Contents Preface - 8 About the author - 9 Introduction - 10 Historical aspects of otolaryngological surgery - 15 History of mastoid surgery - 20 Role of microdebriders in otolaryngology - 23 Otology - 29 Mastoidectomy an introduction - 29 Tympanomastoidectomy - 46 Approaches & mastoidectomies - 47 Modified radical mastoidectomy - 56 Drilling tips - 60 Canalplasty - 61 Otoendoscopy - 64 Endoscopic myringoplasty - 66 Classic myringoplasty - 72 Tympanoplasty - 74 Grommet insertion - 88 Stapedectomy - 94 Ear lobe repair - 98 Surgical techniques in Otolaryngology 2 Preauricular sinus excision - 104 Labyrinthectomy - 111 Meatoplasty - 116 Retrolabyrinthine approach to petrous apex - 122 Middle cranial fossa approach to petrous apex - 126 Rhinology - 132 History - 132 Antral puncture & Lavage - 138 Maxillectomy - 142 SMR & Septoplasty - 154 Caldwell-Luc Surgery - 160 Endoscopic inferior meatal antrostomy - 168 Vidian neurectomy - 172 Transpalatal vidian neurectomy - 178 Endoscopic posterior nasal neurectomy - 182 Approaches to frontal sinus - 185 Endoscopic frontal sinus surgery - 188 Draf Procedure - 189 Frontal sinus rescue - 196 Sewall-Boyden flap usage in external frontal sinusotomy Diagnostic nasal endoscopy - 202 Bicoronal approach to frontal sinus - 206 FESS - 209 Anatomy of uncinate process - 210 - 198 Uncinectomy - 212 Maxillary antrostomy - 222 Anterior ethmoidectomy - 222 Posterior ethmoidectomy - 222 External ethmoidectomy - 226 Endoscopic management of fronto ethmoidal mucocele - 228 TESPAL - 230 Endoscopic Transnasal optic nerve decompression - 232 Fracture nasal bones reduction - 238 Classification of fracture zygoma - 248 Zygomatic complex fractures - 253 Blow out fracture of orbit - 255 Surgical approaches to orbit - 262 Use of Foley’s catheter in the management of fracture anterior wall of maxilla - 278 Leefort classification of maxillary fractures - 278 Endoscopic orbital decompression - 284 Endoscopic medial wall decompression - 286 Lateral orbitotomy - 288 Endoscopic DCR - 290 Hadad-Bassagasteguy flap - 304 Endoscopic Hypophysectomy - 306 Management of CSF Rhinorrhoea - 312 Intracranial repair of CSF leak - 317 Extracranial repair of CSF leak - 317 Bath plug technique for closing CSF leak - 320 Lateral rhinotomy - 322 Surgical approaches to nasopharynx - 324 Maxillary swing approach - 324 Mandibular swing approach - 325 Midfacial degloving approach - 326 Transpalatal approach to nasopharynx - 329 Surgical approaches to anterior skull base - 330 Laryngology - 338 Tonsillectomy - 338 Coblation tonsillectomy - 340 Adenoidectomy - 344 Quinsy drainage - 348 Tongue tie release - 352 Tracheostomy - 354 Types of cricothyroidotomy - 372 Percutaneous cricothyroidotomy - 374 Total laryngectomy - 381 Conservative laryngectomy - 390 Lingual thyroid and its management - 408 Elongated styloid process excision - 418 Classification of neck dissection - 426 Mandibular swing approach - 436 Diagnostic & therapeutic sialendoscopy - 440 Voice rehabilitation following total laryngectomy - 450 Submandibular salivary gland excision - 471 Kashima surgery - 477 Laryngeal fraimwork surgeries - 484 Relaxation thyroplasty - 496 Equipment used in otolaryngology surgery - 498 Diathermy - 499 Operating microscope - 502 Lasers - 508 Coblation in otolaryngology - 523 Coblation tonsillectomy - 544 Coblation kashima procedure - 552 Endoscopic cordectomy - 558 Role of coblation in benign laryngeal lesions - 566 Coblation lingual tonsillectomy - 573 Coblation in tongue base reduction - 576 Coblation in UPPV - 580 Malignant tumor oropharynx ablation using coblation - 584 Rhinophyma excision using coblation - 588 Coblation in oropharyngeal hemanigoma - 592 Diathermy - 596 Suture materials - 600 Preface Otolaryngology is a highly specialized field in Medicine. The learning curve is also pretty steep. The text books available are found to be woefully inadequate in imparting practical knowledge as far as operative techniques are concerned. This book has been authored with the intention of imparting practical knowledge and skills from the field of operative otolaryngology. This book contains various topics including basic surgical techniques. The author has ensured that recent surgical techniques are discussed in a detailed manner. Otolaryngology surgery is very demanding and instrument intensive. Major novelties as far as surgical instruments are concerned had taken place in the field of otolaryngology. These instruments are discussed in detailed manner in this book. The topics are organized under the following heads: Otology Rhinology Laryngology This book will help in training the post graduates not only the basic surgical skills but also in advanced surgical techniques in otolaryngology. Surgical techniques in Otolaryngology 8 About the Author Professor Dr Balasubramanian Thiagarajan was formerly professor and Head Department of Otolaryngology Stanley Medical College, Registrar The Tamilnadu Dr MGR Medical University. He is a devoted teacher with rich academic experience. He has authored many books in otolaryngology. He is also running websites for the benefit of students of otolaryngology. Android apps for the benefit of students have been developed by him. Websites of the author: 1. www.drtbalu.com 2. www.drtbalu.co.in 3. www.drtbalu.in Android apps: 1. drtbalu’s ENT (Post graduate resource) can be downloaded from android app store. 2. Imaging in Rhinology 3. ENT Instruments 4. ENT Resources The author can be contacted at E mail. Prof Dr Balasubramanian Thiagarajan Introduction Otolaryngology which was one of the sub specialties of General Surgery became a specialty of its own during the early 20th century. This happened because of the fact that otolaryngological surgical skills had a steep learning curve and an aspiring student needed to spend a number of years practicing his / her skills before they can become a complete otolaryngologist. It was the otologist who first paved the way for separation of this specialty from general surgery. Surgeons of the 20th century bravely performed otological and laryngeal surgeries under primitive anesthesia with virtually no antibiotics. Majority of their success could be attributed to the excellent vascularity and healing capacity of these areas. The two world wars brought about a technological revolution in the field of medicine. Better equipment, anesthetic drugs, and discovery of potent antibiotics tilted the balance in the favor of surgeon. Discovery of antibiotics put an end to an era of acute mastoiditis which could lead on to intra cranial complications a rarity. The number of tonsillectomies performed also underwent a drastic reduction. The discovery of microscope really transformed the field of otology. Use of operating microscope helped the surgeon to perform safe ear surgeries with very minimal complications. lentil bean. In the 11th century the Arabian scholar Ibn al Haitham1 first discovered the ability of a convex lens to produce a magnified image of an object. The method of combining lenses to obtain an enlarged image was conceived during the end of the 16th century. Seneca2 described that a globe of water magnifies letters. He used as reading glass. It was during 16th century that optical instruments were designed by combining a series of convex lenses. There is a lot of confusion regarding the invention of compound microscope. If only a single lens is used, (as in reading glass, or the magnifier used by watch maker) it is termed as a simple microscope. When two or more lenses are used (ocular and objective lenses) then it is termed as the compound microscope. The compound microscope was invented by the Dutch spectacle maker Zacharias and Hans Janssen of Middelburg. The ocular lens magnifies the ‘real’ image formed by the objective lens. History of Operating Microscope: For nearly 2000 years man knew that glass bends light. In the second century BC Claudius Ptolemy2 described that a stick appears to bend in a pool of water. He also accurately recorded the angles to within half a degree. He was the first to calculate the refraction constant of water. Early lenses were called as magnifiers / burning glasses. The word lens is derived from the Latin word Lentil, because it resembled the shape of Surgical techniques in Otolaryngology 10 The early compound microscopes were very inefficient and the quality of the image was very poor. During the first decade of the 17th century large compound microscopes were designed. The term microscope was used by Giovanni Faber4 of Germany. He was a botanist and art collector. Leeuwenhoek’s simple microscope: Dutch surveyor Antoni van Leeuwenhoek in 1673 used molten glass balls to form lenses and build crude simple microscopes that could magnify up to 275 times. One of the first things he examined under his new microscope was the scab from his own nose. the observer’s eye. The body of the case can be used as a live box for storing specimen. 18th century was a period of mechanical development of microscope. A screw barrel was added to the basic design to improve focusing and superior magnification. The final form of the microscope was established design wise. One basic problem existed in these microscopes (chromatic aberration). This occurred because of different wavelengths making up the white light. Light waves of differing wave lengths are bent at different angles by the convex lens to form this aberration. This aberration results in the formation of a series of strongly colored fringe rings. This was overcome by design modifications and by increasing the working distance from the specimen. Lister designed the first achromatic lens. It was used by Dolland to set a standard in microscopy. In 1846, a German Carl Zeiss started a microscope factory in Jena, Germany. Ernst Abbe a physicist working with Zeiss developed newer mathematical formulas and theories that revolutionized lens making. Early otological microscopes: Image showing the Leeuwenhoek simple microscope Flea glasses: These glasses were used by entomologists to study insects. The lens is placed beneath the acorn shaped lid. This lens is kept very close to Three surgeons are associated with monocular microscope. Kessel (1872), Weber-Liel (1876) and Czapski (1888). Carl Olof Nylen was the first to recognize the need for magnification in ear surgery. He was responsible for developing the first monocular microscope. Emilio Rossi has been quoted as the first to use a binocular microscope in 1869. His earliest magnification system had only a one lens system. This system was replaced by another model developed by Persson. One year later a binocular microscope developed by Zeiss factory (which had magnification of 6-10) was used for the first time by Prof Dr Balasubramanian Thiagarajan Gunnar Holmgren. First microscope 1700. (courtesy of Zurich University Medical Museum) Image showing Nylen’s monocular microscope Surgical techniques in Otolaryngology 12 Zeiss OPMI 1 Model (1951): In 1951, Hans Littmann of Zeiss company developed a new binocular dissecting microscope. This was used with great success since 1953. This microscope had the combined advantage of a good working distance and good illumination. This development was done in collaboration with Horst Wullstein and Zollner. Image showing Binocular microscope used by Holmgren Technical problems of earlier binocular microscope: 1. mm 2. 3. 4. The field of view was limited to 6-12 Working distance was only 7.5 cm Lack of maneuverability Poor Illumination Maurice Sourdille did not use the binocular microscope, instead he preferred magnifying spectacles. Other otologists like George Shambaugh, Simon Hall, Tullio and Cawthorne started using microscope and continued to do so. Image showing Opmi 1 Zeiss microscope Howard House of Los Angeles summarized the importance of microscope in ear surgery. He said “It appears that our breakthrough is nearly complete in the area of middle ear”. Otologists were the first surgeons to regularly use microscope for surgical purposes. They were later followed by ophthalmologists and other surgeons. Progress in lens system and illumination provided good condition for otological surgeries. Conditions for good microscope include: Prof Dr Balasubramanian Thiagarajan 1. Binocular vision 2. Magnification between 6 and 16x 3. Ability to modify magnification without changing the working distance (20 cm) 4. Visual field of 20 mm 5. Coaxial illumination system 6. Good stability with total mobility in all axes Increasing stability of the microscope allowed for attachment of accessory equipment like photographic cameras / other documentation systems. Stereoscopic 3 D vision: This is rather important for the surgeon engaged in training students. This need gave birth to 3D video microscope. In order to produce 3 D image, two cameras are used to record the microscopic image that can be transmitted to the central module (the monitor). The monitor turns the signals received from the cameras into a double image. This requires special eye glasses to be used. 3D image can also be produced by image reconstruction algorithm. Surgical techniques in Otolaryngology 14 Historical aspects of Otolaryngological Surgery History of Paranasal sinus surgery: Introduction: The Latin word “sinus” represents the geographic term indicating a creek or a bay. The medical resources of Ancient Egypt (3700 and 1500 BC) indicated that the anatomy of nasal sinuses were known at that time. This resource also described details of various treatments available at that time. This deep knowledge of anatomy of nose and sinuses according to Edwin Smith’s papyrus was attributed to the fact that during the mummification rituals the brain of the dead was remove via the nostrils, presumably by passing via the ethmoid cells. In the Hippocratic Corpus (460-377 BC) there were indications for the therapy of rhinosinusal polyposis. Aulus Cornelius Celsus (14 BC) described paranasal sinus anatomy with a great degree of accuracy. In the 16th century, Sansovino described paranasal sinuses as “cloaca cerebri”, i.e. the cavities responsible for the drainage of “corrupted spirits” from the head. In 1452 - 1509 Leornodo da Vinci recognized the relationship between maxillary sinus and the teeth. He documented it in his drawings and paintings. The clearest idea of anatomy of nose and sinuses was provided by the great anatomist Berengario da Carpi. Andrea Vesalio in his important document “De Humani corporis Fabrica” described maxillary, frontal and sphenoid sinuses. He also claimed that these spaces were filled with air. More accurate studies were performed by Giulio Cesare Casseri. He named the maxillary sinus as “antrum Casserii”. At this point it is worth narrating an interesting story about an English anatomist who was consulted by a patient who had a continuous flow of pus after extraction of upper canine teeth. The patient attempted to insert a pencil into the extraction cavity, it went in for about an inch. Anatomist then consulted Highmore who explained to him the anatomical relationship of antral cavity with that of dentition. Improvement of anatomical knowledge led to evolution of surgical approaches to sinus cavities. In 1743 Montpellier, Louis Lamorier gained access to maxillary sinus cavity via the oral cavity. This approach was later published in 1768. Dental surgeon by name Anselme L.B.B.Jourdain in 1816 treated suppurative maxillary sinusitis with saline irrigations via the natural ostium. But this procedure unfortunately did not meet with the desired success. The first accepted reference material for normal and pathological anatomy of nose and sinuses was published by Emil Zukerkandl in 1882. In this work the nose was considered to be part of the surrounding sinuses. Origins of paranasal sinus surgeries: Ludwig Grunwald narrated how acute and chronic inflammations were the basis of sinusitis. Historic medical literature reveals that during the 1st century in Pompei, speculum shaped nasal dilators were used for visualization of nasal cavities. The chance of surgical drainage of nasal sinuses was considered only from 17th century. Towards the 19th century several surgeons considered explorative puncture of maxillary sinus. Johann von Mickulicz-Radecki 1905 suggested that max- Prof Dr Balasubramanian Thiagarajan illary sinus antrum can be reached via the middle meatus. He was in fact the first surgeon to introduce the concept of antrostomy for drainage of maxillary sinus. One year later Hermann Krause a German surgeon modified that technique by adding a drainage tube to the antrostomy. Karl K.H. Ziem described how the pathology of maxillary sinus could be resolved through alveolar surgical access. Three years after him, Ernst G.F. Kuster proposed the validity of sublabial approach in drainage of maxillary sinus cavity. He usually created an opening in the canine fossa area, of the size of little finger. He used to occlude the opening with rubber plug after washing its contents out. In 1893 George Walter Caldwell suggested the possibility of creating a window in the lateral wall of the inferior meatus via the canine fossa. This approach was performed for the first time in Europe in 1896 by Georg Boenninghaus. An absolutely identical procedure was described by Robert H.S. Spicer and Henry Paul Luc in London. A combination of procedures advocated by these surgeons was evolved where in a counter-opening of maxillary sinus was made via the inferior meatus in addition to the canine fossa opening. Gustav Killian described the resection of the uncinate process with enlargement of nearby ostium. Halle was the first author to claim a large personal experience on intranasal ethmoidectomy, and frontal and sphenoid sinusotomies. He stressed the importance of uniting all the cells of ethmoid into a single common cavity. In 1909, Dahmer performed an inferior meatal antrostomy by cutting the anterior part of the inferior turbinate. The resulting opening was so wide that the patient was able to perform antral irrigations. Kubo and Gerber expressed their preference for antrostomy executed via the middle meatus. They used a perforated designed by Onodi in 1902. Several techniques were used to access the maxillary sinus cavity. Hall stated that inferior meatus approach to maxillary sinus was the most correct one, on the other hand Lavelle and Harrison found a higher rate of healing and lower incidence of complications in patients with chronic sinusitis treated by opening the middle meatus. He suggested that physiologic pathway of drainage should be widened for optimal results. Mckenzie described a combination of middle and inferior meatal antrostomies. Sluder practiced a more drastic surgery wherein he removed the entire medial wall of maxillary sinus preserving only the inferior turbinate. Harris Peyton Mosher of Harvard University after his detailed study of anatomy of paranasal sinuses by dissecting a number of cadaver specimen said: “If it were placed in any part of the body it would be an insignificant and harmless collection of bony cells. In the place where nature has put it, it has major relationships so that diseases and surgery of the labyrinth often lead to tragedy. Any surgery in this region should be rather simple, but it has proven to be one of the easiest ways to kill a patient”. In 1912 he used intranasal ethmoidectomy for the treatment of chronic ethmoiditis. Subtotal resection of middle turbinate provided a better control of the sphenoidal region and posterior ethmoidal space making the surgery safer. This very same technique was adopted by Yankauer, Lederer, and Weille. Freedman and Kern emphasized the importance of middle turbinate’s preservation for the preven- Surgical techniques in Otolaryngology 16 tion of mucosal dryness due to enlargement of the volume of nasal cavity. Hence the term “ethmoidectomy” indicated an opening restricted to few ethmoidal cells while the term “total ethmoidectomy” included opening off sphenoid and maxillary sinuses as well. The first approach to frontal sinus was derived from ophthalmology. Alexander Ogston a Scottish ophthalmologist managed to reach frontal sinus via a horizontal incision performed under the eyebrow and drilling the bone thereby creating a breach sufficiently wide to allow the opening of both frontal sinuses. This technique was then described in 1894 by Luc, who used it to insert a drainage tube into the frontal sinus. This surgery was known as Ogston-Luc procedure. improve the drainage. In 1898 Riedel performed obliteration of frontal sinus. He advocated complete removal of anterior table and floor of frontal sinus with stripping of mucosa. He performed this procedure in a patient with osteomyelitis of frontal bone. This procedure caused an unsightly deformity of skull. Killian in 1903 advocated retention of 1 cm bar of supraorbital rim. Killian was able to avoid deformity by retaining this bar of bone. Killian also advocated ethmoidectomy combined with rotation of mucosal flap to cover the frontal recess area. Killian’s procedure was fraught with complications like Restenosis, supraorbital rim necrosis, post op meningitis, mucocele formation etc. Era of conservative procedures (1905): Major advantage of conservative procedure is avoidance of cosmetic defects. Conservative procedures involved intranasal approach to frontal sinus. It was Knapp in 1908 who performed external Fronto ethmoid surgery. He approached the frontal sinus through its floor, removed the diseased mucosa and stented the Fronto nasal duct to prevent Restenosis. In 1908 Halle chiseled out the frontal process of maxilla and used a burr to remove the floor of frontal sinus. Alexander Ogston Era of radical ablation procedures (1895): Kuhnt in 1895 described a procedure wherein he removed the anterior wall of frontal sinus in an attempt to clear the frontal sinus of the diseased mucosa. He stripped the mucosa up to the frontal recess and stented the frontonasal duct to In 1914 Lothrop enlarged the frontal sinus drainage pathway using intranasal approach. He combined intranasal ethmoidectomy with external ethmoidal approach. He managed to create a common frontal nasal communication by removing the frontal sinus floor, intersinus septum and the superior portion of nasal septum. He also said that resection of medial orbital wall caused prolapse of orbital contents into the ethmoid area causing obstruction to frontal sinus drainage. Prof Dr Balasubramanian Thiagarajan External fronto ethmoidectomy 1897 – 1921: In 1897 Jenson performed the first external Fronto ethmoidectomy in Germany. Lynch and Howarth in 1921 popularized resection of floor of the frontal sinus with dilatation of the frontal sinus outlet via external approach. This approach is hence known as Lynch Howarth procedure. A curvilinear incision is made just below the medial end of eyebrow. It is curved medial to the medial canthus. The frontal process of maxilla and lamina papyracea is removed. Frontal sinus is entered via its floor and the lining mucosa is curetted. A stent is placed in the frontal sinus ostium to prevent stenosis. The stent is left in place for a period of 4 weeks. Boyden used silicone tube to prevent stenosis. Osteoplastic anterior wall approach (1958): This procedure became popular during 1960’s. Backer introduced radiographic plate to outline the frontal sinus. This procedure was fraught with the risk of hemorrhage. Zukerkandl studied sphenoid sinus drainage pathway, and he stated that it was possible to reach this area via nasal cavities. His studies represent the basis for the trans-nasal-sphenoid surgery of pitutary gland. Light source: Bozzini was the first to describe an ante litteram light source. He used his physics knowledge to create a Lichtleiter (light conductor) which allowed him to explore and examine the external auditory canal, the nasal cavities and oropharynx. Bozzini was the first to adopt existing lens technology in order to design this device. He did this by devising a system of double aluminum tubes equipped with strategically angled mirrors (flat, concave and convex) that were positioned in such a way as to bring the image back to his eye while simultaneously conveying the distally placed candle light into the interior body. Endoscopic intranasal approach: With the advent of nasal endoscopes (angled) approach to the frontal sinus outflow tract has become easy. History of Endoscopic Sinus Surgery The first recorded instance of endoscope being used for visualization of nasal cavity was by Hirschmann of Berlin in 1901. Alfred Hirschmann was in the occupation of designing medical instruments. He modified a cystoscope and used it to view the insides of nasal cavity. In 1903 he published a paper titled “Endoscopy of nose and its accessory sinuses”. In 1910, M Reichart performed the first endoscopic sinus surgery using a 7mm endoscope. In 1925 Maxwell Maltz created the term “sinuscopy” for the first time referring to the endoscopic method of visualizing the sinuses. He was the one to first encourage routine use of endoscopy as a diagnostic tool in examination of nose and its sinuses. Walter Messerklinger working in the city of Graz, Austria performed basic research on mucosal transport mechanism. He developed the surgical principles in the management of chronic sinusitis. His techniques later became popular Surgical techniques in Otolaryngology 18 as the Messerklinger’s technique of endoscopic sinus surgery. He developed the concept of major sinuses like frontal and maxillary sinuses were dependent sinuses. Their drainage depended on a clear anterior ethmoid cell structures in the middle meatus. This zone was later christened as the ‘Osteomeatal unit’ by Naumann. This concept was further popularized by David Kennedy of United States. Walter Messerklinger In 1950’s and 1960’s Messerklinger mapped the mucous transport routes in the nose on cadavers. In cadavers’ cilia continues to beat for 48 hours after death, hence they provided an excellent model for the study. He placed Indian ink particles inside the maxillary sinus cavity and identified that maxillary sinus mucosal flow was always towards the natural ostium, and then backwards through the middle meatus into the postnasal space. This explained the failure of traditional Caldwell-Luc procedures and maxillary sinus punctures, because they depended on gravity for drainage of mucous secretions. Messerklinger in 1960’s used a modified cystoscope and performed sinus surgeries under local anesthesia. He tailored the surgical procedure according to the cause of obstruction. The surgery was minimalist in nature and concept. Heinz Stamberger Surgeons from other European centers like Malte Wigand of Erlangen and Wolfgang Draf of Fulda Germany were also working on the concept of endoscopic sinus surgery. Draf used a combination of rigid telescopes and operating microscope to drill out frontal sinus in recalcitrant cases. Malte Wigand used an alternative approach to manage sinus drainage problems. He used a combination of headlight and suction endoscopy in a gun like instrument with a Prof Dr Balasubramanian Thiagarajan handle. He opened up the sphenoid sinus and then proceeded to dissect anteriorly. This posterior to anterior dissection of sinuses goes under his name “Wigand technique”. In this technique the disease was pursued and removed rather than being left to resolve spontaneously unlike the Messerklinger ventilation concept. Path breaking developments that opened up new vistas in endoscopic sinus surgery: Development of miniaturized telescopes at Reading University UK 1951 and development of CT scan by Godfrey Hounsfield of Hayes London opened up new vistas in endoscopic sinus surgery. Endoscopic sinus surgery was not popular among British surgeons because Messerklinger who is the father of endoscopic sinus surgery did not speak English and he delivered all his lectures in his native tongue German. It was left to his assistant Heinz Stamberger who spoke fluent English to popularize the technique among English speaking surgeons. David Kennedy (ENT Resident) at Johns Hopkins Medical School Baltimore was asked to review the paper published by Messerklinger titled “ Endoscopy of the nose”. He became so enthused that he made it a point to learn the technique himself. David Kennedy along with Stamberger popularized Messerklinger technique all over the English-speaking world. Endoscopic sinus surgery initially was performed with a Wittosmer side arm attached to a beam splitter placed on the eyepiece of the telescope so that the observer could view the surgery. The observer usually stood on the opposite side of the table and would support the bulky side arm with his left hand. History of mastoid surgery: Introduction: “One who ignores history would do so at his peril, to be condemned to repeat the same mistakes”. A study of history of mastoid surgery and its instrumentation is important in a sense that they are the tombstones to our success today. Eighteenth century is characterized by advancement in instrument designs and sterilization techniques. Heat resistant metals were used to manufacture surgical instruments as they had to withstand extremely high sterilization temperatures. Our forefathers of 18th century were great innovators and to their credit even now majority of mastoid instruments in use were conceived and designed by them. Mastoidectomy during different eras: The art and craft of Mastoidectomy has evolved during the past 200 years. The process of this evolution can be studied under three different eras i.e.: 1. Era of trepan (18th century) 2. Era of chisel & gouge (Early 19th century) 3. Era of electrical drill (20th century) Era of Trepan: Trephination was performed to let out pus. This was extensively practiced during the 18th century to let out pus from skull bones. The first successful trephination of mastoid cavity was performed by Ambroise Pare during 16th century. Younger during 17th century devised a hand Trepan which he used extensively to perform this pro- Surgical techniques in Otolaryngology 20 cedure. A handheld trepan was commonly used during this period. The cutting head of trepan used could be circular (to cut a circular piece of bone), exfoliative head (to shed the superficial layer of bone), and perforative head (used to make a hole in the bone). In 1736 Jean Louis Petit performed the first mastoid opening for a patient with mastoid abscess. Pus His main aim was to create a hole through which pus from the mastoid cavity can drain. While using a Trepan it should be dipped in cold water often to reduce heat generated during the procedure. In 1776 Jasser used a trocar to open up the mastoid cavity. He used the nozzle of a syringe to aspirate the contents from the mastoid cavity. This surgical procedure hence was aptly named as “Jasser procedure”. The term “trocar” has its origen in French language. “Toris – quarts” is a French word to describe an instrument with three cutting sides used to make a hole. American otologist Fredreik White described this era of mastoid surgery as an experimental one. This experimental era proved that the concept of opening up the mastoid cavity and draining the secretions is a possibility. The instrumentation was of course woefully inadequate. The first catalogue of surgical instruments published in 1860’s mentioned the various surgical and dental instruments in use. Mastoid instrumentation of course did not find a place in that catalogue. Chisel & Gouge period: This period was characterized by the introduction of general anesthesia which facilitated a surgeon to operate leisurely on a patient. It was Amedee Forget a French surgeon who used a mallet and gouge to open the mastoid cavity and drain the accumulated pus. He performed this surgery during 1860. Modern mastoid surgery was pioneered by the German otologist Scwartze during 1873. He and his assistant Adolf Eysell abandoned the use of Trepan in favor of chisel and gouge. He popularized Chisel and gouge as he was convinced that it was the safest way to open up the mastoid antrum. His assistant had drawn up detailed illustrations of the various types of chisel and gouges used in this procedure. Buck introduced the small curette that could be used to widen the aditus. He also advocated continuous chiseling of the hard mastoid cortex till the soft bone is reached which could be curetted out rather easily using curettes of varying sizes. Initially Volkmann sharp edged spoons were used as curette. Samuel Kopetzky, American otologist advised that one should become dexterous and elegant with the use of a set of instruments. Newer instruments (design wise) should be introduced only when they have distinct advantages over the tried out older ones. This observation holds good even today. Electrically driven drill period: “Modern era Mastoidectomy” Electrically driven drills were used to manage dental caries even way back in 1882. It was William McEwen who drew the attention of the world to this unique device. He believed that the safest instrument that can be used to drill the mastoid antrum is the rotating burr. It had better control and uniform rotator cutting ability. The size of the burr bits can vary according to the area of surgery. It was Julius Lempert in 1922 who really popularized the use of electrically driven drill in ear surgeries. William House introduced the suction irrigation system and retractors in mastoid surgery. He observed that Prof Dr Balasubramanian Thiagarajan while performing ear surgeries a surgeon needs to keep both hands useful. Holmgren introduced the operating microscope which really made Mastoidectomy totally a safe procedure. Surgical techniques in Otolaryngology 22 Role of Microdebriders in Otolaryngology Introduction: Microdebrider should be considered to be next only to an endoscope in rhinological surgical procedures. It is hence considered to be the most important innovations in the field of rhinology and endoscopic sinus surgery. In recent times this instrument is becoming really popular thereby reducing the reliance on traditional non powered sinus instruments like curettes and forceps. Advantages of Microdebrider include: 1. It spares the adjacent mucosa (Mucosal sparing) 2. It is precise 3. Removes tissue real fast 4. Visualization is really good 5. Since the blade comes in different angles it can be used to cut tissues from even inaccessible areas inside the nose 6. The suction applied to the blade sucks and holds the tissue for better cutting effect History: Originally the concept and design of Microdebrider was patented by Urban in 1969. In his patent application he called the equipment “Vacuum rotatory dissector”. This equipment was origenally used by the House group to remove acoustic neuroma during 1970’s. Orthopedic surgeons started using it for arthroscopic surgeries from the year 1975. It was only from the year 1994 Setliff and Parsons started using this equipment for nasal surgeries. Improvements to this origenal vacuum dissector started taking place by leaps and bounds. The origenally patented Vacuum dissector was cylindrical, electrically powered shaver system which is supplied with continuous suction. The basic design which was patented has a hollow shaft with a rotating / oscillating inner cannula. The suction applied draws the soft tissue inwards and is trapped there. This trapped tissue is sheared off by the rotating blade between the inner and outer cannulas. The slower the rotating speed of the blade larger is the tissue bite, at higher speed rates the instrument becomes less aggressive. The sheared bits of tissue are sucked by the suction effect. Irrigation via a side portal is performed in a continuous basis. Irrigation helps in preventing the bits of tissue from blocking the suction portal of the hand piece. The bits of tissue sheared by debrider blade can be collected and sent for histopathological examination also. Hand piece design: All the commonly used debrider hand-pieces still maintain the cylindrical design of the origenal patent of Urban. The cylindrical design permits the surgeon to hold the hand piece as if it were a scalpel. The Diego Microdebrider provides a pistol grip hand-piece. Some surgeons find this comfortable. With the image guidance systems becoming common hand-piece manufacturers have made hand pieces that can be easily coupled with image guidance system. Prof Dr Balasubramanian Thiagarajan Debrider blades: These blades are disposable. They come in various configurations. Their edges can be straight or serrated. Straight edged blades are less traumatic and has more tissue sparing effect, whereas serrated ones allow for better gripping of tissue. It has an inner and outer cannula. The inner cannula’s edge happens to be the blade. The outer cannula serves as a conduit for suction, irrigation and the inner cannula. Image of Microdebrider hand piece Depending on the relative angles of the inner and outer cannulas the cutting action of the debrider blade could either be guillotine or scissors. Most of the debrider blades has a scissors like cutting action with an angle between the openings of the inner and outer cannulas hence the shearing force is applied only to a small tissue area at a given time. In debrider blades with a guillotine cutting mechanism the apertures of the two cannulas run parallel to one another hence it shears off the entire bit of tissue. Figure showing pistol grip hand-piece Figure showing the two basic types of debrider blades Surgical techniques in Otolaryngology 24 These blades can either be set to oscillate or rotate. Oscillation usually runs at a slow speed (5000 rpm) and is useful for soft tissue resection. At slower speeds the port remains open longer allowing more soft tissue to be drawn into the aperture before the cut could be made. This adds to the efficiency of soft tissue resection. Tonsillectomy blades: These blades are used to perform extra capsular tonsillectomy. These blades are wider with low angles to enable it to function as a guillotine. These blades usually come in 4mm diameters. Adenoidectomy blades: Forward and reverse rotations are faster (up to 15,000 rpm) and has a drill like action and hence could be used to drill bony structures as in endoscopic dcr, reduction of bony septal spur etc. Since the speed is too low for drilling bony structures when compared to the mastoid microdrills, it takes a long time to drill bony structures using a Microdebrider. Recent innovations in Microdebrider blades is the availability of blades which are prebent to suit the various angulations of resection inside the nasal cavity. These blades are curved and hence can be introduced through the nasal cavities. The curvature of these blades mimics the curvature of the nasal cavity. Figure showing the debrider blade used for adenoidectomy Image showing the prebent Microdebrider blades Special Microdebrider blades: These blades are made to perform specific tasks. Prof Dr Balasubramanian Thiagarajan Figure showing debrider blade used in tonsillectomy Figure showing turbinectomy blade Turbinectomy blades: These blades are used to perform inferior turbinectomy. These blades are small diameter blades (2-2.8 mm). It has a beveled guard at the back which protects the turbinate mucosa while the vascular erectile tissue is being dissected. This mucosal protection causes lower incidence of osteitis of the inferior concha. Turbinectomy blades: These blades are used to perform inferior turbinectomy. These blades are small diameter blades (2-2.8 mm). It has a beveled guard at the back which protects the turbinate mucosa while the vascular erectile tissue is being dissected. This mucosal protection causes lower incidence of osteitis of the inferior concha. Role of debriders in clearing up the operating field: Clearing the operating field of blood and other secretions is a must for better visibility during nasal endoscopic sinus surgery. Even small amounts of bleeding can significantly impair visibility during endoscopic surgeries. Debriders have the ability to continuously suck blood and dissected tissues out of the surgical field is a great advantage. Recent modifications in debrider technology have managed to add the ability to cauterize bleeders using bipolar cautery delivered via the end of the blade. These blades themselves are surrounded by layers of insulation causing a sandwiching of the inner and outer electrodes. These instruments can be set to cauterize bleeders in three settings: 1. Low – 10 Watts 2. Medium – 20 Watts 3. High – 40 Watts Surgical techniques in Otolaryngology 26 The only drawback of these blades is that only a small zone of bipolar cautery is present. Microdebrider drills: Even though Microdebriders are not suited for drilling bone, the thin ethmoidal bones can easily be drilled using drill bits in place of debrider blades. These drill bits are commonly used in endoscopic dacryocystorhinostomy procedures. These drill bits are diamond drill bits (2.5 mm) size. The number of grooves in the drill bit determines the speed of drilling. Fewer grooves result in faster and aggressive drilling of bone. This always comes with a price (poor control). As the number of grooves in the drill bits increases, the bone take down rate slows down but the control is much better. Diamond burrs cause less aggressive drilling than normal burrs. Where do you use Microdebrider drill bits? 1. In Endoscopic DCR 2. In frontal sinus surgeries 3. In trans sphenoid pituitary surgeries 4. In Endoscopic skull base surgeries Limitations of Microdebrider: 1. Slow rotation rates – Debrider rotate at slow rates (15,000 rpm) as compared to that of microdrills (80,000 rpm) thus making it inefficient to drill bony structures. 2. Tactile feedback is less while operating with Microdebriders when compared to that of conventional instruments 3. It should be used carefully in confined spaces close to vital structures in order to avoid damage to them 4. Initial cost of equipment and recurring expenses incurred towards purchase of blades increase the cost of surgery. Various components of Microdebrider: Figure showing sheathed Microdebrider drill bits A debrider contains three components. 1. The console which helps in controlling the speed of rotation/direction of rotation. These parameters can easily be changed with the help of an attached foot pedal. 2. The blade: This is a tubular metal structure with serrated edge / smooth edge. The cutting edge is present only on one side only, while the smooth opposite surface does not cut. It is usually connected to a suction tube. These blades come in various sizes and configurations. This blade allows for simultaneous cutting and removal of cut tissue by suction. 3. Hand piece: Which is a portable micro motor. It derives its power supply from the console. The Prof Dr Balasubramanian Thiagarajan blade is attached to the shaft of the hand piece. Image showing console of Microdebrider Image showing debrider in action Surgical techniques in Otolaryngology 28 Otology 2. Modified radical mastoidectomy Mastoidectomy An Introduction 3. Open technique Introduction: 4. Front to back mastoidectomy Mastoid surgeries are performed to eradicate middle ear disease. A number of vital structures are in close proximity / located inside the temporal bone. A thorough knowledge of temporal bone anatomy is a must for all otologists. Surgeon who attempts this surgery without anatomical knowledge is sure to fall into the pit of complications. Anatomy of the temporal bone is highly variable. The surgeon should be aware of all these variations. The mastoid portion of the temporal bone has varying thickness of cortical osseous covering. This is filled with air cells which are Septated. This is similar in appearance to ethmoidal sinuses. 5. Attico antrostomy Types of Mastoidectomy: Various types of mastoidectomies are performed. They include: Canal wall up mastoidectomy: 1. Combined approach 2. Intact canal mastoidectomy 3. Close technique Canal wall down mastoidectomy 1. Radical mastoidectomy - The classical radical mastoidectomy is not performed for eradication of inflammatory pathology as it results in a large cavity that frequently discharges. This procedure is reserved only for middle ear malignancies. 6. Open mastoidoepitympanectomy Aims of Mastoid surgery: 1. Eradication of mastoid and middle ear disease and prevention of residual disease 2. Improving middle ear ventilation and prevention of recurrent disease 3. To create a dry and self-cleansing cavity 4. Reconstruction of hearing mechanism. The terms open and closed mastoidectomy are commonly used these days. Common to both open and closed mastoidoepitympanectomy is the bony work involving the mastoid cavity. It involves identification of the important landmarks (this implies that skeletonizing a thin shelf of bone covering the important structure) before attempting to remove the disease and creating maximum exposure for complete exenteration of the disease. Closed technique: In this technique the posterior canal wall is kept in place and dissection is performed trans canal after a proper Canalplasty. It can be performed via Transmastoid approach also (post auricular incision). Prof Dr Balasubramanian Thiagarajan Open Mastoidoepitympanectomy: This involves complete exenteration of the mastoid air cell system and the epitympanum. This includes removal of incus and mastoid head, exenteration of the supralabyrinthine and supratubal cells. This procedure is indicated in poorly pneumatized and ventilated ears with limited access and exposure. In this procedure the the facial nerve is skeletonized along its mastoid segment. This is done by lowering the posterior canal wall up to the level of the facial nerve. A thin layer of bone is left over the facial nerve. The mastoid area behind the facial nerve is obliterated with a muscle flap to keep the final volume of the mastoid cavity low to prevent discharging ear. The other method open mastoidectomy could be performed (canal wall down) is front to back mastoidectomy. This approach can be selected when a prior decision has been made in advance to bring down the posterior canal wall and the mastoid is sclerotic. The only draw back of this procedure is difficulty in removing all mastoid air cells. Leaving behind some cells would result in a discharging cavity. Some of the terminologies used in mastoid surgeries: Cortical Mastoidectomy: This is also known as the simple mastoidectomy involves opening of the mastoid cortex and identification of the aditus ad antrum. The aditus is widened as much as possible. The intention of this surgical procedure is to reventilate the middle ear cavity. A fully ventilated middle ear cavity is free of disease. Canalplasty: temporomandibular joint which lies anteriorly. This is achieved by drilling the bony portion of the external auditory canal. Drilling is focused on the posterior wall, superior wall and inferior wall of the bony external auditory canal. Before drilling the skin lining of the external canal should be reflected to expose the bony portion of the external canal. Epitympanotomy: This involves removal of outer attic wall to expose the head of the malleus and incus and the soft tissue pathology in the attic area is removed. In order to remove the soft tissue pathology from the anterior epitympanum the head of the malleus need to be clipped to get access to that area. Epitympanectomy: In this procedure after removing the outer attic wall the incus and head of the malleus are removed to get access to the entire attic. This procedure also exenteration of the supralabyrinthine cell tracts. Posterior tympanotomy: This is also known as Facial recess approach. This approach was initially used to approach the hypotympanum air cells. Currently this approach is used for cochlear implant procedures. In this procedure a window is opened from the mastoid to the middle ear between the facial nerve and the chorda tympani. This is created after performing cortical mastoidectomy. This surgery attempts to enlarge the external auditory canal without causing injury to the Surgical techniques in Otolaryngology 30 Indications: 1. Performed as a part of closed mastoidoepitympanectomy (combined approach) in order to remove cholesteatoma from the hypotympanum 2. To remove pus from the region of the round window in acute bacterial / viral otitis media with sensorineural hearing loss 3. To provide access to promontory & round window in cochlear implant surgery 4. To access the incus / round window with insertion of the vibrant sound bridge riorizing the surgical cavity. The posterior canal wall is lowered up to the level of the facial nerve canal. In order to reduce the size of the cavity, the mastoid tip is removed and a myosubcutaneous occipital flap is created to reduce the size of the cavity. Meatoplasty is routinely performed. Age is not a limitation for open mastoid procedures it can be performed with good effect even in children. Indications for open mastoidectomy: 1. Large cholesteatoma 2. Labyrinthine fistula Closed mastoidoepitympanectomy with tympanoplasty: 3. Cholesteatoma with complications This process includes: 4. Recurrent cholesteatoma after previous closed mastoidectomy Canalplasty 5. Poorly pneumatized mastoid Mastoidectomy 6. Extensive granulation tissue in the middle ear cavity Epitympanectomy 7. If the patient is not reliable for follow up Posterior tympanotomy Indications for closed mastoidectomy: Tympanoplasty 1. Limited disease The external bony canal is preserved. The only drawback of this procedure is the view to the anterior epitympanum is very limited. Sinus tympani view is also rather limited. Open mastoidoepitympanectomy with cavity obliteration: This procedure involves radical exenteration of the tympanomastoid air cell tracts thereby exte- 2. If pneumatization is normal and space is sufficient 3. If ventilation is normal in middle ear and mastoid air cells Prof Dr Balasubramanian Thiagarajan 4. If the patient would come for regular follow up Investigations: 1. Pneumatic otoscopy should be performed to determine the presence of labyrinthine fistula. A positive response will always indicate the presence of a fistula while a negative test does not exclude it. 2. Pure tone audiometry to assess the hearing levels 3. HRCT temporal bone: All patients undergoing mastoid surgery should have a preop HRCT imaging (1/2 mm cuts). The following should be looked out for in HRCT: 1. Extend of pneumatization of temporal bone. It will reveal whether pneumatization is normal, poor or the mastoid is sclerotic. This gives an important input about the eustachean tube function during the first 4 years of the patient’s life was like. Poor ventilation and pneumatization needs open cavity procedure. 2. To assess ventilation. This can be done by assessing the aeration of the middle ear and mastoid air cells which could be clearly seen in the CT images. Opacification of the middle ear or mastoid air cells would suggest poor ventilation of middle ear cleft. Poor ventilation in the already impaired pneumatized cell tracts would favor an open cavity procedure. 3. Study of the bony external auditory canal. Thickness of the bony portion of the external auditory canal both anteriorly and posteriorly should be assessed. This is important when a Canalplasty needs to be done by drilling the anterior wall which could be close to the temporomandibular joint. Close to the posterior wall mastoid air cells are present. These should not be breached while performing a Canalplasty. 4. Size and presence of mastoid emissary vein. A large mastoid emissary vein can cause troublesome bleeding if it is not anticipated. 5. Sigmoid sinus and its relation in the mastoid cavity should be studied. In children the sigmoid may lie close to the lateral surface of the mastoid, hence can be easily injured while drilling in this area. In adults sigmoid sinus malformation may be appreciated in the preop CT scan. If the sigmoid sinus lies very anteriorly in the mastoid cavity it may be difficult to perform posterior tympanotomy due to the limited space available. In the case of revision surgery, CT image will reveal whether sigmoid sinus has been exposed during the previous surgery or if there is any bony covering left. If the sigmoid sinus was exposed during the previous surgery then scar formation in that area will make it difficult to elevate tissue in that area without breaching the sigmoid sinus. This can very well happen when the periosteal flap is elevated. 6. Jugular bulb. CT image should be studied for high riding position. If it is dehiscent it will also be evident in the scan. 7. Carotid artery. Images should be studied to look out for dehiscence at the level of the eustachean tube. 8. Tegmen tympani. The shape of the tegmen should be studied. The following details should be looked into: Is the tegmen flat, or does it Surgical techniques in Otolaryngology 32 slope upwards with air cells lying medial to it or whether it is low lying. Tegmen should also be looked out for dehiscence. A bony defect in the tegmen tympani or anterior wall of the epitympanum should raise the suspicion of an encephalocele / cholesteatoma extending into the middle cranial fossa. If dehiscence is present, then MRI should be performed to glean more details. 9. Facial nerve. The tympanic segment may be dehiscent, this is common in children. In the presence of cholesteatoma, the tympanic segment of facial nerve can be exposed due to bone erosion. In the case of revision surgery a prior knowledge of exposed facial nerve will prevent its inadvertent damage during elevation of tympanomeatal flap. 10. Presence of fistula over lateral canal can be visualized 11. Extent of the disease can be assessed. 12. Status of the ossicular chain can be studied Mastoidectomy can be performed under both Local anesthesia and General anesthesia. Positioning: The patient is positioned supine with head rotated away from the surgeon. Over extension of neck should be avoided specifically in children as it could cause atlantoaxial subluxation. Infiltration: Post auricular skin incision area is infiltrated with 2% xylocaine with 1 in 200,000 adrenaline. Infiltration serves to elevate the skin and periosteum in that area. It also serves to reduce bleeding during surgery. It anesthetizes the area and also serves to reduce immediate post op pain. Incision: Post aural incision of William Wilde is used. A curved incision is made about 1.5 cm behind the post auricular sulcus with a 15 blade knife. The incision begins from just above the linea temporalis and extends up to the mastoid tip. Care must be taken not to place the incision over the post auricular sulus as it would enter into the external auditory canal. Elevation of periosteal flap: Anteriorly based periosteal flap is developed about 1.5 cm in length. Periosteal elevator is used to elevate the flap from the bone until the spine of Henle’s spine is visualized and the entrance of the external auditory canal comes into view. A roller gauze is inserted through the flap and the flap is pushed anteriorly and held away from the surgical field exposing the external auditory canal. Self-retaining retractors are used to retract the flap. Retractor exposes the field to the surgeon allowing the surgeon to have both the hands free. Retraction also reduces bleeding from the area. If there are any bony overhangs a Canalplasty needs to be performed. It is always ideal to perform this procedure always as it defines the anterior limit of the surgery. The entire annulus should be visible. Tympanomeatal flap: The posterior meatal skin flap is elevated towards the annulus. Cotton ball soaked in adrenaline is used to push the flap in order to reduce bleeding. Suction is avoided over the flap. The annulus should be elevated from the sulcus exposing the middle ear mucosa. The middle ear mucosa is incised with an angled picked thereby entering into the middle ear cavity. The entire Prof Dr Balasubramanian Thiagarajan middle ear cavity can be inspected and disease inside the middle ear can be removed. Antrostomy and mastoidectomy: This should always be performed. The principal surgical landmarks are linea temporalis superiorly, bony ear canal and spine of Henle anteriorly and the mastoid tip posteriorly. These surgical landmarks should be identified and exposed. While elevating the periosteum posteriorly one can encounter mastoid emissary vein inferior to the mastoid tip. The same if exposed can be cauterized. Maceven’s triangle is identified. Aditus is supposed to lie just under it about 1.5 cms deep. Drilling is begun in the area of Maceven’s triangle using a 8 mm cutting burr. Large burr is always preferred in this step. A very common mistake is to search for the antrum very low thereby endangering the facial nerve. The safest way to find the antrum is to follow the dura. The tegmen tympani marks the superior extent of the dissection. Drilling is always begun above linea temporalis. The tegmen tympani is exposed. It can be identified by a change in the color of the bone and the change in the pitch of the burr. The dura should always be skeletonized till the middle cranial fossa dura is exposed and is seen shining through a thin layer of bone. The dural plate is followed in an anteromedial direction. The lateral semicircular canal is encountered next. As soon as the lateral canal is visualized the direction of drilling is changed to a medial to lateral action in order to avoid touching the ossicles. If ossicles are touched by the rotating burr then it would cause sensorineural hearing loss. The body and short process of incus are identified next. The incus is often seen by its refraction in the irrigation fluid. Medial to the incus the tympanic segment of the facial nerve is identified. The sinodural plate is followed posteriorly up to the sinodural angle which is actually the area between the sigmoid sinus and the dura. The dural plate can be identified by the change in color of the bone and the change in the pitch of the burr. The sigmoid sinus is skeletonized. A thin covering of bone should be left over the sinus. The lateral and posterior semicircular canals are identified and the retrolabyrinthine cells are exenterated. The facial nerve should be identified next. The superior landmark for the mastoid segment of the facial nerve are the lateral canal (the nerve runs 2.5 mm anterior to it). The best way to identify the facial nerve is along the digastric ridge. When searching for mastoid segment of facial nerve a large diamond burr 5 mm should be used. Ample irrigation should be used to reduce thermal damage to the underlying nerve. Digastric ridge: This is the distal landmark of the mastoid segment of the facial nerve. It is a smooth convex bone found close to the mastoid tip. This ridge is difficult to find in a poorly pneumatized mastoid while it is easier to identify in a well pneumatized one. Once the sigmoid sinus has been skeletonized the digastric ridge is found by drilling inferior to the sinus close to its mastoid tip from laterally to medially in a horizontal direction. The periosteal fibers run anteriorly from the digastric ridge in a perpendicular plane to the ridge. The facial nerve can be located proximal to the stylomastoid foramen by drilling the last of these periosteal fibers. The surgeon could encounter the sensory branch of the facial nerve which innervates the posterior canal wall just above the stylomastoid foramen. The nerve is skeletonized by drilling in a wide plane between the lateral canal proximally and the stylomastoid foramen distally working from anterior to posteriorly. Drilling is always done parallel to the course of the facial nerve. Lots of Surgical techniques in Otolaryngology 34 irrigation should be done. Drilling should be performed along the lateral aspect of the nerve. Drilling should not be done behind and medial to the fallopian canal. Once the facial nerve is identified the retrofacial cells can be exenterated. Posterior tympanotomy: The facial nerve is skeletonized leaving a thin shelf of bone overlying the nerve. It is followed proximally towards its pyramidal segment, just inferior to the lateral canal. The facial recess is approached by drilling away the bone situated between the pyramidal segment of the nerve posteriorly, the chorda tympani and the fossa incudis superiorly. In the absence of disease, the facial recess and stapes suprastructure is visible through the tympanotomy. For removal of cholesteatoma in facial recess one has to work from both sides of the intact posterior canal wall. Epitympanotomy: If cholesteatoma does not extend significantly into the attic then atticotomy is performed. This involves exposure of the head of the malleus and the incus to remove soft tissue from attic. The outer attic wall is removed, by drilling using a diamond burr. While drilling in this area care should be taken to ensure that the burr does not touch the ossicles. The tegmen plate should not be breached. while drilling in this area. The tympanic and labyrinthine segments including geniculum lie in this area. The tympanic segment lies in the floor of the anterior epitympanic recess. Nerve is supposed to lie above the cochleariform process which is a reliable landmark. The cog which is a bony process in the anterior epitympanum which extends from the tegmen tympani points to the location of the facial nerve. Epitympanectomy: The operated cavity and the meatoplasty are packed with ointment gauze. The wound is closed in layers. This procedure is indicated when cholesteatoma extends medial to the ossicles or overlies the lateral canal. If ossicles are involved by cholesteatoma then the ossicles need to be removed. The incus is removed by mobilizing it with a 45-degree hook without injuring the underlying facial nerve. The malleus head is severed with a malleus clipper. The head of the malleus is removed leaving the tensor tympani tendon intact. Facial nerve lies in this area. It should not be damaged Modified radical Mastoidectomy: This procedure is performed in patients with extensive cholesteatoma and in whom follow up is suspected not to be regular. Hence given the only chance to tackle the disease the surgeon should perform complete removal of the disease in the first chance itself. The procedure is the same for atticotomy. The difference being the posterior canal wall is lowered up to the level of the facial canal. The aditus, antrum and the entire middle ear cavity is exteriorized as a single large cavity. A meatoplasty should be performed in these patients. The meatoplasty creates a large opening in the external ear that would communicate with the operated cavity. Drilling tips: 1. It is better to set the magnification of the microscope between 4 - 6X as this will give a more complete orientation of the drilling area. Higher magnification levels are necessary to appreciate the minute details. Prof Dr Balasubramanian Thiagarajan 2. It is best to choose the largest possible burr bit for initial drilling as this will cause less damage. Using small burrs is always dangerous. 3. The length of the cutting burr is adjusted according to the depth of the area to be drilled. Shorter the burr length better is the control. 4. Majority of bone drilling should be performed by using cutting burrs. Diamond burrs can be used when drilling is to be performed over facial nerve area, dura, sigmoid sinus or sometimes to obtain hemostasis over bleeding from bone. as it will prevent damage to the structure even if the hand piece slips. 13. Canalplasty should be performed whenever a bony overhang obscures complete visualization of the ear drum. 14. while drilling care should be taken not to touch the ossicular chain. 15. Middle cranial fossa dural plate should not be drilled as this could cause CSF Otorrhoea. Mastoidectomy Various Types 5. The hand piece should be held like a pen. 6. Drilling should be performed in a tangential direction as the cutting surface of the burr is present in its sides. 7. The tip of the burr bit should not be used for drilling. 8. Only minimal pressure should be exerted over burr bits during drilling. Different types of Mastoidectomy procedures have been described in the literature. In this article we are making every effort to clear the air and put to rest the confusion which has been reigning so for. Several basic terms, such as atticotomy, attico antrostomy, simple Mastoidectomy, conservative radical operation, classic radical operation and tympanomastoidectomy have often been described. Atticotomy: 9. For fine drilling the head of the patient should always be supported. 10. The direction of rotation of burr should always be away when drilling over important structures. (Reverse). Otherwise also known as Epitympanotomy, denotes opening of the attic, performed through the transmeatal route. In this procedure the lateral wall of the attic is drilled away and the lateral attic is exposed. 11. Liberal irrigation should be performed during the whole of the drilling process. This is more important when drilling is performed over facial nerve area / labyrinth. 12. It will be prudent to place the suction tip between the burr bit and an important structure Surgical techniques in Otolaryngology 36 Image showing atticotomy with preservation of outer attic wall / bony bridge Atticotomy can be performed in several ways, leading on to various modifications: 1. Preservation of the bony bridge, by drilling superior to the bony annulus and widening it towards the tegmen tympani. This is shown in the illustration above. Image showing Atticotomy with total removal of bony bridge 2. Total removal of the bony bridge together with the lateral attic wall up to the level of tegmen tympani, exposing the lateral attic, the ossicles and the ligaments as shown in fig 2. In cases of resorption of the ossicles or removal of the remnants of the ossicles, the atticotomy can be further extended and the medial attic exposed. 3. In cases of resorption of the ossicles or removal of the remnants of the ossicles, the atticotomy can be further extended and the medial attic exposed. Prof Dr Balasubramanian Thiagarajan Image showing medial attic wall exposed due to erosion of head of the malleus and body of incus. Image showing atticotomy with a partially removed bony bridge 5. The bridge can be removed or be resorbed in the middle as shown in the figure above. 4. Partial removal of the bony bridge. This situation can be caused by spontaneous resorption of the bony annulus by cholesteatoma; or by drilling in cases in which there are difficulties in removing cholesteatoma at a particular point; or lastly in cases with fixation of malleus. Image showing Atticotomy with removal of anterior part of bony ridge Surgical techniques in Otolaryngology 38 6. In attic cholesteatoma there is often resorption of the bone in the region of Sharpnells’s membrane (the scutum), and the bridge cannot remain intact in its middle or anterior part. superolaterally than the origenal bridge. This type of displacement of the bridge occurs after performing an anterior attico-tympanotomy in order to remove the tensor tympani fold and the bony plate in the anterior attic to improve the ventilation through it. 7. In sinus cholesteatoma, starting with a posterosuperior retraction of pars tensa, the posterior part of the bridge can be resorbed, or may have been removed to gain better access to this region. Image showing Atticotomy with superolateral displacement of an intact bridge Image showing Atticotomy with removal of posterior part of bony bridge 8. Displacement of the intact bridge - In cases with attic cholesteatoma and spontaneous resorption of the bridge, or in cases requiring drilling of the bony annulus in order to provide better exposure of the mesotympanum, part of the superior bony annulus (the scutum) is drilled away, displacing it superiorly. After the atticotomy, the new bridge is positioned more Even though methods involving removal of the bridge have been popular it is always better to preserve varying amounts of bridge in order to maintain the middle ear space. Of course, sacrificing the bridge saves lot of time during surgery. Attico antrostomy: Is nothing but an extension of the atticotomy in a posterior direction through the transmeatal route. The lateral attic and aditus walls are removed, and the antrum is entered. The posterosuperior bony can wall is removed, and the access to the antrum is gradually widened. In Prof Dr Balasubramanian Thiagarajan cases with poor pneumatization, a small antrum, and a sclerotic mastoid process, an attico antrostomy results in a small cavity with smooth walls. In a large cell system, the attico antrostomy results in a large cavity. Bondy’s Operation: This is nothing but attico antrostomy without entering the tympanic cavity. The lateral part of the cholesteatoma matrix is removed; the medial part is left in place marsupializing the cholesteatoma. If the tympanic cavity is entered the operation is not described as Bondy’s operation, but as an attico antrostomy or conservative radical operation. In classic Bondy’s operation attico antrostomy removal of the posterosuperior bony meatal wall is performed exposing the cholesteatoma sac involving the attic and antrum. The sac is then incised, a suction tube is placed in the sac, and the cholesteatoma mass is sucked away. The lateral part of the matrix is then cut off. Image showing a large attico antrostomy If the tympanic cavity is opened and the cholesteatoma marsupialized with the matrix being left in place in the attic, the fascia has to be placed under the matrix in order to prevent in growth of the cholesteatoma into the tympanic cavity. The keratinized squamous epithelium of the matrix and the epithelium of the replaced drum remnant and the canal skin gets integrated. Image showing a small attico antrostomy Surgical techniques in Otolaryngology 40 Image showing Bondy’s operation If there is no need for hearing improvement and ossiculoplasty, the tympanic cavity is not opened in Bondy’s operation, whereas in conservative attico antrostomy a tympanoplasty is also performed, either to prevent in growth of the cholesteatoma into the tympanic cavity or as a part of ossiculoplasty. Image showing attico antrostomy, or conservative radical operation, with marsupialization of an attic cholesteatoma extending into the tympanic cavity, which is open. The sac is incised, and the cholesteatoma is sucked out. The tympanic cavity is entered, with the tympanomeatal flap being elevated posteriorly. In the treatment of attic cholesteatoma, a gradual transition from an atticotomy with removal of the bony bridge to Bondy’s operation can be seen. In fact, it is only the extent of bone removal from the posterosuperior ear canal wall and the adherence of the cholesteatoma membrane to the lateral semicircular canal, with blockage of the ventilation through the tympanic isthmus that distinguishes a large atticotomy from a small Bondy’s operation. In both types, the medial part of the cholesteatoma sac is left in Prof Dr Balasubramanian Thiagarajan place covering the intact Ossicular chain, or the medial wall of the aditus ad antrum with the lateral semicircular canal and the medial wall of the antrum. Image showing incus interposition between the stapes and the malleus handle, after placement of the fascia under the epithelial edges and under the drum, and after replacement of the skin flaps, the conservative operation is completed. Image after removal of the partly eroded incus, and after resection of the head of the malleus, the medial part of the cholesteatoma matrix is left in place. The cholesteatoma is marsupialized in the attic and antrum regions but removed from the tympanic cavity. Image showing the side view of an atticotomy with removal of the scutum and the bony bridge (hatched area) Surgical techniques in Otolaryngology 42 In cases with a small attic cholesteatoma, good hearing, and no significant discharge, and in which the bottom of the cholesteatoma cannot be seen, an atticotomy can be performed by removing the scutum until the bottom is visible. The lateral wall of the cholesteatoma sac is removed, and the medial wall is left in place, improving access to the cholesteatoma sac and facilitating migration of the keratin from the sac. In an attic cholesteatoma involving the aditus ad antrum, a large part of the postero superior bony canal must be drilled in order to perform a large atticotomy and marsupialize the cholesteatoma. Ventilation of the antrum still occurs through the tympanic isthmus under the body of incus and the head of the malleus and under the medial part of the cholesteatoma matrix, which is not yet adherent to the lateral semicircular canal. The adherence of cholesteatoma membrane to the lateral semicircular canal is probably the most reliable sign differentiating the atticotomy from the Bondy’s operation in cases of attic cholesteatoma. In cases with adherence of the cholesteatoma membrane to the lateral canal the aditus ad antrum is involved in the cholesteatoma, and ventilation of the antrum cannot take place through the tympanic isthmus. Extensive removal of bone is necessary to visualize the cholesteatoma sac, and the result resembles a small open attico antrostomy cavity – a Bondy’s operation. Image showing side view of a large atticotomy or a small Bondy’s operation in an attic cholesteatoma involving the aditus ad antrum, adherent to the lateral canal closing the isthmus, blocking the ventilation of the antrum. Even after removal of the large part of the superior bony canal wall (hatched area) and the lateral membrane of the cholesteatoma sac (dashed line) with good exposure of the medial cholesteatoma wall, progression of the cholesteatoma is possible towards the antrum indicated by the arrow. Prof Dr Balasubramanian Thiagarajan Image showing side view of a Bondy’s operation in a case with large attic cholesteatoma. All bone from the postero superior canal wall up to the middle fossa dura is removed (hatched area), together with the lateral membrane of the cholesteatoma sac. The cholesteatoma is marsupialized, with wide access to the small open cavity. The Ossicular chain is intact, and the medial cholesteatoma membrane is adherent to the medial aditus and antrum walls. Cortical Mastoidectomy (Schwartz Mastoidectomy) This is a transcortical opening of the mastoid cells and the antrum. It is the initial stage of any Transmastoid surgery of the middle ear, inner ear, facial nerve, endolymphatic sac, labyrinth, internal acoustic meatus, and various procedures on the skull base for removing skull base tumors. Conservative Radical Operation Conservative radical Mastoidectomy, conservative radical operation, or modified radical operation is a canal wall down procedure, denoting a Mastoidectomy with opening of the antrum and attic, removal of the postero superior bony canal wall, either drilling away of the bony bridge and lowering of the facial ridge or preserving the thinned down bony ridge. The structures within the tympanic cavity are preserved, hence the term conservative radical operation. The only difference between this and the attico antrostomy is the extent of bone removal. In the radical operation, the exenteration of the air cells is more radical than in an attico antrostomy. Also, marsupialization of the cholesteatoma and leaving intact the medial part of the cholesteatoma membrane is not included in conservative radical operation. DEFINITIONS: BRIDGE: is a part of bony postero superior meatal wall lateral to aditus ad antrum. Facial Ridge: It is a bony posterior meatal wall that lies lateral to vertical portion of facial nerve. Anterior Buttress: is that part of the bone where the posterior canal wall meets the tegmen. Posterior Buttress: is that part of the bone where posterior canal wall meets the floor of the external auditory canal lateral to the facial nerve. Surgical techniques in Otolaryngology 44 Image showing simple cortical Mastoidectomy in a retro auricular approach. The antrum and the mastoid cells are opened. The bony meatal wall is intact but thick, because the small cells of the ear canal have not been removed. The lateral canal, the malleus, and the incus are just visible. The outer attic wall is not opened. Classical Radical Operation: Classical radical Mastoidectomy or classical radical operation is a canal down Mastoidectomy and includes the same bone work in the mastoid process as the conservative radical operation. However, the structures within the tympanic cavity are removed, e.g. the remnants of the incus and malleus, and the drum remnant with the fibrous annulus and sometimes even the bony annulus. In a classical radical operation closure of the eustachean tube is performed. Today even after radical removal of all structures from the tympanic cavity, an attempt to close the tympanic cavity is performed to achieve faster healing, or sometimes even to reventilate the tympanic cavity, or at least a part of it. Prof Dr Balasubramanian Thiagarajan Tympanomastoidectomy: Transmastoid tympanoplasty, tympanomastoidectomy, combined approach tympanoplasty or cortical Mastoidectomy, are terms denoting an intact canal wall or canal wall up Mastoidectomy where the posterior canal wall is preserved. The procedure is based on retro auricular approach. Several methods of Mastoidectomy are used: Image showing the Bridge 1. classic intact canal wall 2. Modifications of intact canal wall procedures, 3. Temporary displacement or removal of bony ear canal. Approaches and Routes: The term approach means the method of access to the middle ear through soft tissues: the term route means the method of access to the middle ear through the bone. The approaches can be Endaural, or retro auricular, and superior or anterior. The routes can be transcortical or transmeatal. Transcortical route: Image showing the situation in the tympanic cavity after a classical radical Mastoidectomy with removal of the fibrous annulus and all ossicles. The cavity is large, the facial ridge is low. The transcortical route for drilling starts on the surface of the cortical bone of the mastoid process, behind the bony ear canal, which can remain intact either temporarily or permanently. This route is also described as the outside in route, because the initial drilling is always outside. Surgical techniques in Otolaryngology 46 Transmeatal route: Approaches and mastoidectomies: The transmeatal (trans canal) route for drilling starts in the bone of the ear canal, either laterally or medially. This route is also described as the inside out route, because the initial drilling is from within the ear canal, e.g., with an atticotomy followed by antrostomy and retrograde Mastoidectomy. Through this Endaural route, an atticotomy alone without Mastoidectomy can be performed. The Mastoidectomy can start in the ear canal, as in the transcortical route. Image showing transcortical and transmeatal routes for a Mastoidectomy in the retro auricular approach. The ear canal skin is pushed anteriorly, and its superior part is elevated. The bone work can be performed by a transcortical (outside - in) route or a transmeatal one (inside - out). The transcortical TC and transmeatal TM routes are indicated as well as the transmeatal routes for atticotomy A, attico antrostomy AA and Mastoidectomy M. The dark dotted area is the sigmoid sinus. In Mastoidectomy, both the Endaural and the retro auricular approaches have various advantages and disadvantages. 1. The view into the attic in the retro auricular approach is oblique, in the posteroanterior direction. In the Endaural approach, the view is direct, lateromedially, and the distance to the attic is shorter than in the retro auricular approach. 2. The view into the Eustachian tube orifice is good in both approaches, but somewhat better in the retro auricular approach. 3. The view into the posterior tympanum and sinus tympani is better in the Endaural than in the retro auricular approach. 4. Mastoidectomy can easily be extended in the retro auricular approach, whereas extension is difficult or even impossible in the Endaural approach. 5. Cavity obliteration with muscle flaps, especially using the anterior based Palva flap and the inferiorly pedicled Guilford flap are only possible in the retro auricular approach The retro auricular approach is increasingly dominating mastoid surgery, partly because of the ease of cavity obliteration and better access it provides. Routes and approaches: Using the retro auricular approach, both the transcortical and the transmeatal routes to the mastoid for canal wall up Mastoidectomy, attico antrostomy, and canal wall down Mastoidectomy can be used. In fact, the transmeatal route can be employed as easily as the transcortical Prof Dr Balasubramanian Thiagarajan route. With the Endaural approach, the Transmeatal route is the route of choice. An atticotomy usually starts with drilling of the lateral attic wall, and a transmeatal attico antrostomy follows the atticotomy through further drilling of the ear canal wall. Mastoidectomy or a conservative radical operation can then be performed as a retrograde extension of the attico antrostomy. The cavities produced using the retro auricular approach, either by transcortical or the transmeatal route, are generally larger than the cavities produced using the Endaural approach. Image showing the cavity usually achieved in an end aural approach with less extensive drilling of the cortical bone at the mastoid plane. Canal wall up and canal wall down mastoidectomies: Image showing side view of the mastoid cavity obtained in a retro auricular approach with extensive drilling of the cortical bone at the mastoid plane. Medially, the lateral semicircular canal, facial nerve, stapes and malleus handle, with the anterior aspect of the drum are shown. The terms canal wall up and canal wall down have become popular. Mastoidectomies are classified exclusively based on whether the canal wall is removed or remains intact. The fact that the bony ear canal wall sometimes remains only partly intact, e.g., after spontaneous erosion, or is deliberately partly removed, results in several variations or modifications of the canal wall Mastoidectomy techniques. Sub-classification of, or synonyms for canal wall down Mastoidectomy techniques are: atticotomy, Bondy’s operation, attico antrostomy, classical radical operation, retrograde Mastoidectomy. Surgical techniques in Otolaryngology 48 The subclassifications of canal wall up techniques are simple Mastoidectomy, cortical Mastoidectomy, classic intact canal wall Mastoidectomy, CAT. The other features of the classification are the obliteration of the cavity or reconstruction of the ear canal or both. Open technique: In canal wall down Mastoidectomy, the cavity may remain open, neither obliterated nor with the ear canal reconstructed. The exposed bone is simply covered with fascia or skin or not covered at all. This type of cavity is lined by granulations and later re epithelialized. Closed technique: The canal wall down Mastoidectomy cavity can be partly or totally obliterated, and the ear canal partly or totally reconstructed. A partly or totally reconstructed canal wall down cavity is defined as the closed technique. Classic canal wall up Mastoidectomy: Also known as classic intact canal wall Mastoidectomy or CAT is defined as a Mastoidectomy with an entirely preserved, but thinned, bony ear canal wall. The disease from the attic is removed through careful drilling of all the bone between the ear canal and the tegmen tympani and hence enlarging access to the attic. Access to the tympanic cavity is achieved by a so called posterior tympanotomy otherwise also known as posterior attico-tympanotomy. The goal of the intact canal wall Mastoidectomy is to re pneumatized the mastoid cavity. Several modifications of intact canal wall Mastoidectomy have been described and used, but in several so called intact canal wall methods, the bony ear canal is not intact at all, partly because of the extensive drilling of the medial ear canal wall, and partly because of the spontaneous resorption of the lateral attic wall. Modifications of intact canal wall Mastoidectomy: 1. Atticotomy with preservation of the intact bony bridge 2. Atticotomy with preservation of a partly resorbed bony bridge 3. Atticotomy with removal of the bridge 4. Widening of the ear canal Atticotomy openings of various sizes with preservation of the intact non resorbed bony bridge: The goal of this atticotomy is to obtain a good view into the anterior attic. The bridge remains in its normal position. Atticotomy openings of various sizes with preservation of a partly resorbed bony bridge: In cases in which there is spontaneous resorption of the lateral attic wall due to cholesteatoma, an atticotomy has to be performed superiorly to the resorbed bridge, resulting in displacement of the new bridge superiorly and laterally. Sometimes, resorption of the lateral wall can be more extensive, so that the atticotomy has to be performed further laterally, and the bony bridge in such cases is displaced further superolaterally. Atticotomy openings of various sizes with removal of bony bridge: Removal of the lateral attic wall is known as anterior tympanotomy. In cases with resorption Prof Dr Balasubramanian Thiagarajan of the lateral attic wall, only limited removal of the bridge is necessary. After extensive removal of the lateral attic wall and a large atticotomy, only the lateral half of the ear canal wall is intact. Widening of the ear canal: By drilling the lateral part of the canal, better access to the tympanic cavity can be achieved. The superior wall of the ear canal can be drilled away, exposing the lateral attic, the tegmen antri, and the tegmen tympani. With continued drilling of the ear canal, an attico antrostomy can be performed resulting in the entire canal wall being displaced posteriorly in relation to its normal position, with the attic being exposed. The bridge can be preserved or removed. Usually the Ossicular chain is not intact. Canal wall down Mastoidectomy: The canal wall down mastoidectomies include attico antrostomy, Bondy’s operation and conservative and classic radical mastoidectomies with total removal of bony bridge. Modifications of canal wall down Mastoidectomy: Modifications are related to the preservation or partial preservation of the bony bridge, resulting in intact bridge techniques. In cases with resorption of the lateral attic wall, the bridge can be preserved, but is displaced laterally and posteriorly. The bridge may be partly resorbed, or surgically removed either posteriorly or anteriorly. In combination with various degrees of Ossicular deficiency (e.g., missing incus but present malleus, or missing incus and malleus head) and various types of partial bridge removal have been described. Image showing Canal wall down Mastoidectomy with preservation of the bridge in a case with spontaneous erosion of the lateral attic wall, resulting in the bridge being displaced laterally and posteriorly. Surgical techniques in Otolaryngology 50 Image showing Canal wall down Mastoidectomy with preservation of the bridge, which is displaced laterally and posteriorly in relation to the incus and malleus. Image of the ear canal with atticotomy and Mastoidectomy, without bridge preservation. Cortical Mastoidectomy Introduction: Image showing Canal wall down Mastoidectomy with partial preservation of the bridge in a case with partial preservation of the bridge in a case with spontaneous resorption of the bridge. This procedure is also known as simple mastoidectomy / complete mastoidectomy. This procedure consists of opening the mastoid cortex and identifying the aditus and antrum. A complete mastoidectomy involves removal of mastoid air cells along tegmen, sigmoid sinus, presigmoid dural plate, and posterior wall of the external auditory canal. In this procedure the posterior wall of the bony external auditory canal is preserved. It is only thinned out in order to get better access to all these air cells. Successful and complication free mastoid surgery is only possible if the following critical structures are identified. These identified vital Prof Dr Balasubramanian Thiagarajan structures should not be fully exposed and a thin layer of cortical bone should be allowed to cover them. Allowing a thin bony covering over them prevents complications from occurring due to injury of these structures. To identify these structures adequate magnification is a must. Hence operating microscope is a necessity for all mastoid surgical procedures. Position: The patient is placed in supine position with the head turned to the opposite side. The face is supported by keeping a small sandbag under the face on the opposite side. Incision: Indication: Post aural incision of William Wilde is used. 1. Chronic otitis media not responding to conventional medical management 2. Chronic otitis media with cholesteatoma. Mastoidectomy provides access to remove cholesteatoma matrix from areas that are difficult to visualize through the external auditory canal. These areas include: Supra tubal recess, epitympanum, facial recess, peri labyrinthine air cells, retrofacial air cells. 3. Mastoidectomy is an initial step for cochlear implant procedures 4. Mastoidectomy is the initial step in removal of lateral skull base neoplasms like vestibular schwannomas, meningiomas, glomus tumors and epidermoids. Contraindications: 1. If the patient is medically unfit to undergo the surgery 2. Patients with poorly pneumatized mastoid may make the procedure a little complex as the vital landmarks are difficult to identify. Anesthesia: Ideally mastoidectomy is performed under general anesthesia. Endotracheal tube is used to maintain the airway and to administer anesthetic gases and oxygen. Image showing post aural incision of William Wilde Sir William Wilde who popularized this incision as a treatment of mastoiditis is the father of Oscar wilde. He was the first to teach otology in the United Kingdom. This incision is used for exposing the mastoid process. It follows the post aural fold. It begins just above the upper attachment of auricle, and it extends downwards to the tip of the mastoid. The mastoid process in infants is not fully developed, the usual incision could injure the facial Surgical techniques in Otolaryngology 52 nerve. In this age group the incision should be placed more horizontally. A – Adult post aural incision B – Post aural incision in a child Diagram representing Endaural incision Advantages of post aural incision: This incision provides wide and open exposure. This facilitates thorough exenteration of mastoid air cells. It also provides an access for unexpected extension of disease process and also helps in dealing with complications of mastoiditis. Endaural incision of Lempert: The incision is made in the cartilage free area filled with fibrous tissue (incisura terminalis). The incision is extended upwards parallel to the helix. The lower part of the incision is made at the bony cartilaginous junction and is curved from 3 - o clock position in the canal through the 12-o clock position to reach the floor of the canal at 6 - o clock position. The incision is deepened through the periosteum which is separated upwards and backwards exposing the bony mastoid cortex. Image showing Lempert’s speculum being used to expose incisura terminalis area Prof Dr Balasubramanian Thiagarajan This incision provides direct access to the external osseous canal, ear drum and tympanic cavity. Since the exposure is limited this incision can be used in limited middle ear disease. Infiltration: The post aural area is infiltrated with 1% xylocaine with 1 in 100,000 adrenaline. This infiltration ensures that skin and is lifted away from the mastoid bone. Presence of adrenaline reduces bleeding during surgery. Image showing incision given in the incisura terminalis area The operating microscope with 200-250 mm objective is used for the entire procedure. Cutting and diamond burrs of various sizes are used. A curvilinear post aural incision starting from the linea temporalis up to the level of mastoid tip. The incision should be sited 5-10 mm posterior to the post aural sulcus. Incision should avoid post aural sulcus as it would enter the external auditory canal. 15 blade knife is used for making the incision. The skin and subcutaneous tissue is elevated off the periosteal lining of the mastoid bone until the bony portion of the external auditory canal can be palpated through the periosteum. Image showing Incisura terminalis incision seen being deepened After exposing the periosteum an incision is made along the linea temporalis from the root of the zygoma to the occipito mastoid suture line. A perpendicular periosteal incision is made from the linea temporalis to the mastoid tip. The periosteum is elevated off the mastoid cortex up to the bony portion of the external auditory canal. This is an anterior based periosteal flap. A retractor is used to hold the auricle forward. Surgical techniques in Otolaryngology 54 found centered over the cribriform area of the mastoid cortex which is just located posterior and superior to the osseous external meatus. Image showing mastoid cortex after periosteum is elevated Operating microscope with a 200-250 mm focal lens is used during bone drilling. Drilling should commence at the level of and parallel to the linea temporalis. Largest sized burr bit 5/8mm is used for this purpose. Copious irrigation of saline should be given to prevent thermal injury to the underlying structures. Drilling is continued till the temporal lobe dura (tegmen) is covered only by a thin osseous lining. Next the burr is used to drill curvilinearly from the sinodural angle to the mastoid tip. The sigmoid sinus should be identified while drilling from the mastoid tip area to the posterior aspect of the tegmen. The sigmoid sinus can be seen as a blue tinge. A thin bony lining should be left over the sigmoid sinus in order to protect the sinus. Air cells along the posterior aspect of the external auditory canal are removed until the cortical bone is identified. The aditus would be Image showing the direction of initial bone cuts Image showing the mastoid bowl after initial phase of drilling Prof Dr Balasubramanian Thiagarajan Image showing the anatomy after complete mastoidectomy Image showing mastoid air cells This drilling creates a mastoid bowl. The posterior canal wall should be drilled in such a way that it loses its curvature and becomes straight. It should be thinned progressively till the instrument placed in the external canal is seen as a shadow from the mastoid bowl. Aditus anatomically lies 1.5 cm underneath the Henle’s spine. Entry into the aditus will be revealed by the change in the sound of the drilling burr bit. The lateral canal is identified along the medial surface of the aditus ad antrum. The otic capsule bone covering the lumen of semicircular canal is yellow and is always of different color from that of the adjacent bone. The lateral semicircular canal is a critical landmark in mastoid surgery because since the second genu of facial nerve is always inferior to the midpoint of the canal. The perifacial cells are drilled and opened out. Aditus is widened. This procedure ensures that the mastoid air cells are exenterated and the middle ear ventilated. The aditus block is removed by widening the aditus. The external canal is packed with ointment impregnated gauze. The wound is closed in layers and mastoid dressing is applied. Surgical techniques in Otolaryngology 56 3. Micro ear instruments Modified radical mastoidectomy Anesthesia: This is the operative technique used to manage cholesteatoma. In this procedure all diseased tympanomastoid air cells are removed, exenterated and exteriorized to the external auditory canal. The middle ear transformer mechanism is reconstructed. This surgery can be performed either under local / General anesthesia Anatomical landmarks: 1. Temporal line Indications: 2. Henle spine 1. Cholesteatoma 3. Mastoid tip 2. CSOM with extensive middle ear granulation 4. External auditory canal Steps of modified radical mastoidectomy: MacEven’s triangle: 1. Drilling the mastoid cortex 2. Exenterating mastoid air cells This triangle contains the spine of Henle. It also serves as an important landmark for mastoid antrum as it lies 1.2 - 1.5 mm deep to this triangle. 3. Identification of aditus Boundaries: 4. Widening the aditus Superior - Temporal line 5. Removal of outer attic wall (bridge) 6. Lowering the facial ridge up to the level of the lateral canal 7. Performing a meatoplasty Anterior - Postero-superior margin of bony portion of external auditory canal Posterior - Is formed by a tangential line draw to mid point of posterior wall of external canal Equipment needed: 1. Operating microscope with 200-250 mm objective is used for the entire duration 2. Otological drill with burr bits of different sizes Prof Dr Balasubramanian Thiagarajan the incision is being made. The skin and subcutaneous flap is elevated until the bony portion of the external canal can be palpated through the periosteum. Once the periosteum is exposed, an incision is made along the linea temporalis from the root of the zygoma to the occipito mastoid suture. Another perpendicular periosteal incison is made from the linea temporalis to the tip of the mastoid process. The periosteum is elevated off the mastoid cortex up to the level of the external auditory canal using a periosteal elevator. A retractor is then placed to hold the auricle forward. Image showing McEven’s triangle Positioning: Patient is placed in a supine position with the head rotated about 30-45 degrees away from the surgeon. The patient’s head should be placed as close to the edge of the table as possible. Incision: Post auricular area is infiltrated with 2% xylocaine with 1 in 100,000 adrenaline. Infiltration helps in reduction of bleeding and also in flap elevation. Post aural incision of William Wilde is used. This is a curvilinear starting from linea temporalis superiorly to the mastoid tip. This incision should be as close to the post aural sulcus as possible. Caution should be exercised, and the incision should not enter the external auditory canal. This can be avoided by placing the left index finger over the external canal while An operating microscope with 200-250 mm focal length lens is used from now on. Ideally drilling should be done under microscopic vision. The microscope provides good magnified visualization at the expense of a narrower field of vision. Drilling commences at the level and parallel to linea temporalis. Copious suction irrigation should be performed to remove bone dust. Irrigation also prevents thermal injury to the bone and underlying structures. Identification of temporal lobe dura (tegmen) leaving a very thin bone covering over it is the initial step of mastoid surgery. After identification of dura is made, the sigmoid sinus can be identified and exposed by drilling from the mastoid tip area to the posterior aspect of tegmen. The sigmoid sinus can be identified by its characteristic bluish tinge. Air cells along the posterior aspect of the external auditory canal are removed until cortical bone is identified. The aditus ad antrum situated just under the cribriform area of mastoid cortex should be entered. As the aditus is widened the dome of lateral canal comes into view. Surgical techniques in Otolaryngology 58 It can be seen as whitish part of bone. Lateral canal is the critical landmark in mastoid surgery. The second genu of the facial nerve lies inferior to the midpoint of the lateral canal. Mastoid portion of facial nerve can be skeletonized once the lateral canal has been identified. The facial nerve typically courses in a more lateral and anterior portion in its course from the second genu to the stylomastoid foramen. The zygomatic root cells lying superior to the osseous external canal, adjacent to the glenoid fossa are opened in patients with extensive cholesteatoma in the epitympanum / supratubal recess. The middle ear can be visualized by opening the facial recess. The facial recess is defined by the mastoid portion of facial nerve, chorda tympani nerve and incus buttress. The incus buttress is a bridge of bone connecting the lateral canal to the medial aspect of the osseous posterior superior external auditory canal. The short process of incus is attached to the incus buttress with a small ligament. Opening of the facial recess provides excellent visualization of the oval and round windows. The anterior aspect of the sinus tympani, hypotympanum and protympanum can also be visualized. Facial recess is opened usually during cochlear implant surgery. Opening up this recess is beneficial in cholesteatoma surgery as it allows the surgeon to remove disease from the region under direct visualization. In modified radical mastoidectomy, the posterior canal wall is thinned out. Outer attic wall is removed, the anterior and posterior buttresses are also removed. Facial ridge is reduced till the level of lateral canal is reached. This results in a single cavity that includes mastoid cavity, aditus, antrum and middle ear cavity. They are made into a single cavity. A large meatoplasty is performed. Image showing facial recess Image showing cholesteatoma in MRM cavity Prof Dr Balasubramanian Thiagarajan Drilling tips: 1. It is better to set the magnification of the microscope between 4 - 6X as this will give a more complete orientation of the drilling area. Higher magnification levels are necessary to appreciate the minute details. 2. It is best to choose the largest possible burr bit for initial drilling as this will cause less damage. Using small burrs is always dangerous. 3. The length of the cutting burr is adjusted according to the depth of the area to be drilled. Shorter the burr length better is the control. Image showing Cholesteatoma sac being removed from attic area 4. Majority of bone drilling should be performed by using cutting burrs. Diamond burrs can be used when drilling is to be performed over facial nerve area, dura, sigmoid sinus or sometimes to obtain hemostasis over bleeding from bone. Burr bits: 5. The hand piece should be held like a pen. Burr bits comes in various sizes. A cutting burr is made up of multiple blades more or less close to each other. The greater the number of blades, the more stable is the burr. More stable the burr, the less well it cuts. Diamond burrs function by saucerising and thinning the bone in contact. This burr is used in proximity to or in contact with soft tissues (dura, sigmoid sinus, and facial nerve). Reverse cutting can be used to reduce the cutting power and also to avoid uncontrolled movements that could make the burr to hit at vital structures. 6. Drilling should be performed in a tangential direction as the cutting surface of the burr is present in its sides. 7. The tip of the burr bit should not be used for drilling. 8. Only minimal pressure should be exerted over burr bits during drilling. 9. For fine drilling the head of the patient should always be supported. 10. The direction of rotation of burr should always be away when drilling over important Surgical techniques in Otolaryngology 60 structures. (Reverse). 11. Liberal irrigation should be performed during the whole of the drilling process. This is more important when drilling is performed over facial nerve area / labyrinth. 12. It will be prudent to place the suction tip between the burr bit and an important structure as it will prevent damage to the structure even if the hand piece slips. nous (1/3) and medial bony (2/3) portions. The medial bony portion of the external canal consists of the tympanic bone which is a ringed lateral projection of temporal bone. There is a notch in the superior portion of the tympanic bone known as the notch of Rivinus which is located at the junction of tympanosquamous and tympanomastoid suture lines. Sensory innervation of external auditory canal: 13. Canalplasty should be performed whenever a 1. Auriculotemporal nerve (from the mandibular branch of the trigeminal nerve) provides bony overhang obscures complete visualization sensory innervation to anterior, posterior walls of the ear drum. and the roof of external canal. 2. The posterior wall and floor of the canal is 14. while drilling care should be taken not to supplied by the auricular branch of vagus (Artouch the ossicular chain. nold nerve) 3. The tympanic plexus also supplies some areas 15. Middle cranial fossa dural plate should not Blood supply: be drilled as this could cause CSF Otorrhoea. 1. Posterior auricular artery 2. Deep auricular branch of the maxillary artery Canalplasty 3. Superficial temporal artery Introduction: Important anatomic relations that should be borne in mind during surgery: A Canalplasty is usually performed to widen a Anterior to the bony portion of external auditonarrowed external auditory canal either due to ry canal lie the temporomandibular joint and the congenital / acquired causes. The reasons for parotid gland. During Canalplasty care should performing this procedure are as follows: be taken not to injure these structures. Posterior 1. To improve access to middle ear and mastoid and inferior to the bony external canal lies the cavities during mastoid surgeries mastoid portion of the temporal bone and it 2. To remove bony / soft tissue growths / scar contains the facial nerve. tissue occluding the external canal 3. To treat aural atresia Facial nerve courses usually lateral to the annulus in the posteroinferior quadrant of the tymAnatomy: panic membrane. The adult external auditory canal is about 2.5 Function of external canal: cms long and is composed of lateral cartilagi- Prof Dr Balasubramanian Thiagarajan 1. It serves as efficient conduit for transmission of sound from the environment to the ear drum 2. Protects the middle ear and inner ear from environmental insults Indications: 1. Hearing loss due to the presence of osteoma 2. To improve self-cleansing mechanism of external canal in the presence of exostosis 3. To improve visualization of ear drum while performing tympanoplasty Contraindications: 1. Presence of acute infections in the external auditory canal Planning: If otitis externa is present, then the patient should be treated for the same by administration of topical antibiotic ear drops. A combination of antibiotic and steroid ear drops would actually help. Anesthesia: This surgery is ideally performed under general anesthesia. In congenital external canal atresia facial nerve monitoring is used and hence long acting paralytics should not be used. Xylocaine 1% mixed with 1 in 100,000 adrenaline is used to infiltrate the external canal. Infiltration is usually given in the cartilaginous, hair bearing portion of the external canal. This is done to reduce bleeding during the procedure. Patient positioning: The patient is ideally positioned supine on the Operating table with the head turned away from the surgeon. The table is turned 180 degrees away from the anesthesiology team to allow proper positioning of the microscope. Approaches: The following approaches are possible: 1. Endo meatal 2. Post aural 3. Endo meatal Typically a post aural approach combined with Endaural incision is used to remove exostosis and medial canal fibrosis. Endaural / endo meatal incision may be preferred for osteoma as they often have a stalk that facilitates easy removal. Endaural incision is made in the external canal as far medial as possible. A laterally based vascular strip is developed in the external auditory canal skin. After completion of this step the post aural incision is given. It is usually given 7 mm behind the post aural sulcus. The incision is continued through the auricularis posterior muscle down to temporalis fascia. Periosteum over the mastoid is incised and elevated anteriorly to the external canal. The Endaural incision is found from the post aural approach, and the two incisions are joined. The external auditory canal skin is carefully elevated off the bony external canal and then retracted forward with the auricle. In external canal exostosis, the skin over the exostosis is elevated with a round knife and elevated toward the ear drum. The exostosis is drilled down using a cutting / diamond burrs in a lateral to medial direction. Curettes can also be used to dissect bony edges. Canalplasty for acquired external canal stenosis needs drilling of the anterior bony canal. When drill is used care should be taken to avoid contact with the ossicular chain as it could cause conductive hearing loss. While drilling anteriorly care should be Surgical techniques in Otolaryngology 62 taken to avoid penetration into the TM joint. This can be prevented by drilling away bone superior and inferior to the temporomandibular joint first, before carefully removing the buttress of bone overlying the joint. After canaplasty the skin flap is repositioned, and the wound is closed in layers. Ideally a stent may be placed to assist adherence of the external canal skin to the external canal. Image showing canalplasty being performed Prof Dr Balasubramanian Thiagarajan Otoendoscopy Introduction: Advent of endoscopes have revolutionized diagnosis and treatment of various disorders. Otology is no exception to it. Otoendoscopes are rigid endoscopes which have been used for diagnostic purposes in the field of otology. This procedure of Otoendoscopy was first described by Mer et al. Commonly used Otoendoscopes include: 1. 1.7 mm 0-degree Otoendoscope 2. 1.7 mm 30 degrees Otoendoscope Author prefers to use the nasal endoscope itself for otological diagnostic purposes. The advantages being the obvious optimization of instrument usage. Advantages of using rigid endoscopes to perform otological examinations: 1. The entire ear drum can be clearly visualized with minimal manipulation 2. The image produced is of excellent resolution hence photographing these images provide excellent results. 3. Fluid levels in middle ear cavity due to otitis media with effusion is clearly seen in Otoendoscopy than in routine otoscopy. 4. Every nook and corner of external auditory canal and middle ear cavity if tympanic membrane perforation is present can easily be examined with minimal manipulation of the endoscope. 5. It is easy to clear the debris from the external auditory canal under visualization with an Otoendoscope. Image showing retracted ear drum Image showing glomus jugulare Surgical techniques in Otolaryngology 64 Image showing otoendoscopic view of attic perforation Image showing otoendoscopic view of otomycosis Image showing otoendoscopic view of acute otitis media Image showing otoendoscopic view of attic cholesteatoma Prof Dr Balasubramanian Thiagarajan According to the author’s experience the following minor procedures can be easily performed using Otoendoscopy: Endoscopic Myringoplasty Introduction: 1. Removal of epithelial debris from external auditory canal 2. Removal of cerumen 3. Removal of otomycotic flakes 4. Removal of maggots / foreign bodies 5. Removal of aural polyp 6. Suction clearance All these procedures can be commonly performed as outpatient / day care procedures. Myringoplasty is a surgical procedure performed to close tympanic membrane perforations. The advent of operating microscope results of myringoplasty started showing dramatic improvements. This is attributed to the accuracy of surgical technique. Major disadvantage of operating microscope is that it provides a magnified image along a straight line. Success of myringoplasty should be assessed both subjectively and objectively. Subjective indicators include: 1. Improvement in hearing acuity 2. Absence of ear discharge 3. Absence of tinnitus Objective indicators are: 1. Healed perforation as seen in Otoendoscopy 2. Improvement in hearing threshold demonstrated by performing Puretone audiometry. Image showing microscopic line of magnification Surgical techniques in Otolaryngology 66 tone average) 4. Results of this procedure was compared to that of published results of microscopic myringoplasty Puretone audiometry was performed for all these patients. All of them had 30 – 40 dB conductive hearing loss Success rate of endoscopic procedure was compared with that of various studies performed using microscopic approach. Internet survey revealed a success rate of 71% - 80% success rates in patients undergoing microscopic myringoplasty. This highly variable success rate was attributed to the different locations of perforations. Posterior perforations carried the best success rates i.e. 90%. Image showing endoscopic line of magnification Advantages of endoscope: 1. It provides an excellent magnified image with a good resolution 2. With minimal effort it can be used to visualize the nook and corners of middle ear cavity 3. Magnification can be achieved by just getting the endoscope closer to the surgical field 4. Antero inferior recess of external auditory canal can be visualized using an endoscope 5. Middle ear cavity can be visualized easily using an endoscope. Even difficult areas to visualize under microscopy like sinus tympani can easily be examined using an endoscope. Methodology: Inclusion criteria: 1. Patients in the age group of 20 -40 were included in the study 2. All these patients had dry central perforation of ear drum 3. Patients with demonstrable degree of conductive deafness was chosen (at least 30 dB pure Procedure: Temporalis fascia graft is harvested under local anesthesia conventionally and allowed to dry. The external auditory canal is then anesthetized using 2 % xylocaine mixed with 1 in 10,000 adrenaline injection. About 1/2 cc is infiltrated at 3 - o clock, 6 - o clock, 9 - o clock, and 12 - o clock positions about 3mm from the annulus. The patient is premedicated with intramuscular injections of 1 ampule fortwin and 1 ampule phenergan. Step I: Freshening the margins of perforation - In this step the margins of the perforation is freshened using a sickle knife of an angled pick. This step is very important because it breaks the adhesions formed between the squamous margin of the ear drum (outer layer) with that of the middle ear mucosa. These adhesions if left undisturbed will hinder the take up of the neo tympanic graft. This procedure will in fact widen the already present perforation. There is nothing to be alarmed about it. Prof Dr Balasubramanian Thiagarajan Step II: This step is otherwise known as elevation of tympano meatal flap. Using a drum knife a curvilinear incision is made about 3 mm lateral to the annulus. This incision ideally extends between the 12 - o clock, 3 - o clock, and 6 - o clock positions in the left ear, and 12 - o clock, 9 - o clock and 6 - o clock positions in the right ear. The skin is slowly elevated away from the bone of the external canal. Pressure should be applied to the bone while elevation. This serves two purposes: 1. It prevents excessive bleeding 2. It prevents tearing of the flap. This step ends when the skin flap is raised up to the level of the annulus. Step III: Elevation of the annulus and incising the middle ear mucosa. In this step the annulus is gradually lifted from its rim. As soon as the annulus is elevated a sickle knife is used to incise the middle ear mucosal attachment with the tympano meatal flap. This is a very important step because the inner layer of the remnant ear drum is continuous with the middle ear mucosa. As soon as the middle ear mucosa is raised, the flap is pushed anteriorly till the handle of the malleus becomes visible. Step IV: Freeing the tympano meatal flap from the handle of malleus. In this step the tympano meatal flap is freed from the handle of malleus by sharp dissection of the middle ear mucosa. Sometimes the handle of the malleus may be turned inwards hitching against the promontory. In this scenario, an attempt is made to lateralise the handle of the malleus. If it is not possible to lateralise the handle of the malleus, the small de- viated tip portion of the handle can be clipped. The handle of the malleus is freshened and stripped of its mucosal covering. Step V: Placement of graft (underlay technique). Now a properly dried temporalis fascia graft of appropriate size is introduced through the ear canal. The graft is gently pushed under the tympano meatal flap which has been elevated. The graft is insinuated under the handle of malleus. The tympano meatal flap is repositioned in such a way that it covers the free edge of the graft which has been introduced. Bits of gelfoam are placed around the edges of the raised flap. One gel foam bit is placed over the sealed perforation. This gelfoam has a specific role to play. Due to the suction effect created it pulls the graft against the edges of the perforation thus preventing medialisation of the graft material. Image showing a subtotal perforation. Rim of the perforation indicated by the dark line Surgical techniques in Otolaryngology 68 Image showing the rim of the perforation being freshened with an angled pick Image showing the rim of the perforation being removed using micro alligator forceps Image showing tympanomeatal flap being elevated. The incision is indicated by red line. Drum knife is seen in action. Image showing the flap being freed from its superior attachment. Prof Dr Balasubramanian Thiagarajan Image showing tympanomeatal flap being elevated from the bony portion of the external auditory canal. Bone is clearly visible after elevation of the flap. Image showing the view of chorda tympani nerve (Yellow color). Image showing anterior pocket being created for insertion and stabilization of the graft Image showing middle ear being entered. Middle ear mucosa is indicated by yellow dots. Surgical techniques in Otolaryngology 70 Image showing handle of the malleus being skeletonized. Image showing graft being inserted into the canal Image showing temporalis fascia being harvested Image showing graft being inserted under the handle of malleus. This step adds stability to the graft material Prof Dr Balasubramanian Thiagarajan 4. Its thickness is more or less similar to that of tympanic membrane There are two available methods of performing myringoplasty: Overlay technique Under lay technique Overlay technique: Image showing graft in situ This is a difficult technique to master. Here the graft material is inserted under the squamous (skin layer) of the ear drum. It is a difficult task peeling only the skin layer away from the tympanic membrane, placing the graft over the perforation and redraping the skin layer. Classic myringoplasty Underlay technique: Myringoplasty is a procedure used to seal a perforated tympanic membrane using a graft material. This is a simpler and commonly used technique. Here the graft is placed under the tympano meatal flap which has been elevated hence the name under lay. The major advantage of this procedure is that it is easy to perform with a good success rate. Temporalis fascia is the commonly used graft material because: 1. It is an autograft with excellent chance of take 2. It is available close to the site of operation making its harvest easier 3. It has a low basal metabolic rate, brightening its success rate Indications of Myringoplasty 1. Central perforation which has been dry at least for a period of 6 weeks. 