse contributing to airway obstruction. Palatal procedures, such as palatopharyngopexy and barbed suture pharyngoplasty, can be utilized to address collapse at the palate and may improve pediatric OSA treatment outcomes.

Although pediatric sleep disorders, including obstructive sleep apnea, are increasingly recognized, this was not the case until recent years. This review takes the reader on a journey from the recognition of obstructive sleep apnea as a disorder that commonly affects children through the subsequent evolution of pediatric sleep surgery.

Trans-sellar surgical approaches can be difficult and unpredictable. Tumors can distort the appearance of the posterior wall of the sphenoid sinus and a surgeon's concerns for avoiding the proximal vascular structures of the region may compromise access for the neurosurgical portion of the operation. Bone removal from the sellar dura is sometimes suboptimal. The meniscus sign is a convenient and reliable method for removal of the posterior wall of the sphenoid sinus during trans-sellar skull base surgery. It is a safe technique that maximizes bone removal and surgical access between the cavernous sinuses and internal carotid arteries. The senior author has employed the meniscus sign in trans-sellar surgery for over 15 years, noting that the technique has been free of surgical complications, reproducible amongst trainees, and reliable in safely providing maximum exposure for the intradural portion of the operation.

Functional endoscopic sinus surgery has become the preferred surgery for a variety of sinonasal pathologies. Lesions confined to the posterior ethmoid sinuses or to the posterior sphenoethmoidal complex are usually treated by the conventional "anterior to posterior" approach. This procedure requires removal of the anterior ethmoids, which might impair the anatomical and functional integrity of the ostiomeatal complex (OMC). Here we describe our experience with an effective and minimally invasive surgical approach to treat these posterior lesions while preserving the OMC. Medical records of patients who underwent trans-superior meatal posterior ethmoidectomy or posterior sphenoethmoidectomy with OMC preservation during functional endoscopic sinus surgery between 2016 and 2021 were analyzed. Twelve patients were included in the study. Their diagnosis included sinusitis (5 patients), fungus ball (3), inverted papilloma (2), allergic fungal sinusitis (1) and mucocele (1). No intraoperative or postoperative complications occurred, and all patients recovered rapidly. Lesions confined to the posterior ethmoids or posterior sphenoethmoidal complex can be treated with trans-superior meatal posterior ethmoidectomy or posterior sphenoethmoidectomy.

Pediatric obstructive sleep apnea is most commonly caused by adenotonsillar hypertrophy, for which adenotonsillectomy remains one of the mainstays of treatment. For patients with persistent obstructive sleep apnea following adenotonsillectomy, or for patients in whom the adenoid and tonsils are not contributing to airway obstruction, individualized treatment is centered around identifying the site of obstruction. Obstruction can occur anywhere along the upper airway and is often multilevel. These sites can include the nasal cavity, nasopharynx, velum, oropharynx, tongue base, and/or supraglottis. Knowledge of this anatomy is essential.

Objective

This historical review aims to discuss not only the surgical significance of eponyms commonly encountered during thyroid operations but also about the people behind them who have lent their names to anatomical structures and surgical landmarks important for completing a safe and effective thyroidectomy.

Finding

Kocher describes anomalous venous anatomy, proper patient positioning and incision placement. Reeve and Joll define anatomical spaces relevant to the dissection of the upper pole of the thyroid that assist with identification and preservation of the nerve of Galli-Curci. The Glands of Owen must also be carefully identified and preserved during thyroidectomy. Identification and protection of the recurrent laryngeal nerve, is guided by anatomical landmarks described by Berry and Zuckerkandl, as well as triangles named after Lore, Beahrs, and Simon.

Conclusion

The elegant simplicity and efficiency in describing complex surgical anatomy and surgical concepts continue to make utilization of eponyms useful during thyroid operations.

The facelift incisional approach to neck dissection offers several advantages including improved cosmesis, increased patient satisfaction, and decreased morbidity. This approach has been previously described using robotic or endoscopic instrumentation, but the clinical outcomes of this approach using standard instrumentation have not been reported. The objective of this study was to determine if the facelift incisional approach to neck dissection can be performed without endoscopic or robotic assistance and achieve improved oncologic and cosmetic outcomes. This was a retrospective cohort study over 4 years at a national comprehensive cancer center. A total of 104 subjects received 113 oncologic neck dissections, of which 35 were performed using a facelift approach. Primary outcomes included rate of negative margins, recurrence, incidence of nerve weakness, and incidence of lymphedema. The mean age of the cohort was 60.1 ± 12.7 years and 72.6% were male. Mean follow up was 23.1 ± 19.1 months (P = 0.21). The 104 subjects (92.9%) had negative margins on final pathology, with no difference between approaches (88.2% vs 94.9% respectively, P = 0.24). Thirty-four subjects (97.1%) in the facelift group had no evidence of disease at study conclusion. There was no difference in marginal mandibular nerve weakness (P = 0.10) nor shoulder weakness (P = 0.59) between groups. There was no difference between postoperative lymphedema (38.2% vs 29.2% for the facelift vs standard incision groups, P = 0.35). A facelift approach to neck dissection using standard instrumentation without robotic or endoscopic assistance achieves acceptable clinical and oncologic outcomes compared to the standard incisional approach with an additional benefit of improved cosmesis.

A myriad of techniques have been described to correct brow ptosis via a blepharoplasty incision, mid-forehead incision, endoscopic approach, pretrichial incision, coronal approach or direct brow lift. There are varying risks and results for each technique including paresthesia, facial nerve injury, alopecia, and unsightly scars. In this article we describe the mini-direct browlift technique that utilizes bone anchored sutures and allows for good cosmesis and control of brow height with minimal morbidity. A myriad of techniques have been described to correct brow ptosis via a blepharoplasty incision, mid-forehead incision, endoscopic approach, pretrichial incision, coronal approach or direct brow lift. There are varying risks and results for each technique including paresthesia, facial nerve injury, alopecia, and unsightly scars. In this article we describe the mini-direct browlift technique that utilizes bone anchored sutures and allows for good cosmesis and control of brow height with minimal morbidity.

The infratemporal fossa is a complex space that both contains and is closely associated with vital neurovascular structures. As such, surgical access of the infratemporal fossa presents a definitive challenge requiring complete understanding of ventral skull base anatomy and expertise with both open craniofacial and endoscopic techniques. Anterior and lateral approaches to the infratemporal fossa vary greatly and may be individualized to each case in order to optimize visualization and instrumentation. Significant progress has been made in the development of surgical techniques for treatment of tumors involving the infratemporal fossa, including expanded endonasal approaches. Endoscopic, minimally invasive, and open approaches each provide distinct advantages and disadvantages. In the present article, we will review indications and limitations of the varied methodology for approaching the infratemporal fossa.