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

Parotidectomy and surgical access to the parapharyngeal space are common procedures for the head and neck surgeon, and an understanding of the complex anatomic relationships in this region is critical for safe navigation and management of both benign and malignant processes here. With the use of 3-dimension stereoscopic imaging techniques, parotidectomy and parapharyngeal space dissection are herein reviewed with an emphasis on important anatomic structures and their relationships.

Tracheotomy is a very common surgical procedure in which an incision is made in the anterior tracheal wall and skin to create an airway. The indications for this procedure include prolonged endotracheal intubation, upper airway obstruction from any cause, improved pulmonary toilet, and in the setting of certain otolaryngologic procedures to facilitate access to the oral cavity, pharynx, and larynx, and may in some cases be required urgently or emergently. The background and basic technique are described herein, with a focus on anatomic features encountered with the assistance of 3-dimensional stereoscopic imaging.

Vocal fold paralysis is a challenging disorder to manage in the pediatric population. While many cases may be managed expectantly, patients with problematic dysphonia, aspiration, or dyspnea may require surgical intervention. Tracheostomy was performed in nearly all patients with bilateral vocal fold paralysis and some patients with unilateral vocal fold paralysis in the past. However, with modern endoscopic and open procedures for vocal fold paralysis, current tracheostomy rates have decreased to 4%-69%. Endoscopic interventions are particularly advantageous in children given high rates of eventual recovery. The perioperative considerations, indications, and techniques for various endoscopic interventions for unilateral and bilateral vocal fold paralysis will be discussed here.

Provided in this review is an overview of pediatric obstructive airway pathologies. This includes many common congenital and acquired entities. Beginning at the front of the nose and extending into the trachea, the presenting signs and symptoms, diagnosis, and medical and surgical management are reviewed.

Laryngeal clefts are congenital anomalies characterized by an abnormal connection between the upper airway and esophagus due to incomplete fusion of the tracheaesophageal septum. These clefts can be mild, with just a deficiency of soft tissue in the interarytenoid space (Type 1) or can extend down into the cartilage of the cricoid (Type 2) as well as into the trachea (Type 3, 4). Presentation of laryngeal clefts is most often characterized by aspiration of thin liquids, recurrent respiratory infections, cough, respiratory distress, and cyanotic episodes. The treatment of Type I laryngeal clefts can be conservative, such as with thickening of feeds and medical management or procedural, such as with injection laryngoplasty or endoscopic surgical repair. Endoscopic surgical repair has been utilized to repair these clefts for several decades, and more recently is being utilized to repair deeper clefts that were previously repaired via an open approach. In this article we will describe the background and indications for repair of laryngeal clefts, and the details of the endoscopic suturing technique.

Endoscopic anterior cricoid split may be performed as an adjunct to balloon dilation in select patients with subglottic stenosis. It offers the possibility for the treatment of more significant, mature subglottic stenosis, as well as congenital subglottic stenosis with cartilaginous anomaly endoscopically whereas previously these patients could only successfully be treated with an open procedure. Here the indications, preoperative workup, operative technique and post-operative considerations are outlined. In certain situations, an endoscopic anterior-posterior cricoid split or open approach may be better suited.

Vallecular cysts are uncommon entities that present with common upper airway symptoms. A challenging but important diagnosis in young infants, vallecular cysts present with stridor, difficulty feeding or sleep apnea. Awake fiberoptic laryngoscopy is most integral to diagnosis and planning for definitive surgical intervention. Suspension microdirect laryngoscopy with marsupialization offers a straightforward and successful means of treatment for most patients. Marsupialization may be undertaken by various instruments including cold steel, laser, coblation, or monopolar cautery.

Laryngomalacia is usually a benign condition that improves on its own in most cases. A small percentage of patients develop severe symptoms and require surgical intervention with supraglottoplasty either hot (laser) or cold to improve the symptoms. Severe laryngomalacia may result in failure to thrive, sleep apnea, stridor, respiratory distress, and in specific cases may require surgical intervention.

Injection laryngoplasty is a procedure that provides support to a vocal fold that lacks either the bulk or the mobility it once had. Two indications are vocal fold immobility from vocal fold paralysis, scarring, or atrophy among other causes or glottic insufficiency resulting from vocal atrophy, sulcus vocalis, or vocal fold neoplasm. A comprehensive pre-operative work up includes evaluation of the vocal folds by indirect flexible laryngoscopy, stroboscopy, direct operative laryngoscopy, and/or ultrasound. Measuring impacts of vocal pathology that may be suited to injection laryngoplasty is done through pediatric reported outcome measures of voice and evaluation of swallow. During the operation the surgeon can choose from different injection materials depending on the need of the procedure. In children, the most typical method of delivery in children is under direct or telescopic and/or microscopic visualization during a procedure under anesthesia. The surgeon must take caution for proper placement of material in relation to the true vocal fold to reduce risks of voice dysfunction, airway obstruction, airway hemorrhage, or injury to the adjacent laryngeal structures. Injection laryngoplasty is the preferred method of surgical management of vocal fold immobility and has proven safe in children of all ages.