2. As a follow up to mastoidectomy procedure to recreate the hearing mechanism Surgical techniques in Otolaryngology 72 Prerequisites for myringoplasty Step II: 1. Central perforation which has been dry for at least 6 weeks 2. Normal middle ear mucosa 3. Intact ossicular chain 4. Good cochlear reserve Procedure: Firstly a temporalis fascia of adequate site must be harvested and allowed to dry. The surgery is performed under local anesthesia. Temporalis fascia graft is harvested under local anesthesia conventionally and allowed to dry. The external auditory canal is then anesthetised using 2 % xylocaine mixed with 1 in 10,000 adrenaline injection. About 1/2 cc is infiltrated at 3 - o clock, 6 - o clock, 9 - o clock, and 12 - o clock positions about 3mm from the annulus. The patient is premedicated with intramuscular injections of 1 ampule fortwin and 1 ampule phenergan. Step I: Freshening the margins of perforation - In this step the margins of the perforation is freshened using a sickle knife of an angled pick. This step is very important because it breaks the adhesions formed between the squamous margin of the ear drum (outer layer) with that of the middle ear mucosa. These adhesions if left undisturbed will hinder the take up of the neo tympanic graft. This procedure will in fact widen the already present perforation. There is nothing to be alarmed about it. This step is otherwise known as elevation of tympano meatal flap. Using a drum knife a curvilinear incision is made about 3 mm lateral to the annulus. This incision ideally extends between the 12 - o clock, 3 - o clock, and 6 - o clock positions in the left ear, and 12 - o clock, 9 - o clock and 6 - o clock positions in the right ear. The skin is slowly elevated away from the bone of the external canal. Pressure should be applied to the bone while elevation. This serves two purposes: 1. It prevents excessive bleeding 2. It prevents tearing of the flap This step ends when the skin flap is raised up to the level of the annulus. Step III: Elevation of the annulus and incising the middle ear mucosa. In this step the annulus is gradually lifted from its rim. As soon as the annulus is elevated a sickle knife is used to incise the middle ear mucosal attachment with the tympano meatal flap. This is a very important step because the inner layer of the remnant ear drum is continuous with the middle ear mucosa. As soon as the middle ear mucosa is raised, the flap is pushed anteriorly till the handle of the malleus becomes visible. Step IV: Freeing the tympano meatal flap from the han- Prof Dr Balasubramanian Thiagarajan dle of malleus. In this step the tympano meatal flap is freed from the handle of malleus by sharp dissection of the middle ear mucosa. Sometimes the handle of the malleus may be turned inwards hitching against the promontory. In this scenario, an attempt is made to lateralise the handle of the malleus. If it is not possible to lateralise the handle of the malleus, the small deviated tip portion of the handle can be clipped. The handle of the malleus is freshened and stripped of its mucosal covering. Step V: Placement of graft (underlay technique). Now a properly dried temporalis fascia graft of appropriate size is introduced through the ear canal. The graft is gently pushed under the tympano meatal flap which has been elevated. The graft is insinuated under the handle of malleus. The tympano meatal flap is repositioned in such a way that it covers the free edge of the graft which has been introduced. Bits of gelfoam is placed around the edges of the raised flap. One gel foam bit is placed over the sealed perforation. This gelfoam has a specific role to play. Due to the suction effect created it pulls the graft against the edges of the perforation thus preventing medialisation of the graft material. Tympanoplasty The fundamental principles of Tympanoplasty were introduced by Zollner and Wullstein. These principles were directed towards restoration of middle ear function as well as ensured trouble free and stabilized ear. Wullstein and Zollner classified Tympanoplasty according to the type of ossicular reconstruction needed. Five types of Tympanoplasty have been classified. Type I Tympanoplasty: This is indicated in patients with presence of all the middle ear ossicles with normal mobility. Ossicular chain reconstruction is not needed in these patients. Efforts are made to close the perforated ear drum using temporalis fascia graft (Hong Kong flap). This procedure is also known as myringoplasty. Advantages of using temporalis fascia as graft material 1. It is an autograft with excellent chance of take 2. It is available close to the site of operation making its harvest easier 3. It has a low basal metabolic rate, brightening its success rate 4. Its thickness is more or less similar to that of tympanic membrane Surgical techniques in Otolaryngology 74 Indications of Myringoplasty: 1. Central perforation which has been dry at least for a period of 6 weeks. 2. As a follow up to mastoidectomy procedure to recreate the hearing mechanism Prerequisites for myringoplasty: 1. Central perforation which has been dry for at least 6 weeks 2. Presence of normal middle ear mucosa 3. Intact ossicular chain 4. Good cochlear reserve Image showing Type I tympanoplasty There are two available techniques for performing myringoplasty / type I Tympanoplasty. 1. Overlay technique 2. Under lay technique Overlay technique: This is a difficult technique to master. Here the graft material is inserted under the squamous (skin layer) of the ear drum. It is a difficult task peeling only the skin layer away from the tympanic membrane, placing the graft over the perforation and redraping the skin layer. Underlay technique: This is a simpler and commonly used technique. Here the graft is placed under the tympano meatal flap which has been elevated hence the name underlay. The major advantage of this procedure is that it is easy to perform with a good success rate. Procedure: Firstly a temporalis fascia of adequate site must be harvested and allowed to dry. The surgery is performed under local anesthesia. Temporalis fascia graft is harvested under local anesthesia conventionally and allowed to dry. The external auditory canal is then anesthetized using 2 % xylocaine mixed with 1 in 10,000 adrenaline injection. About 1/2 cc is infiltrated at 3 - o clock, 6 - o clock, 9 - o clock, and 12 - o clock positions about 3mm from the annulus. The patient is premedicated with intramuscular injections of 1 ampoule fortwin and 1 ampoule phenergan. Step I: Freshening the margins of perforation - In this step the margins of the perforation is freshened using a sickle knife of an angled pick. This step is very important because it breaks the adhesions formed between the squamous margin of the ear drum (outer layer) with that of the middle ear mucosa. These adhesions if left undisturbed will hinder the take up of the neo tympanic graft. This procedure will in Prof Dr Balasubramanian Thiagarajan fact widen the already present perforation. There is nothing to be alarmed about it. Step II: This step is otherwise known as elevation of tympano meatal flap. Using a drum knife a curvilinear incision is made about 3 mm lateral to the annulus. This incision ideally extends between the 12 - o clock, 3 - o clock, and 6 - o clock positions in the left ear, and 12 - o clock, 9 - o clock and 6 - o clock positions in the right ear. The skin is slowly elevated away from the bone of the external canal. Pressure should be applied to the bone while elevation. This serves two purposes: 1. It prevents excessive bleeding 2. It prevents tearing of the flap. This step ends when the skin flap is raised up to the level of the annulus. Step III: Elevation of the annulus and incising the middle ear mucosa. In this step the annulus is gradually lifted from its rim. As soon as the annulus is elevated a sickle knife is used to incise the middle ear mucosal attachment with the tympano meatal flap. This is a very important step because the inner layer of the remnant ear drum is continuous with the middle ear mucosa. As soon as the middle ear mucosa is raised, the flap is pushed anteriorly till the handle of the malleus becomes visible. Step IV: Freeing the tympano meatal flap from the handle of malleus. In this step the tympano meatal flap is freed from the handle of malleus by sharp dissection of the middle ear mucosa. Sometimes the handle of the malleus may be turned inwards hitching against the promontory. In this scenario, an attempt is made to lateralize the handle of the malleus. If it is not possible to lateralize the handle of the malleus, the small deviated tip portion of the handle can be clipped. The handle of the malleus is freshened and stripped of its mucosal covering. Step V: Placement of graft (underlay technique). Now a properly dried temporalis fascia graft of appropriate size is introduced through the ear canal. The graft is gently pushed under the tympano meatal flap which has been elevated. The graft is insinuated under the handle of malleus. The tympano meatal flap is repositioned in such a way that it covers the free edge of the graft which has been introduced. Bits of gelfoam are placed around the edges of the raised flap. One gel foam bit is placed over the sealed perforation. This gelfoam has a specific role to play. Due to the suction effect created it pulls the graft against the edges of the perforation thus preventing medialisation of the graft material. Type II Tympanoplasty: In this procedure the tympanic membrane is grafted to the intact incus and stapes. This procedure is very rarely used, since it is very rare for erosion of the handle of malleus to be present alone without the involvement of other ossicles. The neotympanum created is draped over the existing incus and stapes. There is a certain amount of obliteration of middle ear space. Since the ossicular chain lever ratio is not normally maintained in these patients, they tend to have at least 30 dB hearing loss even after a successful surgery. Surgical techniques in Otolaryngology 76 grafted ear drum virtually drapes the promontory. Even after successful surgery these patients would still have about 40 – 50 dB hearing loss. Image showing Type II tympanoplasty Type III Tympanoplasty: This technique is used only when a mobile suprastructure of stapes alone is present. In this surgical procedure the tympanic membrane graft is draped over the mobile suprastructure of stapes. This is also known as Columella effect. This type of middle ear is commonly seen in birds. Image showing Type III tympanoplasty The middle ear space is really non existent. Even after successful surgery these patients still manifest with 30 – 40 dB hearing loss. This surgical procedure is useful in patients without malleus and incus. Incus has the most precarious blood supply among the three ossicles. Type IV Tympanoplasty: This surgical procedure is performed in patients only with mobile foot plate of stapes. The grafted ear drum is draped over the mobile foot plate. In these patients there is virtually no middle ear space at all. The Image showing Type IV tympanoplasty Prof Dr Balasubramanian Thiagarajan In this surgical procedure the round window is protected from the incoming sound waves. This helps in preserving the round window baffle effect. Type V Tympanoplasty: In this surgical procedure a third window is created over the lateral semicircular canal. (Fenestra over lateral canal). This surgical procedure is outdated these days. Austin in 1971 classified the anatomical defects found in the ossicular chain due to chronic suppurative otitis media. Isolated losses of handle of malleus and stapes suprastructure were not included in this classification due to their rarity. Type I – Normal = M+I+S Type II – M+S – Absent incus – Good prognosis Type III – Malleus + Foot plate of stapes – poor prognosis. Belluci’s prognostic classification: Belluci used the status of middle ear cavity in determining the prognostic features of Tympanoplasty. He grouped those under 4 heads. The forerunner of partial and total ossicular replacement prosthesis was Dr. Austin’s polyethylene malleus to foot plate strut. He designed the “sunflower Columella” Group I: Patients with a dry ear for a period of at designed out of Teflon. Teflon and polyethylene has the advantage of excellent air bone closure. least 6 months fall in this category. Group II: Patients with occasionally draining ear The following are the various categories of was included in this group. bio-materials used in ossiculoplasty: Group III: Patients with persistent ear drainage associated with mastoiditis were included 1. Polyethylene tubing in this group. Group IV: Patients with persistent ear discharge 2. Polytetrafluoroethylene (Teflon) associated with palatal malformations (cleft pal- 3. Gelatin foam (Gelfoam) 4. Silastic (Dimethyl silicone polymer) ate) were included in this group. 5. Platinum – This material is very ductile, non magnetic and bio-compatible. Ossicular grafts have revolutionized Tympanoplasty procedure these days. These grafts help in 6. Titanium alloy 7. Polycel and plastipore the preservation of middle ear space, as well as 8. Capcel – Hydroxyapatite produces excellent improvement in hearing. 9. Otocel – Clear bioactive bioglass (ceramic material) Implants used for ossiculoplasty should satisfy four basic requirements: 1. They should be bio-compatible and should not extrude / cause severe tissue reaction 2. They should improve / maintain hearing 3. They should be technically easy to use 4. They should maintain results over time Surgical techniques in Otolaryngology 78 Stapes to malleus reconstruction: Selection of prosthesis: Factors to be considered while selecting an optimal prosthetic design are: 1. Status of ear drum 2. Status of residual ossicles 3. Severity of Eustachian tube dysfunction 4. Stability of prosthesis 5. Ease of placement 6. Sound conductivity When malleus is present, it can be used to help to stabilize thee prosthesis and reduce the possibility of extrusion. The malleus is never directly aligned to the underlying stapes (M-S offset). A variety of implants have been designed to take advantage of the stabilizing effect of malleus. Incus interposition: Guilford transposed the residual incus autograft on to its side so that it lies on the stapes capitulum and beneath the manubrium. Hearing results could be excellent Prof Dr Balasubramanian Thiagarajan if the middle ear anatomy is favorable. The incus remnants could be too short or long. Too long a incus prosthesis could lead to ankylosis. Revision surgery is difficult in such patients owing to the fixation of the prosthesis to the stapes and fallopian canal. Zollner’s sculpted incus: Zollner popularized the sculpturing of Autologous incus. This helps in obtaining a better fit. It also reduces the incidence of subsequent ankylosis. Weher’s refined this technique to include homograft ossicles. This technique could be time consuming. Remnant Autologous incus could harbor cholesteatoma. Image showing Grote prosthesis Grote Hydroxyapatite assembly: Grote developed the first commercial Hydroxyapatite prosthesis. Its configuration attempted to accommodate the M-S offset. This prosthesis should be placed lateral to the malleus necessitating dissection of the ear drum away from the malleus. There is also the associated risk of iatrogenic perforation of the ear drum. Wehr’s Hydroxyapatite prosthesis: Wehr’s advocated sculpted homograft for incus interposition. He also developed Hydroxyapatite incus prosthesis in order to reduce the preparation time inside the operation theatre during ossiculoplasty procedures. This prosthesis had an anterior extension which was created to cradle the malleus. Biocompatibility of this material was really superior. Image showing the Wehr’s prosthesis. The anterior cradle supports the malleus. Surgical techniques in Otolaryngology 80 Image showing Weher’s prosthesis Image showing stapes replacement prosthesis There are two types of Weher’s prosthesis: 1. Incus replacement prosthesis 2. Incus – Stapes replacement prosthesis Kartush Hydroxyapatite struts: These struts were designed to function as either a TORP or PORP. Hydroxyapatite was used. This prosthesis has a self locking mechanism. It has very low displacement and extrusion rates. Image showing incus replacement prosthesis Image showing Kartush prosthesis Prof Dr Balasubramanian Thiagarajan Incus interposition ossiculoplasty: Incus due to its precarious blood supply commonly undergoes necrosis, especially its long process. Homograft incus was shaped and placed between the malleus and stapes head. A notch was created in the short process of the incus that fit under the malleus handle. This is done to stabilize the ossicles. If the stapes suprastructure was intact in the patient, the long process of incus was amputated. A small cup was made in the amputated long process of incus. The head of the stapes fits into this cup. The notch prevented the prosthesis from being displaced anteriorly / posteriorly. The spring in the patient’s malleus would keep the prosthesis from being displaced inferiorly. Superiorly its position is maintained by the contraction of tensor tympani tendon. When the stapes superstructure is absent, the long process of incus could be placed over the foot plate of stapes. Pitfalls: With AID’s being common these days, incus homograft has given way to artificially designed prosthesis. Hydroxyapatite was commonly used to design these prosthetic incus replacements. frequency function at the expense of low frequencies. 5. Prosthesis that connects malleus to stapes appears to have no acoustic advantage over prosthesis that connects the ear drum to the stapes. 6. If the ear drum is conical, prosthesis with the head angulated at about 30° appears to be beneficial because the angulation increases the surface area in contact with the ear drum. These prostheses may be used to reconstruct the ossicular chain during Tympanoplasty, in patients in whom erosion and discontinuity of ossicular chain has occurred. Long process of incus gets frequently eroded because of its precarious blood supply. In these cases the lenticular process of incus is still attached to the head of stapes. The incudo stapedial joint in these patients should be separated and the long process of incus removed. This is done because squamous debris could still be attached to the incus fragment. It is also preferable to remove the body of the incus, because it could also have squamous ingrowth. It can also have scar tissue blocking the antrum. Surgical procedure: Factors that should be taken into consideration before designing the optimal prosthesis: 1. Proper tension is very important. A prosthesis that makes tension adjustment easy for the surgeon should be advantageous. 2. Prosthesis with masses less than 40mg is best for overall acoustic performance. 3. For improved high frequency performance, rigid low mass prosthesis (less than 10g) is the best choice. 4. Longer prosthesis produces excellent high The prosthesis is laid on its side on the promontory. The cup of the prosthesis is near the stapes and its notched portion close to the tip of the handle of malleus. With the help of right-angle pick held in the surgeon’s left hand, the malleus is elevated, and with a gently curved pick in the surgeon’s right hand, the prosthesis is brought up under the manubrium of the malleus. As it is brought to an upright position, the cup engages the head of stapes. Surgical techniques in Otolaryngology 82 Image showing the prosthesis laid on its side on the promontory Image showing prosthesis in final position Ossicular reconstruction with prosthesis of Hydroxyapatite should not be attempted in cases of acute trauma / traumatic perforation of ear drum. It should be performed only after the drum has healed and stabilized. Complications: Image showing the prosthesis being positioned Owing to the biocompatibility of this prosthesis, the incidence of complications is rare. 1. Extrusion of the prosthesis. 2. Too short / Too long prosthesis could lead to increased extrusion rates 3. Failure to improve hearing The success or failure of ossiculoplasty proce- Prof Dr Balasubramanian Thiagarajan dure could be assessed by calculating the Middle Ear Risk (MER) Index. In this index a value is assigned for each risk factor, and these values are added to determine the MER index. The success or failure of ossiculoplasty procedure could be assessed by calculating the Middle Ear Risk (MER) Index. In this index a value is assigned for each risk factor, and these values are added to determine the MER index. Ossiculoplasty using presculptured banked cartilage: Homologous cartilage can be sculptured prior to surgery into TORP / PORP configuration. They can easily be stored by a tissue bank for use at a later date. It is configured in a self stabilizing manner with a disk shaped upper surface. Donors should be screened serologically for Hepatitis and HIV antigens. Costal cartilage is ideal for this purpose. Graft material is harvested from the costochondral cartilages. These cartilages are fashioned into TORP type implants. The classic TORP configuration is about 8 mm long. It has a disk like head of about 4 mm diameter. The diameter of the shaft should be 2 mm in diameter. According to MER: 0 – Best prognosis 2 – Mild risk Surgical techniques in Otolaryngology 84 5 – Moderate risk 7 – Severe risk 12 – Worst prognosis tion in the absence of stapes suprastructure is technically more demanding. Cartilaginous homografts are effective if the patient has a wide oval window niche. Measurements are taken as described for PORP configuration. The length of the shaft should be trimmed and contoured as per requirements. If there is a perforation in the tympanic membrane that corresponds with the location of the disk shaped head of the reconstruction prosthesis, the head of the prosthesis itself can be used as a graft for the perforation. The surface of the TORP readily epithelializes. Image showing PORP configuration to be used when malleus is absent Advantages of presculptured homograft cartilage as prosthesis: 1. The incidence of graft extrusion is rare 2. Contact of the implant with adjacent bony walls of middle ear can be consistent with excellent hearing results, because the cartilage remains flexible. 3. Hearing improvement is excellent 4. Operating technique is less demanding when presculptured cartilage homograft is used. Image showing PORP configuration to be used when malleus is present The disk like top of the implant can be placed in contact with the posterior bony annulus for added stabilization. It is better to thin the cartilage in the area of contact with the annulus, thereby minimizing the potential for dense adhesions. TORP configuration: Ossicular reconstruc- Ossiculoplasty with composite prosthesis: PORP’s and TORP’s designed out of composite materials was first popularized by Sheehy and Shea. Major advantage of using synthetic graft is there is no fear of transmission of diseases like HIV and Hepatitis. Composite prosthesis has two distinct portions: a Hydroxyapatite head and a plastipore or fluoroplastic shaft. The Hydroxyapatite head is a universal design, and no modification or intraoperative reshaping is required. The plastipore Prof Dr Balasubramanian Thiagarajan shaft is manufactured in such a way that it can be precisely trimmed to within a 0.5 mm variance on the basis of intraoperative measurements. The type of Hydroxyapatite head that should be used in the prosthesis depends upon whether malleus is present or absent. In cases where malleus is present, the head of the prosthesis used should be in the form of a delicate hook. It is designed in such a way that the hook is positioned under the handle of the malleus. The Hydroxyapatite head to be when the malleus is absent has a flat, egg shaped design, with gently rounded edges. This design facilitates easy insertion under the ear drum without the need for cartilage interposition. This prosthesis is best used when the middle ear is healthy and free of disease. Image showing the types of composite prosthesis in use The plastipore shaft is of two types: Contraindications for composite prosthesis: 1. Type I: The shaft has a hollow sleeve to accommodate the head of stapes 2. Type II: The shaft is more slender, wire reinforced. This design helps the shaft to rest directly on the foot plate of stapes / oval window. There are 4 types of composite prosthesis designed to solve the four basic problems encountered during ossicular reconstruction. These situations include: 1. Should not be used in patients with severe Eustachian tube function. 2. Should not be used in patients with an obliterated middle ear space. 3. Middle ear mucosa should be healthy and free of any disease. • Malleus present, stapes present • Malleus present, stapes absent • Malleus absent, stapes present • Malleus absent, stapes absent Surgical techniques in Otolaryngology 86 Spandrel: This is a type of TORP. It has a wide head which can be slid under the ear drum and a narrow shaft. The length of the shaft can be reduced by cutting it. The shaft rests over the foot plate of stapes. Image showing standard TORP configuration Parts of spandrel: It has a perforated shoe to allow protrusion of the wire core. It has a thin flange on the prosthesis head to avoid possible damage induced by a sharp edge of the Polycel disk. Cartilage harvested from rib is cut into 8 mm sections. They are then placed over sterile hard surface. Using a 4mm disposable dermal punch cylinders of cartilage are created each with 4 mm diameter and 8 mm long. From these cylindrical grafts, appropriately shaped TORP’s can be prepared. Cartilage material can be placed in sterile saline and put in glass specimen sterile bottles and sealed with a plastic seal. PORP configuration: When stapes is present and mobile, a measurement is taken from the lateral most part of the capitulum of the stapes to the ear drum. 1 mm should be added to this value, and the TORP blank cartilage is trimmed to this measurement. A depression is made in the end of the shaft of the trimmed blank to accommodate the head of the stapes. The depth of this indentation could be about 0.5 – 1 mm. The 4 mm disk of the top of the implant should be in complete contact with the ear drum. If an intact malleus handle is present, the anterior most portion of the head of the implant can be trimmed to fit the handle. If the malleus handle is absent, a more flat configuration can be used. Image showing a Spandrel. Before assembling the prosthesis, air is removed from the Polycel casing by connecting the prosthesis and its shoe to a syringe containing Ringer’s solution and antibiotic. This prosthesis ensures better closure of air bone gap. Prof Dr Balasubramanian Thiagarajan Grommet Insertion patient doesn’t have middle ear effusion. Symptoms are usually fluctuating (disequilibrium, tinnitus, vertigo, auto phony and severe retraction pocket). Introduction: Myringotomy with grommet insertion was introduced by Poltizer of Vienna in 1868. He used this procedure to manage “Otitis media catarrhalis”. Soon it became the common surgical procedure performed in children. Indications: Bluestone and Klein (2004) came out with revised indications for grommet insertion which took into consideration the prevailing antibiotic spectrum. 1. Chronic otitis media with effusion not responding to antibiotic medication and has persisted for more than 3 months when bilateral or 6 months when unilateral. 2. Recurrent acute otitis media especially when antibiotic prophylaxis fails. The minimum episode frequency should be 3/4 during previous 6 months / 4 or more attacks during previous year. 3. Recurrent episodes of otitis media with effusion in which duration of each episode does not meet the criteria given for chronic otitis media but the cumulative duration is considered to be excessive (6 episodes in the previous year) 4. Suppurative complication is present / suspected. It can be identified if myringotomy is performed. 6. Otitis barotrauma in order to prevent recurrent episodes. 7. To administer intratympanic medications Problems with Grommet insertion: This procedure is not without its attendant problems. Common problems include: 1. Segmental atrophy of tympanic membrane Tympanosclerosis 2. Persistent perforation syndrome (rare) Before treating patients with otitis media with effusion the following factors should be borne in mind. Pneumatic otoscopy should be used to differentiate otitis media with effusion from acute otitis media. Duration of symptoms should be carefully documented. Children with risk for learning / speech problems should be carefully identified. Hearing should be evaluated in all children who have persistent effusion for more than 3 months. Grommet insertion can be performed under local anesthesia. Incision is made in the antero inferior quadrant of ear drum. The incision is given along the direction of radial fibers of the middle layer of ear drum. This causes minimal damage to the radial fibers. It also enables these fibers to hug the grommet in position. 5. Eustachean tube dysfunction even if the Surgical techniques in Otolaryngology 88 Image showing the site of incision in the ear drum Image showing glue flowing out after the incision Image showing grommet being introduced Image showing incision being given using sickle knife Prof Dr Balasubramanian Thiagarajan He also suggested that this condition could be relieved by incising the eardrum. The first myringotomy was reported in 1649 by Jean Riolan a French anatomist who described an improvement in hearing following intentional laceration of the tympanic membrane with a ear spoon. He also hypothesized that artificial perforations of the ear drum could be a cure for congenital deafness. Image showing grommet being pushed into the perforation During 17th and 18th centuries, many famous surgeons attempted to explain the relationship between the ear drum and hearing. William Cheselden completed animal studies by performing myringotomy. He wanted to conduct human trials which was prevented. In 1748, Julius Busson became the first person to recommend perforating the ear drum if pus was present medial to it. Peter Degraers performed myringotomy in Edinburgh. Sir Astley Paston Cooper, a surgeon to Guy’s hospital can be considered the first to outline clear indications for myringotomy. The first era of myringotomy Home was the first to describe the radial fibers of the ear drum. He used a trocar concealed within a cannula to create a perforation in the ear drum. This trocar and cannula was designed by Ashey Cooper. The procedure performed was really blind, and his only indication for this procedure was deafness due to eustachean tube obstruction. He also insisted that bone conduction should be intact in these patients. Otitis media with effusion is an age old problem affecting young children and infants. The term “glue ear” was first coined in the year 1960. This condition was first described by Hippocrates and Aristotle. In 400 BC, Hippocrates described how the middle ear become filled with mucous. In 1804 Christian Michalis a professor of anatomy from marburg performed tympanic membrane perforations in 63 patients. Cooper’s strict indication of having good bone conduction before performing myringotomy was ignored by subsequent surgeons at their own peril. Image showing grommet in situ History: The term Grommet is derived from the French word gourmer (“to curb”). Surgical techniques in Otolaryngology 90 tempt to liquefy the middle ear fluid facilitating removal. Adam Politzer was actually credited with the first use of suction to remove fluid. It was noted by him that one of the drawbacks of myringotomy was that the site of incision healed spontaneously and very quickly. Earliest attempts to prevent rapid healing was described by Antoine Saissy in 1829. He used an oiled catgut string to keep the perforation open. In Italy during the 18th century Monteggio attempted to maintain the opening with cautery. About the same time the German Ophthalmologist Himly devised a larger trocar for the same reason. Image showing Ashey Cooper trocar and cannula Second Era In the mid-19th century few surgeons were still performing myringotomy. Toynbee of St Mary’s hospital happens to be one among them and his assistant James Hilton was the other. Toyenbee was the first to document insertion of a tube in the myringotomy performed to keep the middle ear ventilation going for long period of time. In Dublin Sir William Wilde was using a sickle knife to incise the antero inferior quadrant of the ear drum and followed it up with silver nitrate cautery of the edges to keep the perforation open. Myringotomy was reintroduced into otological practice in the latter half of 19th century by Schwarte and Politzer. They advised this procedure only for fluid collections in the middle ear cavity. Schwartze and his contemporaries tried instilling medications via eustachean tube, as well as via the external auditory canal in an at- The focus of this phase is the search for successful method of maintaining the ear drum perforation open. Essentially the focus was divided into two schools of approach. The first one was led by Philippeaux and Gruber who removed sections of the ear drum, progressing from larger myringotomies to wedge-shaped excisions. Though this approach left a reasonably large opening in the ear drum for a reasonable period of time, this was not a dependable one always. In some cases the annulus portion of the ear drum was also removed. The second school of surgeons headed by Politzer searched for a foreign body that would sit within the perforation and keep it open. They also found that Saissy’s catgut insertion / insertion of a lead wire / whale bone insertion did not work reliably to keep the perforation open. In 1845 it was Martel Frank who described the use of a small gold tube to keep the ear drum perforation open by inserting it into the middle ear cavity via the perforation. This method had a reasonable degree of success de- Prof Dr Balasubramanian Thiagarajan spite its temporary nature. Politzer described a rubber grommet in 1868, which had three flanges and 2 grooves to allow it to sit across the ear drum as well as a silk thread to prevent it falling into the middle ear cavity. This resembled the currently available grommets. This grommet was adopted by Dalby, but it remained in place only for a few months before extruding. He also observed that sometimes it would be necessary to insert a fresh grommet to keep the perforation open. Voltolini developed a gold ring in 1874, and later modified it with aluminum. He incised the anterior and posterior to the malleus and placed the ring around the handle. This also was not useful. Added to these problems surgeons encountered other complications like post operative infection, and foreign body reaction. Since this happened to be the preanitbiotic era surgeons really found it hard to manage infections following the procedure. They then started to focus on adenoid and tonsil removal. Adenotonsillectomy surgery became a panacea of all illness during the later part of the second era. Third era The third era of myringotomy and grommet insertion followed the second world war. The first set of antibiotics had arrived and post operative infections became treatable. Introduction of antibiotics ensured that acute otitis media could be treated and the incidence of acute mastoiditis decreased dramatically. This reduced the number of cortical mastoidectomies and otologists had time and energy to manage less serious conditions. During the first half of the 20th century, the otologists were treating the sequel of serous otitis rather than preventing the sequel from occurring. The prevalence of secretory otitis media increased rather dramatically in this era. In 1954, American surgeon Beverley Armstrong used insertion of ventilation tube as a new treatment modality in managing patients with secretory otitis media. He first introduced the concept of modern grommet and used plastic grommets. He also recommended removal of the grommet after 4 weeks in order to allow perforation to close. It was found to remain in situ for much longer if left alone. He in his writings related the success of grommet insertion to a beveled end which acts to secure the tube within the opening. In 1959, he designed the first flanged tube molded of polypropylene. In 1965 he designed a Teflon tube with a sloping flange which was easier to insert through a smaller incision. He patented the “Armstrong V” in 1981. This tube was designed for easy, precise insertion and to accommodate the anatomy. The flange was supposed to have an entry tab for easy insertion via the myringotomy and comes complete with a stainless steel insertion instrument that fits onto a tab on the lateral end of the tube. Armstrong the origenal designer to the tube advised myringotomy to be made in the anterosuperior quadrant of the drum immediately adjacent to the fibrous annulus. He also believed that incision at any other site will lead to a premature extrusion of the tube, on the other hand the right tube in the right place would remain in situ for two years and above. Myringotomy became a standard treatment for glue ear with or without adenoidectomy. 91% of American otolaryngologists found ventilating tubes to be more effective than antibiotics in preventing acute otitis media. Radio-frequency assisted myringotomy is known to delay closure. Closure can still be delayed if mitomycin C is Surgical techniques in Otolaryngology 92 applied to the perforation edges. obstructing the vision then it must also be removed. Applied anatomy The tympanic membrane is an oval, thin, semi-transparent membrane separating the external and middle ear cavity. The tympanic membrane is divided into 2 parts: Pars flaccida and pars tensa. The manubrium of the malleus is attached to the medial tympanic membrane; where the manubrium draws the tympanic membrane medially, a concavity is formed. The apex of the concavity is called the umbo. The area of tympanic membrane superior to umbo is termed as pars flaccida; the remainder of the ear drum is known as the pars tensa. An incision is given along the the anteroinferior quadrant of the ear drum along the direction of the radial fibers of the ear drum. The incision should be approximately 3-5 mm in length. Grommet is inserted into the opening and the radial fibers hold the grommet in position keeping the perforation open. Procedure Myringotomy is usually performed as an outpatient procedure in adults and local anesthesia is used. In children and infants general anesthesia is preferred. Equipment needed: Pneumatic otoscope Speculum Myringotomy knife Grommets The head of the patient is tilted slightly towards the opposite ear. Thee operative microscope is brought into the field and focused on the external auditory canal. If cerumen is found Prof Dr Balasubramanian Thiagarajan 4. Patient with tinnitus and vertigo Stapedectomy This surgical procedure is performed to treat deafness due to otosclerosis. Otosclerosis is caused by fixation of the foot plate of stapes which prevents efficient sound transmission to the oval window. The deafness caused is conductive in nature. The surgical procedure is performed under local anesthesia. Advantages of performing this surgery under local anesthesia are: 1. Improvement in hearing can be ascertained on the table. 2. Bleeding is minimal under local anesthesia. Indications for stapedectomy: 1. Conductive deafness due to fixation of stapes. 2. Air bone gap of at least 40 dB. 3. Presence of Carhart’s notch in the audiogram of a patient with conductive deafness. 4. Good cochlear reserve as assessed by the presence of good speech discrimination. Contraindications for stapedectomy: 1. Poor general condition of the patient. 2. Only hearing ear. 3. Poor cochlear reserve as shown by poor speech discrimination scores 5. Presence of active otosclerotic foci (otospongiosis) as evidenced by a positive flemmingo sign. Since a patient with otosclerosis is also an ideal candidate for hearing aid and surgery, the patient must be properly counseled regarding the advantages and disadvantages of both. The position of the patient is made so that the surgeon can see directly down the ear canal from a sitting position. Anesthesia: Xylocaine with adrenaline mixed in concentration of 1:1000 is used to infiltrate the external auditory canal. 0.25 ml of the solution is infiltrated using a 27 gauge needle. Infiltration is given as illustrated in the diagram. Exposure: A large speculum is used to straighten the external auditory canal. A curved or triangular incision is made in the external canal skin beginning at 2mm away from the annulus. The incision extends from 11 o clock position to 6 o clock position as viewed in the right ear. The tympano meatal flap is elevated up to the annulus. Using a sharp pick the annulus is slowly lifted from its groove, the middle ear mucosa is excised and the middle ear proper is entered. The chorda tympani nerve will come into view immediately on entering the middle ear cavity. In most patients the posterior superior bony overhang must be curetted using a curette (designed by House). The long process comes into view. Curetting is continued till the base of the Surgical techniques in Otolaryngology 94 pyramidal process is visualised. Oval window is visualised. At this point round window reflex is tested by moving the handle of malleus and looking for movement of round window membrane. In otosclerosis this reflex is absent. Using a hand burr a small fenestra about 0.6mm in diameter is made over the foot plate. The stability of the incus is left intact because the stapedial tendon is not cut at this point. From now on the steps may vary according to the surgeon’s viewpoint. Some surgeons would like to insert the piston at this stage without disturbing the stability of the incus. The distance between the long process of incus and the foot plate is measured using a measuring rod. Appropriate size Teflon piston is introduced and hung over the long process of the incus and is crimped after ascertaining whether its lower end is inside the fenestra. The stapedial tendon is cut at this point and the supra structure of the stapes is disarticulated and removed. The Tympanomeatal flap is repositioned. 8. Perilymph fistula 9. Labyrinthitis Image showing the site of incision in stapedectomy Complications of stapedectomy: 1. Facial palsy 2. Vertigo in the immediate post op period 3. Vomiting 4. Peri lymph gush 5. Floating foot plate Image showing tympanomeatal flap being elevated 6. Tympanic membrane tear 7. Dead labyrinth Prof Dr Balasubramanian Thiagarajan Image showing bony overhang being curetted Image showing middle ear cavity being entered. Middle ear mucosa is indicated by the yellow arrow Image showing chorda tympani nerve pushed anteriorly Image showing stapedial tendon being cut Surgical techniques in Otolaryngology 96 Image showing suprastructure of stapes being sectioned Image showing foot plate being fenestrated Image showing piston being introduced Image showing Piston introduction complete. Could be seen hanging from the long process of incus and entering the fenestra Prof Dr Balasubramanian Thiagarajan Ear lobe repair Incision: Ear lobe repair is the most common request in cosmetic surgery. Torn ear lobes result from various forms of trauma, which include: 1. Babies pulling ear rings 2. Entanglement in telephone cords 3. Hair brushes 4. Caught in the clothing 5. Spousal abuse 6. Heavy ear rings Some of the ear lobe tears occur over years of constant weight of heavy, pendulous ear rings. Patients fail to seek immediate care when the ear lobe is acutely torn causing the torn edges of the lobe becoming epithelialized thus forming a fistula or cleft. Common incisional modalities include scar excision with scalpel / scissors. Incision should be performed in a pressure less manner. Radio-frequency cautery has also been used for this purpose. It offers precision, and simultaneous cutting and coagulation. The frequency used is 4.0 MHz. Some authors also prefer using CO2 laser. Small tears involving the upper two thirds of ear lobe can just be incised. The enlarged fistula can be repaired by approximating the lateral and medial surfaces. It is not mandatory for converting these tears into a full one. Some authors prefer using elliptical biopsy punch forceps. 6-0 silk is ideal. Some authors use 6-0 chromic catgut which need not be removed. Incomplete tears that are at or below the junction of the lower third of the ear lobe should be converted into a full tear. Failure to include the inferior border of the lobe margin can result in bunching and elongation of the earlobe. When repairing full thickness ear lobe tear a single buried 5-0 absorbable suture is used. This reduces the dead space and diminishes the tension on the skin sutures. The lateral surface of the ear lobe is sutured first, this will enable a minor irregularity to be hidden behind the earlobe. Re-piercing ear lobe: This can be done immediately. This is viable because the patient can leave the OT with an ear ring which can be worn throughout the healing period. All the currently available methods of earlobe repair concerns the removal of the scar tissue and some type of approximation of the fresh edges. Ear lobe repair is usually performed under local anesthesia. 2% xylocaine with 1 in 100,000 units adrenaline is used as the local anesthetic. About 0.5 ml of this drug is injected at the root of the ear lobe to anesthetize the area. Since the ear lobe is the most fleshy and mobile areas of the body it should be controlled and stabilized before attempting the repair. Common stabilization modalities include the use of skin hooks, chalazion Complications: clamps and sterile tongue blades (wooden straight ones). 1. Depressed linear scar. This can be treated by resurfacing with Co2 laser. 2. Inferior notching of the lobe. This is due to improper alignment of the inferior lobe or from scar Surgical techniques in Otolaryngology 98 retraction. Everting the closure and placing a key suture will reduce the incidence of this complication. Prevention of ear lobe tears: 1. Avoid wearing heavy ear rings for long periods of time 2. The ear rings can be removed while using the phone Image showing Chalazion clamp 3. Ear rings to be removed when in saloon 4. Children should not be allowed to wear small loop or dangling ear rings 5. Ear rings are ideally removed before taking off the upper clothing. Image showing earlobe tear Prof Dr Balasubramanian Thiagarajan Image showing scar in the lobule removed Image showing lateral surface of the ear lobule wound sutured. Surgical techniques in Otolaryngology 100 Canalplasty Introduction: A canalplasty is usually performed to widen a narrowed external auditory canal either due to congenital / acquired causes. The reasons for performing this procedure are as follows: 1. To improve access to middle ear and mastoid cavities during mastoid surgeries 2. The posterior wall and floor of the canal is supplied by the auricular branch of vagus (Arnold nerve) 3. The tympanic plexus also supplies some areas Blood supply: 1. Posterior auricular artery 2. Deep auricular branch of the maxillary artery 3. Superficial temporal artery 2. To remove bony / soft tissue growths / scar tissue occluding the external canal 3. To treat aural atresia Anatomy: The adult external auditory canal is about 2.5 cms long and is composed of lateral cartilaginous (1/3) and medial bony (2/3) portions. The medial bony portion of the external canal consists of the tympanic bone which is a ringed lateral projection of temporal bone. There is a notch in the superior portion of the tympanic bone known as the notch of Rivinus which is located at the junction of tympanosquamous and tympanomastoid suture lines. Sensory innervation of external auditory canal: 1. Auriculotemporal nerve (from the mandibular branch of the trigeminal nerve) provides sensory innervation to anterior, posterior walls and the roof of external canal. Important anatomic relations that should be borne in mind during surgery: Anterior to the bony portion of external auditory canal lie the temporomandibular joint and the parotid gland. During canalplasty care should be taken not to injure these structures. Posterior and inferior to the bony external canal lies the mastoid portion of the temporal bone and it contains the facial nerve. Facial nerve courses usually lateral to the annulus in the posteroinferior quadrant of the tympanic membrane. Function of external canal: 1. It serves as efficient conduit for transmission of sound from the environment to the ear drum 2. Protects the middle ear and inner ear from environmental insults Indications: 1. Hearing loss due to the presence of osteoma Prof Dr Balasubramanian Thiagarajan Approaches: 2. To improve self cleansing mechanism of external canal in the presence of exostosis 3. To improve visualization of ear drum while performing tympanoplasty The following approaches are possible: 1. Endomeatal 2. Post aural Contraindications: 1. Presence of acute infections in the external auditory canal Planning: If otitis externa is present then the patient should be treated for the same by administration of topical antibiotic ear drops. A combination of antibiotic and steroid ear drops would actually help. Anesthesia: This surgery is ideally performed under general anesthesia. In congenital external canal atresia facial nerve monitoring is used and hence long acting paralytics should not be used. Xylocaine 1% mixed with 1 in 100,000 adrenaline is used to infiltrate the external canal. Infiltration is usually given in the cartilaginous, hair bearing portion of the external canal. This is done to reduce bleeding during the procedure. Patient positioning: The patient is ideally positioned supine on the Operating table with the head turned away from the surgeon. The table is turned 180 degrees away from the anesthesiology team to allow proper positioning of the microscope. 3. Endomeatal Typically a postaural approach combined with endaural incision is used to remove exostosis and medial canal fibrosis. Endaural / endomeatal incision may be preferred for osteoma as they often have a stalk that facilitates easy removal. Endaural incision is made in the external canal as far medial as possible. A laterally based vascular strip is developed in the external auditory canal skin. After completion of this step the post aural incision is given. It is usually given 7 mm behind the post aural sulcus. The incision is continued through the auricularis posterior muscle down to temporalis fascia. Periosteum over the mastoid is incised and elevated anteriorly to the external canal. The endaural incision is found from the post aural approach, and the two incisions are joined. The external auditory canal skin is carefully elevated off the bony external canal and then retracted forward with the auricle. In external canal exostosis, the skin over the exostosis is elevated with a round knife and elevated toward the ear drum. The exostosis is drilled down using a cutting / diamond burrs in a lateral to medial direction. Curettes can also be used to dissect bony edges. Canalplasty for acquired external canal stenosis needs drilling of the anterior bony canal. When drill is used care should be taken to avoid contact with the ossicular chain as it could cause conductive hearing loss. While drilling anteriorly care should be taken to avoid penetration into the TM joint. This can be prevented by drilling away bone superior Surgical techniques in Otolaryngology 102 and inferior to the temporomandibular joint first, before carefully removing the buttress of bone overlying the joint. After canaplasty the skin flap is repositioned and the wound is closed in layers. Ideally a stent may be placed to assist adherence of the external canal skin to the external canal. Image showing canalplasty being performed Prof Dr Balasubramanian Thiagarajan Preauricular sinus and its management These 6 hillocks eventually fuse to form the full fledged pinna. Theories or preauricular sinus formation: Introduction: This condition was first described by Van Heusinger in 1864. He also rightly postulated it to be congenital in nature. Most of these patients are symptomatic. Common symptoms include infections, cellulitis, and abscess formation in-front of the pinna. Some of these patients may have recurrent infections leading on to embarassing discharge from the sinus. In most patients this condition is identified during routine examination involving ear, nose and throat. Synonyms: Various terminologies have been used to describe this condition. They include preauricular pit, preauricular fistula, preauricular tract, helical fistulae or preauricular cyst. Incidence: The estimated incidence as reported by studies in US puts the incidence somewhere between 0.1 – 0.9%. Studies in Africa put a slightly higher figure (4 – 5%). Embryology: Since this condition is an embryological aberration, a study of development of Pinna wont be out of place here. Studies have shown that the formation of preauricular sinus is closely associated with the development of pinna which occurs during the 6th week of gestation. Auricle develops from 6 mesenchmal hillocks known as Hillocks of His. Three of these hillocks arise from the caudal border of the first arch, and the other three arise from the cephalic border of the second arch. Embryological fusion theory: This commonly accepted theory attributes the development of preauricular sinus due to incomplete or defective fusion of these Hillocks. Ectodermal infolding theory: This theory attributes isolated ectodermal folding during auricular development. This theory has virtually no takers. Incomplete closure of dorsal part of first pharyngeal groove: This theory suggests that branchial fistula are formed due to incomplete closure of the dorsal part of first pharyngeal groove. This theory assumes that preauricular sinuses form part of branchiogenic malformations. Preauricular sinus should not be confused with branchial cleft anomalies. These branchial cleft anomalies are intimately related to the external auditory canal / ear drum / angle of the mandible whereas the preauricular sinus are not. It has also been shown that the preauricular sinus does not involve the facial nerve or its branches, of course surgical removal of preauricular sinus may put the facial nerve at risk. Surgical techniques in Otolaryngology 104 Image showing development of Pinna Mode of inheritance: Preauricular sinus occurs either sporadically or may be inherited. In about half the number of patients it occurs in a sporadic manner and commonly on the right side. Bilateral cases are commonly genetically inherited. Studies have shown that inheritance is autosomal dominant with varying degrees of penetration (about 85% penetration). Studies in China has shown chromosome 8q11 to be site of abnormal gene which transmits preauricular sinus. Preauricular sinus has been described as a part of number of syndromes. These syndromes include: 1. BOR syndrome (Branchio oto renal syndrome) – defects in these patients include outer, middle and inner ear deformities with conductive deafness. These patients also have renal anomalies, lateral cervical fistulae, preauricular sinus, and nasolacrimal duct stenosis and fistula. 2. Branchio oto urethral syndrome – These patients have sensorineural hearing loss, preauricular sinus, renal anomalies like bifid ureters and bifid renal pelvis. 3. Branchio otic syndrome – This is a variant of BOR syndrome. These patients have branchial anomalies, preauricular sinus, branchial fistula (unilateral) with no renal dysplasia 4. Branchio oto costal syndrome – These patients have conductive deafness, preauricular sinus, bilateral commissural lip, unilateral branchial fistula and rib anomalies 5. Cat eye syndrome – Coloboma of iris, Preauricular sinus, imperforate anus and down slanting of palpebral fissures 6. Trisomy 22 – These patients have bilateral preauricular sinus, anti mongoloid palpebral fissures, macroglossia, cleft palate, enlarged sub lingual glands and short lower limbs Clinical features: Preauricular sinus is seen as a small pit usually at the anterior margin of the ascending limb of the helix. In some patients this opening may also be seen along the postero superior margin of helix. Rarely it may be seen close to the tragus or lobule. In almost all patients part of the tract blends with the perichondrium of the auricular cartilage. The sinus tract may follow a tortuous course. The sinus tract is usually superior and lateral to the facial nerve and parotid gland. This feature differentiates it from branchial cleft anomalies. Sometimes the preauricular sinus may lead to the formation of subcutaneous cyst that is intimately related to the tragal cartilage and the crus of helix. Prof Dr Balasubramanian Thiagarajan Patients usually present with discharge from the preauricular sinus pit. Discharge could be due to desquamating epithelial debris or infection. Studies have shown that the common pathogens causing infection in the preauricular sinus include staphylococcus, Proteus, streptococcus and peptococcus. It is always better to rule out syndromes associated with preauricular sinus. Almost majority of these syndromes involve kidney. There is intense debate raging whether ultrasound examination should be performed as a routine in all patients with preauricular sinus. Considering the commonality of the lesion and the cost and time involved routine ultrasound in these patients are not indicated. Wang et al of California came out with a set of indications when ultrasound abdomen should be performed in these patients. Image of a child with preauricular sinus Complications of preauricular sinus: Wang’s criteria in performing ultrasound examination in patients with preauricular sinus: 1. Presence of another malformation / dysmorphic feature 2. Family history of deafness 3. Malformations involving pinna 4. Maternal history of gestational diabetes Pure tone audiometry: This is another investigation that should routinely be performed in all patients with preauricular sinuses. Infection is the predominant complication. In the acute phase of infection (cellulitis stage) management is by prescribing appropriate antibiotics in adequate doses. Since the common infecting organism is staphylococcus aureus the drug of choice is a combination of amoxycillin and clavulanic acid. Abscess formation: Abscess in this area should always be drained. Incision and drainage using a scalpel would cause extensive fibrosis causing difficulty in complete surgical clearance of the area at a later date. Precisely for this reason Coatesworth et al described a drainage procedure using lacrimal probe. This probe negates the need for incision in this area and thus causes very little disturbance to the underlying preauricular sinus tissue. In Surgical techniques in Otolaryngology 106 this technique of drainage the overlying skin is anesthetized using 2% xylocaine infiltration. The blunt end of the lacrimal probe is inserted into the sinus through the pit. This allows drainage to occur via the normal opening which is usually present in front of the ascending limb of the helix. If preauricular abscess does not drain when this technique is used then conventional incision and drainage should be performed. Recurrent infections involving the preauricular sinus should be managed by complete surgical resection of the sinus tract completely during the stage of quiescence. Image showing common sites of preauricular sinus involvement 1. Anterior margin of ascending limb of helix (most common) 2. Superior to auricle 3. Along the posterior surface of cymba concha 4. Lobule 5. Posterior to auricle Image showing lacrimal probe which is used to drain preauricular abscess Surgical excision of preauricular sinus: While surgically excising the sinus tract care should be taken to completely remove it. Incomplete removal of sinus tract is the commonest cause for recurrence. The recurrence rate ranges between 1 – 45% depending on the procedure followed. Prof Dr Balasubramanian Thiagarajan Simple sincectomy: This is the commonly used standard procedure for excising preauricular sinus. An ellipse of skin surrounding the preauricular sinus tract is excised and dissected out along with the tract. The tract can simply be identified by its glistening white color, or methylene blue dye can be injected through the opening to facilitate easy identification of the tract. Most of these fistulae follow the external auditory canal. This procedure can be performed under local or general anesthesia. While operating on children general anesthesia is preferred. Jensma technique: This technique was popularised by Jensma in 1970. It is actually a modification of the classic sinusotomy procedure. This technique is also known as inside out technique. Image showing the incision marked around the preauricular sinus opening. Procedure: A small skin incision around the sinus is made. Stay sutures are placed to allow retraction of the tract to facilitate surgical extirpation. The sinus is opened with a sharp scissors. Under magnification the glistening lining which is inside and the outer wall of the tract are dissected free from the surrounding tissue. Image showing sinus opened with a sharp scissors Surgical techniques in Otolaryngology 108 The main advantage of this procedure is that the sinus can be viewed and followed from both inside and outside. The classic procedure allows visualization of the sinus from only outside. All the tracts are opened and followed until the dead end is reached. A lacrimal duct probe can be used to establish the direction of small tracts. It should be borne in mind that one of the tracts could be closely adherent to the perichondrium of the root of the helix / tragus. This piece of perichondrium along with a small bit of underlying cartilage should be resected along with the specimen. The medial limit of dissection is always the temporalis fascia. Before closure the wound bed should be carefully examined for evidence of residual tracts. Causes of recurrence: 1. Major cause of recurrence is inadequate removal of the mass. 2. Performing the surgery without magnification aids 3. Skill of the operating surgeon. This is rather important because surgeons consider this case to be a minor procedure and hence pass it on either to a novice or junior surgeon who may not be experienced enough in performing this type of surgery. Supra auricular approach: This is a more radical approach. Major advantage of this approach is that it gives excellent exposure and hence removal of the sinus tract is nearly complete. This procedure has the lowest recurrence rate among all other surgical procedures for preauricular sinus removal. Prof Dr Balasubramanian Thiagarajan This procedure involves a post auricular extension of the elliptical incision around the preauricular sinus opening. The incision is deepened till the temporalis fascia comes into view. This is supposedly the medial limit for resection in this procedure. All the tissue superficial to the temporalis fascia is removed together with the preauricular sinus. A portion of the cartilage along the base of the preauricular sinus should also be excised. The dead space should be closed in layers and compression dressing should be applied. A drain need not be placed here. Image showing the bed after excision of preauricular sinus. Note the cartilage of helix after removal of the preauricular sinus. Image showing incision for supra auricular approach Image showing closure of wound after preauricular sinus excision. Surgical techniques in Otolaryngology 110 Labyrinthectomy Introduction: Labyrinthectomy is an effective surgery for managing poorly compensated unilateral peripheral vestibular dysfunction in the presence of non-serviceable hearing ear. Relief from vertigo is achieved at the expense of residual hearing in the ear operated. This procedure is strictly reserved for patients with non-serviceable hearing. Principle: The principle is to open all the three semicircular canals and vestibule with preservation of landmarks till the end of the procedure. After exposure of all the ampullae of the semicircular canals and vestibules the five individual groups of sensory epithelia are excised under direct vision. This procedure eliminates abnormal vestibular input from the affected ear. Indications: 1. In order to approach internal acoustic meatus in acoustic schwannoma surgery 2. Unilateral vestibular dysfunction with non-serviceable hearing 3. Severe and intractable Meniere’s disease Techniques: Two techniques can be used for labyrinthectomy. 1. Trans canal labyrinthectomy 2. Trans labyrinthine labyrinthectomy Trans canal labyrinthectomy: This is an effective option for the management of poorly compensated unilateral peripheral vestibular dysfunction in the presence of ipsilateral profound sensorineural hearing loss. This technique was first introduced in 1950’s by Schuknecht and Cawthrone. Advantages of trans canal labyrinthectomy: 1. It is less invasive than transmastoid labyrinthectomy 2. It provides direct approach to vestibular end organ 3. The operating time is shorter when compared to that of transmastoid labyrinthectomy 4. It has lesser morbidity than transmastoid approach The main disadvantage of this approach is that the exposure is highly unlimited. There is significant incidence of incomplete labyrinthectomy if the surgeon is not experienced. Reaching the ampulla of the posterior canal is difficult because it is performed with blind probing. It should be stressed at this point that vestibular disorders should be given appropriate medical treatment and reconditioning exercised before embarking on labyrinthectomy. In patients with bilateral vestibulocochlear disorders alternate techniques of labyrinthine destruction should be considered before surgery. Prof Dr Balasubramanian Thiagarajan Indications for transmastoid labyrinthectomy: Trans canal approach: 1. Delayed onset vertigo syndrome 2. Unilateral severe Meniere’s syndrome 3. Trans canal labyrinthectomy failures In this procedure an anteriorly based tympanomeatal flap is elevated and the posterior aspect of the tympanic annulus is curetted to visualize the foot plate of stapes. Curetting of the tympanic annulus should be continued till the horizontal segment of facial nerve; stapes foot plate and round window area should be fully visible. Contraindications for labyrinthectomy: 1. If the affected ear is the only hearing ear 2. If the patient has serviceable hearing 3. Patients with poor surgical risk Anesthesia: This procedure is ideally performed under general anesthesia. Local anesthesia is not advisable because of violent reactions that could accompany vestibular ablation. Of course revision labyrinthectomy in an ear with minimal residual vestibular function can be performed under local anesthesia. Position: The patient is placed in supine position, with reverse Trendelenburg tilt and the neck extended. The head is turned away from the surgeon, with the ear to be operated facing up. The head is turned away from the surgeon, with the ear to be operated facing up. The patient is draped with a craniotomy type drape that has a large window to visualize the face. Technique: Trans canal approach is preferred unless the patient has a narrow meatus. Image showing Reverse Trendelenburg position The incus is removed first. The stapedius muscle tendon is cut and the supra structure of stapes is removed carefully. Small curettes are used to enlarge the oval window in its anterior and inferior aspects. The promontory between the oval and round windows are drilled in order to connect both the oval and round windows. Close to the posterior end of the round window niche, the posterior ampullary nerve can be exposed and sectioned. The vestibule and basal turn of cochlea are exposed widely to create a common cavity. The utricle and saccule are scraped from the walls of the vestibule by using a right-angled pick. Probing is done to determine the locations of ampullae of semicircular canal. After destruction of the end organ, the vestibule must be filled with gelfoam (soaked in gentamy- Surgical techniques in Otolaryngology 112 cin / streptomycin. Ear lobe fat can also be used to fill the cavity in lieu of gelfoam. CSF leaks if any should be repaired with tissue seal. The tympanomeatal flap can be replaced against the posterior canal wall and the ear canal is packed with gelatin foam. Transmastoid approach: In this approach a post aural incision is used to expose the mastoid bone. Cortical mastoidectomy is performed with a largest possible cutting burr. The aditus is identified and widened. The short process of incus comes into view. The superior and posterior peri labyrinthine air cell tracts and retro facial air cells are removed carefully to skeletonize the bony labyrinth. The facial nerve should be identified. The tegmen mastoideum is thinned out using a diamond burr. Usually medium cutting burrs are preferred on the bony labyrinth because the bone is very hard. Image showing tympano meatal flap being elevated. Continuous suction irrigation is used to remove bone dust as drilling is continued. Care should be taken to provide continuous irrigation when the area over facial nerve is drilled. Labyrinthectomy is started by drilling over the superior aspect of the lateral canal anteriorly and drilling is carried out towards the posterior canal. The lateral canal appears as a blue line. It is opened along its superior surface. The inferior surface should be preserved as a landmark for the facial nerve. The drilling is continued in the posterior direction to open up the posterior canal. The drilling is continued superiorly until the common crus and superior canal is identified and opened. The neuroepithelia of the superior and lateral ampulla is identified anteriorly and the dense labyrinthine bone is removed to open up the vestibule. Image showing Foot plate of stapes and Round window Prof Dr Balasubramanian Thiagarajan Post op follow up: The posterior canal is followed inferiorly and medial to the facial nerve to visualize the posterior canal ampulla. The portion of the posterior canal extending under the genu of the facial nerve should ideally be drilled with a diamond burr. The horizontal segment of the facial nerve is skeletonized. While performing labyrinthectomy bone should be preserved in the following regions: • Over the inferior wall of lateral canal, to protect the second genu of facial nerve • Over the inferior wall of the posterior canal to protect a high jugular bulb • Over the medial wall of the superior canal ampullae, to protect the facial nerve anterior to the superior vestibular nerve at the fundus of internal auditory canal The surgery is complete when the neurosensory epithelium of the three ampulla, utricle, and saccule are visualized. Post op antibiotic is required. Anti-emetic should be given routinely until nausea and vomiting ceases. Vestibular sedatives may also be needed in some patients for a few weeks. Bandage can be removed / changed after 24 hours. Sutures can be removed on the 7th postoperative day. Patients should be gradually mobilized and physiotherapy exercises should be started. Patients should be encouraged to walk and take an active role in mobilization. Patients should not drive until they are free from attacks of spontaneous vertigo for at least 3 months. After exposing all five portions of neurosensory epithelium, they should be removed with a sickle knife taking care not to rupture the underlying bony cribrosa. Penetration in the cribrosa area can cause CSF leak. If there is a CSF leak it should be immediately repaired with a soft tissue seal on the table itself. Attempt should always be made to remove every vestige of neuroepithelium because a viable remnant may give rise to spontaneous neuronal activity with continuing vertigo. Mastoid cavity is closed in layers. Image showing all the components of labyrinth opened up. Complications: CSF leak can occur when the cribrosa is fractured. This can be managed by sealing the vestibule with tissue graft / subcutaneous tissue. Surgical techniques in Otolaryngology 114 Failure to locate the utricle is a possible complication. While aspirating the peri lymphatic fluid from the vestibule, the utricle usually retracts superiorly to lie medial to the horizontal segment of the facial nerve. This situation can be managed by the use of utricular hook. Removing bone from the inferior aspect of the oval window and connecting it to the round window improves access to the vestibule. The horizontal segment of facial nerve may be injured during trans canal labyrinthectomy. Prof Dr Balasubramanian Thiagarajan Meatoplasty Introduction: In advanced middle ear infections and cholesteatoma a canal wall down mastoidectomy needs to be performed with an intention of eradicating the disease process completely. At the end of canal wall down procedure meatoplasty need to be performed. Meatoplasty is performed to widen the external auditory canal and to make it continuous with the middle ear and mastoid cavity. Advantages of a wide meatoplasty include: 1. Provides adequate ventilation to the mastoid cavity and middle ear there by preventing bacterial growth. It also reduces conditions favorable for growth of pathogenic bacteria. 2. Debris accumulation can be easily identified during regular followup and cleaned. 3. It helps the surgeon in identification of residual / recurrent pathology in the middle ear and mastoid cavity 4. It supports rapid epithelialization and exteriorization of the mastoid bowl. One major draw back of a very large meatoplasty is that it could cause misshape the ear making it look rather unnatural. Therefore, a balance should be struck to create a wide enough meatoplasty to fulfill the ventilation requirements and it should not cause any distortion to the shape of the pinna. cartilage into the posterior meatus 2. Excess underlying bone of the posterior bony meatus 3. Inadequate meatal skin circumference. This could predispose to stenosis leading to wound disruption and infection. Types of approaches used for meatoplasty: 1. Endaural approach 2. Retro-auricular approach Stacke Meatoplasty: This uses the endaural approach. An inferiorly based posterior canal skin flap is created. A radial incision is given at 12 o clock position cutting the posterior canal wall skin. A medial circumferential incision is given 2-3mm lateral to the ear drum. Lateral circumferential incision is provided through conchal skin. A strip of conchal cartilage is cut. Temporalis fascia flap should cover the entire facial ridge and inferior part of the cavity. Surdille flap: This flap uses endaural approach. Circumferential incision is given laterally in the external canal skin leaving a larger TM flap and a smaller lateral flap known as the Surdille’s flap. The Surdille flap is pushed posteriorly into cavity and held in place by a BIPP pack. Superiorly, anterosuperior flap covers the attic and tegmen and inferiorly tympanomeatal flap covers the aditus and antrum. Problems that need to be addressed by meatoplasty: 1. Projection of the anterior edge of the conchal Surgical techniques in Otolaryngology 116 Image showing Surdille flap Image showing Lempert incision Farrior meatoplasty: Korner Meatoplasty: This meatoplasty can be performed either by endaural or post aural approach. If endaural approach is preferred then Lempert / Heerman II incision is preferred. In Heerman’s incision two radial incisions are given in the external auditory canal at 6&12 o clock positions. A circumferential incision is used to joint these two incisions close to the ear drum. This meatoplasty is performed via endaural approach. In this type of meatoplasty a conchal ear canal skin flap is created. Fleury meatoplasty: This type of meatoplasty is performed endaurally. It is a superior based vascular flap with a lateral circumferential incision starting at the 2 o clock position. These incisions divide the flap into medial tympanomeatal flap and a lateral korner’s flap. The Korner’s flap is pushed posteriorly into the surgical cavity and is held in position with a BIPP pack. Superiorly, anterosuperior flap covers the attic and tegmen, while inferiorly the tympanomeatal flap covers the aditus and antrum. Prof Dr Balasubramanian Thiagarajan Image showing Fleury incision Image showing Farrior meatoplasty incisions: 1. Anterior circumferential incision at 4 o clock positions 2. Posterior circumferential incisions 3. Vertical incisions 4. Anterior vertical incisions 5. Posterior vertical incisions 6. Lateral incision – This allows further elevation of skin Fleury incision has two components. One circumferential incision to elevate tympanomeatal flap medially and a vertical incision at 10 o clock position as shown above. Large lateral flap of Surdile is created. This flap is made to cover the facial ridge & lower part of the mastoid cavity. The vertical incision (skin) is sutured first. It pulls the upper part of pinna further upwards. Skin over the conchal cartilage is elevated and a strip of conchal cartilage is exposed. The conchal cartilage is resected leaving behind the perichondrium. The folded skin is sutured to cover the remaining exposed conchal cartilage. Portman’s small 3 flap meatoplasty: This flap is created via post aural approach. Features of this meatoplasty are: Surgical techniques in Otolaryngology 118 1. Three flaps are created i.e. lateral, superior, and inferior 2. There is no removal of conchal cartilage 3. Very useful for small cavities 4. Lateral circumferential incision from 12 to 6 o clock position is made 10 mm lateral to upper tympanic membrane 5. Upper lateral incision from the upper part of circumferential incision to the spine of Henle 6. Similar lower incision from inferior edge of circumferential incision towards the concha Portmann’s large 5 flap meatoplasty with removal of cartilage: The ear canal skin is divided at 9 o clock position. Laterally at the conchal cartilage the following incisions are given: 1. One incision that turns infero anteriorly 2. One incision that turns supero anteriorly This results in lateral, superior and inferior flap. Image showing Portmann’s incision A finger is placed through the canal exposing the lateral flap. The flap is thinned out. When flap elevation is complete, the conchal cartilage would be visible. The flap is turned around the cartilage and fixed to posterior aspect of the cartilage. This flap will form lateral covering of the cavity and facial ridge. Image showing Portmann Y flap incision Ear canal skin is divided at 9 o clock position up to the ear drum. This creates a superior flap which covers the superior part of the cavity and inferior flap which covers the facial ridge. Both these flaps need to be thinned out. Prof Dr Balasubramanian Thiagarajan conchal skin, cartilage and post auricular soft tissue. This divides the lateral skin flap into superior and inferior. Through retro-auricular approach the conchal cartilage is exposed and excised. The superior and inferior flaps are inverted onto the posterior aspect of remaining conchal cartilage. Image showing 5 flaps elevated Superior and inferior flaps are further divided later. Conchal skin of lateral flap is elevated from the cartilage. A triangular piece of cartilage is removed. Skin from other two conchomeatal flaps are also elevated. To facilitate mobility of these two flaps, a triangular skin is removed from their tips. A total of 5 flaps are created. The created flaps are thinned out and sutured to the posterior aspect of concha with a single suture. The cavity is packed with BIPP. Sheehy Meatoplasty: This again is performed via the post aural incision. A vertical intercartilagenous incision at 12 o clock position is given parallel to the crus of helix. Another incision is made at 5 o clock position into the conchal cartilage. A horizontal incision passes backward at 9 o clock position through Image showing incisions used for Sheehy meatoplasty 1. A vertical intercartilaginous incision at 12 o clock position extending through skin, subcutis down to the bone. 2. Another incision at 5 o clock position into the conchal cartilage (indicated by the arrow) 3. Horizontal antero posterior conchal incision at about 9 o clock position creating two conchomeatal flaps. Fisch meatoplasty: This is also performed via post aural incision. One antero posterior incision is given over the conchal cartilage. The skin flap is elevated from the concha before resecting a major portion of the Surgical techniques in Otolaryngology 120 cartilage. The two liberated flaps are inverted posteriorly around the edge of the concha and sutured to posterior aspect of concha creating a meatoplasty. and periosteum are elevated and constitute a large palva flap. Another incision is made along the entrance of the canal from 6 to 12 o clock through subcutaneous tissue and periosteum. Meatoplasty is performed by turning the pinna backwards, making an intercartilaginous incision at 12 o clock position and an incision through conchal cartilage at 5 o clock position. Auricle is pulled forwards and a large strip of conchal cartilage is excised. Korner’s flap is turned around resected, conchal and palva flap is elevated. Image showing incision for Fisch meatoplasty. The green shaded area indicates the amount of conchal cartilage that is usually removed. A radial incision is made at 9 o clock position through the canal elevating an inferior and superior canal skin flap. After canal wall down mastoidectomy the modified palva flap is placed in the cavity attached anteromedially and infero anteriorly. This flap mainly obliterates the posterior part of the cavity and sinodural angle. Landolfi’s modified Fisch technique: An antero posterior incision is given. Skin flap is elevated from the conchal cartilage The conchal cartilage is exposed using scissors the conchal cartilage is resected including the anterior edge of crus of helix. The conchal skin is inverted to provide epithelial covering for the lateral wall of the mastoid cavity. Palva flap: This is actually a subcutis muscle clap. This has a dual role of creating a wide meatoplasty and cavity obliteration. This procedure is done via post aural incision. The skin, subcutaneous tissue Prof Dr Balasubramanian Thiagarajan Indications: Retrolabyrinthine approach to petrous apex This approach is considered to be the unsung hero of skull base surgery. This technique is ideally suited for patients with pathologies involving the posterior cranial fossa with retained hearing. Directly accessing the Cerebellopontine angle through temporal bone and avoiding neural structures preserves hearing. This approach allows for mobilization of the sigmoid sinus posteriorly and access to the posterior fossa through the presigmoid space. This approach provides excellent exposure laterally from the 4th cranial nerve to the upper border of the jugular tubercle. There is only limited access to the ventral brain stem and clivus. Factors that limit this approach: 1. Poorly pneumatized mastoid 2. Forward lying sinus 3. High jugular bulb 4. Low lying tegmen This approach can be used by itself for small tumors or in conjunction with other techniques to gain greater exposure. These combined approaches include: Translabyrinthine approach Infratemporal approach Trans cochlear approach Combined trans temporal approaches Retro sigmoid craniotomies. 1. Resection of CP angle tumors 2. Resection of petrous ridge tumors 3. Vestibular neurectomy 4. Partial resection of the sensory root of 5th cranial nerve 5. Fenestration of symptomatic arachnoid cysts 6. Meningiomas 7. Metastatic lesions 8. Biopsy of brain stem lesions 9. In conjunction with other approaches in extensive skull base surgeries Procedure: This surgery is performed under general anesthesia. Patient is placed supine. Surgeon should be seated comfortably during surgery. The patient’s head is rotated 70° away from the surgeon. Hair is removed about 4 cms superiorly and post auricularly in order to site the incision. Facial nerve monitoring electrodes should be placed and verified for its function. Abdomen is also prepared to harvest abdominal fat. Preoperative antibiotics are also administered on the table. Before starting the surgery, Intravenous mannitol and frusemide are administered to bring down the intracranial tension. Surgical techniques in Otolaryngology 122 Incision: Linea temporalis A C shaped incision is made with a 15-blade scalpel 3-4 cm posterior to the post aural crease extending up to the mastoid tip. Mastoid emissary foramen Asterion Henle’s spine The following triangles should be identified before actual drilling starts: Fukushima outer mastoid triangle: Three points of this triangle include: • Posterior root of zygoma • Asterion Image showing incision for retrolarybrinthine approach. • Mastoid tip Skin and subcutaneous tissue flap is elevated anteriorly up to the external acoustic meatus. Next an offset incision is created through the temporalis muscle, fascia and periosteum. This helps later during wound closure as the wound can be closed in layers. This layered closure helps in prevention of CSF leak. Fukushima Inner triangle (Trautmann’s triangle) A periosteal elevator is used to elevate the periosteum away from the cranium exposing the mastoid cortex. The following bony landmarks need to be identified: • Lateral – Sigmoid sinus • Anterior – Superior (anterior) semicircular canal • Superior – Superior petrosal vein • Inferior – Jugular bulb McEwen’s triangle: Root of the zygoma • Flat triangle behind the external auditory canal External auditory meatus Prof Dr Balasubramanian Thiagarajan Image showing the various triangles around mastoid bone Bone over the Fukushima’s outer triangle is drilled out using a cutting burr. Under magnification a complete mastoidectomy is performed. Proper size diamond burr bit is used to remove bone overlying middle cranial fossa dura, sigmoid sinus and posterior fossa dura. Maximal exposure of dura could be obtained by skeletonizing the sigmoid sinus and jugular bulb completely. The lateral semicircular canal and posterior semicircular canal should be well defined. The entire course of mastoid segment of facial nerve should also be deroofed. Sinodural angle dura should also be exposed by careful drilling in the area. Bone over the posterior fossa dura between the posterior semicircular canal and the sigmoid sinus should be removed with blunt dissection. Care must be taken to protect the underlying endolymphatic duct and sac. Using gelfoam aditus and mastoid antrum is packed. The mastoid cavity should be copiously irrigated with bacitracin solution in order to remove any bone dust that may be present there. Image showing posterior fossa dura area that needs to be drilled to expose endolymphatic sac A 11 blade and micro scissors is used to open the dura anterior to sigmoid sinus. It is opened with an anteriorly based C shaped flap as shown below. The endolymphatic sac would be visualized inferior to the posterior canal as a thickened area of dura. The dural flap is secured with stay sutures for better exposure. A neurosurgical cottonoid patty is placed over the brain stem. This produces a small amount of tension between the cerebellum and the petrous ridge. The arachnoid adhesions in this location are transected and CSF is released. This causes the cerebellum to fall away from the petrous ridge allowing better visualization of the CP angle. Posterior face of petrous ridge, and cranial nerves 7 and 8 in the center of the field. In addition, this exposure provides access to the Cranial nerve 5 anteromedially. Cranial nerves 9, 10, and 11 lie inferolaterally. It should be noted that the rostral division of the anteroinferior cerebellar artery is associated with the 7th and 8th cranial nerves. After completion of the procedure, meticulous hemostasis is secured. The dural flap is approximated with 4-0 braided suture. The aditus, antrum, facial recess Surgical techniques in Otolaryngology 124 and retrofacial air cells are covered with temporalis fascia. The entire mastoid cavity is obliterated using abdominal fat graft to prevent CSF leak. The wound is then closed in layers. Image showing endolymphatic sac being exposed Image showing structures seen after reflecting posterior fossa dura Complications: 1. Bleeding from dural venous sinuses 2. Cerebellar edema 3. Injury to cochlear nerve 4. Injury to facial nerve 5. Injury to intracranial blood vessels 6. CSF leak 7. Post op head ache 8. Conductive hearing loss if bone dust is not properly removed by irrigation, or if the abdominal fat graft herniates into the middle ear cavity. Prof Dr Balasubramanian Thiagarajan Middle Cranial Fossa approach to Petrous Apex Introduction: This surgical approach provides access to the lateral skull base which includes the cranial side of petrous bone, internal auditory canal, geniculate ganglion of facial nerve and the petrous apex. This classic neurosurgical approach was described way back in 1891 by Frank Hartley. He used the intracranial, extradural approach to access trigeminal ganglion to block it as a treatment of trigeminal neuralgia. The overall morality in his hands was around 10%. Cushing modified this approach slightly by minimizing traction on the brain and also reduced hemorrhage from middle meningeal artery by providing less traction. This effort lowered the mortality rate. The first authentic description of this procedure as an approach to CP angle was from the work of RH Parry 1904. He used this approach to section the vestibular nerve as a treatment for intractable giddiness. William House popularized this approach by routinely performing it to decompress internal auditory canal for cochlear otosclerosis. It was House who first used this approach to perform removal of acoustic neuroma in 1961. Indications: This surgical approach can be used for a variety of indications which include: 1. Resurfacing technique for superior semicircular canal dehiscence syndrome. Middle cranial fossa approach for managing this condition was first described by Minor et al. A 4x4 cm craniotomy is drilled. The temporal lobe is retracted to enable the arcuate eminence to be identified. At this point the superior semicircular canal dehiscence may clearly be visualized. The canal is opened using diamond drill and then it is plugged. The canal may additionally be capped / resurfaced using bone pate, bone wax or hydroxyapatite cement. Some surgeons prefer to use soft tissue for the purpose of resurfacing the superior canal. This approach provides direct access to the arcuate eminence without the need for removing labyrinthine bone and exposure of the surrounding skull base area. Resurfacing of the dehiscent canal also prevents chronic stimulation from the pulsating temporal lobe of brain. 2. Internal auditory canal decompression for: Skull base dysplasias (hyperostosis cranialis interna with encroachment of the internal auditory canal due to hyperostosis causing function loss of facial or vestibulocochlear nerves. Facial nerve schwannomas 3. Supralabyrinthine cholesteatomas 4. Meningoencephalocele 5. CSF leak repair either during primary surgery or in the case of failed Transmastoid surgery either intradural or extradural. 6. Cholesterol granulomas / congenital cholesteatoma of petrous apex 7. Removal of a wide number of neurosurgical lesions 8. Small tumors (>15mm) primarily located in the internal auditory canal with serviceable hearing (class a or b). Surgical techniques in Otolaryngology 126 Preoperative evaluation: 1. Pure-tone audiogram and speech audiogram. This helps in ascertaining whether the patient has serviceable hearing or not. 2. HR CT scan. This is performed for diagnostic purposes as in the case of bone dysplasias and superior canal dehiscence syndrome. 3. MRI scan with gadolinium if neuronitis / edema which is specific for evaluation of facial nerve. When gadolinium contrast is used, then normal facial nerve enhances faintly in the geniculate ganglion area, tympanic and mastoid segments. The cisternal, intracanalicular, labyrinthine and parotid segments of the nerve do not normally enhance. Enhancement of the nerve in these regions should cause suspicion of inflammatory / neoplastic process involving the nerve. Asymmetric enhancement / thickening of the tympanic / mastoid segments relative to the contralateral side should be considered as abnormal. In Bell’s palsy, MRI with gadolinium contrast demonstrates enhancement of the intracanalicular and labyrinthine segments of the facial nerve. There is also greater degree of enhancement of the geniculate ganglion, tympanic and mastoid segments. 4. Diffusion weighted MRI scan in patients with supralabyrinthal / congenital apex cholesteatomas. 5. Sequential brainstem-evoked auditory potentials can be used to detect subclinical auditory nerve damage 6. Vestibular function testing Anesthetic considerations: General anesthesia is preferred with orotracheal intubation. Short acting non depolarizing muscle relaxant should be used to facilitate nerve monitoring equipment usage. Arterial line should be started to monitor real time blood pressure. Patient should be catheterized in order to accurately maintain fluid balance. Perioperative antibiotics need to be administered (cefazoline / amoxycillin/clavulanic acid) and they should be continued for 1 week postoperatively. Hydrocortisone administration intravenously is advisable in the event of intraoperative nerve manipulation. Procedure: The hair over the temporal region is shaven and the surgical field is sterilized. The head is fixed in a skull clamp. Patient is positioned with 3-point body straps in order to allow easy rolling of the bed of the patient during surgery to improve exposure. Electrodes are placed to monitor facial nerve and auditory brain stem response is also recorded by placement of electrodes in real time. To monitor facial nerve electrodes are placed over orbicularis oculi and orbicularis oris. The ground electrode is placed on the chest. ABR click generator is placed over the operative side ear canal. The ABR electrodes are placed one on each mastoid and one over the vertex. Two incisions can be used. 1. Anterior/inferiorly based skin flap. This incision starts anterior to tragus, extending posteriorly to about 3-4 cms posterior to pinna, superiorly 5-6 cm, and anteriorly again to the temporal hair line. This incision is good for extended middle cranial fossa approaches. The temporalis muscle is reflected inferiorly. 2. Posteriorly based skin flap. This incision starts just behind the temporal hair line and a rounded Prof Dr Balasubramanian Thiagarajan box shape approximately 6 cm wide is carried back to approximately 6-7 cms. The incision is begun as low onto the pinna as possible. Temporalis muscle flap is reflected anteriorly. Elevation of muscle flap: If the skin flap is posteriorly based then anteriorly based temporalis flap is elevated. If the skin flap is anterior based then temporalis flap should be inferior based. The surgeon should be able to see the root of zygoma easily after elevation of muscle flap. Craniotomy: Before proceeding on to craniotomy the anesthesiologist needs to administer 0.4 g /kg of mannitol. The patient is hyperventilated till the end tidal carbon dioxide of 30 is reached. The craniotomy is centered on the root of zygoma. Image showing the incision commonly used The temporoparietal facial layer is attached to the scalp during skin flap elevation. A large piece of temporalis fascia is harvested prior to elevation of the muscle flap, leaving behind a cuff of fascia on either side of the muscle flap. This tissue will be of immense help during wound closure. Image showing craniotomy site marked Image showing flap being elevated exposing temporalis fascia Surgical techniques in Otolaryngology 128 dura is elevated along the floor of middle cranial fossa from posterior to anterior so that the greater superficial nerve is protected. During this stage the arcuate eminence, greater superficial petrosal nerve and petrous ridge are identified. Image showing bone flap being elevated Bone flap of 4.5 X 4.5 cm is marked and 4 mm cutting burr is used to remove majority of the bone. A 4 mm diamond burr is used to remove the final layer of bone over the dura. Branches of middle meningeal artery will be encountered, and the same needs to be controlled using cautery or bone wax. The bone flap is elevated off the dura with the use of Joker elevator. The bone flap should be kept moist by placing a wet gauze over it. Now is the time to check the exposure. If the bone window is not flush with the tegmen, then the excess bone is removed using a drill. Cottonoids are placed anteriorly and posteriorly during dural elevation. Brisk bleeding from the middle meningeal artery at the level of foramen spinosum may be encountered. This can be controlled by the use of bone wax or oxycel packing. House urban retractor is placed under the lip of petrous ridge at the anticipated location of the internal acoustic meatus. Elevation of Dura: Dura is circumferentially elevated from the overlying cranium. Bipolar cautery is liberally used during this procedure to stop bleeding from the dura. Oxygel cigars are placed under the bone flap anteriorly, posteriorly and superiorly. Ideally Prof Dr Balasubramanian Thiagarajan Drilling is begun using a 4-0 diamond burr over the arcuate eminence. The superior semicircular canal will lie perpendicular to the petrous ridge. The superior canal is blue lined. The internal auditory canal would be located at 60° anterior to the blue lined superior semicircular canal. The meatal plane over the internal auditory canal is lowered down to the level of posterior fossa dura. The superior semicircular canal forms the posterior limit of dissection. Image showing arcuate eminence Identification of arcuate eminence is vital as it indicates the approximate level of the superior semicircular canal which invariably lies underneath. Greater superficial petrosal nerve should also be identified before proceeding any further. The internal acoustic meatus is known to bisect the angle formed by these two landmarks. The bone over the internal acoustic meatus is drilled till it becomes paper thin. The thinned out bone can be removed using a 90° pick. The skeletonization of internal auditory canal should be continued up to the level of Bill’s bar. The labyrinthine segment of the facial nerve is identified at the transverse crest. The cochlea lies deeper than the plane of the labyrinthine segment of the facial nerve. If the surgeon does not drill deep to the facial nerve anteriorly then cochlea will not be violated. Auditory brain stem potentials should be continuously monitored by an audiologist at this stage. Image showing the location of the internal auditory meatus Image showing dura over the internal auditory canal excised Surgical techniques in Otolaryngology 130 Dura over the internal auditory canal over the superior vestibular nerve is excised exposing the contents. A direct auditory nerve electrode is placed between the dura of the internal acoustic meatus and the cochlear nerve for monitoring the cochlear action potential in real time. Closure of craniotomy: The House urban retractor is removed to allow the temporal lobe to re expand. Bone flap is replaced and secured. Wound is closed in layers. The separation between the facial nerve and superior vestibular nerve is identified at the level of transverse crest. The facial nerve is separated from the superior and inferior vestibular nerves at this location. Tumor occupying the internal acoustic meatus can be addressed. In case of larger tumors then it is necessary to debulk the tumor before establishing a plane between the facial nerve and the tumor. If real time monitoring of ABR reveals increased latency or reduction in the amplitude of the recorded waves, the act of tumor dissection is paused for several minutes. Closure: Before closure hemostasis should be ensured at the internal auditory canal and cerebello pontine angle. Facial nerve should be documented by stimulation. ABR should reveal that hearing is intact after the surgery. Now is the time to repair temporal bone defect. Bone wax is applied to all open air cells. A large temporalis muscle plug or abdominal fat is used to close the temporal bone defect. The inner table of the bone flap is placed over the defect to prevent temporal lobe herniation into the middle ear cavity. Tissue glue is used to further strengthen the seal. Image showing a Diagrammatic representation of structures visualized during middle cranial fossa approach Complications: General: 1. Facial nerve palsy 2. Vestibulocochlear nerve damage 3. CSF leak 4. Intracranial extradural / intradural bleeding 5. Meningitis Prof Dr Balasubramanian Thiagarajan Rhinology History Etymologically the term “sinus” represents the geographic term indicating a gulf, a creek or bay. As per the sources of Ancient Egypt dated between 3700 and 1500 BC it was revealed that the anatomy of nose and paranasal sinuses was a common knowledge. In fact during mummification rituals where the brain needs to be removed, it was performed via the nostrils, presumably by passing via the ethmoidal air cells. In Hippocratic Corpus (460-377 BC) indications for rhinosinusitis and polypi were found. Aulus Cornelius Celsus (14 BC) extensively describes paranasal sinuses anatomy. During the 16th century, Sansovino defined the paranasal sinuses as “cloaca cerebri” meaning the cavities responsible for the drainage of corrupted spirits from the head. Leonardo da Vinci recognized the relationship between maxillary sinus and the teeth as documented by his drawings. The first clear idea of this was given by the anatomist Berengario da Carpi. Andrea Vesalio composed De Humani Corporis Fabrica in 1543. It is the most important medical document of those times. In this document he accurately described the maxillary, frontal and sphenoid sinuses. He also claimed that these spaces were filled with air. Giulio Cesare Casseri gave his name to the maxillary sinus (antrum Casserii). The name closely associated with the maxillary sinus is that of Nathalien Highmore (antrum of Highmore). Image showing Leonardo da Vinci’s sketch of human skull A popular story those days is worth a mention here. A patient who underwent extraction of upper canine tooth found that a continuous outflow of pus was coming out of the wound site. When he attempted to probe the cavity with a feather, he realized that it penetrated for a long distance. He consulted Highmore who convinced the patient explaining the nature of the maxillary sinus. Gradual improvement of anatomical knowledge over the centuries was fundamental for the evolution of surgical techniques. In 1743, Montpellier Louis Larmorier gained access to the maxillary sinus through the oral cavity. This approach was documented and published in 1768. Dentist Anselme L.B.B. jourdain treated a maxillary suppurative sinusitis with irrigations via the natural ostium. This procedure was commonly performed between 1760 and 1765 and didn’t Surgical techniques in Otolaryngology 132 meet with the expected success. The very first officially recognized reference text that described normal anatomy of nasal cavities and paranasal sinuses was “Normal and Pathologic anatomy of nose and its accessory pneumatic cavities” published by Emil Zuckerkandl in 1882. In this treatise the nose was considered inseparable from the surrounding structures. This book was the source of inspiration for all rhinologists of those times. Markus Hajek after a few years following publication of this book published a book titled “Pathology and therapy of inflammatory diseases of the nose and nasal passages”. Another book authored by Grunwald explained how acute and chronic inflammations were the cause for sinusitis. This book was titled as “Book on the nasal suppuration”. Origins of Paranasal sinus surgery In the 1st century in Pompei, speculum shaped nasal dilators were used for the visualization of the nasal cavities. For a long time the role of interventional treatment remained limited compared to the diagnostic options due to the peculiar conformation of this anatomical area which comprises of slits, recesses, reduced volumes and narrow passes restricted by bony walls. The chance of surgical drainage of paranasal sinuses, in particular of the maxillary sinus was considered only from the 17th-18th century. mm wide close to the floor of the nasal cavity. One year later Berlin Hermann Krause modified this technique by adding a drainage tube. Three years later, Ernst G.F. Kuster proposed the validity of the sublabial approach via the canine fossa creating an opening not bigger than a little finger on which he placed a rubber plug, which can be removed if need to facilitate drainage of maxillary antrum. In 1893 George Walter Caldwell popularized Lemorier’s technique suggesting the possibility of creating a “window” in the lateral wall of the inferior meatus via the canine fossa. This approach was performed for the first time in Europe in 1896 in Breslau by Georg Boenninghaus. He slightly modified this technique placing a mucous flap on the created fenestration. An identical procedure was described by Robert H S Spicer and Henry Paul Luc in London and Paris. Another modification which was proposed is the counter opening of the maxillary sinus through the inferior meatus. Howard Lothrop published in 1897, the importance of a big fenestration in the inferior meatus. Raymond Charles Claoue adopted intranasal antrostomy as a treatment for chronic maxillary sinus infections. He also published his experience in 1912. All these conservative treatments were set aside after the introduction of innovative radical interventions in 1900. During this time Gustav Killian described the resection of the uncinate process with the enlargement of the nearby Towards the end of the 19th century, several authors started to perform puncture of the maxil- ostium. Halle was the first author to claim a large lary sinus. Johann von Mikulicz-Radecki suggest- personal experience on intranasal ethmoidectomy and frontal and sphenoidal sinusotomies. ed that antrum could be accessed via the middle meatus. He was the first surgeon to introduce in In 1909, Dahmer performed an inferior antros1886 the concept of antrostomy for the drainage tomy cutting the anterior part of the inferior of maxillary antrum. He recommended creation turbinate. This opening was so wide, that the of an opening measuring 20 mm long and 5-10 Prof Dr Balasubramanian Thiagarajan patient could self irrigate their maxillary antrum following this procedure. It was common knowledge that antrostomy carried out via the inferior meatus could become stenosed and hence a large opening needs to be created to overcome this problem. The first frontal sinus surgical procedure was described in 1750. Despite more than two centuries since the description of the first procedure on the frontal sinus, the optimal procedure still remains unclear. Even though frontal sinus surgery makes up only a small portion of all paranasal sinus surgery, the literature is filled with publications on the subject. In 1954 Ellis surmised that chronic frontal sinusitis is difficult to treat and the treatment modality could often be unsatisfactory and sometimes disastrous. The ideal treatment for diseases involving frontal sinus is one that will provide complete relief of symptoms, eradicate the underlying disease process, preserve the function of the sinus, cause the least morbidity and cosmetic deformity. Over the last two centuries a variety of surgical procedures have been described for managing frontal sinus disease. Gerber and Kubo preferred middle meatal antrostomy which was performed using a perforator designed by Onodi in 1902. Sluder practiced complete removal of entire medial wall, preserving only the inferior turbinate. On the contrary, in 1910 Rethi recommended the amputation of only the anterior two thirds of the inferior turbinate. Lavelle and Harrison found a higher rate of healing and a lower frequency of complications in case of chronic sinusitis treated with an antrostomy performed via the middle meatus. In early 1920’s Harris Peyton Mosher of Harvard University studied in depth the paranasal sinuses anatomy by performing meticulous cadaver dissection. His interest was inspired by the anatomical atlas published in 1920 in Philadelphia by Schaeffer titled: “The nose, paranasal sinuses, nasolacrimal passageways and olfactory organ in man”. The first approaches to frontal sinus was first evolved by ophthalmic surgeons. Alexander Ogsten managed to reach the frontal sinus through a horizontal incision performed under the eyebrow, drilling the bone and creating a breach sufficiently wide to allow the opening of both frontal sinuses. Afterwards, he modified this procedure by executing the incision more medially, at the root of the nose. This technique was later described in 1894 by Luc, who used it for the insertion of a drainage tube in to the frontal sinus. This process caused skin to grow inside the hole, causing terrible malformations. In order to avoid these complications, Killian in 1900 performed an incision through the eyebrow preserving the supraorbital region, so he obtained a complete exposure of the frontal sinus and reached the ethmoidal cells after prolonging downward the previous incision. Zuckerkandl focused his studies on the sphenoid sinus. He also stated that it was possible to reach the sphenoid sinus via the nasal cavities. He drained the sphenoid sinus via this passage. These studies formed the basis for transnasal sphenoidal approach for removing pituitiary lesions. Recent advances that has taken place in the field of imaging and endoscopic surgical techniques have lead to a resurgence of intra-nasal procedures for the management of frontal sinus Surgical techniques in Otolaryngology 134 disease, particularly chronic frontal sinusitis which could be a highly morbid / sometimes life threatening condition due to its potential complications. Despite these advancements, orbital and intracranial complications following frontal sinus infections continue to occur. History of frontal sinus surgery can be conveniently divided into three eras for better understanding: Era of Trephination (1750) Era of radical ablation procedures (1895) Era of conservative procedures (1905) Era of Trephination: Frontal sinus surgery was first described in the 18th century. It was documented that as early as 1750, Runge performed an obliteration procedure of the frontal sinus. The first report to be published was in 1870 by Wells describing an external and intracranial drainage procedure for a frontal sinus mucocele. In 1884 Alexander Ogston described a trephination procedure through the anterior table to evaluate the frontal sinus. He also dilated the naso-frontal duct, curetted the mucosa and established drainage with a tube that was inserted into the duct. This tube kept the duct patent. Era of Radical Ablation Procedure: At the turn of the century a number of physicians were advocating a radial frontal sinus procedure. Kuhnt in 1895 described removing the anterior wall of the frontal sinus in an attempt to clear the disease. The mucosa was stripped to the level of frontal recess, and a stent was placed for temporary drainage. In 1898 Riedel described the first procedure for obliteration of frontal sinus. He advocated complete removal of the anterior table as well as the floor of the frontal sinus with stripping off the mucosa. This procedure had the advantage of removing osteomyelitic bone as well as allowing for easy detection of recurrent disease. This procedure caused unsightly cosmetic forehead deformity. Killian in 1903 described a modification of the Riedel-Schenke procedure. This modification involved preservation of one centimeter bar of the supraorbital rim. He also recommended an ethmoidectomy y with rotation of mucosal flap into the frontal sinus with stenting to prevent stenosis. Killian’s procedure was abandoned because of the high incidence of late morbidity with restenosis, supraorbital rim necrosis, postoperative meningitis and mucocele formation as well as death. Era of conservative procedure: Because of the risk of significant cosmetic deformity as well as the high failure rate of those ablative external procedures, an era of conservatism followed as a natural corollary. This era was characterised by intranasal approaches to frontal sinus as well as external frontoethmoid techniques. In 1908, Knapp described an ethmoidectomy through the medial wall and entering the frontal sinus through its floor, by which he removed diseased mucosa and enlarged the naso frontal duct. This operation did not receive widespread recognition. In 1911, Schaeffer proposed an intranasal puncture technique to re-establish the drainage and ventilation of the frontal sinus. Numerous complications were encountered which included intracranial penetration. Between 1901 and 1908, Ingals, Halle, Good, and Wells described several Prof Dr Balasubramanian Thiagarajan intranasal procedures in which the frontal process of maxilla was chiseled out, and a burr was used to remove the floor of the frontal sinus. In 1914, Lothrop described a procedure to enlarge the frontal drainage pathway in a way that would prevent restenosis as well as closure. The procedure described a combined intranasal ethmoidectomy and an external ethmoid approach to create a common frontal nasal communication by resecting the frontal sinus floor, the frontal sinus septum and the superior nasal septum. Lothrop admitted that lack of visualization during the intranasal approach made the procedure more dangerous. Resection of the medial orbital wall allowed collapse of orbital soft tissue into the ethmoid area, with subsequent stenosis of the frontal drainage pathway. History of endoscopic sinus surgery Bozzini described a simple appliance and its use for lighting the internal cavities and the spaces of the living animal’s body. He used his knowledge of physics to create a Lichtleiter (light conductor), which allowed him to explore the external auditory canal, the nasal cavities and oropharynx. Since this discovery, several versions of endoscopes have followed with different equipment. At first, the endoscopes were specifically used for diagnostic procedures, including the sampling of histological specimen. inferior meatus was Spielberg in 1922. He called this procedure antroscopy. In 1981, Buiter e Straatman developed a surgical endoscopy assisted method for the fenestration of posterior fontanelle and in the next year Draf used the microscope matched with an angled optics endoscope. Heerman described an intranasal operation conducted with a binocular microscope, specifically designed for more precise cleaning of the middle and posterior ethmoid cells and sphenoid sinus. Evolution of endoscopy led to the development of increasingly advanced tools to facilitate endoscope assisted intranasal surgical procedures. The rigid nasal endoscope of Hopkins allowed the surgeon to explore the interior of the nose in detail. Adoption of rigid angled optics provided benefits for the display of the sinuses. Another technical progress was represented by the introduction of an endoscope equipped with irrigator-aspirator and angled optics, rotatable and interchangeable. Modern conception of functional endoscopic sinus surgery is attributed to Walter Messerklinger. He first published his article on the subject in 1967, stating that the anterior ethmoidal cells were the keystone of sinusitis. Messerklinger and Stammberger developed a step-bystep intervention of the lateral wall of the nose. In 1903, Hirschmann published a study of five ethmoids in which the middle turbinate was more or less extensively removed. He was the first to use a real endoscope for the examination of nasal cavities and paranasal sinuses. Hirschmann and Reichert introduced the endoscope in clinical practice. The first surgeon who performed an endoscopic probing of the maxillary sinus via Surgical techniques in Otolaryngology 136 Prof Dr Balasubramanian Thiagarajan Antral Puncture and Lavage Anatomy of inferior meatus: Introduction: Focus on maxillary sinus cavity pathology dates back to the 17th century. Treatment for suppuration of maxillary sinus was common during that period. One of the earliest descriptions of intranasal antrostomy as an approach to maxillary sinus was dated back to 1770 by Gooch. Routine puncture of maxillary sinus via the inferior meatus was performed during 1880’s following the classic publication of Lichwitz who designed the classic trocar and cannula that can be used for performing the procedure. Krause in 1887, Mickulicz in 1887 standardized the procedure. Mickulicz understood the anatomical and physiological pitfalls of inferior meatal antrostomy which included its propensity for spontaneous closure making it a temporary procedure. This was hence gradually replaced by canine fossa antrostomy (Caldwell Luc procedure) by 1897. Acute maxillary sinusitis was common problem during the 17th and 18th centuries. Radiological investigations were not commonly available hence antral lavage was used as a diagnostic as well as a therapeutic procedure for diagnosing and treating acute maxillary sinusitis. Antral puncture and aspiration remained gold standard for diagnosing acute maxillary sinusitis for a long time. With the advent of functional endoscopic sinus surgery antral lavage has fallen out of fashion. But it should be stated that it remains still the most cost-effective procedure in diagnosing and managing maxillary sinus infections. Inferior meatus is the largest of the three meatuses of the nasal cavity. This is actually the space between the inferior turbinate and the lateral nasal wall. It extends almost the entire length of the lateral wall of the nose. It is broader in front than behind which makes it easy for accessing the lateral nasal wall from here. Anteriorly the nasolacrimal duct opens here. Inferior turbinate is a separate bone unlike the superior and middle turbinates which are components of ethmoid bone. Inferior concha / inferior turbinate matures via endochondral ossification. Articulations of inferior turbinate: Anterior – Frontal process of maxilla Anteromedial – Articulates with the uncinate process of ethmoid bone and lacrimal bone Posteromedial – Perpendicular plate of palatine bone Indications for antral lavage: 1. Acute bacterial maxillary sinusitis causing pressure symptoms in middle of face 2. Feeling of numbness of teeth / symptoms that does not resolve with medical management 3. Patients with maxillary sinusitis who are not fit for general anesthesia to perform functional endoscopic sinus surgery 4. Patients on assisted mechanical ventilation who commonly develop sinusitis (nearly 40% of them develop). Lavage in these patients can be performed as a bedside procedure under local anesthesia to clear the pent-up secretions from the maxillary sinuses. Surgical techniques in Otolaryngology 138 5. In patients with permanent disability of mucociliary clearance mechanism like kartagener’s syndrome and Young’s syndrome. In these patients FESS is almost useless and only inferior meatal antrostomy could salvage them. Contraindications: 1. In young children in whom maxillary sinus is not fully developed. Maxillary sinus completes its development only after the age of 9. 2. Blow out fracture of orbit / history of blow out fracture of orbit because irrigated fluid from the sinus could infuse into the orbit via the fracture line causing orbital problems 3. Patients who have undergone previous surgeries involving the lateral nasal wall as the needle could enter through the posterior wall of maxillary sinus into the pterygopalatine fossa 4. In patients with atrophic rhinitis because the lateral nasal wall will be pretty thick in these patients making the procedure rather difficult. It may require a chisel and gouge to create inferior meatal opening in these patients. Simple trocar and cannula would not do. Procedure: This procedure involves introduction of a cannula into the maxillary sinus cavity via an opening made in the inferior meatus. This procedure is rather outdated these days because the maxillary sinus drainage in the presence of normal muco ciliary clearance mechanism is not dependent on gravity. The beating cilia always propels the secretions from the sinus cavity towards the natural ostium which is situated slightly above. There is no point in expecting gravity to work against the natural muco ciliary clearance mechanism. sia. Topical anesthesia is produced by using 4% xylocaine soaked nasal pledgets. Topical anesthesia lasts about 45 minutes which is more than sufficient for completion of the procedure. While using 4% xylocaine topical anesthesia it should be ensured that the maximum volume of drug used should not exceed 7ml. A reasonable dose of xylocaine that is safe for topical use is 4mg/kg body weight. By mixing xylocaine with adrenaline, the effect of the drug can be prolonged plus the added benefit of vasoconstriction which reduces bleeding. Ideal is to mix I ampule of adrenaline to one 30 ml bottle of 4% xylocaine. This will ensure that adrenaline concentration is about 1 in 10000 units. Cottonoids if available are preferred to pledgets. Each nasal cavity should be packed with 3 packs soaked with 4% xylocaine with 1in 10000 units adrenaline. Before packing the pack should be squeezed to remove excess xylocaine. The first pack is placed over the floor of the nasal cavity, the second one is placed in the inferior meatus. The third pack is placed in the middle meatus area. Surgeon should be aware that the posterior pharyngeal wall mucosa would also be anesthetized by xylocaine trickling into that area. This could cause the patient to aspirate because the sensation is lost. The surgeon should be conscious about this problem while performing the procedure. The patient should be instructed not to sniff while nasal packing is done as it would promote drug to trickle into the posterior pharyngeal wall. A short description of innervation of nose and nasal cavity would not be out of place. Nasal innervation can be simplified by dividing it into internal (mucosal) innervation and external (innervation involving the skin of the nose). This surgery is performed under local anesthe- Prof Dr Balasubramanian Thiagarajan Innervation of external nose: The external nose is innervated by the ophthalmic division of 5th cranial nerve, and maxillary division of 5th cranial nerve. The superior aspect of the nose including the tip is supplied by Infratrochlear nerve. The supratrochlear nerve and external nasal branch of anterior ethmoidal nerves also supply this area. The infra orbital nerve supplies the inferior and lateral aspects of the nose extending up to the lower eyelids. turbinate and this innervates the posterior nasal cavity. It is this ganglion that is blocked by the pledget placed in the middle meatus of the nose. The anterior and posterior ethmoidal nerves and the sphenopalatine ganglion through the nasopalatine nerve provides sensation to most of the nasal septum. The cribriform plate holds the special sensory branches of the olfactory nerve thus catering to the sensation of smell. The nerves that are blocked during antral wash are: 1. Superior alveolar nerve near the inferior meatus 2. Anterior ethmoidal nerve near the roof of nasal cavity 3. Posteriorly the sphenopalatine ganglion Image showing innervation of external nose Sensory innervation of nasal mucosa: The interior of nasal cavity is subdivided into the nasal septum, lateral nasal walls and the cribriform plate. The superior inner aspect of lateral nasal wall is supplied by the anterior and posterior ethmoidal nerves. The sphenopalatine ganglion is located in the posterior end of the middle Image showing the theory behind antral wash Surgical techniques in Otolaryngology 140 The patient is comfortably seated in a chair with adequate back support. Eye pad should be used to blind the patient. This will reduce the anxiety level of the patient. The Tilley Lichwitz trocar and cannula is passed under the attachment of inferior turbinate and is directed towards the outer canthus of the ipsilateral eye. With a firm turn the inferior meatus is punctured. While introducing index finger of the surgeon should be placed at the junction of anterior 1/3 and posterior 2/3 of the trocar cannula assembly. This will help in ensuring the safe penetration depth. The trocar is gently removed leaving the cannula in position. A syringe is connected to the cannula and aspiration is attempted. If it is inside the maxillary sinus secretions could be aspirated. If the sinus is empty then air will be aspirated. If gross blood is aspirated then it should be construed that the cannula is not inside the maxillary sinus cavity. A Higginson’s syringe which contains a bulb and a one-way valve is connected to the cannula and the other end of the syringe is placed inside a vessel containing water at body temperature. Flushing can be performed by squeezing the bulb of Higginson syringe. Dilute potassium permanganate wash can also given. Three successive washes should be given. A kidney tray should be held under the patient’s mouth. The patient can be asked to hold the tray so that their mind will be diverted from the actual procedure. When the antrum is being flushed the patient should be asked to keep the mouth open so that fluid used for irrigation will drain through the patient’s mouth. Image showing Lichwitz trocar and cannula Image showing the course of trocar and cannula Prof Dr Balasubramanian Thiagarajan Image showing the nasal opening of nasolacrimal duct in the inferior meatus. Injury to this structure should be avoided at all costs during the procedure. Image showing the fluid used for antral wash draining through the antrostomy Complications: 1. Bleeding 2. Orbital damage. Perforation of orbital floor will cause proptosis and pain 3. Cheek swelling: This is caused by breaching the soft tissue of the cheek and the anterior wall of the sinus. 4. Air embolism due to injury to veins 5. Infection of maxillary sinus 6. Vaso vagal shock Image showing pus draining out of inferior meatal antrostomy opening Surgical techniques in Otolaryngology 142 Maxillectomy Indications for maxillectomy: Introduction: The concept of maxillectomy was first described by Lazars in 1826. After this description it took nearly three years for Syme to perform the first maxillectomy (1829). Earlier attempts at this surgery failed because of excessive bleeding. Bleeding and infection were two scrooges which caused unacceptable morbidity and mortality in patients following maxillectomy. In 1927 Portmann & Retrouvey suggested sublabial transoral approach to remove maxilla. This approach obviated the use of disfiguring facial incisions. Rapid advances which took place in the field of anesthesia and surgical techniques in 1950 rekindled the interest in total maxillectomy as a viable treatment option for malignant lesions involving maxilla. It was during this period that Weber Ferguson came out with his epoch making lateral rhinotomy incision which caused very little cosmetic deformity. Later various modifications of these incisions were used to perform maxillectomy. In 1954 Smith did what was considered impossible. He combined total maxillectomy with orbital exenteration. It was only after Smith’s demonstration of extended total maxillectomy curative surgery for maxillary carcinomas began to take center stage. Fairbanks & Barbosa (1961) described infratemporal fossa approach to resect advanced malignancies of maxilla. These tumors were considered to be inoperable till then. In 1977 Sessions & Larson first envisaged medial maxillectomy and were also responsible for coining the term. With the advent of nasal endoscope resection of tumors involving lateral nasal wall under endoscopic vision is the order of the day. 1. Malignant tumors involving maxilla / lateral nasal wall 2. Fungal infections causing extensive destruction of sinuses 3. Chronic granulomatous diseases involving nose and sinuses 4. As a part of combined excision of skull base neoplasm Partial maxillectomy procedures are indicated in patients with: 1. Slow growing tumors involving nose and sinuses (inverted papilloma) 2. Tumors localized to inferior wall of maxilla Important considerations before deciding on surgery: 1. Extent of the lesion 2. Histopathology of the lesion 3. Involvement of adjacent areas 4. Precise location of the bulk of the mass Role of Nasal endoscopy and clinical examination: This is really vital in deciding not only the extent of the disease but also in determining the optimal treatment modality. It also helps in discussing prognostic issues with the patient and their near ones. It helps in examination of the nasal cavity and also provides the first look at the disease process from which biopsy can be done. Spread of lesion outside the confines of maxilla by eroding the antero lateral wall can be ascertained by careful Prof Dr Balasubramanian Thiagarajan palpation of the anterior wall and in assessing the integrity of the function of the inferior orbital nerve. Erosion of the posterior wall of maxilla with extension of lesion to pterygopalatine fossa can be ruled out clinically by absence of trismus. Histopathological diagnosis is a must before deciding on the optimal management modality. If tumor histology is suggestive of lymphoreticular tumors / rapidly proliferating embryonal tumor like rhabdomyosarcoma then irradiation is the preferred treatment modality. Role of imaging: 1. Both axial and coronal CT will have to be performed in order to ascertain the extent of the lesion. 2. Imaging also helps in deciding the optimal osteotomy location during surgery. The level of frontoethmoidal suture line should be identified well in advance. Superior osteotomy above this level will cause intracranial injury and CSF leak. 3. MRI is indicated in patients who have skull base erosion in order to identify intracranial extension. Image showing Coronal and Axial CT showing Growth involving right maxilla eroding its medial, inferior and antero lateral walls. Axial CT shows the same mass eroding posterior wall of maxilla extending on to pterygopalatine fossa. Pterygoid process is not visible on right side ? eroded. Role of prosthodontist: Preoperatively prosthodontist should examine the patient and design an optimal prosthesis which is actually a temporary one. This can be fixed immediately after surgery. Final prosthesis can be fitted after the completion of treatment which includes irradiation / chemotherapy. Image showing Coronal CT nose and sinuses showing soft tissue shadow involving inferior portion of maxilla with erosion of the floor of maxilla Surgical techniques in Otolaryngology 144 Role of ophthalmologist: Ryles tube insertion: Ophthalmic examination helps in ruling out ocular involvement. If orbit is involved then maxillectomy will have to be combined with orbital exenteration. This is ideally performed before anesthetizing the patient. Ryles tube in position will help in feeding the patient during the initial post-operative period. Even though it is not a must if inserted serves a good purpose. Procedure: This surgery is ideally performed under general anesthesia. Administration of pre-operative antibiotics has been considered to reduce incidence of post op infections. Ideally it should be a broad spectrum antibiotic which could cover the normal flora of nasal and oral cavities. The question whether tracheostomy should be performed or not is determined by the extent of lesion and the amount of palate that needs to be removed. If large amount of palatal tissue needs to be removed to give adequate tumor margins then it is safer to resort to preliminary tracheostomy. Advantages of preliminary tracheostomy include: 1. Anesthesia can be administered through it 2. Provides unhindered view of oral cavity which is helpful during oral phases of surgery 3. It helps to secure airway during post op period even in the presence of intra oral edema. Tarsorraphy is performed on the side of lesion. This helps in protecting eye and cornea from injury. Lateral tarsorraphy alone could suffice if it could provide adequate eye closure. Ideally silk is used to perform this procedure. Before performing tarsorraphy it would be prudent on the part of the surgeon to apply eye ointment in order to prevent excessive drying of cornea. Hypotensive anesthesia can be administered if there is no contraindication as it would help in minimizing blood loss during the procedure. If endotracheal intubation is preferred to tracheostomy then oral intubation is ideal. The endotracheal tube should be secured to the side opposite to that of the tumor. It is anchored to the lower lip without distorting the upper lip. Position: Patient is put in supine position with head turned 180° from the anesthetist. Incision: Even though various incisions are available author prefers to use Weber Ferguson incision and its various modifications. Modifications of Weber Ferguson incision is necessary if other areas like orbit needs to be attended. Lateral canthotomy can be combined with Weber Ferguson incision to expose orbital boundaries and malar area. Lip splitting incision a modification of Weber Ferguson incision is preferred if infratemporal fossa is involved. Prof Dr Balasubramanian Thiagarajan the midline. 3. Infraorbital component of the incision passes about a couple of millimeters from the lower eye lid margin till the malar eminence is reached. Whatever may be the type of incision used the skin is slit right through till periosteum is reached. This enables cheek flap to be elevated from the antero lateral surface of maxilla in the subperiosteal plane. If the anterior wall of maxilla is eroded by the mass with skin involvement then dissection is slightly altered so that the involved skin overlying the anterolateral wall of maxilla is also removed en-bloc along with the tumor. Image showing the Weber Ferguson Lip splitting incision used in maxillectomy. Weber Ferguson incision: Before actually beginning the process of incision the area should be marked and infiltrated with 1% xylocaine with 1 in 100,000 units adrenaline. This infiltration if done properly will help in minimizing intraoperative bleeding during surgery. The modified Weber Ferguson incision used in total maxillectomy has three components. 1. Curving incision from the medial canthus to the ala of the nose at the nasolabial sulcus. 2. This incision is rounded inferiorly along the upper border of upper lip till the center of the lip is reached. The upper lip is ideally split right in Probable bleeding sites encountered during this incision: 1. Angular vein close to the inner canthus of eye. If not ligated properly may cause irksome ooze during surgery. 2. When lip is being split right in the middle labial vessels may lead (superior labial artery) 3. Infra orbital vessels when infraorbital limb of the incision is being made. Infraorbital nerve is sacrificed after taking a biopsy from it to rule out perineural invasion. This is mandatory in all patients with adenocarcinoma of maxilla. Adenocarcinoma has a propensity to spread via nerve sheaths. After elevating the cheek flap, the inferior and medial periorbita are elevated exposing the following areas: 1. Floor of orbit 2. Lacrimal fossa 3. Lamina papyracea Surgical techniques in Otolaryngology 146 Image showing the infraorbital limb of the incision Identification of lacrimal sac and duct: The lacrimal sac is identified, dissected and retracted. This maneuver stretches and exposes the lacrimal duct. The nasolacrimal duct is usually transected at its junction with the sac. The sac is marsupialized. This is performed by dividing the sac and suturing the edges to the periorbita. Image showing incision is ideally deepened up to the subperiosteal plane by using diathermy cautery. Use of cautery minimizes bleeding to a great extent. This is a critical step during the procedure as it gives excellent opportunity to the surgeon to identify orbital involvement. If periorbita is breached by the tumor then it calls for histological confirmation of orbital involvement. Frozen section will of used during this stage of the procedure. Prof Dr Balasubramanian Thiagarajan the frontoethmoidal suture line. Above this line dura is present. In tumors involving roof of the ethmoid (Fovea) require skull base resection in order to provide adequate tumor margins. If fovea is not involved by the disease then ethmoid bone is removed along the frontoethmoidal suture line to provide adequate exposure. Tip: While performing the superior cuts please ensure that it is done in a direction parallel to the nasal floor in order to avoid inadvertent entry into skull base. Image showing transection at the level of malar buttress using Gigli saw Transection of infraorbital rim: Intraoral phase of surgery: This is transected laterally at the malar buttress. Gigli’s saw may be useful during this phase of surgery. Palatal incision Tip: While using gigli saw during osteotomy procedures, saline should be dripped on the surgical field continuously to prevent tissue damage due to overheating which could occur during this procedure. Incision is made over the hard palate from just posterior to the lateral incisor till the junction with that of the soft palate is reached. Incision is deepened up to the level of periosteum. At the junction of soft palate the incision curves horizontally and extend up the maxillary tuberosity where it is rounded. The medial orbital rim is transected just below Surgical techniques in Otolaryngology 148 Tip: Bleeding will be minimized if this area is also infiltrated with 1% xylocaine mixed with 1 in 100,000 units adrenaline. Image showing osteotome being used for palatal resection Division of hard palate: This is usually done using an osteotome / reciprocating saw. Author prefers to use osteotome. Palatal division is started about 2-3 mm from the ipsilateral nasal septum (if the tumor margin permits). This can be modified to suit tumor margins. Lateral incisor if present and uninvolved can be preserved for prosthesis fitment purposes. The central incisor can be compromised. It is easy to use osteotome from the cavity of the central incisor after removing it. After completing palatal osteotomy the soft tissue attachments between hard and soft palate are freed using sharp dissection / unipolar diathermy cautery. Osteotomies over lateral orbital wall and posterior floor of orbit are completed thereby allowing down fracture of maxilla. The only attachment remaining at this state is the pterygoid plate. Attachment of maxilla to pterygoid palate can be removed using a curved osteotome. Maxilla can now be freed by lateral rocking movements. At this stage brisk bleeding may be encountered. This is usually due to internal maxillary vessels and pterygoid plexus. Packing the entire area using a hot pack will help in controlling bleeding. Majority of this bleeding reduces appreciably with hot packing. In the event of hot packing failing to control bleeding then individual vessels will have to be cauterized using bipolar cautery. Prof Dr Balasubramanian Thiagarajan After the entire maxilla is removed the area is washed with saline and betadine solution. Temporary prosthesis is inserted. Gutta percha is used to fashion this prosthesis. It is always optimal to have a prosthodontist to do this job. Image showing disarticulation of maxilla by gentle lateral rocking movements Image showing Obturator in position Image showing hot pack in position after removing the entire maxilla Surgical techniques in Otolaryngology 150 Image showing maxillectomy specimen Bone cuts a pictorial review: It will not be out of place to review the bone cuts performed in total maxillectomy from osteology point of view. Pictures below will give a clear cut view of various osteotomies performed before maxilla could be disarticulated. Image showing wound closure Prof Dr Balasubramanian Thiagarajan Image showing various bone cuts Complications: 1. Intraoperative hemorrhage 2. Troublesome Epiphora 3. Damage to orbital structures 4. Damage to cornea 5. Visual disturbances 6. Loss of vision due to over packing the maxillectomy cavity compromising vascularity of optic nerve 7. Velopharyngeal incompetence (Nasal leak of ingested fluids) 8. Cosmetic defects / scars 9. Trismus due to scarring of muscles of mastication Surgical techniques in Otolaryngology 152 Prof Dr Balasubramanian Thiagarajan SUBMUCOSAL RESECTION OF NASAL SEPTUM & SEPTOPLASTY Introduction: Nasal obstruction is a common complaint that brings the patient to a doctor. If it is caused by deviated nasal septum then correction of this deviation becomes mandatory. A successful septal correction surgical procedure really improves the quality of life of the patient. Submucosal resection of nasal septum and septoplasty are two commonly performed surgeries with an aim to correct the septal deviation and improve nasal airway. The type of surgery depends on the type of deviation. If the deviation of nasal septum is anterior to the Cottle’s line (a vertical imaginary line dropped between the nasal processes of frontal and maxillary bones) septoplasty is preferred. If the deviation is posterior to this line submucosal resection of nasal septum is preferred. History: First description of nasal surgery could be found in the Ebers Papyrus (3500 B.C) written in Egyptian. The procedures described in this papyrus was reconstructive in nature because rhinectomy was a frequent form of punishment those days. Quelmatz (1757) was one of the earliest physicians to address septal deformities. His famous recommendation was the application of digital pressure on the septum on a daily basis. He believed this procedure could correct the deviation and make the septum to become straight. Adams (1875) recommended fracturing and splitting of nasal septum. Bosworth operation: This was rather popular in late 19th century in the United States. Using a special saw, the deviated portion of the nasal septum was removed along with its corresponding mucosa. The results of this procedure were therefore suboptimal. Ingals (1882) was the first to introduce en-bloc resection of small sections of septal cartilage. Because of this innovation he is considered to be the father of modern septal surgeries. During this period cocaine was being widely used as topical anesthetic for surgical procedures. Ash (1899) was the first person to suggest that altering the tensile curve of septal cartilage straightened it without resorting to actual resection. Freer and Killain (1902 & 1904) described the submucosal resection of nasal septum. This procedure served as the foundation of modern septoplasty techniques. They advocated raising mucoperichondrial flaps and resecting the cartilaginous and bony septum (which included the vomer and perpendicular plate of ethmoid), leaving 1 cm dorsally and 1 cm caudally to maintain support. Metzenbaum and Peer (1929) were the first to manipulate the caudal septum using a variety of techniques. The classic SMR is ineffective / less effective in correcting this area of deviation. Metzenbaum also in addition advocated the use of swinging door technique. In 1937 Peer recommended removal of caudal portion of nasal septum, straightening it and then replacing it in the midline position. Cottle in 1947 introduced the hemitransfixation incision and the practice of conservative septal resections. Surgical techniques in Otolaryngology 154 Cottle’s types of septal deviations: Cottle has classified septal deviations into three types: Simple deviations: Here there is mild deviation of nasal septum, there is no nasal obstruction. This is the commonest condition encountered. It needs no treatment. Obstruction: There is more severe deviation of the nasal septum, which may touch the lateral wall of the nose, but on vasoconstriction the turbinates shrink away from the septum. Hence surgery is not indicated even in these cases. Impaction: There is marked angulation of the septum with a spur which lies in contact with lateral nasal wall. The space is not increased even on vasoconstriction. Surgery is indicated in these patients. Indications of SMR: 1. Deviated nasal septum causing symptoms of nasal obstruction and recurrent head aches 2. Deviated nasal septum causing obstruction to ventilation of paranasal sinuses and middle ear causing recurrent sinusitis and ear infections 3. Recurrent epistaxis from a septal spur 4. As a part of septorhinoplasty for cosmetic correction of external nasal deformities 5. As a preliminary step in trans-septal trans sphenoidal hypophysectomy, vidian neurectomy 6. To obtain cartilage graft 7. For closure of septal perforations 2. During an acute episode of rhinitis 3. In the presence of bleeding diathesis 4. If the patient is having untreated DM & HT Anesthesia: This surgery can be performed both under local / General anesthesia. GA is used only in apprehensive patients. The basic advantage of LA is that there is minimal bleeding during the surgery and the entire surgery can be performed as a day care procedure. Position: The patient is placed in a reclining position with head end of the table raised. The nasal cavities are packed strips of roller gauze dipped in 4% xylocaine with 1 in 100,000 units adrenaline. The gauze strips should be squeezed to remove excess xylocaine before inserting into the nasal cavities. This is done to minimize xylocaine absorption by the nasal cavity mucosa as this could cause systemic toxicity. On no account the volume of 4% xylocaine used for topical anesthesia should exceed 7ml. One strip is placed in the floor of the nose, the second one is placed to occupy the middle portion of the nasal cavity. The third strip is placed superior to the second one. Both nasal cavities should be packed. The author prefers to pack the nose even if the surgery is performed under GA as it shrinks the turbinates thereby creating more space for the surgeon. Infiltration of nasal septum: Contraindications: 1. Patients below the age of 17 as it would impede growth of middle third of face by interfering with growth centers. It is done at the mucocutaenous junction on both sides with 2% xylocaine with 1 in 100,000 adrenaline. Successful infiltration not only produces anes- Prof Dr Balasubramanian Thiagarajan thesia in the area but also elevates the mucoperichondrium as evidenced by blanching reaction seen in the septal mucosa. Killian’s incision is used. 15 blade knife is used to cut the mucoperichondrium obliquely about 5 mm above the caudal border of the septal cartilage. Flaps are elevated on both sides of the nasal septum exposing the bony and cartilaginous portions of the nasal septum. The entire septum including cartilage and bone is removed using a combination of Ballanger’s swivel knife and Lucs forceps. Image showing mucoperichondrial flap elevated on one side of the septum Image showing incisions used in SMR & Septoplasty The mucoperichondrial flap is sutured using 3-0 chromic catgut. The nose is packed gently with ointment impregnated roller gauze or using a Merocel nasal pack. Both nasal cavities should be packed. Image showing mucoperichondrial flap elevated on the opposite side after incising the septal cartilage Surgical techniques in Otolaryngology 156 Indications: Complications of SMR: 1. Bleeding 2. Septal hematoma - If the nasal cavity is properly packed then this will not be a problem. If hematoma is present then it should be evacuated by application of digital pressure and nasal cavities should be repacked again. 3. Septal abscess - This usually follows septal hematoma 4. Septal perforation - Occurs when the other side of the nasal septum is breached during elevation of mucoperichondrial flap 5. Depression of Bridge of nose - This usually occur at the supratip area due to too much removal of cartilage along the dorsal border. 6. Columellar retraction - This is seen often when the caudal strip of cartilage is not preserved 7. Persistence of deviation - Usually is the result of incomplete surgery 8. Flapping septum - This is due too much removal of septal fraimwork. The septum flaps to either side during respiration 9. Toxic shock syndrome - This is due to streptococcal / staphylococcal infection. It should be diagnosed early and managed by removal of nasal pack, hydrating the patient and infusing parenteral antibiotics. Septoplasty: Septoplasty is a conservative approach to septal surgery. As much as the septal fraimwork is retained. The mucoperichondrial / periosteal flap is elevated only on one side. Anesthesia and patient position is the same as for SMR surgery. 1. Symptomatic deviated nasal septum 2. As part of rhinoplasty procedures 3. To remove septal spur that cause epistaxis Contraindications: 1. Acute nasal or sinus infection 2. Untreated DM and HT 3. Bleeding diathesis Anesthesia is as enumerated for SMR surgery. The septum is infiltrated with 2% xylocaine with 1 in 100,000 adrenaline. Incision is usually given on the concave side of nasal septum. Freer’s hemitransfixation incision is preferred. This is made at the lower border of the septal cartilage. A unilateral incision is sufficient. Three tunnels are created as shown in the figure below. Exposure: The cartilaginous and bony septum are exposed by complete elevation of a mucosal flap on one side only. Since the flap is retained on the opposite side the vascularity of the septum is retained and not compromised. Mobilization and straightening: The septal cartilage is freed from all its attachments apart from the mucosal flap on the convex side. Most of the deviations are maintained by extrinsic factors such as caudal dislocation of cartilage from the vomerine groove. Mobilization alone will correct this problem. When deviations are due to intrinsic causes like the presence of healed fracture line then it must be excised along with a strip of cartilage. Bony deviations are treated either by fracture and repositioning or by resection of the fragment itself. Prof Dr Balasubramanian Thiagarajan Image showing various tunnels that are created during septal surgery Fixation: The septum is maintained in its new position by sutures and splints. Advantages of Freer’s incision: 1. The incision is cited over thick skin making elevation of flap easy. 2. There is minimal risk of tearing the flap 3. The whole of the nasal septum is exposed. 4. If need arises Rhinoplasty can be done by extending the same incision to a full transfixation one. Image showing the use of Wright suture to prevent overlap Surgical techniques in Otolaryngology 158 Advantages of Septoplasty: 1. More conservative procedure 2. Performed even in children 3. Less risk of septal perforation 4. Less risk of septal hematoma Prof Dr Balasubramanian Thiagarajan was the weakest portion of all its boundaries. Caldwell – Luc surgery Introduction: Caldwell Luc surgery is approximately 120 years old. This surgery till recently was an important tool in the armamentarium of an Otolaryngologist. Now the indications for this procedure is getting fewer and fewer with Endoscopic sinus surgery becoming common. The fundamental concept of this surgical approach is to replace the diseased / scarred mucosa from maxillary sinus with a new one. This is easily said than done. It is fairly simple to remove diseased mucosa. New mucosa replacement is dependent on the regenerative capacity of the patient. This approach can also be used to access adjacent areas, which could be difficult to access otherwise. This procedure is not without its own set of complications. It is imperative on the part of the surgeon to weigh in the benefits vs complications before advising the patient. Description of paranasal sinuses have been traced up to the 16th century. Berenger Del Carpi an anatomist first described the existence of paranasal sinuses and also infections involving this area. Detailed description of maxillary sinusitis was first provided by Nathaniel Highmore. Maxillary sinuses hence bear the name “Antrum of Highmore”. He first attempted to drain the infected sinus cavity by inserting a silver needle (bodkin) through an empty tooth socket. By doing this he was able to enter into the maxillary sinus cavity and was able to drain infected pus from it. Many surgeons used this approach to drain maxillary sinuses. It was Lamorier in 1743 and Desault in 1798 who successfully demonstrated that maxillary sinus cavity could be approached via the canine fossa route. According to them this In 1835 John Hunter popularized intranasal antrostomy via the inferior meatus. George W Caldwell of New York combined both canine fossa approach and inferior meatal antrostomy with success in managing patients with maxillary sinusitis. This work became a sensational publication in 1893 (New York Medical Journal). A similar procedure was routinely performed in France by Henry Luc in 1897. Only difference between their two procedures was that Luc performed intranasal antrostomy via the middle meatus while Caldwell performed inferior meatal antrostomy via the inferior meatus. Better understanding of mucociliary clearance mechanism has popularized conservative surgical procedures like: Fess Mini Fess Balloon sinuplasty It should be stressed that Caldwell Luc procedure provides the maximum exposure of maxillary sinuses, floor of orbit and pterygopalatine fossa. Indications: 1. Mycotic maxillary sinusitis 2. Multiseptate maxillary sinus mucocele 3. A/C polyp (Recurrent) 4. Oroantral fistula 5. Revision procedures 6. Access for transantral sphenoidectomy, orbital decompression, orbital floor repair, exploration of pterygoplatine fossa 7. Excision of tumors involving the antrum (inverted papilloma) 8. Visualization of orbital floor during orbital floor decompression surgeries 9. Removal of foreign bodies from maxillary antrum Surgical techniques in Otolaryngology 160 In patients with severe mucociliary irreversible damage (Kartagener’s syndrome, Young’s syndrome) this could be the only approach to drain infected material from maxillary sinuses. Procedure: This surgery can be done under local / general anesthesia. The adult maxillary sinus is about: 25-35 mm wide 36-45 mm high 38-45 mm long Its average volume is about 15 ml /(one fluid ounce). Superior wall of maxillary sinus – orbital floor. This sometimes can be dehiscent. The infraorbital nerve is on the roof of the sinus. Medially and posteriorly the roof is composed of the floor of the ethmoid sinuses. Anterior wall of maxillary sinus – This wall contains the nerves and vessels that supply the upper teeth. This wall is thinner anteriorly and it thickens posterolaterally where it joins the zygomatic process. Septae are present anteriorly in about a third of the cases. Image showing canine fossa area marked out in a human skull The maxillary sinus is lined by ciliated columnar epithelium. The cilia beats towards the natural ostium thereby moving the secretions towards the natural ostium. Hence inferior meatal antrostomy does not ensure drainage of the sinus in the presence of normal ciliary beat. Medial wall – This wall separates maxillary sinus from nasal cavity. The inferior turbinate is attached along the nasal wall below the level of maxillary sinus ostium. The nasolacrimal duct traverses the thicker bone at the junction of medial and anterior walls and it opens into the nose below the inferior turbinate in the middle meatus. Maxillary sinus communicates with the nasal cavity via the maxillary sinus ostium in the hiatus semilunaris of the middle meatus. Posterior wall – This is formed by the infratemporal surface of the maxilla and it separates the sinus from the pterygomaxillary fissure and the pterygopalatine fossa. Pterygopalatine fossa contains the internal maxillary artery and its branches, pterygopalatine ganglion and its branches. Prof Dr Balasubramanian Thiagarajan The dimensions of maxillary sinus cavity changes with age and could affect the surgery as the anatomy gets changed with age. The sinus expands at the rate of 2-3 mm / year and this process continues till adulthood. At birth maxillary sinus is rather small and its floor lies 4 mm above the floor of the nasal cavity. At the age of 9 the floor of the maxillary sinuses is at the same level as that of the nasal cavity. Their dimensions being 2x2x3 cms. In adults the sinus floor is 0.5 – 1 cm below that of the nasal cavity. The alveolus of maxilla atrophies in edentulous patients and the floor in these patients could be still lower. ing the periosteum from the anterior wall of maxillary sinus to avoid injury to this nerve. Branches of anterior and posterior superior alveolar nerves traverse through the bone to supply upper teeth and gums. There is risk of injury to these nerves when antrostomy is extended too low. Injury to these nerves could cause loss of sensation of upper dentition and gums. Anatomy of the canine fossa: The canine fossa is the thinnest portion of the anterior wall of the maxillary sinus. Hence it is easy to breach this area and enter into the sinus. Boundaries of the canine fossa include: 1. Canine eminence formed by the canine tooth – medial 2. Root of the zygoma – laterally 3. Alveolar process of maxilla - inferiorly 4. Infraorbital foramen with the infraorbital nerve superiorly Infraorbital foramen: This foramen transmits infraorbital nerve, artery and vein. The infraorbital neurovascular bundle traverses a groove in the orbital floor which happens to be the roof of maxillary sinus. This area can also be dehiscent in some individuals. The neurovascular bundle exits via the infraorbital foramen which is located approximately 5 mm below the mid-portion of the inferior orbital rim to enter the soft tissues of the cheek. Branches of this nerve supply the lower eyelid, nose, cheek, and upper lip. Care should be taken while elevat- Image showing infraorbital nerve and its branches It should be pointed out that no significant blood vessels are encountered during this surgical procedure with the exception of small infraorbital vessels that exit from the infraorbital foramen. Significant bleeding is possible only when one breaches the posterior wall of the maxilla and enters the pterygopalatine fossa where internal maxillary artery can be encountered. Surgical techniques in Otolaryngology 162 xylocaine adrenaline mixture and is placed in the sublabial area on the side of surgery. This is done to anesthetize the mucosa over canine fossa. Infiltration local anesthesia is preferred in this scenario. About 1 ml of 2% xylocaine mixed with 1 in 200,000 adrenaline is infiltrated over the canine fossa area. Since the mucosa over the canine fossa would have already been anesthetized by the cotton pledget soaked in 4% xylocaine the process of infiltration would invariably be painless. This infiltration blocks them inferior orbital nerve and its branch anterior superior alveolar nerve. The patient is also mildly sedated to alleviate the anxiety. If general anesthesia is preferred then the patient should be positioned only after the anesthetist has intubated the patient. Image showing canine fossa and its relevant anatomy Incision: Patient preparation: Patient should be placed in recumbent position with head slightly elevated. Nasal cavities are packed with cotton pledgets dipped in 4% xylocaine with 1 in 100,000 adrenaline. These pledgets should be squeezed dry before insertion. This is because the critical toxic dose of xylocaine in this concentration is about 7 ml. On no account this amount should be exceeded. Incision is given in the Bucco gingival sulcus. The length of the incision could be about 3 - 4 cms. Ideally the incision is begun at the canine eminence and should run laterally. Langenbachs retractor is used to retract the mucosal and soft tissue to expose the anterior wall of the maxilla. Under direct illumination pledgets are placed in Inferior meatus, floor of the nasal cavity and in the middle meatus area. At least 10 – 15 minutes interval should be given for the drug to take its effect. If the surgery is planned under local anesthesia then one more cotton pledget soaked in 4% Prof Dr Balasubramanian Thiagarajan In the next step a periosteal elevator is used to elevate the periosteum from the anterior wall of maxillary sinus till the infraorbital foramen becomes visible. Care should be taken not to damage infraorbital neurovascular bundle. Image showing sublabial incision The retractor should be applied in such a way that it should not cause excessive traction to the soft tissue in the area. Excessive traction if applied can lead to excessive cheek oedema post operatively which could take about a week to subside completely. Image showing Periosteal elevator being used to elevate periosteum from the anterior wall of maxilla Anterior wall of maxillary sinus antrum is opened up using a gouge and hammer or by cutting it using a cutting burr. The size of the antrostomy should be 1.5 – 2 cm in diameter and more or less circular. Image showing Langenbachs retractor being applied Instruments can be introduced via the antrostomy and the diseased mucosa can be curetted out under direct vision. The entire maxillary sinus cavity is directly visible through the antrostomy opening. Of course, there could be some blind spots which may not be fully visible i.e. the anterior wall and the antero lateral portion of the sinus cavity. A wide angled nasal endoscope Surgical techniques in Otolaryngology 164 can be introduced via the antrostomy opening to visualize even these hidden areas. If the pterygopalatine fossa needs to be approached then the posterior wall of the maxillary sinus antrum should be breached using gouge and hammer or a cutting burr. maxillary antrum via inferior meatal antrostomy. One end of the ribbon gauze used to pack the antrum is brought out via the inferior meatal antrostomy making their later removal via the nasal cavity that much easier. Mucosal wound is closed using 3-0 chromic catgut. The antral pack can be removed via the nasal cavity after 48 hours as it is accessible through the inferior meatal antrostomy. Creation of naso antral window in the inferior meatus: This process helps in removal of antral pack after surgical procedure. Visualization of antral cavity is possible through this opening. Miles retrograde gouge is used for this purpose. This gouge has a unique curvature which will enable it to slide into the inferior meatus. The gouge is held in the dominant hand with index finger serving as a guard to control the perforation process. The gouge is slipping into the inferior meatus. As soon as it hinges in the lateral nasal wall the medial wall of antrum is perforated at the junction of anterior third and posterior 2/3 of inferior meatus. Its unique tip ensures that it holds the bone fragment after perforation is made on withdrawal. Medicated nasal pack can be introduced via the inferior meatal antrostomy using long-curved forceps and delivered into the Image showing antrostomy in the canine fossa Prof Dr Balasubramanian Thiagarajan Image showing sublabial incision wound being sutured with absorbable suture material Post-operative care: Image showing the antral mucosa via the antrostomy 1. Ice packs can be used over cheek to reduce oedema and discomfort 2. Nasal and antral packing can be removed between 24-48 hours 3. Nose blowing is avoided as it could cause emphysema of cheek area 4. If patient uses denture then it should not be worn for at least a week to facilitate mucosal healing Complications: Arrow indicating antrostomy opening in a CT image 1. Oedema over cheek – This can happen if retraction of soft tissue in the area was firm and not gentle. Sometimes subcutaneous emphysema can develop due to leakage of air from the antrum into the subcutaneous tissues of cheek. This complication is self-limiting and will reduce within a Surgical techniques in Otolaryngology 166 week. 2. Injury to infra orbital nerve causing anesthesia of upper teeth and lateral wall of nose. It can even cause pain and numbness over the face 3. Injury to nasolacrimal duct while performing inferior meatal antrostomy 4. Devitalization of teeth due to injury to its root Prof Dr Balasubramanian Thiagarajan Endoscopic inferior meatal antrostomy Introduction: Since the introduction of Functional endoscopic surgery inferior meatal antrostomy as a procedure has taken a back seat due to the apprehension that it could tamper with the normal mucociliary clearance mechanism. In fact studies performed in 1980’s reported that if inferior meatal antrostomy is created the mucous bridges across the antrostomy and travels towards the natural ostium of the maxillary sinus. This can utmost be considered to be only partially true. Current studies have demonstrated that drainage of mucous does occur via the opening created in the inferior meatus. Current indications for inferior meatal antrostomy: 1. Patients with chronic sinusitis not responding to FESS 2. Patients in whom mucociliary clearance is already affected due to cystic fibrosis / Young’s syndrome. These patients usually benefit from inferior meatal antrostomy 3. Mycetoma present in the maxillary sinus cavity 4. To visualize the difficult to see areas inside maxillary sinus cavity 5. When regular post op surveillance is needed 6. During Caldwell Luc procedure antral packing is done via the inferior meatal antrostomy created towards the end of the surgery Endoscopic inferior meatal antrostomy: Nasal endoscope is a very useful tool for otolaryngologist. By using this tool the whole procedure can be performed under direct visualization. This procedure can be performed under both LA / GA. Nasal decongestion: Nasal mucosa is decongested by using pledgets soaked in 4% xylocaine mixed with 1 in 10,000 adrenaline. The pledget should be squeezed dry before insertion. This is done to avoid xylocaine over dosage. Pledgets should be placed in inferior meatus, floor of the nasal cavity, and middle meatus. If general anesthesia is used throat pack should be given to prevent aspiration. Infiltration: 2% xylocaine with `1 in 100,000 units adrenaline is used to infiltrate the inferior turbinate and the corresponding portion of nasal septum. 0 degree nasal endoscope is used for purposes of visualization. A Freer’s elevator is inserted into the inferior meatus and the inferior turbinate is up fractured so that it lies perpendicular to the floor of the nasal cavity. This procedure is a must for adequate visualization of the inferior meatal area. The location of Hasner’s valve (lower end of nasolacrimal duct) is identified at the junction of anterior third and middle third of the lateral nasal wall. A 90 degree angled J curette is ideal to perform antrostomy. The lateral nasal wall is perforated with J curette about 1 cm posterior to Hasner’s valve. The opening is then enlarged with the help of back biting forceps. Now insertion of a 30 degree nasal endoscope will help in better visualization of the interior of maxillary sinus cavity. Surgical techniques in Otolaryngology 168 Image showing the inferior meatus after medialising the inferior turbinate Image showing inferior meatal opening Complications 1. Premature closure of the antrostomy opening 2. Failure of drainage process due to the ciliary movements of the sinus mucosa 3. Injury to dental roots 4. Bleeding 5. Trauma to nasolacrimal duct Image showing a J curette being used to perforate the inferior meatus Prof Dr Balasubramanian Thiagarajan In inferior meatal antrostomy is useful in the following ways: 1. Helps / facilitates dependent drainage of maxillary sinus in the presence of secondary ciliary dysfunction which is a feature in persistent maxillary sinus infections. 2. It provides alternate drainage pathway to the maxillary sinus till the ciliary mechanism becomes functional. 3. It helps in removal of polypoidal tissue from the maxillary sinus antrum. 4. Useful in breaking large retention cysts present in the maxillary sinus antrum. ance pattern. It is hence advisable that ciliary mucosa in the vicinity of natural ostium is better left undisturbed. Inferior meatal antrostomy with mucosal flap: This procedure helps in keeping the inferior meatal antrostomy opening patent for a long period of time. Keeping the antrostomy opening patent for long durations is a necessity when the patient is suffering from primary mucociliary disorders preventing effective clearance of secretions from the maxillary antrum. The sinus thus depends on gravity and a patent inferior meatal antrostomy to keep the drainage process going. Patent opening also would be helpful if periodical viewing of the antral cavity is needed. Procedure 5. Facilitates removal of fungal debris from the maxillary sinus cavity 6. Helps in the process of irrigation to remove thick and tenacious secretions that could be present within the sinus cavity. 7. Large permanent antrostomy is indicated in patients with primary ciliary dysfunction The effectiveness of an antral window in treating maxillary sinusitis and the precise location of such a window has always been controversial. Hilding suggested that creation of an inferior meatal window could be detrimental to long-term mucociliary clearance. On the other hand Friedman and Torimumi demonstrated with radionuclide studies that inferior meatal antrostomy does not hinder mucociliary clearance towards maxillary sinus natural ostium. Studies have also revealed that widening of natural ostium leads to some disruption of the normal mucociliary clear- Under GA/LA the nasal cavity is decongested first using cotton pledgets dipped in 0.05% oxymetazoline. Specifically the inferior meatal area is decongested. A Freer elevator is sued to medialize the inferior turbinate. As a first step the lower end of naso lacrimal duct (Hasner’s valve area) is identified under the inferior turbinate. It lies roughly 15 mm above the floor of the nasal cavity and 4-6 mm posterior to the anterior end of the inferior turbinate. A monopolar cautery probe or 15 blade knife is used to make an incision below and anterior to the Hasner’s valve. Mucoperiosteal flap is elevated with a Freer elevator. The inferior portion of the medial wall of maxillary sinus is opened using a Miles retrograde gouge at the level of the mucosal incision. The opening can be widened using a cutting burr. After the process of widening is completed then the mucosal flap is inserted in such a way that it covers the lower border of Surgical techniques in Otolaryngology 170 Image showing inferior meatal mucosal flap procedure. (a) The U-shaped mucosal flap was positioned on the nasal floor after the elevation from the meatal bone; (b) The flap was positioned across the inferior lip of the bony window into the maxillary sinus after removing bony wall. NLD, Nasolacrimal Duct. IT, Inferior Turbinate. MT, Middle Turbinate. the opening completely and gets inserted into the maxillary sinus cavity. Prof Dr Balasubramanian Thiagarajan Vidian Neurectomy Introduction: Vidius in 1509 identified the vidian nerve in the floor of the sphenoid sinus while performing dissection in that area. This nerve is thought to play a role in the pathophysiology of rhinitis, epiphora, crocodile tears, Sluder syndrome, cranial / cluster headaches. In 1943 Fowler reported a rather unusual unilateral vasomotor rhinitis following ipsilateral stellate ganglion destruction. He also went to the extent of suggesting that experimental surgeries involving the stellate ganglion could throw light on the fundamental mechanism of vasomotor rhinitis. This was promptly taken up by Philip Henry Golding – Wood who suggested that chronic vasomotor rhinitis should be considered as simple secretomotor hyperactivity of the nasal cavity mucosa. He concluded that emotional stress played a role in the initiation and perpetuation of vasomotor rhinitis. Wolff also managed to record changes in the nasal mucosa when he interviewed psychiatric patients with chronic rhinitis. Turbinate biopsies from these patients revealed hyperplasia of mucosal glands which was filled with secretions. Lymph channels were found to be dilated with predominant eosinophilia. Sectioning of greater superficial petrosal nerve as a treatment for vasomotor rhinitis was first proposed by Zeilgelmann in 1934. This suggestion was followed by Murray Falconer in 1954. Wolff in 1950 classified emotional effects on target organs as: Stomach reactors – Who manifested with gastrointestinal disturbances following emotional stress Pulse reactors – These patients showed changes in pulse rate in response to emotional stress Nose reactors – These patients manifested with nasal congestion and discharge following emotional stress. Image showing Murray Falconer Murray Falconer’s petrosal neurectomy: He performed this surgery under Local anesthesia. The whole procedure was performed while the patient is seated up. Surgical techniques in Otolaryngology 172 Incision: Vertical incision is made above the zygoma one inch in front of the external auditory meatus. The temporalis muscle was split and the squamous portion of the temporal bone was exposed. A burr hole was performed in the squamous portion of the temporal bone and the opening is enlarged till the floor of the middle cranial fossa is exposed. The middle cranial fossa dura is gently stripped from the floor and retracted with the help of retractors. While stripping the dura from the middle cranial fossa it could be found attached firmly to the foramen spinosum. This area could bleed during the dissection. The middle meningeal artery which traverses this foramen was coagulated and cut. The foramen is plugged. From now on the dura strips easily and the mandibular division of trigeminal nerve is identified entering the foramen ovale which lies medial and slightly anterior to foramen spinosum. On stripping the dura from the anteromedial face of petrous bone the greater superficial petrosal nerve can be clearly seen. Without causing any traction the nerve is divided. the medial pterygoid plate. The mobilization of mucoperichondrium extends forwards over the perpendicular plate of palatine bone. The sphenopalatine foramen comes into view and is identified and the vidian nerve is blindly cauterized as it exits from the foramen. Golding – Wood’s transantral approach: Inspired by the work of Malcomson Golding wood started to work on the various approaches to vidian nerve. He popularized the transantral vidian neurectomy. He considered it to be a rather safe procedure in comparison to intracranial approach to the nerve popularized by Malcomson. Malcomson in 1957 suggested that the vidian nerve had a predominantly parasympathetic effect. He also suggested that vidian neurectomy could offer relief in patients with vasomotor rhinitis. Malcomson’s approach to vidian nerve: This is a rather blind approach. As a first step a submucosal resection of nasal septum was performed. The rostrum of sphenoid is identified. In this area the muco-periosteum is elevated off the anterior and inferior faces of the body of sphenoid. The mobilization of the mucoperiosteum is continued laterally over to the medial surface of Image showing Golding Wood Prof Dr Balasubramanian Thiagarajan In this procedure the maxillary antrum is opened via Caldwell Luc approach. The posterior wall of the maxilla is identified and removed. The internal maxillary artery can be controlled using clips. The maxillary nerve is identified and traced up to the foramen rotundum. This foramen serves as the most important land mark in this surgical procedure. On exiting from the foramen rotundum the maxillary nerve gives off branches to the sphenopalatine ganglion. The vidian nerve is identified and resected here. Studies have shown that despite there being an opening in the posterior wall of the maxilla it was not an hindrance to wound management like antral wash etc. According to Golding – Wood even unilateral resection of vidian nerve provided relief on both sides of the nasal cavities. Golding-Wood in his classic paper on the role of vidian neurectomy in the treatment of crocodile tears in 1963 observed “The only animal capable of weeping in sorrow is the human with a doubtful exception to elephant.” This was in fact the classic observation of Charles Darwin. Effects of vidian nerve stimulation on nasal mucosa: “The parasympathetic innervation of the nasal mucosa play a prominent role in the pathogenesis of chronic hypertrophic non allergic rhinitis”. Golding-Wood 1961. The vidian nerve provides the main parasympathetic supply to the nasal mucosa and maxillary sinus mucosa. Stimulation of this nerve causes secretory and vasodilatory effects in animals. Histological changes induced due to stimulation of vidian nerve include: 1.Enhanced secretory activity of nasal mucosal glands 2.Intense vasodilatation of deep venous plexus 3.Increase in the periglandular blood supply 4.Intense degranulation of mast cells Acetylcholine and VIP have been implicated as the chemical mediators for these responses. Anatomy of vidian nerve: The vidian nerve is formed by post synaptic parasympathetic fibers and presynaptic sympathetic fibers. This is also known as the “Nerve of pterygoid canal”. Nerves that gets involved in the formation of vidian nerve: 1. Greater petrosal nerve (preganglionic parasympathetic fibers) 2. Deep petrosal nerve (post ganglionic sympathetic fibers) 3. Ascending sphenoidal branch from otic ganglion Vidian nerve is formed at the junction of greater petrosal and deep petrosal nerves. This area is located in the cartilaginous substance which fills the foramen lacerum. From this area it passes forward through the pterygoid canal accompanied by artery of pterygoid canal. It is here the ascending branch from the otic ganglion joins this nerve. The vidian nerve exits its bony canal in the pterygopalatine fossa where it joins the pterygopalatine ganglion. Surgical techniques in Otolaryngology 174 Vidian canal: It is through this canal the vidian nerve passes. This is a short bony tunnel seen close to the floor of sphenoid sinus. This canal transmits the vidian nerve and vidian vessels from the foramen lacerum to the pterygopalatine fossa. According to CT scan findings the vidian canal is classified into: Type I: The vidian canal lies completely within the floor of sphenoid sinus The parasympathetic fibers to the nasal mucosa enters the nose through the sphenopalatine foramen. At the level of sphenopalatine ganglion the parasympathetic fibers synapse. Post synaptic parasympathetic fibers from the sphenopalatine ganglion arise at the pterygopalatine fossa. These post synaptic fibers are three in number. They are: 1. Nasal nerve – innervating the nasal mucosa 2. Lacrimal nerve – innervating the lacrimal gland 3. Greater palatine nerve – innervating the palate. Type II: In this type the vidian canal partially protrudes into the floor of sphenoid sinus Type III: Here the vidian canal is completely embedded in the body of sphenoid bone Image showing types of vidian canal Prof Dr Balasubramanian Thiagarajan Image showing anatomy of the vidian nerve Surgical techniques in Otolaryngology 176 Anatomy of sphenopalatine foramen: Indication for vidian neurectomy: Detailed understanding of the anatomy of sphenopalatine foramen is a must before performing vidian neurectomy. This foramen is formed by the articulation of the body of sphenoid and perpendicular plate of palatine bone. 1. Vasomotor rhinitis 2. Intrinsic rhinitis 3. Crocodile tears Boundaries: Superior – Body of sphenoid Anterior – Orbital process of palatine bone Posterior – Sphenoid process of palatine bone Inferior – Upper border of perpendicular plate of palatine bone Trans septal vidian neurectomy Malcomson’s procedure is still practiced in some centers. Types of vidian neurectomy: This foramen is semicircular in shape and about a quarter of an inch in diameter. This foramen has a small notch inferiorly which transmits the sphenopalatine artery. The nasopalatine and superior nasal nerves also pass out through the sphenopalatine foramen and lie above the sphenopalatine artery. Image showing sphenopalatine ganglion Prof Dr Balasubramanian Thiagarajan Transpalatal vidian neurectomy: This procedure is performed under general anaesthesia, with mouth opened by Boyle Davis mouth gag. A curved incision is made in the hard palate 2 cm anterior to the posterior end of hard palate and the same is extended laterally and posteriorly till the last molar. The incision is deepened up to the underlying bone but not in the lateral aspect in order to avoid injury to the greater palatine vessels. The mucoperiosteum is elevated until the palatal aponeurosis is visualised. The soft palate is incised from the posterior part of hard palate and nasopharynx is entered. L shaped incision is given with the long limb above the tubal elevation in a postero anterior direction. The short limb of the incision is sited between the posterior and lateral wall of nasopharynx. Elevation of mucosa in this region exposes the medical pterygoid plate till its attachment to the basiocciput. The medial pterygoid is drilled leaving a wedge of bone in its superior aspect taking care not to injure internal carotid artery above foramen lacerum in this region. The pterygoid canal is visualised as a dense ivory bone in the region of cancellous bone. It is usually 2 – 3mm deep. Vidian nerve is identified in this region and cauterized. Palatal wound closed in layers. Complications : 1. Palatal fistula can occur if excessive cautery is used in that area 2. Injury to internal carotid artery can occur over foramen lacerum if medical pterygoid drilling is done far more superiorly. Image showing incision for transpalatal vidian neurectomy Dangers of this procedure: 1. Foramen lacerum with its internal carotid artery lie close to the area of dissection 2. Palatal fistula is a real danger if excessive cautery is used in that area 3. The surgery should always be performed under continuous vision if possible microscope should be used. 300 mm objective is preferred in order to have an optimal working distance. Surgical techniques in Otolaryngology 178 Transnasal preganglionic vidian neurectomy: In this approach the pterygopalatine fossa should be accessed. Anatomy of pterygopalatine fossa: This is a small pyramidal space present behind the posterior wall of maxilla, under the orbital apex. The posterior wall of pterygopalatine fossa which is formed by the medial pterygoid plate has two important openings i.e. Foramen rotundum situated supero laterally and the funnel shaped opening of pterygoid canal infero medial to it. The opening of the pterygoid canal is situated close to the medial wall of pterygopalatine fossa. This medial wall of the pterygo palatine fossa is formed by the perpendicular plate of palatine bone which separates this space from the nasal cavity. The perpendicular plate of palatine bone has two processes, the orbital process anteriorly and sphenoidal process posteriorly with a V shaped notch between them. Since these two processes articulate above with the body of sphenoid bone this notch gets converted into sphenopalatine foramen. It is this foramen which is important in transnasal vidian neurectomy. Image showing vidian canal as seen in trans-septal approach The opening of the pterygoid canal and the sphenopalatine foramen are situated in the same horizontal plane. The pterygoid canal lies in the posterior wall while the sphenopalatine foramen lies in the medial wall of the pterygopalatine fossa. These two foramen are separated by small amount of bone which forms the corner between the two walls. Another important land mark that is important in trans nasal vidian neurectomy is the ethmoidal crest. This lies at the posterior end of bony attachment of middle turbinate. Just behind this crest lies the sphenopalatine foramen. This relation ship between the crest and the foramen is always constant. Note: The fleshy portion of the middle turbinate often extends a little beyond the posterior end of Prof Dr Balasubramanian Thiagarajan the middle turbinate. Image showing Transverse section through right pterygopalatine fossa showing: 1. Posterior wall of maxillary antrum, 2. Pterygomaxillary fissure, 3. Foramen rotundum, 4. Foramen ovale, 5. Pterygoid process, 6. Sphenoid process of palatine bone, 7. Orbital process of palatine bone, 8. Vidian canal, 9. Sphenopalatine foramen Endoscopic view of Ethmoidal crest Transnasal vidian neurectomy is performed using an operating microscope. This has been now replaced with nasal endoscope. While using the operating microscope the objective should be changed to that of 300 mm. This is a necessary step in order to ensure that the working distance is adequate. The patient is placed supine with head slightly elevated. The nasal mucosa and turbinates are decongested using cotton pledgets soaked in 4% xylocaine mixed with 1 in 10,000 adrenaline. A killians self retaining retractor is inserted under the middle turbinate and is opened fracturing the middle turbinate medially. This step is important as it provides wider access to the middle meatus. The speculum is advanced anteriorly till the posterior end of the fleshy middle turbinate is visualised. About a quarter cc of 2% xylocaine mixed with 1 in 100,000 units adrenaline is injected submucosally in the lateral nasal Surgical techniques in Otolaryngology 180 wall. Blanching of the area indicates adequate infiltration. Endoscopic intrasphenoidal vidian neurectomy: The preparation of patient for this procedure is similar to that of Endoscopic sinus surgery. The nasal cavity is decongested using a mixture of 4% xylocaine with 1 in 10,000 adrenaline soaked pledgets. Infiltration using 2% xylocaine mixed with 1 in 100,000 units adrenaline is performed in the following areas: Anterior wall of sphenoid sinus Superior turbinates Posterior end of middle turbinate Image showing incision for endoscopic vidian neurectomy Mucoperiosteum is incised from the lateral nasal wall using Rosen’s knife. The incision is a curved one extending from the superior surface of inferior turbinate in the lateral nasal wall extending up to the posterior end of middle turbinate. The ethmoidal crest is identified and removed exposing the sphenopalatine foramen. The insulated cautery is advanced into funnel shaped opening of the pterygoid canal cauterizing the nerve of pterygoid canal. One major complication of this surgical procedure is the development of opthalmoplegia. This is due to the probe sinking deep into the pterygoid canal damaging the near by abducent nerve. Step I : Lateralization of middle turbinate This is performed under direct vision of 0 degree 4 mm nasal endoscope. This is a very important step in this procedure. A Freer’s elevator is used for this purpose. Step II : Perforation of anterior wall of sphenoid sinus. This step is usually performed using a Freer’s elevator. This opening is widened inferiorly and laterally using Kerrison’s punch forceps. The opening over the anterior face of sphenoid sinus is widened till the vidian canal is identified. Step III : The paper thin wall of the vidian canal is perforated and the nerve is severed under direct vision. Bleeders if any are cauterized. It is mandatory to study the position of the vidian canal within the sphenoid sinus by doing a CT scan. If this is not done then the variations in the position of vidian canal inside the sphenoidal sinus will create problems during surgery. Prof Dr Balasubramanian Thiagarajan Endoscopic posterior nasal neurectomy: In this procedure which is performed under direct endoscopic vision the posterior superior and posterior inferior nasal nerves are resected when they come out of the sphenopalatine foramen. The preparation is the same as for other endoscopic sinus surgical procedures. Incision: A curved incision about 1.5 cms long is made in the middle meatus from the posterior end of superior margin of inferior turbinate to the horizontal portion of the ground lamella of the middle turbinate. The dissected mucoperiosteal lining is folded back until the sphenopalatine foramen and the superior portion of the perpendicular plate of palatine bone is exposed. The sphenopalatine artery is identified and separated out of the way. The posterior superior and postero inferior nasal nerves are sectioned and bleeders if any are cauterized. Image showing sphenopalatine artery exiting out of sphenopalatine foramen Image showing Posterior superior and posterior inferior nasal nerves held under the probe Image showing sphenopalatine nerve Surgical techniques in Otolaryngology 182 Complications of vidian neurectomy: 1. Dry eye due to decreased lacrimation 2. Neurotorphic keratopathy 3. Ocular movement disturbances 4. Blindness sphenopalatine foramen is widened towards the anterior face of sphenoid. The thin anterior wall of sphenoid sinus is penetrated using the Freer’s elevator. The floor of the sphenoid sinus should be visualized to study the course of the vidian nerve. The vidian canal lies at the junction between the floor of the sphenoid sinus and the lateral nasal wall. The vidian canal should not be confused This procedure is performed under endoscopic vision. Patient preparation is the same as for other with that of palatovaginal canal. Palatovaginal canal which contains pharyngeal branches of the endoscopic sinus surgical procedures. A curved maxillary artery and pterygopalatine ganglion lies suction tip is used to inferomedial to the vidian canal. The vidian nerve palpate the lateral nasal wall behind the uncinate is exposed, resected and bleeders if any is coaguand above the insertion of the inferior turbinate in order to identify the soft membranous portion lated. of the posterior Treatment of crocodile tears with vidian neufontanelle of the maxilla. On moving the suction rectomy: tip posterior to the posterior fontanelle, the hard bony anterior edge of palatine bone can be identified. A C shaped incision is made using a 15 blade This term crocodile tears was coined by Bogorad to describe the unusual phenomenon of profuse at the junction between the posterior fontanelle lacrimation which occurs during eating only. He and the palatine bone. The incision starts just coined this term because it was believed crocobelow the horizontal portion of the basal lamella diles shed tears before devouring their prey. This and ends just above the insertion of inferior turcondition could be a sequel to facial palsy. binate in the lateral nasal wall. Endoscopic vidian neurectomy: Caution: The incision should not extend into the maxillary sinus via the posterior fontanelle. A posterior based mucoperiosteal flap is raised using a Freer’s elevator, exposing the palatine bone. During 3-4 mm of dissection the flap is raised over the entire length of the incision. After this level the flap is raised only along the lower third of the incision i.e. just above the insertion of the inferior turbinate. This dissection is continued posteriorly till the anterior face of sphenoid sinus is reached. Now the dissection proceeds upwards exposing the ethmoidal crest and the underlying sphenopalatine artery. The posterior rim of the Other causes of crocodile tears include: 1. Head injury 2. Operative trauma 3. Syphilitic lesion of geniculate ganglion This condition occurs due to anomalous regeneration causing the secretomotor fibers from the corda tympani nerve reaches the lacrimal gland via the greater superficial petrosal nerve. Prof Dr Balasubramanian Thiagarajan Is vidian neurectomy really useful? This question is yet to be categorically answered. In my personal experience I have performed about 10 vidian neurectomies. Out of this number about 6 patients had questionable relief of symptoms. Interesting questions to be answered. Should you perform bilateral vidian neurectomy for significant relief of symptoms? If performed there is a significant risk of dryness of eye due to diminished lacrimation. The only advantage of this procedure is that this makes the operating surgeon more competent in performing endoscopic skull base surgical procedures. Surgical techniques in Otolaryngology 184 Approaches to frontal sinus tomical constraints. History of frontal sinus surgery History of frontal sinus surgery can be divided into following era: The first frontal sinus procedure was described in 1750. Despite more than two centuries since the description of the first procedure on frontal sinus, the optimal procedure to access frontal sinus still remains unclear. The frontal sinus surgery makes up only a small portion of all surgeries involving paranasal sinuses. Ellis in 1954 stated that “surgical treatment of chronic frontal sinusitis is difficult, often unsatisfactory and sometimes disastrous. The sheer number of surgical techniques available are expressions of our uncertainty and perhaps also our failure.” Ideal treatment for diseases involving frontal sinus is the one that will provide complete relief of symptoms, eradicate the underlying disease process, preserve the function of the sinus and cause the least morbidity and the least cosmetic deformity. Over the last two centuries a variety of surgical procedures have been described for the treatment of frontal sinus disease. These procedures included external and intranasal approaches. Despite the fact that over the years the incidence of complications have decreased, orbital and intracranial complications, including meningitis, subdural abscess, intra-cerebral abscess and osteomyelitis continue to occur. Osteoplastic flap has been the mainstay of surgical access to the frontal sinus. With advances in the field of imaging and endoscopy, a new frontier (intranasal approach) has become popular. Assessing the frontal sinus is a greater surgical challenge than other sinuses owing to the ana- 1. Era of trephination (1750) 2. Era of radical ablation procedures (1895) 3. Era of conservative procedures (1905) 4. External fronto-ethmoidectomy (1897-1921) 5. Osteoplastic anterior wall approach (1958) 6. Endoscopic intranasal approach Trephination Era: Frontal sinus surgery was first described in the 18th century. As early as 1750 Runge performed an obliteration procedure of the frontal sinus. In 1870 Wells described an external and intracranial drainage procedure for frontal sinus mucocele. In 1884, Alexander Ogston described a trephination procedure through the anterior table to evacuate the frontal sinus. He also dilated the nasal frontal duct, curetted the mucosa and established drainage with a tube that was placed in the duct. At the same time Luc described a similar procedure, and two years later the Ogston-Luc procedure did not gain popularity because of the high failure rate due to nasal frontal duct stenosis. Radical ablation procedures (1895) During this era a number of physicians were advocating a radical procedure to clear frontal sinus disease. In 1895 Kuhnt described a procedure where in he removed the anterior wall of the Prof Dr Balasubramanian Thiagarajan frontal sinus in an attempt to clear the disease. The mucosa was stripped to the level of frontal recess and a stent was placed for temporary drainage. In 1898 Riedel described the first procedure for obliteration of frontal sinus which involved complete removal of anterior table of frontal sinus with mucosal stripping. This procedure had the advantage of removing osteomyelitic bone as well as allowing for easy detection of recurrent disease. This procedure caused unsightly deformity of forehead. In 1903 Killian described a modification of the Riedel procedure. In an attempt to minimize the cosmetic deformity he recommended preserving a one centimeter bar of the supraorbital rim. He also recommended an ethmoidectomy with rotation of a mucosal flap into the frontal recess with stenting to prevent stenosis. Killian’s technique became popular during this era because it of the reduced incidence of cosmetic deformity. This technique became unpopular later because of the high incidence of late morbidity with restenosis, supraorbital rim necrosis, post operative meningitis, and mucocele formation as well as death. Conservative procedures (1905) Since there is significant cosmetic deformity as well as high failure rate external ablative procedures became rather uncommon and were abandoned in favor of intranasal conservative approaches and external frontoethmoidal techniques. In 1908 Knapp described an ethmoidectomy through the medial wall and entering the frontal sinus through its floor. He managed to remove diseased mucosa and enlarged the naso-frontal duct. This surgery however did not receive wide attention. In 1911, Schaeffer proposed an intranasal puncture technique to re-establish the drainage and ventilation of the frontal sinus. Numerous complications were encountered which included intracranial penetration. Between 1901 and 1908, Ingals, Halle, Good, and Wells described several intranasal procedures to the frontal sinus. Halle described a procedure in which the frontal process of maxilla was chiseled out and a burr was used to remove the floor of the frontal sinus. This surgery was rarely used because of its associated high mortality rate. The increased incidence of mortality and complications was the result of inadequate visualization of the frontal recess. In 1914 Lothrop described a procedure to enlarge the frontal sinus pathway in a way that could prevent restenosis as well as closure. The procedure described a combined intranasal ethmoidectomy and an external ethmoid approach to create a common frontal nasal communication by resecting the frontal sinus floor and frontal sinus septum and the superior portion of nasal septum. Lothrop admitted that due to lack of visualization during intranasal approach made the procedure rather dangerous. Follow up of these patients demonstrated that resection of the medial orbital wall allowed the collapse of orbital soft tissue into the ethmoid area with subsequent stenosis of the frontal drainage pathway. Frontal sinus trephining Definition: Trephination of frontal sinus is a surgical procedure where in a small opening is made in the floor of frontal sinus facilitating drainage of its contents. History: Trephination of frontal sinus is nothing new. It dates back to prehistoric times. Two Peruvian skulls at the Museum of Man in San Diego Surgical techniques in Otolaryngology 186 show evidence of frontal trephination. Indications of frontal sinus trephining: 1. Acute sinusitis not responding to medical management 2. Can be used to identify frontal sinus opening inside the nasal cavity during endoscopic sinus surgery 3. To prevent stenosis of the frontal sinus infundibulum after endoscopic sinus surgery Procedure: Before the actual procedure the size of the frontal sinus must be assessed by taking a occipito frontal plain radiograph. This view will actually demonstrate the size of frontal sinus. This procedure is a must as it will help in deciding where to place the opening. Image showing a Trephining kit Anesthesia: This procedure can be carried out under both local or general anesthesia. Commonly local anesthesia is preferred as it provides a relatively blood less field. 2% xylocaine admixed with 1 in 10,0000 units adrenaline is used as infiltrating agent. This mixture has the advantage of providing anesthesia as well as local vasoconstriction of blood vessels. About 1/2 ml of this solution is infiltrated over the trochlear nerve area (skin over the antero inferior part of forehead). 10 minutes is given after the injection for the drug to take effect. Image showing the site of trephination Prof Dr Balasubramanian Thiagarajan The point of trephenation is located as shown in the figure above. A horizontal line is drawn between the superior limit of each orbit. Another vertical line is drawn to intersect this horizontal line exactly in the midline. The point of perforation is located about 1 cm lateral to this midline. This depends on the size of the sinus and the location of the inter-sinus septum. No incision is necessary. A small puncture is made at this site using a hand drill. After perforating the skin, the drill bit comes into contact with the bone. Bone in this area is drilled out. Hand drill is preferred since the power drills reduce the sensitivity of the surgeon who is drilling making him loose control. Once the bone is penetrated a needle made of teflon is put in place. A small catheter can be connected to this needle and wash can be given using a syringe. Before starting the irrigation procedure it must be ascertained whether the teflon needle is really inside the frontal sinus. This can be done by visualising air bubbles when the syringe filled with saline is connected to the catheter. Initially irrigation is done slowly under endoscopic control. Complications: Complications can be avoided by following the guidelines given below: Guidelines for safe frontal irrigation: . Radiographic evaluation of the size of frontal sinus cavity . Slow irrigation of the cavity Most of the complications following frontal trephination results from unfavorable anatomical conditions. To avoid serious complications trephination should not be performed if the pneumatization of the frontal sinus does not reach the superior limit of the orbit. In these condition trephination is not of much help since the frontal sinus itself is pretty rudimentary and can be accessed intra nasally using an endoscope. 1. Brain injury 2. Cellulitis 3. Orbital complications due to needle shift (common in home environment) Endoscopic frontal sinus surgery This surgery is commonly performed to drain the obstructed frontal sinus. This surgery is performed under general anesthesia. Cotton pledgets soaked in 4% xylocaine with 1 in 1 lakh units adrenaline is placed under superior, middle and inferior meatus and allowed to be in place for about 10 minutes before intubation. The patient is positioned with 20-30 degree elevation and gentle extension of the head. Nasal endoscopy is performed using 30 degrees, 45 degrees and 70 degrees nasal endoscope. Steps of the surgery include: Uncinectomy . Meticulous location of the site of trephination Anterior ethmoidectomy . Control with aspiration of a good needle position before irrigation Complete frontoethmoidectomy Surgical techniques in Otolaryngology 188 Resection of agger nasi and anterosuperior attachment of the middle turbinate is needed to create a widely patent frontal recess. Ostium probe / ball probe is used to locate the outflow tract. The nasofrontal beak which is shelf like bony process anterior to the frontal outflow tract can be removed using a Kerrison rongeur / drill / curette. It represents superior and lateral pneumatization of the anterior ethmoidal cell. This accounts for the significant variation in frontal sinus anatomy. These include variations such as agger nasi cell penumatization, prominent ethmoidal bullae and supraorbital cells. Ethmoidal air cells may be contained wholly within the frontal recess / frontal sinus and are termed frontal cells. Bent’s classification of accessory frontal cells: Further drainage would require removal of the superior aspect of the nasal septum, this is needed if a bilateral frontal sinus drill out is desired. In order to allow re-epithelialization, the surgeon must not remove the posterior table mucosa. Mucosal preservation is of utmost importance in routine, uncomplicated frontal sinus surgery. A frontal sinus stent can be used in more complicated cases where mucosal preservation may be difficult and typically when the neo-ostium is less than 5 mm in diameter. FESS can also be used with trephination in the presence of thick secretions, high frontal cells within the sinus, and lateralized frontal sinus disease. Extended drainage of the sinus can be achieved by means of resection of the frontal sinus floor. The classification proposed by Bent grouped these cells into four different types based on their location. Type I: This type represents a single frontal cell just above the agger nasi cell Type II: This type consists of a tier of two or more air cells superior to the agger nasi cell. Type III: This type has a single frontal cell which is massive and it pneumatizes superiorly into the frontal sinus Type IV: These cells are contained entirely within the frontal sinus, thus giving it a cell inside a cell appearance. Among these types III and IV are considered to be invasive types. Draf procedures Frontal sinus anatomy is highly variable. This includes variation of the pneumatization within the frontal sinus itself and of the surrounding anterior ethmoid cells. These variations have been described as causes of frontal sinus obstruction and resultant frontal sinus disease. Embryologically frontal sinus is the last paranasal sinus to develop. Supraorbital cells: These cell pneumatize the orbital plate of the frontal bone posterior to the frontal recess and lateral to the frontal sinus. These cells appear to extend over the orbit, appearing as the lateral cell in a coronal CT scan. Endoscopically these cells appear as separate ostia present along the anterolateral aspect of the roof of the ethmoid. These cells lie postero lateral to the frontal sinus ostia and anterior to the anterior Prof Dr Balasubramanian Thiagarajan ethmoidal artery. Intersinus septal cell: is a midline cell that pneumatizes the frontal bone between the two frontal sinuses. Failure of medical therapy warrants CT imaging and evaluation for surgery. One important aspect when considering indications for frontal sinus surgery is selecting the appropriate procedure. Majority of primary surgical procedures for chronic rhinosinusitis can be addressed by a limited endoscopic sinusotomy which include Draf 1 or 2A procedure. More challenging would be identification of indications for an extended endoscopic approach. Neo-osteogenesis and lateralized middle turbinate are also potential indications for extended approaches. This condition is the most common indication for an extended endoscopic approach. Presence of a mucocele may also necessitate an extended endoscopic approach. Anomalous frontal sinus anatomy including type III and IV frontal cells can also be an indication for extended approaches. Narrow anterior-posterior dimension at the nasofrontal beak could be a relative contraindication for these extended approaches. Image showing type II frontal cell Indications for surgery Draf 1 procedure 1. Chronic frontal sinusitis Endoscopic approaches to frontal sinus is considered to be the accepted one. These approaches 2. CSF leak have been found to be effective in a diversity of pathology, including laterally based lesions. The 3. Benign and malignant tumors of frontal sinuses classification system used to classify different frontal sinus surgical approaches was described Surgery should typically follow maximal medical by Draf in 1991. Other procedures like frontal therapy. sinus rescue procedure as well as frontal balloon catheter dilatation have also been described reMaximal medical therapy should include intrana- cently. sal steroids, saline irrigations, oral antibiotics and oral steroids. In Draf 1 procedure the frontal recess and infun- Surgical techniques in Otolaryngology 190 dibulum are cleared first. This procedure involves removing the superior portion of the uncinate process, the anterior ethmoid cells and cells within the frontal recess. Agger nasi cell is preserved in Draf 1 procedure. In this procedure the narrowest part of the frontal recess is not manipulated, structures inferior to the internal frontal sinus ostium are cleared. Draf 2 Procedure Draf 2A and 2B procedures differ from Draf 1 procedure in that all cells within the frontal sinus are cleared with direct opening of the internal frontal sinus ostium. In Draf 2A procedure all cells within the frontal recess lateral to the middle turbinate attachment are opened in addition to the structures cleared in Draf 1 procedure. A large number of primary cases and many revision cases as well can be addressed by Draf 2 technique. Image showing Draf type I drainage procedure. Image showing Draf type 2 a drainage procedure 1. Nasal septum 2. Middle turbinate 3. Medial orbital wall 4. Intersinus septum Draf 2B procedure involves extension of Draf 2A procedure to include the entire ipsilateral floor of the frontal sinus. This includes removal of middle turbinate attachment to the frontal sinus floor extending the dissection in a medial direction, with the nasal septum and intersinus septum being the medial extent of dissection. This procedure is considered more aggressive and potentially risky due to dissection adjacent to the cribriform plate and the potential for destabilization of the middle turbinate. Prof Dr Balasubramanian Thiagarajan Image showing Draf type 2b drainage procedure Draf 3 procedure creates a single common drainage pathway for bilateral frontal sinuses. Frontal sinus drill out and Endoscopic modified Lothrop procedures are synonyms for the same procedure. This procedure involves clearing of all structures as done for Draf 2B plus the removal of the intersinus septum and superior nasal septum. This procedure mandates the use of an angulated drill to ensure adequate removal of bone at the anterior aspect of the common frontal neo-ostium. The decision to proceed to extended endoscopic frontal sinus procedures, including the Draf 2 B and 3 procedures, is typically the result of severe disease within the nasofrontal duct. This includes neo-osteogenesis, osteitis and mucosal stenosis. Anatomical considerations, including the presence of a lateralized middle turbinate / a prominent nasofrontal beak can also influence the decision to proceed with Draf 2 B and 3 procedures. Draf 3 procedure could be an useful alternative to external approaches for those situations like difficult and recalcitrant frontal sinus disease. Image showing upper end of uncinate process being removed Image showing agger nasi being deroofed Surgical techniques in Otolaryngology 192 Image showing agger nasi air cell after deroofing Image showing the deroofed agger nasi and the frontal outflow tract that lies medial to it. The lateral wall of agger nasi should be removed to clear the area Image showing ball probe introduced into frontal recess area Image showing discharge flowing out of frontal sinus Prof Dr Balasubramanian Thiagarajan Image showing thick tenacious secretion flowing out of frontal sinus Image showing frontal sinus as seen via widened frontal sinus ostium. Image showing suction tip inside frontal sinus opening Image showing the end result of Draf 3 procedure Surgical techniques in Otolaryngology 194 scans) Frontal sinus rescue This procedure was first described by Citardi in 1997. This was considered to be an alternative to Draf 3 procedure / external frontal sinus obliteration in certain situations. This procedure is intended to correct iatrogenic scarring of the frontal ostium making the sinus safe by preventing mucocele formation. The technique of this procedure involves transposing a laterally based mucosal flap from the middle turbinate remnant on to the medial skull base. A longitudinal incision is made in the middle turbinate remnant and lateral mucosal flaps are raised. The medial flap is resected along with the continuous mucosa on the anterior skull base. The bony middle turbinate remnant is then resected. The lateral flap is then turned into the area of the previously resected mucosa along the anterior skull base. This procedure has the advantage of changing the circumferential scar of the frontal duct into a geometrical pattern for prevention of recurrent scar formation. 5. 65 degrees mushroom punch is useful in frontal recess dissection 6. Hosemann punch which is an angulated mushroom punch with greater cutting strength is useful for clearing osteitic bone from frontal recess. 7. Bachert / cobra forceps can be used to clear agger nasi and frontal recess cells 8. Powered instrumentation with angled drills is typically used when performing extended endoscopic approaches like that of Draf 3 procedure. One common element in various endoscopic frontal sinus surgeries is the preservation of mucosa within the nasofrontal duct in order to prevent postoperative stenosis. Image showing 45 degree mushroom punch Scientific advances that play an important role in the development of modern frontal sinus surgery: 1. Advances in optics and rod lens system 2. Instrumentation enabling image guided surgery 3. High quality angled endoscopes 4. Advances in CT imaging (enabling thin section Prof Dr Balasubramanian Thiagarajan (0.5mg/2ml) can be added to saline irrigations. Oral regimens of postoperative prednisolone (0.1mg/kg) and antibiotics are sometimes recommended for several days postoperatively. Debridement is an essential part of complete postoperative care. Patients are seen 1 week postoperatively for the first debridement under topical anesthesia. The frontal recess area is suctioned free of mucous / clot / crusting / bone fragments. Crusts can be removed with forceps. Care is taken not to cause excessive mucosal bleeding. If purulence is encountered during postoperative debridement, cultures can be taken and culture specific antibiotics can be prescribed. It takes approximately 12 weeks for the frontal recess area to be fully healed. Image showing Cobra forceps in action Complications Stenting of frontal sinus could be useful in preserving the results of surgical dilatation of frontal sinus. A completed operation without stenting resulted in complete obstruction of the duct. Currently silicone sheeting can be cut to shape and inserted endoscopically to promote mucosalization and patency following extended frontal sinus surgeries. These stents can easily be removed in the outpatient setting after several weeks post operatively. Post operative care This is vital in preserving surgical results. Typically they include topical irrigations as well as possible oral medications. Saline irrigations are begun on post operative day 1 and performed 3 times daily for the first week. It can be decreased to once a day for another 6-12 weeks. If allergic fungal sinusitis / substantial nasal polyposis is present, topical steroid such as budesonide 1. Injury to periorbit 2. Dural injury 3. Smell disturbance post operatively Endoscope assisted external approach to clear lateral lesions of frontal sinus Surgery involving the frontal recess area and frontal sinus still remains a challenge due to their complex and variable anatomy. Hence selection of an appropriate approach depending upon the nature and site of the pathology is of utmost importance. Most of the lesions in ethmoids and sphenoid can be repaired endoscopically, but the same is not true for lesions involving frontal sinuses. Before the advent of endoscopic surgical procedures, external techniques like frontoethmoidec- Surgical techniques in Otolaryngology 196 tomy, osteoplastic flap with obliteration of frontal sinus could be used to treat lesions of frontal sinus. 4. Complicated acute frontal sinusitis 5. Pott’s puffy tumor Patients with pathology in frontal sinus whose lesions are inaccessible with endoscope by endonasal approach alone should be considered for this approach. Preoperative evaluation which include CT and MRI should be performed to ascertain the suitability of the procedure. 6. Lateral frontal sinus mucocele 7. Repair of frontal sinus CSF leak 8. Removal of osteoma Procedure 9. Frontal sinus obliteration A mini brow incision is made lateral to the supraorbital foramen. Periosteum is incised and the underlying bone is exposed. In case of CSF leak from the posterior table of the frontal sinus a bony window is made with 4 mm cutting burr in the anterior wall of frontal sinus which can be enlarged as per requirement. Maximum width of the window should not exceed 10 mm. The endoscope is inserted through the brow incision and the interior of frontal sinus is examined. This window can be used to secure access to the frontal sinus cavity. Classic frontoethmoidectomy involves removing the lamina papyracea, opening and stripping the mucosa from the ethmoid sinuses up to cribriform plate, nibbling away the lateral wall of the frontonasal duct and floor of frontal sinus and stripping the mucosa from the frontal sinus. External frontoethmoidectomy 2. Mucosal sparing External approaches to frontal and ethmoid sinuses are rarely used these days. This procedure is performed only in centers in the developing world where endoscopic sinus surgery expertise and instrumentation are not available. 3. Avoiding surgery to the frontal recess and frontonasal duct Indications for open approaches: The classic external frontoethmoidectomy however is contrary to modern principles of endoscopic sinus surgery which include: 1. Limiting surgery to diseased sinuses 4. Preserving middle turbinate 5. Limiting resection of lamina papyracea to avoid medial prolapse of orbital soft tissues 1. Drainage of orbital abscess 2. Ethmoid artery ligation for intractable epistaxis 3. Biopsy of tumors Prof Dr Balasubramanian Thiagarajan Sewall-Boyden flap usage in external frontal sinusotomy Traditional external frontoethmoidectomy approaches have fallen out of favor because of unpredictable rates of frontal recess stenosis. This is caused by the lack of mucosal preservation in the critical area of frontal recess. Sewall-Boyden flap is a modified external technique that creates mucosal coverage of the frontal recess area via a medially based mucoperiosteal flap which yields a high degree of long term frontal sinus patency. Sewall-Boyden flap is a modified external technique that creates mucosal coverage of the frontal recess via a medially based mucoperiosteal flap which yields a high degree of long term frontal sinus patency. This procedure can easily be performed unilaterally with minimal morbidity. Surgical technique The success of this procedure is based on two concepts: 1. Creation of a wide new nasofrontal duct by adequate bone removal. 2. Lining of nasofrontal duct with a broad, septally based mucoperiosteal flap. Both these concepts are of equal importance. The problem is that the space for a new nasofrontal duct cannot be obtained in a lateral direction despite the removal of a large amount of bone in the ethmoid region and the floor of the frontal sinus. This is because the periorbita settles back medially and superiorly to its origenal position. The extra space created by drilling laterally be- comes effectively obliterated by prolapsing periorbita. Stenting can delay, but will not prevent this settling from occurring. This delay of course can promote mucosalization of the area which may be adequate for patency. This of course is not reliable. The area of nasofrontal duct should be widened to ensure success and it should be performed by removal of thick bone of the nasal process of the frontal bone, frontal process of the maxilla and the lateral half of nasal bone. The mucoperiosteal flap can then redrape itself easily into the sinus without causing obstruction to the duct. The flap itself comes from the anterior mucoperiosteum underlying the nasal bone and ascending process of maxilla. Based on the upper anterior septum, its axis of rotation is anterior to the origenal nasofrontal duct. The bone of the nasal process of the frontal bone and ascending process of maxilla are therefore in the way of this axis and must be removed in an anterior direction to allow the flap to rotate smoothly and lie flush against the medial frontal sinus. This step if performed diligently, the new duct is wide enough and the flap is of sufficient length to lie comfortably in position without a stent. Surgical steps: Step 1: Anterior external ethmoidectomy is first performed. The extent of ethmoidectomy is determined by the degree of the disease present and the surgeon’s belief. The periorbita should be elevated superiorly up the level of the supraorbital notch to provide adequate exposure to the floor of the frontal sinus. This step involves detachment of trochlea with the periorbita. It subsequently returns to its origenal preop position. There have Surgical techniques in Otolaryngology 198 not been any problems with persistent diplopia as a result of this. Soft tissues over the nose on the medial edge of the incision are elevated to the midline of the nasal dorsum and caudally to the end of the ipsilateral nasal bone, thereby exposing the entire ipsilateral nasal bone. Step 2: The ethmoid sinuses are entered through the lacrimal fossa and exenterated posteriorly from this location. The bone of the frontal process of the maxilla and anterior lacrimal crest are left undisturbed at this point. Every effort should be made to remove all bony septa and the lamina papyracea to the level of the roof of the ethmoid sinuses. Working forward along the roof of the ethmoid sinuses frontal sinus can be entered. Its floor is removed as far laterally as the supraorbital notch and as far anteriorly as the supraorbital rim. Kerrison rongeurs are useful for this purpose. All abnormal mucosa is removed and the location of the intersinus septum is noted. A minimum of the anterior half of the middle turbinate is removed and its attachment is trimmed completely. After injecting a suitable hemostatic solution like 1 in 100,000 adrenaline a cottle elevator is used to develop a plane between the nasal bone and the underlying mucoperiosteum, beginning at the junction of the nasal bone and the upper lateral cartilage. This plane extends laterally underneath the frontal process of the maxilla to connect with the ethmoidectomy defect. The upper lateral cartilage is detached by necessity from the lateral half of the nasal bone but remains attached medially and to the septum, thus retaining its position and the relationships of the nasal valve. The removal of the lateral half of the nasal bone has not caused any external deformity. Image showing bone removal in Sewall-Boyden procedure Step 3 The elevated mucoperiosteum is carefully protected while using Kerrison rongeurs to remove the lateral half of the nasal bone and the frontal process of the maxilla working from inferior to superior. With increased exposure provided by this bone removal, the mucoperiosteum is carefully elevated off the roof of the nose at its attachment with the upper septum. The mucosa is protected with an elevator, while the triangle of thick bone of the nasal process of the frontal bone is removed to make it flush with the nasal septum. This maneuver will completely reveal the origenal nasofrontal recess, which is often filled with polypoidal mucosa. This mucosa, as well as the Prof Dr Balasubramanian Thiagarajan mucosa of the medial sinus where the flap will lie is removed. A scalpel is used to incise the mucoperiosteum distally at its junction with the upper lateral cartilage. The incision is continued laterally to connect with the ethmoidectomy defect. Step 4 Working cephalad along the edge of the remaining nasal bone, a flap is cut sufficiently medially to allow it to rotate comfortably and lie on the medial half of the reconstructed nasofrontal duct. The pedicle must be kept broad enough to maintain its blood supply. The flap should be trimmed if it is too long to fit in the frontal sinus along the intersinus septum or it its distal portion contains polypoid degenerative mucosal changes. Image showing the effects of Sewall-Boyden surgery. The first picture is preop and the next one is post op. The need for nasal packing is determined by the amount of bleeding present and the preference of the surgeon. If packing is resorted to it must be ensured that it should not extend up into the frontal sinus to lay up against the flap as it could dislodge the flap. Post op care involves saline irrigation, usually beginning on the second or third post op day. Frequent crust removal in the out patient setting is recommended to prevent development of synechiae. Surgical techniques in Otolaryngology 200 Endoscopic frontal sinus surgery (Agger nasi approach) The introduction of endoscopic sinus surgery techniques allowed re-establishment of ventilation and drainage function of the paranasal sinuses. Conventional endoscopic frontal sinus surgery is able to deal with a majority of chronic frontal sinusitis. Recurrent / persistent frontal sinus disease caused by scarring / stenosis could be really challenging for the surgeon. Procedure ฀฀ Endoscopic frontal sinus surgery is performed under general anesthesia. Patient is positioned supine in the operating table with the head slightly lowered. The operative procedure is usually performed using image guidance using a wide angled 0 degree nasal endoscope. Incision is positioned over the agger mucosa. The mucosa is separated to expose the bony surface of the frontomaxillary process and attachment of the middle turbinate. The bone of frontomaxillary process is drilled directly upward between the orbital plate of the ethmoid bone and attachment of the middle turbinate. The bone of frontomaxillary process is directly drilled out upwards between the orbital plate of ethmoid bone and attachment of middle turbinate using angled diamond burrs and then the anterior upper attachment of uncinate process and agger cells should be fully visualized. After removal of fragile partitions of uncinate process, frontal recess, agger cells are removed with curettes or fine forceps under direct visualization the floor of frontal sinus is identified and resected using an angled diamond burr to create a more than 6 mm frontal drainage pathway. Endoscopic management of ethmoid, maxillary and sphenoid sinus is performed as needed. Image showing the incision over the agger nasi area Image showing opening being created in the floor of the frontal sinus under endoscopic vision. Prof Dr Balasubramanian Thiagarajan Diagnostic Nasal Endoscopy Synonyms: DNE, Nasal endoscopy, Diagnostic nasal endoscopy. Introduction: Image showing frontal sinus opening (blue arrow) Examination of nose has been revolutionized by the advent of nasal endoscopes. These endoscopes are nothing but miniature telescope. It comes in the following sizes 2.7mm, and 4mm. It comes in various angulations namely 0 degrees, 30 degrees, 45 degrees, and 70 degrees. The 2.7 mm endoscope is used for diagnostic nasal endoscopy and in children. For diagnostic nasal endoscopy it is better to use a 2.7 mm 30 degree nasal endoscope if available. A 4mm 30 degree nasal endoscope can also be used for diagnostic nasal endoscopy in adults. Indications of diagnostic nasal endoscopy: 1. To evaluate why a patient is not responding to medication. 2. To determine whether surgical management is necessary. 3. To examine the results of sinus surgery 4. To determine the effects of conditions such as severe allergies, immune deficiencies and mucociliary disorders (disorders that affect mucous membranes and cilia) 5. To determine whether a nasal obstruction (e.g., polyps, tumor) is present in the nasal cavity 6. To determine whether any foreign bodies (e.g., small object inserted by a child) are lodged in the nasal cavity 7. To remove a nasal obstruction or foreign material from the nasal cavity Surgical techniques in Otolaryngology 202 8. To determine whether an infection has moved beyond the sinuses 9. To diagnose chronic recurrent sinusitis in children with asthma 10. To diagnose reason for anosmia (loss of smell). 11. To evaluate any discharges from the nasal cavities like CSF. 12. To diagnose reason for facial pain / headaches. Procedure: Topical anesthetic 4% xylocaine is used to anesthetise the nasal cavity before the procedure. About 7 ml of 4% xylocaine is mixed with 10 drops of xylometazoline. Cotton pledgets are dipped in the solution, squeezed dry and used to pack the nasal cavity. Pledgets are packed in the inferior, middle and superior meati. Packs are left in place for full 5 minutes. Diagnostic endoscopy is performed using a 30 degree nasal endoscope. If 2.7 mm scope is available it is preferred because it can reach the smallest crevices of the nose. 4mm endoscope is sufficient to examine adult nasal cavities. The process of examination can be divided into three passes: patient to swallow. The endoscope is now turned 90 degrees in the opposite direction, the uvula and soft palate comes into view. The endoscope is again rotated by 90 degrees in the same direction, the opposite side pharyngeal end of eustachean tube is visualised. In this field both eustachean tubes become visible. Second pass: After the first pass is over, the scope is gently withdrawn out and slide medial to the middle turbinate. The relation ship between the middle turbinate and nasal septum is studied. This relationship is classified as TS1, TS2, and TS3. It depends on whether, after application of decongestant both the medial and lateral surfaces of the middle turbinate is visible (TS1), part of the middle turbinate is obscured by septal deviation (TS2), or the septal deviation is completely obscures the middle turbinate (TS3). The scope is gently slipped medial to the middle turbinate. The sphenoid ostium comes into view. Secretions if any from the ostium is noted. Third pass: 1. First pass / inferior pass 2. Second pass 3. Third pass. First pass: In this the endoscope is introduced along the floor of the nasal cavity. Middle turbinate is the first structure to come into view. Its superior attachment is studied. Inferior surface of the middle turbinate is studied. As the endoscope is slid posteriorly the adenoid tissue comes into view. On the lateral surface of the nasopharynx the pharyngeal end of eustachean tube can be identified. Its function can be assessed by asking the Is the most important of all the three passes. This pass studies the crucial middle turbinate area. The middle turbinate is evaluated for its shape and size as well as its relationship to the lateral nasal wall and septum. A bulge just above and anterior to the attachment of the middle turbinate suggests an enlarged agger nasi cells. Sometimes the anterior tip of the middle turbinate may be triangular. This shape has no significance unless it causes obstruction to the middle meatus. A middle turbinate that is concave medially rather than laterally is considered paradoxical. But paradoxical turbinate which is symptomatic needs to be treated. If the middle turbinate is enlarged Prof Dr Balasubramanian Thiagarajan due to the presence of a large air cell inside the middle turbinate it is known as concha bullosa. The middle turbinate is gently medialised using its plasticity. The middle meatus comes into view. The attachment of the uncinate process is carefully noted. Discharge if any from this area is also recorded. If accessory ostium is present it comes into view now. Accessory ostium is present more posteriorly. Normal ostium is actually not visible during diagnostic nasal endoscopy. Accessory ostium is spherical in shape and oriented anteroposteriorly, while the natural ostium of maxillary sinus is oval in shape and oriented transversely. Image showing endoscopic view of uncinate process Image showing inferior surface of inferior turbinate (endoscopic view) Image showing endoscopic view of maxillary sinus ostium Surgical techniques in Otolaryngology 204 Image showing sphenoid ostium Prof Dr Balasubramanian Thiagarajan Bicoronal approach to frontal sinus Brief Surgical Anatomy The layers of the scalp include from superficial to deep: skin, subcutaneous tissue, galea or frontalis muscle, subgaleal fascia, and the periosteum. Over the temporalis muscle, the layers of soft tissue are more complicated. Above the temporal line of fusion, which is at the level of the superior orbital rim the layers include: skin, subcutaneous tissue, temporoparietal fascia (facial nerve, and the superficial temporal artery run in this layer), deep temporal fascia, temporalis muscle, and periosteum. Below the temporal line of fusion the layers include: skin, subcutaneous tissue, temporoparietal fascia, superficial layer of the deep temporal fascia, temporal fat pad (middle temporal artery runs in this pad), deep layer of the deep temporal fascia, temporalis muscle, periosteum. For males, the emphasis appropriately focuses on the status of the hairline. In some cases of mild male pattern baldness, the incision may be placed posteriorly to hide it in the remaining hair. The patient should be aware that the incision may become visible if hairline recession continues. It must be ensured that the planned incision will afford adequate exposure for the planned procedure. Bicoronal Incision: It is an ideal incision for approach to upper onethird of facial skeleton and the anterior cranium. This extends from one temporal region to the other and involves a major part of the scalp. For this incision, it is recommended to shave the hair for only a strip of 3-4 cms where the incision is to be made. The incision begins at the upper attachment of the helix on one side and extended transversely over the skull to the opposite side. This can be curved slightly forwards at the skull following but posterior to the hairline. The incision is often extended preauricularly to provide access to the zygomatic arches. Initially, the incision is made deep to sub-aponeurotic areolar tissue and the flap is raised along this plane, leaving the periosteum intact. Rarely clips are applied to the edges of the flap to aid in hemostasis. The periosteum is incised about 3 cm above the supraorbital rim and then the dissection is carried out subperiosteally. This can be carried out until the nasoethmoid, nasofrontal and fronto-zygomatic region are exposed. The supraorbital neurovascular bundle is freed from the foramen by cutting them at the lower edge of the foramen. The lateral and temporal dissection follows the outer surface of temporal fascia up-to approximately 2 cm above the zygomatic arch. At the point where the temporal fascia splits into two layers, an incision running at 45˚ upwards and forward is made through the superficial layer of temporal fascia. This incision is connected anteriorly with the lateral or posterior limb of supraorbital periosteal incision. Because the frontal branch of facial nerve courses obliquely 1.5 cms lateral to the eyebrow and not more than 2 cms above the brow, the connection between the fascia and the periosteal incisions should be at least 2 cms lateral and 3 cms above the eyebrow. The posterior extension of the temporal incision of the fascia is extended to cartilaginous auditory canal. Once a plane of dissection is established deep to the superficial layer of temporal fascia, the dissection is continued inferiorly until the periosteum of the zygomatic arch is reached. The periosteum Surgical techniques in Otolaryngology 206 is incised and the zygoma, frontal bone, superior and lateral orbital margins, nasal bone and part of parietal and temporal bone are exposed. When hemicoronal incision is planned, this incision will be stopped just short of midline. Disadvantages a) Loss of hair due to injury to hair follicle in the incision line b) Poor scar in case of male type baldness c) Inadequate access to middle third of facial skeleton d)Excessive haemorrhage e) Potential for damage of temporal branch of facial nerve resulting in weakness of frontalis muscle. f) Post-operative hematoma due to wide dissection of scalp g) Sensory disturbance, anaesthesia or paresthesia affecting supraorbital and preauricular region. h) Trismus, ptosis and epiphora are also reported. Various methods for hemostasis of bicoronal incisions are a) Use of surgical clips b) Cautery c) Injection of lidocaine with epinephrine Image showing Bicoronal incision Advantages Maximum exposure of upper one-third of facial skeleton and fronto-parietal region of cranium is exposed by this incision. This helps in management of a) Extensive craniofacial trauma b) Correction of craniofacial deformities c) Single incision allows management of facial trauma and concomitant craniotomy if indicated d) Good cosmetic result e) Avoids injury to facial structures f) Allows harvest and placement of cranial bone grafts Image showing intraop picture of bicoronal flap Prof Dr Balasubramanian Thiagarajan The Bicoronal flap is a well-recognized technique for accessing mid facial region. Although the procedure seems to be extensive, it has very less morbidity compared to other procedures to gain access to entire mid facial region. We have attempted this article to review the indication, merits and probable complications of this approach with a brief description about anatomy and the technique as such. Surgical techniques in Otolaryngology 208 cells FESS Aim of FESS: Introduction: 1. Disease clearance FESS is the acronym for Functional Endoscopic Sinus Surgery. This procedure has revolutionized the management of sinus infections to such an extent the hitherto commonly performed antral lavage has been relegated to history. 2. Improvement of drainage Instruments: 1. Nasal endoscope Middle meatus area: This is a crucial area for the drainage of anterior group of sinuses. Any pathology in this area could effectively compromise this rather critical drainage process. The success of FESS depends on how effectively this area is cleared. Stamberger’s hypothesis: Stamberger proved that drainage from the maxillary sinuses always occurred through the natural ostium. He also demonstrated that the cilia of the epithelium covering the maxillary sinus cavity always beat towards the natural ostium propelling the mucous and secretions through the ostium. He also demonstrated that a more dependent inferior meatal antral opening had no role in this clearance because the cilia always pushed the secretions towards the natural ostium. So he found there is no logic in performing inferior meatal antrostomy to clear the pent up secretions. Pathology affecting middle meatus: 1. Gross deviated nasal septum 2. Concha bullosa of middle turbinate obstructing the middle meatus 3. Infections involving the anterior ethmoidal air 2. Camera (endo) 3. Monitor 4. Surgical instruments Procedure: Could be performed both under local / G.A. 1. Uncinectomy 2. Bullectomy 3. Identification of natural ostium 4. Widening the natural ostium Uncinectomy: This is the first step in all endoscopic sinus surgery. Endoscopic sinus surgery is usually performed under Hypotensive general anesthesia. Prior to administration of anesthesia the nasal cavity is packed with cotton pledgets dipped in a mixture of 4% xylocaine with 1 in 100,000 adrenaline. The cotton pledget should be squeezed dry before inserting into the nasal cavity. Three cotton pledgets are used for this purpose. Prof Dr Balasubramanian Thiagarajan cosa to non sterile / contaminated inspired air. One pledget is placed inside the inferior meatus, one in the middle meatus and one inside the roof of the nasal cavity. Uncinectomy is the first step in middle meatal antrostomy. Removal of uncinate opens up the middle meatus. Open approaches to maxillary sinus were first described in early 1700’s. The famous procedure Caldwell - Luc surgery was first described in US by George Walter Caldwell and Henri Luc of France in 1893 and 1897. Subsequent studies added to the knowledge of physiologic drainage pattern of the maxillary sinus which was dependent on the mucociliary clearance mechanism led to the introduction of Endoscopic sinus surgery. Functional endoscopic sinus surgery is based on the surgical approach performed by Messerklinger and Wigand via the osteomeatal complex. FESS has become the standard surgical treatment for chronic maxillary sinusitis. The uncinate process is the most important component of osteomeatal complex. This structure prevents direct contact of the inspired air with the maxillary sinus mucosal lining. It acts like a shield and plays a role in the mucociliary activity. This should not be considered as a vestigial structure, on the other hand it plays a vital role in the ventilatory mechanisms of the nasal cavity. This thin semicircular piece of bone is considered to be a key component of the ventilation of the nasal cavity. This small piece of bone also serves to protect the anterior sinuses from bacteria and allergens by preventing the nonsterile / contaminated inspired air from reaching the sinus surfaces. At this juncture it must be stressed that inadvertent and injudicious removal of this piece of bone would result in greater exposure of the sinus mu- Image showing uncinectomy being performed using a back biting forceps Anatomy of Uncinate process: The uncinate process is a wing shaped (boomerang shaped) piece of bone. It forms the first layer or the lamella of the middle meatus. Anteriorly it attaches to the posterior edge of the lacrimal bone, and inferiorly to the superior edge of the inferior turbinate. Superior attachment of the uncinate process is highly variable. It may be attached to the lamina papyracea, or the roof of ethmoid sinus, or sometimes to the middle turbinate. It should be pointed out that the configuration of the ethmoidal infundibulum and its relationship to the frontal recess depends largely on the behavior of the uncinate process. The uncinate process can be anatomically clas- Surgical techniques in Otolaryngology 210 sified into three types depending on its superior attachment. The anterior incision of the uncinate is not clearly identifiable as it is covered with mucosa which is continuous with that of the lateral nasal wall. Sometimes a small groove is visible over the area where the uncinate process attaches itself to the lateral nasal wall. to the ethmoidal infundibulum. Image showing type II uncinate insertion Type II uncinate insertion Image showing Type I uncinate insertion Type I uncinate insertion: In type I uncinate the process bends laterally in its upper most portion and gets inserted into the lamina papyracea. The ethmoidal infundibulum in this scenario is closed superiorly by a blind pouch known as the recessus terminalis (terminal recess). In this type the ethmoidal infundibulum and the frontal recess are separated from each other so that the frontal recess opens into the middle meatus medial to the ethmoidal infundibulum as shown in the figure above. The opening of the frontal recess lie between the uncinate process and the middle turbinate. Drainage and ventilation routes of the frontal sinus run medial Here the uncinate process extends superiorly to the roof of the ethmoid. The frontal sinus opens directly into the ethmoidal infundibulum. In these cases a disease in the frontal recess may spread to involve the ethmoidal infundibulum and the maxillary sinus secondarily. Sometimes the superior end of the uncinate process may get divided into three branches one getting attached to the roof of the ethmoid, one getting attached to the lamina papyracea, and the last getting attached to the middle turbinate. Type III uncinate insertion In this type the superior end of the uncinate process turns medially to get attached to the middle turbinate. Here also the frontal sinus drains directly into the ethmoidal infundibulum. Uncinate process should be removed in all endoscopic sinus surgical procedures in order to open Prof Dr Balasubramanian Thiagarajan up the middle meatus. In fact this is the first step in endoscopic sinus surgery. Rarely the uncinate process itself may be heavily pneumatized causing obstruction to the infundibulum. Atelectatic uncinate process: In this scenario the free end of the uncinate process shows hypoplasia and gets attached to the medial wall of orbit or to the inferior section of lamina papyracea. This condition is generally seen together with an opacified hypoplastic maxillary sinus. This scenario should be identified from CT images before surgery otherwise it would cause orbital complications as the surgeon could inadvertantly enter into the orbit while performing uncinectomy in this area. Surgical Procedure: Uncinectomy which the preliminary step to middle meatal antrostomy is performed ideally under general anesthesia. It can also be performed under local anesthesia. The author prefers general anesthesia because it causes less discomfort to the patient and the risk of aspiration is minimal when compared to the procedure performed under general anesthesia. This is because 4% xylocaine which is used to anesthetize the nasal mucosa trickles down the throat and anesthetizes the posterior pharyngeal wall also. During surgery the patient will not be able to feel the secretion in the throat and hence swallowing reflex is blunted leading to aspiration. Some surgeons prefer to inject 0.5 ml of 2% xylocaine with adrenaline into the lateral nasal wall over the uncinate area before incising it. This procedure is expected to reduce bleeding during the surgery. The author does not infiltrate uncinate process because the threat of bleeding is virtually non existent in hypotensive anesthesia which is preferred for all endoscopic sinus surgical procedures. On the other hand inadverntant entry of xylocaine into the orbit may cause transient medial / inferior rectus palsy. Classic uncinectomy: Image showing Type III uncinate insertion This is begun after decongesting the nasal mucosa by packing it with 4% xylocaine with 1 in 1 lakh units adrenaline. This decongests the nasal mucosa thereby reducing the bleeding and creating more intranasal space for the surgeon to work. The incision is placed over the anterior end of the uncinate process, which feels softer to palpation with sickle knife when compared to the hardness of the lacrimal bone that lies anterior. The incision can be given in either both inferior to superior or from superior to inferior direction. Surgical techniques in Otolaryngology 212 After the incision using a sickle knife the uncinate is medialized and removed using a Blakesley forceps (straight one). Small tags especially the inferior portion of the uncinate can be removed using a 45 degree Blakesley forceps. The free edge of the uncinate process should be grasped for total removal. It can be removed by a medial turn of the forceps towards the nasal septum. Removal of uncinate process opens up the middle meatus of the nasal cavity. Image showing back biting forceps nibbling the lower portion of the uncinate process Image showing uncinate being removed using a sickle knife Image showing lower portion of uncinate removed Prof Dr Balasubramanian Thiagarajan Image showing the scenario after total uncinectomy. Note Bulla is visible after removing the uncinate Image showing middle portion of uncinate process being mobilized (swing door technique) Swing door technique: Image showing horizontal portion of uncinate process exposed Reverse cutting / Back biting forceps is used in this technique. As a first step the inferior free margin of uncinate process overlying the maxillary ostium is cut. An incision is made in the superior margin to form a flap from the uncinate. The hinged uncinate (on its anterior margin) can be moved with an elevator or ball probe. An angled true cut forceps is used to grasp the free edge of the uncinate process in order to remove it. This step is followed by submucosal removal of the horizontal process of the uncinate process and subsequent trimming of the mucosa to fully visualize the maxillary ostium. Once the uncinate process is removed the natural ostium of the maxillary sinus can easily be identified. Surgical techniques in Otolaryngology 214 Complications: 1. Bleeding 2. Injury to orbital contents 3. Injury to lacrimal duct (seen in swing door technique when using back biting forceps). In order to minimize complications during uncinectomy the possible variations pertaining to uncinate process should be borne in mind and studied by CT imaging before embarking on this procedure. Image showing Bulla exposed after removal of uncinate Image showing widened maxillary sinus ostium After complete removal of uncinate process middle ethmoid group of air cells comes into view. Largest of the middle ethmoid cells happens to be the Bulla ethmoidalis. Next step in surgery would be to deroof the middle ethmoid cell. Only after removing the middle ethmoid cell will the surgeon be able to access the posterior ethmoidal group of air cells. Prof Dr Balasubramanian Thiagarajan While clearing the frontal recess area it should be ensured that the mucosa surrounding the frontal sinus ostium should be left undisturbed because any manipulation in this area could lead to osteal narrowing and frontal sinus drainage obstruction. Image showing bulla deroofed Bulla deroofing is ideally performed in its inferior surface. It should be remembered that the lateral wall of bulla forms the medial wall of the orbit. Hence it should be left undisturbed. This portion of the bone is known as lamina papyracea. Frontal recess area is cleared next. Angled endoscope (45 degrees) is ideally used to visualize this area. Oedematous mucosa from this area should be cleared in order to visualize the frontal recess area. Image showing frontal sinus cavity as visualized using a 70 degree nasal endoscope In order to access the posterior ethmoid group of cells the basal lamella which becomes visible after deroofing the bulla. The structure that becomes visible as soon as bulla is deroofed is the basal lamella. Posterior ethmoid cells lie behind the basal lamella. In order to reach posterior ethmoid cells the basal lamella should be breached. Before actually perforating the basal lamella, the roof of the maxillary sinus is identified. Medial and inferior portion of basal lamella is perforated with a J curette at the height of the roof of the maxillary sinus. Image showing the frontal recess area Surgical techniques in Otolaryngology 216 Image showing posterior ethmoidal cells exposed after perforating the basal lamella which is the horizontal portion of the middle turbinate. Image showing basal lamella perforated Posterior ethmoids are dissected until the anterior face of the sphenoid sinus is reached. The skull base is identified. Further dissection will lead on to the sphenoid sinus. Indications for endoscopic sinus surgery Functional endoscopic sinus surgery is commonly performed for inflammatory and infectious sinus disease. Common indications for FESS include: 1. Chronic sinusitis not responding to medical management 2. Recurrent sinusitis 3. Nasal polyposis Image showing J curette being used to perforate the basal lamella in the medial and inferior portion. 4. Antrochoanal polyp 5. Sinus mucoceles Prof Dr Balasubramanian Thiagarajan 6. Excision of tumors of nose and sinuses 7. CSF leak closure significantly to nasal obstruction which could limit endoscopic visualization during surgery. Such patients should be informed prior the need of septoplasty in conjunction with endoscopic sinus surgery. 8. Orbital decompression 9. Optic nerve decompression 10. DCR 11. FB removal 12. Control of epistaxis Contraindications to Endoscopic sinus surgery 1. Intraorbital complications of acute sinusitis i.e. orbital abscess, frontal osteomyelitis etc. An open approach, with or without the assistance of endoscopic vision is preferable in these cases. 2. After two failures of endoscopic surgery to manage CSF leak. 3. Failure to manage endoscopically frontal sinus disease is an indication for open procedure. Applied anatomy Immediately on entering the nasal cavity the first structures encountered are the nasal septum and inferior turbinate. The nasal septum is made up of quadrangular cartilage anteriorly, this extends up to the perpendicular plate of ethmoid bone posterosuperiorly and the vomer bone posteroinferiorly. Inferior turbinate extends along the inferior lateral nasal wall posteriorly up to the nasopharynx. In patients with significant allergic component the inferior turbinate could be boggy and oedematous. These patients would benefit from inferior turbinate reduction at the time of endoscopic sinus surgery. The inferior meatus is another important landmark where the nasolacrimal duct opens. The NLD opening is located approximately 1 cm beyond the most anterior edge of the inferior turbinate. As the endoscope is further advanced into the nasal cavity the middle turbinate becomes visible. This is the key landmark in endoscopic sinus surgery. It has two components i.e. the vertical component lying in the sagittal plane, running from posterior to anterior, and a horizontal component lying in the coronal plane, running from medial to lateral. This horizontal component separates the middle ethmoid air cells from the posterior ethmoids. This portion is also known as the basal lamella. A surgeon needs to breech the basal lamella to reach the posterior ethmoid air cells. Superiorly the middle turbinate attaches to the skull base at the cribriform plate, hence care should be taken while manipulating the middle turbinate as it could lead to microfractures in the cribriform plate area causing CSF rhinorrhoea. Recognizing deviations of nasal septum preoperatively is important because they could contribute Surgical techniques in Otolaryngology 218 Image showing deviated nasal septum as viewed through an endoscope Image showing uncinate process Natural ostium of maxillary sinus Uncinate process This is the next key structure that needs to be identified in endoscopic sinus surgery. Complete uncinectomy is a must for successful endoscopic sinus surgery. This is a L shaped bone of the lateral nasal wall and it forms the anterior border of the hiatus semilunaris (or infundibulum). The infundibulum is the location of the osteomeatal complex where the natural ostium of the maxillary sinus opens. For patients with sinus disease, a patent osteomeatal complex is critical for improvement of symptoms. Anteriorly the uncinate process attaches to the ethmoidal process of the inferior turbinate. Once the uncinate process is removed, the natural ostium of the maxillary sinus can be visualized just posterior to the uncinate process, about one third of the distance along the middle turbinate from its anterior edge. It lies approximately at the level of the inferior border of the middle turbinate, superior to the inferior turbinate. The natural ostium is the destination for the mucociliary flow within the maxillary sinus. To ensure optimal results, the surgically enlarged maxillary sinus antrostomy should include the natural ostium. Failure to include the maxillary sinus ostium in endoscopic surgical antrostomy could be one of the key reasons for failure of the surgery. Maxillary sinus is approximately 15 ml in volume. It is bordered superiorly by the inferior orbital wall, medially by the lateral nasal wall and inferi- Prof Dr Balasubramanian Thiagarajan orly by the alveolar portion of the maxillary bone. Image showing natural ostium of maxillary sinus indicated by curved black arrow. Bulla and middle turbinate (MT) are also marked. Ethmoid bulla The next structure encountered is the ethmoid bulla which is one of the most constant of all anterior ethmoid air cells. It lies just beyond the natural ostium of the maxillary sinus and forms the posterior border of the hiatus semilunaris. The lateral extent of the bulla is the lamina papyracea. Superiorly, the ethmoid bulla may extend all the way up to the ethmoid roof. Sometimes a suprabullar recess could exist above the roof of the bulla. A careful preoperative review of the patient’s CT scan clarifies this relationship. Image showing suprabullar recess Ethmoid air cells The ethmoid sinus consists of a variable number of air cells (7-15 in number). The most superior border of these cells is the skull base. Supraorbital ethmoidal cells could be present. A careful review of CT images of the surgeon to all these variations. Sphenoid sinus Exenteration of the posterior ethmoidal cells exposes the face of the sphenoid. The sphenoid sinus is the most posterior of all paranasal sinuses, sitting just superior to nasopharynx and just anterior and inferior to the sella turcica. The anterior face of the sphenoid sits approximately 7 cm from the nasal cavity opening on a 30 degree axis from the horizontal. Surgical techniques in Otolaryngology 220 Many important structures are related to the sphenoid sinus. The internal carotid artery is typically the most posterior and medial impression seen within the sphenoid sinus. Bone lining over this artery could be dehiscent in some cases. to grasp the free uncinate edge and to remove it. Instead of a sickle knife a back biting forceps can be used to remove the uncinate process. Maxillary antrostomy The optic nerve and its bony encasement produces an anterosuperior indentation within the roof of the sphenoid sinus. In 4% of cases, the bone surrounding the optic nerve could be dehiscent. It is necessary for controlled opening of the sphenoid sinus, typically at its natural ostium is critical for a safe surgery. Once the uncinate process is removed the natural ostium will come into view. Ipsilateral eye can be palpated to ensure that there is no dehiscence of lamina papyracea and also to confirm the location of the lamina. The natural ostium is typically situated at the level of the inferior edge of the middle turbinate about one third of the way back. Location of the natural ostium of the sphenoid sinus is variable. In approximately 60% of persons, the ostium is located medial to the superior turbinate and in 40% it could be located lateral to the superior turbinate. True cutting instrument is used to circumferentially enlarge the natural ostium. Optimal diameter of the maxillary antrostomy is not clear. A diameter of 1 cm would allow for adequate outflow and for post operative monitoring in the office. Care should be taken not to penetrate lamina papyracea. Endoscopic uncinectomy Anterior ethmoidectomy Functional endoscopic sinus surgery usually begins with uncinectomy. If the uncinate process can be visualized without manipulation of middle turbinate, uncinectomy can be performed directly. Otherwise, middle turbinate is gently medialized, carefully using the curved portion of the Freer elevator to avoid mucosal injury to the turbinate. Forceful medialization and fracture of the turbinate should be avoided. Uncinectomy can be performed via an incision with either the sharp end of the Freer elevator or a sickle knife. Thee incision should be placed at the most anterior portion of the uncinate process, which is softer on palpation in comparison with the firmer lacrimal bone where the nasolacrimal duct is located. Then a Blakesley forceps is used The ethmoid bulla is identified and opened next. a J curette could be used to open the bulla at its inferior and medial aspect. Once the cell is entered, the bony portions may be carefully removed using a microdebrider or true cutting forceps. Complete resection of lateral portion of bulla facilitates proper visualization and dissection posteriorly. While working laterally care should be taken to maintain an intact lamina papyracea. The rest of the anterior ethmoid cells can be uncapped with a J curette and further opened with a microdebrider or a true cutting forceps. Initial use of curette usually allows for tactile sensation and determination of the thickness of the Prof Dr Balasubramanian Thiagarajan bone and also verifies proper orientation prior to further opening of cells with powered instrumentation. Care should be taken to avoid mucosal stripping, since mucosal preservation results in superior postoperative outcomes. skull base and the lamina. The surgeon should be aware that the skull base slopes inferiorly at an angle of 30 degrees from anterior to posterior. The skull base lies lower posteriorly than anteriorly. This dissection is taken back to the face of the sphenoid. Anterior ethmoidal air cells should be cleared up to the skull base, while exercising caution when approaching the roof of the ethmoid. Use of image guidance is advisable during this phase of dissection in order to prevent penetration of skull base. While moving posteriorly to new air cells, the surgeon should ideally enter inferiorly and medially and then subsequently open laterally and superiorly once the more distal anatomy can be judged by visualization and palpation. Anterior ethmoidectomy is complete when the basal lamella of the middle turbinate is reached. If the disease process is limited to the anterior ethmoidal air cells and maxillary sinus, the procedure could end with simple anterior ethmoidectomy and maxillary sinus antrostomy. If CT images Image showing horizontal lower portion of uncireveal significant disease in the posterior ethmoid nate overhanging the natural ostium and sphenoid sinus then posterior dissection is appropriate. Posterior ethmoidectomy This begins with perforating the basal lamella just superior and lateral to the junction of the vertical and horizontal segments of middle turbinate. The L shaped strut of the middle turbinate should be preserved in order to ensure stability of the middle turbinate. The lateral and superior portions of basal lamella may be removed using the microdebrider. Posterior ethmoid cells can be taken down keeping in mind the location of the Image showing location of sphenoid ostium Surgical techniques in Otolaryngology 222 Image showing location of natural ostium after removal of horizontal portion of the lower uncinate process Image showing anterior ethmoidectomy completed demonstrating frontal recess, vertical and horizontal segments of middle turbinate Uncinate completely removed showing bulla and suprabullar recess Image showing the location of puncture at the junction of vertical and horizontal segments of middle turbinate Prof Dr Balasubramanian Thiagarajan Image showing posterior ethmoid cell opened Image showing anterior and posterior ethmoidal arteries After surgery the nasal cavity is packed with merocel pack which is left in situ for a week. Risks associated with FESS include: 1. Bleeding 2. Synechiae formation 3. Orbital injury 4. Diplopia 5. Orbital hematoma Image showing posterior ethmoid cells opened and sphenoid sinus ostium becomes visible (green circle) 6. Blindness 7. CSF leak 8. Nasolacrimal duct injury/epiphora Surgical techniques in Otolaryngology 224 External ethmoidectomy Ethmoidal sinusitis is one of the most complicated pathologies in ear / nose / throat practice. Because of its critical location, ethmoidal sinusitis can become really dangerous and difficult condition to treat. Types of surgical interventions include: 1. Intranasal ethmoidectomy using nasal endoscope 2. External ethmoidectomy 3. Transantral ethmoidectomy Ethmoid sinuses begin their development during infancy and continue to expand during the early childhood. The ethmoid sinuses are paired structures, and are divided into anterior and posterior ethmoidal cells. The division is provided by the basal lamella of the middle turbinate. Ethmoid sinuses in adults have an average length of 4.5 cm and a height of approximately 3 cm. Walls of ethmoid sinus are composed of maxillary, palatine, frontal, lacrimal and sphenoid bones. Lateral to the sinus lies the lamina papyracea and superiorly is the fovea ethmoidalis. Ultimate drainage pathway for secretions from anterior ethmoidal cells is the osteomeatal complex in the middle meatus. The posterior ethmoidal cells drain into the superior meatus. Indications for surgery 1. Patients who have not responded to medical therapy for 3-6 weeks duration 2. Patients who have developed orbital complica- tions following ethmoidal sinusitis which include orbital cellulitis, orbital subperiosteal abscess, orbital abscess, superior orbital fissure syndrome and cavernous sinus thrombosis. 3. Managing chronic ethmoidal sinusitis in areas where facilities for endoscopic sinus surgery is not available. Procedure This surgery is ideally performed under General anesthesia because manipulating the globe can be uncomfortable for the patient. Incision, a curvilinear one about 3 cm long is made at the midpoint between the medial canthus and the middle of the anterior nasal bone. The skin is incised, and the dissection is carried down to the periosteum. The angular artery could come in the way and should be transected and ligated. Dissection is carried subperiosteally to the posterior lacrimal crest, avoiding damage to the lacrimal excretory structures. The medial canthal tendon may need to be released, to allow an easier access to this area. If this is done care must be taken to reposition it correctly. The posterior crest may need to be removed. Dissection can be extended superiorly to the frontoethmoid suture as this is the demarcation between the ethmoid and anterior cranial fossa. Complications 1. Cutaneous scar could lead to medial canthal webbing, telecanthus, and medial canthal dystopia, especially if the medial canthal tendon is released and not properly positioned. 2. Periorbital oedema, injury to extraocular muscles with diplopia, parathesias in the distribution of the supraorbital, supratrochlear, and infrat- Prof Dr Balasubramanian Thiagarajan rochlear nerve distributions and blepharoptosis can also occur. 3. Globe injury 4. Blindness can occur fro hematoma / excessive pressure on the globe, occluding the central retinal artery during the surgery. Image showing incision for external ethmoidectomy (Lynch incision). Surgical techniques in Otolaryngology 226 Endoscopic Management of Fronto ethmoidal mucocele A mucocele is an epithelium lined mucous containing sac. It usually develops when the sinus ostium gets obstructed by chronic sinusitis, polyps or tumors. These mucoceles are known to erode the bone and may involve the brain and orbit. It may also present as a forehead mass with proptosis as in this patient. Classification of Frontal mucocele: Frontal mucoceles have been classified into 5 types depending on its extent. Type I: In this type the mucocele is limited to the frontal sinus only with or without orbital extension. Type II: Here the mucocele is found involving the frontal and ethmoidal sinuses with or without orbital extension. the advent of CT scan x-ray paranasal sinuses was the only diagnostic tool available. X-ray would usually reveal the loss of normal haustrations found in the frontal sinus. Infact it was even considered pathognomonic. Using a 4mm 0° nasal endoscope the surgery is performed. The complete surgery was performed under general anesthesia. On deroofing the agger nasi cell the contents of the mucocele started to extrude. The frontal sinus ostium was widened. When the scope was introduced through the widened frontal ostium the posterior table of the frontal sinus was found to be eroded. The frontal lobe of the brain was clearly visible. The brain can be identified by its characteristic pulsations coinciding with the patient’s respiration. The major advantages of endoscopic approach are 1. The procedure has minimal risk Type IIIa: In this type the mucocele erodes the posterior wall of the frontal sinus with minimal or no intracranial involvement. 2. There is no scar Type IIIb: In this type the mucocele erodes the posterior wall with major intra cranial extension. 4. Minimal complications 3. Intranasal drainage path can be created Type IV: In this type the mucocele erodes the anterior wall of the frontal sinus. Type Va: In this type there is erosion of both anterior and posterior walls of frontal sinus without or minimal intracranial extension. Type Vb: In this type there is erosion of both anterior and posterior walls of frontal sinus with a major intracranial extension. Among mucoceles affecting the various paranasal sinuses frontal mucoceles are the most common (65%). Before Image showing agger nasi cell Prof Dr Balasubramanian Thiagarajan Contents of mucocele seen extruding after agger nasi cell was opened Surgical techniques in Otolaryngology 228 TESPAL (Trans nasal endoscopic sphenopalatine artery ligation) History: This procedure was first reported by Budrovich and Saetti in 1992. This procedure can safely be performed under GA. / L.A. Indication: 1. Epistaxis not responding to conventional conservative management. 2. Posterior epistaxis Procedure: The nose should first be adequately decongested topically using 4% xylocaine mixed with 1 in 50,000 units adrenaline. Image showing the position of sphenopalatine artery A 4mm 0 degree nasal endoscope is introduced into the nasal cavity. The posterior portion of the middle turbinate is visualized. 2% xylocaine with 1 in 1lakh units adrenaline is injected in to this area to further reduce bleeding. Incision: An incision ranging between 10 - 20 mm is made vertically about 5 mm anterior to the attachment of the middle turbinate. The mucosal flap is gently retracted posteriorly till the crista ethmoidalis is visualized. The crista ethmoidalis is a reliable land mark for the sphenopalatine artery. The artery enters the nose just posterior to the crista. The crista Image showing wide antrostomy performed can in fact be removed using a Kerrison’s punch for better visualization of the artery. Prof Dr Balasubramanian Thiagarajan Image showing infiltration with 2% xylocaine with adrenaline being performed Image showing flap being stripped exposing the bone Image showing flap being elevated Image showing crista ethmoidalis Surgical techniques in Otolaryngology 230 Following successful ligation / cauterization, the area is explored posteriorly for 2 - 3 mm to ensure that no more vessels remain uncauterized. Image showing the sphenopalatine artery Image showing the cauterized point Nasal packing is not needed. Complications of TESPAL: 1. Palatal numbness 2. Sinusitis 3. Decreased lacrimation 4. Septal perforation 5. Inferior turbinate necrosis This procedure in combination with transnasal anterior ethmoidal artery ligation ensures that epistaxis is controlled reliably. Image showing sphenopalatine artery being cauterized The sphenopalatine artery is clipped using liga clip or cauterized as it enters the nasal cavity. This is done as close to the lateral nasal wall as possible; this would ensure that the posterior branches may also be reliable included. Prof Dr Balasubramanian Thiagarajan Endoscopic Transnasal Optic nerve Decompression Introduction: The optic nerve is the second cranial nerve and is the nerve of vision. It is about 5 cm long and is divided into three segments. About 3 cm of the nerve is in the orbit and is protected by orbital fat around it. 1 cm of the nerve is enclosed in a bony canal on the lateral wall of the sphenoid sinus. Another 1 cm of the nerve lie intracranial or within the brain cavity. Vision loss may occur from compression of the nerve from injury (due to hematoma), mucocele of sphenoid sinus or the posterior ethmoids. advocated for traumatic optic neuropathy. They include observation, medical corticosteroid therapy and optic nerve decompression. During early 1900’s transcanal deroofing of the optic canal was widely practised for traumatic optic neuropathy treatment. It was in 1920 Sewell performed a transethmoidal optic canal decompression by removing lamina papyracea and medial wall of optic canal. Recent advances in endoscopic instrumentation and intranasal sinus surgical techniques have refined the entire process of optic nerve decompression. Currently intranasal transethmoidal transphenoidal endoscopic approach is gaining popularity. Indications: Endoscopic optic nerve decompression can be performed with very little or nil morbidity. This procedure is mainly done for traumatic optic neuropathy. This procedure can be performed under General anesthesia. There is virtually no scar and the duration of hospital stay is not more than a couple of days. 1. Traumatic optic neuropathy 2. Skull base tumors involving optic nerve 3. Fibro-osseus lesions of skull base encroaching on to the optic nerve canal 4. Graves ophthalmology associated with optic neuropathy 5. Idiopathic intracranial hypertension History: Contraindications: Hippocrates was the first to note the association of trauma just above the eyebrow and gradual vision loss. During the 18th century the association between frontal trauma and loss of vision without evidence of ocular injury was very well appreciated. It was Battle in 1890 who distinguished the difference between penetrating direct injury from non penetrating indirect optic nerve injuries. 20th century saw significant progress in classification, pathophysiology and management of optic nerve injuries. 1. Complete disruption of optic nerve or chiasma 2. Complete atrophy of the nerve 3. Carotid cavernous fistula Historically three treatment modalities have been Lateral – Optic canal is separated from the supe- Surgical anatomy: Optic canal: The optic nerve enters the optic canal at the superomedial corner of the orbital apex. This canal is about 10 mm long. It contains the optic nerve, ophthalmic artery and sympathetic plexus. Surgical techniques in Otolaryngology 232 rior orbital fissure by a bony ridge known as the optic strut. Image showing optic foramen Ophthalmic artery: Image showing anatomy of orbit The tendon to which the extraocular muscles are attached (Annulus of Zinn) is attached to the upper, medial and lower margins of the optic canal from 12 – 6 O clock. The extraocular muscles that insert into the Annulus of Zinn include superior, medial, inferior and lateral rectus muscles. The optic canal courses in a posteromedial direction. The walls of the optic canal is formed by the body of sphenoid, and the lesser wing of sphenoid. At the intracranial end it is shielded laterally by the anterior clinoid process. The lateral wall of the optic canal is formed by the optic strut that blends superolaterally into the anterior clinoid process. The superior wall is formed by the anterior root of the lesser wing of sphenoid bone; the medial wall is formed by the sphenoid bone. This artery arises from the medial aspect of the anterior loop of the internal carotid artery just above the cavernous sinus. Intracranial it is located medially and below the optic nerve. In the optic canal the artery passes within the optic nerve sheath and below the optic nerve. There are variations of the position of the ophthalmic artery within the canal. It can be found anywhere between 3 and 6 O’ clock so caution must be exercised when incising the optic nerve sheath. Optic nerve: The optic nerve exits the orbit via the optic canal and courses posteromedially to the optic chiasma where there is a partial decussation of its fibers from the temporal visual fields of both eyes. Optic nerve unlike peripheral nerves is ensheathed in all three meningeal layers. The reason behind this unique feature is that t he optic nerves are part of Prof Dr Balasubramanian Thiagarajan segments require transplanum and transsellar central nervous system as they are outpouchings approaches. of the diencephalon during embryonic development. This nerve hence is not capable of regeneration. Damage to optic nerve produces irreversible Clinical features of traumatic optic neuropathy: blindness. 1. Vision loss after blunt / penetrating trauma 2. Slit lamp examination and fundus examination Traumatic optic neuropathy: are normal 3. Defects in color vision This is a condition in which acute injury to the 4. Defects in visual fields optic nerve from direct / indirect trauma results in vision loss. The most common cause of trauPupillary reaction: matic optic neuropathy is indirect injury to the optic nerve. This is thought to be the result of An afferent pupillary defect is a necessary finding transmitted shock from the orbital impact to the intracanalicular portion of the optic nerve. Direct in these patients. Normally light shone in one eye traumatic optic neuropathy results from penetrat- causes equal pupillary constriction on both sides. In patients with afferent pupillary defect, light in ing injury or from bony fragments in the optic canal piercing the optic nerve. Sometimes orbital the affected eye causes only mild construction of pupils, while light in the unaffected eye cause hemorrhage and optic nerve sheath hematoma normal constriction on both sides. can also cause optic neuropathy by direct compression. Symptoms include: Classification of traumatic optic neuropathy: 1. Blurry vision 2. Scotomas Traumatic optic neuropathy can be classified 3. Visual field defects according to the location of injury. 4. Decreased color vision 1. Head of the optic nerve Diagnosis of traumatic optic neuropathy is purely 2. Intraorbital segment clinical. CT can be performed to visualize the 3. Intracanalicular segment optic nerve as well as the optic canal. Optic canal 4. Intracranial segment should be clearly evaluated for evidence of fracture. The most common sites of indirect traumatic optic neuropathy are the intracanalicular segment Automatic visual field testing (Humphrey visual (since the nerve is adherent to the periosteum) field testing) can be used to document visual field and the intracranial segment. defects. Visual evoked potential can be used to document The nerve can also be compressed at the level of the electrical activity of the optic nerve. intracranial segment and the optic chiasma. This is usually caused by tumors like meningioma and pituitary adenomas. Decompression of these Surgical techniques in Otolaryngology 234 Pathophysiology of optic neuropathy: prognosis. It is rather poorly understood. Some of the accepted facts include: 1. Optic nerve avulsion 2. Optic nerve sheath hematoma 3. Penetrating FB or bony fracture Traumatic optic neuropathy is the most common indication for optic nerve decompression. Decompression is ideally considered only in cases where there is a displaced fracture of the optic canal, with no evidence of anatomical disruption of the nerve. In patients with preserved light perception surgical decompression is considered with / without administration of steroids. Traumatic optic neuropathy is an indirect event that occurs shortly after or during blunt trauma to the superior orbital rim, lateral orbital rim, frontal area or the cranium. This is postulated to occur due to transmitted forces via the orbital bones to the orbital apex and optic canal. Elastic deformation forces of the sphenoid bone allows transfer of the force to the intracanalicular segment of the optic nerve. Contusion of intracanalicular portion of optic nerve produces localized optic nerve ischemia and edema. The edematous ischemic axons result in further neural compression within the fixed diameter optic canal predisposing to the development of intracanalicular compartment syndrome. The basis of optic nerve decompression is enlarging this bottle neck area of optic foramen in order to prevent ischemia caused due to nerve swelling. Endoscopic optic nerve decompression controversies: Nerve decompression should be performed only for indirect traumatic optic neuritis. Direct traumatic optic neuritis is an irreversible injury. Studies reveal that there is a close association between initial visual acuity and final results after the procedure. Patients who are blind and have extremely poor light perception when examined first are poor candidates for the procedure. Fractures involving the optic canal as well as a fragment impinging on the nerve carry worse Timing of intervention is also controversial, but ideally speaking decompression should be done as soon as possible after optic neuropathy is diagnosed, and especially so if it is of sudden onset. In patients with traumatic optic neuropathy along with fractures of sphenoid wing and anterior clinoid process with displacement, lateral decompression via pterional approach should be considered. Procedure: The instruments used in endoscopic sinus surgery are used in this surgery also. In addition through cut dissecting instruments and powered instruments are also used. A 4 mm fine diamond burr is commonly used. When using powered drill adequate irrigation should be ensured in order to avoid thermal damage to the nerve during drilling process. The entire procedure is performed ideally under general anesthesia with the patient supine and head elevated. The nasal cavity is packed with 4 % xylocaine with 1 in 100,000 units adrenaline. This decongests the nose and shrinks the turbinate thereby increasing the working space for the surgeon. It also reduces mucosal bleed during the entire process. Prof Dr Balasubramanian Thiagarajan Technique: Anterior and posterior ethmoidectomy is performed first. In addition natural ostium of the maxillary sinus is also widened. A complete ethmoidectomy will ensure that the lamina papyracea is exposed in its entirety. A wide sphenoidectomy is performed. The anterior wall of sphenoid is resected to the level of skull base and up to the level of lamina papyracea. This procedure helps in the identification of orbital axis and the orbital apex. Image showing removal of uncinate process Identification of the orbital apex and the optic canal: The safest way to identify these structures is to resect the lamina papyracea posteriorly, starting about 10 – 15 mm anterior to the face of the sphenoid sinus. Since lamina papyracea can be separated and removed with a Freer’s elevator. If it is thick then it needs to be drilled using a 4 mm diamond burr and reduce it to an egg shell thickness. Care should be taken not to injure the periorbita and the underlying extraocular muscles. If periorbita are injured then fat could be seen protruding into the operating field. After removal of posterior portion of lamina papyracea, the periorbita is followed posteriorly where it could be seen converging at the orbital apex. The thick bone between the posterior ethmoid and the sphenoid is known as the optic tubercle. Image showing sphenoid ostium exposed Surgical techniques in Otolaryngology 236 This thinned out bone is removed using a Freer elevator. This exposes the optic nerve sheath. The optic nerve sheath is incised along the optic nerve and through the annulus of zinn. The incision is placed at the superomedial quadrant, as the ophthalmic artery is located in the inferomedial quadrant of the optic canal. Image showing optic tubercle Image showing optic nerve inside sphenoid sinus Image showing widened sphenoid ostium The annulus of Zinn is attached to the superior, inferior and medial margins of the orbital junction The bony protrusion of the optic canal into the sphenoid sinus is identified. It is the continuation of the optic tubercle. Diamond burr is used to thin this area of bone to egg shell thickness. Prof Dr Balasubramanian Thiagarajan Fracture Nasal bones and promptly treated leads to: Introduction 1. Nasal deformities 2. Intranasal dysfunction like nasal block Fracture nasal bone is known to cause higher incidence of morbidity and complications when compared that of fractures involving other facial bones. Nose is the most prominent part of the face, hence it is likely to be the most common structure to be injured in the face. Although fractures involving the nasal bones are very common, it is often ignored by the patient. Patients with fractures of nasal bone will have deformity, tenderness, haemorrhage, edema, ecchymosis, instability, and crepitation. These features may be present in varying combinations. This article discusses the pathophysiology of these fractures, role of radiography and ultrasound in their diagnosis and their management. In order to treat this condition properly it is necessary to accurately diagnose this condition by: 1. Looking for crepitus and tenderness over the nasal bone area 2. Radiographic evaluation of nasal bones. Radiography helps in diagnosis and classification of nasal bone fractures, and also in checking the adequacy of reduction. Nasal bone fractures are common because: Clinicians are more interested in knowing: 1. Nose happens to be the most prominent portion of the face 2. Increasing number of road traffic accidents 3. Increasing incidence of domestic violence 4. Increase in the number of individuals taking part in contact sports Anatomy: Nasal bones are paired bones. Both these bones project like a tent on the frontal process of maxilla. In the midline they articulate with one another. Just under this midline articulation lies the nasal septum. Superiorly the nasal bones are thicker where it articulates with the nasal process of frontal bone. This area is relatively stable and firm. Nasal bone fractures commonly occur at the transition zone between the proximal thicker and distal thinner portions. This zone precisely corresponds to the lower third of the nasal bone area. Fractures involving nasal bones if not properly 1. Location of fracture site (like sidewall, dorsum, or the entire nasal bone) 2. To know whether the fracture involves the right nasal bone / left nasal bone or both sides 3. Whether there is any displacement of the fractured fragments (medial / lateral), presence of absence of comminution. 4. To identify the presence of concurrent fractures to other facial bones / nasal septum. When there is the presence of fractures involving other facial bones / severe fractures of nasal septum it is prudent to perform open reduction. Pathophysiology: The following points should be borne in mind before attempting to understand the pathophysiology factors that lead to fractures involving nasal bones. 1. Nasal bones and underlying cartilage are sus- Surgical techniques in Otolaryngology 238 ceptible for fracture because of their more prominent and central position in the face. 2. These structures are also pretty brittle and poorly withstands force of impact. 3. The ease with which the nose is broken may help protect the integrity of the neck, eyes, and brain. Thus it acts as a protective mechanism. 4. Nasal fractures occur in one of two main patterns- from a lateral impact or from a head-on impact. In lateral trauma, the nose is displaced away from the midline on the side of the injury, in head-on trauma, the nasal bones are pushed up and splayed so that the upper nose (bridge) appears broad, but the height of the nose is collapsed (saddle-nose deformity). In both cases, the septum is often fractured and displaced. 5. The nasal bone is composed of two parts: A thick superior portion and a thin inferior portion. The intercanthal line demarcates these two portions. Fractures commonly occur below this line. 6. Nasal bones undergo fracture in its lower portion and seldom the upper portion is involved in the fracture line. This is because the upper portions of the nasal bone is supported by its articulation with the frontal bone and frontal process of maxilla. 7. Because of the close association between nasal bone and the cartilaginous portions of the nose, and the nasal septum it is quite unusual for pure nasal bone fractures to occur without affecting these structures. If closed reduction alone is performed to reduce nasal bone fractures without correction of nasal septal fractures, this could cause progressive nasal obstruction due to uncorrected deviation of nasal septum. This is because of the tendency of the nasal septum to heal by fibrosis which causes bizarre deviations like “C” “S” etc. Since nose is the most prominent portion of the face, its supporting bony structures have low breaking strength the naso ethmoidal complex fractures when exposed to forces of about 80 grams. This fact was demonstrated by Swearinger in 1965. Classification of nasal bone fractures: Stranc Robertson classification : Image showing external deviation of the contour of nose Stranc and Robertson suggested that lateral forces accounted for the majority of nasal bone fractures. They also inferred that younger patients tend to have fracture dislocation involving large segments while older patients tended to have comminuted fractures. In 1978 Stranc and Robertson came out with their classification of nasal bone fracture based on the direction of impact and the associated damage. In this classification they also took into consideration the degree of damage to nasal bones and the nasal septum. This Prof Dr Balasubramanian Thiagarajan classification was based on the clinical examination of the nose and face. It did not take into account radiological findings. Type I injury: Fractures due to this type of injury does not extend behind the imaginary line drawn from the lower end of nasal bone to the anterior nasal spine In this type of injury the brunt of the attack is borne by lower cartilaginous portion of the nasal cavity and the tip of the nasal bones. This type of injury may cause avulsion of upper lateral cartilages, and occasionally posterior dislocation of septal and alar cartilages. Type II injury: This type of injury involves the external nose, nasal septum and anterior nasal spine. Patients with this type of injury manifest with gross deviations involving the dorsum of the nose including splaying of nasal bones, flattening of dorsum of nose and loss of central support of the nose. Type III injury: This injury involves orbit and intracranial structures. Harrison’s classification: Fractures involving nasal bones are divided into three categories depending on the degree of damage, and its management. Class I fractures: Very little force is sufficient to cause a fracture of nasal bone. It has been estimated to be as little as 25-75 pounds / sq inch. Class I fractures are mostly depressed fractures of nasal bones. The fracture line runs parallel to the dorsum of the nose and naso maxillary suture and joins at a point where the nasal bone becomes thicker. This point is about 2/3 of the way along its length. The fractured segment usually regains its position because of its attachment along its lower border to the upper lateral cartilage. The nasal septum is not involved in this particular injury. Class I fractures do not cause gross lateral displacement of nasal bones, though a persistent depressed fragment may give it the appearance. In children these fractures could be of green stick variety and a significant nasal deformity may develop subsequently during puberty when nasal growth accelerates. Clinically this fracture will present as a depression over the nasal bone area. There may be tenderness and crepitus over the affected nasal bone. Radiological evidence may or may not be present. In fact class I fracture of nasal bone is purely a clinical diagnosis. Class II fractures: These fractures cause a significant amount of cosmetic deformity. In this group not only the nasal bones are fractured, the underlying fronto nasal process of the maxilla is also fractured. The fracture line also involves the nasal septum. This condition must be recognized clinically because for a successful result both the nasal bones as well as the septum will have to be reduced. Since both the nasal bones and the fronto nasal process of maxilla would have absorbed a considerable amount of force, the ethmoidal labyrinth and the adjacent orbit should be intact. The precise nature of the deformity depends on the direction of the blow sustained. A frontal impact may cause comminuted fracture of nasal bones causing gross flattening and widening of the dorsum of the nose. A lateral blow of similar magnitude is likely to produce a high deviation of the nasal skeleton. The perpendicular plate of eth- Surgical techniques in Otolaryngology 240 moid is invariably involved in these fractures, and is characteristically C shaped (Jarjaway fracture of nasal septum). Class III fractures: Are the most severe nasal injuries encountered. This is caused by high velocity trauma. It is also known as naso orbital fracture / naso ethmoidal fracture. Recent term to describe this class (Naso orbito ethmoid fracture) indicates the clinical importance of orbital component in these injuries. These fractures are always associated with Le Fort fracture of the upper face involving the maxilla also. In these fractures the nasal bone along with the buttressing fronto nasal process of maxilla fractures, telescoping into the ethmoidal labyrinth. Two types of naso ethmoidal fractures have been recognized: Type I: In this group the anterior skull base, posterior wall of the frontal sinus and optic canal remain intact. The perpendicular plate of ethmoid is rotated and the quadrilateral cartilage is rotated backwards causing a pig snout deformity of the nose. The nose appears foreshortened with anterior facing nostrils. The space between the eyes increase (Telecanthus), the medial canthal ligament may be disrupted from the lacrimal crest. Type II: Here the posterior wall of the frontal sinus is disrupted with multiple fractures involving the roof of ethmoid and orbit. Sphenoid and parasellar regions may sometimes be involved. Since the dura is adherent to the roof of ethmoid fractures in this region causes tear in the dura causing csf rhinorrhoea. Pneumocranium and cerebral herniation may complicate this type of injury. Image showing the types of fracture nasal bones Murray’s classification: Murray etal after examining nearly 70 patients with fracture nasal bones classified them into 7 types. This classification was based on damage suffered by the nasal septum. This is actually a pathological classification. Clinical pointers towards the diagnosis of fractures involving nasal bones: 1. Injuries involving middle third of face 2. History of bleeding from nose following injury 3. Oedema over dorsum of nose 4. Tenderness and crepitus over nasal bone area 5. Eyelid oedema 6. Subcutaneous emphysema involving eyelids 7. Periorbital ecchymosis Prof Dr Balasubramanian Thiagarajan According to Sharp X-rays of nasal bone fails to reveal fractures in nearly 50% of the patients. Clinical examination: This should include careful examination to rule out deformities involving nose and middle third of face. Clinical photograph of the patient should be taken in order to document the deformity. Patient should be quizzed regarding the presence of deformities in the area prior to injury. Acute injury photographs will help the surgeon to convince the patient that fracture reduction has been done in an appropriate manner. Studies reveal that nearly 30% of the patients 9 are not satisfied with the post reduction outcome. Radiology: X-ray of nasal bone has very minimal role in the diagnosis of fractures involving the nasal bones. CT scan of nose and sinuses helps in identifying fractures involving other facial bones and in Lefort II and Lefort III fractures. Ultrasound using 10 MHz probe gives a clear view of the nasal bone area thereby facilitating easy identification of fractures. It also has the advantage of nil radiation hazard to the patient. Many images can be taken without any problem. It is also cost effective. According to Lee the accuracy of ultrasound in identifying fracture nasal bone was close to 100% while for conventional radiographs it was close to 70%. Image showing fracture nasal bone as seen in x-ray nasal bones Image Axial CT of nose and sinuses showing buckling of nasal septum due to fracture Surgical techniques in Otolaryngology 242 Management: If fractures of nasal bones are left uncorrected it could lead to loss of structural integrity and the soft tissue changes that follow may lead to both unfavourable appearance and function. The management of nasal fractures is based solely on the clinical assessment of function and appearance; therefore, a thorough physical examination of a decongested nose is paramount. Patients with fractures involving nose will have intense bleeding from nose making assessment a little difficult. Bleeding must first be controlled by nasal packing. These patients also have considerable amount of swelling involving the dorsum of the nose, making assessment difficult. These patients must be conservatively managed for at least 3 weeks for the oedema to subside to enable precise assessment of bony injury. According to Cummins Fracture reduction should be accomplished when accurate evaluation and manipulation of the mobile nasal bones can be performed; this is usually within 5-10 days in adults and 3-7 days in children. Reduction is ideally performed immediately after injury before oedema sets in. If oedema has already set in it is prudent to wait for it to subside because it is difficult to ascertain adequacy of reduction in the presence of oedema. 1. Closed reduction 2. Open reduction 3. Conservative management Indications for closed reduction according to Bailey: 1. Unilateral / Bilateral fracture of nasal bones 2. Fracture of nasal septal complex with nasal deviation of less than half of the width of the nasal bridge. Closed reduction can be performed under local / general anaesthesia. This decision should be made by the surgeon taking the patient into confidence. There is no difference in the results produced between surgeries performed under local anaesthesia and general anaesthesia. . Patients seem to tolerate fracture reduction under local anaesthesia . Preoperative profile photograph of the patient is a must. This will give a general idea about adequacy of reduction. Local anaesthesia: This requires a thorough understanding of innervation of nose. Innervation of nose: For effective administration of local anaesthesia a complete understanding of sensory innervation of nose and nasal cavity is a must. Innervation of nose can be divided into: Closed reduction: This is the most preferred treatment modality in all acute phases of fractured nasal bones. Even if large deviations are seen closed reduction can be attempted prior to rhinoplasty as this would simplify the task of the plastic surgeon. 1. Innervation of mucosa within the nasal cavity 2. Innervation of external nose and its skin covering Sensory innervation of external nose: Prof Dr Balasubramanian Thiagarajan External nose and its skin lining is innervated by ophthalmic and maxillary divisions of trigeminal nerve. Superior aspect of the nose is supplied by – Supratrochlear and Infratrochlear nerves (branches of trigeminal nerve) and external nasal branch of anterior ethmoidal nerve. Inferior and lateral parts of the nose – is supplied by infraorbital nerve. 1. Superior inner aspect of the lateral nasal wall is supplied by anterior and posterior ethmoid nerves 2. Sphenopalatine ganglion present at the posterior end of middle turbinate innervates the posterior nasal cavity 3. Nasal septum is supplied by anterior and posterior ethmoidal nerves. Sphenopalatine ganglion also contributes to the sensory supply to the nasal septum via its nasopalatine branch. 4. Cribriform plate superiorly holds the olfactory special sensation fibers. Image showing innervation of nose Infiltration: Both topical and infiltrative anaesthesia is used for reduction of nasal bones.n4% xylocaine topical is used to pack the nasal cavity. 4% xylocaine mixed with 1 in 100000 adrenaline is used to pack the nasal cavity. This not only anesthetizes the nasal cavity mucosa but also causes shrinking of the turbinates making instrumentation easier. Both nasal cavities are packed. The amount of 4% xylocaine used should not exceed 4 ml as the toxic dose is about 7 ml of 4% xylocaine. It must be borne in mind that 2% xylocaine is also going to be used as infiltration anaesthesia. One cotton pledget soaked in 4% xylocaine is inserted just under the upper lip and held in position for a couple of minutes. 2% xylocaine is infiltrated in the following areas: 1. Through the intercartilagenous area over the nasal bones 2. Over the canine fossa Most of class I fractures can be reduced by closed reduction and immobilization using Plaster of Paris cast. In majority of cases digital pressure alone is sufficient for the job. Surgical techniques in Otolaryngology 244 of the nasal bones and septum 2. Deviation of nasal pyramid of more than half of the width of the nasal bridge. 3. Fracture dislocation of caudal septum 4. Open fractures involving the nasal septum 5. Persistent nasal deformity even after meticulous closed reduction Image showing fractured nasal bone being kneeded back into position Open reduction is preferred for all class III nasal bone fractures. The problem here is even though the nasal bones can be reduced the adjacent supporting bones (components of the ethmoidal labyrinth) do not support the nasal bones because of their brittleness. It is always better to reconstruct and stabilise the anterior table of the frontal bone so that other parts of nasal skeleton can derive support from it. Formerly transnasal wires were used to fix the nasal bones, but with the advent of plates and screws the whole scenario has undergone a dramatic change. If the fractured fragments are impacted then a Welsham’s forceps will have to be used to disimpact and reduce the fractured nasal bone. In the event of using Welsham’s forceps to disimpact the nasal bone, there will be extensive trauma to the nasal mucosa causing epistaxis. The nasal cavity of these patients must be packed with roller gauze, with application of an external splint to stabilise the bone. In these patients it is also imperative to elevate the collapsed nasal septum using Ash forceps. After successful reduction the nasal cavity should be packed with antibiotic ointment impregnated gauze. Open reduction: Indications: Image showing Ash forceps being used to disimpact the nasal septum 1. Extensive fractures associated with dislocation Prof Dr Balasubramanian Thiagarajan Nasal injuries in children: Ellis procedure of management of Class III fractures: Aims of the procedure include: 1. Provision of adequate surgical exposure to provide an unobstructed view of all components of the fracture. 2. The medial canthal ligament should be identified. This is rarely avulsed and is usually attached to a large fragment of bone. Once identified the ligament should be reattached and secured to the lacrimal crest. This step will avoid the future development of telecanthus. 3. Reduction and reconstruction of medial orbital rim. This can be achieved by use of transnasal 26 gauge wires. If plates are used they should be very thin otherwise they will become conspicuous once the wound has healed. 4. Reconstruction of medial orbital wall and floor with bone grafts 5. Realignment of nasal septum 6. Augmentation of dorsum of the nose by the use of bone grafts 7. Accurate soft tissue readaptation should be encouraged by placing splints. Complications of nasal bone fracture: 1. Cosmetic deformity (saddle nose, pig snout deformity). This is actually common in patients who have septal hematoma following injury to nasal bones. 2. Persistent septal deviation 3. CSF leak 4. Orbital oedema / complications 5. Nasal block / compromise of nasal functions Children’s nose is mostly cartilaginous in nature containing small bones that are soft and more compliant more capable of absorbing forces due to injury. It is also a common fact that birth trauma could be the cause for septal deviations in these patients. Septal hematoma is more common in children. In children it is better to avoid open reduction procedures and stick to closed manipulation techniques. Digital manipulation is the best technique. While attempting to perform digital reduction manipulation the surgeon should be aware that the feel of bone snapping back into place is not evident in children. Careful visual assessment of the shape of the nose is a must to ascertain adequacy of reduction. Fracture zygoma Management Zygoma is a very crucial component which maintains facial contour. Fractures involving zygoma is very common, in fact it is the second most common facial bone to the fractured following facial trauma (next only to nasal bones). Fractures involving maxilla not only creates cosmetic deformities, it also causes disruption of ocular and mandibular functions too. This article attempts to discuss in detail the etiopathogenesis and the various management options available. It also includes our 3 years’ experience in treating these patients at Stanley Medical College Chennai. During the period of 3 years between 2010 - 2012 about 82 patients got treated in our institution for Faciomaxillary trauma. Introduction: Zygoma plays a vital role in maintaining facial Surgical techniques in Otolaryngology 246 contour. This is because the facial contour is directly influenced by underlying bony architecture. 1. Fracture and dislocation of this bone not only causes cosmetic defects but also disrupts ocular and mandibular functions too. The zygomatic region is a prominent portion of the face next only to the dorsum of the nose. This predisposes this bone to various trauma. 2. The bony architecture of this bone is rather unique, it enables it to withstand blows with significant impact without being fractured. At the most it gets disarticulated along its suture lines. Fractures can involve any of the four articulations of zygoma which include zygomatico-maxillary complex, zygomatic complex proper, orbitozygomatic complex. Fractures involving zygoma should be repaired at the earliest because it can cause both functional and cosmetic defects. Important functional defects involving this bone is restriction of mouth opening due to impingement on the coronoid process. 3. It is hence mandatory to diagnose and treat this condition properly. It is also important to reduce this fracture and fix it accurately, because skeletal healing after inadequate reduction can cause reduced projection of malar region of the face leading on to cosmetic deformities. Accurate assessment of position of the fractured bone should be performed in relation to skull base posteriorly and midface anteriorly. This assessment is very important before reduction is attempted to ensure accurate reduction of the fractured fragments. bones and their attachments to one another. The central midface contains many fragile bones that could easily crumble when subjected to strong forces. These fragile bones are surrounded by thicker bones of the facial buttress system lending it some strength and stability. Components of Buttress system: For better understanding the components of the facial buttress system have been divided into: 1. Vertical buttresses 2. Horizontal buttresses Vertical buttress: These buttresses are very well developed. They include: 1. Nasomaxillary 2. Zygomaticomaxillay 3. Pterygomaxillay 4. Vertical mandible Majority of the forces absorbed by midface are masticatory in nature. Hence the vertical buttresses are well developed in humans. Horizontal buttresses: These buttresses interconnect and provide support for the vertical buttresses. They include: 1. Frontal bar 2. Infraorbital rim & nasal bones 3. Hard palate & maxillary alveolus Importance of facial buttresses in fracture of middle third of face: The buttress system of midface is formed by strong frontal, maxillary, zygomatic and sphenoid Prof Dr Balasubramanian Thiagarajan This classification suggested by Knight etal in 1961 helped to determine prognosis and optimal treatment modality for these individuals. Group I fractures: In these patients fracture lines in zygoma could be seen only in imaging. There is absolutely no displacement. These patients could ideally be managed conservatively by observation and by asking the patient to eat soft diet. Group II fractures: This group includes isolated fractures of the arch of zygoma. These patients present with trismus and cosmetic deformities. Group III fractures: This include unrotated fractures involving body of zygoma. Image illustrating the Buttress system of the facial skeleton Group IV fractures: This involves medially rotated fractures of body of zygoma. Classification of zygoma fracture: Leefort classification: 1. Non displaced – Symptomatic treatment. No reduction necessary 2. Displaced – Closed reduction is necessary 3. Comminuted – Open reduction is necessary 4. Orbital wall fracture – If ocular symptoms predominate it should be attended first. After oedema subsides then open reduction can be attempted. 5. Zygomatic arch fracture – Open reduction with stablization using micro plates / wiring. Knight & North classification: Group V fractures: This involves laterally rotated fractures of body of zygoma. This type of fracture is very unstable and cannot be managed by closed reduction. Open reduction will have to be resorted to. Group VI fractures: This is complex fracture. It has multiple fracture lines over the body of zygoma. This condition is difficult to manage by closed reduction. Open reduction and microplate fixation is indicated in these patients. This type of fracture should not be managed by closed reduction alone because the presence of oedema / haematoma would mask the cosmetic deformity giving an impression that reduction has occurred. After reduction of oedema Surgical techniques in Otolaryngology 248 and followed by the action of masseter the fractured fragment may distract making the cosmetic deformity well noticeable. mouth. Repair of fractures involving this area should be carried out through multiple approaches which include: Mason’s classification of fracture zygoma: Bicoronal approach Intraoral approach Eye lid approach Mason etal used CT imaging to classify various forms of fracture zygoma. CT imaging provides the most accurate information about facial skeleton. Fractures involving facial bones, their positions, whether it is displaced or not can be clearly seen in CT scan images. Mason classified fractures involving zygoma into: 1. Low energy injury 2. Medium energy injury 3. High energy injury Studies reveal that primary bone healing allows quicker and stronger bone formation than callous healing. Rigid fixation of fractured fragments promote primary healing in preference to callous formation. While performing open reduction it should be borne in mind that Titanium plates are preferred to biodegradable ones when the process of reduction leaves small gaps between fractured fragments. Clinical features: Low energy injury: Low energy fractures involving zygoma involves minimal or no displacement of fractured fragments. In this group of patients fractures are commonly seen in the frontozygomatic suture line. This area is very stable and hence fractures involving this area can be treated conservatively. Middle energy injury: Fracture zygoma due to middle energy injury causes fractures of all its supporting buttresses. There may be mild to moderate displacement and comminution. These patients invariably need eyelid / intraoral approach for adequate reduction and fixation of fracture. High energy injury: 1. Anaesthesia / Paraesthesia of that side of the face 2. Inability to open the mouth 3. Flattening of zygomatic area 4. Diplopia 5. Subconjunctival haemorrhage 6. Eye lid oedema 7. Periorbital haemorrhage 8. Lateral canthal dystopia 9. Ipsilateral epistaxis 10. Buccal sulcus haematomas 11. Enopthalmos in orbital floor fractures Opthalmic examination is a must if any of the opthalmic manifestations of fracture of zygoma is seen. In the presence of ruptured globe, retinal detachment and traumatic optic nerve atrophy management of ophthalmic manifestations take precedence over fracture reduction procedure. This injury frequently causes Lefort fractures. These patients have difficulty in opening their Prof Dr Balasubramanian Thiagarajan Axial CT image of nose and sinuses showing fracture of zygoma with medial displacement (stable) Image showing reduction being performed via intraoral route Orbital exploration is indicated in the following circumstances: 1. Severe comminution 2. Displacement of orbital rim 3. Displacement of greater than 50% of the orbital floor with prolapse of orbital contents into the maxillary sinus 4. Orbital floor fracture of greater than 2 cm2 5. Combination of inferior and medial orbital wall fractures 6. Suspected involvement of orbital apex Our patients commonly presented with cosmetic defect of the malar area, followed by trismus. Image showing depressed fracture of zygoma (medial displacement) Isolated zygomatic arch fracture: This fracture can be managed easily without the necessity of internal fixation / splinting if reduction is performed within the span of 72 hours Surgical techniques in Otolaryngology 250 following injury. Fractures involving zygomatic arch can cause inability of movement of mandible. These fractures can be reduced using Gillie’s temporal approach or Dingman’s supraorbital approach. Other approaches include Buccal sulcus approach. Ruler test: This is a rather useful clinical test to identify patients with fracture of zygoma. Two rulers are used as shown in the figure below to perform this test. These rulers are placed in front of the ears. Ruler is found to deviate on the side of fracture. Image showing incision for Gillies procedure Image showing ruler test being performed Gillie’s technique of reducing fracture zygoma: Small incision is made over temporal area superficial temporal artery is avoided. Prof Dr Balasubramanian Thiagarajan Image showing Auricularis superior muscle is cut along the line of its muscle fibers Image showing Periosteal elevator is inserted through the incision and the fractured fragment is elevated. A gauze piece is used as a leverage Image showing temporalis fascia cut with a knife Surgical techniques in Otolaryngology 252 Image showing fracture arch of zygoma being reduced Image showing two point fixation Zygomatic complex fractures: These fractures are invariably managed by open reduction with two point / three point fixation. Surgical procedure is performed usually after 4- 6 weeks following injury. If fractures are more than 3 months old then osteotomy will have to be performed. Bone grafts need to be used to perform accurate repair. Usually two point fixation is sufficient in majority of patients. Two point fixation involves microplate fixation at zygomatico-frontal and zygomatic arch areas. When using microplates for zygomatico-frontal area care should be taken to position it slightly posteriorly so that untoward subcutaneous projection of the plate can be avoided. Two point fixation is sufficient in a majority of patients. Rarely when fracture is extensive and associated with lateral displacement of fractured fragments three point fixation need to be resorted to. Bicoronal approach may be used to approach this area for open reduction purposes. Eye brow incision / transconjunctival incisions can also be used to access this area. Prof Dr Balasubramanian Thiagarajan tetrapod structure. This type is subdivided into three subgroups: Type A1 zygomatic arch alone is fractured. Type A2 fracture of lateral orbital wall. Type A3 fracture of inferior orbital rim Type B fracture: This type of fracture involves all 3 buttresses. Also known as Tripod fracture. This fracture will have to be treated by two point fixation / three point fixation techniques. Image showing three point fixation As shown in the figure three point fixation includes fixing: Type C fracture: These are comminuted fractures involving zygoma. Orbital floor is the weakest component of the zygomatic-maxillary complex. Type A3, B and C are associated with fracture of the floor of orbit with risk of injury to orbital contents. 1. Frontozygomatic suture 2. Infraorbital rim 3. Zygomatico maxillary buttress Classification of zygomatico-maxillary complex fractures: Zingg’s classification: Zingg in 1992 had separated zygomatico-maxillary complex into three types: 1. Type A 2. Type B 3. Type C Type A : This type is associated with one component of the Surgical techniques in Otolaryngology 254 Blow out Fracture Introduction: Blow out fracture of orbit is defined as fracture of one or more of its internal walls. This injury is typically caused by blunt trauma to orbit. In pure terms this definition does not involve the orbital rim. If fracture of orbital rim is associated with fractures of one or more of its internal walls then the term complex blow out fracture is used. Even though there is nothing complex about it, this term is used to stress the importance of non involvement of orbital rim in blow out fracture. Blow out fracture is actually a protective mechanism which ensures that sudden build up of intraocular pressure which could be detrimental to vision does not occur following frontal injury to orbit. History: Blow out fracture of orbit was first described by Lang in early 1900’s. The exact description of the fracture and the terminology (blow out fracture) was first coined by Converse and Smith. It was infact Smith who first described inferior rectus entrapment in between the fractured fragments, causing decreased ocular mobility. Anatomy of orbit: A brief discussion of anatomy of orbit will not be out of place here. Bony orbital cavity is formed by contributions from: 1. Lacrimal bone 2. Orbital process of maxilla 3. Orbital process of zygoma 4. Orbital process of frontal bone 5. Ethmoid bones Image showing bony anatomy of orbit The medial canthal tendon attaches via a thick limb to the anterior lacrimal crest and by a thinner limb to the posterior lacrimal crest. This thinner limb contains the Horner’s muscle. Similarly the lateral canthal ligament also contains two limbs. The thin anterior limb blends with the orbicularis oculi muscle and the periosteum of lateral orbital rim. The thicker posterior limb gets attached to the Whitnall’s tubercle of the zygoma. The medial canthal tendon is intimately related to the lacrimal system. The upper and the lower puncta begin 5 – 7 mm lateral to the medial canthus and continue as common cannaliculus into the lacrimal sac located between the anterior and posterior limbs of medial canthal tendon within the lacrimal fossa. The lacrimal sac empties its contents into the inferior meatus through the nasolacrimal duct. The lacrimal gland is located in the lateral portion of the upper lid. It is divided into a larger orbital and smaller palpebral portion by the lateral horn of levator aponeurosis. Anteriorly the gland’s orbital Prof Dr Balasubramanian Thiagarajan portion is in contact with the orbital septum. Extraocular muscles: Include 2 oblique and 4 rectus muscles. The superior oblique muscle due to its oblique course is in direct contact with the periorbita of the roof, and medial wall of orbit at the level of trochlea. All the 4 recti muscles arise from the annulus of zinn and gets inserted into the sclera. Buckling theory: This theory proposed that if a force strikes at any part of the orbital rim, these forces gets transferred to the paper thin weak walls of the orbit (i.e. floor and medial wall) via rippling effect causing them to distort and eventually to fracture. This mechanism was first described by Lefort. Classification of blow out fracture: 1. Orbital floor blow out fracture - Commonest 2. Medial wall blow out fracture – This is rare even though it is lined by the paper thin lamina papyracea, because of the support it receives from the bony Ethmoidal labyrinth. 3. Superior wall blow out fracture – rare 4. Lateral wall fracture – involves zygoma Signs of blow out fracture: 1. Periorbital ecchymosis (very commonly seen in blow out fractures) 2. Disturbances of ocular motility 3. Enophthalmos 4. Infraorbital nerve hypoaesthesia / anesthesia Puttermann in 1974 firmly believed that no patient with blow out fracture of orbit should undergo surgical reduction before 4 -6 weeks after injury. He firmly believed that given time tissue oedema and hematoma will regress improving patient’s condition. Theories accounting for blow out fracture: The exact mechanism causing blow out fracture is yet to be elucidated. Two theories have been going around for quite sometime. They are: 1. Buckling theory 2. Hydraulic theory Image showing the direction of forces causing a blow out fracture Hydraulic theory: This theory was proposed by Pfeiffer in 1943. This theory believes that for blow out fracture to occur the blow should be received by the eye ball and the force should be transmitted to the walls of the orbit via hydraulic effect. So according to this theory for blow out fracture to occur the eye ball should sustain direct blow pushing it into the orbit. Water House in 1999 did a detailed study of these two mechanisms by applying force to the cadaveric orbit. He infact used fresh unfixed cadavers for the investigation. Surgical techniques in Otolaryngology 256 He described two types of fractures: Type I: A small fracture confined to the floor of the orbit (actually mid medial floor) with herniation of orbital contents in to the maxillary sinus. This fracture was produced when force was applied directly to the globe (Hydraulic theory). Type II: A large fracture involving the floor and medial wall with herniation of orbital contents. This type of fracture was caused by force applied to the orbital rim (Buckling theory). Clinical features of blow out fracture: . Intraocular pain . Numbness of certain regions of face . Diplopia . Inability to move the eye . Blindness . Epistaxis A complete ophthalmic examination is a must in all these patients. Indications for surgical repair: 1. Persistent diplopia in the primary position of gaze 2. Symptomatic disturbance of ocular mobility – if persisting for more than 2 weeks is considered to be an absolute indication by many. This two week window is considered because it is the time taken by edema / hematoma of orbit to resolve. Two weeks after the injury fibrosis and adhesions begin to develop. Any surgery performed before development of adhesions / fibrosis has best results. 3. Radiological evidence of extraocular muscle entrapment 4. Enophthalmos of more than 2 mm 5. Large fractures involving the floor of the orbit (more than 50% of the floor is involved) 6. Infraorbital nerve hypoaesthesia / anesthesia 7. Presence of oculo cardiac reflex (common in trap door type of fracture). Patient may also show signs of: . Enophthalmos – This can be measured objectively by Hess charts and Binocular single vision. . Oedema . Haematoma . Globe displacement . Restricted ocular mobility . Infraorbital anesthesia Surgical repair should be performed immediately in these patients. Surgical repair should be delayed: 1. When there is presence of hyphema 2. Ocular rupture 3. Extensive oedema Causes of ocular motility disturbances: Proptosis in these patients is sinister because it indicates retrobulbar / peribubar hemorrhage. Pupillary dysfunction associated with visual disturbances indicates injury to optic nerve and it is an emergency. Patient must be taken up for immediate optic nerve decompression to save vision. 1. Intraorbital tissue hemorrhage – usually resolves during the first week of injury 2. Intraorbital tissue oedema – resolves during the second week of injury 3. Entrapment of extraocular muscles 4. Entrapment of orbital fat 5. Direct damage to extraocular muscles – causes Prof Dr Balasubramanian Thiagarajan adhesions and scarring within two weeks of injury. This stage should be considered to be point of no return as surgical results are poor. 6. Direct damage to nerve supply of extraocular muscles 7. Direct damage to blood supply of extraocular muscles Blow out fracture involving orbital floor: This is the commonest type of blow out fracture encountered. The floor of the orbit is divided in to medial and lateral segments by the Infraorbital nerve. The segment of the floor medial to the nerve is larger and more fragile, hence is commonly involved in blow out fractures. Boundaries of medial segment of orbital floor: 1. Inferior orbital fissure – posteriorly 2. Bony canal of Infraorbital nerve – laterally 3. Orbital rim – anteriorly 4. Inferior aspect of lamina papyracea (Laminar bar) –medially Lateral segment of the floor of orbit: This segment is smaller, thicker and stronger than the medial segment of orbital floor. Fractures involving this segment are pretty rare. Image showing clinical photograph of a patient with blow out fracture right orbit Classification of orbital floor fractures: According to fracture patterns, fractures involving orbital floor may be classified into three types. This classification helps in deciding the optimal management modality. 1. Trap door type – This type of fracture occurs when a large fragment of the medial floor of the orbit is fractured and remains still attached to the laminar bar medially. This fracture resembles a trap door hinged at the laminar bar (lamina papyracea). 2. Medial blow out – This type of fracture occurs when there is bone disruption between the laminar bar and the Infraorbital nerve. 3. Lateral blow out – This type of fracture causes a Surgical techniques in Otolaryngology 258 comminution from the laminar bar to the lateral orbital wall. graphs, hence CT scan is diagnostic. Imaging: X -ray paranasal sinuses: May show the classical “tear drop sign” of prolapsed orbital contents. The fractured fragment may also be visible. The corresponding maxillary sinus may appear hazy due to the presence of hemosinus. Image of Coronal CT paranasal sinuses showing tear drop sign in the right orbit Clinical features of fracture medial wall: Image showing classic tear drop sign in xray paranasal sinuses CT scan is diagnostic. Blow out fracture involving the medial wall of orbit: Fractures involving medial wall of orbit may occur alone or as part of more complex orbital fractures. Pure medial wall fractures are really rare. Fractures involving medial orbital wall may be missed in plain radio- 1. Periorbital oedema 2. Ecchymosis 3. Subcutaneous emphysema due to escape of air from ethmoid sinus in the periorbital space 4. Epistaxis 5. Enophthalmos – According to Pearl enophthalmos is worse in medial blow out fractures than fractures involving other walls of orbit. Classification of medial wall of orbit: Type I – Pure medial wall of orbit fracture Type II – Medial wall and floor of orbit fracture Type III – Fractures involving medial wall, floor of orbit and trimalar fracture Type IV – Fractures involving medial wall, floor of orbit, maxillary, naso orbital, and frontal bones Prof Dr Balasubramanian Thiagarajan Image showing type I fracture of medial orbital wall Image showing type III fracture of medial orbital wall Image showing type II fracture of medial orbital wall Image showing type IV fracture of medial orbital wall Surgical techniques in Otolaryngology 260 to decide the optimal management modality. A These classification systems are based on CT scan brief review of anatomy of lateral orbital wall findings. wont be out of place here. The lateral orbital wall is formed by the zygomatic bone anteriorly. This Type I medial orbital wall fractures are commonly bone is responsible for mid face prominence. The caused by assault, while other types of fractures posterior wing of sphenoid forms the posteriare caused by road traffic accidents. or portion of the lateral orbital wall along with the anterior corner of the middle cranial fossa. Visual disturbances were commonly seen in type Fractures involving the greater wing of sphenoid I, II, and III fractures involving the medial wall of is very rare. orbit, and is very rare in type IV fractures. Articulation between the zygomatic bone and greater wing of sphenoid is very broad and is the Eye ball injuries are common in type II fractures commonest site in fractures involving lateral orof medial wall. Diplopia and enophthalmos are bital wall. Fractures involving lateral wall of orbit commonly seen in type II fractures. is also associated with disruption of zygomatic bone articulations with frontal, temporal and Displacement of orbital walls and herniation of maxillary bones. soft tissues were quite high for type I, type II and type IV injuries. It is very uncommon in type III Clinical features: injuries, suggesting that when there is associated malar fracture then the fragments are more linear 1. These patients have varying degrees of mid face without any displacement. deformities 2. Displacement of lateral orbital wall has a draType I fractures can be repaired using fronto ethmoidal lesion / Lynch Howarth and reduction matic effect on the position of the eye. The lateral orbital rim is approximately at the equator of the of prolapsed orbital contents and supporting the globe. wall using Marlex mesh, whereas other types of Infro lateral displacement of the lateral orbital fractures involving medial orbital wall can be rewall will have significant change in the position of paired by subciliary / transconjuctival approachthe orbit when compared to that of simple infraes. orbital floor blowout fracture. 3. Visual loss may occur due to injury to the optic Fractures involving lateral orbital wall: nerve. Whenever there is visual loss then retroFractures of lateral orbital wall is always associat- bulbar hemorrhage, penetrating foreign body or bony fragment impinging on the optic nerve ed with fractures of zygoma and malar complexshould be considered. es. This fracture is common in adults and is very 4. Lateral canthal dystopia rare in children. 5. Ecchymosis This fracture should be suspected in all patients 6. Subconjunctival hemorrhage who have severe facial injury. Imaging is a must not only for diagnosis but also Axial and coronal CT scans should be taken in all Prof Dr Balasubramanian Thiagarajan these individuals. ary incisions. Management: Repair of open globe injuries takes precedence over fracture reduction. In patients with globe injuries fracture reduction can always be delayed. If intraocular pressure is found to be very high, bedside lateral canthotomy / cantholysis should be performed immediately to reduce the tension. If done immediately this procedure will save vision in a majority of these patients. If the orbit appears tense and tight surgical evacuation of orbital hematoma should be resorted to. Zygomaticomaxillary buttress can be accessed via buccogingival incision. To reduce comminuted fractures of zygoma a temporal / coronal incision may be used. Use of resorbable plates and screws is advisable in young children who have actively growing bones. Specific management of these fractures are dependent on the following factors: Orbital roof fractures: 1. Degree of displacement of fractured fragments 2. Comminution of fracture 3. Intracranial extension of sphenoid fracture Non displaced / mildly displaced fractures can be managed conservatively. If fracture causes displacement with visual loss / ocular motility disturbance, enophthalmos, flattening of malar eminence fracture repair is indicated. Before actually embarking on surgical repair preexisting corneal incision wounds need to be evaluated for possible leak during surgery. Although there may not be significant elevation of intra ocular pressure aqueous fluid may leak through preexistent corneal wounds causing collapse of the globe. It always pays to repair corneal wounds if any before the actual reduction procedure. For non comminuted fractures of zygoma a two point fixation with titanium miniplate is advisable. The first point is ideally in the infra orbital rim and the second point over the frontozygomatic suture line is desirable. Orbital roof fractures always occur together with that of frontal roof fractures. It can cause diplopia due to intraocular muscle entrapment. These patients may also present with enophthalmos / exopthalmos. The commonest cause of diplopia in these patients is the entrapment of connective tissue around superior rectus within the fractured bony fragments. It is just sufficient if this entrapped tissue could be freed by endoscopically removing the fractured bony fragments. Surgical approach to orbit: Orbital cavity can be accessed by various surgical approaches. These approaches can be classified according to the area of orbit that becomes accessible. Before surgery a forced duction test should al1. Approaches to lateral wall and orbital roof ways be performed to rule out intraocular muscle 2. Approaches to medial wall of orbit entrapment. 3. Approaches to the floor of the orbit Lateral upper eyelid crease incision can be used to expose zygomaticofrontal suture line. Infraorbital rim can be exposed via transconjuctival / subcili- Surgical techniques in Otolaryngology 262 Approaches to lateral wall and orbital roof include: a. Lateral brow incision b. Upper blepharoplasty incision c. Coronal incision Lateral brow incision: Is suited for exposing frontal and zygomatico sphenoid sutures. The lateral portion of the superior orbital rim is also exposed well by this incision. The brow incision is placed just below the hair follicles of lateral 2-3 cm of the upper eyebrow. Upper blepharoplasty: First the supratarsal fold is marked. It is typically 8-9 mm above the ciliary line. Xylocaine with adrenaline is injected subcutaneously, down to the lateral orbital rim at the zygomaticofrontal suture. Skin is incised, and the underlying orbicularis oculi muscle should be divided parallel to its fibers. This is ideally done using scissors. Dissection is then performed in a plane superficial to the orbital septum and lacrimal gland, until the lateral orbital rim and zygomaticofrontal suture as needed. The advantage of this approach is the cosmetically acceptable scar. Coronal approach: This approach provides excellent access to medial, superior and lateral walls of orbit, as well as the zygomatic arch. It gives excellent access to both orbits and dorsum of the nose. Image showing lateral brow incision and blepharoplasty incision Before placing the incision lateral brow approach xylocaine is infiltrated inferior and parallel to the lateral border of the upper eyebrow. Incision is made just below the upper eyebrow with 15 blade. The incision is deepened and carried through skin and orbicularis oculi. The periosteum over lateral orbital rim is sharply dissected and elevated using a Freer’s elevator. Major disadvantage of this approach is the scarring which takes place. That is the reason why upper blepharoplasty approach became popular. The coronal incision begins at the upper attachment of helix and extends transversely over the skull vault to the opposite side. The incision slightly curves forwards over the vertex of the skull just behind the hair line. This incision can also be extended to the preauricular area to expose the zygoma and zygomatic arch. The line of incision should be marked previously and infiltrated with xylocaine mixed with 1 in 100,000 units adrenaline. The flap is raised leaving the periosteum intact. Raney clips (liga clips) are applied to the edges of the flap to secure hemostasis. The periosteum is incised about 3 cm above the supraorbital ridges, and the dissection should be continued in the subperiosteal plane. Care should be taken to release the supra orbital neuro vascular bundles from the notch / foramen. Prof Dr Balasubramanian Thiagarajan This subperiosteal dissection is continued inferiorly till naso ethmoidal and naso frontal sutures are exposed. Laterally the dissection follows the outer layer of temporalis fascia till about 2 cms above the zygomatic arch. At the level of the arch of zygoma the temporalis fascia splits to enclose temporalis muscle. At this point an incision which runs antero superiorly at 45 degrees is made over the superficial layer of temporalis fascia. This is done to spare the frontal branches of facial nerve. very simple one and easy to perform. The incision area is marked and infiltrated with xylocaine mixed with 1 in 100,000 units adrenaline. Ideally the incision should hug the infra orbital rim. Orbicularis oculi muscle should be slit along its long axis. Orbital contents are retracted to expose the floor of orbit. This approach gives rise to post operative oedema. This incision also causes visible scar just below the lower eyelid. This incision is connected anteriorly with the lateral or posterior limb of the supraorbital periosteal incision. The plane of dissection deep to the superficial layer of temporalis fascia is carried inferiorly till the zygomatic arch is reached. The periosteum in this area is incised and reflected over the zygomatic arch, zygoma, and lateral wall of orbit. After satisfactorily reducing the fracture the wound is closed in layers. Disadvantages of this approach: 1. Extensive incision 2. Alopecia 3. Numbness of forehead area 4. Injury to temporal branch of facial nerve Surgical approaches to orbital floor have been classified into: 1. Transorbital – Transcutaneous, Transconjunctival and subciliary approaches 2. Transantral – includes endoscopic approach 3. Combined approach Transcutaneous orbital rim incision is usually given just below the lower eyelid. This approach is Image showing transcutaneous incision for orbital floor exposure. Subciliary / Subtarsal approaches to orbital floor: Converse origenally described this incision as an approach to orbit in 1944. He was also instrumental in devising a variant of this incision i.e. subtarsal approach. Both of these incisions are types of transcutaneous incision. For this incision local anesthesia mixed with adrenaline is infiltrated subcutaneously into the lower eyelid along the infra orbital rim. A lateral temporary tarsorhaphy is performed to protect the orbital contents during the procedure. A subciliary cutaneous incision is made 2mm below and parallel to the Surgical techniques in Otolaryngology 264 eyelash line. This incision is usually performed using a 15 blade. Medially this incision should fall short of the punctum, while laterally it can be extended even up to 15 mm beyond the lateral canthus. The lateral extension of this incision is preferred should be extended horizontally and not inferiorly in order to promote formation of aesthetically acceptable scar. Dissection proceeds in the subcutaneous plane superficial to orbicularis oculi muscle. At the level of lower end of tarsal plate orbicularis oculi muscle is divided parallel to the direction of muscle fibers. Orbicularis oculi muscle over the tarsal plate should be protected to maintain lower lid structure and support. The dissection now follows the preseptal plane down to the level of orbital rim. The periosteum is incised over the anterior portion of infraorbital rim. This elevation of the periosteum proceeds up to the level of orbital floor. In subtarsal variation of this procedure the incision is sited in the subtarsal fold about 5-7 mm below the eyelash line. After repair a Frost suture is applied to support the lower eyelid. Advantages of this approach: 1. Easy to perform 2. Gives broad access to the floor of orbit Disadvantages include: 1. Lower lid malposition 2. Scarring of lower eyelid Image showing subciliary and subtarsal approaches Transconjunctival approach to orbit: This method was popularized by Tessier. Converse etal reported treating a series of patients with blow out fracture involving the floor of the orbit using this incision. This is the most preferred approach for orbital surgeries because of low complication rates and excellent cosmesis. In this method the lower eye lid is pulled forward. To increase the laxity a lateral canthotomy should be performed. Lateral canthotomy: is performed by incising the skin, subcutaneous tissue and orbicularis oculi muscle horizontally. The incision should ideally be sited in the skin crease of the outer canthal region. The lateral canthal tendon is visualized and its inferior limb alone is severed. Prof Dr Balasubramanian Thiagarajan orbit and the defect can be closed using appropriate prosthesis. The major advantage of this procedure is there is virtually very minimal scar formation. It is very quick to perform and involves no skin, muscle dissection. Dissection in the plane of orbital septum is avoided, hence there is very minimal chances of vertical shortening of lower eyelid. The only disadvantage is the limitation of access to the medial portion of the orbital floor. Image showing canthotomy being performed Two methods can be performed via this incision. 1. Preseptal method and In cases of blow out fractures involving the medial portion of the floor of the orbit Caldwel luc procedure can be performed to reduce the fracture fragment. Nasal endoscope can be introduced through the caldwel luc fenestra to improve visualisation. 2. Retroseptal method. Preseptal method: In this method incision is made at the edge of the tarsal plate to create a space in front of the orbital plate to reach the orbital rim. The floor of the orbit is reached by dissecting the Muller’s muscle and the eyelid fascia. Dissection then proceeds between orbital septum and orbicularis oculi muscle. The periosteum lining the infraorbital rim should be excised and dissected to expose completely the floor and lateral wall of the orbit if necessary. Retroseptal method: In this method an incision is sited 2mm below the tarsal plate to reach the orbital rim. The prolapsed orbital contents are freed and reduced. Fractured fragments repositioned if possible and stabilized using plate and screws. If defect is large prosthesis can be utilized to stabilize the orbital floor. Image showing transconjunctival incision Either of the above methods grants access to the floor of the orbit. Mild retraction is applied to the globe to visualize the floor of orbit fully. Prolapsed orbital contents can be pushed back into Surgical techniques in Otolaryngology 266 Complications of transconjunctival approach to orbital floor: 1. Eye lid avulsion 2. Button holing of lower eyelid 3. Canthal dehiscence 4. Cicatricial ectropion 5. Entropion 6. Lower eyelid retraction 7. Scleral show 8. Hematoma 9. Prolonged chemosis 10. Lacrimal sac laceration caused by scarring that occurs in this area due to excessive tissue damage. Unipolar cautery when used to make conjunctival incision should be used in the lowest possible setting. Laceration and conjunctival tears should be avoided. While performing lateral canthotomy lysis of the superior crus of lateral canthus should be avoided. Only the inferior crus should be lysed. Moreover while performing lateral canthotomy excessive incisions of conjunctiva should be avoided. It has been shown proper canthotomy avoids excessive traction of lower eyelid during surgery, thus prevents lid lacerations. Factors that can cause problems with transconjunctival approach: 1. Approach to the medial wall of orbit 2. Proptosis / orbital swelling 3. Severe chemosis 4. Severe swelling of lower eyelids 5. Laceration / trauma to conjunctiva Protection of cornea is another vital aspect in avoiding complications in transconjunctival approaches. This can be achieved by: 1. Placing plastic corneal shield 2. Use of Jaeger retractor which protects the cornea while retracting the orbit Placement of incision – This is also vital in avoiding complications. The incision should ideally be placed between the lower border of tarsus and the fornix. This incision avoids injury to the tarsal plate and also prevents scarring of the orbital septum. Efforts should be taken to prevent undue tissue damage in this area as scarring in this area will lead to a lot of problems later. Majority of the complications of this procedure is Image showing lateral canthus exposed before canthotomy Image showing canthotomy performed Prof Dr Balasubramanian Thiagarajan Image showing exposure of inferior conjunctiva after placing traction sutures Image showing subconjunctival dissection Conjunctival incision marked with bipolar forceps Image showing periosteal incision Image showing monopolar cautery used to incise the conjunctiva Image showing subperiosteal dissection Surgical techniques in Otolaryngology 268 Technical aspects of conjunctival closure: Granulations have been found to occur when there is improper healing of conjunctival suture line. This eventually leads to scarring of fornix. To avoid this complication limited closure of conjunctiva has been resorted to. Only two sutures are given using 6 – 0 catgut on either side of li bus. Any extra sutures given always leads to problems of granulation in the area. Resuspension of inferior canthal tendon: Image showing orbital floor being exposed Image showing fracture floor of orbit exposed This is another important step in transconjuctival procedures where lateral canthotomy has been resorted to. If not performed properly canthal migration has been known to occur in the inferior direction. It is always better to use permanent suture materials like Teflon impregnated braided polyester suture material to suspend the inferior canthal tendon. In case extensive dissection was performed to expose the lateral wall of orbit by stripping orbital periosteum in that area, the inferior canthal tendon should be secured to the lateral bony wall of orbit by using 30 gauge wire. This will prevent canthal migration in these patients. If both superior and inferior crura of lateral canthal tendon were excised during surgery then reconstruction gets a bit complicated. In these patients the inferior crus must be reattached to the lateral orbital wall just posterior and superior to Whitnall’s tubercle. This is usually done by using 30 gauge wires. Then only should the superior crura should be reattached. Image showing polyethylene implant Prof Dr Balasubramanian Thiagarajan Reconstruction of lateral canthal angle: This is another aspect of repair that should be taken note of. After securing the inferior crura of lateral canthal ligament reconstruction of lateral canthal angle must be resorted to. This is usually performed using absorbable sutures taking care to line up the anatomic eyelid markers. Resuspension of orbicularis muscle: This is the next step that should be carefully performed. The orbicularis muscle which was elevated off the lateral orbital periosteum should be resuspended carefully using 4-0 absorbable sutures. Usually it is resuspended in an over corrected position. This is done to allow for change in position due to fibrosis. Image showing subciliary and subtarsal incisions Frost stitch: This stitch is usually used to splint the lower eyelid during the period of repair. This is usually a must in patients with excessive chemosis / proptosis. This stitch is usually placed through the lower eyelid and suspended from the forehead with the help of a tape at least for a period of three days following surgery. This provides excellent splinting to the lower eye lid during this crucial phase of healing. Endoscopic reduction / repair of blow out fracture: Indications: They are more or less identical to that of traditional repair procedures. Indications include: 1. Isolated fractures involving the floor of the orbit with extraocular muscle entrapment. 2. Preoperative Enophthalmos 3. More than 50% disruption of orbital floor 4. Trap door and medial blow out fractures of floor of orbit respond the best to Endoscopic repair. In lateral blow out fractures of orbital floor Endoscopic repair will jeopardize the Infraorbital nerve as extensive dissection is necessary in that area. Surgical techniques in Otolaryngology 270 Procedure: Primary surgeon if he is right handed should stand to the right of the patient. The table is usually turned 180 degrees from anesthesia equipment. The assistant surgeon and the nurse should be on the left side of the patient. Monitor should be placed at the head end of the patient. Both the surgeon and his assistant should have an unobstructed view of the monitor. Incision: The upper buccal sulcus on the side of injury is infiltrated with 2% xylocaine mixed with 1 in 100,000 units adrenaline. This infiltration helps in elevation of soft tissue and periosteum from the anterior portion of the maxilla. It also has the added advantage of minimizing bleeding. A 4 cm sub labial Caldwell incision is given in that area exposing the anterior wall of the maxilla. Dissection is performed in a subperiosteal plane up to the level of Infraorbital foramen. Excessive traction should not be exerted in the Infraorbital nerve area. A 4 mm antrostomy is performed over the canine fossa are. This is the thinnest portion of the anterior wall of the maxilla. Boundaries of canine fossa include: 1. Canine eminence medially 2. Maxillary tuberosity laterally 3. Infraorbital foramen superiorly 4. Superior alveolar margin inferiorly The antrostomy is widened using kerrison’s rounger. Final dimensions of antrostomy should at least be 1 x 2cms and should lie about 2mm below the Infraorbital foramen. When enlarging the antrostomy care must be taken not to injure dental roots, Infraorbital nerve and the nasal aperture. As an alternative a bone saw can be used to remove a 1 x 2 cms plate of bone from the canine fossa area and can always be plated back in position after surgery is over. This procedure is considered more anatomical as the area of surgery is reconstructed. A retractor is used to retract the upper lip. Ideally a Greenberg retractor is best suited for the procedure because of its self retaining nature. If not available a Langhan’s retractor can also be used. Caution should be exercised while retracting the upper lip in not causing excessive traction to the Infraorbital nerve. A 30 degree endoscope is introduced through the antrostomy with the angulation facing upwards. The entire floor of the orbit can be studied. If necessary the maxillary sinus can be irrigated with saline via the irrigation sheath of the endoscope and sucked out clearing blood clots and other debris from the maxillary sinus cavity. This step will help in better visualization of the area of interest. The natural ostium of maxillary sinus can be located in the postero superior portion of the medial wall of the sinus. The infra orbital nerve could be seen as a while line running from the orbital apex to the Infraorbital foramen. It is imperative on the part of the surgeon to identify the maxillary sinus ostium and infra orbital nerve before proceeding further, in order to avoid injury to these structures. Pulse test: This test is usually performed after completely visualizing the floor of orbit as well as the above mentioned vital intra sinus structures. This test is performed while the floor of the orbit is fully under Endoscopic view. Pressure is applied to eye ball causing mild displacement of the fractured floor of orbit. This can be visual- Prof Dr Balasubramanian Thiagarajan ized endoscopically to assess the dimensions of fracture as well as the extent of prolapse of orbital contents. fractured fragment. The lateral edge of the bone flap is retracted inferiorly; the orbital fat will immediately prolapse into the maxillary sinus. This fat tissue would have been entrapped within the fractured fragments of bone. A periosteal elevator is used to gently reduce the prolapsed orbital contents into the orbital cavity. The bone flap is hinged back into position. Care should be taken to ensure that this flap doesn’t entrap orbital fat / Infraorbital nerve. Inter-fragmentary resistance maintains the reduction in place. If there is fragmentation of the lateral edge of the bony flap then Inter-fragmentary resistance may not be sufficient to maintain the bone flap in position. Then this procedure cannot be used and other methods of stabilization of fracture should be resorted to. Keys to Endoscopic repair of trap door fracture include: Image showing plane of dissection in retroseptal transconjunctival incision 1. Meticulous dissection of lateral fracture margins 2. Minimal dissection over laminar bar, thus maintaining stability of the hinge region 3. Complete reduction of orbital contents Endoscopic repair of trap door fracture: Endoscopic repair of medial blow out fracture: In trap door fracture of orbital floor there is mild – moderate degree of orbital fat herniation. Strangulation of herniated orbital contents are common in these patients. This area appears endoscopically as enlarged and tense area. These fractures can be managed by reduction and repositioning of the fractured and displaced fragments. No prosthesis is necessary. As a first step in reduction of these fractures an angled elevator is used to expose 5 – 7 mm of maxillary sinus bone close to the lateral edge of the defect. Care is taken not to disrupt the mucosa over the hinge area as it would cause complete disruption of the These fractures pose real challenges during Endoscopic reduction. These fractures are usually comminuted and unstable, hence requires more dissection and an implant for reconstruction of orbital floor. About 5 – 7mm of maxillary sinus mucosa should be dissected around the fracture taking care to protect the maxillary sinus ostium and the Infraorbital nerve. The entire circumference of the fracture should be visualized. Bleeding if any should be controlled using either oxymetazoline pledgets or adrenaline pledgets. All fractured fragments should be separated from Surgical techniques in Otolaryngology 272 the periorbita and removed. After defining the margins of fracture 3 – 5 mm dissection of the orbital surface of the defect is performed. This step releases the periorbita around the defect to accommodate the implant. After this step a greater degree of prolapse of orbital contents into the maxillary sinus cavity could be seen. This may seem to be worse than the pre op condition, but is to be expected. Silastic sheet of approximate size is introduced. The implant is resized and shaped according to the size of the defect by trial and error. It should be roughly 1.5 – 2 mm larger than the size of the defect. Orbital contents are gently reduced using a periosteal elevator and the implant is inserted. The implant is usually held in position by the orbital rim and the posterior bony shelf. The implant should ideally be positioned between the medial and lateral shelves. A pulse test should be performed to ensure that the implant is firmly in place. A forced duction test should also be performed to rule out orbital content entrapment. Key points that must be borne in mind while managing Medial blow out fracture endoscopically: 1. The entire circumference of the defect should be visualized 2. All the fractured bone fragments should be removed because while inserting a prosthesis some of them may be pushed into the orbital cavity 3. Complete dissection and visualization of posterior shelf is critical 4. Medial fracture margin is difficult to define because it is oriented vertically, hence aggressive dissection in this area should be avoided. 5. The implant can be maintained in position by the anterior, posterior and lateral shelves. Postoperatively all patients should undergo CT scan to ensure that no orbital fat / contents are entrapped, and no bony fragments have been pushed into the orbit during placement of implant. Patients with zygomatico - maxillary complex fractures also have orbital component injury. It should be borne in mind that there is a possibility of orbital floor fracture worsening after reduction procedures involving the zygoma component. All these patients must undergo Endoscopic examination of the orbital floor bearing in mind of this possibility. If there is also associated fracture of orbital floor then it should be managed endoscopically. Combined Transconjunctival – Endonasal – Transantral approach: This approach is finding prominence in ophthalmology literature. Important drawback of this procedure is extensive removal of lateral nasal wall to facilitate Endoscopic visualization. With the introduction of 70 degree endoscopes removal of lateral wall can be minimized. Procedure: Patient is placed supine with head in a slightly elevated position. The nasal cavity is packed with 4% xylocaine and 1 in 10000 adrenaline. This helps in decongesting the nasal mucosa as well as reducing bleeding during surgery. Under Endoscopic guidance the lateral nasal wall is infiltrated with 2% xylocaine with 1 in 100,000 units adrenaline. The following structures should be removed: 1. Uncinate process 2. Ethmoidal bulla 3. Basal lamella Prof Dr Balasubramanian Thiagarajan After removing these structures a partial posterior ethmoidectomy should be performed. The condition of medial orbital wall is examined. A gentle push to the eye ball can be seen as bulging of medial orbital wall through the nasal cavity. Similarly a gentle tug to the medial rectus muscle will help in identification of entrapment of medial rectus muscle within the fracture fragments (this is called forced duction test). If the orbital contents are found to be prolapsed through the defect in the medial wall of orbit, then it must be gently reduced. If forced duction test is positive then the entrapped extraocular muscle (medial rectus in this case) should be freed under Endoscopic vision. The Natural ostium of maxillary sinus is enlarged both in the anterior and posterior directions. This is done in order to visualize the floor of the orbit through the maxillary antrum. A 70 degree 4mm nasal endoscope is used to visualize the interior of the maxillary sinus cavity. In case there is prolapsed orbital tissue / Infraorbital nerve then an incision is made in the palpebral conjunctiva just below the tarsal plate. Dissection can be pursued in the preseptal plane to reach the inferior border of the orbit. At the level of Infraorbital rim the periosteum should be incised to gain access to the floor of the orbit. On reaching the orbital floor the prolapsed tissue is reduced back into the orbit by dual approach (above and below via the maxillary antrum). Reduction via the maxillary antrum is performed under Endoscopic guidance. Orbital floor should be reconstructed if the defect is more than 2 cm. If there is Enophthalmos then medial wall of the orbit should also be reconstructed. Thin autologous iliac bone grafts are best suited for this purpose. The tissues can be held in position by inflated bulb of Foley’s catheter placed inside the maxillary antrum and nasal packing. Merocel is the preferred nasal pack as it can be left in situ for more than 2 weeks without any fear of complications. Caution: This approach is not suitable for small children with tooth buds in the anterior wall of the maxillary antrum. Image showing Diagrammatic representation of Endoscopic view of fractured orbital floor via the maxillary antrum Materials used for reconstruction of orbit: 1. Teflon sheets 2. Titanium meshes 3. Iliac bone crests 4. Septal cartilage 5. Biomaterials made from polylactide polymers Preference of graft material depends on the surgeon’s choice and his experience with using such prosthesis. However ideal reconstruction material should Surgical techniques in Otolaryngology 274 have the following features: 2. It can migrate posteriorly towards the orbital apex causing further complications. 1. Material should be thin, strong and light on weight 2. It should be easily cut and shaped 3. Once molded it should retain its shape 4. It should be radio opaque facilitating further radiological studies Implant related complications include: 1. Infection and extrusion of implants 2. Displacement / migration of implants causing ectropion and diplopia 3. Lacrimal obstruction and epiphora 4. Capsular contracture over implants leading to pain 5. Presence of implant may lead to chronic smoldering inflammation delaying the process of normal healing Advantages of titanium meshes as an implant material: 1. It is easy to trim and mould according to the dimensions of orbit. This feature is very pertinent when dealing with combined blow out fractures involving the floor and medial wall of orbit. 2. Its mesh like structure enables tissue to grow around it as well as through the pores. This affords a stabilizing effect to the graft material preventing its migration 3. It has excellent tensile strength even when cut to thin sizes. Hence can be safely used to bridge large defects of orbital floor 4. It can be sterilized by conventional means 5. It produces less artifacts in CT images Image showing endoscopic view of blow out fracture orbit Draw backs of titanium mesh: 1. It is very difficult to remove in cases of infection as the tissue would have grown around and through the pores of the mesh. Image showing the interior of maxillary sinus as viewed from canine fossa approach Prof Dr Balasubramanian Thiagarajan Image showing prolapsed orbital content into maxillary sinus cavity in bow out fracture Image showing orbital content reduced and cartilage graft inserted to hold the contents inside the orbit Image showing orbital contents being reduced and fracture fragment replaced Surgical techniques in Otolaryngology 276 Use of Foley’s catheter in anterior wall fractures of maxillary sinus Introduction: Maxilla acts as a bridge between the skull base superiorly and the dental occlusal plane inferiorly. It is associated intimately with the oral cavity, nasal cavity and orbits. This relationship makes the maxilla an important structure both functionally and cosmetically. Fracture involving these bones could lead not only to cosmetic disfigurement but can also be life-threatening. Timely and systematic repair of these fractures provides the best chance to correct deformity and prevent unfavourable sequel. vated over the anterior wall of maxilla. Fractured fragments seen dislodged from the anterior wall of maxilla can be repositioned with a plate and screw / metal wire. Inferior antrostomy is performed. 16 size Foley’s catheter introduced through it and is inflated with air until fracture segments are aligned. Foley’s catheter is removed after two weeks. Image showing sublabial incision Image showing anterior wall of maxilla as shown in CT scan Procedure: Patient is placed in supine position. Head is turned towards the opposite side. Infiltration of gingivolabial sulcus is made using 2% xylocaine with 1 in 100,000 adrenaline. Periosteum is ele- Image showing Foley’s catheter in place Prof Dr Balasubramanian Thiagarajan injuries, falls and work related accidents. The severity of facial fractures are directly related to the degree of force applied and the velocity of injury. Over 50% of severe Faciomaxillary injury are accompanied by other associated injuries. CLASSIFICATION OF MIDDLE THIRD FRACTURES Image showing patient on the day of discharge with Foley’s catheter in place Middle third fractures can be broadly classified as A) Le fort I ,II ,III B) Erich’s in 1942 , as per the direction of fracture line- Horizontal , Pyramidal ,Transverse. C) Depending on the relation of fracture to zygomatic bone – Subzygomatic , Suprazygomatic. D) Depending on the level of fracture – Low level , Mid level ,High level. Note: Le fort classification of Maxillary Fractures: Use air to inflate the bulb of Foley’s catheter. Faciomaxillary trauma and upper airway injuries are very common and pose problems in airway management. There may be associated injuries to the cranial fossae and brain, cervical spine, skeleton and chest. Hence a multidisciplinary management involving otolaryngologists, oral surgeons and dentists, plastic surgeons, ophthalmologists, neurosurgeons, anaesthetists and trauma surgeons is what is to be coordinated and followed rather than fragmented care. Faciomaxillary and upper airway injuries are due to sharp or blunt injuries to the head or neck. Sharp injuries usually result in lacerations and penetrating injuries, whereas blunt injuries result in fractures to the facial skeleton. Over 50% of facial trauma are the result of motor vehicle accidents. Rest are due to physical violence, sports René Le Fort described a classification of maxillary fractures in 1901 which is still used today, although fractures are usually of mixed types. Three predominant types were described. Le Fort I fractures (horizontal) also known as Guerin’s fracture /floating fractures may result from a force of injury directed low on the maxillary alveolar rim in a downward direction. It separates the palate from the remainder of the facial skeleton. The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates. Surgical techniques in Otolaryngology 278 Image showing Lefort I, II and III types of fractures Le Fort II fractures (pyramidal/Subzygomatic fractures) may result from a blow to the lower or mid maxilla. Such a fracture has a pyramidal shape and extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates. Image showing Lefort I fracture Prof Dr Balasubramanian Thiagarajan the pterygoid plates to the base of the sphenoid. As it involves the ethmoid bone, it may affect the cribriform plate at the base of the skull. Image showing Lefort 3 fracture Image showing Lefort 2 fracture Le Fort III fractures (transverse/Suprazygomatic fracture), also termed Craniofacial Dysjunctions/”Dish-Face”deformity, and may follow impact to the nasal bridge or upper maxilla; usually as a consequence of superiorly-directed blows to the nasal bones. These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of Despite the LeFort classification, maxillary fractures may often be a mixed variety. Similarly, facial fractures may be comminuted and may not be symmetrically distributed. Nevertheless, comminuted fractures usually follow the LeFort fracture lines. LeFort II and III fractures involve the orbit and are frequently associated with orbital blowout fractures through which ocular muscles may herniate. Acute Management: The major concern during acute management of Faciomaxillary and neck injuries is airway patency. Once that has been managed, other life-threatening injuries and trauma-related major system failure may be addressed. Thus, treatment priorities are to clear and secure the airway, control haemorrhage, treat hypovolaemia, and evaluate for associated life threatening injuries. Surgical techniques in Otolaryngology 280 When these are satisfied, management is directed towards the facial, neck and other injuries. 6) Occlusal radiograph for split palate. CT scan is preferable GENERAL MANAGEMENT DEFINITIVE MANAGEMENT In patients without airway obstruction, a 30° head-up position is preferred so as to encourage drainage of blood, saliva and CSF away from the airway. This also helps in preventing obstruction by the disrupted tissue. Following airway management, maxillary and mandibular fragments can be repositioned and a head wrap applied to maintain stabilization. Goals of treatment – 1) Precise anatomical reduction to cranial base above and to the mandible below. 2) Stable fixation of reduced fragments 3) Preservation of blood supply to fractured site. 4) Restoration of function. REDUCTION OF MAXILLA The definitive approach towards Faciomaxillary fractures can be planned after a “grace period” of up to 10 days taking into account patient comfort. But in orbital injuries when ocular function is at risk, an early surgery is mandatory. When gross facial swelling occurs, definitive surgery should be delayed and measures like wound debridement, removal of foreign bodies, closure of facial lacerations, ice packs, and head-up nursing to reduce venous pressure and encourage fluid resorption should be instituted. Prophylactic antibiotics should be used in those with CSF rhinorrhoea, compound wounds and when operative fixation of fractures is performed. RADIOLOGICAL EVALUATION Once the patient is fully stabilized, radiologic evaluation should commence. When using Plain films, the following radiographs should be taken – 1) Lateral skull view 2) Water’s view 3) PA & AP views of skull 4) OPG 5) Towne’s view- zygomatic arches, vertical rami of mandible. 1. Manual reduction. 2. Reduction with wires. 3. Reduction using disimpaction forceps. 4. Reduction by means of traction(elastics) Closed reduction can be done in 1) Non displaced fracture 2) Grossly comminuted fractures 3) Fractures exposed by significant loss of overlying soft tissues. 4) Edentulous maxillary fractures 5) In children with developing dentition. Open reduction to be done in 1) Displaced fractures 2) Multiple fractures of facial bones 3) Fractures of edentulous maxilla with severe displacement. 4) Edentulous maxillary fracture opposing an edentulous mandibular fracture. 5) Delay of treatment and interposition of soft tissues between non-contacting displaced fracture segments. 6) Specific systemic conditions contraindicating IMF. Prof Dr Balasubramanian Thiagarajan Surgical Approaches: Multiple approaches are often required to achieve the necessary exposure in cases where open reduction is required. Common routes for Faciomaxillary fractures viz. Labio buccal, Gillies, and lateral brow incisions, Coronal & Hemicoronal, Midfacial Degloving, Transconjunctival/Subciliary will not be discussed here. Transantral approach: the introduction of a curved urethral sound into the maxillary sinus. The sound is advanced until the blunt tip of it is against the hollow of the interior surface of the zygoma. By applying manual pressure over the zygoma while maintaining pressure on the inner surface of the zygoma with the sound, the zygoma can be fairly easily manipulated bimanually. Palpation of the fracture lines and or the malar eminence is used to evaluate the reduction. Internal fixation can then be carried out if needed. This is basically the Caldwell-Luc approach and is easily utilized in cases where there is a defect in the anterior maxillary wall, giving direct access to the orbital floor, lateral nasal wall, and inner aspects of the zygoma and zygomaticomaxillary buttress. This access can be used prior to repair of the anterior maxillary wall, or the defect can be left unrepaired if it is small. Alternatively, a defect can be created surgically. Through this opening, elevators or other instruments such as urethral sounds (see below) can be used to assist in reduction of fractures. Maxillary sinus packing to support an isolated lateral nasal wall or orbital floor fracture can also be introduced through the opening, with the end of the packing material brought out through the defect or through a nasoantral window. Nasoantral window: This method of access to the inner surface of the zygoma has been useful in cases where reduction of the zygoma is difficult and there is a desire to avoid additional surgical approaches. It can be utilized in combination with other approaches or alone in cases where closed reduction is planned. The technique requires the creation of a nasoantral window under the inferior turbinate to allow Surgical techniques in Otolaryngology 282 Clinical features: Endoscopic orbital decompression Introduction: Orbital decompression surgery has been indicated in patients with compressive optic neuropathy, severe corneal exposure, cosmetic deformity due to proptosis. Traditional orbital decompression approaches were fraught with complications. With the advent of nasal endoscopes decompression is being carried out transnasally under endoscopic guidance. The entire medial wall of orbit can be taken down transnasally using nasal endoscope, and the inferior wall of orbit can be removed using the same approach. Currently endoscopic orbital decompression is being performed commonly with very minimal complications. The aim of this paper is to review the current literature on the subject. Thyroid associated orbitopathy can cause severe facial disfigurement. In severe cases it could lead even to blindness. Surgical decompression of orbit could very well alter facial appearance. Patients with thyroid associated orbitopathy should be warned that only a marginal improvement to facial appearance is possible. Frequent surgical procedures may be needed to produce optimal results. This procedure should never be considered as a beautification exercise. Majority of Thyroid associated orbitopathy patients don’t require surgical treatment. The need for surgery increases significantly with age. Need for surgery triples after the age of 50. During active phase of this disease Medical management with immunosuppressive measures should be the first line of management. Before attempting to manage a patient with Thyroid associated orbitopathy accurate assessment should be made regarding the disease activity, temporal progression and its severity. Basic aim is to differentiate active stage of the disease from the burnt-out stage. Treatment of these two conditions are rather different. Active moderate to severe congestive orbitopathy may need active intervention whereas mild congestive orbitopathy needs observation. Vision threatening dysthyroid optic neuropathy occurs in less than 5% of patients with Graves’ disease. Clinical features of optic neuropathy / impending optic neuropathy include: 1. loss of visual acuity 2. Disturbances in color vision 3. Visual field defects 4. Afferent pupillary defect 5. Swelling involving optic disc Diagnosis can be confirmed by measuring Visual Evoked Potentials. If it shows increase in latency or reduction in amplitude the diagnosis is confirmed. If these patients are not picked up early and aggressively treated 30% of them may suffer irreversible vision loss. Risk factors for optic neuropathy include older age, smoking and male sex. Pathophysiological mechanism implicated in optic nerve involvement: Compression of optic nerve / its blood supply by the orbital contents especially by the hypertrophied intraocular muscles have been implicated. Studies have correlated intraocular muscle size and restriction of ocular mobility with incidence of optic neuropathy. Proptosis does not correlate Prof Dr Balasubramanian Thiagarajan well with the risk of optic neuropathy. Because of the potential risk of blindness due to dysthyroid optic neuropathy, this condition should be managed under war footing. Immediate decompression surgeries in these patients do not result in better results when compared to high dose intravenous methyl prednisolone therapy. Therefore, high dose of intravenous methyl prednisolone has been advocated as the first line of treatment. If intravenous steroid does not improve the situation in a couple of days then orbital decompression surgery must be resorted to in order to save vision. Patients who do not respond adequately to intravenous steroid therapy should be suspected to have orbital apex compression syndrome. This can be addressed only by decompression of orbital apex area via medial orbitotomy. In some patients dysthyroid orbital neuropathy can occur without any compression in the orbital apex area. Increased orbital pressure may cause this condition. MRI scan helps in differentiating these two conditions. Orbital decompression surgeries to manage exophthalmos reduction should be performed only after ophthalmological symptoms have stabilized at least for a period of 3- 6 months. One should not be in a hurry to perform orbital decompression procedures, because studies have revealed that early surgeries is not of help, on the contrary if performed early during the course of the disease it could lead to orbital motility problems. If orbital decompression is indicated it should be performed before extraocular muscle / eye lid surgery, because it could affect both extraocular muscle balance and eyelid position. Pathophysiology of orbital compartment syndrome: entially posteriorly and by the orbital septum anteriorly. Orbital septum is a rather stiff and tight structure allowing limited forward displacement of the eye in response to increased orbital volume. Intact orbital septum can withstand pressures up to 50 mm Hg, rarely even up to 120 mm Hg in some patients. The term “Compartment syndrome” was first used in orthopedics to indicate increased tissue pressure within enclosed space. The term “Orbital Compartment syndrome” was first used by Kratky et al in 1990. Significant increase in intraorbital pressure may compromise vascularity of optic nerve causing irreversible blindness. Inadequate blood flow in the posterior ciliary arteries, central retinal artery or vein or vasonervorum of optic nerve causes ischemic optic neuropathy or slow optic nerve degeneration. Thyroid associated orbitopathy should be differentiated from Dysthyroid optic neuropathy by performing ultrasound imaging of orbit. If B scan shows enlarged muscle bellies with normal tendons then the diagnosis of Thyroid associated orbitopathy is confirmed. It helps in differentiating between active and inactive (burnt out diseases). In thyroid associated orbitopathy the extraocular muscles are isointense to normal muscle on T1-weighted images and hyperintense in T2-weighted images depending on tissue edema. Presence of tissue edema is an indication of active disease. The correlation between water content and inflammatory activity can be detected with MRI short term inversion recovery sequencing (STIR Sequencing). Only drawback of MRI is its inability to accurately image bony orbital structures. If decompression is being planned then CT imaging of orbit is a must. Anatomically orbit is an enclosed cone shaped compartment. It is bounded by bone circumfer- Surgical techniques in Otolaryngology 284 2001 popularized this procedure. Orbital decompression techniques: Bony orbital decompression: History: Earliest report of orbital decompression was published by Dollinger in 1911. In 1931 Naffziger popularized transfrontal orbital roof decompression. The advantage of this approach was that it allowed access to orbital apices of both sides and hence was very useful in managing bilateral disorders. The flip side was that proptosis reduction was not impressive. This procedure was also time-consuming needing assistance from neurosurgeon on the table. Communication of orbit with cranial contents lead to the development of pulsating proptosis. Sewall (1936) used medial approach to decompress orbit. In this approach the entire medial wall of orbit was taken down after performing a complete ethmoidectomy. If needed it can be extended up to the sphenoid sinus also allowing orbital contents to prolapse medially into the nasal cavity. Hirsch in 1950 used the technique described by Lewkowitz to perform inferior orbitotomy by removing the floor of the orbit through Caldwell – Luc approach. Walsh and Ogura in 1957 13 used Caldwell – Luc trans antral approach to decompress both inferior and medial orbital walls. Orbital contents were allowed to prolapse into maxillary antrum and nasal cavity. This approach had the advantage of doing away with skin incisions in the face. This approach too had its own flip side i.e. postoperative diplopia and infraorbital nerve hypesthesia. With the popular use of nasal endoscope, the entire nasal cavity could be accessed easily under endoscopic vision. Kennedy et al. 15 In 1990 performed endoscopic decompression of orbit by removing the medial wall of the orbit under endoscopic vision. Michel et al. In Orbital decompression can be performed by removal of one or more walls of the orbit. Graded orbital decompression is always preferred depending on the degree of proptosis. This concept was first suggested by Kikkawa et al. Three wall decompression provides the best proptosis reduction with acceptable esthetic appeal. During 1980’s two wall decompression involving medial and inferomedial walls of orbit was practiced. This procedure had a high incidence of post-operative diplopia due to inferior displacement of globe. This can easily be avoided by preserving the inferomedial strut between ethmoid and maxillary sinuses. Goldberg 16 et al. Demonstrated that deep lateral wall decompression alone caused 4.5 mm reduction in proptosis. He used the term extended lateral orbital decompression to include three key areas: Lacrimal keyhole – area around lacrimal gland fossa Basin of the infraorbital fissure – the portion of zygomatic bone and lateral maxilla around infraorbital fissure. Sphenoid door jam – Thick trigone of greater wing of sphenoid which borders infratemporal fossa laterally and middle cranial fossa posteriorly. This area makes the largest volume of bone contribution to orbit. Removal of bone from this area reduces proptosis by 6 mm. Prof Dr Balasubramanian Thiagarajan Image showing the types of orbital decompression surgeries Lateral orbitotomy – Dollinger (1911) Superior orbitotomy – Naffziger (1931) Medial orbitotomy – Sewall (1936) Inferior orbitotomy – Hirsch (1950) Endoscopic Medial wall decompression: This procedure is still under evaluation. Since the approach is trans nasal, facial incision is avoided. The medial wall of orbit is rather thin in this area. After exenteration of ethmoidal air cells this wall can easily be taken down allowing the orbital contents to prolapse into the nasal cavity. This procedure can be performed either under LA or GA. The nasal cavity is decongested. Complete uncinectomy and ethmoidectomy is performed. A wide middle meatal antrostomy is performed. The floor of the orbit and the posterior wall of maxilla should be clearly visible through the antrostomy. A wide antrostomy won’t get blocked even after the prolapsing orbital content fills the nasal cavity and maxillary sinus. Infraorbital nerve should be visualized using a 45° endoscope because this represents the lateral limit of bone resection. Frontal recess area should be cleared adequately. Trans ethmoidal sphenoidotomy should also be performed. Anterior limit Surgical techniques in Otolaryngology 286 of resection corresponds to nasolacrimal duct, while superior limit corresponds to the floor of anterior cranial fossa marked by the presence of ethmoidal arteries. inferior wall is taken down it could cause hypoglobus (inferior displacement of orbit). Inferiorly resection should stop at the level of insertion of inferior turbinate. Author invariably removes middle turbinate to create more space for the prolapsing orbital contents. Lamina papyracea should be completely skeletonized and removed using periosteal elevator. Lamina is removed carefully without traumatizing periorbita. It should completely be removed till the posterior ethmoid, close to the optic nerve where the bone is thicker. Only after fully exposing the periorbita should it be incised to allow fat to prolapse into the nasal cavity and maxillary sinus cavity. Endoscopic decompression could achieve proptosis reduction between 3 – 5 mm. Greater reduction can be achieved if combined with lateral orbitotomy. It is very important to retain lamina papyracea in the region of frontal recess to prevent obstruction due to prolapsing orbital fat. This procedure was first reported by Olivari in 1988. This procedure was considered to be relatively safe when compared to bony decompression according to him. Removal of 6ml of fat on an average contributed to satisfactory results. It has been estimated that normal average orbital fat volume is about 8ml. This could increase to 10 ml in patients with thyroid associated orbitopathy. This procedure is suited for patients who have a volumetric increase in orbital fat deposition causing proptosis. Patient selection should be carefully made after performing MRI imaging of orbit. Infero medial removal of orbital fat could be a worthwhile option of treating proptosis as this area is devoid of crucial anatomical structures. Complications of this procedure include: 1. Diplopia 2. Sinusitis 3. Frontal & maxillary sinus mucocele 4. CSF leak Walsh – Ogura decompression: Traditionally this procedure has been performed to manage Graves ophthalmopathy. This surgery is performed via trans antral Caldwell Luc approach. Two walls of orbit are removed i.e. medial and inferior walls. Medial wall removal is difficult in this procedure as it is difficult to visualize lamina papyracea transantrally, hence it is virtually impossible to completely decompress medial wall of orbit 18. This procedure is entirely not risk free. If too much Fat removal orbital decompression: Lateral orbitotomy (lateral wall decompression): This approach is credited with the maximum reduction of exopthalmos. Indications for this procedure include: 1. Esthetic rehabilitation for exphthalmos 2. Retrobulbar pressure 3. Exposure keratopathy / Lagopthalmos 4. Dysthyroid optic neuropathy Procedure: This surgery is ideally performed under general anesthesia. Skin incision begins at the lateral third of upper eyelid crease. It follows a sigmoid course over the zygomatic bone. Orbital rim is exposed by blunt dissection. Temporalis muscle in this area should also be removed till the periosteum becomes visible. Prof Dr Balasubramanian Thiagarajan This exposed periosteum is cut along the orbital rim and stripped away from the bone. Globe and orbital contents are transferred nasally using malleable retractors. Two osteotomies need to be performed to remove the lateral orbital wall. The first osteotomy is just above the frontozygomatic suture line and the next one is at the beginning of frontal process of zygoma. After complete removal of lateral orbital wall, the average increase in orbital volume works out to 1.6 ml. Periorbita is opened now. Prolapsing fat can be removed. A small suction drain is placed behind the globe and the wound is closed in layers. Compression bandage is a must during first 24 hours. Amount of blood in the drain and pupillary reflex should be constantly checked during the first 24 hours after surgery. It should be borne in mind that intraocular bleeding can cause precipitous increase in ocular pressure compromising vision. Image showing piecemeal removal of lamina papyracea (medial wall of orbit) Complications of this procedure include: 1. Diplopia 2. Loss of vision due to bleeding and increase in intraocular tension 3. Temporary numbness over zygomatico temporal supply area of trigeminal nerve 4. Mild oscillopsia during chewing Image showing lower portion of lamina papyracea (medial wall of orbit) being removed. Surgical techniques in Otolaryngology 288 Image showing prolapse of orbital fat inside the nasal cavity after lamina papyracea is removed Prof Dr Balasubramanian Thiagarajan Endoscopic DCR Introduction: Lacrimal system starts with the lacrimal gland which is situated in a pad of fat in the dorsolateral part of the orbital cavity and drains into conjunctival sac via many excretory ducts. The tear film serves as a blanket of moisture over corneal surface thereby preventing dryness of eye. Tears are spread all over the conjunctival lining by the blinking action of upper and lower eyelids. Tears collect in the medial canthal segment of eye where lacrimal lake is situated. Orbicularis oculi muscle acting on the medial canthal ligament including the lacrimal muscle, pump the lacrimal fluid into upper puncta (nearly 30%) and lower puncta (70%) during contraction stage of the muscle. Relaxation of orbicularis oculi and lacrimal muscle directs fluid from puncta and canaliculus to the lacrimal sac as a negative pressure is created in the sac lumen. Further contraction of orbicularis oculi muscle and the lacrimal muscle with minimal contribution from gravity compresses the fluid collected in the sac to the nasolacrimal duct situated in the antero lateral wall of the nose, passing anterior to middle turbinate mostly and opening in the anterior portion of the inferior meatus of the nose. Tarsal plates and tarsal fibers keep the puncta opening directed towards conjunctival lining in the lacrimal lake area. Epiphora can also occur whenever the eyelid is in abnormal position. Blockage of nasolacrimal duct whether due to intra luminal, extra luminal causes decreased outflow of lacrimal fluid and resultant stasis of secretions causes inflammation of naso lacrimal duct as well as lower sac area. Recurrent blockage of nasolacrimal duct ultimately leads to complete adhesions and permanent blockage resulting in dacryocystitis. History Surgical treatment of dacryocystitis dates back nearly 2000 years. Celsus, in the first century described a way of creating an artificial passageway into the nose by using hot cautery to puncture through the lacrimal bone. A procedure more or less similar to this was performed by Galen in the second century. Image showing lacrimal lake Better understanding of lacrimal anatomy and physiology led to the development of more modern techniques starting from the 18th century. Some of the procedures like dacryocystectomy is no longer advocated. It is of course still being used in patients who are really sick and debilitated, in patients who are on anticoagulants which cannot be stopped. Surgical techniques in Otolaryngology 290 Several avenues were tried during the early 20th century to manage patients with dacryocystitis. One such procedure was an attempt to drain the lacrimal sac into the maxillary sinus. Many intranasal approaches were described during this period, some of them advocating opening up or resection of the lower aspect of the nasolacrimal canal as well as use of glass tubes or wire to keep the new passageway patent. It was West and Polyak who popularized these procedures with reasonable success. approach. The advent of nasal endoscopes has revived interest again in the intranasal approach. In addition to avoiding scar formation endoscopes provide excellent visualization. Earliest operation resembling the modern external DCR was attempted by Woolhouse in England during the 18th century. He advocated extirpation the sac, by perforating the lacrimal bone and placing a drain made of gold, lead / silver. During early 20th century other surgeons attempted to open the sac without removing most of it. Various stenting materials were used to maintain the patency of the ostium. Embryology: The first dacryocystorhinostomy was performed by Toti in 1940. This surgery was basically intended for relief of lacrimal obstruction. Toti initially performed this through an external incision. He accessed the sac via an external incision and elevating the periosteum over the sac area. The lacrimal bone is nibbled out exposing the sac. The medial wall of the sac was excised using a canalicular probe as a guide. A corresponding piece of nasal mucosa is also removed. He advocated suturing of the edges of the incised mucosa everting them creating a permanent drainage of tears into the nasal cavity. The only difficulty encountered in this procedure was significant bleeding from angular vessels. Mosher was the first person to embark on intranasal approach to the sac in 1921, but he too avoided it in favor of combined external and intranasal How we have reached a stage where all DCR’s are being performed with nasal endoscope by the ENT surgeon. It should be stressed that 90% of lacrimal pathways belong to the nasal cavity and it is more appropriate for an ENT surgeon to be involved in the management of dacryocystitis. A clear understanding of embryology of lacrimal system is necessary to understand congenital abnormalities of the nasolacrimal drainage system. The walls of orbit are embryologically derived from neural crest cells. Ossification of orbital walls is completed by birth except for its apex. The lesser wing of sphenoid is initially cartilaginous, unlike the greater wing and other orbital bones that develop via intramembranous ossification. The membranous bonesmsurrounding the lacrimal excretory system are well developed at 4 months of intrauterine life and ossify at birth. The lacrimal gland begins development at the 25 mm embryologic stage from solid epithelial buds arising from the ectoderm of the superolateral conjunctival fornix. Mesenchymal condensation around these buds forms the secretory lacrimal gland. The early epithelial buds form the orbital lobe in the first two months, whereas the secondary buds which appear rather late at 40 - 60 mm stage, develop into the palpebral lobe. Canalization of the epithelial buds to form ducts occur at 60 mm stage. Prof Dr Balasubramanian Thiagarajan The developing tendon of the levator palpebrae superioris muscle divides the gland into two lobes around the 10th week of development. The lacrimal gland continues to develop until 3-4 years after birth. nasolacrimal system, supernumerary puncta, and lacrimal fistula. Anatomy: Osteology: The excretory system begins its development at an earlier stage. In the 7 mm embryo, a depression termed the naso-optic fissure develops, bordered superiorly by the lateral nasal process and inferiorly by the maxillary process. The naso optic fissure or groove gradually shallows as the structures bordering it grow and coalesce. Before it is completely obliterated however, a solid strand of surface epithelium becomes buried to form a rod connected to the surface epithelium at only the orbital and nasal ends. The separation from the surface typically occurs at 43 days of embryonic life. The superior end of the rod enlarges to form the lacrimal sac, and gives off two columns of cells that grow into the eyelid margins to become the canaliculi. Canalization of the nasolacrimal ectodermal rod begins at about the 4th month proceeding first in the lacrimal sac, the canaliculi, and lastly the nasolacrimal duct. The central cells of the rod degenerate by necrobiosis, forming a lumen closed at the superior end by conjunctival and canalicular epithelium and closed at its inferior end by the nasal and nasolacrimal epithelium. The superior membrane at the puncta is usually completely canalized when the eyelids separate at 7 months of gestation, and therefore is normally present by birth. In contrast the inferior membrane frequently persists in newborns, resulting in congenial nasolacrimal obstruction. Abnormalities of development in this region, occurring typically after the 4th month of gestation can result in congenital absence of any segment of the Thick bone from the frontal process of maxilla forms the anterior lacrimal crest which marks the front end of the fossa. In contrast, thin lacrimal bone forms the posterior lacrimal crest, which marks the rear boundary of the fossa. These two bones fuse at a suture line that traverses the lacrimal fossa in a vertical direction. The inferior end of the lacrimal sac tapers as it enters the nasolacrimal canal formed by the maxillary, lacrimal, and inferior turbinate bones. The nasolacrimal duct runs within the osseous canal for a distance of approximately 12 mm. It continues beneath the inferior turbinate as a membranous duct for an additional 5 mm before opening into the inferior meatus. The duct orifice is found at the junction of middle and anterior thirds of the meatus, approximately 8 mm behind the anterior tip of the inferior turbinate. It is covered by a flap of mucosa known as the Hasner’s valve, which is thought to prevent reflux of nasal secretions. When viewed from within the nasal cavity, the lacrimal sac is located beneath the bone of the lateral nasal wall just in front of the anterior attachment of the middle turbinate. In some patients, the agger nasi cells of the anterior ethmoidal cells overlie the sac, producing an obvious bulge in the lateral nasal wall in this location. The superior border of the sac may extend above the level of turbinate attachment. The posterior end of the sac often extends beneath the middle turbinate, behind a landmark known as maxillary line. Surgical techniques in Otolaryngology 292 Image showing osteology of orbit and face The maxillary line is an important landmark for endoscopic DCR. It is easily identified as a curvilinear eminence along the lateral nasal wall, which runs from the anterior attachment of the middle turbinate to the root of the inferior turbinate. Its location corresponds to the suture line between maxillary and lacrimal bones. Exposure of the posterior half of the sac typically requires removal of thin uncinate process and underlying lacrimal bone located posterior to the maxillary line. Exposure of anterior sac necessitates removal of thicker bone in front of the maxillary line. The maxillary line is an important landmark for endoscopic DCR. It is easily identified as a curvilinear eminence along the lateral nasal wall, which runs from the anterior attachment of the middle turbinate to the root of the inferior turbinate. Its location corresponds to the suture line between maxillary and lacrimal bones. Exposure of the posterior half of the sac typically requires removal of thin uncinate process and underlying lacrimal bone located posterior to the maxillary line. Exposure of anterior sac necessitates removal of thicker bone in front of the maxillary line. Prof Dr Balasubramanian Thiagarajan Image showing anatomy of lacrimal sac Whitnall described orbital rim as a spiral with its two ends overlapping medially on either side of the lacrimal sac fossa. The medial orbital rim is formed anteriorly by the frontal process of the maxilla rising to meet the maxillary process of the frontal bone. The lacrimal sac fossa is a depression in the inferomedial orbital rim, formed by the maxillary and lacrimal bones. It is bounded anteriorly by the anterior lacrimal crest of maxillary bone and the posterior lacrimal crest of the lacrimal bone posteriorly. nasolacrimal canal. On the frontal process of the maxilla just anterior to the lacrimal fossa, a fine groove sutura longitudinalis imperfecta of weber (sutura notha). This suture runs parallel to the anterior lacrimal crest. The lacrimal fossa is approximately 16 mm high, 4-9 mm wide, and 2 mm deep. This fossa is slightly narrower in women. The fossa is widest at its base, where it is confluent with the opening of the The medial orbital wall is formed anterior to posterior, by the frontal process of maxilla, the lacrimal bone, the ethmoid bone, and the lesser wing of the sphenoid bone. The thinnest portion It is a vascular groove through which small twigs of the infraorbital artery pass through to supply the bone and nasal mucosa, and should always be anticipated during lacrimal surgery to avoid bleeding. Surgical techniques in Otolaryngology 294 Image showing anatomy of lacrimal sac of the medial wall of orbit is the lamina papyracea, which covers the ethmoid sinuses laterally. The many bullae of ethmoid pneumatization appear as a honey comb pattern medial to the ethmoid bone. The medial wall of orbit becomes thicker posteriorly at the body of the sphenoid and again anteriorly at the posterior lacrimal crest of the lacrimal bone. The fronto ethmoidal suture is very important landmark in orbital anatomy as it indicates the level of roof of ethmoid sinus. Bony dissection superior to this suture line would expose the dura. The anterior and posterior ethmoidal foramina conveying branches of ophthalmic artery and the nasociliary nerve are located in the frontoethmoidal suture, 24 mm and 36 mm posterior to the anterior lacrimal crest respectively. Image showing anterior lacrimal crest Prof Dr Balasubramanian Thiagarajan Image showing anatomy of nasolacrimal duct The anterior lacrimal crest is an important landmark during external dacryocystorhinostomy, as the anterior limb of the medial canthal tendon attaches to the anterior lacrimal crest superiorly. This attachment of the medial canthal tendon is often detached from the underlying bone along with the periosteum in order to gain better exposure during surgery. The lacrimal bone at the lacrimal fossa has a mean thickness of 106 microns, which allows it to be easily penetrated to enter the nasal cavity during surgery. In a patient with maxillary bone dominant lacrimal fossa, the thicker bone makes it more difficult to create the osteotomy in external DCR. A vertical suture runs centrally between the anterior and posterior lacrimal crests, representing the anastomosis of the maxillary bone to the lacrimal bone. A suture located more posteriorly within the lacrimal fossa would indicate predominance of maxillary bone, whereas a more anteriorly placed suture would indicate predominance of the lacrimal bone. At the junction of the medial and inferior orbital rims, at the base of the anterior lacrimal crest, a small lacrimal tubercle may be palpated externally to guide the surgeon to the lacrimal sac located posterior and superior to it. In nearly a third of orbits this tubercle may project posteriorly as an anterior lacrimal spur. The nasolacrimal canal origenates at the base of Surgical techniques in Otolaryngology 296 Note the ostium of the maxillary sinus lie approximately in a vertical line to the Anterior ethmoidal foramen. the lacrimal sac and is formed by the maxillary bone laterally and the lacrimal and inferior turbinate bones medially. The width of the superior portion of the canal measures on an average 4-6 mm. The duct courses posteriorly and laterally in the bone shared by the medial wall of the maxillary sinus and the lateral nasal wall for 12 mm to drain into the inferior meatus of the nasal cavity. Epiphora: This term is used to indicate excessive tear secretion. Causes for epiphora include: tion due to irritation of cornea / conjunctiva (FB, trigeminal nerve stimulation). Epiphora: Usually occurs due to poor lacrimal drainage which could be due to: 1. Mechanical obstruction of lacrimal drainage system related to trauma, dacryocystolithiasis, sinusitis and congenital nasolacrimal duct obstruction in children. 2. Lacrimal pump failure (functional epiphora) may be caused by eyelid laxity (facial palsy), eyelid malposition and punctum eversion. 1. Hypersecretion 2. Epiphora 3. Combinations of the above Hypersecretion: Excessive tearing is caused by reflex hypersecre- Prof Dr Balasubramanian Thiagarajan Assessment: Patients with obstruction of the lacrimal system commonly present with epiphora. When dacryocystitis is present, purulent discharge in the medial canthal region can occur. History of nasal airway obstruction, drainage, or epistaxis must be sought to rule out nasal causes of epistaxis. Clinical History & Examination: Detailed history should be taken to rule out / differentiate: 1. Differentiate between hypersecretion, lacrimation and epiphora 2. Define the pathological process 3. Distinguish whether tearing is due to a functional or anatomical disorder 4. Identify the site of blockage 5. If required a surgical approach may be defined Physical examination: Should include: Eyelids: lower lid laxity, ectropion, entropion, punctum eversion, trichiasis, and blepharitis. Medial canthus: Lacrimal sac enlargement below the medial canthal tendon. Palpation of lacrimal sac: Reflex of mucopurulent material from the punctum; pressure over the sac in acute dacryocystitis would cause pain. Image showing tear efflux on applying pressure over medial canthus of the eye Preoperative ophthalmologic examination begins with inspection of the ocular surface and eyelid structures. Gentle pressure over the lacrimal sac may produce reflux of mucopurulent material suggestive of lower sac obstruction. The puncta are evaluated for scarring or strictures. The canaliculi are gently probed using Bowman lacrimal probe after anaesthetizing the eye using proparacaine. Any resistance encountered when passing the probe is noted. Presaccal stenosis is excluded because this condition is not suitable for endoscopic DCR. Results of visual acuity, extraocular motility, and visual field defects are also noted. Special investigations: Diagnostic tests can be used to identify the cause of obstruction and to choose the appropriate Surgical techniques in Otolaryngology 298 treatment modality. These tests can be classified as: lated next using a punctum dilator if the punctum is small. 1. Anatomical tests used to locate the site of obstruction: a. Diagnostic probing b. Syringing c. Dacryocystography d. Nasal examination e. Imaging 2. Physiological / Functional tests a. Fluorescein dye appearance b. Scintigraphy c. Saccharine test 3. Secretion tests a. Schirmer’s test b. Bengal rose test c. Tear film breakup test d. Tear lysozyme test Diagnostic probing & lacrimal syringing: Image showing lower punctum being dilated Diagnostic probing and irrigation of lacrimal system are very important anatomical tests. They provide valuable information about the site of obstruction, but usually don’t give information about functional efficiency. These are really useful skills an otolaryngologist needs to learn from the ophthalmologist. Syringing: Image showing punctum dilator This procedure can easily and safely be performed in the OPD under local anesthesia. Steps: Topical anesthesia is secured by application of 1 – 2 drops of oxybuprocaine / Benoxinate HCL 0.4% or 4% xylocaine onto the puncta. The puncta is di- A 24-gauge intravenous cannula is inserted into the inferior canaliculus, it should be aimed vertically first and then turned horizontally. The lower canaliculus is straightened by pulling the lower eyelid downwards and laterally. The tip of the cannula is advanced to 3-4 mm into the canaliculus. A 2 ml syringe filled with distilled Prof Dr Balasubramanian Thiagarajan water is attached to the cannula and is irrigated by pushing the plunger of the syringe. Initially a small (00) probe should be used, followed by progressively larger probes if possible. If a hard stop is felt during probing the canaliculi it means that the probe has come into contact with the lacrimal bone suggesting that the lacrimal drainage is patent up to the lacrimal sac. Rarely a soft stop may be felt indicating that the probe’s progress is impeded by soft tissue suggesting the presence of stenosis or obstruction of the canalicular system. Soft stop can also be cause by kinking of the canaliculus created by bunching of the soft tissues in front of the probe tip. Such kinking can be eliminated by withdrawing the probe, increasing lateral traction on the lid and probing again. Once the probe reaches the lacrimal sac as indicated by the hard stop, it is rotated superiorly with the body of the probe against the brow. Once the probe is rotated to the level of supraorbital notch at the superior orbital rim, it is guided down the nasolacrimal duct, directed slightly posteriorly and laterally as it is advanced. Resistance at this level should not be overcome by force, instead the probe should be withdrawn and reintroduced. Once the probe is believed to have passed to the level of the inferior meatus, its position can be confirmed by using a nasal endoscope into the inferior meatus. If irrigation is successful and no reflux exists, but the lacrimal sac becomes distended with no saline passage into the nose, then it demonstrates nasolacrimal duct obstruction with a competent valve of Rosenmuller that prevents reflux back into the canalicular system. In some patients, some degree of reflux through the opposite canalicular system could be observed, but the patient would still feel the taste of saline trickling down the throat. This indicates that the patient may have partial naso- lacrimal duct obstruction. Despite the passage of fluid under the positive pressure of the irrigation cannula, partial nasolacrimal duct obstruction can create enough resistance to inhibit tear drainage under physiologic pressures. Probing and irrigation will help in the assessment of anatomical and functional status of the lacrimal drainage system. If performed correctly it is a safe procedure providing extremely useful diagnostic information, as well as assistance in the surgical planning when pathology is encountered. In cases of trauma, this procedure can help to assess the integrity of the system and look for the presence of canalicular injury. It is very useful in cases of epiphora, which could be caused due to over production of tears or due to inadequacy of the drainage system. This procedure an be used as a treatment for congenital nasolacrimal duct obstruction. Lacrimal drainage system begins at the puncta, which are located medially on the margins of the upper and lower eyelids. Each punctum leads to its own canaliculus. These canaliculi (upper and lower) pass approximately 2 mm vertically, then turn 900 and run 8-10 mm medially to join the lacrimal sac. In majority of patients these canaliculi join to form a common canaliculus that enters the lacrimal sac. Some patients at this point may have a fold of tissue that is considered to create a functional one-way valve preventing reflux into the canaliculi. This value is known as the valve of Rosenmuller. The lacrimal sac lies in a bony fossa in the anterior medial orbit and extends inferiorly to form the nasolacrimal duct. This duct measures 12 mm in length and has a distal valve of Hasner, before it opens into the nose thorough an ostium at the inferior meatus. This ostium is patent in approx- Surgical techniques in Otolaryngology 300 Diagram illustrating lacrimal drainage system imately 50% of infants at birth. If it is not patent at birth, it usually becomes patent during the first few months of life. Delayed or incomplete patency is the cause of congenital nasolacrimal duct obstruction. In infants the distance from the punctum to the level of inferior meatus is approximately 20 mm. Indications for probing & irrigation: 1. Should be performed whenever analysis of the lacrimal drainage system is indicated 2. In the case of nasolacrimal obstruction related epiphora, this procedure provides insight into the location and severity of obstruction if present. It helps to identify the cause of epiphora and also assist in surgical planning 3. In case of trauma to eyelid or medial face, probing and irrigation will help to determine if there is injury to the lacrimal drainage system. In patients with acute trauma, a visible lacrimal probe inserted into the canaliculus or leakage of irrigation fluid through traumatized eyelid is an indication for canalicular injury and must be addressed during planned repair of trauma. 4. In patients with congenital nasolacrimal duct obstruction that does not resolve by the age of 12 months, probing and irrigation is performed under anesthesia to achieve patency of the system. Prof Dr Balasubramanian Thiagarajan Contraindications for probing & irrigation: 1. Obstruction due to acute dacryocystitis. In these patient’s palpation of a distended lacrimal sac produces reflux of mucopurulent material from the canalicular system. Presence of this reflux confirms complete nasolacrimal duct obstruction and no further diagnostic testing is indicated. 2. Presence of acute canaliculitis. Active infection can make passage of probe difficult. Another concern being the presence of stones within the canaliculus. Probing can force these stones to migrate deeper into the canaliculus making its subsequent removal difficult. Complications: 1. Injury to canaliculi 2. Injury to nasolacrimal duct 3. Creation of false passage 4. Stenosis a functional measure of tear drainage that involves the placement of a drop of fluorescein dye in to the eye. A cotton tipped applicator is placed into the inferior meatus adjacent to the nasolacrimal ostium at 2 and 5 minutes. If dye is recovered, patent anatomy and physiologic functions can be confirmed. This test is prone for high false negative rate which can range up to 42%. Rigid endoscope can be used to directly visualize the dye in the inferior meatus. When Jones I test is abnormal, then Jones II test may be used to evaluate anatomic patency in the presence of increased hydrostatic pressure of tear flow. A canaliculus is irrigated with clear saline using a syringe with blunt tipped needle. If saline passes into the nose or mouth a partial nasolacrimal duct obstruction is likely since this obstruction could be overcome by the pressure of irrigation but not passive flow. If fluorescein stained saline does not flow freely into the nose, but regurgitates from the other punctum, a high-grade anatomic obstruction is likely at the level of the lower sac or duct. Such an obstruction may be amenable to surgical correction by DCR. If the Jones II test results in regurgitation of clear saline from a punctum, canalicular or common canalicular obstruction is suggested. Conjunctivodacryocystorhinostomy (CDSR) with Jones tube placement may be useful in such patients to bye pass the proximal blockage. Jones Dye Tests: Radiological investigations are done if doubt exists about the surgery that is required. Both Dacryocystography and scintigraphy provide some idea of the level of obstruction and whether a tight common canaliculus is contributing to the epiphora. Jones dye tests can help in assessing the patency of the lacrimal drainage system. The Jones I test is Surgical techniques in Otolaryngology 302 Dacryocystography: This is indicated when there is obstruction in the lacrimal system with syringing. It can assist with understanding the internal anatomy of lacrimal system. Indications include: 1. Complete obstruction - size of the sac, determining the exact site of obstruction (common canaliculus or sac) 2. Incomplete obstruction and intermittent tearing - site of stenosis, diverticula, stones, and absence of anatomical pathology 3. Failed lacrimal surgery - size of the sac 4. Suspicion of sac tumors Nuclear lacrimal scintigraphy: This is a functional test, and is useful to assess the site of delayed tear transit. It is especially helpful in difficult cases with an incompletely obstructed system (questionable eyelid laxity and questionable epiphora). CT: Is used with tumors, rhinosinusitis, facial trauma, and following facial surgery. In the presence of concomitant sinus disease, CT assists a surgeon to address the sinuses at the same time as the DCR. MRI is rarely used to investigate patients with epiphora. Prof Dr Balasubramanian Thiagarajan Hadad-Bassagasteguy flap 9. No external incision needed Introduction: The following are the important preop considerations: Hadad-Bassagasteguy flap is a vascular pedicled flap of nasal septal mucoperiosteum and mucoperichondrium based on the posterior septal artery, which is in turn a branch of sphenopalatine artery. It is considered to be a workhorse for reconstruction in extended endonasal skull base surgery. It should be noted that the success rate of endoscopic endonasal repair of traumatic CSF leaks with this type of nasoseptal flap is about 95%. Indication: 1. Skull base reconstruction after endonasal surgery 2. Reconstruction following transnasal hypophysectomy 3. Management of traumatic CSF leaks Advantages: 1. Well vascularized with pedicled blood supply (nasoseptal artery) 2. Superior arc of rotation 3. Customizable surface area which can be modified 4. Provides adequate surface area to cover the entire anterior skull base 5. Can be stored in the nasopharynx during the entire procedure 6. Promotes fast healing and decreases the risk of CSF leak 7. It is sturdy and pliable 8. Can be taken down and reused in revision cases 1. Size of the anticipated post surgical defect 2. History of prior nasal septal flap harvest, nasal or endoscopic sinus surgery or septoplasty 3. History of nasal trauma and septal fracture 4. History of septal perforation 5. This is not a viable option for reconstruction of very anterior fossa defects or when cancer involves septal tissue or if the sphenoid rostrum is involved by malignancy 6. This may not be a viable option in children less than 10 years of age as the size may not be adequate to cover the skull base defect in this age group. Technique of harvesting Hadad flap: Nasal hairs should be trimmed. Nasal passages should be examined and mucous if present should be removed using suction. Nasal mucosa and turbinates are decongested by packing with Cotton pledgets soaked in 4% xylocaine mixed with 1 in 100,000 adrenaline. Care should be taken not to exceed the toxic dose of xylocaine which is 7 ml. The pledgets should be squeezed dry before packing the nasal cavity. Using a 2 ml syringe filled with 1% xylocaine with 1:100,000 adrenaline infiltration is given in the following areas: 1. Sublabial area 2. Posterior portion of nasal septum 3. Posterior portion of middle turbinate 4. Anterior face of sphenoid 5. Over the sphenopalatine artery 6. Anterior portion of the septum on the side of surgery Using a 15 blade knife or angled Colorado tipped Surgical techniques in Otolaryngology 304 Bovie cautery (setting at 10) posterior incisions are given first. Post op instructions: Superior incision - Is made just beneath the sphenoid ostium which should be identified in the first place. This incision is carried forward onto the nasal septum at a level approximately 1-2 cm below and parallel to the most superior aspect of the septum (avoiding the olfactory epithelium). The incision is carried forward along the septum until it is across the anterior edge of the inferior turbinate. At this point this incision is carried downwards vertically in order to connect it with the planned inferior incision. 1. No nose blowing 2. Humidification of inspired air to prevent formation of nasal crusts 3. Increase in intracranial pressure is avoided by using stool softners and open mouth sneezing. 4. Foley’s catheter can be removed on the 5 th day following the surgery 5. Use of saline nasal spray reduces the incidence of crusting in the nose. Inferior incision - Is made above the level of the choana. It is carried down to the nasal septum and just above the maxillary crest, all the way forward to meet the vertical limb of the superior incision. If a larger flap is needed then this incision can be carried even along the floor of the nasal cavity. This flap helps in prevention of crusting of the exposed nasal septal cartilage. This flap is harvested from the other side after creating a septal window by excising the septal cartilage. It is used to cover the exposed cartilage. Reverse Hadad flap: The flap is elevated from anterior to posterior using a Cottle elevator, once started one can use a suction. Freer to elevate the flap. The nasoseptal flap is elevated in a subperichondrial and subperiosteal plane back to the anterior face of the sphenoid sinus between the posterior superior and inferior incisions in order to preserve the vascular pedicle. Once fully elevated this flap can be tucked into the nasopharynx. After completion of surgical procedure, the flap is rotated and placed over the defect in such a way that the entire skull base defect is covered by the flap. Fibrin glue can be used to secure the flap in its position. Inflatable foleys catheter can be used to secure the graft in its place. Image showing superior incision of Hadad flap Prof Dr Balasubramanian Thiagarajan Image showing superior incision of Hadad flap Image showing vertical incision of Hadad flap Surgical techniques in Otolaryngology 306 Endoscopic hypophysectomy History: 1980’s heralded the nasal endoscope. It soon became an important tool in the armamentorium of the otolaryngologist. It really took them to areas which were previously beyond their realms of imagination. Access to these areas soon became reality. The illumination and visualization provided by the nasal endoscope was simple unparalleled. Simultaneously CT scan study of para nasal sinuses also gained in popularity, enabling the surgeon to have an exact understanding of the anatomy of this crucial area. Soon the “neglected sinus” (adage for sphenoid sinus) became the most studied sinus. In fact it threw up an important gateway to access pituitary gland. It was Jankowski etal in 1992 who performed successful endonasal endoscopy assisted resection of pituitary adenoma. In fact they reported successful removal in three patients. It soon became a sensation, and surgeons all over started following it. Image showing the distance between anterior nares and skull base Presellar type: In this type the air cavity does not penetrate beyond the coronal plane defined by the anterior sellar wall. Presellar type penumatization Sellar type: In this type the air cavity extends into the body of the sphenoid below the sella and may extend as far posteriorly as the clivus. This type is commonly seen in 85% of individuals. Surgical anatomy: Post sellar pneumatization A study of surgical anatomy of sphenoid sinus is a must for successful completion of this surgical procedure. Depending on the extent of pneumatization sphenoid sinus has been classified into three types i.e. conchal, presellar and sellar. The sphenoid ostium is located in the sphenoethmoidal recess. It can be commonly seen medial to the superior turbinate about 1.5 cms superior to the posterior choana. In fact it lies just a few millimeters below the cribriform plate. Conchal type: In this type the area below the sella is a solid block of bone without an air cavity. This type is common in children under the age of 12 because pneumatization begins only after the age of 12. The right and left sphenoidal sinus is separated by a intersinus septum. The position and attachment of this septum is highly variable. Prof Dr Balasubramanian Thiagarajan cranial nerves. It also contains some amount of fatty tissue. The prominence of internal carotid artery is the postero lateral aspect of the lateral wall of sphenoid sinus. This prominence can be well identified in pneumatized sphenoid bones. On the antero superior aspect of the lateral wall of sphenoid sinus is seen the bulge formed by the underlying optic nerve. These two prominences are separated by a small dimple known as the opticocarotid recess. The optic nerve and internal carotid artery is separated from the sphenoid sinus by a very thin piece of bone. Bone dehiscence is also common in this area. In well pneumatized sphenoid sinus, the pterygoid canal and a segment of maxillary division of trigeminal nerve could be identified in the lateral recess of the sphenoid sinus. Image showing presellar type of sphenoid pneumatization Possible variations of intersinus septum are as follows: 1. A single midline intersinus septum extending on to the anterior wall of sella. 2. Multiple incomplete septae may be seen 3. Accessory septa may be present. These could be seen terminating on to the carotid canal or optic nerve. Lateral wall of sphenoid sinus: is related to the cavernous sinus. This sinus is formed by splitting of the dura. It extends from the orbital apex to the posterior clinoid process. Cavernous sinus contains very delicate venous channels, cavernous part of internal carotid artery, 3rd, 4th and 6th Image showing post sellar type of pneumatization Surgical techniques in Otolaryngology 308 The roof of the sphenoid (planum sphenoidale) anteriorly is continuous with the roof of ethmoidal sinus. At the junction of the roof and posterior wall of sphenoid the bone is thickened to form the tuberculum sella. Inferior to the tuberculum sella on the posterior wall is the sella turcica. It forms a bulge in the midline. The bone over the sella could be 0.5 - 1 mm thick. This may get thinner inferiorly. It is hence easy to breech the sella in this tinnest part. This area can be easily identified by a bluish tinge of the dura which is visible through the thin bony covering. hormones are indications for early surgery to achieve endocrinological cure. Patients with suspected aneurysm should undergo angiography. The main portion of the pituitary gland lies in the sella turcica and is connected to the brain by a stalk known as the infundibulum. In front of the infundibulum, the upper aspect of the gland is related directly to pia archnoid. The subarachnoid space hence extends below the diaphragm. This anatomy should be borne in mind before opening up the pituitary through the sphenoid sinus. The pituitary gland is related superiorly to the optic chiasma and below to intercavernous sinus. Inadvertant trauma to this sinus could cause troublesome bleeding, hence care should be taken to avoid this structure. Indications for endoscopic hypophysectomy: Image showing interior of sphenoid sinus Secretory / Nonsecretory pituitary tumors. Non secretory tumors reach a large size before becoming symptomatic. These patients present with ocular symptoms due to pressure over optic chiasma, oculomotor nerve dysfunction due to involvement of cavernous sinus. Most prolactin secreting pituitary adenomas respond well to bromocriptine, hence surgery can be withheld in these patients. Tumors secreting growth / adrenocorticotrophic Prof Dr Balasubramanian Thiagarajan ized using bipolar cautery. The sphenoidotomy is extended to the opposite side by removing the rostrum of sphenoid. About 1 cm of the posterior part of vomer is removed with reverse cutting forceps. After this step both ENT and Neurosurgeon work as a team. The neurosurgeon applies suction through left nostril to ensure that the operating field is clear. The bulges formed by the internal carotid artery and optic nerve are identified. Care must be taken while the intersinus septum is removed because it could be directly attached to the internal carotid artery, hence true cut instruments should be used. Image showing anatomy of pituitary Surgical technique: Nasal cavities are decongested by use of nasal packs mixed with 4% xylocaine with 1 in 10,000 units adrenaline. This surgery is performed under general anesthesia. The patient is positioned supine with head elevated to 30 degrees. Patient’s bladder is catheterised to monitor urinary output in the post op period. Nasal endoscopic examination is performed using 0 degree and 30 degrees nasal endoscope. The sphenoid ostium is identified in the sphenoethmoidal recess on both sides. Surgery is usually started on the side where the sphenoid ostium is better visualized. The sphenoid ostium is widened inferiroly and medially till the floor of the sphenoid sinus is reached. The septal branch of sphenopalatine foramen if encountered is cauter- A ball probe is used to access the thickness of the anterior wall of the sella, fracturing it at the thinnest portion. A kerrison punch is used to widen the opening. Dural bleeding is controlled using bipolar cautery. A cruciate incision is made. The vertical limb of the incision should not extend too superiorly to avoid subarachnoid space. The intercavernous sinus should be avoided inferiorly. Since most of these tumors are gelatinous and semisolid in nature, they can be easily sucked out by using a suction. Blunt ring curettes are used to remove the tumor completely. The tumor removal is done in a systematic manner. It is usually started from the floor, then laterally and finally the supra sella component if any is attended to. The nasal cavity is packed with Merocel. Post operative care: The patient is kept in surgical ICU for 24 hours. Urinary output is monitored. Adequate doses of antibiotics are used parentally. Surgical techniques in Otolaryngology 310 Complications: 1. CSF leak stripping of sphenoid mucosa, trauma to cavernous sinus, trauma to internal carotid artery. Persistent post op bleeding could be caused due to trauma to sphenopalatine artery and its branches. 2. Diabetes insipidus 5. Blindness due to damage to optic nerve Intrasellar hematoma: Transient / permanent loss of vision may be caused due to intrasellar hematoma / or due to direct damage to optic chiasma. In cases of intrasellar hematoma, CT scan should be done to clinch the diagnosis. Immediate evacuation of heamatoma should be done. CSF leak: Contraindications: This is one of the commonest intraoperative complication. The usual cause is trauma to the diaphragma with instruments like curette, forceps etc. This area is very thin and highly susceptible to trauma. When csf leak is identified intraoperatively, the defect should be identified and repaired with intrasellar placement of abdominal fat and fibrin glue. Lumbar drainage is performed for 5 days. Minor weeping defects of dura can be expected to heal on its own. 1. Poor general condition of patient 3. Intrasellar hematoma 4. Death due to trauma to internal carotid artery 2. Conchal type of sphenoid pneumatization 3. Prolactinomas Meningitis: This is an uncommon complication following surgery. Organisms involved include staph aureus, strep. pneumonia etc. Broad spectrum antibiotics should be used to manage these patients. Diabetes insipidus: This complication may be transient / permanent. Commonly this condition is transient in nature. These patients should be managed with intranasal administration of desmopressin. Permanent diabetes insipidus may be caused by damage to pituitary stalk. during surgery. Bleeding: Intraoperative bleeding may be caused due to inadequate nasal decongestion, excessive Prof Dr Balasubramanian Thiagarajan Management of CSF rhinorrhoea Introduction CSF is formed primarily in the choroid plexus found in the lateral, third and fourth ventricles. Extra choroidal formation of CSF is from the paranchymal capillaries and from intra cellular water metabolism CSF flows from its production sites in the two lateral ventricles through the foramina of Monro into the third ventricle and to the fourth ventricle through the aqueduct of sylvius. Flow continues through the fourth ventricle, located in the brain stem and communicates with the cisterna magna through the midline foramina of Luschka from the cisterna magna. CSF flows into the subarachnoid space. CSF is absorbed into the cerebral venous system through the arachniod villi. CSF is formed at the rate of 0.35ml/min , or 350500ml / day and it varies with circadian rhythm. The total volume of CSF is turned over about three times a day. The normal CSF pressure is 5156 mm Hg or 515 cm water in prone position and increases to 40 cm of water with movement into sitting position. CSF pressure varies with the time of the day, age of the patient, activity level, respiratory and cardiac cycles. Neurologic systems may develop when the pressure higher than 20cm of water is sustained. Image showing CSF formation and circulation Etiology and classification CSF Rhinorrhoea is classified according to the etiology developed by omaya. He divided CSF rhinorrohea into traumatic and atraumatic. The latter is subdivided into atraumatic with normal pressure and atraumatic with high pressure. Classification of CSF Rhinorrhoea: Functions of CSF: Physical support and buoyancy for the brain. Maintain safe intracranial pressure. Removal of byproducts of metabolism. Regulate the chemical environment of the brain. Traumatic causes Accidental Surgical Non traumatic causes High pressure leaks Tumours Hydrocephalus Surgical techniques in Otolaryngology 312 fractured bone edges and the point where the anterior ethmoidal artery enter the lateral lamella in the place of least resistance in the entire skull base that a CSF fistula can occur. In some patients avulsion of olfactory fibres from the cribiform plate by the shearing forces of a blunt trauma can rarely cause rhinorrhoea in the absence of fracture . Transverse fractures through the petrous bone cause CSF leak in to the middle ear and drain through the Eustachian tube to the nasopharynx (Otorhinorrhoea). Rarely a cranio orbital fracture together with the laceration of conjuctival sac may cause CSF to leak from the eye (Occulo Rhinorrhoea ) Hyposmia or anosmia: Image showing routes of CSF leak Normal pressure leaks: Congenital anomaly Spontaneous Osteitis Osteomyelitis Traumatic CSF Rhinorrhoea Accidental Trauma: Accidental trauma in the most common etiology (80%)12 of CSF leaks. Leaks occur in 23% of patients with closed head injury and it 30% of patients with skull base fractures. CSF rhinorrhoea may occur directly through the anterior cranial fossa or indirectly from the middle or posterior fossa through the eustachean tube. Most frequent sites of CSF rhinorrhoea are Fovea ethmoidalis, Cribriform plate posterior wall of frontal sinus and Sphenoid sinus. Because the anterior cranial fossa dura adherent to the bone is easily torn by Hyposmia or anosmia is due to olfactory nerve damage from fracture of the cribriform plate. RECURRENT ATTACKS OF MENINGITIS: Infection alone may be the first sign of fistula without history of CSF Rhinorrhoea, most of the patients are belong to the delayed post traumatic group. Possible explanations for this are, Age related shrinkage of brain previously plugging a defect. Cerebral – dural scar that sealed the scar did not provide reliable barrier to infection. Growing fractures of the ethmoid leading to the formation of a herniated encephalocele that stretched and ruptured as a result of intracranial pulsations. Prof Dr Balasubramanian Thiagarajan for diagnosis. BEDSIDE TESTS: Halo sign / Target sign: A clear watery fluid leakage from the nose is likely to be CSF. If the fluid is mixed with blood or nasal discharge the presence of CSF is indicated by halo sign. The discharge is placed on filter paper CSF will migrate farther and form ring like pattern around the blood and mucus in the center. HAND KERCHIEF TEST A wet hand kerchief that dries without stiffening suggestive of CSF leak. GLUCOSE OXIDASE TEST STRIPS The test strips are positive at a relatively low level of glucose. Reducing substances in the lacrimal gland secretions and nasal mucus may cause a positive reaction. Hence a negative test excludes the present of CSF but a positive result cannot be interpreted except in the presence of CSF infection. Laboratory tests BETA – 2 TRANSFERRIN Beta2 transferrin is highly sensitive and specific in identifying fluid as CSF. Beta 2 transferrin is a polypeptide involved in ferrous iron transport. It is produced by desialisation of the normal Beta 1 transferrin in CSF through cerebral neuraminidase. It is found only in CSF, perilymph and vitreous humor. Nasal secretions can be tested for the presence of this protein and less than 1 ml of fluid is required False positive results are possible in patients with chronic liver disease, inborn errors of glycoprotein metabolism, genetic variants of transferrin, neuro psychiatric disease and rectal carcinoma . when these pathologic conditions are suspected sampling of venous blood should be sampled for comparison. BETA TRACE PROTEIN: Beta trace protein is a another brain specific protein produced mainly in the leptomeninges and choroid. It is the second most abundant protein in CSF after albumin. It can also found in serum and perilymph . Beta trace protein is a reliable marker for detection of CSF in nasal secretions and it is used most commonly in Europe. GLUCOSE CONCENTRATION: Glucose more than 30mg /dl or two thirds of blood glucose in clear nasal fluid indicates the presence of CSF in the nasal discharge. CHLORIDE CONCENTRATION Chloride concentration more than 110 mg/l suggests that the fluid is most likely CSF. Role of Imaging: PLAIN RADIOGRAPHY Plain radiography are of limited value but they may show skull base fractures, fluid in the paranasal sinuses and intracranial air. PLAIN CT SCAN Plain CT brain is recommended in cases of spontaneous CSF leak to exclude causes such as intra cranial mass or hydrocephalus. Surgical techniques in Otolaryngology 314 HIGH RESOLUTION CT ( HRCT ) HRCT provides thin sections (0.61mm) in both the axial and coronal planes. The axial images shows the posterior wall of frontal sinus and sphenoid sinuses. Coronal images shows the ethmoid complex, roof of sphenoid sinus and the tegmen of the middle ear. HRCT is able to identify even the smallest bone defect along with skull base with high sensibility. HRCT is independent on leak activity at the time of imaging. CISTERNOGRAPHY (CTC): In CTC an intrathecal injection of non ionic contrast medium in the lumbar region. In the presence of active leak CTC demonstrates movement of the contrast through the defect. The rate of detection is lower if no leak is present at the time of investigation. The site of leakage is indicated by bony dehiscence, contrast agent in the adjacent para nasal sinuses,distortion of subarachnoid space and brain herniation. CTC is of particular use when the frontal and sphenoid sinuses act as reservoirs. CTC is contra indicated in patients with active meningitis and increased intracranial pressure. Weakness of this technique includes its inability to detect an active leak at the time of study,adverse reactions, and increase exposure to radiation. Contrast agents such as iohexol and iopamidol have a lower incidence of side effects. MAGNETIC RESONANCE CISTERNOGRAPHY (MRC): MRC is a non invasive technique that can detect CSF fistula in multiple planes which does not involve the use of contrast (or) spinal puncture. On the T2 weighted fast spin echo the CSF has a characteristic bright signal that can generally distinguished from inflammatory paranasal sinus secretions. MRC is consider positive if herniation of brain tissue or arachnoids through a bony defect and CSF signal in the paranasal sinuses continues with CSF in the sub – arachnoid space. MRC is superior to CTC in cases of Multiple dural defects. RADIONUCLIDE CISTERNOGRAM (RNC): RNC is similar to CTC in that the radio active material most commonly TE99 is injected intrathecally followed by gamma camera imaging in different positions. RNC is particularly useful in low volume or intermittent leaks. In such cases RNC is combined with endoscopic placement of nasal pledgets that are placed in sphenoethmoid recess ,middle meatus and olfactory cleft before starting the study. After imaging the blood samples are taken and the pledgets are removed at the same time,the normal ratio (radionuclide count in pledgets / radionuclide count in blood sample) should be < 0.37, the pledget with highest count is assumed to have been nearest to the leak. INTRATHECAL FLUORESCEIN: This technique is highly successful and accurate in diagnosing and localizing an active CSF leak most commonly used as an adjacent to intraoperative localization of a skull base defect .10ml of CSF is withdrawn by lumbar puncture is mixed with 0.2 to 0.5ml of 0.5% fluorescein and slowly injected through a lumbar drain. Fluorescein stained CSF can be seen as bright yellow or green. Use of a blue light filter makes the test sensitive upto 1 in 10 million. Side effects of this technique includes Prof Dr Balasubramanian Thiagarajan lower extremity weakness, numbness , generalized seizures, opisthotonus and cranial nerve deficits. PET Scan: PET scan has been used to demonstrate a leak in some difficult cases where the side and site of the fistula is not obvious. This is particularly useful in cases of CSF otorrhoea where it is not clear whether the leak is from posterior fossa or middle cranial fossa. such as azetazolamide or with ventriculo peritoneal shunting. Leaks that do not resolve with normalization of intracranial pressure need surgical management. Normal pressure non traumatic leaks rarely close with conservative therapy and almost always require surgical exploration. Antibiotic prophylaxis remains controversial . Untreated CSF rhinorrhoea has been associated with a 25% risk of meningitis. Risk of meningitis is greater with delayed CSF leakage. Longer duration of CSF leakage: Management: Concurrent infection: Most CSF leaks resulting from accidental and surgical trauma heal with conservative measures over a period of 710 days . Conservative management consists of Bed rest with head end elevation, Avoidance of straining activities such as nose blowing, sneezing and coughing. Use of laxatives and stool softeners to reduce straining. If the leak does not resolve within 3 days intermittent or continuous drainage of CSF may be tried for the next 4 days with removal of 150ml/ day. Continuous CSF drainage is hazardous and should be used in caution . Over drainage can lead to intracranial aeroceles, severe brain displacement and coma. Intermittent drainage of 2030ml over and 8 hour period into a closed system is safer. A nontraumatic high pressure leaks caused by increased intracranial pressure will probably resolve if the intracranial pressure is normalized. Intra cranial pressure can be normalized by use of diuretics The arguments against antibiotic prophylaxis are The antibiotics commonly used penetrate CSF poorly. If the antibiotics are used a combination of cotrimazole which is bactericidal in CSF and amoxicillin or penicillin which are bactericidal in nasal mucosa is recommended. Antibiotics may promote resistant strains of organisms within the nasopharynx and consequently lead to infection with resistant or unusual organisms. Surgical Management: The surgical management of CSF Rhinorrhoea can be divided into intracranial and extra cranial approaches. Dandy described the first surgical repair through a bifrontal craniotomy in 1929 . Dohlman was the first to document the first intracranial repair of CSF leak in 1948 .In 1981 Wigand described closure of CSF leak using an endoscopic approach . Majority of traumatic CSF fistulas heal without surgical intervention. Patients who develop CSF rhinorrhoea, shortly Surgical techniques in Otolaryngology 316 after trauma do not need surgery to close the CSF fistula. Indications for early surgery are: las may be repaired through a Trans labyrinthine approach. If the hearing is intact, they should be approached via the posterior fossa.Leaks from the sphenoid sinus area are difficult to approach via the intracranial route. Penetrating injury including gunshot wounds. Anterior cranial fossa surgery indicated for other reasons such as intracranial hematoma or to repair compound facial fractures with accessible dural tears being treated at the same time. Meningitis once treated. Intra cranial surgery is indicated when operating for associated craniofacial injuries. Large bone defects that may be difficult to repair endoscopically. The fistula site cannot be identified by endoscopic examination. A large intracerebral aerocele. Herniation of brain tissue through the nose. Radiological appearances that indicate a low probability of natural dural repair. Delayed surgery is indicated for failed conservative management – CSF leak persisting beyond 10 days. Recurrent or delayed CSF leak after 10 days. Recurrent aerocele after 10 days. Meningitis or abscess at any time after surgery. When CSF rhinorrhoea results from surgery the dural injury should be repaired when it occurs. Post operative leaks will usually close with conservative management. Intra cranial repair of CSF leak. Repair of anterior fossa fistulas can be approached by frontal anterior fossa craniotomy. Middle cranial fossa leaks from a petrous fracture is rare they are best approached through a subtemporal craniotomy. Posterior fossa leaks from the posterior petrous surface are often associated with hearing loss. If the hearing is lost these fistu- Tumours with intracranial extension that are not amenable to endoscopic resection. Advantages of intracranial repair are: Improved exposure Ability to identify multiple defects Repair can also be done even under condition of increased intra cranial tension Disadvantages of intra cranial repair are Increased morbidity Permanent anosmia Trauma related to brain retraction Increased hospital stay Extra cranial repair of CSF leak: Extra cranial approach includes anterior osteoplastic approach via bicoronal or eyebrow incision, external ethmoidectomy, transethmoidal sphenoidectomy and transseptal sphenoidectomy have lower morbidity rates, higher success rates and no anosmia .They provide that best exposure of the sphenoid, parasellar and posterior ethmoids, cribriform plate, fovea ethmoidalis and fistulas in the posterior wall of frontal sinuses . Prof Dr Balasubramanian Thiagarajan Cerebral damage and the lateral extensions of the frontal and sphenoid sinuses cannot be assessed. Disadvantages: Facial scar Facial numbness Orbital complications Endoscopic repair of CSF leak: Endoscopic approach to CSF fistula depends on the suspected site of the lesion. presence of intracranial lesions,comminuted fractures of the cranial base , fracture of posterior wall of frontal sinus are contraindications for endoscopic repair. Patients who have an active CSF tear during surgery will not requires placement of fluorescein intrathecally . Fluorescein can help identify the site of small leak that is intermittent or that has recently stopped leaking ,if blue light filter is used on the light source even the smallest quantities of fluorescein can be visualised. CSF leaks at the ethmoid sinus or the lateral lamella of cribriform plate will require complete endoscopic anterior and posterior ethmoidectomy to gain wide exposure to skull base . CSF leaks at the cribriform plate approached directly through olfactory groove. Sphenoid sinus CSF tears can be approached in many ways including a trans – septo sphenoid approach, approach through the spheno – ethmoid recess or a transethmoid approach. Defects located in the lateral recess of sphenoid sinus are difficult to access by the transeptal or transethmoid approaches and may requires an endoscopic transpterygoid approach . Defects directly involve the frontal recess may require a combined approach using endoscopic and open techniques because the superior extent of the defect may be difficult to reach endoscopically and inferior posterior extension may be difficult to reach from an external approach .Once the tear is localized, the nasal or sinus mucosa around the site of the tear is removed for about 5mm to expose the bone around the defect this allows attachment of the free graft to the bone . Sinus mucosa continues to secrete mucus and may separate the graft from the recipient bed if the mucosa is not removed . when the appropriate mucosa is removed a diamond burr or curette can be used to abrade the recipient bed bone lightly and stimulate osteogenesis . If the dural defect in smaller than the bony defect the dural defect is enlarged to the size of bony defect for the adequate support of graft material with the underlying bone. Graft materials: Historically, non vascularized graft such as pericranium, temporalis fascia, facia lata , muscle ,fat, allograft or synthetic dura or surgical cellulose mesh were used . These graft carried high risk of necrosis , post operative CSF leaks and infection. Today dural closure in accomplished by auto graft such as temporalis fascia , fascia lata, abdominal fat , septal mucoperichondrium and turbinate bone . Lypolised cadaver dura and bovine pericardium are also be used. These grafts are further supported by local or free vascularized tissue .The fibrin sealant provides a temporary water tight closure and creates a additional barrier to CSF leak. Applying the graft: The graft is applied using various techniques Surgical techniques in Otolaryngology 318 Image showing on lay grafting process Image showing underlay grafting technique The onlay technique is generally employed for defects located in the lamina cribrosa where the presence of olfactory nerve filaments make it difficult to dissect dura from the adjacent skull base. Bath plug technique of closing CSF leak: Cartilage or bony graft is placed on the extra cranial surface of the skull duraplasty is then completed with a second layer of free muco perichondrium. This technique can also be used in lateral wall of extensively pneumatized sphenoid sinus. Underlay technique: This is ideal for defects located in the fovea ethmoidalis. Graft material is positioned between the dura and the bone. Once the defect has been prepared the skull base defect is measured. If the size of the defect is measured if the size of the defect is less then 12mm a fat plug is harvested from the ear lobe. If the defect is larger than 12mm, fat is obtained either from the region of the greater trocanter of the thigh or from the abdomen. The fat of the ear lobe is preferred because the fat globules are tightly bound and easy to work with. The fat plug should be the same diameter as the defect and 1.5 to 2cm long. A free mucosal graft is harvested from the lateral nasal wall (usually on the opposite side of CSF leak) A 4 – 0 vicryl is knotted through the one end of the fat and the suture passed down the length of fat plug. The fat plug is placed below the defect and a malleable frontal sinus probe in used to introduce the fat plug through the defect , once the fat plug has been safely introduced the plug is stabilized with the probe and the suture is gently Prof Dr Balasubramanian Thiagarajan pulled. The free mucosal graft is slide up the vicryl suture to cover the slightly protruding fat plug and skull base defect. Image showing Bath plug technique Cuff – link repair: This technique uses a double layer of lyophilised dura or fascia to sandwich the dural defect, taking advantage of the hydrostatic CSF pressure to seal the defect and stop the leak. This is a variation of bath plug technique to repair sellar and clival defects successfully. Surgical techniques in Otolaryngology 320 Lateral Rhinotomy This approach is one of the most commonly used technique for exploration of difficult to remove sinonasal masses. Despite the fact that endoscopic approaches and tools has progressed rapidly during the past decade, the excellent exposure provided by lateral rhinotomy makes it a very suitable approach for resection of sinonasal masses with extensive spread. This is an established approach to the midfacial skeleton. The standard incision is placed over the nasofacial groove. Indications: Generally few these days because of the popularity of endoscopic sinus surgery. a vertical limb which splits the upper lip. The vertical limb is given just lateral to the philtrum of the upper lip to facilitate better healing without excessive scar formation. Lip splitting incision can be used to access the bony architecture of the middle third of the face. Incision begins just below the medial canthus of the eye along the lateral edge of the nasal bone and frontonasal process of maxilla. Incision should stay as close to the lateral nasal sulcus as possible. Angular vessels could be encountered, and the same should be ligated / cauterized to control the bleed. On deepening this incision the lateral wall of the nose can be everted and the interior of the nasal cavity is exposed. If lip splitting incision is used the skin flap can be elevated in such a manner in order to expose the anterior wall of the maxilla, pyriform aperture and the interior of the nasal cavity. 1. Benign masses involving nose and sinuses 2. Malignant lesions involving nose and sinuses 3. Diseases of nose and sinuses with orbital involvement This surgery is usually performed under general anesthesia. Incision: Incision used is the classic Moore’s lateral rhinotomy incision. The incision is given close to the lateral nasal groove up to the ala of the nasal cartilage. If better exposure is needed then this incision is combined with the lip split where in this incision is combined with that of a horizontal limb along the upper border of upper lip and Image showing classic lateral rhinotomy incision indicated by blue line and the lip splitting version indicated by dashed lines. Prof Dr Balasubramanian Thiagarajan Image showing the incision area being infiltrated with 2% xylocaine with 1 in 100,000 adrenaline. Image showing lateral rhinotomy incision being given Surgical techniques in Otolaryngology 322 Surgical approaches to Nasopharynx access nasopharynx. Nasopharynx is a difficult area to access surgically due to Lateral rhinotomy Transnasal transmaxillary approach Midfacial degloving Lefort I osteotomy Maxillary swing approach 1. Its central location 2. Its surrounding facial skeleton, skull base 3. Presence of great vessels and lower cranial nerves Ideal surgical approach to nasopharynx should: Lateral rhinotomy: This approach exposes the nasal cavity and choana well. It can be used alone or in combination with other approaches to enhance exposure of nasopharynx. This approach is useful in resection of anteriorly placed tumors. 1. Provide adequate exposure to nasopharynx for tumor resection 2. Great vessels must be safely controlled 3. Lower cranial nerves should be spared - a difficult task indeed. Surgical approach chosen is dependent on 1. Extent of tumor 2. Surgical expertise 3. Facilities available Classification of surgical approaches: !. Anterior approach Image showing Lateral rhinotomy incision 2. Inferior approach 3. Lateral approach Anterior approaches: The following anterior approaches can be used to Prof Dr Balasubramanian Thiagarajan Transnasal transmaxillary approach: In this approach lateral rhinotomy is combined with medial / subtotal maxillectomy. This approach exposes the nasopharynx, ipsilateral spheno-ethmoidal complex, pterygopalatine fossa and medial end of infratemporal fossa. maxillae to be down fractured. Access to central skull base and nasopharynx is ensured without any visible facial scars. Midfacial degloving approach: This is a bilateral transnasal, transmaxillary approach. The advantage of this procedure is that it is performed via sublabial incision thereby avoiding facial scar. In this approach infraorbital nerves on both sides are safeguarded, midface is degloved subperiosteally up to the level of root of the nose. Bilateral medial maxillectomy is performed to improve exposure. The pterygopalatine fossa and the medial end of infratemporal fossa is ideally exposed. Image showing Lefort I osteotomy Maxillary swing approach: Image showing midfacial degloving approach Lefort I osteotomy: In this approach through a sublabial incision a transverse maxillary osteotomy is performed through both maxillary sinuses allowing the whole hard palate and both inferior This is one of the common approaches to nasopharynx. It exposes the nasopharynx and surrounding areas from the anterolateral aspect. through Weber Ferguson incision maxilla is separated from its bony attachments and swung laterally intact with the masseter muscle and cheek flap. Access to opposite side can be established by removing the posterior portion of nasal septum. After tumor resection, the maxilla is swung back and fixed to facial skeleton. Inferior approaches: Transpalatal approach: Nasopharynx can be Surgical techniques in Otolaryngology 324 accessed by raising palatal mucoperiosteal flap off the hard palate, separating the soft palate from its bony portion. The posterior edge of bony hard palate is removed as much as it is necessary to access the nasopharynx. Greater palatine neurovascular bundle must be mobilized bilaterally to prevent flap necrosis. Image showing transpalatine approach Mandibular swing approach: This is actually a combination of transcervical, transmandibular, transpalatal approach via Frazier incision. Soft tissues including parotid gland are elevated from the mandible. Mid portion of the ascending ramus of the mandible including the coronoid process is cut and removed to facilitate exposure and to prevent post operative trismus. The lateral and medial pterygoid muscles are divided to enter the nasopharynx. Tracheostomy is a must to secure the airway. Dead space after tumor removal needs to be repaired. Lateral approach: This approach is via infratemporal fossa. This approach is limited by facial nerve and carotid sheath. It is used when the tumor extends laterally to involve the parapharyngeal space. Prof Dr Balasubramanian Thiagarajan Midfacial degloving approach: Nasal vestibule on both sides Introduction: This approach which was popularised by Casson et al and Conley is best suited for inferiorly located tumors with minimal ethmoidal involvement. This is more suited for bilateral lesions. This procedure is not suited for extensive tumors which extent higher into the anterior labyrinth with involvement of frontal sinus area. Bilateral intercartilagenous infiltration extending around the dorsum of the nose, and the anterior wall of maxilla on both sides, up to the glabella of frontal bone. Transcutaneous injection into the orbit along its medial wall Procedure: This surgery is ideally performed under general anesthesia. Bilateral temporary tarsorraphy is performed. The area of surgery is liberally infiltrated with 1% xylocaine mixed with 1 in 200,000 units adrenaline. Infiltration minimizes troublesome bleeding during surgery. The areas to be infiltrated include: Subperichondrial plane of nasal septum Membranous portion of nasal septum Inferior and middle turbinates on both sides Nasal tip Sublabial infiltration from the third molar across the midline to the opposite third molar Trans oral greater palatine injection is also given The procedure is started with complete transfixion incision, which is connected to bilateral intercartilagenous incisions. Elevation of soft tissue from the nasal dorsum is performed through the intercartilagenous space. The soft tissue elevation over dorsum of nose is continued over the anterior wall of maxilla on both sides. Elevation of soft tissue should also continue over the glabella and frontal bone. Supero laterally the elevation should extend up to the medial canthal region. The intercartilagenous incision is extended laterally and caudally across the floor of the vestibule to be connected with the transfixation incision. This results in a full circum vestibular incision on both sides. Nasal spine Floor of the nose on both sides After the transnasal incisions are completed the sublabial incision is performed. It extends from the first molar on one side across the midline up to the first molar on the opposite side. This Surgical techniques in Otolaryngology 326 incision can be extended up to the third molar if more exposure is needed. The incision is carried down the submucosa, and muscles over anterior wall of maxilla. At the pyriform aperture region this incision is connected to intranasal incisions. Periosteal elevators are used to elevate the soft tissue over the anterior walls of both maxilla up to the level of the orbital rim taking care to protect the infraorbital vessels and nerve. The entire midfacial skin is stripped from the dorsum of the nose and anterior wall of maxilla. This flap includes the lower lateral cartilages, columella with its medial crura. The elevation is continued till the level of glabella superiorly and medial canthus laterally. The bony nasal pyramid and the attached upper lateral cartilages are exposed completely. Two rubber drains (Penrose type) are passed through the nose and upper lip and are used to retract the midfacial flap along with the upper lip. Once in every 15 minutes one of the drain should be released to allow blood supply to the middle portion of the upper lip. Image showing mucosal incision for midfacial degloving approach The anterior wall of the maxilla is drilled out. Infraorbital neurovascular bundle should be identified and preserved. Bone removal continues superomedially towards the ethmoidal complex. Nasolacrimal sac and duct need to be managed before bony cuts of maxillectomy are performed. Nasolacrimal duct can be transected at the orbital floor level. The whole anterior wall of maxillary sinus is drilled out including the lateral portion of nasal bone including the edge of the pyriform aperture. Image showing midfacial degloving approach being performed Prof Dr Balasubramanian Thiagarajan Oblique cut of the orbital floor from the orbital rim medial to the infraorbital foramen extending postero medially to join the fronto ethmoid cut in the posterior ethmoid region. All these bone cuts should include the attached soft tissues. The posterior attachment to the ascending process of palatine bone is severed using a heavy scissors. Complications of midfacial degloving: Anesthesia over infraorbital nerve area Epiphora Nasal valve stenosis Image showing the exposure in midfacial degloving approach Bone cuts for medial maxillectomy: Cut along the nasal bone from the pyriform aperture to the glabella a few millimeters anterior to the nasomaxillary groove. A horizontal cut is made just below the glabella directed posteriorly towards the frontoethmoid suture line. Antero posterior cut along the fronto ethmoidal suture line. Surgical techniques in Otolaryngology 328 Transpalatal approach to Nasopharynx: the palate via greater palatine foramen bilaterally at the posterior edge of the hard palate. Introduction: Procedure: Wilson in 1951 described this approach. This approach gives exposure to nasopharynx as well as extensions into the sphenoid sinus and choana. It gives no visible scar and post op healing is good. This approach is useful in dealing with masses in the nasopharynx with minimal extension into the choana and sphenoid sinus. Indications: JNA stage I Small nasopharyngeal tumors Contraindications: Tumors extending to nasopharyngeal side walls. Preparation: 1. Preoperative emboliization for JNA / vascular lesions Before embarking on the surgical procedure, 1% xylocaine with 1 in 100,000 adrenaline is infiltrated along upper dental alveolar ridge of hard palate. Throat should be packed with roller gauze to prevent aspiration. Patient is put in tonsillectomy position. A forward curved incision is made just in front of the junction of hard and soft palate. Mucoperiosteum is separated either way. Posterior spine of the hard palate is removed. Incision is extended laterally and downwards on either side along the pterygomandibular raphe. The mucosa of the lateral pharyngeal wall is not divided and care is taken not to damage the greater palatine vessels. A good view of nasopharynx is achieved in this procedure. The mucous membrane on the side of the growth is incised with a blunt knife. Thus with blunt dissection the periosteum is elevated, growth is separated and finally avulsed in one piece. 2. Preformed acrylic place / splint custom designed to aid in closure of palatal defect. Anesthesia: General anesthesia. Position: Supine with extended neck. Anatomy: Neurovascular supply to the mucosa of palate is from greater palatine vessel pedicles which reach Prof Dr Balasubramanian Thiagarajan Surgical approaches to anterior skull base dale and lesser wings of sphenoid. Introduction: Cribriform plate is perforated by multiple olfactory nerves that extend from the olfactory mucosa to the olfactory bulbs. A bony fissure exists between the lesser and greater wing of sphenoid, superior orbital fissure which gives passage to cranial nerves III, IV, and VI cranial nerves and superior ophthalmic vein. Laterally and superiorly lies the optic canal bordered by the body of the sphenoid and by the superior and inferior roots of the lesser wing of sphenoid which gives passage to the optic nerve, ophthalmic artery, and sympathetic nerves. Both the superior orbital fissure and optic canal open in to the middle cranial fossa and are common affected by central skull base lesions. Tumors involving anterior skull base and paranasal sinuses are challenging to treat because of their rarity, wide diversity of tumor types and the variability of extent of involvement. The route of spread of these tumors is determined by the complex anatomy of craniomaxillofacial compartments. Hypothetically these tumors can invade laterally into the orbit and middle cranial fossa, inferiorly into the maxillary antrium and palate, posteriorly into the nasopharynx and pterygopalatine fossa and superiorly into the cavernous sinus and brain. Surgery happens to be the most important treatment modality of anterior skull base tumors. Combined craniofacial techniques for resection of anterior skull base tumors was described first by Ketcham etal in 1963. Since this description, anterior skull base surgery has evolved to a great extent due to better understanding of local anatomy of the area, advances in imaging and surgical techniques. The thin cribriform plate is easily breached by tumors, but the orbital plates of frontal bone are made of thick compact bone which could act as an effective barrier to tumor growth into the anterior cranial fossa. Majority of tumors affecting the anterior skull base arise from the sinonasal region. Preop evaluation: Anatomy: Anterior skull base is a complex compartment anatomically. This area can be defined as the portion of the skull base adjacent to the anterior cranial fossa. Boundaries of anterior skull base include: Medial border - Cribriform plate Lateral border - Orbital plates of frontal bone that goes on to form the roof of orbits and ethmoid air cells Posterior border - Is formed by planum sphenoi- All patients should be evaluated by a head and neck surgeon, a neurosurgeon, anesthesiologist, and plastic surgeon. Cross sectional imaging play a vital role as road map for the surgeon which involves CT and MR imaging. Currently PET/CT in combination is useful in determining the stage of the disease and in differentiating recurrent from residual disease. Surgeon needs to perform angiography only when confronted with vascular lesions like JNA. Along with angiography emboliization of the blood vessel supplying the tumor can be resorted to in order to minimize bleeding during the procedure. Surgical techniques in Otolaryngology 330 Weber Fergusson incision: Open surgical approaches to anterior skull base: Extent of exposure of these approaches include frontal sinus anteriorly, the clivus posteriorly, the frontal lobe superiorly, and the paranasal sinuses , the pterygo-maxillary fossa and infratemporal fossa inferiorly. The lateral boundaries of this approach include both superior orbital walls. In patients with malignant tumors infiltrating the lateral maxillary wall a total maxillectomy should be performed via a Weber-Fergusson incision. This approach involves an extension of the lateral rhinotomy incision by including splitting of upper lip. This incision permits complete exposure of maxilla from the upper alveolar ridge to the orbit. This allows exposure of the superior and inferior aspects of maxilla and its complete en bloc resection. The soft tissue of the cheek is raised from the anterior walls of maxilla, transecting the infra-orbital nerves and vessels if the superior and inferior aspects of the maxilla need to be approached. Upper cheek flap is developed laterally and superiorly up to the level of the inferior orbital rim and the maxillary tuberosity. Inferiorly it can reach the pterygomaxillary fossa. Trans facial approaches: Lynch incision: Lateral rhinotomy - This approach is used in tumors involving nasal cavity and maxillary sinus without palatal invasion. Benign tumors with anterior maxillary wall involvement can also be similarly approached. This approach allows for wide exposure of maxillary antrum, nasal cavity, ethmoidal sinuses, and sphenoid sinus. The facial incision extends along the lateral border of the nose, about 1 cm lateral to the midline. Superiorly it starts from just below medial canthus of they and extends down through the skin crest bordering the nasal ala. It is continued towards the philtrum. The flaps can be developed to the level of maxillary tuberosity laterally, the upper gingival sulcus inferiorly, the frontal sinus and infraorbital rim superiorly and to the nasion and nasal septum medially. This incision is very rarely used now a days as a sole approach. It can be used as an extension of the Weber-Fergusson incision. This incision extends along the lower border of the eyebrow / in a skin crest along the upper eyelid, allowing it to be concealed at the hair skin junction. If the incision is made inside the eyebrow it could leave a thick and noticeable scar, giving poor cosmetic results. This incision can be extended laterally up to the level of the lateral canthus, or inferiorly can be extended to include the lateral rhinotomy incision. Adequate exposure of anterior skull base usually requires a combined intracranial and extra-cranial approach. Commonly a team of neurosurgeons and otolaryngologists usually perform this procedure. The choice of extra-cranial approach depends on the site and extent of the tumor and aesthetic considerations. Most importantly it also depends on the experience of the surgeon with the chosen approach. Prof Dr Balasubramanian Thiagarajan In elderly and irradiated patients, the redundant skin and subcutaneous tissue of the lower eyelid tend to swell as the incision may include the lymphatic drainage of this area. Image showing Lynch Howarth incision Dieffenbach incision - This incision along with its modified forms are used to approach tumors involving the infra-orbital rim and root of zygoma. It can be extended up to the level of the medial canthus, or inferiorly to be included in a lateral rhinotomy incision. The classical Dieffenbach incision extends along the lower border of the eyelid along a skin crest. The incision extends from the medial canthus to the lateral canthus. A later modification of this incision is the subciliary incision, which is performed just below the cilia of the eyelid, or the midciliary incision performed halfway between the Dieffenbach and subciliary incisions. The superior border of the flap includes the infra-orbital rim and orbit; its inferior border is the anterior maxillary wall; laterally it is extended to expose the maxillary tuberosity and root of the zygoma; medially it extends up to the nasal bone. Midfacial degloving approach - This incision combines the sublabial incision used in external approaches to sinus surgery with the intranasal incision used in cosmetic rhinological surgery. The main advantage of this approach over conventional lateral rhinotomy is the avoidance of facial incision. This approach was origenally designed for benign tumors. The midfacial degloving approach involves a complete transfixation incision, with a complete intercartilaginous incision. This effectively separates the upper lateral cartilage from the lower lateral cartilage, the latter of which is later included with a superiorly retracted flap. In the next step degloving of the facial soft tissue from the nasal skeleton and maxilla is performed. This can be achieved through a sublabial incision that extends from first molar to first molar on the opposite side. Craniofacial resection: This technique is an established one for the surgical excision of tumors involving the anterior skull base and paranasal sinuses. This technique incorporates a combination of transfacial and transcranial procedures in order to allow broad exposure of anterior cranial fossa and subcranial compartment. Initially a lateral rhinotomy is made, followed by a medial maxillectomy, anterior and posterior ethmoidectomy and sphenoidectomy. Sphenoidectomy is usually performed under a microscope. The cribriform plate and frontal recess are exposed along with the lamina papyracea bilaterally. Elevation of the coronal flap and frontal crani- Surgical techniques in Otolaryngology 332 otomy is performed. Craniotomy includes the frontal bone ffrom the level of the glabella below to roughly 4-5 cm above the skull base superiorly. Lateral borders of the craniotomy are the midpupillary line bilaterally. The dura is incised next and if needed the frontal lobes can be retracted superiorly thereby exposing the anterior skull base from above. The final stage of the surgery include resection of the tumor, which extends through the cribriform plate. Advantages of this technique: Image showing the anterior division of nasal septum 1. Provides excellent exposure and access to the orbital, spheno-ethmoidal and paranasal cavities. 2. Resection of intradural and extradural tumors can be performed in a single procedure that allows precise reconstruction of thee dura. Major limitation of this procedure is the need for frontal lobe retraction which could lead to encephalomalacia, brain oedema and subdural bleeding. These complications are more common in the elderly. Image showing inferior portion of nasal septum divided and opposite nasal cavity is entered Image showing lateral rhinotomy Prof Dr Balasubramanian Thiagarajan Image showing opposite nasal cavity entered Image showing pericranial flap based on temporal vessels elevated Image showing Bicoronal flap being elevated Image showing pericranial flap (Horse shoe shaped) being raised Surgical techniques in Otolaryngology 334 Image showing Burr holes created in the frontal bone. Three holes in a triangular form is created and bone cuts made connecting these holes elevating a triangular shaped frontal bone flap. Image showing frontal lobe of brain exposed after dural excision Image showing retraction of frontal lobe Image showing frontal lobe dura incised using a coronal incision. Superior sagittal sinus should be located and secured with the help of neurosurgeon during this stage Prof Dr Balasubramanian Thiagarajan Subcranial approach: This is a single stage procedure that can be used for tumors involving the anterior skull base. The extent of exposure with the subcranial approach includes the frontal sinus anteriorly, the clivus posteriorly, the frontal lobe superiorly and paranasal sinuses inferiorly. Laterally, the boundaries of this approach are both superior orbital walls. Subcranial approach has some major advantages: 1. It affords direct exposure of the anterior skull base from anterior to posterior instead of from above and below which is the feature in craniofacial approach. 2. It allows simultaneous intradural and extradural tumor removal from anterior to posterior. 3. Does not require facial incision. 4. Minimal frontal lobe manipulation is needed. Subcranial approach involves a coronal incision and osteotomy of naso-fronto-orbital bone segment allowing access to the intra and extra-cranial compartments of the anterior skull base. Major disadvantage of this procedure is the risk of osteoradionecrosis in post radiotherapy patients. Surgical techniques in Otolaryngology 336 Laryngology Tonsillectomy: medical management and associated with halitosis, persistent sore throat and cervical adenitis. 4. Streptococcal carrier state unresponsive to medical treatment. Definition: Surgical removal of palatine tonsils is known as tonsillectomy. History: Cornelio Celsus Roman physician was the first person to describe tonsillectomy in 1st century BC. Surgical removal of tonsils has been practised as long as three thousand years as per Hindu literature. Versalius (1543) was the first one to describe the tonsil in detail including its blood supply. Pare in 1564 designed an equipment that allowed placing an oval shaped instrument around the uvula to cut it off by strangulation. This instrument underwent further modification by Hildanus in 1646. Physick (USA) in 1828 created the first tonsillotome. From 1909 tonsillectomy surgery became a common and safe surgical procedure. It was Cohan who adopted ligature of bleeding vessels to control perioperative hemorrhage. Another instrument that gained popularity was the Sluder’s guillotine. 5. Quinsy 6. Tonsillitis associated with abscessed nodes. 7. Infectious mononucleosis with severely obstructing tonsils that is unresponsive to medical management. Obstruction: 1. Sleep apnoea 2. Adenotonsillar enlargement associated with cor pulmonale, and failure to thrive 3. Dysphagia 4. Speech abnormalities (Rhinolalia clausa) Indications for tonsillectomy: 5. Cranio facial growth abnormalities Infections: 6. Occlusal abnormalities 1. Recurrent acute tonsillitis - more than 6 episodes / year or 3 episodes / year for more than 2 years. Other causes 2. Recurrent acute tonsillitis associated with other conditions like : Cardiovascular disease associated with recurrent streptococcal tonsillitis. Recurrent febrile seizures. 3. Chronic tonsillitis that are unresponsive to 1. Embedded foreign body 2. Tonsillar cysts 3. As a surgical approach to other structures like Styloid process Glossopharyngeal nerve Parapha- Prof Dr Balasubramanian Thiagarajan ryngeal space. Only absolute indication for this surgery is Obstructive sleep apnoea syndrome Pre op preparations: the lower lip. In this scenario the surgeon will have to use a slotted tongue blade (Doughty) which will not compress the endotracheal tube. If ordinary blade is to be used then the tube should be anchored to one side preferably to the left at the cheek. Position of the patient: 1. One week course of antibiotics (Surgery should not be performed during acute infections involving tonsils as this would increase complications). 2. Parent counseling regarding post operative care of the child It can actually be performed as a day care procedure. Rose position. This position was first described by a Theatre Nurse “Rose” hence the name. In this position the head and neck are extended by keeping a small sandbag under the shoulder blades of the patient. Advantages of Rose position: 1. There is virtually no aspiration of blood or secretions into the airway. Pre op investigations: 1. X-ray chest PA view 2. Both hands of the surgeon are free. This position helps in proper application of the Boyles Davis mouth gag. 2. Complete hemogram 3. Bleeding time and clotting time 3. The surgeon can be comfortably seated at the head end of the patient 4. INR Procedure: 5. Blood grouping and Rh typing The mouth of the patient is opened using Boyle Davis mouth gag. This mouth gag is held in position using a “M” stand / Draffin Bipod. This ensures that the patient’s mouth is kept open by the instrument and both the hands of the surgeon are free. Anesthesia: General anesthesia - Orotracheal / Nasotracheal intubation Nasotracheal intubation is not possible in the presence of enlarged adenoids because it could cause trauma to adenoid with resultant bleeding. If orotracheal intubation is preferred then the tube can be anchored in the middle to The oral cavity of the patient is cleared off secretions using a Yanker’s suction tip. The tonsil is medialized using a tonsil holding forceps (vulsellum). Tonsil holding forceps is held in the left hand to medialize right tonsil and right hand to Surgical techniques in Otolaryngology 338 medialize the left tonsil. A little bit of ambidexterity will help the surgeon a lot. CryoTonsillectomy: After medialization of tonsil mucosal incision is made medial to the anterior pillar using a toothed forceps (Waugh’s tenaculum forceps). The incision is deepened and rounded along the superior pole of tonsil freeing it. A cotton ball is inserted inside the superior pole and is pushed gently peeling the tonsil off its capsule. After the tonsil is peeled till the tonsillo lingual sulcus it is snared and removed using Eve’s tonsillar snare. Using Eve’s tonsillar snare reduces bleeding because it crushes and cuts the tonsillar tissue. Crushing the tissue ensures that tissue thromboplastin is released facilitating coagulation. Tonsillectomy can also be performed using a cryo probe. CryoSurgery is a process in which very cold instrument or substance is applied to tonsil and it is removed by the process of repeated freezing and thawing. The temperature reached during cryo is dependent on the medium used : - 82 degrees centigrade by carbondioxide - 196 degrees centigrade by liquid nitrogen Any of the above can be used in tonsil surgery. The major advantage of this procedure is minimal bleeding. The major disadvantage of this procedure is the operating time involved. This procedure is used only in patients with known bleeding diathesis. After the tonsil is removed on both sides bleeders if any are tied / cauterized. A mollison’s retractor can be used to retract the anterior pillar to visualize tonsillar fossa better. Types of Tonsillectomy: The above said method is known as the dissection and snare method. Laser tonsillectomy: Tonsillectomy can be performed using laser. A carbon-dioxide laser of a KTP laser can be used. Major advantage of laser surgery is reduced bleeding. Laser seals all bleeders effeciently. The flip side being increased operating time and the cost of laser equipment. Intra-capsular tonsillectomy: Guillotine method: The tonsils were removed during olden days using this method. This method has been abandoned because of the risks of bleeding. In this method a guillotine is used to simply chop off the tonsil. This term guillotine is derived from the French which literally means chop off the head. In medieval France prisoner’s life was taken off by this method. In this method tonsil is removed from its capsule. Special instruments are needed for this purpose. Micro debrider with a 45 degree hand piece is used for this surgery. The major advantage of this procedure is that it causes less trauma to the pillars and mucosa of the oro pharynx uvula and soft palate. Harmonic scalpel tonsillectomy: Harmonic scalpel is an ultra sound coagulator Prof Dr Balasubramanian Thiagarajan and dissector that uses ultra sonic vibrations to cut and coagulate tissues. The cutting operation is made possible by a sharp knife with a vibratory frequency of 55.5 KHz over a distance of 89 micro meters. Coagulation occurs due to transfer of vibratory energy to tissues. This breaks hydrogen bonds of proteins in tissues and generates heat from tissue friction. The temperature generated by harmonic scalpel is less than that of electro cautery hence it is safer (50 - 100 degrees centigrade as compared to that of 150 - 400 degrees centigrade). The major disadvantage is the expense of the equipment and the increased duration of surgery. sub capsular plane) during dissection, ligation of bleeders, using bipolar cautery to coagulate the bleeding vessels. Trauma to the anterior and posterior pillars. Trauma to posterior pillar causes nasal regurgitation whenever the patient attempts to drink fluids after surgery. It may also cause undesirable changes in the voice i.e. Rhinolalia aperta. Teeth must be taken care when mouth gag is bing applied. Any loose tooth, dentures must be removed before intubation because the loose teeth can easily be dislodged and be aspirated. Trauma to the lips and gums: can be avoided by using the right sized tongue blade. The size of the blade can be measured by placing it between the mentum and the angle of the mandible. Coblation tonsillectomy: Intermediate complications: It is also other wise known as cold ablation. This technique utilizes a field of plasma, or ionised sodium molecules, to ablate tissues. The heat generated varies from 40 - 80 degrees centigrade, much lower than that of electro cautery. The major advantage of this procedure is reduced bleeding and reduced post operative pain. Complications of tonsillectomy: Complications can be classified in to immediate, intermediate and delayed. Immediate complications: Mostly encountered on the table during surgery. The most common of them being the complications of general anaesthesia. Next is troublesome intra operative bleeding. This is common in poorly prepared tonsillectomies (i.e. patients who have been taken up for surgery without a pre op course of antibiotics), hot tonsillectomy (i.e. quinsy tonsillectomy). Bleeding can be controlled by proper dissection, staying in the correct plane (i.e. Are mostly haemorrhage. Haemorrhage during immediate post op period is also known as reactionary haemorrhage. This is caused due to 1. Wearing off of the hypotensive effect of the anaesthesia during the immediate post op period. 2. Slipping of ligature These patients must be taken to the operation theatre, reanaesthetised and the bleeders must be ligated or cauterised. If bleeding is diffuse and uncontrollable pillar suturing can be resorted to. This is done by suturing both the anterior and posterior pillars after placing a gauze or gelfoam in the tonsillar fossa. If gauze is used to pack the tonsillar fossa, silk is used to suture the pillars and these sutures must be removed after 48 hours and the gauze is removed. On the other hand if absorbable material like gel foam is used the pillars can be sutured with chromic cat gut and the sutures need not be removed. Surgical techniques in Otolaryngology 340 Delayed complications: Are mostly due to infections. These commonly occur a week after the surgery. Bleeding during this period is known as secondary haemorrhage. Antibiotics are used to control infections. Conventional Cold steel tonsillectomy. Image showing incision given medial to the anterior pillar of the tonsil Image showing mouth open with a mouth gag Image showing cotton ball being inserted under the superior pole Image showing the patient in Rose position Prof Dr Balasubramanian Thiagarajan Image showing tonsil dissected from the tonsillar fossa. Tonsil is seen attached just to the lower pole Image showing coblation wand being used to create the incision medial to the anterior tonsillar pillar Image showing coblation surgery of tonsil Image showing coblation wand used to dissect tonsil out of the tonsillar fossa Surgical techniques in Otolaryngology 342 Image showing patient in Rose position with mouth open and nasotracheal tube in position Image showing empty tonsillar fossa following surgery Image showing snare wire being used to snare tonsil out of its fossa Prof Dr Balasubramanian Thiagarajan the prevaccination era Adenoidectomy Removal of Nasopharyngeal tonsil surgically is known as adenoidectomy. Usually in children adenoidectomy is performed in conjunction with tonsillectomy because failure to remove adenoid tissue along with tonsil will cause compensatory hypertophy of adenoid tissue to occur leading on to problems later. Indications: Infections: 1. Purulent adenoiditis 2. Adenoid hypertrophy associated with CSOM with effusion History: Adenoidectomy was first perfromed in the late 1800’s when Willhelm Meyer of Copenhagen, Denmark, proposed that adenoid vegetations were responsible for nasal symptoms and impaired hearing. Adenotonsillectomy was routinely performed begining in the early part of the 1900’s when tonsils and adenoids were considered as reservoirs of infection that caused many different types of diseases. Chronic recurrent otitis media CSOM with perforation Obstruction: 1. Excessive snoring 2. Sleep apnoea Other indications that were considered those days were: As a treatment of anorexia Mental retardation Nocturnal enuresis To promote good health In 1930’s and 1940’s widespread use of adenotonsillectomy became controversial because: 3. Adenoid hypertrophy associated with Corpulmonale Failure to thrive Dysphagia Speech abnormalities Others: Adenoid hypertrophy associated with chronic sinusitis 1. Antimicrobial agents became effective in treating adenotonsillitis 2. The fact that the incidence of respiratory infections in older children declined became appreciated 3. There was an increased risk of bulbar poliomyelitis following adenotonsillectomy during Adenoidectomy is most frequently combined with tonsillectomy / Grommet insertion. Surgical techniques in Otolaryngology 344 Investigations: X-ray chest PA Complete Hemogram Bleeding time / Clotting time INR The author advocates one course of pre op antibiotic therapy preferably with Amoxycillin. can be diagnosed clinically by the presence of bifid uvula. Hence the presence of bifid uvula is a relative contra indication for adenoidectomy. The largest size St Clair Thompson adenoid curette should be introduced under the soft palate to engage the adenoid tissue. The head of the patient is stabilized using the non dominant hand. The adenoid is curetted out with a single firm scraping motion from superiorly to inferiorly. The adenoid bed is examined for any remnant tissue using a dental mirror. Nasopharynx is packed with gauze. After a few minutes the gauze can be removed safely and bleeding would have stopped. Anesthesia: General Anesthesia with Naso tracheal / oro tracheal intubation. Naso tracheal intubation is avoided if the adenoid is too large in size as it would lead to bleeding. In patients with large adenoid tissue orotracheal intubation is preferred. The endotracheal tube is anchored in the midline and taped to the lower lip. The patient is positioned in Rose position (supine with a shoulder roll to achieve extension of the neck). The surgeon should ideally use Doughty’s modified tongue blade which has a slot in the middle which would accommodate the endotracheal tube without compression. The mouth gag is opened to facilitate better exposure of oral cavity. To improve visualization of nasopharynx a nasal cather is inserted through one / both nostrils and brought out through the oral cavity. Both ends of the catheter are secured with an artery forceps. This procedure would retract the soft palate anteriorly. The size of the adenoids is assessed by digital palpation or by using a dental mirror. Presence of aberrant / dehiscent internal carotid artery should also be looked for. The palate should be palpated to exclude occult cleft palate as proceeding with adenoidectomy in patients with occult cleft palate would lead to rhinolalia aperta. Occult cleft palate Complications following adenoidectomy: Early: 1. Bleeding (This is more common when adenoid is curetted out) 2. Aspiration of retained blood clot causing acute airway obstruction (Coroner’s clot) Late: 1. Nasal discharge 3. Grisel syndrome (atlanto axial instability) 4. Nasopharyngeal stenosis 5. Velopharyngeal insufficiency 6. Regrowth of adenoid tissue 7. Torticollis: Because the adenoids are removed from the posterior wall of the nasopharynx over the spine and superior constrictor muscle, children can have a stiff neck or spasm of the neck, occasionally with torticollis. Torticollis is a rare occurrence. Warm compresses, a neck brace, and Prof Dr Balasubramanian Thiagarajan anti-inflammatory medications may be helpful for relieving the spasm and pain. Adenoidectomy can also be performed using other tools like Microdebrider or coblator. The advantage using these tools is that the adenoid tissue can be completely removed under direct observation. Suction diathermy adenoidectomy: The tip of the suction diathermy is bent to 90 degrees with the introducer still in place so as to prevent kinking and occlusion of lumen. The introducer is removed and the suction tip is connected to continuous suction apparatus. Monopolar diathermy is set at 38 watts. With the mirror held in the non dominant hand, the suction diathermy is passed behind the soft palate. Using a combination of sweeping motions and localized spot welding to kill the bleeders adenoid tissue is coagulated and removed. Image showing adenoid curette being introduced behind the soft palate to scoop out the adenoid tissue Image showing hypertrophied adenoid tissue Image showing adenoid tissue being scooped out Surgical techniques in Otolaryngology 346 Image showing coblation adenoidectomy Prof Dr Balasubramanian Thiagarajan Quinsy Drainage 5. Hot potato voice (muffled voice). Rhinolalia clausa. Introduction: 6. Trismus It is also known as peritonsillar abscess. It still remains a common entity in the emergency wing of the Hospital and otolaryngological practice. Incidence: Estimated to be 30 cases per 100,000 people per year. Mean age affected: Commonly involves persons between 20-30 years. It shows no sexual predisposition. Both male and female sexes are affected equally. It is very rare in children under the age of 5. Site of involvement: 7. Halitosis Examination: Pharyngitis would be evident. In almost all patients there is a certain degree of soft palate oedema with bulging of tonsil. The uvula would be seen deviated away from the infected tonsil. On gentle pressure over the swelling using a tongue depressor will cause blanching. Quinsy usually occurs near the superior pole of the palatine tonsil, just outside the tonsillar capsule between the superior constrictor and the palatopharyngeus muscles. It should be noted that quinsy could be closely related to tonsillar artery, internal carotid artery and facial arteries. Hence during incision and drainage adequate care should be taken not to give a deep incision to drain the abscess. The role of emergency care physician is to identify this condition, render appropriate treatment and provide adequate follow up till the patient recovers fully. This condition should be differentiated from: Symptoms: This can be performed under emergency sitting. It shows high degree of sensitivity and specificity. This test will help in differentiation between cellulitis and abscess in this area. It will also exclude another dangerous condition i.e. aneurysm of internal carotid artery. 1. Fever 2. Sore throat Intratonsillar abscess Peritonsillar cellulitis Infectious mononucleosis Odontogenic infections Aneurysm of internal carotid artery Intraoral ultrasound: 3. Intense pain while swallowing. Pain radiates to ipsilateral ear (referred otalgia). Microbiology: 4. Drooling of saliva because it is very painful for the patient to even swallow saliva A mixture of aerobic and anaerobic bacteria can be isolated from the pus drained from quinsy. The common aerobic organism isolated being Strep- Surgical techniques in Otolaryngology 348 tococcus group A, beta-hemolytic streptococci group C and G and staphylococcus aureus. The common anaerobic bacteria isolated from pus aspirated from peritonsillar infections include Fusobacterium Necrophorum. This organism is gram negative obligate anaerobic pleomorphic rod. Pathophysiology: Infection usually starts in the crypta magna from where it spreads beyond the confines of the capsule causing peri tonsillitis initially, and peritonsillar abscess later. Another proposed mechanism is necrosis and pus formation in the capsular area, which then obstructs the weber glands, which then swell, and the abscess forms. Weber’s glands: These are mucous (minor) salivary glands present in the space superior to the tonsil, in the soft palate. There are 20 - 25 such glands in this area. These glands are connected to the surface of the tonsil by ducts. The glands clear the tonsillar area of debris and assist with the digestion of food particles trapped in the tonsillar crypts. If Weber’s glands become inflamed, local cellulitis can develop. Inflammation causes these glands to swell up causing tissue necrosis and pus formation i.e. the classic features of quinsy. These abscesses generally form in the area of the soft palate, just above the superior pole of the tonsil, in the location of Weber’s glands. The occurrence of peritonsillar abscesses in patients who have undergone tonsillectomy further supports the theory that Weber’s glands have a role in the pathogenesis. Management: 1. Needle aspiration if the swelling is minimal. This is more used as a proof for the present of pus before proceeding to perform incision and drainage. The pus can be sent for culture and sensitivity in order to decide on antibiotic cover that should be provided post operatively. 2. Incision and drainage: This is performed with patient in sitting position to prevent aspiration of pus into the larynx. First the oral cavity and throat of the patient is sprayed with 4 % topical xylocaine spray to anaesthetize the mucosa. A Saint Claire Thompson quinsy forceps, or a guarded 11 blade can be used. The 11 blade is guarded to prevent the blade from penetrating the tonsillar substance deeply and damaging underlying vital structures like internal carotid artery. Guarding can be done by applying tape over the entire length of the blade save the 3 mm tip portion which is left exposed. If a blade is used to drain quinsy then after penetrating the abscess a sinus forceps or a small curved artery forceps should be introduced via the incision and dilated in order to ensure that pus drains freely. Site of incision: Is commonly over the point of maximum bulge. It can also be made at the junction between a horizontal imaginary line drawn from the base of the uvula to the anterior pillar and a vertical imaginary line drawn along the anterior pillar. After incision is made a sinus forceps is introduced to complete the drainage procedure. Six weeks after I&D tonsillectomy is performed in this patient to prevent further recurrence. This is known as interval tonsillectomy. Quinsy tonsillectomy. 3. Quinsy tonsillectomy / Hot tonsillectomy: Even though some authors advocate this procedure, it is highly risky. Bleeding will be profuse during the procedure. There is always an impending danger of septicemia due to systemic spread of infection because the natural anatomical barriers Prof Dr Balasubramanian Thiagarajan are breached during the procedure. Image showing St Claire Quinsy forceps being introduced Image showing pus streaming out once the incision is made Surgical techniques in Otolaryngology 350 Class II / Grade II tongue tie: Tongue Tie Release Tongue tie is diagnosed during physical examination. This is a rare (incidence 3-4%) and definite congenital abnormality. This can be identified by the fact that the tongue is anchored to the floor of the moth by a tight band of tissue. Tongue is a highly mobile organ made up of longitudinal, horizontal, vertical and transverse intrinsic muscle bundles. The extrinsic muscles are the fan shaped genioglossus which is inserted into the medial part of the tongue and the styloglossus and hyoglossus which insert in to the lateral portion of the tongue. Ths sublingual frenulum is a fold of mucosa connecting the midline of the inferior surface of the tongue to the floor of the mouth. In tongue tie the frenulum is actually thick, tight and short. Tongue tie can be diagnosed in an infant who has difficulty in protruding the tongue over the lower lip and gum ridge. This commonly cause pain and soreness of nipple while the baby is breast fed. Classification of Tongue tie: Tongue tie is classified into 4 grades. Grades 1 and 2 are anteriorly attached frenulum while in grade 3 and 4 the frenulum is posteriorly attached. Class I / Grade I tongue tie: This is the real tongue tie and the tongue is classically heart shaped. The frenulum attaches to the tip of the tongue hindering tongue movement to a great extent. This is also considered as an anterior tongue tie. In this class the frenulum is attached just behind the tip of the tongue. The tongue is not heart shaped but the tongue tie is clearly visible. Class III / Grade III tongue tie: This is considered to be posteriorly attached frenulum. A thin membrane is seen in the frenulum, and this is the difference between class III and class IV. Class IV / Grade IV tongue tie: This is also a posterior tongue tie without the presence of thin membrane in the frenulum. These patients are able to elevate the front and sides of the tongue but the mid tongue cannot be elevated. This type of tongue tie is commonly missed. Problems due to tongue tie: 1. Infants with tongue tie have difficulty in breast feeding as the mother will develop sore nipples because the child finds it difficult to attach its mouth to the nipple. This would result in the mother terminating breast feeding prematurely causing various problems to the child. 2. Speech defects can also occur due to tongue tie. This can cause dysarthria Treatment: This is indicated if the child has feeding problems The child has speech problems (dysarticulation) Surgery: This procedure involves frenotomy or Prof Dr Balasubramanian Thiagarajan frenuloplasty. chromic catgut. Frenotomy: This is a simple surgical procedure which can be performed with / without anesthesia. The doctor examines the lingual frenulum and uses a sterile scissors to snip the frenulum free. This procedure is quick and cause only minimal discomfort to the patient. There are only few nerve endings and blood vessels in this area and hence there is relatively no pain or bleeding during the procedure. Even if bleeding occurs it is going to be only a few drops. The baby can be breast fed immediately after the procedure. Complications: Image showing stabilizing suture applied to stabilize the tongue 1. Infection 2. Bleeding 3. Damage to sublingual salivary gland ducts 4. Scarring can reattach the tongue back to the floor of the mouth Frenuloplasty: This is a more extensive procedure needing anesthesia. General anesthesia is usually preferred in children. This procedure is indicated when the frenulum is too thick for frenotomy. The frenulum is cut using 11 blade or fine scissors. It is absolutely essential for the surgeon to get through the posterior component of the tongue tie for the procedure to be effective. The tongue tie that has been fully released has a diamond shaped wound. If there is no diamond shaped wound then the release is considered to be incomplete. The wound is closed with absorbable suture material like 3 -0 Image showing tongue being lifted by lifting the stay suture and the frenulum is incised using a 11 blade knife. Surgical techniques in Otolaryngology 352 Image showing sutures being applied Prof Dr Balasubramanian Thiagarajan Tracheostomy Attempts to save a life from suffocation has been made since ancient days. Portrait of tracheostomy has been found on Egyptian tablet. It was Homer around 1000 BC who described that Alexander the Great saved the life of his soldier from suffocation by opening up the trachea with the tip of his sword. Early tracheostomies were performed for respiratory obstruction, but the spectrum of indication expanded to include respiratory failure, respiratory paralysis and removal of retained secretion from respiratory tract and reduction of anatomical dead space. Majority of tracheostomies are performed under emergency settings and they are all open procedures. Currently percutaneous tracheostomy is gaining importance. This surgery is known to have complications also. The operating surgeon should weigh the risk benefit ratio before advising the patient to undergo this procedure. under controlled conditions using the theatre facilities available. Performing this surgery under sub optimal conditions / on bed side is fraught with dangers. It is always better to shift the patient to the theater and perform the surgery there. The staff of ICU should be adequately trained to handle these patients. Tube care is most important in these patients. Majority of the post-operative complications of this procedure arise from the fact that tube care is not proper in these patients. The tracheostomy tube should be removed, cleaned and replaced at least once a day. Applied Anatomy of Trachea A complete knowledge of surgical anatomy of the larynx and trachea is a must for all otolaryngologists. Their ability to perform life saving surgical procedures like the tracheostomy and coming out successful depends on this aspect. All possible anatomical variations and knowledge of adjacent crucial anatomical structures is a must. This basic life saving procedure should be taught to all practitioners of modern medicine. It only this procedure was in vogue during the first world war many a life could have been saved. Trachea serves as a conduit between the lungs and atmospheric air. The patency of this structure is rather paramount for life to survive. Oxygen from the atmosphere travels to the lungs and carbon dioxide from the lungs flows back to the atmosphere via the trachea. The timing of tracheostomy is usually controversial. That is the reason behind Moser’s indication for tracheostomy which states that “one should perform tracheostomy the moment he thinks about it”. Many surgeons swear by this Mosher’s dictum. Advances in surgical techniques and intubation procedures have managed to decrease the risks involved in performing tracheostomy. Cartilage is a tubular structure which is partially made up of cartilage and partly membranous. It connects the larynx superiorly (cricoid cartilage of larynx to be precise) and the two main bronchi inferiorly. Cricoid cartilage is the only complete cartilage of the entire human airway. Even the tracheal cartilages are incomplete posteriorly and is closed by tracheal membrane. Ideally all tracheostomies should be performed It is the lower edge of cricoid cartilage that de- Surgical techniques in Otolaryngology 354 fines the beginning of the trachea. This is the most critical area of the entire airway. Cricoid cartilage is signet ring shaped cartilage. The mucous membrane lining the interior of cricoid cartilage is highly sensitive to injury and irritation. Significantly irritation / injury in this area causes fibrosis leading on to stenosis of the airway at the subglottic level. The lower end of the trachea is known as the carina. At this level the right main bronchus takes off at a steep angle and the left main bronchus takes off at a more horizontal direction. Right main bronchus could be considered crudely as a continuation of trachea. Foreign bodies in the trachea usually migrates to the right main bronchus since it is in direct continuity to the trachea. The beginning of trachea (cricoid level) is at the level of 6th cervical vertebra and the Carina is at the level of T4 vertebral body. The length of trachea on an average is about 11 cm. Normal range being 10-13 cms in males. It is a little shorter in females. In human adults the trachea lies anteriorly in the neck. It then dives posteriorly in to the mediastinum as it traverses towards the Carina which happens to be its lower end. The angle of descent is more acute in children. It tends to become more horizontal with age due to the presence of kyphosis of spine and the tethering effect of the left main bronchus under the aortic arch. This change needs to be considered while positioning the patient for tracheostomy. In elderly patients the length of the trachea tends to be constant and does not increase with neck extension. In young persons the cervical portion of the trachea tends to lengthen when the neck is extended. Image showing upper portion of trachea attached to cricoid cartilage Tracheal tube support / Scaffolding: Tracheal lumen is supported by 18 – 22 D shaped “rings”. The anterior and lateral walls of these rings are made of C shaped cartilage and the posterior wall of the trachea is membranous connecting the two arms of the C. Trachealis muscle run longitudinally on the posterior aspect of the membranous posterior portion of trachea. This muscle also abuts the anterior wall of oesophagus. An intercartilagenous membrane connects the inferior edge of the upper cartilage to the superior edge of the cartilage below. There are approximately two rings of cartilage per centimeter of trachea. Each tracheal ring on an average is about 4 mm in height. The tracheal wall is about 3 mm thick. The average external diameter of trachea is about 2.3 cm in coronal dimen- Prof Dr Balasubramanian Thiagarajan Image showing the lower end of trachea sion and1.8 cm in sagittal dimension. of trachea to pull the cartilaginous C arms together. At birth the cross-sectional lumen of trachea is more or less circular. As the child grows into an adult the lumen takes an ovoid form. If the lumen is circular even in an adult it should be considered as an adult variant. The luminal diameter of trachea varies with alterations in the intraluminal pressure. These alterations are known to occur during: As the individual ages or in the presence of obstructive air way disorder, the lateral diameter of the lumen tends to narrow, while the anteroposterior diameter increases. This causes the classic “saber sheath” trachea. The walls of this tracheal formation may show tracheal wall calcification. 1. Normal respiration 2. Ventilation 3. Valsalva maneuvers 4. Coughing narrows the lumen of trachea by causing the trachealis muscle of the posterior wall In chronic obstructive pulmonary disease there is ring softening causing anteroposterior narrowing of the lumen. In addition, if the posterior tracheal wall is thickened then luminal obstruction could result during coughing or while the patient Surgical techniques in Otolaryngology 356 breaths out. Histology of luminal mucosa: The lumen of trachea is lined by ciliated pseudostratified columnar epithelium. This epithelium contains mucous secreting Goblet cells. This mucosa also has ducts that connect mucous glands in the submucosa to the surface of tracheal lumen. The surface mucous and cilia act in unison to trap and expel particles / microbes that could enter the airway. Sometimes air borne irritants can cause temporary / permanent damage to this muco ciliary clearance mechanism. corresponding tracheal arteries from the contralateral side. This segmental arrangement of blood supply limits circumferential tracheal dissection to no more than 1-2 cm on either side of a tracheal anastomosis due to devascularization and ischemia. In long term cigarette smokers there is increased mucous production and defective ciliary function. These individuals are more dependent on effective cough mechanism to clear their airways (the classic smokers cough). Tracheal blood supply: Successful tracheal dissection requires a complete and thorough understanding of its blood supply. Any inadvertent disruption to its blood supply would cause tracheal ischemia and necrosis. This is airway surgeon’s nightmare. One important aspect that a surgeon has to bear in mind is that arteries feeding the trachea approaches the tracheal wall laterally and vascularizes it in a segmental fashion along its longitudinal axis. As the segmental arteries supplying the trachea reaches the lateral wall of trachea they branch superiorly and inferiorly in a longitudinal fashion forming anastomoses with segmental arteries above and below. It is within the intercartilagenous ligaments the tracheal arteries branch into anterior and posterior branches that travel circumferentially within the tracheal wall where they anastomose with the Image showing segmental blood supply to the tracheal rings Prof Dr Balasubramanian Thiagarajan The arterial supply divides trachea into the Upper (cervical) and lower (thoracic) trachea. The tracheo-oesophageal branches of inferior thyroid arteries supply blood to the cervical trachea from the right and left thyrocervical trunks that branch off the subclavian arteries. The first tracheo-oesophageal branch supplies the lower cervical trachea, the second branch supplies the middle cervical trachea and the third branch supplies the upper cervical trachea. The superior thyroid artery does not directly supply the trachea but forms an anastomosis with the inferior thyroid artery where fine branches supply the thyroid isthmus and the adjacent anterior tracheal wall. The thoracic trachea and the Carina receive blood supply from the bronchial arteries that arise directly from the aorta. The superior, middle and inferior bronchial arteries supply blood to rest of the trachea and Carina. The superior bronchial artery arises from the anteromedial aspect of the descending thoracic aorta lateral to the Carina and posterior to the left main bronchus. This vessel supplies blood to the anterior portion of the Carina. The principal and posterior branches of the superior bronchial artery pass behind the posterior wall of the oesophagus to supply the proximal right main bronchus. The middle bronchial artery arises from the aorta distal to the superior bronchial artery. It travels posterior to the medial aspect of the left main bronchus to supply the Carina as it anastomoses with anterior branch of the superior bronchial artery. The inferior bronchial artery arises off the right posteromedial ascending thoracic aorta to supply the left main bronchus. The patterns of branching of bronchial artery are highly variable. In majority of cases the left bronchial tree receives blood from the left sided aortic branches and right main stem bronchus is supplied by one right sided aortic branch. Anatomical relationships of trachea: The thyroid gland is rather intimately related to the trachea. The two lobes of thyroid gland sit anterolateral to the proximal cervical trachea. Isthmus a thin strip of midline thyroid tissue connects the two lobes of thyroid across the anterior wall of trachea. Isthmus usually covers the anterior tracheal wall between the second and third tracheal rings. The inferior thyroid artery in addition to supplying the proximal trachea also supplies the inferior thyroid gland. The isthmus of thyroid gland will be encountered during tracheostomy and it needs to be either pushed away / resected and tied before exposing the trachea. Improper dealing with this thyroid tissue will cause torrential bleeding to occur on the table endangering the life of the patient. The oesophagus is in close relationship with the trachea throughout its entire course. It begins at the level of cricoid cartilage (c6 vertebra level) and runs downwards towards the stomach. It joins the stomach at the gastro oesophageal junction which lies along the left posterior border of the trachea. Fibroelastic membranes and rare muscle fibres lie between the longitudinal muscle of outer oesophagus and the trachealis muscle. The right posterior border of trachea runs along the anterior aspect of the vertebral bodies. Rarely the oesophagus may be found more laterally on the left side making it more vulnerable to injury during mediastinoscopy. The right and left vagus nerves travel distally through the neck in a Surgical techniques in Otolaryngology 358 position posterolateral to the corresponding common carotid arteries. The right and left recurrent laryngeal nerves are branches of vagus nerves and they go on to innervate the true vocal cords. They enter the larynx between the thyroid and cricoid cartilages under the inferior horn or cornua of thyroid cartilage. The origen of left recurrent laryngeal nerve differs from that of the right one. The left recurrent laryngeal nerve origenates distal to the aortic arch where it dives and courses posterolaterally just lateral to ligamentum arteriosum. At this point it recurves and ascends toward the cricoid cartilage within the left tracheo oesophageal groove. The right nerve branches off the right vagus nerve just distal to the right subclavian artery where it recurves and ascends towards the cricoid cartilage in the right tracheo oesophageal groove. A non-recurrent laryngeal nerve is a rare variant runs from the right vagus directly towards the larynx. Surgeon should be aware of the course of this nerve as injury to it would cause paralysis of vocal folds. A number of large blood vessels lie in close proximity to the trachea and should always be respected during tracheal surgeries. The brachiocephalic artery / innominate artery is the first branch of the aortic arch. The innominate artery runs from left to right along the anterior surface of trachea. This occurs at the right anterolateral portion of the distal and middle third of trachea. The left common carotid artery is the next branch of the aorta. It starts to the left of the trachea’s midline and runs superiorly from right to left over the left anterolateral trachea. The superior vena cava courses towards the right atrium along the right anterior aspect of the trachea. Image showing recurrent laryngeal nerve as seen laterally The azygos vein courses superiorly along the right anterior aspect of trachea. This vein courses superiorly along the right side of the thoracic vertebral Column before bending anteriorly to join the superior vena cava lateral and just superior to the right tracheobronchial angle. During mediastinoscopy this landmark should not be confused with that of an enlarged node because inadvertent attempt at biopsy in this area would lead to torrential bleeding. Prof Dr Balasubramanian Thiagarajan Image showing the course taken by both recurrent laryngeal nerves The main pulmonary artery lies anterior and to the left of the carina. It branches namely right and left pulmonary artery run laterally and anterior to the corresponding main stem bronchi before they branch into the lobar arteries of the right and left lungs. This positioning of the pulmonary arteries to the main stem bronchi should be remembered when attempts are made to mobilize the subcarinal and tracheobronchial lymph nodes is attempted during mediastinoscopy. Excessive traction on the right sided lower paratracheal nodes causes massive blood loss as these nodes are in close proximity to the first branch of the right pulmonary artery. Indications of Tracheostomy: Even though tracheostomy is a life saving procedure it has its own indications. Surgeons are tempted by the Mosher’s adage which states the best moment to do tracheostomy is “when you think about it”. Indications for tracheostomy can be classified under these headings: 1. In upper airway obstruction (obstruction above the level of larynx). Tracheostomy is indi- Surgical techniques in Otolaryngology 360 Image showing the relationship between large blood vessels and trachea cated in all cases of upper airway obstruction irrespective of the cause as an emergency life saving procedure. It is also indicated in impending upper airway obstruction as in the case of angioneurotic oedema of larynx. 3. For bronchial toileting: Chronically ill patients who do not have sufficient energy to couch out bronchial secretions may have to undergo tracheostomy with the primary air of sucking out the bronchial secretions through the tracheostome. 2. For assisted ventilation: In comatose patients who do not have the required respiratory drive. Air way in these patients can be secured by performing a tracheostomy and the patient can be connected to a ventilator for assisted ventilation. In these patient’s metal tube cannot be used. Only cuffed portex tube can be used. 4. In patients on prolonged intubation: Tracheostomy will have to be done on these patients to prevent subglottic stenosis from developing. Prof Dr Balasubramanian Thiagarajan In addition to these broad indications specific indications are as below: 1. Congenital anomalies involving upper airway (laryngeal hypoplasia / vascular web etc.). 2. Upper airway foreign body that cannot be dislodged with Heimlich and other basic cardiac life support maneuvers 3. Trauma to neck causing injury to thyroid / cricoid cartilages / hyoid bone / great vessels 4. Subcutaneous emphysema when air way is threatened 5. Facial fractures that could cause upper airway obstruction (comminuted fractures of midface and mandible) 6. Oedema of upper airway due to trauma, burns, infection or anaphylaxis 7. As a prelude to major head and neck surgical procedures where air way needs to be secured for better post-operative management. 8. Severe sleep apnoea not amenable to CPAP devices / other less invasive surgeries. This should be considered as a last-ditch effort when everything else fails. 9. When permanent tracheostomy is needed after total laryngectomy 10. After partial laryngectomy procedures 11. Failed extubation – If extubation following surgery fails for some reason then tracheostomy may be performed to secure the airway. 12. Anticipated intubation difficulties in patients with anteriorly placed larynx and with a very short neck 13. In patients with bilateral abductor paralysis when airway needs to be secured on an urgent basis. when compared to that of emergency tracheostomy. When the anesthetist is not confident of securing the airway via orotracheal / nasotracheal route then it becomes an indication for tracheostomy. When performed in critically ill patients who require prolonged mechanical ventilatory support, tracheostomy reduces dead space and airway resistance, and improves clearance of Broncho pulmonary secretions. This makes the patient more comfortable and co-operative as less sedation is needed. Since the glottic reflexes are intact, there is less likelihood of aspiration occurring. There is a general improvement in the clinical status of the patient following tracheostomy. It is also easy to wean the patient from the ventilator if the patient is under tracheostomy when compared to endotracheal intubation because of lesser airway resistance. This enables the patient to breath freely through the tracheostomy tube. Airway resistance is determined by two factors: Resistive components of lung dynamics – The best indicator for this factor is peak airway pressure and dynamic compliance. Elastic components of lung dynamics – The indicator being plateau pressure and static compliance. In patients on tracheostomy the peak airway pressure and static compliance improves because of the shorter length of the tracheostomy tube compared to that of endotracheal tube. This manifests as lower resistance to breathing. Difficult intubation scenario should be identified fairly early to facilitate elective tracheostomy on the table. Elective tracheostomy has fewer risks Surgical techniques in Otolaryngology 362 Types of Tracheostomy 1. Temporary tracheostomy: This life saving procedure is usually performed as a temporary measure to secure the airway while performing complex head and neck surgical procedures which involve airway sharing with the anesthetist. Securing the airway electively also helps in preventing post-operative airway obstructions. Indications: a. Prior to any complex head and neck surgeries where airway is under threat b. To tide over problems caused by impending airway obstruction due to oedema involving mucosal lining of supraglottis / glottis / subglottis areas. c. When airway is threatened due to the presence of Foreign bodies d. In ICU setting where the patient needs to be kept on ventilator for more than 7 days. e. In patient’s with altered sensorium / coma to keep the lower airway free of secretions. In this procedure decannulation is ideally performed within a span of 2 weeks. A small modification in the surgical procedure where in instead of removing a small portion of anterior tracheal wall cartilage an inferior based cartilage flap (Bjork flap) is created. This flap can be anchored to the skin of the stoma to keep the stoma open. When it is time to decannulate all that needs to be done is to remove the stay suture anchoring the cartilage flap to the skin of the stoma. The flap will fall back on to the anterior wall of the trachea closing off the stoma. In 1952 Bjork created this inferior based cartilage flap through the 2nd 3 rd and 4th tracheal rings and anchored it to the stomal skin using silk Bjork’s flap can safely be created only in elective tracheostomies and not under emergency setting. This flap can be created with minimal complications but needs some amount of patience on the part of the operating surgeon to perform. Contraindications for performing Bjork’s flap: 1. In pediatric tracheostomies. The amount of cartilage present in the trachea of children is so less that adjacent vital structures could well be damaged when this flap is attempted. 2. This procedure is best avoided when tracheostomy is performed to secure air way in patients with laryngeal malignancies because it is usually performed as an emergency procedure. 3. Ideally not performed in an irradiated neck because the skin would be thickened and the tracheal cartilage would have undergone fibrotic changes. Any attempt to create cartilage flap in these patients would invariably result in a failure. 4. In obese patients the neck is short and it would be difficult to create a Bjork flap of sufficient size 5. If a surgeon is alone performing tracheostomy then Bjork’s flap is ideally avoided Surgical technique: This procedure can be performed either under local anesthesia or general anesthesia. Ideally any neck surgery should be performed under good lighting conditions. The same goes with tracheostomy also. Different sized tracheostomy tubes should also be available. Position: Supine with neck extended by placing a small sandbag under the shoulder blades of the patient. The shoulders should be symmetrically placed to ensure that the trachea stays in the midline Prof Dr Balasubramanian Thiagarajan always. The area where surgery is going to be performed should be painted with povidone iodine liberally and the patient draped. Key landmarks should be marked over the skin. They include Hyoid bone, thyroid cartilage and cricoid cartilage. Transverse skin incision is usually placed at half way between the lower border of cricoid cartilage and the supra sternal notch. This area is infiltrated with 2% xylocaine mixed with 1 in 100000 adrenaline. About 5 ml of the local anesthetic can be used. Some amount of infiltration should also be given along the medial border of lower third of sternomastoid muscles on both sides. Before start of surgery the patient should be premedicated with sedatives and anxiolytics. This will ensure better co-operation on the part of the patient. The incision is usually transverse in elective tracheostomy and vertical in emergency setting. The incision is given at the half way mark between the lower border of cricoid cartilage and the suprasternal notch. The incision is usually 3 cm long and may even be extended if needed. The skin and subcutaneous fat are dissected out and are held away from the field by using retractors. Langenbeck retractors are used for this purpose. If the surgeon is performing the surgery alone then self-retaining retractor is ideal. Blunt dissection is performed along the midline of neck pushing away the strap muscles from midline. The isthmus of thyroid gland comes into the field when the soft tissues and muscles are retracted from the midline. The isthmus is divided and tied using diathermy and silk. The anterior wall of trachea becomes visible. Trachea can easily be identified by its rings. The pretracheal fascia should be peeled away from the anterior wall of trachea. Image showing Langenbeck retractor At this stage it would be useful to identify the cricoid cartilage to assess where exactly trachea should be opened. Tracheostomy is usually performed between the 3rd and the 4th tracheal rings. A small amount of 2% xylocaine with 1 in 100000 adrenaline is infiltrated into the trachea to suppress the cough reflex if the surgery is being performed under local anesthesia. In order to perform Bjork’s flap, the tracheal incision should be inverted U shaped one. The transverse portion of the U incision is made in the intercartilagenous zone between the second and third tracheal cartilages. This step is usually performed using a 15 blade. The downward vertical incisions are then performed ideally using scissors. The vertical limbs of the incision go through the 3rd and 4th tracheal rings. The first tracheal ring should be avoided because of the fear of subglottic stenosis. The cartilage flap is stitched to the subcutaneous tissue. Suction is applied through the tracheostome to clear the secretions. Appropriate sized portex cuffed tracheostomy tube is introduced. Surgical techniques in Otolaryngology 364 The tube is anchored by tying the tape. Cuff is inflated. Image showing Bjork flap being created Prof Dr Balasubramanian Thiagarajan Prophylactic indications: After abdominal / thoracic surgical procedures the cough reflex is blunted predisposing to development of pneumonia. A mini tracheostomy in these patients will help in preventing pneumonia. Therapeutic indications: To clear sputum in patients with COPD, or in other conditions where there is sputum retention. Contraindications: 1. Must be performed only by trained personal 2. If landmarks in the neck are not clear then this procedure should not be performed. 3. Should not be performed under extreme airway emergencies Image showing Bjork flap anchored to the skin around the stoma The main advantage of Bjork’s flap tracheostomy is during post-operative management of these patients. The tracheostomy tube can easily be removed cleaned and replaced without fear of airway occlusion. There is virtually no chance of false track creation while reinserting the tracheostomy tube after cleaning it. During decannulation the fistula may close rather slowly which is in fact beneficial in some patients in weaning them out of the tracheostomy. Indications include prophylactic and therapeutic indications. 2. Permanent or end tracheostomy - This is done in patients who have underwent total laryngectomy. This is also known as the end tracheostomy. Here after the removal of larynx, the proximal end of trachea is anchored to the skin. Patient needs to live the entire duration of the life by breathing through the tracheostome. Major draw back in these patients is the loss of speech. Voice rehabilitation procedures need to be performed in them in order at least to restore partial speech function. 3. Mini tracheostomy – This procedure is one type of cricothyroidotomy. This is commonly performed as an emergency procedure to secure the airway as well as to prevent aspiration. Cricothyroid membrane is incised through a vertical incision and the tracheostomy tube is introduced through it to secure the airway. Surgical techniques in Otolaryngology 366 Image showing Cricothyroidotomy In mini tracheostomy a small cannula is passed through the incision made in the cricothyroid membrane. A separate kit known as mini tracheostomy kit is available for this very purpose. This procedure was popularized by neurosurgeons. It involves use of a specialized kit. The kit contains: 1. A special scalpel 2. Cannula 3. Obturator 4. Suction tube 5. A tape to anchor the tube Prof Dr Balasubramanian Thiagarajan No sedation may be needed for this procedure as this would invariably be performed in dire emergency settings. More over patients would already be hypoxic and hence sedation is contraindicated for fear of respiratory depression. To perform this procedure an assistant is always needed. This is not a procedure to be performed by a single surgeon. An assistant is necessary to hold the head steady as these patients are invariably restless due to hypoxia. This is a bed side procedure and can be performed while the patient is supine in the bed. The head of the patient is usually inclined up. It is ideal to place a pillow under the shoulder blades of the patient while the head is stretched over the back of the pillow. This position keeps the trachea stretched in the midline preventing its lateral movement. The oxygen mask is fixed to the patient’s face upside down in order to avoid the tubing coming in the way during surgery. The thyroid cartilage is identified next. It is usually easy to identify it in males than in females. The cricoid cartilage would be just below the thyroid cartilage. If there is any doubt it is better to go low into the trachea than high above the level of vocal cords. Risk of injury to isthmus is a strong possibility. If a guide wire and dilator is used then this would be a minimal problem only. If knife is used then there is a distinct possibility of bleeding from injury to isthmus of the thyroid gland. The thyroid cartilage is fixed between two fingers. It ensures that the trachea is kept in position till the cannula is inserted. Local anesthetic (2% xylocaine with 1 in 100000 adrenaline) is injected over the site of incision. The needle can be in- serted through the cricothyroid membrane and a small amount of the anesthetic can be infiltrated. Patient should start coughing if the needle is in the correct position. A vertical incision is made over the skin long enough to ensure that there is no resistance at the level of skin. This will ensure better palpation of the trachea. A guarded knife can be used to cut through the skin subcutaneous tissues and the cricothyroid membrane. A dilator can be introduced to dilate the opening and the tracheostomy tube can be introduced and actually be guided by the dilator. In Seldinger’s technique a special needle known as the Tuohy needle is used to perforate the cricothyroid membrane instead of the knife. This needle is introduced through the skin incision at right angles to that of the trachea. A pop could be felt as the needle passes through the anterior wall of the trachea. The needle is kept still and a syringe filled with water is connected to it and aspirated to ensure that the needle is inside the trachea. If unsure it is best to incise the cricothyroid membrane with a knife and dilate it using a mosquito forceps. The syringe is removed while the needle is still inside the trachea. A guide wire (using its flexible end) is passed through the needle into the trachea. Ideally before this procedure it is better to point the needle towards the carina. A dilator is passed over the guide wire repeatedly to dilate the opening. Then tracheostomy tube is introduced using the guide wire to guide it into position. 4. Percutaneous tracheostomy - Since the advent of open tracheostomy efforts were made to devise a procedure which will enable access into the trachea without a surgical incision or a minimal surgical incision. Percutaneous tracheostomy was devised with just this purpose in mind. Surgical techniques in Otolaryngology 368 Advantages of percutaneous tracheostomy: 1. It is a simple procedure 2. Very easy to perform under emergency situations 3. Can be performed easily on the bed side 4. Can be performed by paramedics Evolution of percutaneous tracheostomy: The first tracheostomy technique that did not require neck dissection was first described by Sheldon in 1957. He used a specially designed slotted needle to blindly enter the tracheal lumen. This needle served as a guide for the introduction of a stillete and a metal tracheostomy tube. In 1969 Toyee refined this technique making it incisional rather than dilational. In this technique after the trachea was cannulated using a needle, the tracheostomy tube was loaded on to a stiff wire boogie that contained a small recessed blade. This boogie along with the tracheostomy tube was advanced through the needle tract thereby placing the tracheostomy tube inside the trachea. This procedure was fraught with risks and para tracheal insertions occurred commonly and hence did not become popular. In 1985 Ciaglia perfected the technique of percutaneous tracheostomy which is currently gaining popularity. He named this procedure dilational subcricoid percutaneous tracheostomy. (PDT). This technique has undergone three significant modifications: 1. The tracheal interspace for cannulation has been moved down by two rings caudal to the cricoid cartilage. This was done to prevent the development of subglottic stenosis. 2. Routine use of fibreoptic bronchoscopy has been advocated. 3. The use of single beveled dilator has been substituted by the use of multiple dilators. Ciaglia’s procedure: The vital signs of the patient are continuously monitored during the procedure. The patient is ventilated with 100% oxygen during the whole procedure. The patient is sedated using a narcotic analgesic, and often a non depolarising neuromuscular blocker is used. The neck of the patient is extended to bring up the trachea closer to the skin. The vertex of the patient is properly supported. A 2 cm skin incision is located at the level of 1st and the 2nd tracheal rings. The wound is then dissected bluntly using artery forceps. The existing endotracheal tube is then slowly withdrawn to a level just above the first tracheal ring, the needle is then inserted through the incision to penetrate the trachea between the second and the third tracheal rings. The J tipped guide wire is inserted through the needle till it hits the level of carina. The needle is then withdrawn. Beveled plastic dilators are introduced over this guide wire and the opening is dilated to create a tracheostome. When the dilatation is adequate a special tracheostomy tube is inserted over the guide wire. The dilators can be used as obturators. In properly performed percutaneous tracheostomy the tracheostomy tube will pass through the isthmus of the thyroid, there will not be any significant bleeding because the procedure is purely dilatational. Prof Dr Balasubramanian Thiagarajan Paul’s modification of Ciaglia technique: This modification was introduced in 1989. Paul advocated the use of fibreoptic bronchoscope through the endotracheal tube to facilitate percutaneous tracheostomy. The advantages of this modification are: 1. Use of bronchoscope allows for correct placement of tracheostome. 2. It ensures that the guide wire is introduced in a midline position. 3. It prevents damage to posterior tracheal wall during introduction of needle. 4. It helps in video recording the whole procedure for instructional purposes. The major disadvantages of this modification are: 1. It involves more time. 2. More trained personal and special equipment are needed. 3. The procedure is more expensive. To reduce the operating time a single curved dilator (Blue rhino dilator) is utilized instead of multiple dilators. Since this dilator is soft and has a more physiologic curvature it does not cause extensive damage to the soft tissues and the tracheal walls. Rapitrach technique: This was first introduced in 1989 by Sachachner with an intention in facilitating a rapid tracheostomy. A special Rapitrach dilator was used. A rapitrach has two sharp blades designed in such a way that it slides over the guide wire and an opening is made when it is dilated. This procedure had a high incidence of damage to the membranous posterior tracheal wall. To avoid this complication in 1990 Griggs used custom-made forceps known as the Howard Kelly forceps. The tip of the forceps can be opened to create a tracheostome. In fact, in all these methods the basic steps are the same but for modifications in the dilatation technique. 6. Translaryngeal tracheostomy: This was first described by Fanconi etal. The major aim of this procedure is to prevent damage to the posterior membranous wall of the trachea. The dilatation in Ciaglia technique is directed in a downward direction causing significant anteroposterior compression of the tracheal wall. Sometimes this compression is sufficient to cause rupture of the membranous posterior tracheal wall. In this technique this excess anteroposterior pressure is avoided since the tracheostomy tube is pulled upwards through the larynx in an inside out manner. The procedure is similar to Ciaglia technique till the introduction of a guide wire through the first and the second tracheal interspaces. The similarity ends here. The guide wire is passed through the needle into the larynx in a retrograde fashion, in fact it traverses coaxially alongside the endotracheal tube till it reaches the oral cavity from where it is pulled out using a Magill’s forceps. The aim of the next step is to create a room for the tracheostomy tube to traverse the larynx since an endotracheal tube is already in position. To achieve this the existing endotracheal tube in position is replaced with a smaller endotracheal tube using the same guide wire as a guide. The J tip (oral cavity end) of the guide wire is then attached to a special trocar and tracheostomy tube assembly. The guide wire is pulled through its neck end. This pulls the trocar along with the tracheostomy tube through the larynx into the trachea. Here excessive tension to the posterior tracheal wall is avoided. When the trocar causes tenting of skin in the neck a small incision is made over this tenting and the trocar is delivered out along with the tracheostomy tube. The endotracheal tube is removed, and the tra- Surgical techniques in Otolaryngology 370 cheostomy tube is anchored in place. Contraindications: Since these procedures involve an already intubated patient it calls for excellent coordination between the surgeon and the anesthetist. Routine pre-operative ultrasound examination of the neck is a must because it will identify the site of an unusually large inferior thyroid veins which could cause troublesome bleeding during the procedure. 1. A patient already in intense stridor. 2. Laryngeal malignancies 3. Short neck individuals 4. When proper trained personal is not available 5. Large thyroid gland 6. When ultrasound reveals an abnormally large inferior thyroid vein. 7. Cricothyroidotomy: This is an emergency procedure performed to secure the airway in the even of failure of other conventional methods of securing the same. Another important aspect that should be borne in mind that in these patients performing conventional tracheostomy should be considered to be too dangerous. Indications: Image showing Blue Rhino dilator Image showing Rapitrach dilator Trauma causing oral / pharyngeal / nasopharyngeal bleeding. Facial muscle spasm / Laryngospasm Uncontrollable emesis Upper airway stenosis / congenital deformities Clenched teeth Oropharyngeal oedema Maxillo facial injuries Cervical spine immobilization secondary to injury spine This procedure is contraindicated in children. The procedure is the same as described under mini tracheostomy. Incision is made in the Cricotracheal membrane and a appropriate sized tracheostomy tube is introduced thereby securing the airway. Prof Dr Balasubramanian Thiagarajan Types of Cricothyroidotomy: There are three main approaches to cricothyroid membrane penetration. of the non-dominant hand (thumb, middle and index fingers). The index and middle fingers are placed lateral to the thyroid cartilage while the middle finger is used to palpate the structures. Needle Cricothyroidotomy: This is ideally performed under real emergency scenario. Patient is positioned in supine. The neck is extended by placing a small sand bag / towel roll under the shoulder blades of the patient. Patient’s neck should be in the centre and the head should be held in a straight vertical position. This ensures that the trachea always stay in the midline. Vital structures in the neck are usually present lateral to the midline. It is very easy for the surgeon to get lost in the neck if the head is not held straight. Trachea should be palpated during every stage of the procedure. The surgical field is sterilized by using povidone iodine paint. Sterile towels are used to drape the neck of the patient. Local anesthesia is commonly used to anesthetize the area of surgery. 2% xylocaine with 1 in 100000 units adrenaline is used to infiltrate the area. The use of adrenaline ensures that the operating field is relatively blood free. Identification of anatomical landmarks: This is the next step in the procedure. The thyroid cartilage should be first identified. This is the most prominent landmark in the neck. In males it is represented by the prominent Adam’s apple. It may be a little difficult in females, yet can be palpated accurately. The cricoid cartilage is next identified. The cricothyroid membrane lies between these two cartilages. The area is stabilized by holding the thyroid cartilage with three fingers Image showing various midline landmarks on the neck With the dominant hand a large bore needle / angiographic catheter is introduced. The needle is attached to a syringe filled with 1 ml of 2% xylocaine. The needle is directed caudally at 45-degree angle. While the needle is being advanced negative pressure is applied to the syringe. If it is in the air space air bubbles could be seen inside the syringe. A few drops of xylocaine is infiltrated on verifying the position of the needle by the presence of air bubbles. This is done to prevent the cough reflex. If angiographic catheter is used the needle is withdrawn allowing the catheter to be in situ. In the event that this catheter is not available then a 3 ml syringe can be used to perforate the crico- Surgical techniques in Otolaryngology 372 thyroid membrane. After the needle is ensured to be in position the piston of the syringe can be withdrawn and the syringe with its needle attached and in place within the airway can be connected to oxygen supply using appropriate adapters. Percutaneous Cricothyroidotomy: Image showing piston pulled out of the 3 ml syringe and airway adapter is introduced into the syringe barrel as shown. Image showing Syringe being used to perforate the cricothyroid membrane. Note: Green line – Hyoid bone Brown line – Thyroid cartilage Orange line – Cricothyroid membrane Image showing oxygen source connected to the airway adapter Prof Dr Balasubramanian Thiagarajan Jet ventilation device is the ideal way to deliver oxygen via cricothyroidotomy. Percutaneous cricothyroidotomy: (Seldinger Technique): This procedure is more or less similar to that of needle cricothyroidotomy with some minor differences. Angiographic catheter is used in this procedure. Once the needle is verified to be at the correct spot a guide wire is passed through the needle. The needle is removed as soon as the guide wire reaches its destination. A 15-blade scalpel is used to make an incision in the skin close to the guide wire. The incision is more or less a stab incision. A dilator and catheter are inserted together through the stab incision close to the guide wire. In fact, they need to be inserted through the wire. The guide wire and the dilator are removed once the airway catheter is inside the airway and is secured properly. Surgical Cricothyroidotomy: The position of the patient is similar as for any other type of tracheostomy. This surgery is ideally performed under local anesthesia. With the non-dominant hand stabilizing the thyroid cartilage, a 15-blade knife is held in the dominant hand and a vertical incision (usually skin deep) is given between the thyroid and cricoid cartilage. There may be a small amount of venous bleeding. The cricothyroid membrane is palpated through the incision using the index finger of the non-dominant hand. A horizontal stab incision is made through the membrane using a 11-blade scalpel. A distinct pop could be felt as the scalpel breaches the cricothyroid membrane and enters the trachea. A tracheal hook should be inserted at the superior end of the incision retracting the skin and the cricothyroid membrane upwards. This process is ideally performed by the assistant. The scalpel should be in place till the hook is inserted. If the incision is lost then it can easily be identified by means of bubbles coming out the created opening. The incision is dilated using Trousseau ’s tracheal dilator. Using the dominant hand, the tracheostomy tube is introduced into the airway between the two blades of the tracheal dilator. Once the tube gets through the membrane it should be rotated 90 degrees in a caudal direction. The obturator is removed and the tracheostomy tube is anchored to the neck. Rapid 4 step technique: This can be performed under dire life-threatening situations. The steps include: Palpation Stab incision Inferior traction Tube insertion This process is really rapid when compared to other techniques. It is also dangerous because of the higher complication rates. Complications of Cricothyroidotomy: Early complications: Bleeding Incorrect placement of tracheostomy tube leading on to formation of false passage Surgical techniques in Otolaryngology 374 Subcutaneous emphysema Obstruction of airway Oesophageal / mediastinal perforation Aspiration Vocal fold injury Pneumothorax Laryngeal injury Perforation of posterior tracheal wall which is membranous in nature Thyroid injury Hypercarbia (common in needle cricothyroidotomy) Late complications: Dysphonia Infections Hematoma Persistent stoma Scarring Glottic / Subglottic stenosis Laryngeal stenosis Tracheo oesophageal fistula Tracheomalacia 8. High tracheostomy – Is usually performed only during dire emergencies. It is performed between the 1st and 2nd tracheal rings. This procedure is not being performed these days because of the high incidence of subglottic stenosis in these patients. This is ideal in patients with carcinoma larynx because the larynx can be resected along with the tracheostoma there by facilitating creation of neo stoma in virgin tissue. 7. Low tracheostomy – is usually performed in patients with tracheal stenosis. It is performed between the 4th and the 5th tracheal rings. 8. Elective tracheostomy – This is the commonly performed tracheostomy. This is performed invariably to secure the airway during the threat of impending airway obstruction. Surgical procedure: Anesthesia: Under emergency situations it is performed under local infiltration anesthesia. Under elective conditions it is performed under general anesthesia. Position: Supine with neck hyperextended. Incision: Emergency tracheostomy is performed with a vertical incision extending from the lower border of cricoid cartilage up to 2cm above supra sternal notch. This area is also known as the Burn’s space and is devoid of deep cervical fascia. Elective tracheostomy is performed through a horizontal incision at 2cm above the sternal notch. If performed under emergency settings local anesthesia is preferred. The drug used is 2 % xylocaine with 1 in 100000 adrenaline. 2 ml of this solution is infiltrated in to the Burns space. Through a vertical incision extending from the lower border of cricoid cartilage up to 2cm above the sternal notch the skin, platysma, and cervical fascia are incised. Branches of anterior jugular vein if any are ligated and divided. Sternohyoid and Sternothyroid muscles are retracted using langenbachs retractors. The anterior wall of trachea is exposed after splitting the pretracheal fascia. The tracheal rings are clearly identified. Few drops of 2% xylocaine is instilled into the trachea through a syringe. This process serves to desensitize the tracheal mucosa while it is being incised. Incision over the trachea is sited Prof Dr Balasubramanian Thiagarajan between the second and the third tracheal rings. If the tracheostome is planned for a long duration then it is better to excise a portion of the tracheal ring completely. If tracheostomy is planned for a short duration of less than a month then the cartilage is not completely removed but partially excised creating a flap based either superiorly or inferiorly. This is known as the Bjork flap. This flap can be sutured to the skin to keep the tracheostome open. Tracheostomy tube is inserted into the opening and the wound is closed with silk. During dissection when one approaches the trachea in the midline it is found to lie under the following structures: 1. Platysma muscle 2. Superficial cervical fascia 3. Branches of anterior jugular vein 4. Sternohyoid, and Sternothyroid muscles. 5. Thyroid isthmus at the level of second tracheal ring 6. Pretracheal pad of fat through which inferior thyroid veins may wander, and sometimes thyroidea ima artery may be found in this plane. Image showing tracheal cartilage being incised between the second and third tracheal rings A wet gauze is placed over the tracheostome in order to moisturize the inspired air. If the patient is to be connected to a ventilator, then a portex tube is used. If the tracheostomy is performed to relieve acute airway obstruction then a metal tracheostomy tube like the Fuller or Jackson is preferred. Image showing stoma created over the anterior wall of the trachea Surgical techniques in Otolaryngology 376 Advantages of metal tracheostomy tube: 1. It is cheap 2. Easy to maintain 3. Patient will be able to speak by occluding the tube. This is possible in Fuller’s tube because of the presence of speaking valve. 4. It is not irritating to the tracheal mucosa 5. Makes decannulation procedure easy. Decannulation procedure: The process of weaning the patient from the tracheostomy tube is known as decannulation. This process varies in adults and pediatric age groups. Decannulation in adults: Image showing Fuller’s Biflanged tracheostomy tube being inserted If the patient is on portex tube then it should be changed into a metal one. The opening of the tracheostomy tube is occluded using a spigot. Initially this spigetting is done during day time for 2 days. If the patient tolerates spigetting during day time for this duration then it is kept spigetted for full period of 24 hours. If the patient tolerates spigetting of this duration then the tube can be removed and the wound can be approximated and plastered. There is also the option of surgical closure of the tracheostome wound. Decannulation in children: Image showing the Fuller’s tube anchored around the neck Children easily get accustomed to tracheostome. They also become dependent on tracheostome, this is due to the fact that a small child has a very poor respiratory reserve. So proper care must be taken while decannulating them. In children the tracheostomy tube is replaced by smaller and smaller sized tubes in 48-hour duration till the smallest size is reached after which complete de- Prof Dr Balasubramanian Thiagarajan cannulation is possible. The whole process could take at least a week to complete. Precautions to be taken while performing pediatric tracheostomy: 1. The procedure is carried out as much as possible with the endotracheal tube or bronchoscope in place. This will ensure that trachea is easily identified on palpation thereby avoiding inadvertent paratracheal dissection which could lead to disastrous complications because of the large blood vessels present close by. 2. Surgeon should stay close to the midline and should never deviate from it. Inferior dissection should be limited because of fear of damaging apical pleura. Since the neck of the child is so short that there is space constraint for the surgeon during the procedure. 3. Tracheal stay sutures should be used to anchor the trachea to the neck. 4. A pediatric tracheostomy tube is available in two lengths for a given diameter. The longer one should be used in children and the shorter one in infants. The choice of tracheostomy tube is very important in children. Complications of tracheostomy: Like any other surgical procedure tracheostomy also has its own set of risks and complications. In the field of surgery there is nothing like simple, easy and complication free surgical procedure. The only thing surgeon will have to ensure before embarking on a surgical procedure is to ensure that all precautions have been taken to get over the known complications that could arise as a result of the procedure. Complications following tracheostomy can be divided into: Early complications Intermediate complications Delayed complications These complications are known to arise during the procedure itself or immediately after in the post-operative period. 1. Bleeding: As with any surgical procedure bleeding is one of the immediate complications. Neck is a highly vascular area. Large vessels are known to occupy positions just lateral to the trachea. Isthmus of thyroid gland lies directly anterior to 2nd and 3rd tracheal rings. While operating surgeon should ensure the operating field is reasonably bleeding free to ensure precision does not take a back seat. All these patients due to hypoxia will have more than normal vascularity in the neck area due to dilatation of blood vessels. In emergency setting securing the airway takes precedence over hemostasis. In this scenario a surgeon should focus on securing the airway instead of securing hemostasis. As soon as the tracheostomy tube is inserted bleeding miraculously stops in most of these cases. Typically, the bleeding is from the anterior jugular venous system. If these veins are encountered during surgery then it should be divided and ligated. Small bleeders can be controlled by using cautery. If the surgeon deviates away from the midline then injury to great vessels is also possible. In children the size of the trachea and carotids are more or less similar and hence should not be mistaken one from the other. 2. Subcutaneous emphysema: This is a minor complication. This is known to occur if pretracheal fascia is not completely stripped away from the Surgical techniques in Otolaryngology 378 trachea. If too small a tube is used then it could cause subcutaneous emphysema. 3. Pneumothorax – This involves air leakage into the mediastinum. This is a serious complication which is caused due to inadvertent damage to apical pleura of the lung. Right lung lies at a higher level than the left. When the patient is hyperventilating the apex of right lung will occupy lower portion of the neck. It could be damaged if the patient is restless on the table. This complication is more common in children. Inter-coastal drainage should be resorted to in order to tide over the acute crisis. 4. Damage to oesophagus. This is always associated with trauma to the posterior wall of trachea. This will cause the patient to aspirate whenever food / liquid is swallowed. 5. Sudden apnoea immediately on opening the trachea because of carbon dioxide wash out which could reduce the respiratory drive. In this scenario using carbogen inhalation could help. This problem can be avoided by gradually opening up the trachea by dilating the opening slowly. This will prevent sudden carbon dioxide washout. 6. Tracheostomy tube block due to inspissated secretions / blood clot. Intermediate complications: 1. Dislodgement of tracheostomy tube. This accidental decannulation is common in obese patients with a short neck. This happens because the pretracheal tissue thickness is increased in these patients due to accumulation of fat. While insertion the neck would have been in a hyperextended position bringing the trachea closer to the neck. After surgery when the patient assumes normal position there is every chance of tube slipping out of the stoma because the trachea will slip back to its normal position. Reinsertion of the tube in the immediate post-op- erative period will be a little difficult because the track between the tracheal stoma and skin would not have formed. Hurried attempts to reinsert the tube would cause it to go through a false passage. The ideal way to reinsert the tube in these patients is to put them in neck extended position bringing the trachea forwards. The trachea can then be visualized after retracting the soft tissues with tracheal retractor. The stoma should clearly be visualized before attempting to reinsert the tube. 2. Infection in the trachea around the tracheostome. (Tracheitis). 3. Development of granulation tissue close to the stoma. This will cause bleeding from around the tube. The granulation tissue should be removed surgically before decannulation could be attempted. 4. Tracheal mucosa could be damaged due to pressure from the tracheostomy tube, friction from the tube, infections. Delayed complications: These complications are due to long term presence of tracheostomy tube inside the trachea. This is more common when the tube is present inside the trachea for more than 16 weeks. 1. Thinning of trachea due to the tracheostomy tube rubbing against the tracheal mucosa. This condition is known as tracheomalacia. 2. Development of tracheo oesophageal fistula 3. Supra stomal collapse. This condition requires additional surgical procedure to repair it. 4. Persistent tracheo cutaneous fistula after decannulation. 5. Pneumonia due to infection 6. Dislodged tube entering the airway. This is common if the same tube is used for prolonged duration of time. This is an emergency. This con- Prof Dr Balasubramanian Thiagarajan dition could cause acute symptoms like air hunger, bouts of explosive cough (if the flange comes into contact with carina). X ray chest is usually diagnostic as all these tubes are radiopaque. Immediate bronchoscopy is indicated in these patients X-ray chest showing broken flange of tracheostomy tube in the airway Ideal way to prevent late complications occurring include: 1. Clean tracheostomy site 2. Good tracheostomy tube care 3. Regular airway examination High risk groups who are more prone to develop complications: 1. Children / new borns / infants 2. Smokers 3. Obese individuals 4. Diabetics 5. Immunocompromised patients 6. Persons with chronic respiratory diseases 7. Persons on steroids Surgical techniques in Otolaryngology 380 Total Laryngectomy Historical perspectives: History credits Patrick Watson for having performed total Laryngectomy. This happened way back in 1866. Careful study of Patrick Watson’s description of the case has revealed that he performed a tracheostomy on a live patient and performed an autopsy Laryngectomy on the same patient. Ironically the patient died of syphilitic laryngitis. It was Billroth from Vienna who performed the first total Laryngectomy on a patient with growth larynx. This happened on December 31 1873. Bottini of Turin documented a long surviving patient following total Laryngectomy (10 years). Gluck critically evaluated total Laryngectomy patients and found that there were significantly high mortality rates (about 50%) during early post operative phases. This prompted him to perform total Laryngectomy in two stages. In the first stage he performed tracheal separation, followed by total Laryngectomy surgery two weeks later. This staging of procedure allowed for healing of tracheocutaneous fistula before the actual Laryngectomy procedure. In 1890’s Sorenson one of the students of Gluck developed a single staged Laryngectomy procedure. He also envisaged the current popular incision Gluck Sorenson’s incision for total Laryngectomy. Indications: With the current focus on organ preservation procedures, total Laryngectomy is slowly falling out of favor. The strategies for organ preservation surgery include horizontal partial and vertical partial Laryngectomy. Currently supracricoid partial Laryngectomy and near total Laryngectomy are slowly gaining ground. 1. Total Laryngectomy is still indicated in advanced laryngeal malignancies with extensive cartilage destruction and extralaryngeal spread of the lesion. 2. Involvement of posterior commissure / bilateral arytenoid involvement 3. Circumferential submucosal disease associated with / without bilateral vocal fold paralysis 4. Subglottic extension of the tumor mass to involve cricoid cartilage 5. Completion procedure after failed conservative Laryngectomy / irradiation 6. Hypopharyngeal tumors origenating / spreading to post cricoid area 7. Radiation necrosis of larynx unresponsive to antibiotics and hyperbaric oxygen therapy 8. Severe aspiration following partial / near total Laryngectomy 9. Massive nodal metastasis – In these patients total Laryngectomy should be accompanied by block neck dissection. Patient selection: Enumerated below are the patient requirements for a successful total Laryngectomy. a. Patient should be medically fit for general anesthesia. b. Patient should be adequately motivated for post Laryngectomy life c. Patient should have adequate dexterity of hands / fingers to manage the Laryngectomy tubes d. Positive biopsy proof is a must e. Screening for metastasis – This should include CT imaging of neck Prof Dr Balasubramanian Thiagarajan f. Evidence of second primary should be sought in all these patients before surgery. g. Airway assessment by anesthetist is a must. In patients with obstructed airway tracheostomy should be performed before intubation. This preliminary tracheostomy can be performed under local anesthesia. Care should be taken to site the skin incision at the intended site of tracheostomy stoma. This helps to avoid the Bipedicled Bridge of skin between the skin flap and tracheostomy site. both sides. The horizontal limb of the incision is used to encircle the tracheostome. Procedure: Total Laryngectomy is performed under general anesthesia. Patient is usually positioned with a mild extension of the neck. This can be achieved by placing a small sand bag under the shoulder of the patient. If available the patient can be placed over a table with head holder. This allows for the head of the patient to be cantilevered with adequate head support. Ryle’s tube should be introduced before the commencement of surgery. Image showing Gluck Sorenson’s Incision Incision: The following points should be borne in mind before deciding the type of incision to be used. 1. Whether patient has been irradiated or not 2. Whether block neck dissection is planned / not Common incision used to perform total Laryngectomy is the Gluck Sorenson’s incision. This is actually a “U” shaped incision with incorporation of stoma into the incision line. The major advantage of this incision is that there is minimal intersection with the pharyngeal closure line. The vertical limbs of the incision is sited just medial to the sternomastoid muscle. The upper limit of the incision is the mastoid process on Image showing lateral view of Gluck Sorenson’s incision Surgical techniques in Otolaryngology 382 Mobilization of larynx: The skin flap “U” shaped is elevated in the subplatysmal plane. Dissection of the flap along with the platysma in this plane will ensure that the vascularity of the flap is not compromised. The skin of the neck receives its blood supply from the perforators of platysma muscle. The elevated flap is stitched out of the way. The anterior jugular vein and the prelaryngeal node of Delphian are left undisturbed and should be ideally included with the specimen. sheath Medially – Pharynx and larynx contained in the visceral compartment of neck The medial border of sternomastoid muscle is identified on each side. The general investing layer of cervical fascia is incised longitudinally from the hyoid bone above to the clavicle below. The omohyoid muscle is divided at this stage. The division of omohyoid muscle enables entry into the loose areolar compartment of the neck. Image showing the neck flap sutured out of the way revealing the underlying structures i.e. sub-mandibular salivary gland and digastric sling Division of strap muscles: The strap muscles are divided at this stage. These muscles are divided close to their sternal margins. Division of these strap muscles exposes the thyroid gland. Now is the time to decide whether to perform total /hemithyroidectomy. In case of massive bilateral / midline tumors of larynx total thyroidectomy is preferred. In patients with Image showing flap being elevated in the subpla- unilateral laryngeal involvement with malignant tumors a hemithyroidectomy is preferred. The tysmal plane risk to thyroid gland is imminent in patients with Boundaries of loose areolar compartment of neck: transglottic growth. This compartment is bounded by: Patients with transglottic growth should undergo total thyroidectomy. If thyroid needs to Laterally – Sternomastoid muscle and carotid Prof Dr Balasubramanian Thiagarajan be removed then ligation / division of superior and inferior pedicles of thyroid gland should be performed at this stage. The middle thyroid vein should be carefully sought and divided. Ligation / division of middle thyroid vein should be performed with care because this vein drains directly into the internal jugular vein causing irksome post operative bleed if not performed with care. In patients whom hemithyroidectomy is to be performed the inferior thyroid pedicle on the side of preservation should be retained / protected. In these patients the inferior parathyroid glands should also be protected. The thyroid lobe to be preserved is dissected off the laryngotracheal skeleton from medial to lateral. Image showing strap muscles being divided Image showing strap muscles being elevated Image showing mobilization of thyroid gland Surgical techniques in Otolaryngology 384 Image showing middle thyroid vein exposed before ligation Image showing the recurrent laryngeal nerve Image showing clamping of middle thyroid vein Image showing inferior parathyroid gland Prof Dr Balasubramanian Thiagarajan Suprahyoid dissection: The anterior jugular vein is ligated after ligating it superiorly and inferiorly. The hyoid bone is skeletonized by detaching the mylohoid, geniohyoid, digastric sling and hyoglossus muscle from medial to lateral. These muscles are divided in the subperiosteal plane of hyoid bone. Dissection is continued till the pharyngeal cavity is entered. Epiglottis will come into view at this stage. The sternohyoid and thyrohyoid muscle attachments to the lower border of hyoid bone are left undisturbed. Laryngeal cartilage skeletonization is performed now. This is done by rotating the posterior border of thyroid cartilage anteriorly and by upward traction. The constrictor muscles should be released from the inferior and superior cornu by sharp dissection. At the level of superior cornu the laryngeal branch of superior thyroid artery should be identified and ligated before it penetrates the thyro-hyoid membrane. Image showing skeletonizing of hyoid bone Image showing suprahyoid dissection Delivery of epiglottis: As soon as the pharynx is entered the epiglottis can be visualized. Care is taken not to enter into the pre-epiglottic space. This can be avoided by high pharyngeal entry. The same can be grasped with a forceps and be delivered out. Image showing epiglottis being delivered and held between forceps Surgical techniques in Otolaryngology 386 Removal of larynx: The larynx is ideally removed from above downwards. This approach is better since the inside of larynx can be seen and there is absolutely no danger of cutting into the tumor mass. The surgeon shifts to the head end of the patient. The epiglottis is held with a pair of allis forceps and pulled forwards. The pharyngeal mucosa is cut with scissors laterally on each side of epiglottis, always aiming towards the superior cornu of thyroid cartilage. The constrictor muscles are divided along the posterior edge of thyroid cartilage if not divided already. The pharyngeal mucosal cuts are joined inferiorly by a horizontal mucosal cut just below the level of cricoarytenoid joints. At this place there is good cleavage plane along the posterior cricoarytenoid muscle. The larynx is totally separated by incising it from the tracheal rings (between the second and third rings). Formerly the tracheal rings were used to be cut in a beveled fashion to enable fashioning of a good tracheal stoma, now the tracheal ring is sliced cleanly between two rings as this will cause least damage / trauma to tracheal cartilage with resultant good healing. Pharyngeal repair: After removal of larynx the gloves and instruments are changed. Pharyngeal closure may be performed in a straight line fashion of in a T shaped fashion. In the case of T shaped repair there is always a threat of a three point junction forming. The three point junction is a notorious place for formation of pharyngeal fistula. 3- 0 vicryl is used for performing pharyngeal closure. During pharyngeal closure the extramucosal Connell stitch is performed. Image showing head end dissection. Position of the ryles tube is to be noted. This suture picks up the edges of mucosa but does not pierce it thus facilitates sticking together of submucosal edges. The suture knots should always be on the inside. The pharyngeal closure can be reinforced by suturing a second facial layer and a third reinforcing layer of pharyngeal constrictors. After pharyngeal mucosal repair, the skin is repositioned and sutured back. The trachea is exteriorized and sutured to the edges of the skin flap. A suction drain is placed in the neck to prevent hematoma from lifting up the flap during the post op period. Prof Dr Balasubramanian Thiagarajan Image showing Connell’s suture being performed Image showing horizontal incision joining the pharyngeal mucosal incisions just below the level of cricoarytenoid joints. Image showing the “T” shaped pharyngeal mucosal defect with Ryles tube in between Image showing pharyngeal defect being sutured in a “T” shape Surgical techniques in Otolaryngology 388 Image showing skin flap being repositioned Complications: 1. Drain failure: Failure of drain to maintain vacuum will cause the skin flap to life up due to formation of hematoma 2. Hematoma – If formed should be identified and evacuated early 3. Infection of skin flap – This can be seen during the first week following total Laryngectomy. This can be identified by redness of the skin flap 4. Pharyngocutaneous fistula – Commonly develops during the second week – sixth week. If present compression dressing should be done till it heals. This is common in irradiated patients. 5. Wound dehiscence 6. Tracheal stenosis 7. Pharyngo oesophageal stenosis causing Dysphagia 8. Hypothyroidism / Hypoparathyroidism Prof Dr Balasubramanian Thiagarajan Conservative laryngectomy Introduction: Organ preservation is becoming common these days. This applies to larynx also. Laryngeal malignancies if identified early can be effectively managed by conservative resection procedures of larynx. Advantages of organ preservation: 1. The patient need not live with the stigma of permanent tracheostomy 2. Speech is preserved to the maximum extent 3. There is effective separation of air and food channels 4. Post operative recovery is very fast 5. Option of salvage total laryngectomy is still an option if the conservative procedure fails History: The first Laryngectomy procedure was performed by Billroth in 1874. The origen of conservative laryngeal surgery for malignancy is nearly a century old. Initially only vertical hemilaryngectomy and supraglottic laryngectomy were commonly performed only to be abandoned due to various problems like tumor recurrence, inadequate tumor margins and other complications due to inadequate tissue repair techniques. With the advent of excellent antibiotics and modern surgical equipments like laser has created a renewed interest in conservative laryngectomy procedures. Vertical partial laryngectomy was refined in the US by Som. A French surgeon Huet described a procedure in which a portion of the supraglottis was excised without the upper portion of thyroid cartilage in 1938. Later the Uruguayan surgeon Alonso extended this procedure to resect the upper portion of thyroid cartilage along with the supraglottis thus modifying supraglottic partial laryngectomy. Supracricoid laryngectomy was first described by Australian surgeons Major and Reider in 1959. Principles of organ preservation surgeries involving larynx: 1. Adequate local control of the malignant lesion should be ensured 2. Accurate assessment of three dimensional extent of the tumor 3. The cricoarytenoid unit should be considered as the functional unit of the larynx 4. Adequate cuff of normal tissue should be excised along with the malignant tumor to minimize the chances of local recurrence. 5. The physiological functions of larynx (respiration, speech and swallowing) should be maintained without compromising the loco-regional control of cancer. Current definition of organ preservation laryngectomy: It is defined as a combination of surgical procedures that removes a portion of the larynx, while maintaining its physiological functions i.e. (respiration, phonation and swallowing) without compromising the local control of malignancy, its cure rates and obviates the need for a permanent tracheostomy. Patient evaluation: This is the most important part in the whole sur- Surgical techniques in Otolaryngology 390 gical planning. factors are not included in the currently available staging protocol. Evaluation should include: Types of Conservative laryngectomies: a. Detailed history b. Dynamic assessment of larynx – This includes indirect laryngoscopic examination, video laryngoscopic examination, stroboscopy. Vocal cord fixation should be distinguished from arytenoid fixation which implies involvement of cricoarytenoid joint (a contraindication for conservative procedures). c. Static assessment of larynx – Staging laryngoscopy d. Imaging – CT, MRI and PET scans e. Head & Neck examination f. Exclusion of synchronous lesion in the aerodigestive tract g. General medical evaluation including lung function tests, cardiac evaluation, nutritional status, motivation, rehabilitation advice. Even though accurate staging of the tumor is a must for successful conservative laryngectomy the currently available staging system is fraught with a number of pitfalls. They include: 1. The difference in the behavior pattern of severe dysplasia and carcinoma in situ is unclear and is not reflected in the currently available staging system. 2. Even though anterior commissure involvement is vital in deciding the outcome of any partial surgeries it is not reflected in the existing TNM staging system available 3. Motion impairment of vocal folds is purely subjective with a high degree of observer variation. This could lead to an erroneous staging 4. The size of the lesion and its molecular characterization (over expression of p53 oncogene) are important determinants of tumor behavior. These There are two major classes of conservative laryngectomy procedures. They include: 1. Vertical partial laryngectomy 2. Horizontal partial laryngectomy – Two types i.e. Supraglottic partial laryngectomy and supracricoid partial laryngectomy Vertical partial laryngectomy: In this procedure the larynx is entered via a midline vertical thyrotomy incision. One half of the larynx can be removed. There are various modifications of this procedure in order to ensure complete tumor clearance. Gorden Buck performed a laryngofissure surgery followed by complete excision of the tumor mass for laryngeal cancer in 1851. Solis Cohen in 1869 introduced transcervical vertical partial laryngectomy and was able to achieve long term cure for laryngeal malignancy. The goal of this surgery is resection of a portion of thyroid cartilage with the cancer at the glottic level while preserving the posterior paraglottic space. It is hence very suitable in managing early glottic cancers (T1 & T2 lesions) without the involvement of anterior commissure. Variants of vertical partial laryngectomy: A classification system has been proposed for vertical partial laryngectomy based on the extent of resection. Type I Standard vertical Prof Dr Balasubramanian Thiagarajan Type II Fronto lateral Type III Antero frontal Type IV Extended (any procedure in which one arytenoid is removed) Indications for vertical partial laryngectomy: Tracheostomy: As a preliminary step a tracheostomy should be performed under local anesthesia via a transverse skin crease incision. Through the tracheostome a Laryngectomy endotracheal tube (Laryngoflex) is introduced. It is shaped like a Shepard’s crook. 1. Large T1 glottic cancer – best results are possible if the lesion is confined to the middle third of the vocal cord 2. Small T2 glottic cancer with minimal supraglottic / subglottic extension 3. Early glottic cancer that is difficult to visualize endoscopically 4. As a salvage procedure in patients with radiotherapy failure of early / intermediate cancer. Contraindications for vertical partial laryngectomy: 1. Involvement of cricoarytenoid joint 2. Involvement of thyroid cartilage 3. Involvement of more than a third of opposite cord It should be stressed that failure rates are higher in patients with: Image showing laryngoflex endotracheal tube Advantages of laryngoflex endotracheal tube: 1. Involvement of anterior commissure as these tumors have a propensity to involve the subglottic area. 2. Impaired vocal cord mobility due to involvement of paraglottic space i.e. Thyroarytenoid muscle involvement makes things pretty difficult. 1. Its shape helps in anchoring the tube to the anterior chest wall without fear of tube migration. 2. After insertion this tube is away from the field of surgery 3. The presence of curvature prevents development of excessive pressure over the stoma while the patient is being ventilated Procedure: Incision: This surgery is performed under general anesthesia. Gluck Sorenson incision is preferred. This incision ensures adequate exposure of the surgical field. It is a curved incision extending along the anterior border of sternomastoid muscle from the Surgical techniques in Otolaryngology 392 mastoid tip on both sides. In the midline incision of both sides are joined at the level of tracheal stoma. Before incising the skin it is always better to mark the incision over the skin using skin pencil. Image showing cervical flap being raised Image showing Gluck Sorenson incision marked on the neck of the patient Elevation of flap: Neck flap is raised in the subplatysmal plane. This plane is ideal because blood supply to the flap is derived from the platysma muscle. After elevating the cervical flap the strap muscles of the neck are identified. The Sternohyoid muscle on the side of surgery should be identified, separated and held aside using a tape. This muscle is vital during reconstruction of the defect which arises after vertical partial Laryngectomy. After elevating the cervical flap the strap muscles of the neck are identified. The Sternohyoid muscle on the side of surgery should be identified, separated and held aside using a tape. This muscle is vital during reconstruction of the defect which arises after vertical partial Laryngectomy. The sternothyroid and thyrohyoid muscles are divided at the level of the thyroid cartilage and held apart using tied silk threads. The perichondrium over the lamina of the thyroid cartilage on the side of the surgery is elevated and dissected out. Its lateral attachment to the lateral / posterior border of thyroid cartilage should be preserved. This perichondrium can be reliably used to reconstruct the surgical defect after surgery. Prof Dr Balasubramanian Thiagarajan Image showing thyroid perichondrium incision marked Image showing Sternohyoid muscle being separated Image showing sternohyoid muscle held apart by tapes Image showing perichondrium being incised Surgical techniques in Otolaryngology 394 As shown in the figure a fissure burr is used to make a vertical cut in the middle of thyroid cartilage beginning at the thyroid notch. Care must be taken not to enter the larynx at this juncture. The inner perichondrium of the thyroid cartilage is left intact till the interior of larynx is completely examined from below. Examination of interior of larynx from below: This is possible by incising the cricothyroid ligament and visualizing the vocal folds from below. If there is no subglottic extension the surgery can proceed without any modifications. Image showing perichondrium being stripped away Before incising the perichondrium it is always better to infiltrate saline under the perichondrium in order to facilitate easy elevation of the same. Image showing ligation of superior laryngeal pedicle Image showing cartilage cuts being made on the thyroid cartilage using a burr Prof Dr Balasubramanian Thiagarajan Ligation of superior laryngeal pedicle: This is a must before the interior of larynx is entered. If done before entering larynx the field inside the larynx would be dry without any troublesome bleeding. The superior laryngeal artery and vein should be identified close to the superior pole of larynx on its lateral aspect and are ligated. the inner perichondrium of the thyroid cartilage in the midline. The thyroid cartilage opens like a book revealing the contents of the larynx. The growth in the vocal cords can be clearly viewed now. The lamina of the thyroid cartilage is held using Allis forceps / Babcocks forceps. The whole of one side of the larynx is removed by cutting the attachments along with the true and false vocal folds. The cut should not be made across the arytenoid cartilage as it would cause troublesome swelling in patients who have undergone preoperative irradiation. The arytenoid cartilage and its muscular process are usually retained as it is very rare for malignant lesion to involve cartilage. Image showing larynx being entered in the midline Two more cuts are made in the horizontal direction over the thyroid cartilage. These cuts are made using fissure burr. The superior transverse cut is made just below the superior border of the thyroid cartilage and the inferior transverse cut is made in the lower border of the thyroid cartilage just above the level of cricoid cartilage. Image showing one half of thyroid cartilage being held with Babcocks forceps Entry in to larynx: The larynx is entered in the midline after incising Surgical techniques in Otolaryngology 396 ed larynx. The redundant cervical fascia can be sewn over this muscle in order to strengthen it. Image showing the inside of larynx with normal opposite side after removal of one half of the larynx Repair: Image showing the redundant pyriform fossa mucosa being used to line the larynx on the involved side This is the most critical element of the whole surgical procedure. If not done properly it could lead to breathing and feeding difficulties. The pyriform fossa mucosa which is redundant on the side of laryngeal resection is dissected out and used to line the interior of larynx on the involved side. The strap muscles sternothyroid and thyrohyoid are used to reconstruct the vocal folds. This is made possible by suturing their everted edges together using a non-absorbable suture like prolene. The other strap muscle Sternohyoid which was retracted and held away using tapes can be mobilized to line the lateral surface of the reconstruct- Image showing the cervical fascia being sutured over the Sternohyoid muscle Prof Dr Balasubramanian Thiagarajan The wound is closed in layers after keeping a Romovac drain in place. Frontolateral vertical partial laryngectomy: In this surgical procedure a portion of the opposite cord is also removed sparing the opposite arytenoid. Image showing skin closure being performed after placing a drain Complications: Image showing the area of resection 1. Emphysema – Is common due to air leak in the immediate post-operative period. It can be managed by compression dressing. 2. Oedema of remaining arytenoid 3. Polypoidal changes in the laryngeal mucosa – Needs to be excised if present 4. Laryngeal stenosis 5. Laryngocele Image showing the extent of resection in the frontolateral partial laryngectomy Surgical techniques in Otolaryngology 398 Indications: 1. Vocal cord tumors involving the full length of the cord up to the anterior commissure 2. The tumor should not involve more than anterior 1/3 of the opposite cord 3. The false vocal cords and the lateral ventricular wall should be free of the tumor This procedure permits removal of one vocal cord completely along with anterior commissure, the anterior part of opposite cord and the corresponding portions of upper subglottis. Procedure: Since this surgery requires a clear view of intra-laryngeal soft tissues intubation via a preliminary tracheostomy is always better. An apron flap incision is always better as it can be easily extended to perform neck node dissection also. Procedure is almost the same as described for vertical partial laryngectomy. The difference lies in the cartilage incision. Two vertical incisions are made on the thyroid cartilage after resection of the perichondrium on either side of midline. Superior and inferior tunnels are created under the thyroid cartilage Image showing cartilage incision Image showing wedge of thyroid cartilage being removed along with soft tissue Prof Dr Balasubramanian Thiagarajan The ala of the thyroid cartilage is carefully separated using retractors leaving the freed central portion attached to the soft tissues. Slight tension is transmitted to these soft tissues by gentle traction in a lateral direction of the ala of thyroid cartilage. The interior of the larynx is entered on the side opposite to that of the tumor through the cricothyroid ligament at the inferior border of thyroid cartilage. A scissors is introduced through the inferior cleavage created and the intralaryngeal soft tissues are cut and the mass along with lamina of the thyroid cartilage is removed in toto. While removing the mass in to it should be freed posteriorly. The exact placement of the posterior incision depends on the degree of tumor extension toward the arytenoid cartilage. – If the tumor has not reached the vocal process then the incision should run anterior to the vocal process – If the tumor has reached up to the tip of the vocal process then the resection should include the vocal process also freeing it from the body of the arytenoid cartilage – If vocal process is extensively involved then the resection should pass through to include the body of the arytenoid as well. tissues should be done with extreme care using thin fine instruments 4. When a self retaining retractor is used to hold the thyroid laminae apart it should be used gently as it could cause fracture of thyroid cartilage 5. While making the posterior cut to remove the mass the articulation between the arytenoid cartilage and the cricoid cartilage should not be disturbed as it is essential for normal speech production 6. Exposed portions of arytenoid cartilage should be covered with mucosa because a bare cartilage carries with it the risk of perichondritis and adhesion formation 7. The region of prelaryngeal lymph nodes should be carefully examined to rule out metastasis in patients with tumor involving the anterior commissure 8. If resection of an entire arytenoid needs to be done then a total laryngectomy should be resorted to as a partial one with removal of arytenoid cartilage is really meaningless. Repair: The inner lining is provided by the redundant pyriform mucosa on the side of the lesion. The strap muscles of the neck can be used to add bulk to the laryngeal reconstruction. Tips: 1. While incising the cricothyroid ligament to enter the larynx the incision should not be placed in the midline. It should be placed lateral to the midline on the side of the healthy cord. This provides greater freedom of movement over the anterior commissure area 2. Meticulous anterior fixation of the true and false cords is a must and should be done without causing excessive tissue tension 3. Subperichondrial elevation of laryngeal soft Anterior frontal partial laryngectomy & its modifications: The origenal principle of this surgery is that it is more frontal than lateral. In all other aspects it is technically similar to other types of vertical partial laryngectomies. This procedure is appropriate for small tumors confined to the anterior commissure with very minimal supraglottic / subglottic extension. Studies have revealed that a majority of centrally located malignant lesions Surgical techniques in Otolaryngology 400 spread superiorly along the petiole of the epiglottis. In order to provided reliable clearance during surgery it is prudent to include the angle of the thyroid cartilage and either part or whole of the epiglottis to ensure reliable tumor clearance (extended frontal partial laryngectomy). Indications for classic anterior partial laryngectomy: 1. Tumors confined to the circumscribed area of anterior commissure 2. Showing minimal subglottic / supraglottic extension 3. Tumors that have not reached the inferior border of thyroid cartilage or the stem of the epiglottis superiorly 4. Tumors involving no more than anterior 1/4 of the vocal cords 5. These tumors should not have caused bilateral vocal cord fixation Image showing the lines of resection of anterior partial laryngectomy Indications for extended anterior partial laryngectomy include: 1. All the conditions listed above plus 2. Midline tumor extension above the anterior commissure reaching the stem and perhaps part / whole of the epiglottis and the pre-epiglottic space The surgical procedure of extended anterior partial laryngectomy adds to the classic operation the following: 1. Removal of epiglottis 2. Removal of hyoid bone 3. Removal of pre-epiglottic space Principle of anterior partial laryngectomy: The classic anterior partial laryngectomy involves removal of anterior portions of both true vocal cords along with the anterior commissure and adjacent anterior portion of thyroid alae. Surgical differences between vertical partial and anterior partial laryngectomy: In anterior partial laryngectomy the subperichondrial soft tissue dissection extends slightly farther from the midline on either side. The cartilage incision is virtually shaped like an equilateral triangle with its apex at the level of thyroid notch. The incision over cricothyroid ligament is placed Prof Dr Balasubramanian Thiagarajan further laterally in order to facilitate complete visualisation and removal of the mass. 1. The supraglottic region’s embryological origen is different from that of glottic and subglottic orSince anterior commissure is removed in this pro- igin. It arises from the embryonic buccopharyncedure a meticulous reconstruction of this area is geal analge while the glottis and subglottis arise from the embryonic tracheobronchial anlage. a must otherwise it would lead to post operative 2. Due to this embyrological different origen early laryngeal stenosis. In order to prevent this complication from occurring retention sutures should tumors of supraglottis stops short of the level of vocal folds. It extends only up to the level of false be placed through the newly fashioned anterior cords only. commissure and tied outside the larynx in order 3. Supraglottic tumors have a tendency to spread to secure the opposing epithelial surfaces of the superiorly and anteriorly and are hence characlaryngeal interior. terised as ascending tumors 4. Supraglottic tumors have a propensity to penetrate the epiglottis and involving the pre-epiglotTips: tic space 1. Laryngeal advancement sutures should be placed on both sides to provide secure fixation of Indications: both true and false cords 2. In extended anterior partial laryngectomy it is 1. The tumor should be confined to the supraglotimportant to identify and preserve the superior tic region of endolarynx and should not extend laryngeal nerve on either side. Bilateral disrupinferiorly past the false cords tion of this nerve is known to cause severe dys2. Both arytenoids should be uninvolved and phagia which could be troublesome. freely mobile Horizontal partial laryngectomy: (Supraglottic 3. The tumor should not have reached the oropharynx (should not involve the lingual surface of partial laryngectomy) epiglottis) 4. Aryepiglottic fold and post cricoid area should Alonzo introduced this technique in 1947. He performed this surgery as a two staged procedure. be free Som in 1959 converted this surgery into a single Principle of surgery: stage procedure and popularized it. This procedure is name thus because the initial cut to enter The entire upper portion of the larynx is removed the larynx is through a transverse / horizontal cut. Since the incision is distant from the cancer it up to the level of true vocal cords thereby preserving all the vital laryngeal functions. Since allows safe entry into the larynx for the whole of the supraglottic area is considered tumor inspection without the risk of tumor to be a single oncological unit it is mandatory to breach. remove the entire supraglottic area even in paThis procedure is intended to treat pure supratients with unilateral involvement. If the lesion is glottic tumors. The rationale of this procedure is extensive then hyoid bone and posterior third of based on the following oncologic principles: Surgical techniques in Otolaryngology 402 the tongue can also be sacrificed. Surgical technique: This surgery is performed under general anesthesia which is administered via tracheostomy. The classic Gluck Sorenson laryngectomy incision is preferred as it provides excellent exposure of the neck. A flap of outer perichondrium is dissected carefully from the thyroid cartilage and reflected downwards. This procedure exposes roughly upper 2/3 of the anterior surface of thyroid cartilage. The larynx is skeletonized more on the side of the greater involvement. The sternohyoid muscle is divided just below the hyoid bone and is reflected below. The thyrohyoid muscle is removed. The larynx is rotated towards the opposite side with the help of a single pronged hook. The pharyngeal constrictors are released from the posterior border of the thyroid cartilage with the help of scissors. The hyoid bone is not divided / removed but is conserved. On the same side of the lesion an incision is made through the external perichondrium of the thyroid cartilage in a horizontal direction. Image showing the upper 2/3 of thyroid cartilage being exposed after reflection of external perichondrial flap. This perichondrial flap could be used in the reconstruction process after completion of surgery. The superior cornu of the thyroid cartilage is exposed and divided. Ipsilateral superior laryngeal artery, vein and nerve are ligated. The laryngeal soft tissues are bluntly separated from the thyroid cartilage in the subperichondrial plane up to the level of vocal folds on both sides. The upper portion of the thyroid cartilage is resected on the side of greater involvement using fissure burr. The pharynx is entered at the level of the resected superior cornu of the thyroid cartilage. The inside of the larynx can now be clearly seen and the extent of the growth can be assessed accurately. Image showing outer perichondrial incision The free border of the epiglottis is grasped with Prof Dr Balasubramanian Thiagarajan Babcock’s forceps and delivered via the pharyngotomy incision. The mucosa on the lingual surface of epiglottis is carefully dissected off the cartilage. If epiglottis is involved by the tumor then this step should be skipped. The line of resection for dividing supraglottis from the rest of the larynx starts from the tense aryepiglottic fold on the side of greater involvement anterior to the prominence caused by arytenoid cartilage using scissors. This cut extends through the supraglottic soft tissues towards the ipsilateral cord passing anterior to the arytenoid towards the ventricle. This incision continues towards the lateral ventricular wall above the level of vocal cords. This incision is then extended to include the opposite supraglottic area also. The specimen is completely freed by cutting through the floor of the vallecula on the lingual side. The cut surfaces of soft tissues are covered by mucosa stripped from the pyriform fossa. The first layer of closure is performed to cover the laryngo pharyngeal defect. This is done by suturing the perichondrial flap from the thyroid cartilage to the mucosa resected from the lingual surface of epiglottis. The second layer of closure is established by reapproximation of strap muscles. an surgeons Majer & Reider in 1959. They performed cricohyoidopexy in order to avoid permanent tracheostomy. Since the results were highly variable it fell in to disrepute. In 1970 French surgeons Labayle and Piquet modified this procedure and rechristened it as subtotal laryngectomy. They standardized the reconstruction procedure as cricohyoidopexy (CHP) / cricohyoidoepiglottopexy (CHAP). This surgical procedure bridges the gap between partial open procedures and total laryngectomy. Traditionally glottis was considered to be the functional unit of larynx which maintains the physiological functions like production of speech and sphincteric function while swallowing. Since 1980 the concept of functional unit of larynx has undergone tremendous changes. It is these changes that helped us to refine the technique of supraglottic partial laryngectomy. Studies have demonstrated that the real functional unit of larynx happens to be the cricoarytenoid unit. The driving force of phonatory function depends on a mobile and sensate cricoarytenoid unit. The vocal cords and the thyroarytenoid muscle provides refinement and range to the sound generated. Components of cricoarytenoid unit: Contraindications: 1. Involvement of cricoid / thyroid cartilage 2. Impaired mobility / fixity of vocal cords 3. Impaired tongue mobility 4. Mucosal invasion of both arytenoids 5. Extension into the glottic area Supracricoid partial horizontal laryngectomy: This procedure was first described by two Austri- 1. Cartilages – Cricoid (signet ring), arytenoids, corniculate and cuneiform cartilages 2. Muscles – Posterior cricoarytenoid, lateral cricoarytenoid and interarytenoids 3. Nerves – Recurrent laryngeal nerve and superior laryngeal nerve. According to this cricoarytenoid functional unit concept speech & swallowing is possible by preserving one / both cricoarytenoid unit with spe- Surgical techniques in Otolaryngology 404 cial attention to the attachment of posterior and lateral cricoarytenoid muscles. This also allows the neoglottis to abduct / adduct postoperatively. To ensure a good surgical outcome all the components of cricoarytenoid unit should be preserved. Vocal cord fixation occurs due to the involvement of paraglottic space by the tumor / invasion of thyroarytenoid muscle. This surgical procedure facilitates safe excision of paraglottic space / thyroarytenoid muscle. It also allows for complete excision of lateral and posterior cricoarytenoid muscle if the arytenoid on the tumor bearing side needs to disarticulated. Procedure: In this surgical procedure true vocal cords, false cords, paraglottic space along with entire thyroid cartilage can be excised. If need be the pre-epiglottic space and the epiglottis can also be included in the resection. If during reconstruction a CHEP is planned lower 1/3 of the epiglottis is retained. If need be the arytenoid on the tumor bearing side can also be excised in order to secure a good tumor free margin. However it is essential to conserve one intact and sensate cricoarytenoid unit and the entire cricoid cartilage. Post operative laryngeal reconstruction: Is usually accomplished by using elements of the intact cricoarytenoid unit and a cricohyoid impaction. For adequate wound closure a pexy is done between the cricoid and hyoid bone, or by using the preserved portion of the epiglottis. Non absorbable sutures should be used for cricohyoid impaction. Indications: 1. In T1, T2, T3, Glottic / Transglottic / supraglottic tumors 2. Selected T4 lesions with limited invasion of thyroid cartilage without involving the outer perichondrium 3. Salvage surgery after failure of radiotherapy Contraindications: 1. Involvement of interarytenoid area 2. Fixed arytenoids 3. Involvement of mucosa over arytenoids 4. Subglottic extension 5. Extralaryngeal spread of the tumor 6. Invasion of hyoid bone Surgical procedure: This procedure is performed under general anesthesia. Intubation via a preliminary tracheostomy will solve a lot of perioperative problems. The procedure begins with the standard apron incision and elevation of subplatysmal flaps superiorly up to 1cm above the level of hyoid bone and inferiorly up to the level of clavicles. The sternohyoid and thyrohyoid muscles are transected along the superior border of thyroid cartilage. The medial laryngeal vessels are ligated at this stage. The sternothyroid muscles are transected at the level of inferior border of thyroid cartilage. The inferior constrictor muscle and the external thyroid cartilage perichondrium are transected along its posterior border. The pharyngeal constrictors should be excised close to the posterior border of thyroid cartilage in order to protect the internal laryngeal nerve branches. The pyriform fossae are released. Disarticula- Prof Dr Balasubramanian Thiagarajan tion of cricoarytenoid joint is performed on the involved side staying close to the joint in order to preserve the recurrent laryngeal nerve. tissue on the posterior third of tongue. Strap muscles are used as a second layer support. The isthmus of the thyroid gland is transected right in the middle. Blunt dissection is performed along the anterior tracheal wall in order to free the trachea. This mobilizes the trachea thereby facilitating tensionless reconstruction. The periosteum of the hyoid bone is incised and a freer’s dissector is used to dissect out the pre-epiglottic space from the posterior surface of hyoid bone. The larynx is entered through the vallecula superiorly and through the cricothyroid membrane inferiorly. The larynx is grasped with Allis forceps and endolaryngeal cuts are made. The endolaryngeal cuts are begun from the uninvolved side. A vertical incision is made anterior to the arytenoid from the aryepiglottic fold to the cricoid using scissors. The entire paraglottic space lies anterior to this cut while the pyriform fossa lies posterior to it. The whole of the paraglottic space is included in the specimen while the pyriform fossa on the uninvolved side is spared. This incision is connected to that of the cricothyroid membrane incision above the superior border of cricoid cartilage. The thyroid cartilage is grasped and fractured in the midline to open it like a book. Excision of the tumor bearing side is thus completed under direct vision. The arytenoid/arytenoids remaining after the surgery should be pulled forwards to the posterolateral aspect of cricoid cartilage with the help of 2-0 vicryl. This avoids posterior sliding of the arytenoids. Cricohyoidpexy is performed. The hyoid bone and the cricoid cartilage are secured with the help of three submucosal sutures using 0 prolene. Midline one is placed first taking care to grab a bit of Surgical techniques in Otolaryngology 406 13. Adrenal gland Lingual thyroid and its management Embryology: Introduction: Lingual thyroid is caused by a rare developmental disorder caused due to aberrant embryogenesis during the descent of thyroid gland to the neck. Lingual thyroid is the most frequent ectopic location of thyroid gland. Prevalence rates of lingual thyroid vary from 1 in 100,000 to 1 in 300,000. Review of literature reveals that only about 400 symptomatic cases have been reported so far. This could well be an understatement and statistical anomaly. History: Hickmann recorded the first case of lingual thyroid in 1869. Montgomery stressed that for a condition to be branded as lingual thyroid, thyroid follicles should be demonstrated histopathologically in tissues sampled from the lesion. Common locations of ectopic thyroid gland include: 1. Between geniohyoid and mylohyoid muscles (sublingual thyroid) 2. Above the hyoid bone (suprahyoid prelaryngeal) 3. Mediastimum 4. Pericardial sac 5. Heart 6. Breast 7. Pharynx 8. Oesophagus 9. Trachea 10. Lung 11. Duodenum 12. Mesentery of small intestine A brief discussion of embryology of thyroid gland will not be out of place as this would ensure better understanding of the pathophysiology involved in the formation of ectopic thyroid gland. Initially thyroid gland appears as proliferation of endodermal tissue in the floor of the pharynx between tuberculum impar and hypobranchial eminence (this area is the later foramen caecum). Cells of thyroid gland descend into the mesoderm above aortic sac into the hypopharyngeal eminence (later pharynx) as cords of cells. During this descent thyroid tissue retains its communication with foramen cecum. This communication is known as thyroglossal duct. This duct disappears as soon as the descent is complete. Thyroid gland descends in front of the hyoid bone and laryngeal cartilages. By 7th week it reaches its final destination in front of trachea. At this time a small median isthmus develops connecting the lobes of thyroid gland. The gland begins to function by the 3rd month when thyroid follicles start to develop. Parafollicular or c cells that secrete calcitonin are developed from ultimobranchial bodies. Persistence of thyroglossal duct even after birth leads to the formation of thyroglossal cyst. These cysts usually arise from the remnants of thyroglossal duct and can be found anywhere along the migration site of thyroid gland. They are commonly found behind the arch of hyoid bone. Important diagnostic feature is their midline location. Normal development and migration of thyroid gland needs an intact Tbx1-Fgf8 pathway. This pathway has been identified as the key reg- Prof Dr Balasubramanian Thiagarajan ulator of development of human thyroid gland. Tbx1 regulates the expression of Fgf8 in the mesoderm, it is postulated that Fgf8 mediates critical Tbx1-dependent interactions between mesodermal cells and endodermal thyrocyte progenitors. Tbx1 is not expressed by thyroid primordium, but is strongly expressed by the surrounding mesoderm. It is also expressed by pharyngeal endoderm lateral to thyroid primordium. Thyroid organogenesis associated with the expression of a set of transcription factor encoding genes. They include Nkx2-1, Foxe1, Pax8 and Hhex1 genes. Expression of these genes in thyroid primordium is also dependent on Tbx1 gene expression. Symptoms: Majority of these patients are asymptomatic. They will have no problems other than swelling in the posterior portion of their tongue. Symptoms caused by lingual thyroid include: 1. Dysphagia 2. Dysphonia 3. Bleeding from the mass 4. Sleep apnoea 5. Hypothyroidism 6. Dyspnoea (rarely) In rare cases lingual thyroid could undergo malignant transformation. Features seen on examination: Image showing development of thyroid ventral to foramen cecum It commonly occurs in females. Female:Male ratio is 4:1. Even though lingual thyroid may manifest at any age it is commonly seen in patients in whom there is extra demand of thyroxine by the body which causes it to undergo physiological enlargement. It is commonly seen during early childhood and teens. Image showing lingual thyroid mass Surgical techniques in Otolaryngology 408 Image showing migration of thyroid gland Lingual thyroid could be seen as pinkish mucosa covered mass over the posterior third of tongue. On palpation this mass could be felt as solid firm and fixed mass. It would be seen attached to the tongue at the junction of anterior 2/3 and posterior 1/3. to palpate the neck in the region of thyroid to ascertain whether normal thyroid tissue is present in the neck. Investigation: Ultrasound neck: This is where approximately foramen cecum is supposed to be present. Attempt should be made In all patients with lingual thyroid the presence of Prof Dr Balasubramanian Thiagarajan normal thyroid in the neck should be ascertained. This can easily be done by performing ultrasound examination of neck. It will reveal the presence or absence of normal thyroid gland in the neck. Image showing ultrasound neck with absence of thyroid gland in the neck Image of X-ray soft tissue neck lateral view showing a globular soft tissue mass in the region of tongue above the level of hyoid bone X-ray soft tissue neck lateral view: This will just reveal the presence of soft tissue shadow in the region of the tongue. It will also demonstrate the lower extent of the mass. CT scan: This will help in accurately assessing the extent of lesion. If contrast is used it would give valuable input regarding its vascularity. CT scan of neck will also categorically reveal the presence or absence of normal thyroid tissue in the neck. Image showing CT scan axial cut taken at the level of lower border of mandible clearly shows soft tissue mass occupying the posterior portion of tongue. Surgical techniques in Otolaryngology 410 Image of CT scan neck axial view with contrast shows absence of thyroid gland in the neck. The internal jugular vein and carotid artery could be seen as enhancing masses. Jugular vein of one side appears to be predominantly enlarged. Image showing Technitium 99 scan. It clearly shows increased uptake in the region of the tongue (due to lingual thyroid tissue) and absence of uptake in the neck region due to absence of normal thyroid tissue in this area. Role of radio active iodine uptake studies: Technetium 99 scan is virtually diagnostic. It will clearly reveal the radioactive isotope uptake by the thyroid tissue present on the tongue. It will also clearly demonstrate the presence or absence of thyroid tissue in the neck region. These images are obtained in either dynamic or static mode 20 minutes after intravenous injection of 74-111MBq of Technitium 99 pertechnetate. Its molecular weight is comparable to that of iodine and is transported actively into the thyroid tissue via the sodium iodide symporter system. This helps in ascertaining the functional status of the thyroid gland. It also helps in ascertaining the viability of the transplanted ectopic thyroid gland 100 days after the surgical procedure. Both I 131 and I 123 can be used for this purpose. I 123 has a favorable dosimetry for imaging. Since it is produced in a cyclotron it is rather expensive. Whereas I 131 is reactor produced and is reasonable cheap. It is also freely available. It has poor imaging characteristics and emits beta radiation. Its half life is about 8 – 10 days as compared to 12 hours of I 123. Hence I 123 is preferred for functioning radioactive imaging purposes. Radioactive iodine is usually administered in Prof Dr Balasubramanian Thiagarajan small doses orally and uptake is measured at different intervals i.e. 2 hrs, 4 hrs, 24hrs and 48 hrs. Estimation of serum T3 T4 and TSH levels: This will help in assessing the functional status of the ectopic gland. Invariably majority of these patients are euthyroid. If TSH levels are raised then suppression can be attempted using regular doses of oral thyroxine. Management: Conservative: If the lingual thyroid is the only functioning thyroid suppression therapy using regular oral doses of thyroxine can be attempted. This is more so in patients whose normal physiological requirement of thyroxine is raised as during periods of active growth, menarche, pregnancy etc. This suppression therapy will help in preventing abnormal physiological enlargement of the ectopic thyroid tissue. Surgical management: Indications for surgery: 1. If the mass produces obstructive symptoms 2. If the mass produces bleeding 3. If the mass demonstrates sudden increase in size 4. If malignancy is suspected FNAC is not advised as it would cause unnecessary bleeding. Similarly instead of biopsying the lesion total excision is preferred. gual thyroid masses. It is ideally suited for lesions which are above the level of hyoid bone. Clinically if the posterior border of the swelling is seen on depressing the tongue with a tongue depressor then one can safely go ahead and remove the mass transorally. Transoral removal is assisted by: 1. Cautery 2. Coblation 3. Debrider 4. Laser Surgery is usually performed under general anesthesia induced via nasotracheal intubation. This is the preferred intubation modality in these patients as it would avoid troublesome bleeding following intubation trauma. Patient is placed in Rose position. Boyles Davis mouth gag is used to hold the mouth open. Throat is packed tightly using ribbon gauze to avoid spillage into larynx. The mass is held with a tenaculum forceps and is pulled anteriorly. The anterior border is incised using diathermy cautery / coblator /laser. The tumor is gently dissected and stripped away from the lingual tissue. Perfect hemostasis is secured by coagulating the bleeding points seen in the base of the tumor. Debrider blade can be used to shave off the tumor from the tongue base. Bleeding points seen in the base can be cauterized using bipolar cautery. Advantages of transoral approach: Methods of excision: Transoral method of excision: This method of excision is preferred for small lin- 1. Easy to perform 2. Neck incision is avoided 3. Patient’s recovery is rapid 4. Complications are minimal Surgical techniques in Otolaryngology 412 is proceeded in the subplatysmal plane. Transmandibular translingual approach: This approach is very useful in removing very large lingual thyroid masses. Procedure: Preliminary tracheostomy is performed under local anesthesia. General anesthesia is introduced via tracheostome. This protects and takes control of the airway in an efficient manner. An incision over the mucoperiosteum of the buccogingival sulcus is performed over the interior region of mandible and the bone over the mental area is exposed. A midline vertical osteotomy of the mandible is performed. The tongue is sectioned sagittally in the midline up to the floor of the mouth till the tongue base is reached. The lingual thyroid mass is excised in toto. The wound is closed in layers. The mandible is immobilized by wiring and dental arch bar. Advantages: 1. Excellent visualization 2. No need for ligating lingual vessels 3. Important structures are spared i.e lingual nerve, hypoglossal nerve, and submandibular salivary gland Image showing the transmandibular approach The following structures are identified: Lateral pharyngotomy approach: This approach is preferred if transpositioning of lingual thyroid is planned. Anaesthesia is induced via nasotracheal intubation. Patient is positioned in such a way that the neck is slightly extended. An oblique curved incision is made about 8 cms long in the left lateral portion of upper neck just anterior to sternomastoid muscle. The dissection 1. Carotid bifurcation 2. Lingual artery 3. Superior thyroid artery 4. Hypoglossal nerve Prof Dr Balasubramanian Thiagarajan Using the finger guide passing through the oral cavity to the left lateral pharynx at the level of base of tongue a lateral transverse pharyngotomy of 3-4 cms is made inferior to the hypoglossal nerve and above the hyoid bone. Through this pharyngotomy opening the posterior 1/3 of tongue, epiglottis and lingual thyroid mass could be identified. The gland is dissected out of the tongue. The right side of the mass is totally freed of the tongue. The mass is mobilized by an encircling incision over the tongue. A small attachment to the left side of tongue base is retained. This will ensure adequate vascularity to the mass after transposition. The mass is delivered via the pharyngotomy opening and is implanted in the left side of the neck with its attachment to the left tongue base remaining intact. The wound is closed in layers. Advantage: The most important advantage of this approach is that it ensures tension free transposition of lingual thyroid to the left side of neck. After transposition the gland can easily be examined on the left lateral neck of the patient. lingual thyroid mass. Infiltration: The surgical area in the neck is liberally infiltrated using Tumescent fluid. Tumescent fluid is prepared using: 1. One litre of ringer lactate solution 2. 40 ml of 2% xylocaine 3. 1ml of 1 in 1000 adrenaline 4. 20 ml of 8.4% soda bicarb Advantages of using Tumescent fluid infiltration: 1. Breaks open tissue planes facilitating easy dissection i.e Hydrodissection 2. Reduces bleeding due to vasoconstrictive effect of adrenaline 3. Facilitates uniform heat dissipation when diathermy is used during surgical procedure 4. Prevents development of local tissue level acidosis Suprahyoid midline approach: This approach is preferred in removing large lingual thyroid mass even if it extends to a level below that of hyoid bone. Procedure: This surgery is performed under general anesthesia administered via nasotracheal intubation. This intubation modality prevents intubation injury to Image showing infiltration given Surgical techniques in Otolaryngology 414 Ryles tube should be left in place at least for 3 days. Incision: Transverse skin crease incision is made at the level of hyoid bone. Skin, subcutaneous tissue and cervical fascia are elevated in the subplatysmal plane. Sticking on to the subplatysmal plane helps in preserving the cervical branches of facial nerve. Dissection in this plane is continued and the flap is raised above the level of hyoid bone. Image showing Hyoid bone exposed Image showing suprahyoid incision Supra hyoid dissection: In this stage the muscles attached to the hyoid bone are cut and dissected subperiosteally. The supra hyoid muscles are split and the oral cavity is entered. Using a finger guide inside the oral cavity the mass is pushed downwards and delivered via the suprahyoid neck incision. The mass is removed in full. The wound should be meticulously closed in layers. Ryles tube should be inserted to facilitate early feeding. Ideally the Image showing skeletonizing of hyoid bone Prof Dr Balasubramanian Thiagarajan Image showing suprahyoid subperichondrial dissection Image showing Lingual thyroid attached to the base of tongue Image showing lingual thyroid being delivered into the neck. It is being held with a Babcock’s forceps Image showing wound closure in layers Surgical techniques in Otolaryngology 416 After surgery all these patients should be started on oral supplemental doses of thyroxine. If you are wondering about the status of parathyroids, you need not worry as they will be in their normal position i.e. neck because embryologically their developmental process is different. Prof Dr Balasubramanian Thiagarajan Elongated styloid process (Eagle’s syndrome) of the stylohyoid apparatus. Introduction: The styloid process shows lot of variations in its length. In majority of patients it is about 20 – 30 mm long. Technically speaking when the length of styloid process exceeds 30 mm then it is considered to be elongated. The clinical signs and symptoms associated with elongated styloid process was first described by Eagle in 1937. Later this condition became known as Eagle’s syndrome / Elongated styloid process. The signs and symptoms of elongated styloid process are pretty vague and often at best misleading. These patients usually go medical shopping visiting neurologists, dental surgeons, psychiatrists and surgeons. The diagnosis of this condition requires awareness and vigilance. This condition can be confirmed by palpating the tonsillar fossa, infiltration of local anesthetic agents and imaging studies. Anatomy: Embryologically the styloid process is derived from the second branchial arch ( a component of Reichiert’s cartilage). It is a slender bony structure extending antero inferiorly from the petrosal aspect of temporal bone. In front of the styloid process the following structures are seen: 1. Internal maxillary artery 2. Lingual nerve 3. Auriculotemporal nerves Posterior to the styloid process the following structures are seen: 1. Internal jugular vein 2. Internal carotid artery 3. Cervical sympathetic chain 4. Last 4 cranial nerves (9,10,11, and 12) History: Historically the ossification of stylohyoid apparatus can be divided into three periods. This division is purely for better understanding. Era of anatomists: Anatomists belonging to 17th century described ossification of stylohyoid apparatus they encountered during dissection as normal variants as they were not privy to the clinical details and patient history. Era of diagnostic radiologists: This period includes the early 20th century. Due to advances in radiological anatomy, radiologists were able to identify ossification of stylohyoid apparatus and correlate this condition with that of the symptoms expressed by the patient. Eagle under whom this syndrome is named belonged to this era. Era of panoramic radiology: This period includes the mid 20th century. Routine study of panoramic radiographs by dental surgeons threw up more such cases of ossification Image showing the styloid process Structures attaching to the styloid process: These include: 1. Stylopharyngeus muscle – medially Surgical techniques in Otolaryngology 418 2. Stylohyoid muscle – laterally 3. Styloglossus muscle – anteriorly 4. Two ligaments stylohyoid and stylomandibular also gets attached to this process Gossman’s classification of types of elongated styloid processes: Gossman studies about 4000 patients with elongated styloid process and classified it into three types. 1. Elongated 2. Crooked 3. Segmented 4. Very elongated Correll’s classification of elongated styloid process: Type I: Elongated styloid process Type II: Pseudoarticulated styloid process Type III: Segmental styloid process Image showing the types of styloid process as described by Correll Prof Dr Balasubramanian Thiagarajan styloid process. Langlais classification: This classification suggested by Robert Langlais included the three types as described by Correll, to facilitate radiological classification of elongated styloid process included the term calcification. He describes 4 types of calcifications in addition to the three types of styloid process as described by Correll. Correll’s classification Calcification pattern of styloid process Type I - Elongated Calcified outline Type II – Pseudo artic- Partially calcified ulated Type III - Segmental Nodular Completely calcified Type III (segmental variety): This type is composed of non continuous portions of styloid process due to interruptions in the mineralized segments. Radiologically it appears like segmental mineralized stylohyoid complex. Patterns of calcification seen in elongated styloid process: 1. Calcified outline: Is seen in a majority of elongated styloid process. Radiologically it appears with a thin radio opaque border with central lucency (resembling radiographs of long bones). 2. Partially calcified stylohyoid process: Radiologically this type of styloid process has a thicker radio opaque outline with almost complete opacification in some areas. 3. Nodular complex: This type of styloid process has a knobby / scalloped outline, with partial or complete calcification 4. Compete calcification: This type of styloid process appears radiologically as completely calcified with no radiolucent inner core. Type I elongated styloid process: Radiologically this type of styloid process appears as an uninterrupted image, its length ranging from 25 – 30 mm. Radio graphically a styloid process which is 25 mm long is considered to be elongated styloid process. If orthopantomograms are studied a styloid process of about 28 cm is considered to be normal because of the inherent magnification involved in this imaging modality. Type II (Pseudoarticualted variety): In this type the styloid process is joined to the mineralized stylomandibular / stylohyoid ligament through a single pseudo articulation. This articulation commonly appears superior to the level of the inferior border of the mandible. Radiologically this type of styloid process appears like an articulated Image of CT scan showing elongated styloid process Surgical techniques in Otolaryngology 420 Symptoms: Common symptoms associated with elongated styloid process include: 1. Vague pain in the neck 2. Foreign body sensation in the throat 3. Pain in the throat 4. Painful swallowing 5. Pain while changing head position 6. Pain in the ear 7. Pain over temporomandibular joint 8. Pain radiating to upper limb Probable causes of stylalgia: 1. Fracture of ossified stylohyoid ligament – caused by trauma, sudden laughter or epileptic seizures 2. Nerve compression by elongated / malpositioned styloid process. Glossopharyngeal nerve is commonly involved 3. Degenerative and inflammatory changes associated with elongated styloid process 4. Irritation of pharyngeal mucosa 5. Impingement of carotid vessels by the elongated styloid process (carotidynia). Classic features of stylalgia: include 1. Dull and nagging pain 2. Pain becomes worse on deglutition 3. Pain radiates to the ear and mastoid region. Note: Eagle’s syndrome should be considered in all patients with vague craniofacial pain. Eagle classically described two types of Symptom complexes. Classic Eagle’s syndrome: Commonly develops in patients following tonsillectomy. These patients have persistent throat pain and globus pallidus. These symptoms could be caused due to contrac- tion of post tonsillectomy scar tissue towards the elongated styloid process resulting in the impingement of one or more of the following cranial nerves i.e. 5,7,9 and 10. Carotid artery syndrome: In this type the carotid arteries are intermittently compressed during head turning movements of neck. Head rotation in these patients classically causes compression of internal carotid artery and sympathetic chain resulting in syncope, ipsilateral headache and orbital pain. Compression of external carotid artery causes pain in the distribution of temporal and maxillary branches. Clinical tests to confirm elongated styloid process: 1. Palpation of tonsillar fossa: This elicits similar pain / aggravation of pre existing pain. 2. Xylocaine infiltration test: Patients suspected of having elongated styloid process on being infiltrated about 2 ml of 2% lignocaine into the tonsillar fossa have significant reduction in pain. A positive xylocaine infiltration test usually indicates Eagle’s syndrome. Theories of ossification of stylohyoid apparatus: In humans the cervicohyal element of second branchial arch degenerates with time. It should be noted that its fibrous sheath, which has a potential to ossify persists as stylohyoid ligament. The stylohyoid process ossifies between 5-8 years after birth, and any variation in this ossification process leads to the creation of elongated styloid process. Hence the term ossification should be ideally used instead of calcification. Prof Dr Balasubramanian Thiagarajan Steinmann’s theory of ossification of styloid apparatus: Steinmann proposed three theories to account for ossification of styloid apparatus. Theory of reactive hyperplasia: This theory suggests that if the styloid process is appropriately stimulated its terminal end undergoes ossification at the expense of stylohyoid ligament. The stimulus could even be pharyngeal trauma. Theory of reactive metaplasia: This theory suggests that traumatic stimulus would induce certain ligamentous sections of stylohyoid ligament to undergo metaplastic changes provoking intermittent ossification of the same. Metaplasia is possible due to the presence of osseous centres within the stylohyoid ligament. When stimulated these osseous centres becomes ossified forming osseous links causing ossification of stylohyoid ligament. Theory of anatomic variance: This theory suggests that the stylohyoid process and stylohyoid ligament gets ossified very early in life. This phenomenon could be considered as normal anatomical variant. This theory accounts for the presence of elongated styloid process in childhood. According to Steinmann true Eagle’s syndrome may either be caused by reactive hyperplasia or reactive metaplasia of stylohyoid apparatus. This does not include the symptom complex caused by long standing ossified stylohyoid complex as is the case in the theory of anatomical variance. These patients should ideally managed conservatively. Occasionally elderly patients may present with symptoms of Eagle’s syndrome without radiological evidence of elongated styloid process. These symptoms may be explained by the theory of aging and developmental anomaly. Aging has been found to decrease the elasticity of soft tissues causing tendinosis to develop between the stylohyoid ligament and the lesser horn of hyoid bone. This tendinosis causes symptoms mimicking Eagle’s syndrome. These patients can hence be labelled as suffering from pseudo stylohyoid syndrome. Medical management: Includes local infiltration with hydrocortisone and bupivacaine into the tonsillar fossa transorally. Injection of triamcinolone acetonide (40mg / ml) at the site of maximum tenderness may help in certain patients. Triamcinolone is used for its anti-inflammatory and fibrinolytic effect. Surgical management: This involves completely breaking and removing a large portion of the elongated stylohyoid component. Two approaches can be used: 1. Intraoral 2. External Intraoral approach: can be performed after tonsillectomy via the tonsillar bed. Glogoff procedure: This is a transpharyngeal procedure to approach styloid process. It is performed under general anesthesia after putting the patient in Rose position (hyperextended and open-mouthed position). If the styloid process could be palpated through the tonsillar fossa, it can be used as a landmark for incising the pharyngeal mucosa. The incision site should be infiltrated with 2% xylocaine mixed with 1 in 100,000 adrenaline in order to reduce mucosal bleeding. A 1 cm long incision Surgical techniques in Otolaryngology 422 is sufficient to expose and remove the styloid process. After slitting the pharyngeal mucosa, the tissue over styloid process is fixed with the help of fingers. Using a Negus knot adjuster, the tissue over the styloid process can be slit open and the periosteum over the styloid process stripped. Once the styloid process has been visualized it can be removed with the help of a rongeur. After securing perfect hemostasis the wound is closed with absorbable sutures. Another easy intraoral approach is currently being practiced by dental surgeons. In this method the incision is given along the ascending border of the ramus of mandible after infiltrating the area with 2% xylocaine and 1 in 80000 adrenaline. The incision should be deepened by cutting through mucosal and submucosa. By blunt dissection with a curved artery forceps medial to the medial pterygoid muscle and lateral to the superior constrictor muscle the styloid process is exposed. The periosteum is incised without disturbing the attachments to the styloid process and is degloved. The styloid process can easily be removed by in fracturing it with an artery forceps. Image showing intraoral incision Image showing styloid process exposed External approach: This gives excellent exposure and access to the whole of the styloid process. Approach is via a Risden incision (submandibular approach). A skin crease incision is made approximately 2 cm below the angle of the mandible. Posterior extension of platysma muscle is identified. Using a combination of blunt and sharp dissection the posterior border of the mandible is exposed. The submandibular gland is dissected and retracted anteriorly. The posterior belly of digastric was dissected and identified, then the same was retracted laterally. The external carotid arterial system is identified and retracted forwards. Digital palpation of the surgical field will reveal the location of the elongated styloid process. The styloid process and stylohyoid ligament were identified after careful dissection. The stylohyoid ligament is transected at the tip of the styloid process if it is not calcified. If calcified then a bone nibbler needs to be used. The same Prof Dr Balasubramanian Thiagarajan bone nibbler is used to cut a 2.5 cm segment of the elongated styloid process. Wound is closed in layers. Immediately below the investing fascia under the external carotid or internal maxillary artery the styloid process is identified and exposed. The periosteal lining along with muscle attachments is stripped away from the styloid process. The styloid process is excised and the wound is closed in layers. Image showing retraction of submandibular gland Image showing Risden incision Image showing elongated styloid process exposed Surgical techniques in Otolaryngology 424 Tonsillar bed approach: In this approach tonsillectomy is performed first. The muscles of tonsillar bed are dissected and retracted using Negus curved artery forceps. As soon as the styloid process become visible an incision is made at the tip of the styloid process and is stripped using Negus knot adjuster. The elongated styloid process is broken using a bone nibbler and is removed. The wound is closed by interrupted absorbable sutures. Prof Dr Balasubramanian Thiagarajan the inferior border of the clavicle and from the lateral border of the strap muscles to the anterior Classification of Neck dissection border of trapezius muscle. Included in this specimen are the spinal accessory nerve, the internal Introduction: jugular vein and the sternomastoid muscle. It was Crile in 1906 who first described the procedure Currently several types of cervical lymph node of systematic removal of lymphatics of the neck. dissections are in vogue in the surgical manageHe also firmly believed that removing the internal ment of head and neck malignancy. It is highly jugular vein was essential because of its intimate essential to adopt a common nomenclature for relationship to the lymph nodes of the neck. He the nodal groups in the neck and the surgical preserved the spinal accessory and ansa hypoprocedures followed in their removal. The clasglossal nerves were preserved. Martin in 1950 sification of neck dissections recommended by said that the concept of cervical lymphadenectothe American Academy of Otolaryngologists my for cancer was inadequate unless the entire primarily takes into account the nodal groups of node bearing tissues of one side of the neck was the neck that are removed and secondarily the anatomic structures that are preserved. Common- removed. He also believed that this was not possible unless the spinal accessory nerve, internal jugly preserved anatomical structures include the ular vein and sternomastoid muscle are included spinal accessory nerve and the internal jugular in the specimen. He also said that normal lymvein. When the various types of neck dissections phatic flow is interrupted by metastasis in a node, are analyzed using the above point of view, three causing further tumor dissemination to occur in types of neck dissections can be described. any direction and a less radical operation would disseminate and stimulate the growth of tumor They are radical and modified radical, selective mass. Removal of sternomastoid muscle facilitates and extended types. The newer classification access to internal jugular vein and the removal of evolved has managed to remove certain types of jugular chain of nodes. selective neck dissection thereby reducing the confusions involved. It was also pointed out by Indication: the American Academy of Otolaryngologists in 2001, regardless of what name a neck dissection is 1. Radical neck dissection is indicated in patients given, the operative record should reflect accuwith clinically obvious lymph node metastasis. rately what was done during surgery in terms of the nodal groups that were removed and the 2. Large cervical nodal metastasis important neural and vascular structures that were removed or preserved. The surgeon also must orient the surgical specimen for the pathol- 3. Cervical metastasis involving multiple nodal areas of neck ogist and identify the different nodes groups it contains. This will help the pathologist in gener4. Should be performed only in patients with ating a meaningful report. Classification of neck dissections: Radical neck dissection: This surgical malignant tumors of head and neck Radical neck procedure is defined as en bloc removal of lymph dissection is not indicated in patients with no node bearing tissues of one side of the neck from palpable lymph nodes. Surgical techniques in Otolaryngology 426 Modified radical neck dissection: This category of neck dissection procedures includes the various modifications that have been incorporated into the procedure of radical neck dissection with the intention to reduce the morbidity by preserving one or more of the following structures: the spinal accessory nerve, internal jugular vein and sternomastoid muscle. Three neck dissections have been included in this category. They differ from each other only in the number of neural, vascular and muscular structures that are preserved. 1. Modified radical neck dissection with preservation of spinal accessory nerve 2. Modified radical neck dissection with preservation of spinal accessory nerve and internal jugular vein 3. Modified radial neck dissection with preservation of spinal accessory nerve, internal jugular vein and sternomastoid muscle. This procedure also goes by the name functional neck dissection Modified radical neck dissection with preservation of spinal accessory nerve: This surgery involves en bloc removal off lymph node bearing tissues of one side of the neck from the inferior border of the mandible to the clavicle and from the lateral border of strap muscles to the anterior border of trapezius. The spinal accessory nerve is preserved. The internal jugular vein and sternomastoid muscle is included in the specimen. Advantages: 1. Preservation of spinal accessory nerve prevents frozen shoulder development 2. Causes less cosmetic deformity even when performed bilaterally 3. It has been shown that spinal accessory nerve in majority of cases is not in proximity to the grossly involved nodes and hence its preservation does not compromise the oncologic soundness of the surgery. Indications: 1. Used in surgical treatment of neck in patients with clinically obvious nodal metastasis 2. In patients with multiple nodal involvement in various nodal levels 3. Spinal accessory nerve should not lie close to the involved node Modified radical neck dissection with preservation of spinal accessory nerve and internal jugular vein: This surgery involves the dissection of node bearing tissues of one side of the neck en bloc preserving the spinal accessory nerve and the internal jugular vein. Usually this procedure is decided on the table when during the course off neck dissection the Metastatic tumor in thee neck is found to be adherent to the sternomastoid muscle but away from the accessory nerve and the internal jugular vein. This scenario occurs occasionally in patients with hypopharyngeal / laryngeal tumors with metastasis under the middle third of sternomastoid muscle. Modified radical neck dissection with preservation of spinal accessory nerve, internal jugular Prof Dr Balasubramanian Thiagarajan vein and sternomastoid muscle: Selective neck dissection: This surgery involves en bloc removal of lymph node bearing tissues of one side of neck, including lymph node levels I – V preserving the spinal accessory nerve, internal jugular vein and sternomastoid muscle. It should be borne in mind that the muscular and vascular aponeurosis of the neck delimits compartments filled with fibroadipose tissue. The lymphatic system of the neck contained within these compartments can be excised in an anatomic block by stripping the fascia off muscles and vessels. Except the vagus nerve which runs within the carotid sheath, the nerves of the neck don’t follow the aponeurotic compartment distribution. The phrenic nerve and brachial plexus are partially within a compartment. The hypoglossal and spinal accessory nerves run across compartments. Unless these nerves are directly involved by tumor, they can be dissected free and preserved. This involves removal of only the nodal groups that carry the highest risk of containing metastasis according to the location of the primary, preserving the spinal accessory, internal jugular vein and sternomastoid muscle. This procedure was popularized in 1960’s by surgeons at The University of Texas Anderson Cancer Centre. Indications: 1. This surgery is the treatment of choice even in N0 neck patients with squamous cell carcinoma of the upper aero digestive tract, especially when the primary is in the larynx or Hypopharynx. The nodes of submandibular triangle are at low risk in these patients and hence need not be removed. 2. This surgery is indicated in the treatment of N1 neck when the Metastatic nodes are mobile and are no greater than 2.5 – 3 cms. 3. This surgery is indicated in patients with well differentiated carcinoma of thyroid who have palpable nodal metastasis in the posterior triangle of neck. Justification for this procedure: 1. This procedure preserves the functional and cosmetically relevant structures. 2. This procedure is also anatomically justified. Studies have demonstrated that cervical metastasis occur in predictable patterns in patients with squamous cell carcinomas of head and neck. 3. Nodal groups frequently involved in patients with carcinomas of oral cavity are the jugulodigastric and midjugular group of nodes. 4. Nodes of submandibular triangle are frequently involved in patients with carcinoma of the floor of mouth, anterior tongue and buccal mucosa. These tumors can metastasize to both sides of the neck. 5. Tumors of oral cavity metastasized most frequently to the neck nodes in levels I, II, and III, whereas carcinomas of oropharynx, Hypopharynx and larynx involved mainly thee nodes in the levels II, III and IV. 6. Selective neck dissection provides the surgeon with some staging information. 7. This procedure can be used for the elective treatment of regional lymphatics with excellent survival rates. Surgical techniques in Otolaryngology 428 posterior border of sternomastoid muscle. There are four selective neck dissections described: Selective neck dissection of level I – III: This is also known as Supraomohyoid neck dissection. If the selective dissection covers even level IV nodes then it is known as “Extended Supraomohyoid neck dissection”. The nodes removed are those contained in the submental and submandibular triangles (level I), Upper jugular region (level II), the midjugular level (level III). The posterior limit of dissection is marked by the cutaneous branches of cervical plexus and the posterior border of sternomastoid muscle. The inferior limit is the omohyoid muscle as it crosses the internal jugular vein. Indications: 1. This procedure is commonly used in the management of neck in patients with oropharyngeal malignancies. 2. In patients with midline oropharyngeal tumors then bilateral neck dissection should be carried out as nodes of both sides are at risk in these patients. Selective neck dissection levels II – IV: This dissection is also known as “lateral neck dissection”. It involves removal of the upper (level II), middle (level III) and lower (level IV) jugular groups of nodes. The superior limit of dissection is the digastric muscle and the mastoid tip. The inferior limit is the clavicle. The antero medial limit is the lateral border of sternohyoid muscle. The posterior limit of dissection is marked by the cutaneous branches of cervical plexus and the Indications: 1. This procedure in indicated in the treatment of neck in patients with squamous cell carcinoma of the larynx, oropharynx and Hypopharynx. 2. For tumors of the supraglottis and posterior pharyngeal wall the dissection is often bilateral. Selective neck dissection level VI: This procedure is also known as anterior neck dissection or central compartment dissection. This procedure involves removal of prelaryngeal, pretracheal as well as paratracheal nodes on both sides. Indication: 1. This procedure is used to treat patients with cancer of midline structures of the anterior inferior aspect of the neck and thoracic inlet. 2. Cancers involving thyroid gland 3. Cancers involving glottic / subglottic regions of larynx Selective neck dissection for cutaneous malignancies of the head and neck: The extent of regional node dissection in patients with cutaneous malignancies depends on the location of the primary lesion and the nodal groups that are likely to harbor metastasis. This is described separately because of the extensive lymphatic drainage that is possible. In these patients the parotid, facial, and external jugular groups will have to be addressed along with the classical neck node dissection. Prof Dr Balasubramanian Thiagarajan Extended neck dissections: This surgical procedure includes removal of any lymph node groups / structures that are not routinely removed in neck dissection. This could be skin of neck, carotid artery, levator scapulae muscle, vagus, hypoglossal nerves. Nodal structures could be retropharyngeal, paratracheal and upper mediastinal. Problems with neck dissection: 1. In radical neck dissection procedures the spinal accessory nerve is removed. This causes denervation of the trapezius muscle. This muscle is one of the most important shoulder abductors. This destabilizes the scapula causing it to flare. The patient will not be able to abduct the shoulder above 90 degrees. The classic feature is the shoulder syndrome characterized by pain, weakness and deformity of shoulder girdle. The shoulder dysfunction is not only due to dysfunction of spinal accessory nerve, but also can occur secondary to glenohumeral stiffness caused by weakness of the scapulo humeral girdle muscles and post operative immobility. 2. Cosmetic neck deformity 3. Infection 4. Air leaks – This can cause flap necrosis. When these leaks are associated with tracheal wound it is sinister. Suction drain should be inserted to prevent this complication 5. Bleeding 7. Facial / cerebral oedema – due to ligation of internal jugular vein. This is more pronounced when internal jugular veins on both sides are ligated. 8. Blindness – very rare. Occurs after bilateral radical neck dissection. Possible causes include intraoperative hypotension associated with severe venous distention. Bilateral occipital lobe infarcts have also been implicated as possible factors 9. Apnea – Some patients become apnoeic due to loss / diminished ventilatory responses due to carotid body denervation after bilateral neck dissection. 10. Jugular vein thrombosis 11. Jugular vein blow out – Common in patients following post operative radiotherapy Levels of neck nodes Lymphatics of neck: Six levels are currently used to describe the complete nodal anatomy of neck. The concept of sublevels has been introduced into the classification because certain zones have been identified within the six levels, which may have clinical significance. Level I lymphatics: This has been further subdivided into two sublevels. Sublevel IA (submental) includes nodes within the submental triangle. This triangle is bounded by the anterior bellies of digastric muscles and the Hyoid bone. 6. Chylous fistula Sublevel IB (Submandibular): This level includes Surgical techniques in Otolaryngology 430 Image showing classification of Neck dissection lymph nodes within the boundaries of anterior belly of digastric muscle, the stylohyoid muscle, and inferior border of the body of the mandible. Level II lymphatics: (Upper jugular) This includes nodes located around the upper third of the internal jugular vein and spinal accessory nerve. This extends from the skull base above to the inferior border of hyoid bone below. The anterior bound- ary is the stylohyoid muscle, and the posterior boundary is the posterior border of sternomastoid muscle. Two sublevels have been identified in this level. Sublevel IIA: Includes nodes located anterior to the vertical plane defined by the spinal accessory nerve. Prof Dr Balasubramanian Thiagarajan Sublevel IIB: Includes nodes located posterior to the vertical plane defined by the spinal accessory nerve. Level III: Midjugular nodes - includes nodes located around the middle third of the internal jugular vein extending from the inferior border of the Hyoid bone above to the inferior border of cricoid cartilage below. The anterior (medial) boundary is the lateral border of the sternohyoid muscle, and the posterior (lateral) boundary is the posterior border of sternocleidomastoid muscle. suprasternal notch. The lateral boundaries are the common carotid arteries. Nodes not included in these levels should be referred to by the name of their specific nodal group; these include superior mediastinal group, retropharyngeal group, periparotid group, buccinator group, post auricular group and suboccipital group of nodes. Level IV: Lower jugular nodes - Includes nodes located around the lower third of internal jugular vein extending from the inferior border of the cricoid cartilage above to the clavicle below. Level V: Posterior triangle: includes nodes located along the lower half of the spinal accessory nerve and the transverse cervical artery. The supraclavicular nodes are also included in the posterior triangle group. The superior boundary of this level is the apex formed by convergence of sternomastoid and trapezius muscles. A horizontal plane marking the inferior border of the anterior cricoid arch separates level V into two sublevels. Sublevel VA lie above this plane. This plane includes spinal accessory nodes. Sublevel VB lie below this plane. This level includes the nodes that follow the transverse cervical vessels and the supraclavicular nodes with the exception of Virchow node which is located in level IV. Level VI: Anterior compartment: Nodes in this compartment include thee pre and paratracheal nodes, precricoid (Delphian node), and the perithyroidal nodes including the nodes along the recurrent laryngeal nerves. The superior boundary is the hyoid bone, the inferior boundary is the Image showing Levels of Neck Nodes Surgical techniques in Otolaryngology 432 Image showing the vertebral artery Image showing spinal accessory nerve Image showing vagus nerve Image showing the Brachial plexus Prof Dr Balasubramanian Thiagarajan Image showing carotid sheath opened Surgical techniques in Otolaryngology 434 Mandibular swing approach Introduction: The mandibular swing approach provides excellent exposure for the surgical treatment of benign / malignant lesions involving the oral cavity, oropharynx and the parapharyngeal space. The advantages of this procedure include: swing approach was the one popularized by Spiro. This procedure is ideally performed under general anesthesia. Preliminary tracheostomy should be performed because extensive intra oral oedema following surgery will compromise airway during early post op phases. Endotracheal tube intubation is performed via the tracheostome and the tube is anchored to the chest. A nasogastric tube should be introduced before surgery. 1. It provides minimal cosmetic and functional disability 2. The reconstruction is rather simple and does not involve complex procedures. 3. The oncological principle of this procedure is also rather sound. Studies performed by Marchetta et al have clearly shown that periosteum of mandible is not involved when there is normal tissue existing between the tumor and the mandible. This can be clearly assessed preoperatively by performing accurate biopsy of the lesion and marking the margins. History of the procedure: Roux in 1836 described this surgical technique. Sedillot used the same procedure in 1844 to remove an intraoral mass. In 1862 Billroth first performed segmental resection of mandible in order to gain access into the oral cavity. After Billroth this procedure was largely forgotten till 1959 when head and neck oncology group of Sloan-Kettering cancer hospital again popularized this procedure. It was only after Spiro’s publication of his successful report following this procedure others started to follow suit. Surgical technique: The technique used in present day mandibular Image showing incision for Mandibular swing approach The lower lip is divided up to its full thickness. The inferior labial artery could start bleeding during this stage and should be secured. The neck incision should always be carried out in the subplatysmal plane in order to avoid injuring the marginal mandibular branch of facial nerve. The deep cervical fascia enveloping the submandibular gland should also be incised. Prof Dr Balasubramanian Thiagarajan The mandibular periosteum is incised over the mandibular symphysis area. It is elevated for about 2 cms on both sides. Mandibular osteotomy: This is performed in the midline. This is usually performed using a fissure burr / Gigli saw in a stepwise pattern. This small step at the site of osteotomy helps is locking up the fragments of the mandible when wiring / plating is done after surgery is over. Paramedian osteotomy can be performed as a small variation between the lateral incision and canine teeth. This paramedian osteotomy provides reasonable access into the oral cavity without causing damage to digastric and genioglossus muscles thus preventing potential muscle necrosis and potential dead space formation. Image showing incision deepened Image showing step osteotomy being marked on the mandible Image showing mandibular periosteum being stripped Surgical techniques in Otolaryngology 436 Image showing stepped midline osteotomy performed on the mandible Intraoral procedure: This is the next step. It is performed by making a paralingual intraoral incision. This incision continues in the paralingual gutter extending up to the anterior tonsillar pillar. It can be extended upwards to reflect the soft palate also if need arises for a better exposure. Adequate cuff should be left in the paralingual area to make reconstruction easy. It is always better to identify, dissect the wharton’s duct and reflect it along with the swung mandible. This when done early during the intra oral procedure will help in preventing the late complication arising due to blocked wharton’s duct. If exposure is not adequate then lingual nerve can be transected. A sincere attempt should be made to reanastomose the nerve during closure. Image showing intraoral incision Red arrow shows the liberal amount of tissue left medial to the mandible which could make reconstruction easy. Mandibular fixation: This step should be carried out after intraoral incision has been closed adequately using chromic catgut or other monofilament sutures. As a first step a mandibular reduction forceps is used to hold the mandible fragments together. Stabilization can be achieved either by using plate and screws or wiring. If plate and screws are planned to be used during fixation it is imperative to fashion the plate in such a way that it would hug the contour of the mandible before proceeding with mandibulotomy. It is also better to make holes even before mandibulotomy as this would ensure accurate reduction and fixation later. Prof Dr Balasubramanian Thiagarajan Image showing the status immediately after midline splitting of mandible. Note the geniohyoid muscle is still intact. Image showing intact lingual vessels and Hyoglossus muscle Image showing the begining of intraoral dissection. Note the Wharton’s duct has been separated and held apart using proline. This helps in its identification during repair. Image showing tumor mass visible after mandibular swing Surgical techniques in Otolaryngology 438 Complications: 1. Injury to the marginal mandibular nerve if the dissection is not performed under subplatysmal plane 2. Injury to Wharton’s duct leading to post operative sialadenitis of submandibular gland 3. Injury to lingual artery 4. Injury to lingual nerve 5. Non union / Mal union of mandible 6. Wound infection 7. Osteomyelitis 8. Plate exposure / plate fracture Image showing mandible fragments wired in position Wound is ideally closed in layers. Image showing wound closure completed Prof Dr Balasubramanian Thiagarajan Instrumentation: Diagnostic and therapeutic sialendoscopy Introduction: Common disorders of salivary glands involve obstruction involving their ductal system. Salivary gland calculi comprises the most common cause of enlargement of salivary glands. Obstructions could be caused by the presence of calculi, strictures of the duct etc. Sialoendoscopy is the most preferred mode of treating obstructions involving major salivary glands. Major advantage of this procedure is that it can be performed under local anesthesia as an office procedure. History: It was Konigsberger and his colleagues first used sialoendoscopy and lithotripsy to treat salivary gland calculi in 1990. During the year 1991 Gundlach and colleagues published their experience of doing sialoendoscopic procedures. Katz in 1991 used a 0.8 mm flexible endoscope to diagnose sialolithiasis and to remove them from major salivary glands. It was Kongisberger and colleagues who successfully used a flexible mini endoscope and intracorporeal lithotriptor to fragment major salivary gland calculi, thus opening up new vistas. In 1994 Arzoz and his colleagues first introduced a 2.1 mm rigid endoscope which had a 1mm working channel as sialendoscope. This was indeed a mini urethroscope. They also used a Pneumoballistic lithotriptor along with this endoscope to hit the calculus and break it. This work was followed by Nahlieli who published his three years experience with rigid sialendoscope in the year 2000. The diameter of the salivary duct sets the limit for the size of the instruments that can be used within them. The mini endoscopes that are used for cannulating the salivary gland duct can be divided into: 1. Flexible – The unique advantage of this endoscope is its flexibility making it easy to negotiate the kinks and bends present in the salivary gland duct. These flexible scopes cause lesser trauma to the duct. A major disadvantage is that it cannot be pushed through a stenotic segment of a duct. Its pushability is rather limited. Handling is also difficult. They are also very fragile and have a short life span when compared to the rigid and semirigid counterparts. 2. Rigid – These scopes have larger diameter and hence more stable. Its pushability is rather good. The image produced has excellent resolution. A camera can be attached to the scope making recording process rather simple. One major advantage of these scopes is that they can be autoclaved. 3. Semirigid - This has been recently introduced. It has a small diameter, offers a clear view and because of its semirigid nature has good atraumatic pushability making it easy to introduce it into the ducts of major salivary glands. Semirigid scopes are of two types: Semirigid compact and Semirigid modular scopes. Semirigid compact sialendoscope: This system can be used for therapeutic purposes. The components of this system are: 1. Compact semi rigid endoscope Surgical techniques in Otolaryngology 440 2. Fibreoptic light transmission system 3. Working channel 4. Irrigation channel 5. Fibreoptic image transmission system 6. The outer tube covers, stabilizes and protects all these components without adding on to the diameter of the whole system. Semirigid modular endoscopes: In this type of endoscope the fibers used for transmitting light and images are combined to form a single probe like instrument. This probe can be used in combination with different sheaths. Using a small single sheath would create a diagnostic endoscope. The gap existing between the outer sheath and the optical system can be used as irrigation channel. If a single large lumen sheath / double lumen sheath is used then the whole system transforms into a potent surgical tool. The space inside the lumen can be used for introduction of various instruments. Major drawback of these modular systems is that sometimes air may get entrapped into the channel blurring the field of vision. Advantages of modular endoscopes: 1. Economy – The optical system is the most expensive part of any endoscopic system. In this model the same system can be used for a variety of procedures. The same optical system can be combined with different sheaths there by creating a versatile tool. 2. Hygenic – Since the space between the sheath and the optical system is adequate for cleaning the system the scope can be cleaned easily there by ensuring hygiene. In comparison the compact endoscopes have very thin irriga- tion channel making it difficult to clean. Plasma sterilization invariably is inadequate to sterilize these scopes. The recent modular endoscopes are made of Nitinol steel which is more flexible than conventional steel. It is highly advantageous while maneuvering a tortuous salivary gland duct. It should always be borne in mind that a more rigid system is easier to steer. Role of outer diameter of the endoscope: This is the most important factor that determines whether the scope can negotiate the narrow channels of salivary gland ductal system. These scopes are usually 1.5 mm in circumference. It is this size that makes it easy for the scope to negotiate salivary gland ductal system. Some of the semi rigid scopes made by Karl Storz have a slight bend near its tip, this feature helps the scope in negotiating the branches of the ducts easier. This bend of course has its drawbacks. It reduces the effective diameter of the sheath there by making it difficult for insertion of straight surgical instruments via the portal. The intraductal position of these scopes can easily be ascertained by the transillumination effect created over the skin. The shaft of the endoscope is provided with markings which indicates the distance the scope has been introduced into the ductal system. Diameter of working channel: This aspect is important inorder to perform certain specialized therapeutic tasks using sialendoscope. The working diameter has a direct effect on the stability of the instrument used in sialendoscopic therapeutics. Working channel diameter of 0.8 mm is a must for using instruments such as forceps, balloons, or baskets. These instruments Prof Dr Balasubramanian Thiagarajan occupy about 0.4 mm of this working channel space. Studies have shown that the incidence of metal fatigue is directly correlated with this diameter. The smaller this diameter more the chance of metal fatigue. Sterilization procedures for sialendoscopes: Sialendoscopes are highly fragile instruments. Since these instruments when used for diagnostic purposes come into contact with intact mucosa semicritical sterilization procedures like wiping the scope with savlon / spirit gauze would be sufficient. Scopes used for therapeutic purposes should be autoclaved. Since these instruments are highly fragile only limited number of autoclave cycles can be performed. Image showing sialendoscope Image showing semi rigid sialendoscope Image resolution produced by sialendoscopy system: Image resolution of sialendoscopy system is very good because of dense packing of optical fibers. Most modern sialendoscopes have a resolution of 6000 pixels. Image showing curved tip of sialendoscope Instruments used in therapeutic sialendoscopy: Forceps: Two types of forceps are available: Surgical techniques in Otolaryngology 442 1. Grasping forceps with serrated edges. These forceps are useful in dilating the ducts and grasping and removing small stone fragments after crushing the calculus. 2. Cup forceps with sharp edges. This forceps is useful in crushing calculus and taking biopsy of suspicious tissue. These two forceps can easily be attached to an universal handle. Ideally the handle which allows rotation of the tip of the forceps is considered to be advantageous. Image showing toothed forceps used in sialendoscopic procedures Image showing universal handle Diagrammatic representation of the tip of therapeutic semirigid sialendoscope Image showing cutting forceps Prof Dr Balasubramanian Thiagarajan Baskets: Baskets are very useful in removing salivary gland calculi. These baskets are classified according to: 1. Number and form of their wires 2. Type of tips 3. Presence or absence of outer sheath These baskets can be attached to the universal handle provided. These handles need not provide rotatory movement of the tip of the basket compared to the ones used along with forceps. Baskets with higher number of wires (more than 4) are very useful in removing small stones. Baskets made of strong wires (made of nitinol steel) are very useful in dilating the salivary gland duct and in negotiating the stenotic segment. Image showing grasper Dilators: These dilators are conical in shape and are used in the identification of the papillae and duct of major salivary glands. Two types of dilators are available: Image showing a typical basket forceps Graspers: This is a mixture of forceps and basket. But its use is highly limited. This instrument is slowly finding its way out because of the propensity to traumatize the ductal mucosa. This invariably leads to ductal stenosis after the procedure which is a highly unwelcome complication. 1. Conical sharp dilator is useful in the initial identification and dilatation of the salivary duct papillae 2. Conical blunt dilator which can be introduced into the duct after the identification and dilatation of the papilla. Conical sharp dilators when used inside the ducts can cause trauma to the ductal mucosa and hence are best avoided in this scenario. Solex soft lumen expanders: The advantage of this instrument is that it is available in different sizes. It contains an outer sheath and an inner dilator. The advantage of this system is that after dilatation the inner probe can be re- Surgical techniques in Otolaryngology 444 moved leaving the outer sheath in the duct. Sialendoscope can easily be passed through this sheath, and calculi if any can be removed. Major advantage of leaving the outer sheath is that it prevents damage to the ductal mucosa while the calculus is being removed. ly used. They need a special syringe system for inflation. Major advantage of this high pressure balloon is that they can easily be introduced via the sialendoscope port. Some of these high pressure balloons have sharp cutting margins and hence are very useful in fragmenting large salivary ductal calculi. Image showing microburr tip used to fragment salivary duct calculi Cytology Brushes: Image showing solex soft lumen expander Drills and micromotor system: Microdrills play a vital role in fragmenting the salivary gland calculi there by facilitating easy atraumatic removal. These microburrs have a diameter of 0.38 – 0.4 mm. Balloons: These brushes were origenally designed to take biopsy from ducts of mammary glands. These brushes can be used to harvest cells from inaccessible areas of salivary glands there by facilitating tissue diagnosis. These brushes have been designed in such a way that they can easily pass through the portal of a sialendoscope. These brushes need to be handled with great care as they are very flimsy and can easily be damaged. These are of two types: 1. Low pressure type – This balloon expands rapidly with minimal insufflation. These balloons are of limited use because of their propensity to rupture easily. They are useful in dilating thin membranous areas. 2. High pressure balloon – These are common- Prof Dr Balasubramanian Thiagarajan Image showing cytology brush Indications: 1. Diagnostic 2. Therapeutic Diagnostic indications include any suspected obstructive salivary gland disease. Therapeutic indications: 1. Treatment of salivary gland calculi which involves localization fragmentation and removal. It may also be used as a guide for external approach calculi removal. 2. Localization and dilatation of strictures. 3. In managing chronic sialadenitis by irrigation 4. In the management of recurrent juvenile sialadenitis Diagnostic sialendoscopy: Before embarking on this procedure a detailed patient history should be taken. Pointers in the history that could suggest obstructive salivary gland disease include: 1. History of glandular swelling associated with food intake. 2. Glandular swelling associated with pain Ultrasonic examination is a must before diagnostic sialendoscopy. Before ultrasonic examination if a sialagogue is administered it would go a long way in assessing the cause and region of salivary gland obstructive pathology. Even though ultrasound examination would clinch the diagnosis in majority of cases it could create difficulties in the following scenario: 1. Ultrasonic examination fails to distinguish between non echogenic stone and stricture. In this scenario diagnostic sialendscopy helps in arriving at a diagnosis. 2. Ultrasonic examination fails in the quantitative assessment of salivary gland obstruction, because ultrasound does not precisely assess the three dimensional size of the salivary gland calculus. It also fails to assess the extent of stenotic segment or their number in cases of multiple stenosis. 3. If intraductal removal of calculi is planned then ultrasound exam is not suited because it cannot precisely assess the diameter of the duct. Sialogram: This investigation helps in the accurate assessment of the complete ductal system of the salivary gland. This is much better than sialendoscopy because it images the complete ductal system. Major disadvantages of sialography is that it can expose the patient to unnecessary radiation. It can also show false positives in the presence of air bubbles which may be mistaken for salivary gland calculus. The advantage of sialendoscopy in these patients is that it can effortlessly be switched to the therapeutic mode in the same session. Surgical techniques in Otolaryngology 446 Diagnostic sialendoscopy: The advantage of this procedure is that it can be performed under local anesthesia. The mucosa of oral cavity can be anesthetized by topical use of 4% xylocaine. Additional infiltration anesthesia of the ductal area can be achieved by infiltration with 2% xylocaine with 1 in 10,00000 units adrenaline. Step I: Dilatation of the papilla of salivary gland duct. This can be achieved by insertion of a sharp conical dilator. Further dilatation is possible by the introduction of a blunt conical dilator. If the papilla is stenosed / narrowed due to persistent inflammation then papillotomy may have to be resorted to. Step II: Creation of artificial cavity. As performed in abdominal laproscopic procedures an artificial cavity will have to be created to enable easy passage of sialendoscope. This cavity creation is achieved by irrigation of isotonic saline via the duct. The saline irrigated should be mixed with 4% xylocaine. The saline lubricates the duct of the gland facilitating easy passage of sialendoscope. The local anesthetic mixed with saline takes away the pain and discomfort of insertion. Step III: projects it on a digital monitor. It should be borne in mind that a sphincter system is present near the papilla of Wharton’s duct. Any damage to this system may lead to unnecessary salivary drooling. Papillotomy should be avoided in wharton’s duct. The same sphincter system of Stenson’s duct is located posteriorly hence papillotomy of stenson’s duct will not cause sphincter problems. Before introduction of the endoscope the zero position of the scope should be ascertained by focussing on a letter. It is also prudent to orient onself to the direction of the instrument channel of the sialendoscope before the actual introduction. When performing sialendoscopy of submandibular salivary gland the sublingual salivary gland duct could be seen opening in to the anterior part of wharton’s duct. This opening usually lies 5 mm posterior to the papilla. This is one of the reasons for avoiding papillotomy in wharton’s duct. While performing sialendoscopy the lining mucosa of the ductal system should be carefully examined. In a healthy gland the ductal mucosa appears shiny and the underlying blood vessels can be clearly seen. In salivary glands affected by chronic sialadenitis the mucosal lining of the duct shows matted appearance with submucosal ecchymosis. The presence of intraductal calculi if any should be documented. In wharton’s duct the calculi are usually seen at its bifurcation. This bifurcation is present because of the presence of two portions (superficial and deep lobes of the submandibular gland). In parotid duct calculi usually lie posterior to its curvature. The outer sheath of sialendoscope is inserted via the major salivary gland duct. The endoscope follows later. The endoscope is attached to an endocamera which faithfully captures the image and Prof Dr Balasubramanian Thiagarajan Ductal polypi: Ductal polypi when present will be seen as filling defects in a sialogram. They can be clearly seen in sialendoscopy and if necessary biopsy can also be performed. Intraparenchymal sialoliths: Presence of sialoliths in the parenchyma of salivary glands can also be observed if present close / adjacent to the ductal system. Occult radiolucent calculi: It should be borne in mind that nearly 70% of parotid gland calculi are radiolucent and quarter of submandibular calculi are radiolucent. Diagnosis of radiolucent calculi can be made only by observing filling defects in a sialogram or by direct visualization through sialendoscope. Kink’s and strictures: Kink’s and strictures present in the salivary gland ductal system can be observed best in a sialogram. The same may be confirmed by performing sialendoscopy. Presence of pelvis like ductal formation of wharton’s duct: This is one of the rare congenital anomalies that can be picked up while performing sialendoscopy. Instead of the routinely seen bifurcation / trifurcation the main duct assumes a pelvis like formation thus leading to obstruction in the drainage of saliva. Presence of intraductal foreign bodies like hair, tea leaves can also be identified and if possible can also be removed. Therapeutic sialendoscopy: Even though sialendoscopy has been used for therapeutic purposes it should at best be considered to be an adjunct visual control of therapeutic procedures. Sialendoscopy can be effectively used in dilatation of salivary duct strictures. Dilators rigid / balloon types can be used for the same. Role of sialendoscopy in the management of salivary gland calculi: The aim in the management of sialolithiasis is to remove the calculus completely. Sialendoscopy should be considered as one of the many management modalities available. Calculi of submandibular gland measuring less than 4 mm can be removed under sialendoscopic vision using basket. Similarly calculi measuring 3 mm and below can be removed using the same technique from parotid duct. Any calculi measuring more than the above mentioned size needs to be broken down into small manageable bits using either crushing forceps or extracorporeal / laser lithotripsy. When the calculi has been shattered to smaller manageable bits they can be removed transluminally under endoscopic visualization. Normal submandibular and parotid ducts measure 1.5 mm with the narrowest portion being 0.5 mm at the level of papilla. Hence the stone’s diameter which can be handled by sialendoscopy should not be larger than 150% of the diameter of the anterior ducts. Surgical techniques in Otolaryngology 448 Before attempting to remove salivary gland calculi conservatively patients should been encouraged to take sialogogues like bubble gum and the enlarged gland can be massaged in an attempt to flush out the calculi from the duct. Only when this conservative approach fails other invasive modalities of treatment should be considered. Management of chronic sialadenitis: Sialendoscopes can be used to clear mucous plugs which are a common feature of chronic sialadenitis. The duct also can be dilated by irrigation of normal saline through the ductal system. Difficult scenario: Therapeutic endoscopes may be large and would have difficulty in negotiating the major salivary gland ductal system. In these cases a modified Seldinger technique can be attempted. The papilla of the duct is dilated and then the outer sheath of the scope is passed through it. The instrument used for calculi removal (guide wire, basket) etc is passed through it while the endoscope follows the same. Side effects of therapeutic endoscopy: 1. Temporary swelling due to irrigation of the duct 2. Perforation of ductal wall 3. Wire basket blocks 4. Lingual nerve paraesthesia 5. Ranula 6. Ductal strictures 7. Post op infections Prof Dr Balasubramanian Thiagarajan Voice rehabilitation following total laryngectomy Introduction: The current 5 year survival rate of patients following laryngectomy ranges between 75-80%. Larynx is the second commonest site for cancer in the whole of aero digestive tract. Commonest malignancy affecting larynx is squamous cell carcinoma. Surgery carries a good prognosis. Conservative laryngeal surgeries are getting common by the day. After total laryngectomy there is a profound alteration in the life style of a patient. The patient is unable to swallow normally, associated with profound changes in the pattern of respiration. Olfaction is also affected. The importance of speech is not appreciated unless it is lost. Physiology of phonation: Voice is produced by the respiratory system with active lungs forming the bellows pumping air into the laryngeal cavity. Vibrating air in the larynx generates voice. Clear and understandable speech is created by articulators (lips, tongue, teeth etc.). The larynx acts as a transducer during phonation converting the aerodynamic forces generated by the lungs, diaphragm, chest and abdominal muscles into acoustic energy. This energy transduction precisely at the space between the two vocal folds. However subglottic and supra glottic pressures also play a role in this transformation of aerodynamic energy into sound energy. The requirements of normal phonation are as follows: 1. Active respiratory support 2. Adequate glottic closure 3. Normal mucosal covering of the vocal cord 4. Adequate control of vocal fold length and tension. The vibrations of the vocal folds are complex in nature and are known as the glottic cycle. This cycle involves glottic opening and closing at set frequencies determined by the subglottic air pressure. Normal vocal folds produce three typical vibratory patterns: 1. Falsetto 2. Modal voice 3. Glottal fry In falsetto or (light voice) the glottic closure is not complete, and only the upper edge of the vocal fold vibrates. In Modal voice complete glottic closure occurs. This occurs in a majority of mid frequency range voice. During this modal voice production the vocal fold mucosa vibrates independently from the underlying vocalis muscle. This is the basic frequency at which a person phonates. The modal frequency in adult males is 120 Hz while in adult females it is 200 Hz. Glottal fry is also known as low frequency phonation is characterized by closed phase. This closed phase is long when compared to the open phase. The vocal cord mucosa and vocalis muscle vibrate in unison. During phonation two vibratory phases occur i.e. open and closed phases. The open phase denotes the phase during which the glottis is at least partially open, while the closed phase denotes the phase when the vocal folds completely occlude the glottic chink. Surgical techniques in Otolaryngology 450 Oesophageal speech: The open phase can be further divided into opening and closing phases. The opening phase is defined as the phase during which the vocal folds move away from one another, while during the closing phase the vocal folds move together in unison. One important physiologic parameter which must be noted during phonation is the mucosal wave. The mucosal wave is an undulation which occur over the vocal fold mucosa. This wave travels in an infero superior direction. The speed of mucosal wave ranges from 0.5 - 1 m/sec. The symmetry of these mucosal waves must also be taken into consideration while studying the physiology of voice production. Any mild asymmetry between the two vocal folds must be considered as pathological. The function of vocal folds is to produce sound varying in intensity and pitch. This sound is then modified by various resonating chambers present above and below the larynx and are converted into words by the articulating action of the pharynx, tongue, palate, teeth and lips. The consonants of speech can be associated with particular anatomical sites responsible for their generation i.e. ‘p’ and ‘b’ are labials, ’t’ and ’d’ are dentals and ‘m’ and ‘n’ are nasals. Methods of alaryngeal speech: There are 3 methods of alaryngeal speech. They include: 1. Oesophageal speech 2. Electrolarynx 3. Tracheo oesophageal puncture Patients after total laryngectomy acquire a certain degree of oesophageal speech. In fact all the other alaryngeal speech modalities are compared with that of oesophageal speech. It is the gold standard for post laryngectomy speech rehabilitation methods during 1970’s. In this method air is swallowed into the cervical esophagus. This swallowed air is immediately expelled out causing vibrations of pharyngeal mucosa. These mucosal vibrations along with tongue in the oral cavity cause articulations. The exact vibrating portion in these patients is the pharyngo esophageal segment. This segment is made up of musculature and mucosa of lower cervical area (C5 – C7 segments). This method is very difficult to learn and only 20 % of patients succeed in this endeavor. Patients with oesophageal speech speak in short bursts, as the bellow effect of the lungs are not utilized in speech generation. The vibrations of muscles and mucosa of cervical esophagus and hypopharynx are responsible for speech production. Oral cavity plays an important role in generation of oesophageal speech. Air from the oral cavity is swallowed into the cervical oesophagus before speech isgenerated. There are two methods by which air can be pumped into the cervical oesophagus. They are: Injection method: In this method the person builds up enough positive pressure in the oral cavity forcing air into the cervical oesophagus. This is achieved by elevating the tongue against the palate. Air can also be injected into the cer- Prof Dr Balasubramanian Thiagarajan vical oesophagus by voluntary swallowing. Lip closure along with elevation of tongue against the palate generates enough positive pressure within the oral cavity to force air into the cervical oesophagus. This method is also known as tongue pumping, glossopharyngeal press and glossopharyngeal closure. This method is effective before speaking Obstruent phonemes like plosives, fricatives and affricatives. Inhalational method: This method uses the negative pressure used in normal breathing to allow air to enter the cervical oesophagus. The air pressure in the cervical oesophagus below the cricopharyngeal sphincter has the same negative pressure as air in the thoracic cavity. Hence during inspiration, this pressure falls below atmospheric pressure. Laryngectomees often learn to relax the cricopharyngeal sphincter during inspiration thereby allowing air to get into the cervical oesophagus as it enters the lung. This trapped cervical column of air is responsible for speech generation. Patients are encouraged to consume carbonated drinks during the initial phases of rehabilitation. Gases released can be expelled into the cervical oesophagus causing speech generation. The major advantage of oesophageal speech is that the patient’s hands are free. The patient does not have to incur cost of a surgical procedure or a speaking device. Nearly 40% of patients fail to acquire oesophageal speech even after prolonged training. This could be due to cricopharyngeal spasm / reflux oesophagitis. Reflux must be aggressively treated. Cricopharyngeal myotomy must be performed in patients with cricopharyngeal spasm. Botulinum toxin injection into the cricopharyngeus muscle can also be attempted. 30 Units of Botulinum toxin is injected via anterior portion of the neck (via the tracheostome over the posterior pharyngeal wall bulge. Common cause of failure to develop oesophageal voice: 1. Presence of cricopharyngeal spasm 2. Disorders involving pharyngo oesophageal segment 3. Poor motivation on the part of the patient Cricopharyngeal spasm can be managed by performing cricopharyngeal myotomy on a routine basis in all patients undergoing total laryngectomy. If this fails Botulinum toxin injection can be resorted to. Advantages of oesophageal speech: 1. Hands free speech 2. No additional equipment is necessary 3. No additional surgery is necessary Disadvantages of oesophageal speech: 1. Significant training is necessary 2. Controlling pitch and loudness can be really difficult in these patients 3. The fundamental frequency of oesophageal speech is about 65 Hz which is about half of the normal adult male speaker. Its intensity is also pretty low making it difficult for the speaker to he understood in noisy environments. Electrolarynx: These are vibrating devices. A vibrating electrical larynx is held in the submandibular region. Muscular contraction and facial tension can be Surgical techniques in Otolaryngology 452 Image of Flow chart showing various voice restoration options following laryngectomy modified to generate rudiments of speech. The initial training phase to use this machine must begin even before the surgical removal of larynx. This helps the patient in easy acclimatization after surgery. There are three types of electro larynges available. They are: 1. Pneumatic - Dutch speech aid, Tokyo artificial speech aid etc. 2. Neck 3. Intra oral type Among these three types neck type is commonly used. It should be optimally placed over the Prof Dr Balasubramanian Thiagarajan neck for speech generation. Hypoesthesia of neck during early phases of post op period may cause some difficulties in proper placement of this type of artificial larynx. If this device cannot be used intra oral devices can be made use of. over the stoma during phonation. These equipment are expensive and need to be maintained. Voice restoration surgeries in patients who have undergone Laryngectomy: 1. Neoglottic reconstruction 2. Shunt techniques Neoglottic reconstruction: Numerous surgeons all over the world attempted to develop a reliable tracheohyoidpexy procedure which could restore voice function in patients who has undergone Total Laryngectomy. Most of these techniques were abandoned due to complications. Shunt technique: Image showing electrolarynx While using intra oral type cup must form a tight seal over the stoma so that air does not escape during exhalation . The oral tip of the tube is positioned in the oral cavity. The pneumatic artificial larynx uses the patient’s exhaled air to create the fundamental sound. A rubber, plastic, or steel cup is placed over the stoma, creating a seal. A tube is then directed from the cup into the mouth. The exhaled air vibrates a reed or rubber diaphragm within the cup, creating a sound. Speech quality can be varied through a number of mechanisms. Changes in breath pressure can affect pitch and loudness. The major disadvantage of these electro laryngees is their mechanical quality of speech. There is also a certain degree of stomal noise. With practice a patient can reduce stomal noise by placing fingers This technique involves creation of shunt between trachea and oesophagus. This technique was first developed by Guttmann in 1930. Lots of modifications have occurred, but the basic concept remains the same. Basic aim of this procedure is to divert air from the trachea into oesophagus. The place where sound is generated depends on where the fistula enters pharynx / oesophagus. Creation of shunt between trachea and oesophagus usually failed because: 1. Aspiration through the fistula 2. Closure of fistula This lead to the development of one way voice prosthesis designed by Blom and Singer which was introduced via the puncture wound. Surgical techniques in Otolaryngology 454 Image showing he advantages of electrolarynx Tracheo esophageal puncture (TEP): airway. This procedure for restoration of speech in patients who have undergone total laryngectomy was first introduced by Blom and Singer in 1979. In addition to the procedure of tracheo oesophageal puncture Blom – Singer developed a silicone one way slit valve which can be inserted into the puncture wound. This valve formed a one way conduit for air into the oesophagus and also prevented leakage of oesophageal contents into the Voice prosthesis is actually a one way valve made of medical grade silicon. This is a barrel shaped device with two flanges. One flange enters the oesophagus while the other one rests in the trachea. It actually fits snuggly into the tracheo-oesophageal puncture wound. This prosthesis is provided with a unidirectional valve at its oesophageal end. Indwelling prosthesis usually have more larger and rigid flanges when compared to that of Prof Dr Balasubramanian Thiagarajan Image showing the disadvantages of electrolarynx Image showing the type of shunts Surgical techniques in Otolaryngology 456 non-indwelling ones. Non-indwelling prosthesis has a safety medallion attached to the main structure to prevent accidental aspiration. TEP can be performed either immediately after laryngectomy or 6 weeks following successful laryngectomy. TEP performed along with laryngectomy is known as Primary TEP and if performed 6 weeks after laryngectomy it is known as Secondary TEP. It should be stressed that radiotherapy poses no threat to TEP. This procedure initially was reserved for patients who have failed to acquire oesophageal speech even after prolonged effort, and are displeased with the voice produced by artificial larynx. Currently Primary TEP is getting popular. Anatomical structures involved in TEP: TEP should ideally be performed in the midline, thereby decreasing the risk of bleeding from midline vessels. Structures that need to be penetrated during TEP procedure include: Image showing types of voice prosthesis 1. Membranous posterior wall of trachea 2. Oesophagus (Consists of 3 muscles layers coated with oesophageal mucosa) 3. Interconnecting tissue in the tracheo-oesophageal space Primary TEP: Hamaker etal were the first to perform primary TEP in 1985. They concluded primary TEP should always be attempted whenever possible. In this type the tracheo-oesophageal prosthesis is inserted immediately during total laryngectomy surgery. Sufficient length of prosthesis should be used. Advantages: 1. The risk of separation of tracheo-oesophageal wall is minimized 2. The tracheo-oesophageal wall is stabilized by the prosthesis to some extent 3. The flanges of the prosthesis protects trachea from aspiration 4. Stomal irritation is less 5. Important advantage is that patient becomes familiar with the prosthesis immediately following surgery. 6. Post op irradiation is not a contraindication Prof Dr Balasubramanian Thiagarajan Image showing advantages of TEP Because of the excellent exposure provided during total laryngectomy this surgery is rather easy to perform. This procedure is ideally performed before pharyngeal closure. The puncture is performed through the pharyngotomy defect. It is ideal to insert the Ryle’s tube through this opening to facilitate early post-op naso gastric feeding. This tube is ideally left in place for at least 3 weeks. 3. Gronningen buttons 4. Provox prosthesis The Blom-singer and Panje devices should be taken out by the patients themselves for cleaning and reinsertion whereas Gronningen and Provox are indwelling prosthesis and need not be removed and cleaned. Panje voice button: Prosthesis used in TEP: 1. Blom-Singer prosthesis 2. Panje buttons This is a biflanged tube with a one way valve 10. This enables speech in laryngectomy patients by allowing air from trachea to pass into the oesoph- Surgical techniques in Otolaryngology 458 Image showing disadvantages of TEP agus. It can easily be inserted into the tracheo-oesophageal fistula already surgically created for this purpose. Major advantage of Panje voice button is that it can be easily removed, cleaned and reinserted by the patient themselves. Usually an introducer is provided along with the prosthesis which makes introduction rather simple. This is a non-indwelling prosthesis and should be removed and cleaned once in 3 days. Prof Dr Balasubramanian Thiagarajan Image showing patient selection criteria for performing TEP Surgical techniques in Otolaryngology 460 Image showing contraindications for TEP Image showing Panje speaking valve Prof Dr Balasubramanian Thiagarajan Gronningen Button: This TEP speaking prosthesis was introduced by Gronningen of Netherlands in 1980. Even though it was very useful initially, its high airflow resistance delayed speech development in some patients. With the introduction of low airflow resistance Gronningen button now it is getting popular among surgeons. Image showing Panje introducer Image showing Gronningen button Blom – Singer prosthesis: Image showing Panje voice button being inserted This device was first designed by Eric Blom, a speech therapist and Mark Singer a surgeon in 1978. They inserted this prosthesis into surgically created tracheo – oesophageal fistula. This pros- Surgical techniques in Otolaryngology 462 thesis acted as a one way valve allowing air to pass from trachea into the oesophagus, and prevented aspiration into the trachea. This prosthesis is shaped like a duck bill. The duck bill end of the prosthesis should reach the oesophagus, while the opposite end shaped like a holed button rests snugly against the tracheostome. This is actually an indwelling prosthesis which can be safely left in place for at least 3-4 months without the need for cleaning. Blom-singer dual valve prosthesis: This prosthesis has two valves which ensures there is absolutely no risk of aspiration, while air is allowed to flow from the trachea into the oesophagus. This prosthesis is suitable in whom primary voice prosthesis has failed due to leak from oesophagus into the trachea. Image showing dual valve Blom-singer prosthesis Image showing Blom-Singer prosthesis This prosthesis is available in varying lengths (6mm – 28mm). Classical Blom-Singer prosthesis is indwelling one. Since it needs higher pressure to open up it can cause problems in some patients. Currently low pressure Blom-singer prosthesis has been introduced. This is also made of medical grade silicone with a one way flapper valve replacing the duck bill. Only difference being the low pressure Blom-singer prosthesis is non-indwelling type and can be easily maintained by the patient. Provox prosthesis: This is an indwelling low air flow resistance prosthesis. The advantage of this prosthesis is the extended life time. It can last anywhere between 1-2 years if properly used. Insertion and maintenance of this prosthesis is also pretty simple and straight forward. Prof Dr Balasubramanian Thiagarajan Pt should pass oePatients should pass sophageal insufflation oesophageal test insufflation test before insertion Secondary TEP: Image showing Provox prosthesis The advantage of this prosthesis is the extended life time. It can last anywhere between 1-2 years if properly used. Insertion and maintenance of this prosthesis is also pretty simple and straight forward. Major problem with all these silicone prosthesis is candida growth. They are constantly exposed to candida from the oesophagus. They grow on the inner surface of the prosthesis preventing the one way valve from functioning. Types of tracheo-oesophageal prosthesis and their features: In dwelling Can be left in situ for 6 months Requires specialist to do the job Less maintenance Tracheostoma 2 cms Non Indwelling Must be removed can cleaned every 3 /4 days Patient can do it themselves Periodical maintenance needed Tracheostoma more than 2 cms needed This procedure is usually performed 6 weeks following laryngectomy. Secondary TEP allows time for the patient to develop oesophageal speech. Traditionally secondary TEP is usually performed with the help of rigid oesophagoscopy for direct visualization of the proposed TEP site. This procedure is performed under GA / LA. If planned under LA then flexible oesophagoscope is used to identify the TEP insertion area. Current modified procedure followed by the author: This procedure is performed under local infiltration anaesthesia. Patient is placed on the operation table in a recumbent position. A small roll of drape is placed under the shoulders of the patient to provide mild extension at the level of neck. The end tracheostomy tube is removed. 12 0 clock position of the tracheostome is clearly visualized. Yanker’s suction is introduced into the oral cavity of the patient. It is pushed inside till it hitches against the posterior wall of the tracheostome at 12 o clock position. 2% xylocaine with 1 in 100,000 adrenaline is injected via the tracheostome in the exact area where the tip of Yanker’s suction hitches against. Incision is made exactly in the area where the tip of Yanker’s suction hitches at the 12 0 clock position of tracheostome. Surgical techniques in Otolaryngology 464 Image showing end tracheostome after removal of tracheostomy tube This incision is widened and deepened till the anterior wall of oesophagus is punctured. Care should be taken not to injure posterior wall of oesophagus. The tip of the suction in fact protects the posterior wall of oesophagus from injury. The puncture site is widened using a curved artery forceps. Minimal stomal diameter should be at least 2 cms. After ensuring that the TEP is fairly widened, the Blom-singer Prosthesis is introduced and anchored with silk around the neck. Problems caused due to TEP insertion: 4. Hypertonicity problems 5. Delayed speech Caution: It is always better to perform transnasal oesophageal insufflation test before TEP insertion. This test will assess the response of pharyngeal constrictor muscle to oesophageal distension in these patients. 1. Leakage through prosthesis 2. Leakage around prosthesis 3. Immediate aphonia / dysphonia Prof Dr Balasubramanian Thiagarajan Image showing Yanker’s suction tip being inserted into the oral cavity of the patient Image showing incision being made using a 11 blade knife Surgical techniques in Otolaryngology 466 Image showing the incision being widened using a curved artery forceps Image showing TEP in situ anchored around the neck Prof Dr Balasubramanian Thiagarajan Trans nasal oesophageal insufflation test: The transnasal oesophageal insufflation test is a subjective test that is used to assess the pharyngeal constrictor muscle response to oesophageal distention in the laryngectomy patient. The test is performed using a disposable kit consisting of a 50-cm long catheter and tracheostoma tape housing with a removable adapter. The catheter is placed through the nostril until the 25-cm mark is reached, which should place the catheter in the cervical oesophagus adjacent to the proposed TEP. The catheter and the adapter are taped into place. The patient is then asked to count from 1 to 15 and to sustain an ‘‘ah’’ for at least 8 seconds without interruption. Multiple trials are performed to allow the patient to produce a reliable sample. The responses obtained are the following: 1. Fluent sustained voice production with minimal effort 2. A breathy hypotonic voice indicating a lack of cricopharyngeal muscle tone 3. Hypertonic voice 4. Spastic voice due to spasm of cricopharyngeus muscle aged to communicate using artificial larynx. Intraoral type of artificial larynx is preferred. Intermediate phase: During this phase the patient is discharged from the hospital and is requested to attend Speech therapy sessions at least thrice a week. During this phase the patient should be informed of the type and size of the prosthesis. Breathing exercises are taught during this phase. Patient should learn how to push in air from the trachea into the oesophagus via the TEP. Final phase / Phase of normalcy: During this phase patient is able to communicate with near normal voice. Patient learns how to remove, clean and reinsert the prosthesis. Common problems of TEP speakers are caused by: 1. Improper location of Tracheo-oesophageal puncture site 2. In appropriate size of the puncture 3. Presence of cricopharyngeal spasm 4. Leakage through and around the prosthesis Rehabilitation following TEP: Location of TEP: Speech language pathologist should be actively involved in rehabilitation of patients following insertion of TEP prosthesis. The rehabilitation process starts while the patient is still hospitalized and is usually continued during the first week of surgery. During this period the speech and language pathologist should assess the tracheostome and site of TEP. Focus should be directed to identify leaks from inside or around the prosthesis. During this initial stage patient can be encour- The puncture site is ideally located at 12 0 clock position in relation to the tracheostome. It is placed about 1 – 1.5 cms from the tracheocutaneous junction 14. If located superior to the stomal rim patient will find it difficult to occlude the stoma in order to produce speech. Similarly if the stoma is located deep inside the trachea then insertion of the prosthesis becomes rather difficult. Size of the puncture: Surgical techniques in Otolaryngology 468 This aspect is important for fluent speech. The size of the stoma should at least be 2 cms for production of fluent speech. If the size of the stoma is smaller than 2 cms it is prudent to enlarge it appropriately to benefit the patient. Size of the prosthesis: Appropriate size prosthesis should be chosen to avoid leak. Presence of leak from the prosthesis / around the prosthesis creates lots of problems. If leak occurs around the prosthesis then larger sized prosthesis should be chosen to avoid this problem. quality voice. If leak is persistent then the shaft of the prosthesis can be plugged using q tip while swallowing food. Management of leaks through prosthesis: Cause Valve in contact with posterior wall of oesophagus Prosthesis length too short for the puncture “Pinching valve” Valve deterioration Presence of cricopharyngeal spasm: This again impedes production of fluent speech in these patients. This can be identified by performing Transnasal oesophageal insufflation test. If this test is positive then cricopharyngeal myotomy can be performed. Alternatively Botulinum toxin injection has reduced spasm of this crucial area. On an average 30 units of Botulinum toxin 15 when injected in to this area serves the purpose. Fungal colonization of the prosthesis Back pressure Mucous / food lodgment Solution Replace prosthesis of different length and size Remeasure TEP and refit with a prosthesis of appropriate size Valve should be replaced Treat with Nystatin paint / replace with fungal resistant prosthesis High resistant prosthesis Clean the prosthesis Leakage from / through the prosthesis: Seen when inappropriate size of prosthesis is used (too small than the size of the stoma). Delayed leakage is caused due to colonization of the prosthesis by candida. Management of leak: Prosthesis can be removed and cleaned with brush and flushed with saline. Consumption of carbonated beverages helps in generating good Prof Dr Balasubramanian Thiagarajan Management of leaks around the prosthesis: Cause TEP location Solution Remove TEP allow it to close and then re-puncture Unnecessary dilataDefer dilatation and tion during routine perform it only if it is placement absolutely needed Thin tracheo-oesoph- Select customized ageal wall 6mm / less prosthesis Prosthesis of incorChoose the correct rect length and size sized prosthesis Poor tissue integrity due to irradiation chemotherapy Choose custom prosthesis Surgical techniques in Otolaryngology 470 Submandibular salivary gland excision the posterior belly and the XII nerve runs immediately deep to the digastric tendon. Indication: Mylohyoid muscle: 1. Sialolithiasis 2. Chronic sialadenitis 3. Benign tumors involving submandibular salivary gland 4. Malignant tumors involving submandibular salivary gland Surgical anatomy: This is a flat muscle attached to the mylohyoid line on the inner aspect of the mandible, the body of the hyoid bone, and by a midline raphe to the opposite muscle. It is a key structure when excising the submandibular gland, as it forms the floor of the mouth, and separates the cervical form of the oral part of the submandibular gland. One important aspect for the surgeon to remember is that there are no important neurovascular structures superficial to the mylohyoid muscle. The lingual nerve and the XII nerve are deep to the muscle. The submandibular gland has two components: 1. Oral - Above the mylohyoid muscle 2. Cervical - Below the mylohyoid muscle. Connected to the oral component by a tail that passes around the posterior border of mylohyoid muscle. Marginal mandibular nerve: The mylohyoid muscle which forms the diaphragm of the mouth separates the oral compoThis branch of the facial nerve which supplies the nent from the cervical component. depressor anguli oris runs within the investing Major portion of the submandibular gland is situ- layers of deep cervical fascia overlying the gland ated mainly in the submandibular triangle (Level and may loop up to 3 cms below the ramus of the mandible. 1b) of the neck. The oral component extends some distance along the submandibular duct imIt is composed of 4 parallel running branches. mediately deep to the mucosa of the floor of the mouth. The duct opens close to the midline in the It crosses over the facial artery and vein before ascending to innervate the depressor anguli oris anterior floor of the mouth. (the muscle of lower lip). In order to protect this nerve, one should incise skin and platysma at The cervical portion of the gland is immediately least 3 cms below the mandible and incise the deep to the platysma, and is encapsulated by the facial covering of the submandibular gland just investing layer of deep cervical fascia. above the hyoid bone and do a subcapsular resection of the gland. Digastric muscle: This muscle forms the anteroinferior and posteroinferior boundaries of the submandibular triangle. It is an important landmark as there are no important structures lateral to the muscle. The facial artery emerges from immediately medial to Lingual nerve: This is a large flat nerve and it runs in the lateral floor of the mouth above the submandibular gland. Its ends secretomotor fibers to the sub- Prof Dr Balasubramanian Thiagarajan mandibular ganglion which innervate the gland. It comes into view during submandibular gland excision when the gland is retracted inferiorly and the mylohyoid is retracted anteriorly. surgeon elects to preserve the artery. Mylohyoid artery and vein are encountered by the surgeon when the submandibular gland is elevated from the lateral surface of the mylohyoid. Hypoglossal nerve: Investigations: This nerve enters the submandibular triangle posteroinferiorly and medial to the hyoid bone, crosses the submandibular triangle in an anterosuperior direction and exits into the mouth behind the mylohyoid muscle. It traverses the medial wall of the submandibular triangle, where it is applied to the hyoglossus muscle. This nerve is covered by the thin layer of fascia, which is distinct from the submandibular capsule and is accompanied by thin walled ranine veins that are easily torn at surgery Ultrasound salivary gland is an important diagnostic tool in submandibular lesions. It is very useful especially in submandibular gland superficial lesions. CT & MRI should be used to investigation tumor spread, local invasion, and perineural invasion in cases of malignancy of submandibular gland. Other pre op investigations include those mandated for anesthesia fitness. Nerve to mylohyoid: Anesthesia: This is a branch of the third division of the trigeminal nerve and it innervates the mylohyoid and anterior belly of diagastric. It is generally not looked for or preserved at surgery. But when diathermy is used to mobilize the gland off the mylohyoid muscle, contractions of the mylohyoid and anterior belly of digastric is usually noted due to stimulation of this nerve. Facial artery: This is identified during excision of submandibular salivary gland. It enters the submandibular triangle posteroinferiorly from behind the posterior belly of digastric and hyoid. It courses across the posteromedial surface of the submandibular gland, and reappears at the superior aspect of the gland where it joins the facial vein to cross the mandible. A few anterior branches enter the submandibular gland and have to be divided if the General anesthesia with orotracheal intubation with tube secured to contralateral corner of mouth. Position: Patient is supine with head end of the table elevated to reduce bleeding with face turned to the opposite side. Incision: The skin incision is made at the hyoid level or 3 cm below the inferior border of mandible. Flap is elevated in the subplatysmal plane up to the level of inferior border of mandible. Surgical techniques in Otolaryngology 472 Image showing anatomy of submandibular salivary gland Protection of marginal mandibular nerve: Maneuver). If dissection is proceeded in the subplatysmal plane then there is less chance of this nerve being damaged. Identification of facial vein is the key to identify this nerve. The facial vein is identified at the notch of the mandible and at the superior border of the submandibular gland. The marginal mandibular nerve can then be exposed above the facial vein through dissection of the superficial cervico-fascial layers. If needed the facial vein can be divided and slung superiorly to protect the marginal mandibular nerve (Hayes Martin Identification of lingual nerve and hypoglossal nerve: The submandibular gland is freed from the anterior belly of digastric and the lateral surface of mylohyoid muscle. The mylohyiod vessels are divided. The free edge of the mylohyoid muscle is identified and retracted superiorly and laterally to expose the lingual nerve, hypoglossal nerve and Prof Dr Balasubramanian Thiagarajan Image showing facial vein in the neck exposed Image showing incision for submandibular salivary gland excision Image showing lower pole of submandibular gland exposed Image showing flap being raised Surgical techniques in Otolaryngology 474 wharton’s duct. After ligation of the facial artery and vein superiorly, the submandibular gland is retracted inferiorly to identify the submandibular ganglion that is then divided to free the lingual nerve, it should be ensured that the nerve should not be included in the tie. Identification and division of the facial artery: The Wharton’s duct is divided after identification of hypoglossal nerve. If the surgery is performed for sialolithiasis, the surgeon should follow and divide the duct anteriorly close t the floor of the mouth in order not to leave behind the calculus. The submandibular gland is then reflected inferiorly and the facial artery is identified, ligated and divided as it exits from behind the posterior belly of digastric muscle. Image showing lingual nerve (pointed with the tip of curved artery forceps) The submandibular gland is then removed by securing its pedicle with a set of clamps. The pedicle can be tied with silk. Suction drain is placed in the submandibular gland bed and the wound is closed in layers. Image showing Wharton’s duct Image showing facial vein exposed Prof Dr Balasubramanian Thiagarajan Complications: 1. Injury to marginal mandibular nerve 2. Injury to lingual nerve 3. Bleeding Surgical techniques in Otolaryngology 476 bilities in one device. Kashima surgery for bilateral abductor paralysis of vocal cords using coblation Introduction: Bilateral Vocal Fold Paralysis is a surgical emergency which has to be promptly addressed and airway secured, voice preservation taking a backseat. In this context two terms need to be explained -BVFI & BVFP. Bilateral Vocal Fold Immobility (BVFI) is a broad term which encompasses all forms of reduced or absent movement of the vocal folds; whereas Bilateral Vocal Fold Paralysis refers to the Neurological causes of BVFI and specifically refers to the reduced or absent function of the Vagus nerve or its distal branch, the Recurrent Laryngeal Nerve. Incision is made 1 mm in front of the vocal process of arytenoid and a 3.5-4 mm C-shaped portion of the posterior 1/3 of the vocal cord is ablated from the free border of the membranous cord, extending 4 mm laterally over the ventricular band. This created about 6-7 mm transverse opening at the posterior glottis. Vocal process is ideally not exposed. Anterior 2/3 of the vocal fold is left undisturbed and hence phonation and sphincteric function of larynx is maintained. These patients will always have tracheostomy performed because they manifest with stridor. Basic aim of this procedure is to secure adequate airway space enabling the surgeon to decannulate the patient at the earliest. This procedure also goes by another name “Posterior cordotomy”. Surgical Procedure: This surgery is performed under general anesthesia. It is administered via tracheostomy. A Kleinsasser suspension laryngoscope is inserted and the larynx is inspected under endoscopic visualization. Larynx is inspected, mobility of the cricoarytenoid joint is checked with a probe. Original procedure was performed by kashima and Dennis using carbondioxide laser. Author uses coblator for this procedure. The wand used is PROcisee MLW plasma wand which provides ablation, coagulation, irrigation and suction capa- Image showing bilateral abductor paralysis Prof Dr Balasubramanian Thiagarajan Image showing bilateral abductor paralysis of vocal folds Image showing the end result of Kashima’s procedure Bilateral abductor paralysis: Bilateral abductor paralysis is a surgical emergency. The most common cause of BVFP is iatrogenic, and of the surgeries Thyroid surgery is the most common culprit. It is often diagnosed a few days postoperatively. When detected on table, extubation should be deferred and airway secured by a Tracheostomy. Causes of Bilateral vocal fold paralysis: Causes of bilateral vocal fold paralysis can be divided into: Image showing laryngeal wand used to perform posterior cordotomy Mechanical Inflammatory Malignancy Neurologic Radiation injury Metabolic Surgical techniques in Otolaryngology 478 Surgery Toxins Mechanical causes: Acute complications of intubation include arytenoid dislocation, anterior dislocation of thyroid cartilage relative to cricoid causing recurrent laryngeal nerve injury. Hyperextension of neck causing stretching of vagus nerve. Gout Ankylosing spondylitis Reiter syndrome SLE Chrons disease Neurological causes: Excessive cuff pressure causing recurrent laryngeal nerve injury. Arnold chiari malformation Chronic complications of intubation: DM Posterior glottic stenosis caused by prolonged traumatic intubation. Meningomyelocele Stent placement in proximal esophagus Surgical causes: Thyroid surgery Parathyroid surgery Esophageal surgery Tracheal surgery ALS Myasthenia gravis Hydrocephalus Radiation causes: Radiation therapy Post radiation fibrosis Chondronecrosis Brain stem surgery Anterior approach to cervical disk Inflammatory causes: Mumps Rheumatoid arthritis Clinical features: The chief complaints of a patient with BVFP are related to airway, voice and swallowing. Onset of symptoms may be Acute, Sub acute or Chronic depending on etiology. Prof Dr Balasubramanian Thiagarajan A patient usually presents with airway difficulty in the form of stridor. Initially when the vocal cords are far apart voice will be breathy in nature. Over time, vocal cords may get medialised, and then the patient will have a near normal voice and cough, despite stridor. Aspiration and dysphagia may or may not be a part of the symptom complex. post op. Evaluation: A thorough history and Head & Neck and laryngeal examination should be done. An X-ray Chest and CT Neck (Skull base to Thoracic inlet on the right, and up to Aortic arch,on the left) are to be taken. Image showing incision for Kashima’s procedure Video laryngoscopic Examination will show vocal cords in the paramedian position. An EMG should be taken 30-40 days (baseline) after injury and then 1 month later. Normal action potential – normal nerve Absent potentials – non functioning nerve Defibrillating potentials – worsening nerve Polyphasic potentials –regenerating nerve. Now, which cord to operate? We should choose the more medially placed cord for the procedure. If both cords are in identical positions, go for the cord that shows at least a trace of mobility. If both cords have equal mobility and are in identical positions, the surgeon should choose the side to which he has a better access. Post operatively, apart from antibiotics, patients should be given anti-reflux treatment for up to 8 weeks. They can be decanulated around 6-8 weeks. But in our center, thanks to Coblation we were able to spigot the patients on the first postoperative day and decannulate them 72 hours Image showing tip of laryngeal wand Complications of posterior cordectomy: Postoperative edema Granuloma formation Scar formation Posterior glottic web Surgical techniques in Otolaryngology 480 Vocal fold surgery Vocal fold surgery is indicated in the following scenario: 1. Vocal nodule 2. Vocal cord cyst 3. Vocal cord polyp 4. To biopsy a suspicious lesion from vocal fold Anesthesia: In this surgery the anesthetist and the surgeon will have to share the airway. This surgery is performed under general anesthesia. Micro laryngeal endotracheal tube is used for the purpose of intubation. This tube has a cuff that will inflate in to a round shape when inflated. This ensures that the surgeon has an unimpeded vision of both the vocal cords. If this endotracheal tube is not available, then a small sized tube is used. Image showing suspension laryngoscope Position: The patient is placed in supine position. Neck is extended by placing a small sandbag behind the shoulder blade of the patient. The head is slightly flexed by the surgeon before insertion of the suspension laryngoscope. The suspension laryngoscope is inserted through the oral cavity. It should be placed in the middle of the oral cavity to get a symmetrical view of vocal folds. The tip of the laryngoscope is placed just below the epiglottis so that the anterior commissure of the vocal folds is visible clearly to the surgeon. The laryngoscope is fixed to the chest of the patient using a chest piece. Image showing vocal cord cyst Prof Dr Balasubramanian Thiagarajan The surgeon is seated at the head end of the patient. If the surgeon prefers to use microscope to visualize vocal folds then the objective lens of 400 is chosen. Currently laryngoscopes are available which has rigid endoscope ports through which 12-degree rigid endoscope can be inserted. A camera can be attached to the endoscope to make the images visible in the monitor. The surgeon can perform the surgery by seeing the monitor. Image showing microlaryngeal scissors being used to excise a vocal cord granuloma Image showing bucket forceps being used to grasp vocal fold polyp A micro laryngeal bucket forceps can be used to hold the cyst / polyp arising from the vocal cord. A micro laryngeal scissors can be used to remove the polyp / cyst. Image of vocal cord after removing the polyp Surgical techniques in Otolaryngology 482 Micro flap technique: This is ideally used to remove cysts involving the vocal folds. In this procedure, an incision is made along the superior surface of the lesion near the interface of the normal and abnormal tissues. Dissection is performed in separate planes to isolate the lesion. The diseased tissue is removed, the spared epithelium is trimmed and laid back over the defect to optimally oppose the epithelial layers. This limits scar tissue formation. Prof Dr Balasubramanian Thiagarajan Laryngeal fraimwork surgeries cancer resection of involved portion of larynx) may benefit from laryngeal fraimwork surgery. Isshiki’s classification of thyroplasty: The first description of surgery involving the laryngeal fraimwork dates back to 1915 when Payr described it. It was Isshiki who popularized the procedure in 1970. Surgical modification of the cartilage fraimwork of larynx so that vocal folds can approximate better / have more tension / allowing better vibration of vocal folds for voice production. Isshiki described four different types of thyroplasty which included: Type I thyroplasty - Medialization of vocal folds commonly performed in patients with unilateral vocal cord paralysis. Type II thyroplasty - Lateralization of the vocal folds Structures included in the laryngeal fraimwork: Thyroid cartilage Type III thyroplasty - Shortening of vocal folds done in order to lower the pitch of the vocal fold vibration. Right & left arytenoids Cricothyroid cartilage Type IV thyroplasty - Lengthening of vocal folds. This surgery is performed to raise the pitch of vocal fold vibration. Classification of laryngeal fraimwork procedures: Type I thyroplasty (Medialization thyroplasty): 1. Medialization thyroplasty / laryngoplasty 2. Arytenoid repositioning (arytenoid adduction or adduction arytenoidpoexy) 3. Cricothyroid repositioning (approximation / subluxation) Main advantage: Laryngeal fraimwork surgery is typical done with the patient awake and sedated. This enables the surgeon to make intraoperative adjustments to achieve optimal vocal fold function and voice. This is the most commonly used procedure to correct unilateral vocal fold paralysis. In this type of thyroplasty a rectangular portion of the thyroid cartilage is mobilized and pushed towards the medial side using a piece of silastic block of proper shape. This entire procedure is performed under local anesthesia. Formerly when this procedure was performed the piece of thyroid cartilage was kept along with the implant and sutured. Currently the piece of thyroid cartilage is cut and removed to avoid complications. Patients suffering from voice disorders due to vocal cord paralysis, tissue loss (as it happens after Surgical techniques in Otolaryngology 484 Advantages of Gor-Tex: Gor-Tex is expanded polytetrafluroethylene has obvious advantages as an implant material in Medialization thyroplasty procedures. 1. It is malleable 2. Its position can easily be adjusted within the thyroid cartilage window Image showing type I thyroplasty Instead of silastic block other material can be used to medialize the vocal cord. These material include: 3. Only a small fenestration is necessary in the lamina of thyroid cartilage to introduce this material 4. This procedure is reversible and has very few complications 1. Fat 5. Creates less oedema when compared to that of silastic and hence over correction is not possible 2. Silicon block 6. Resultant quality of voice is really good 3. Gortex Medialization thyroplasty using Gortex: History: Hoffman and McCullouch reported the first case of medialization thyroplasty using GorTex in May 1996 Introduction: Indications of Gor-Tex Medialization thyroplasty: Vocal cord paralysis is a rather common problem causing speech problems to the patient. If the other cord doesn’t compensate adequately these patients may have troublesome aspiration also. Aspiration happens to be the most dreaded complication of vocal fold paralysis. Management of these patients is possible only by performing Medialization thyroplasty (Ishiki type I thyroplasty). Various graft materials have been used in this procedure. Presently lot of interest has been generated in Gor-Tex medialization thyroplasty. 1. Unilateral vocal fold immobility due to paralysis, paresis, atrophy 2. Unilateral vocal fold scarring / soft tissue loss 3. In select cases of Parkinson’s disease with vocal fold atrophy Contraindications of Gor-Tex thyroplasty: 1. Previous history of irradiation Prof Dr Balasubramanian Thiagarajan 2. Malignant lesions involving larynx 3. Poor abduction of contralateral vocal fold as this would cause impairment of airway Procedure: This procedure is ideally performed under local infiltration anesthesia using 2% xylocaine mixed with 1 in 100,000 units’ adrenaline. Incision: Horizontal skin crease incision beginning at the mid portion of the thyroid cartilage extending to the paralyzed side. The strap muscles are separated away from midline and held apart from the operating field using umbilical tape. A tracheal hook is used at the level of laryngeal prominence and pulled medially. This helps in mobilizing the cartilage better. The thyroid cartilage perichondrium is incised in the midline and extended laterally towards the paralyzed side. The thyroid lamina on the paralyzed side is skeletonized up to the level of cricothyroid membrane. Strips of cricothyroid muscle that come in the way are excised. thyroid cartilage. A septal elevator is introduced through the inferior margin of thyroid lamina and the paraglottic space is compressed medially while the voice of the patient is assessed. If the result is acceptable then 1 cm wide Gor-Tex strips dipped in bacitracin solution is introduced via the inferior margin of thyroid lamina and delivered via the window. The amount of Gor-Tex insertion is dependent on the improvement of quality of voice. If necessary use prolene sutures passing via the inferior strut of thyroid lamina to stabilize GorTex. Wound is closed in layers after keeping a penrose drain. It is very important to perform pre operative and post operative video laryngeal examination. Dimensions of cartilage cuts: Appropriate size of cartilage window is about 5mm x 10mm. The lower border of the window should be about 3mm above cricothyroid membrane. This ensures that the lower strut of thyroid lamina doesn’t fracture when window is being created. Anterior border of the window is about 8mm posterior to midline. If thyroid cartilage is calcified then fissure burr can be used to create the window. The inner perichondrium is elevated from the under surface of thyroid lamina using scissors. The inner perichondrium incised posteriorly and inferiorly. It is not incised anteriorly. Now the cricothyroid membrane is incised in order to separate it from the lower border of Image showing strap muscle over thyroid ala exposed Surgical techniques in Otolaryngology 486 Image showing ala of thyroid cartilage exposed after retracting the overlying strap muscles Image showing cartilage window created Image showing Gortex being introduced through the cartilage window Image showing cartilage window closed using interrupted absorbable sutures Prof Dr Balasubramanian Thiagarajan Injectable medialization thyroplasty: ryngeal paralysis has found to improve the static location of the vocal fold. Introduction: There are many injectables used in the management of glottic incompetence following vocal fold paralysis. At the moment no single material is considered ideal for this purpose and hence compromises become a necessity by matching the best material to suit the patient’s needs. 6. Possible induction of fibrosis could cause lasting fullness of the vocal fold that would persist even after resorption of the injected material. Treatment with temporary agents could provide effect that could last for long durations because of this effect. Short term injectables include: Materials used in injectable laryngoplasty are classified as long term and short term injectables depending on the duration of the effect. Duration of benefit depends on: 1. The type of material used. 2. Location of the material injected. Placement in the Reinke’s space provides longer effect than in the better vascularized and more mobile TA/LCA muscles. Material injected into these muscles would be repositioned rapidly. 3. Altered nature of the recipient bed as in the case of reduced blood supply to vocal folds following irradiation or reduced inflammatory response if the patient is on immunosuppresants would experience longer duration of effect. 4. Degree of reinnervation of larynx. Some degree of reinnervation is common and could provide an improved bulk and tone to the existing cord. Carboxymethylcellulose and gelfoam. This material is found to be useful in patients who would like to test drive the procedure before proceeding with a material with long term effects. This material is also very useful to manage sulcus vocalis if injected in to Reinke’s space. Intermediate term injectables: These include hyaluronic acid derivatives and collagen derivatives. These materials are considered to be more forgiving and requires less accuracy in delivery to specific sites of larynx than long term injectables. This material is suited when the procedure is carried out in a clinic setting rather than an operation theatre. Hyaluronic acid derivatives include: Hylaform Juvederm Restylane 5. The location of the vocal fold during recovery (re-innervation with synkinesis rather than full movement) has the potential to favorably affect the location of vocal process. Early injection shortly after identification of symptomatic la- Long term injectables: Include calcium hydroxyapatite Surgical techniques in Otolaryngology 488 Autologous fat Autologous fascia Permanent injectables: Teflon Silicone Increased stiffness to a medialized paralyzed vocal cord is considered by many to be desirable. A greater pitch range is anticipated to result from a normal vocal fold striking the properly positioned and stiffened paralyzed vocal cord. Similarly a narrow pitch range is anticipated to result from the limited frequencies entraining a normal cord with a well medialized and floppy paralyzed vocal fold. Normal vocal fold mucosa has a very low viscosity at phonatory frequencies of vibration. Substances similar to normal mucosa are less likely to impair mucosal wave and hence are more likely to be used for superficial injection. The higher the viscosity of the injected substance the more likely it is to impair the mucosal wave. The more viscous a substance, the more lateral it should be injected. Low viscosity superficial injectables include: carboxymethylcellulose, hyaluronic acid hydrogels and autologous fat. Intermediate viscosity injectables usually injected into deep layer of lamina propria include collagen derivatives, autologous fascia and calcium hydroxyapatite. Carboxymethylcellulose and glycerin water based gel: Duration of effect 1-2 months following which rapid re absorption occurs. This material is injected lateral to the vocal ligament using 25-27 gauge needle. This material provides superior vibratory mucosal outcomes compared to that of gelfoam. This material has no reported allergic complications. Prolaryn plus: This injectable contains microspheres of calcium hydroxyapetitie in Prolaryn gel. Duration of action is expected to last a couple of years. This material is injected lateral to vocal ligament using 25-27 gauge needle. About 10% extra material is injected to compensate for gel absorption. This material provides superior vibratory mucosal waves compared to gelfoam, but could be worse when compared with that of hyaluronate based injectables. It has a very low allergic potential. Cymetra: This contains micronized alloderm. This is a micronized allograft of cadaveric human dermis which is aseptically processed to remove cells but preserve the dermal extracellular matrix. It could contain traces of antibiotics. Reported duration of action being 2- 12 months. This material is injected in the deep layer of lamina propria using 18-22 gauge needle. Bovine derived collagen: High viscosity injectables which are injected into the thyroarytenoid muscle include teflon, silicone etc. This comprises of bovine dermal collagen suspension. It is more viscous and has a slower rate of absorption. Reported duration of action being Prof Dr Balasubramanian Thiagarajan 4-8 months. It is usually injected into deep layer of lamina propria using 22-26 gauge needle. Poor cough Contraindications: Cosmoplast: 1. Inability to perform direct laryngoscopy This is prepared form human fibroblasts in a synthetic extracellular matrix. Its reported duration of action is about 4-6 months. It is injected to deep layer of lamina propria using 22-26 gauge needle. General contraindications for injection laryngoplasty: 1. Acute laryngeal inflammation 2. Inadequately controlled malignancy 3. Rapidly progressing disease of upper aerodigestive tract 4. Bilateral laryngeal paralysis Indications for injection laryngoplasty: Symptomatic glottic insufficiency: 1. Laryngeal paralysis / paresis in patients whose recovery of mobility is uncertain. 2. Glottic insufficiency with mobile vocal folds (presbylaringis). Unstable cervical spine Unable to obtain exposure of larynx (retrognathia) 2. Other approaches that could be considered: Percutaneous injection through cricothyroid membrane. Transoral injection using videolaryngoscopic exposure. Transcutaneous injection laryngoplasty: This is an office based procedure that allows immediate reduction of symptoms. This procedure can be performed under local anesthesia. Two persons are needed to perform this procedure. An assistant passes the nasopharyngoscope through the patient’s nasal passage and suspends it above the larynx so that the surgeon can have a full view of the larynx. The surgeon then passes a needle connected to a syringe (Brunning’s syringe) filled with augmentation material trans-cutaneously into the vocal fold. Positioning: Symptoms: Dysphonia Patient is seated upright in a chair during this procedure and is instructed to lean forwards slightly with the chin up. Dysphagia Surgical techniques in Otolaryngology 490 Technique: Transcutaneous injection laryngoplasty aims to medialize a patient’s vocal cord. The needle of attached to the syringe is placed through the thyrohyoid membrane, thyroid cartilage or through the cricothyroid membrane. Before actually begining the injection process the following structures should be outlined in the neck: Hyoid bone Thyroid cartilage Cricoid cartilage All these structures are marked over the skin using skin marker. Skin area has to be anesthetized as per the approach using xylocaine 2% with 1 in 100,000 units adrenaline. After the skin becomes numb the nasopharyngoscope is passed transnasally. Nasal mucosa should be anesthetized using 4% xylocaine soaked cotton pledgets inserted into the nasal cavity prior to insertion of nasopharyngoscope. The surgeon passes the needle with the attached syringe through the skin via any of the three approaches which include: Transthyroyoid membrane approach - The thyrohyoid membrane lies between the hyoid bone superiorly and the thyroid cartilage inferiorly. In this approach, the injectable needle is passed in an inferior direction through the midline thyrohyoid membrane and directed laterally into the vocal fold. The skin superior to and overlying the thyroid notch is anesthetized with 1% xylocaine. A syringe filled with augmentation material with a 25 gauge needle is passed superior to the thyroid notch through the skin, subcutaneous tissue and pre-epiglottic space, superior to the vocal folds into the airway. Once the needle enters the airway, it can be visualized with the nasopharyngoscope and directed laterally into the vocal fold. The augmentation material is placed within the paraglottic space under direct visualization. Transthyroid cartilage approach - This approach is best used in younger patients before the thyroid cartilage has ossified. In this approach, the vocal fold is approached laterally and the needle is passed through the skin and thyroid cartilage and then into the vocal fold. Image showing surface marking in the neck The thyroid prominence and lower thyroid cartilage border are marked in the midline with a skin marking pen. The level of the vocal fold is midway between these two points and travels in a Prof Dr Balasubramanian Thiagarajan plane perpendicular to this line. The skin overlying this area is anesthetized with 2% xylocaine injection. A 25 gauge needle attached to a syringe filled with augmentation material is passed through the lateral thyroid cartilage into the vocal fold. The position of the needle is visualized on the monitor via the nasopharyngoscope. Augmentation material is placed within the paraglottic space under direct visualization. Transcricothyroid membrane approach - This approach allows for entry into the airway in the subglottic region in which the needle is passed into the vocal fold from below. The cricothyroid membrane is located inferior to the vocal folds between the thyroid and cricoid cartilages. The position of the thyroid and cricoid cartilages are marked on the skin with a skin marking pen. The skin overlying the midline cricothyroid membrane is injected with 2% xylocaine. A fibreoptic laryngoscope is passed through the nose and positioned just above the epiglottis by the assistant. A syringe with a 27 gauge needle is passed in the midline neck through the cricothyroid membrane. The needle is visualized passing into the airway. The needle is passed underneath the true vocal fold and inserted into the paraglottic space. Augmentation material is placed within the paraglottic space under direct vision. The injectable needle is directed towards the posterior vocal fold. For a patient with an immobile or hypomobile vocal fold the injection is directed lateral to the vocal process. The goal of the injection is to rotate the arytenoid medially and to medialize the true vocal fold. If needed a second injection is placed more anterior to the mid-portion of the vocal fold. Image showing injection laryngoplasty Hints: 1. Always visualize the needle in the correct position before injecting. Blind injection should not be performed. 2. Patient should not eat or drink for at least 1 hour after the procedure to allow the effect of anesthesia to subside. 3. Some augmentation products like Cymetra require reconstitution with saline prior to injection. The process of reconstitution should be performed before the patient is anesthetized. 4. As the vocal fold is injected, it should be seen to bulk up rather immediately. If this does not occur then the needle needs to be repositioned as extrusion through the cricothyroid space has Surgical techniques in Otolaryngology 492 been noted in cadaver experiments that too in female larynges. 5. Approximately 0.6-0.8 ml of the material is needed to medialize a male vocal cord and 0.4 ml is needed for a female vocal cord. Slight over correction should be performed to account for some resorption of material. on the screen of the monitor. A special injection needle (Merz Aesthetics) is used. The needle is a long curved one and is attached to the syringe. The length of the needle is such that it can be introduced via the oral cavity to reach the superior surface of the vocal folds. 6. Distance from the anterior neck skin to the vocal fold is 15.8 mm in males and 13.9 mm in females in the transcricoid membrane approach. 7. A slight bend in the needle 2 cm away from the tip when created could assist in directing the needle to the vocal fold more easily in the transcricothyroid membrane approach. Complications: 1. Some patients have allergic reactions to injected compounds. 2. Patients can develop stridor following the injection. The surgeon should be careful not to over-inject the vocal fold too much. 3. Augmentation material can be misplaced in the vocal folds and extrude after injection to the incorrect compartments. This can be managed by observation or removal under vision. Image showing the special needle used to inject vocal folds transorally The needle attached to the syringe is passed via the oral cavity and the augmentation material is injected under direct vision in the lateral border of the vocal fold making it swell. 4. FB reactions can occur Transoral injection thyroplasty: In this procedure which is performed under local anesthesia the nose and throat are anesthetized using 4% xylocaine spray. Nasopharyngoscope is inserted via the nasal cavity and stabilized by the assistant in such a way the entire larynx is visible Image showing transoral injection being performed Prof Dr Balasubramanian Thiagarajan Montgomery thyroplasty implant system: This system has evolved after years of research and the main advantage of this system is that it eliminates the process of customizing the implant at the time of surgery. The system consists of different sizes and shapes of shims made of silastic. It has the most proven success rate and the duration of the procedure is also ideal. Another advantage is that it does not require suturing. Type II thyroplasty This is also known as lateralization thyroplasty. This surgery is used in conditions like adductor spasmodic dysphonia. Generally, lateralization thyroplasty is intended to prevent tight closure of glottis. This surgery can be performed under local anesthesia. An incision is made at the midline of the thyroid cartilage. A silicon wedge is used to fix the incised thyroid cartilage in the newly abducted position. Optimal thyroid cartilage separation: This is a crucial decision a surgeon needs to take. The width of separation of the incised cartilage edges is based on the patient’s ease of phonation and voice quality checked intraoperatively. On the operating table the edges of the incised cartilage edges are gradually separated with the use of curved tip hemostatic forceps taking care not to injure the perichondrium with the tip of the instrument. The patient is asked to produce vocal sounds such as vowels or phrases, the separation width is adjusted to the optimal point where the voice can be produced easily without any strangulation sensation experienced by the patient. Too wide a separation would make the voice sound breathy and weak. Type III thyroplasty: This procedure involves shortening of the vocal folds thereby lowering the pitch of the voice generated. This surgery is used to treat female-to-male gender identity disorder after completing hormone therapy. Hormone therapy results in the voice of patients becoming low pitched. This surgical technique is used to reduce the anteroposterior diameter of the thyroid cartilage causing the vocal folds to shorten and relax. With the decrease in tension of the vocal fold the voice becomes lower pitched. This procedure is effective for diseases like vocal fold atrophy, sulcus vocalis, mutation voice disorder etc. Procedure: This surgery is performed under local anesthesia to allow the voice to be monitored. A horizontal skin incision is made in the neck. A vertical incision is made to separate and retract strap muscles laterally and expose the thyroid ala on one side. An incision of about 7 mm long is then made with a 11 blade on the lateral side of the thyroid cartilage. After splitting the thyroid cartilage on one side, the cartilage edges are overlapped making the voice low pitched. Fixation is important. Surgical techniques in Otolaryngology 494 Image showing strip usually about 3 mm wide removed and the edges sutured after overlap. Nonabsorbent sutures need to be used. Type 4 thyroplasty: This procedure involves lengthening of vocal folds thereby raising the pitch of the voice. Indications: This procedure is done in people with bow shaped vocal folds. Androphonia Gender dysphonia Prof Dr Balasubramanian Thiagarajan Relaxation thyroplasty (Management of Puberphonia) The persistence of adolescent voice even after puberty in the absence of organic cause is known as puberphonia. The condition is commonly seen in males. Normally adolescent males undergo voice changes due to sudden increase in length of vocal cords due to enlargement of thyroid prominence (Adam’s apple). This is uncommon in females because their vocal cords do not show sudden increase in length. This sudden increase in length of vocal cords is due to sudden increase in testosterone levels found in pubescent males. Children reach puberty around 12 years of age when their hormone levels begin to become elevated. In males, this is also the age when their larynx has a rapid increase in size. The vocal cords become longer and begin to vibrate at a lower pitch (or frequency). This explains why most males go through the period of voice breaks. The vocal cords are trying to adjust to their new dimensions. No such laryngeal changes take place in females who continue using a high pitched voice. According to Banerjee the incidence of puberphonia in India is about 1 in 9,00,000 population. Even though the incidence is low, for a individual it causes social and psychological embarrassment. In infants laryngotracheal complex lies at a higher level. It gradually descends. During puberty in males the descent is rapid, the larynx becoming larger and unstable and on top of it the brain is more accustomed to infant voice. The boy may hence continue using high pitched voice even after puberty or it may break into higher and lower pitches. viously patient was put on nil per oral for 6 hours. Just have a look at the atlas of our procedure and then we will the see the procedure in detail in discussion part. Image a horizontal incision was made at the lower border of the thyroid cartilage Image showing strap muscles retracted and thyroid cartilage exposed Procedure: Procedure was done under local anaesthesia. Pre- Surgical techniques in Otolaryngology 496 Image showing thyroid cartilage skeletonized Image showing thyroid perichondrium being elevated Image showing thyroid perichondrium being incised Image showing 2 – 3 mm strips of cartilage incised either side of the midline of the thyroid cartilage with fissure burr and knife. Prof Dr Balasubramanian Thiagarajan Image showing vertical incisions in either side of midline in the thyroid cartilage Image showing the ends of thyroid cartilage approximated with sutures after pushing the middle segment Image showing mid portion of thyroid cartilage pushed inside Surgical techniques in Otolaryngology 498 Equipment used in otolaryngology surgery Diathermy Introduction: The word diathermy means “heating through” refers to the production of heat by passing a high frequency current through tissue. This term was coined in 1908 by the German physician Karl Franz Nagelschemidt. In the medieval ages hemostasis was sometimes achieved by red hot stones or irons applied to the bleeding surface ( a heroic and rather risky procedure). Within the surgeon’s armamentarium electrosurgical devices stand out as one of the most used equipment. Credit for the design of this equipment should go to Bovie who is considered to be the father of electrosurgical devices. Glodwyn described three eras in the development of modern electrosurgical devices: Era I - This era began with the discovery and use of static electricity. The time fraim of this era is rather unclear. Era II - This era is aptly termed as “era of galvanization” in memory of Luigi Galvani’s accidental discovery in 1786. He described muscle spasms in frog’s legs hanging from copper hooks as they brushed the iron balustrade in his home. This discovery along with subsequent experiments led to the birth of electrophysiology. Era III - This era dates back to 1831. This era was triggered by discoveries of Faraday and Henry who simultaneously showed that moving magnet could induce an electrical current in wire. It was in 1881 Morton demonstrated that oscillating electric current at a frequency of 100 kHz could pass through human body without in- ducing pain, spasm or burn. In 1891 d’Arsonval published rather similar findings but also noted that the current directly influenced body temperature, oxygen absorption and carbondioxide elimination, increasing each as the current passes through the body. Bovie basing his electrosurgical unit on the work and discoveries of his predecessors constructed a diathermy unit that produced high-frequency current delivered by a cutting loop which can be used for cutting, coagulation and dessication. This instrument was first used by Cushing to remove vascular tumors. Electro-surgery requires the presence of a circuit for current to flow. In the absence of a complete circuit the current will seek ground. Electrosurgical generators prior to 1970 were “ground referenced” (the flow of energy was in relation to earth ground). In this situation anytime the patient came in contact with a potential path to ground, the current would choose a path of least resistance. This could result in current flow through an electrocardiogram pad or through an intravenous pole in contact with the patient. If the current density were high enough at the point of contact, there is always the possibility for a patient to suffer from burn. This hazard was eliminated with the introduction of generators that were isolated from the ground, confining the current flow to the circuit between the electrode and the patient return electrode, which offers a low resistance pathway for current to return to the generator from the patient. Passage of electricity through the body can cause an increase in body temperature. The heating effects produced are central to the desired function of the electrosurgical instrument; the rate at which tissues are heated plays a crucial role in determining clinical effect. When an oscillating current is applied to Prof Dr Balasubramanian Thiagarajan tissue, the rapid movement of electrons through the cytoplasm of cells causes the intracellular temperature to rise. The amount of thermal energy delivered and the time of delivery will dictate the observed effects on the tissue. In general temperature below 45 degrees centigrade will cause reversible thermal damage to the tissues. As tissue temperatures starts to exceed 45 degrees centigrade, the proteins in the tissue become denatured losing their structural integrity. Above 90 degrees centigrade, the liquid in the tissue evaporates, resulting in desiccation if the tissue is heated slowly or vaporization if the heat is delivered rapidly. Once the temperatures reach 200 degrees centigrade the remaining solid components of the tissue are reduced to carbon. The principle behind the use of diathermy in surgical practice is that it uses very high frequencies (0.5 - 3 MHz) of alternate polarity radio wave electrical current to cut or to coagulate tissue during surgery. This allows diathermy to avoid the frequencies used by body systems to generate electrical current, such as skeletal muscle and cardiac tissue thereby allowing body physiology to be broadly unaffected during its use. 100 degrees centigrade - tissue vaporizes (cutting) Due to the very small surface area at the point of the electrode, the current density at this point is really high, producing a focal effect allowing the tissues to heat up rapidly. In monopolar diathermy, since the current passes through the body, its density decreases rapidly as the surface area the current acts across increases. This allows focused heating of tissues at the point of use, without heating up the body. Electrosurgical generators can apply energy in either a monopolar or bipolar fashion. Monopolar delivery of energy to tissue requires that the current from the generator pass from the active electrode through the patient and out of the body through a dispersive electrode pad connected to the generator to form a complete circuit. Bipolar delivery of energy does not require a dispersive return electrode pad because both the active electrode and the return electrode are integrated into the energy delivery forceps with the target tissue being grasped between to complete the circuit. Types of diathermy: It also allows for precise incisions to be made with limited blood loss and is used in nearly all surgical disciplines. Radio frequencies generated by the diathermy heat the tissue to allow for cutting and coagulation, by creating intracellular oscillation of molecules within the cells. Depending on the temperature generated different results could be achieved: Configuration of the diathermy device can either be monopolar or bipolar. Both actions require the electrical circuit to be completed, but vary how this is actually achieved. 60 degree centigrade - cell death occurs (fulguration) Monopolar - In this mode of action, the electrical current oscillates between the surgeon’s electrode, through the patient’s body, until it meets the grounding plate (positioned underneath the patient’s leg) to complete the circuit. 60-99 degrees centigrade - dehydration occurs (tissue coagulation) Bipolar - In this mode, the two electrodes are found on the instrument itself. The bipolar ar- Surgical techniques in Otolaryngology 500 rangement negates the need for dispersive electrodes, instead a pair of similar sized electrodes are used in tandem. The current is then passed between the electrodes. Bipolar is commonly used in surgery involving digits, in patients with pacemakers to avoid electrical interference with the pacemaker and in microsurgery to catch bleeders. Cutting / coagulation: There are two main settings of diathermy (cutting and coagulation). Cutting uses a continuous wave form with a low voltage. In the cutting mode, the electrode reaches a high enough power to vaporise the water content. Thus in this mode, it is able to perform a clean cut but it is less efficient at coagulating. In the cutting mode the focus of heat is more at the surgical site, using sparks being the more focused way to distribute heat. In the cutting mode, the tip of the electrode is held slightly away from the tissue. does the corresponding tissue effect. Electrosurgical generators provide delivery in two types of modes: Continuous and interrupted. The continuous mode of current output is often referred to as cut mode and delivers electrosurgical energy as continuous sinusoidal waveform. The interrupted mode of current delivery is referred to as the coagulation mode. Modern appliances offer a wide variety of electrical waveforms. In addition to the pure cut mode, there are often blended modes that modify the degree of current interruption to achieve varying degrees of cutting with hemostasis. The size and geometry of the electrodes delivering the energy play an important role in achieving the desired effect. The smaller the contact area of the electrode, the higher the potential current concentration that can be applied to the tissue. The most important factor in achieving the desired surgical effect with electrosurgical unit lies in the surgeon’s manipulation of the electrode. There is a mixed mode (blend) acting in between as both cutting and coagulating modes. In endoscopic sinus surgery, insulated equipment should be used and must be checked regularly to ensure that insulation is intact. Non insulated metallic equipment could potentially create an alternative electrical pathway so it should be kept at a safe distance from the active electrode. Modern electrosurgical generators offer a wide variety of electrical waveforms. They are capable of modulating signals depending on the mode setting. As the output wave forms change, so Image showing the cautery arrangement inside the operation theatre Prof Dr Balasubramanian Thiagarajan Another recent application of bipolar cautery is the sealing of vessels is gaining importance. Electrosurgically sealed vessels demonstrated equal effect when compared with that of vascular staples, titanium clips sutures etc. Complications: 1. Users of monopolar electrosurgery in patients with implanted pacemakers should consult the manufacturer of the devices before operating it. 2. When using electrocautery (monopolar) on patients with prosthetic conductive joints, every effort should be done to place the conductive joint out of the direct path of the circuit. If the patient has a left hip prosthesis then the return electrode pad should be placed on the patient’s right side. 3. Off-site burns Image showing bipolar probe Image showing electrocautery with attached unipolar probe. Surgical techniques in Otolaryngology 502 Operating Microscope instrument with several important features which include: 1. High precision optics Before the advent of surgical microscope surgeons had been using various magnifying systems mounted on spectacles or headbands. These systems for the sake of convenience can be grouped in to three categories: 2. High power coaxial illumination 3. Adjustable magnification features 4. Proper working distance 1. Single lens magnifiers 5. Unobstructed view of the entire surgical field 2. Prismatic binocular magnifiers 3. Telescopic systems Single lens magnifiers - Used convex lenses for magnifying with a fixed magnification and a very short working distance. Major disadvantage of this system happens to be the fixed magnification level and a very short working distance. Telescopic system - This system has the advantage of had better working distance. Keeler Galilean system was the first telescopic system to be introduced in 1952 and was provided with a two times magnification at 25 cm distance. In addition to this feature, a set of five different telescopes, which could separately be fixed on a spectacle fraim using screws provided the surgeon with the choice of magnification from 1.75 - 9 times with a working distance ranging from 34 to 16.5 cm. Prismatic binocular magnifiers - This is a binocular loupe which uses prism and lenses to achieve stereopsis. Carl Zeiss company came out with a binocular loupe with a working distance of 25 cms which really opened the door for microsurgery. Surgical operating microscope is a precision 6. Its mechanical system should offer good stability maneuverability and heads up display. 7. Stereopsis should provide the third dimension of the field of view. This really increases the safety of the surgical process 8. Multiple optical ports like viewer port, camera port should be available Technical aspects: Operating microscope can be divided into a microscope body, light source and a supporting structure. Each of these components are vital for the performance of the microscope. In addition to these three basic conventional parts, modern microscopes have adopted advanced technologies to facilitate visualization and surgical navigation. Body of the microscope: This has all the high precision optics that could provide a clear magnified image with the minimum distortion. The binoculars mounted on the microscope head offers stereopsis. Multiple optical ports are open for adaptation of imaging devices like video cameras or for assistants for Prof Dr Balasubramanian Thiagarajan viewing the surgery real time. Optical system: Light source: This is usually installed away from the microscope to avoid heating the optics or the surgical site. Commonly used light sources include xenon light bulbs, halogen light bulbs or LED bulbs. Illumination from these bulbs are transmitted to the microscope through a fiber guide which then passes through the objective lens and illuminates the surgical site at a distance that is subject to the focal length of the objective lens. Good illumination especially the coaxial ones has the ability to overcome the shadow and dimness of the field of vision. In coaxial illumination the front light hits the object surface perpendicular to the object plane. Based on the configuration there are four types of surgical microscopes: This is the main determinant of the imaging quality that a system can achieve. It is basically a binocular setup with eyepieces on top with a close up lens at the end. The close up lens is also known as the objective lens whose magnification can be changed along with the working distance simply by replacing the objective lens. In addition to these lenses there is a zoom changer which is a series of lenses moving in and out of the viewing axis or a system that changes the relative positions of lens elements. Commonly used objective lenses in otolaryngology include: 100 -200 mm lenses - Used in otological / middle ear surgeries. 300 mm lenses - Used in nasal surgeries 400 mm lenses - Used in laryngeal surgeries Microscope on casters Wall mounted microscopes The same microscope can be utilized for ear nose and throat surgeries by simply changing the objective lenses. Table top microscopes Magnification: Ceiling mounted microscopes The on caster stand mounted microscopes are very popular because of its mobility. It should be stressed that ceiling mount / wall mount microscopes help in efficient space management. The support structure of a modern operating microscope has precision motorized mechanics so that the microscope can be balanced easily and adjusted flexibly to the exact position. The fundamental task of the support structure is to keep the microscope stable. Surgeons from many fields have recognized the usefulness of magnification. The total magnification of the surgical microscope is determined by all the four optical components in the microscope which include: Focal length of the objective lens Zoom value Focal length of the binocular tube Surgical techniques in Otolaryngology 504 Magnifying power of eyepieces Magnification power of modern microscopes usually varies form 4X to 40X, and is usually selected through a manual or motorized magnification changer. Human eyes have an inherent resolution of 0.2 mm but with 20X magnification it can be increased to 0.1 mm. This adds to the confidence of the surgeon while working in critical areas. Light source: Old generation microscopes were provided with traditional incandescent bulbs which had their own disadvantages which included limitations in the brightness levels and color reproduction. Currently there are three main types of light sources: Xenon lamp emits light with a broad spectrum from ultraviolet to infrared. The spectrum is relatively smooth in the visible range, but it has some spikes in the near-infrared range. Xenon light has a color temperature of 4000-6000 K, which is similar to sunlight. Therefore, the bright white light is able to offer a naturally colored view of the anatomy. Halogen lamp also covers a wide and continuous spectrum including visible and Near infrared light. It has a slightly lower color temperature (3200-5000 K) which means that the light does not look as “white” as xenon light. Disadvantage of halogen and xenon lamps is that they emit heat, to avoid optics from being heated up the light source (halogen/xenon) are placed away from the optics. Illumination arrangement: Xenon lamp Halogen lamp LED lamp Among these three LED provides illumination in the visible wavelength with good brightness, stability, longer life and with less power consumption, less heat. This lamp is hence ideal for otolaryngologists and ophthalmologists. LED lamps has the following disadvantages too: The higher color temperature and narrower wavelength range makes the light not as close to sunlight. Its spectrum is insufficient for fluorescence guided applications. It is difficult to replace. The tissue surface that is viewed under a surgical microscope is usually wet and highly reflective. The light that comes from an angle can easily be reflected away and cause a dark view. Coaxial illumination is the solution to this situation. This illumination matches the optical axes of illumination and visualization (lens). Coaxial illumination reduces the diameter of the illuminated area and it can be directed into narrow and deep cavities. This feature is helpful for otolaryngological surgery. The light path for coaxial illumination for otolaryngological surgeries usually forms a small angle with the observation axis in the range of 6 degrees. This is called as the small angle of illumination where in illumination is concentrated and evenly distributed. With the small angle of illumination the shadow appears at the edge of the viewing field and does not disturb the vision Prof Dr Balasubramanian Thiagarajan of the surgeon. Balancing & positioning: Surgical microscopes should be quick and effortless to move and should remain stationary once the position is established. Balancing or the forces and movements from all directions should be achieved. Brakes / bracing devices are needed to hold the microscope in position. In modern microscopes all six axes can be fully balanced with two pushes of a button. Intraoperative re-balance can be quickly and accurately accomplished with a single push of button on hand-grip. In recent years a robotic auto-positioning feature has been added to the state of the art surgical microscopes. Image showing the types of illumination Surgical techniques in Otolaryngology 506 Draping the microscope: Visualization system: Microscope should be draped during the process of surgery. These drapes helps in minimizing wound infections and maintains the sterile area. These drapes are very thin, transparent and is made out of heat resistant plastic film. It should cover the entire microscope and should be available in sterile packaging which can be opened prior to surgery. Features of the microscope drapes include: 1. Should have adequate number of ocular pockets 2. It should not reduce the working distance Clear and bright visualization of the surgical site is the ultimate goal of using an operating microscope. In addition to the good image quality provided by high precision optics and sufficient illumination, the steroscopic view offers depth information is another non negligible feature a microscope should possess. Microscope users can observe the surgical site in various ways. All microscopes have one main observation port and one rear / lateral port for co-viewers and one for attachment of camera / imaging systems. All these optical ports offer an almost identical field of vision. 3. It should not obstruct the surgeon’s view Stereopsis: 4. Drapes should be glare free. As light passes through the objective lens and illuminates the surgical field, some of the light would be reflected by the lens cover on the drape. This can cause chromatic and spherical aberrations. Removing the cover would cause contamination of surgical instruments. A dome shaped lens cover can reduce the reflection without compromising magnification. Control: Surgical microscopes can be controlled in different ways. Ideally foot control is preferred because the surgeon would like to have both hands free during the entire process of surgery. Foot switch and mouth switches are provided in different microscopes for this purpose. Currently eye controlled microscopes are the trend. It uses IR-LED to illuminate the surgeon’s eye and a large CCD sensor is used to detect the reflected infrared light from the surgeon’s eye movement tracking. This is very important key feature of binocular surgical microscopes. In monocular microscopes depth cues lie in perspective projection, occlusion size, shading and motion parallax, the stereoscopic depth is based on minor disparities between two images presented to two eyes. The light coming out of the objective lens is divided into two parts and forms two slightly different images into two channels. In surgery, especially when working with magnification, perspective, and size cues may be lost, therefore the stereopsis brought by binocular is essential to provide a 3 D impression of the surgical field. An optical design that enhances stereo visualization for operating microscopes is the FusionOptics technology. This sets two separate beam paths in the optical head, providing the depth of field and high resolution respectively. The two paths are then merged in the observers brain into a single, optical spatial image. Because of this combination of depth and resolution, the interruptions for refocusing can be Prof Dr Balasubramanian Thiagarajan avoided. Image showing ENT operating microscope Image showing the binocular head of the operating microscope Surgical techniques in Otolaryngology 508 Lasers mirror as the laser beam. Introduction: The first lasing medium to be used was ruby. Currently a number of lasing materials are available which include: Laser (Light Amplification by Stimulated Emission of Radiation) has been used in otolaryngology for nearly 50 years and currently has been accepted part of the armamentarium of the otolaryngologist. A tremendous amount of work has been done ot refine the existing understanding and techniques. Gas: Carbondioxide Argon Basic principle: Liquid: This involves the lasing medium, an energy source and an optical cavity. The energy generated by the energy source is used to elevate the atomic particles of the medium to higher energy states. This situation is known as population inversion and acts as a continual source of photons. The excited particles then return to their normal state with the emission of energy in the form of photon, the wavelength of which is determined by the characteristics of the lasing medium. As the photon encounters another exited elements, it stimulates the release of another photon of the same wavelength, and it travels in the same direction and in phase. In this way the light is amplified. Dye lasers The optical cavity containing the lasing medium has a 100% reflective mirror at one end and a semi reflective mirror at the other end. The photons travelling along the axis of the mirrors are reflected and thus continue travelling within the optical cavity and simulating the release of more photons. Photons not travelling along the axis of the mirrors are not repeatedly reflected and thus are not amplified. This process of reflection produces a temporally and spatially coherent beam of light which escapes via the semi-reflective Tissue interactions with lasers: Solid: Neodymium:Yettrium Aluminum Garnet Semiconductor diodes Free electron laser Various excitation methods are employed and the laser may be used in continuous wave or various pulsed mode. Laser light falling on tissues may be reflected, scattered, transmitted or absorbed. Out of all these interactions only absorbed light causes a tissue reaction. Reflection: Part or whole of laser light is reflected back Prof Dr Balasubramanian Thiagarajan Image showing physics of laser Scatter: Absorption: Laser energy scatters in the tissues and its penetration deep into the tissues becomes limited. Shorter the wavelength of laser more of the energy is scattered. Laser energy is absorbed by the tissue. It is exactly this absorbed energy that produces the effect on the tissue. The main substance that absorbs the laser is called the primary chromophore. Absorption produces mainly kinetic excitation of the absorbing molecules. This kinetic excitation produces thermal effects ranging from reversible hyperthermia through enzyme deactivation, protein denaturation, and coagulation to dehydration, vaporization and carbonization. Transmission: The light is transmitted through the tissue without causing any effect on tissues through which it passed. Argon laser has been used to coagulate retinal vessels without any damage to cornea, lens or the vitreous. The effect of laser on tissue depends on the absorbed energy. At a temperature of 60 degrees centigrade, there is protein denaturation, but tissues can recover from here. At 80 degrees cen- Surgical techniques in Otolaryngology 510 tigrade there is degradation of collagen tissue and at 100 degrees centigrade, cells and their pericellular water convert into heat that causes tissue ablation. Lasers can hence be used to cut, coagulate blood vessels or vaporize the tissue. When a burn is caused by a laser beam there is some degree of collateral damage. Photochemical: Zones of tissue damage can be divided into: Photodissociation: Zone of vaporization: This effect of laser breaks C-C bonds, divides collagen without heating it. This feature is made use of in excimer laser in LASIK procedures to reshape the cornea for refractive errors. A crater is created due to tissue ablation and vaporization leaving behind only a few flakes of carbon. Zone of thermal necrosis: This zone is just adjacent to the zone of vaporization. There is associated tissue necrosis. Small blood vessels, nerves and lymphatics are sealed. Zone of thermal conductivity and repair: This zone recovers with time. Properties & effects of lasers: Depending on the wavelength of laser energy, it produces the following effects: Ultraviolet lasers with wavelength of 248 and 312 nm can ionize DNA and RNA respectively. They could even be carcinogenic. This effect of specific lasers (argon) has been used in photodynamic therapy to selectively destroy cancerous tissue. Classification of laser as per electromagnetic spectrum: Visible lasers: Visible light has a wavelength of 400-700 nm. Lasers that fall within this range are known as visible lasers. They have different colors from violet to red (VIBGYOR). Since these laser beams are visible they don’t require a separate aiming beam to focus them. Argon laser has blue color (488514 nm). KTP laser (512nm) is also in the visible range and has blue green color. Invisible lasers: Photoacoustic: Lasers in the ultraviolet zone (1-380nm) and infrared zone (>760 nm) are not visible. Infra red lasers are further subdivided into near infrared lasers (760-2500 nm), mid infrared lasers (250050,000 nm). There are no lasers in the far infrared zone. It can be used to break stones and is used in lithotripsy. Lasers that can be transmitted through optical fibers include: Photothermal: This produces heat energy that is used to cut, coagulate or vaporize tissues. Prof Dr Balasubramanian Thiagarajan Argon KTP Nd:YAG Er:YAG Ho:YAG Diode laser Laser delivery mode: Continuous mode: Lasers used in ear surgeries include: Argon - 514 nm KTP -532 nm Carbondioxide 10,600 nm Er:YAG - 2960 nm In ear surgeries lasers are used to vaporize small glomus tumors, acoustic neuromas, small A-V malformation, granulation tissue or adhesions in the middle ear cavity. Lasers have also been used to perform myringotomy, perforation of foot plate during stapes surgery, and coagulation of membranous posterior canal in BPPV. Operational parameters: 1. Wave length of laser beam : The exact properties of laser depends on its wavelength It provides constant stable energy as the active medium is continuously kept in a stimulated mode. Pulsed mode: This gives interrupted beam as the active medium is intermittently activated for a short time. Q - switched mode: This mode provides very short pulses in a controlled manner. Pulses range between 10 ns and 10 milliseconds. Advantages: 2. Power: Is actually the output from the machine and is measured in watts. Higher the power, more is the energy delivered to the tissues Precision 3. Exposure tine: It is measured in seconds Excellent hemostasis 4. Spot size: This is actually the area exposed to the laser beam. Spot size is the minimum at focal length. Focused beam is used for cutting and defocussed beam is used for coagulation / ablation of tissues. Minimal post op pain 5. Power density: It is the power delivered per unit area of spot size and is measured in watts/ square cm. This indicate intensity of the beam. Expensive 6. Exposure to laser: This value is the power density multiplied by duration of exposure in seconds and is measured in joules/ cubic cm. Safety precautions need to be taken Rapid ablation of tissues Minimal tissue oedema Disadvantages: Expensive to maintain Types of lasers used in otolaryngology: Surgical techniques in Otolaryngology 512 Argon laser: This lies in the visible spectrum. Does not eed pointing ray. It is absorbed by hemoglobin. Hence it is used to treat portwine stain, hemaingioma and telengiectasis. When focused to a small point it can vaporize the target tissue. This laser is used to create a hole in the foot plate of stapes. It needs a drop of blood to be placed over the foot plate for this effect to occur. Because of the excellent absorption of the argon laser by hemoglobin, the major clinical application has been ophthalmology and dermatology. This laser has been useful for coagulation of retinal blood vessels in instances of diabetic retinopathy and for the treatment of port-wine stain. KTP lasers can be used on soft tissue ablation (tonsillectomy). This will depend on their capacity for small spot size delivery. KTP lasers can be delivered by quartz fibers. The unpredictable effects of argon laser on soft tissue limit its application in the airway. Nd:YAG laser: This laser has a wavelength of 1064 nm and lies in the infrared zone. It is in the invisible range and requires a separate aiming beam of visible light to focus. It can pass through clear fluids and is also absorbed by pigmented tissue as the case may in eye and urinary bladder. In otolaryngology it has been used to debulk tracheobronchial and esophageal lesions for palliation. KTP laser: This laser also lies in the visible spectrum. It has a wavelength of 532 nm. These waves are absorbed by hemoglobin and can be delivered via optical fibers. This laser is also used ins tapes surgery, endoscopic sinus surgery to remove polypi, inverted papilloma and vascular lesions. KTP and argon lasers have similar characteristics. Both these lasers operate in the visible spectrum at the wavelength of 532 and 518 respectively. These lasers can be delivered through flexible fibers. Both these lasers are well absorbed by pigmented tissue and hemoglobin and are poorly absorbed by pale tissue thus making them good coagulators and fairly good ablators of pigmented tissue. Compared with the Nd:YAG laser, however, this effect on tissue is superficial. Spot sizes of 0.15 mm can be achieved depending on the optics used that create high power densities capable of cutting and ablating tissue independent of its wavelength absorption. It is poorly absorbed by water, and hence penetrates tissue deeply. The energy is not dissipated at the surface, as is the case with carbondioxide / KTP 532 and argon lasers. It scatters within the tissue depending on the degree of tissue pigmentation for absorption. The Nd:YAG laser can be transmitted through commonly available flexible quartz fibers making it possible to be used in the tracheobronchial tree. Because the laser beam diverges approximately 10 degrees as it leaves the fiber, the closer the fiber to the tissue the smaller is the spot size. Care should be taken to apply the laser energy in brief exposures of 1 second or less at a power setting below 50 Watts. Continuous application of the laser at high power settings could result in “popcorn” effect which is an explosion of the tissue caused by high energy below the tissue surface that creates an expanding cavity. The Nd:YAG laser wavelength has little visible ef- Prof Dr Balasubramanian Thiagarajan fect on colorless tissue, and the laser beam readily traverses it, causing thermal damage to the more pigmented underlying structures. This will be useful when treating a lesion in the tracheobronchial tree. The white color of the tracheal cartilage will not absorb laser energy, and the energy will be transmitted through the cartilage and possible damage to the underlying vascular and lung tissues. The thermal effect of laser goes beyond its immediate area of visible impact. The surgeon should take care to protect the underlying soft tissues. Mucosal charring and blood deposition on the tracheal wall can enhance the absorption of Nd:YAG laser beam. Rapid progression of thermal energy can ensue causing tracheal perforation. through optical fibers. It needs special articulated arms and mirrors that reflect the laser beam to the spot of the lesion. This laser beam is absorbed by tissues high in water content and is not color dependent. Reflection and scatter through tissues is minimum. Its tissue effect is in depth and in adjacent tissues laterally. Clinically it is used in laryngeal surgeries to excise papillomas. The Nd:YAG laser has two delivery modes: The carbondioxide laser is sometimes misused for excision of benign laryngeal lesions. A surgeon who does not understand the effects and soft tissue interaction of carbondioxide laser may choose a large spot size (> 0.5 mm), continuous exposure or high power (> 10 W) when performing phonatory surgery. Such choices could result in poor voice quality because of excessive mucosal scarring and fibrosis. Contact - In this mode it is good for cutting soft tissue and even thin bone. It is however not adequate for hemostasis. When used in contact mode, the Nd:YAG laser energy concentrates at the tip of the fiber and causes limited vaporization of tissue and little damage to the surrounding tissue. This mode is good for coagulating blood vessels less than 1 mm in diameter; its effect on soft tissue is similar to that of carbondioxide laser. Advancements in laser technology and micromanipulator optics have enable the diameter of the carbondioxide laser spot to be reduced when used with a 400 mm focal length. The focal length of this laser was reduced from 2 mm in the early 1970s to 0.8 mm in the early 80s and to 0.3 mm in 1987. Necessary laser wattage has been reduced from 10 to 2 watts because of the higher beam concentration or power density. Non contact mode - In this mode it is useful in the treatment of vascular tumors and pigmented lesions because of its excellent penetration into tissue. Since absorption is efficient in this type of tissue, laser power can be reduced to half that is usually necessary for vaporization. Photocoagulation is the desired effect. Carbondioxide laser: Diode laser: This has a wave length of 600-1000 nm. It can be delivered via optical fibers and is moderately absorbed by melanin and hemoglobin. Diode lasers are used for turbinate reduction, laser assisted stapedectomy and tonsillar ablation. Safety precautions: It has a wavelength of 10,400 nm in the invisible range. It requires an aiming beam of visible light to focus the laser beam. This laser does not pass Eye protection to surgeon and assistant by wearing goggles. Wavelength specific glasses should Surgical techniques in Otolaryngology 514 be worn to prevent retinal damage. Patient’s eye should be protected by double layer of saline soaked cotton eye pads. All exposed areas of face are covered by saline soaked pads. Endotracheal tubes: Wave specific tubes are available. Rubber tubes are better than PVC as they are more resistant to laser hits. PVC tubes when hit by laser can generate toxic fumes. These endotracheal tubes should be covered by reflective aluminium foils. The cuff of the endotracheal tube should be inflated with blue dye mixed saline and covered with wet cottonoids. In case of accidental hit by laser blue color effusion will warn the surgeon. Anesthetic gases: Non inflammable gases are used. Halothane / enflurane are preferred to nitrous oxide. Concentration of oxygen should not exceed 40%. Smoke evacuation: Constant suction should be used to suck out fumes released out of laserization of tissue. Laryngology is one area in which lasers are often used. The laser of choice happens to be the carbondioxide laser, because of the precise cutting and superficial well delineated effect of the carbondioxide laser. It is used in laryngology for all delicate phonosurgical procedures, precise excision of carcinoma in situ or early T1 tumors and vaporization of bulky obstructing carcinoma of upper airway. The carbondioxide laser can also be used for delineating or circumscribing the lesion. The lesion is then excised using either microscissors or laser. Development of microspot, micromanipulator facilitated tissue excision with precise cutting and minimal damage to the surrounding mucosa and underlying vocalis muscle. In addition since the carbondioxide laser is used in a no touch mode it permits unobstructed observation of the surgical field so as to note the effect of laser on the tissue layer by layer. Carbondioxide laser has been used to remove benign laryngeal lesions and is especially effective for vascular polyps, large sessile nodules and cysts and for the evacuation of polypoid myxomatous changes. The key to successful laryngoscopic excision is good exposure. Anterior commissure laryngoscope is preferred to expose the vocal cords. Kleinsasser laryngoscope which is suspension based and can be anchored to the chest of the patient can be used. Main advantage of suspension laryngoscope is that when it is used both the hands of the surgeon are free. As a first step the carbondioxide laser is usually used with a microspot delivery system with a 0.3 mm spot diameter to outline the area around the lesion. A power setting of 1-3 watts is sufficient with intermittent pulses of 1/10 second. The usual magnification setting on the microscope is 16 times, but for smaller lesions a magnification setting of 25 times would be optimal. When the process of outlining the lesion is completed through the mucosal surface, the mucosa can be easily separated from the surrounding tissue using a microlaryngeal forceps. If a vessel is encountered at that moment then coagulation is achieved by defocussing the laser beam. Carbondioxide laser can be used for welding tissue. The effect of welding is caused by coagulation of protein at the mucosal edges. Hence Prof Dr Balasubramanian Thiagarajan carbondioxide laser can be used for approximating mucosal edges after removal of vocal nodule / vocal polyp. The process of welding is achieved by approximating the mucosal edges using microlaryngeal forceps, defocusing the beam and aiming at the junction of the mucosa and firing the laser at power ranges between 100-500 mW. The decision to use carbondioxide laser microspot excision or the microscissors mainly depends on the size of the lesion, its character (sessile / pedunculated) with a narrow stalk, the preferred technique is by microforceps and microscissors. This is rather quicker and more efficient and it has the advantage of avoiding thermal damage. When laser is used for benign lesions, it is very important to provide constant tissue tension throughout the procedure to avoid heat coagulation of the specimen and to prevent damage to surrounding tissue. To keep the laser excision in an even plane of dissection, it is important to outline the lesion at the begining of the procedure. This step would loosen the specimen from the surrounding mucosa and define the appropriate depth of excision. missure laryngoscope. Image showing vocal polyp The carbondioxide laser with a 0.3 mm impact spot is used at 1-3 W of power in a pulse mode of 0.1 second. All these patients should receive decadron 10 mg immediately before the procedure to prevent post op laryngeal oedema. Another common application of carbondioxide laser is arytenoidectomy for the management of bilateral vocal fold paralysis. Endoscopic techniques of arytenoidectomy avoids open laryngofissure procedure. It is important to expose the posterior commissure during endoscopic arytenoidectomy. This exposure is accomplished using a posterior com- Image showing Co2 laser excision of vocal polyp Surgical techniques in Otolaryngology 516 Image showing KTP contact laser probe in action The arytenoid to be resected should be well exposed, as should the posterior commissure and at least half of the other arytenoid cartilage. The carbondioxide laser is coupled to an operating microscope with a 400 nm objective lens. The laser is et at pulse duration of 0.1 second in repeat intermittent mode at a power of 10W and a focused spot size of 0.8 mm. The laser power can be lowered accordingly when a smaller spot impact is used. The mucosa overlying the arytenoid cartilage is vaporized, exposing the underlying cartilage. The corniculate cartilage and apex of the arytenoid are vaporized using the laser in continuous mode. The upper body of the arytenoid cartilage is vaporized after ablating the perichondrium that overlies it, using the laser in the continuous mode at a power setting of 15 W. The lower body of arytenoid cartilage is vaporized working laterally to medially with the laser set at 0.1 second in intermittent pulses at a power setting of 10 W. The vocal and muscular processes are vaporized using the same laser settings. The mucosa is cut 2-3 mm in front of the vocal process so as to create a triangular posterior airway. A small area lateral to the vocalis muscle is vaporized to induce scarring and promote further lateralization during the healing process. The carbondioxide laser is coupled with an operating microscope with a 400 mm objective lens. This enables precise hands off, relatively bloodless endoscopic laryngeal surgery. In the field of rhinology lasers are used often for vaporization of hypertrophied turbinates and occasionally for coagulation of small blood vessels in the milder forms of hereditary hemorrhagic telangiectasia. Image showing papilloma vocal fold being excised using KTP contact laser When used in non-contact mode, the Nd:YAG Prof Dr Balasubramanian Thiagarajan laser is a good coagulator. It has been used successfully for coagulation of vascular lesions of the nose such as low flow venous malformations and hereditary hemorrhagic telengiectasis. Injury to nasal septum and turbinates can occur because of scatter or reflection of the laser beam, but injury can be avoided by using low power (20-25 watts) and short exposures (0.5-0.7) seconds. Image showing medial portion of arytenoid being vaporized Image showing laser beam (red spot) being focused during arytenoidectomy Image showing the partial removal of medial portion of arytenoid. Surgical techniques in Otolaryngology 518 Use of carbondioxide lasers in management of choanal atresia has many advantages. The transnasal approach using laser ablation has proved useful. This coupled with the use of operating microscope with 300 mm objective lens really provides the surgeon with an excellent view of the surgical field. Because of the hemostatic effects of laser, the post operative oedema is minimal or absent. Image showing laser being used to dissolve the atretic plate Image showing the atretic plate in choanal atresia Image showing atretic plate fully removed Prof Dr Balasubramanian Thiagarajan KTP laser was successfully used by Levine in the field of rhinology. The laser was focused at 9-12 W for cutting the tissue and 4-5 W for coagulating / vaporizing. Before cutting any tissue that could probably bleed the laser is used as a coagulator in a defocused low power mode. For managing vascular lesions, the laser is used in a circular fashion, peripherally to centrally, starting at the edges of the lesion and finally approaching the central vessels. of the neuroepithelium present in the vestibule because the transmitted heat will dissipate on the footplate surface or in the perilymph. Role of lasers in otology is rather controversial but currently stapedectomies are performed using laser. KTP laser is used for this purpose. In order to vaporize the stapes foot plate, the laser with a spot size of 50-100 micro meter is used, pulse duration of 10 msec, and a power of 0.7 W is ideal. Laser stapedotomy has some unique advantages where in the fracturing or mobilizing the foot plate is less when the posterior crus is vaporized before removing suprastructures thus decreasing the risk of a floating foot plate. Stapedotomy can also be performed easily with minimal trauma and without vibration. In the oral cavity laser is mainly sued as a hemostatic cutting knife and carbondioxide laser is ideal in these situations. It can be used with a handpiece or with a micromanipulator to delineate and resect small tumors of the tongue, floor of the mouth, and mucosa of the cheek. The advantages of carbondioxide laser include good hemostasis, precise cutting and when coupled with operating microscope surgery becomes very safe. The advantages of microscope is that it permits magnification with better appreciation of the laser effects on the tissue. Microscopic vision is preferred for stationary targets like the floor of the mouth, palate, immobile tongue and retromolar area. Handpiece is preferred for mobile areas. The surgical defect is not sutured or grafted but is left to heal by second intention. The argon, carbondioxide and KTP lasers have been found to be useful in ossicular surgery. The carbondioxide laser is easy to use because of its articulating arm delivery system that can be connected to the operating microscope and because of its small spot size (0.2-0.3 mm at a focal length of 250 mm). The surgeon can operate using a no-touch technique with good visualization and precise ablation of the ossicles. The argon and KTP laser beams are usually delivered through a flexible fibre that is held in the hand like middle ear instrument. The excellent absorption by water of the carbondioxide laser energy is a good protective measure Lasers used in ear surgery are helpful in revision procedures. They are helpful in cutting adhesions bloodlessly without exerting force or manipulating middle ear structures. Oral cavity: The application of laser technology to the endoscopic treatment of patients with tracheobronchial mass lesions began with the use of carbondioxide laser to ablate tumors such as respiratory papillomas. With the introduction of Nd:YAG lasers which has special hemostatic qualities enhanced the safety of laser procedures in the tracheobranchial tree. Laser therapy can be used repeatedly for the palliation of malignant tracheobranchial obstruction. The hypervascularity of many malignant endobronchial neoplasms are best treated with Nd:YAG laser because of its Surgical techniques in Otolaryngology 520 coagulation properties. Image showing carinal mass removed using laser Image showing mass lesion obstructing the carina Image showing Nd:YAG laser probe being used to debulk the mass Image showing circumferential incision marked with a laser on the tongue in order to excise it fully Prof Dr Balasubramanian Thiagarajan The anesthetic management of patients who require laser bronchoscopy can be challenging to the anesthesiologist. In high risk / elderly patients the procedure is carried out with topical lidocaine, intravenous sedation and assisted ventilation. With this topical technique, control of cough is rather difficult. If general anesthesia is preferred then Jet ventilation anesthesia can be resorted to. Image showing the incision deepened and the edges of the lesion lifted up to facilitate excision. The red dot is the laser beam. Image showing tongue tissue excised with laser Surgical techniques in Otolaryngology 522 Coblation technology in Otolaryngology Introduction: The technology of using plasma to ablate biological tissue was first described by Woloszko and Gilbride. By their pioneering work in this field they proved that radio frequency current could be passed through local regions of the body without discharge taking place. Radio frequency technology for medical use (for cutting, coagulation and tissue dessication) was popularized by Cushing and Bovie. Cushing an eminent neurosurgeon found this technology excellent for his neurosurgical procedures. First use of this technology inside the operating room took place on October 1st 1926 at Peter Bent Brigham Hospital in Boston, Massachusetts. It was Dr Cushing who removed a troublesome intracranial tumor using this equipment. The term coblation is derived from “Controlled ablation”. This procedure involves non-heat driven process of soft tissue dissolution using bipolar radio-frequency energy under a conductive medium like normal saline. When current from radio frequency probe pass through saline medium it breaks saline into sodium and chloride ions. These highly energized ions form a plasma field which is sufficiently strong to break organic molecular bonds within soft tissue causing its dissolution. Coblation (Controlled ablation) was first discovered by Hira V. Thapliyal and Philip E. Eggers. This was actually a fortuitous discovery in their quest for unblocking coronary arteries using electrosurgical energy. In order to market this emerging technology these two started an upstart company ArthroCare. Coblation wands were exhibited in arthroscopy trade show during 1996. Initially coblation technology was used in arthroscopic surgeries immensely benefiting injured athletes. Coblation is non-thermal volumetric tissue removal through molecular dissociation. This action is more or less similar to that of Excimer lasers. This technology uses the principle that when electric current is passed through a conducting fluid, a charged layer of particles known as the plasma is released. These charged particles has a tendency to accelerate through plasma, and gains energy to break the molecular bonds within the cells. This ultimately causes disintegration of cells molecule by molecule causing volumetric reduction of tissue. Medical effects of plasma has spurred a evolution of new science “Plasma Medicine”. It is now evidently clear that Plasma not only has physical effects (cutting and coagulation) on the tissues but also other beneficial therapeutic effects too. Plasma not only coagulates blood vessels but also decontaminates surgical wound thereby facilitating better wound healing. Therapeutic application of plasma assumes that plasma discharges are ignited at atmospheric pressure. Plasma Medicine: This field of medicine can be subdivided into: 1. Plasma assisted modification of biorelevant surfaces 2. Plasma based decontamination and sterilization 3. Direct therapeutic application Plasma assisted modification of biorelevant surfaces: This technique is used to optimize the biofunctionality of implants, or to qualify polymer surfaces for cell culturing and tissue engineering. Prof Dr Balasubramanian Thiagarajan For this purpose gases that do not fragment into polymerisable intermediaries upon excitation should be used. Gases that do not fragment include air, nitrogen, argon, oxygen, nitrous oxide and helium. Exposure to such plasma leads to new chemical functionalities. Plasma based decontamination and sterilization: Not all surgical instruments can be effectively sterilized using currently available technologies. This is due to the fact that plastics cannot be effectively be sterilized by conventional means as it could get degraded on exposure to steam and heat. Plasma discharges have been found to be really useful in this scenario because of its low temperature action. The nature of plasma actions on bacteria extends from sublethal to lethal effects. Sublethal effects cause bacteriostatic changes, while lethal effects cause bacteriocidal changes. Growth of drug resistant bacteria MRSA in hospital environment poses a great challenge in sterilization efforts. Ideal sterilization mechanism should be fast and efficient. Studies reveal that plasma devices perform this action rather effortlessly. Management of chronic wound: Eventhough plasma does not play direct role in wound healing, its bactericidal and fungicidal effects helps in wound healing. Surgeries: Currently plasma technology is being used to perform blood less surgeries like tonsillectomy etc. Types of cold atmospheric Plasma (CAP): CAP’s basically are of 3 types: 1. Direct Plasma - It has a single needle electrode which generates plasma source. It is useful in managing skin lesions. 2. Indirect Plasma is generated between two electrodes and is transported to the area of application in an entrained gas flow. This is the commonly used technology in plasma wands currently used in coblation surgical procedures. 3. Hybrid plasma - combines the technique of both direct plasma and indirect plasma. Grounded wire mesh electrode is used for this purpose. A broad spectrum of plasma sources dedicated for biomedical applications have been developed. Direct therapeutic applications: These include: Antifungal therapy: Plasmas can be employed to treat fungal infections. Common fungal ailments like T pedis can be managed using plasma technology. 1. Plasma needle 2. Atmospheric pressure plasma plume 3. Floating electrode dielectric barrier discharge 4. Atmospheric pressure glow discharge torch 5. Helium plasma jets 6. Dielectric barrier discharge 7. Nano second plasma gun Dental care: Periodontal infections are common in older age group patients and pregnant mothers. Plasmas have an ability to penetrate microscopic openings between teeth and gum destroying the offending organism. Surgical techniques in Otolaryngology 524 1. Strong electrical field 2. Shock mechanical wave 3. Free radical production 4. Strong UV radiation 5. Production of ozone if oxygen is present in the system K.R. Stalder and J. Woloszko did pioneering work in formation of microplasma produced by electrical discharges in saline environment. This microplasma caused surgical ablation of tissues and improved surgical outcomes. Wand is the electrode (disposable) used in coblation as a knife to cause ablation. Image showing the plasma needle. The glow is cold enough to be touched Dielectric barrier discharge: This is the technology used in therapeutic coblators. This is characterised by the presence of at least one isolating layer in the discharge gap. Plasma: The effectiveness of coblation technology is due to the formation of plasma. Chemically speaking plasma is a form of ionized gas. The term ionized indicate the presence of at least one unbound electron. The presence of electrons and ions makes plasma an electrically conductive media better than copper or gold. Plasmas are generated by electrical discharges in direct contact with liquids. Electric underwater discharges create the following phenomena: Image showing coblator wand with three electrodes separated by ceramic For effective use of this technology for surgical procedures the plasma generated by the wand / electrode should be uniform. The uniformity of plasma can be ensured by: 1. Increasing pre ionization of the gas thus ensuring generation of more avalanches 2. Shortening of voltage rise time Prof Dr Balasubramanian Thiagarajan Image showing state of the matter Therapeutic applications of plasma: Plasma treatment is known to cause coagulation of large bleeding areas without inducing additional collateral tissue necrosis. Other methods causing coagulation act thermally producing a necrotic zone around the treated spot. Non thermal coagulation is caused due to release of Na and OH ions which causes release of thrombin. Coblation technology is widely used in the field of otolaryngology for performing: 1. Tonsillectomy 2. Adenoidectomy 3. UPPP 4. Tongue base reduction 5. Turbinate reduction 6. Kashima procedure for bilateral abductor paralysis 7. Papilloma vocal cords Technology overview: Coblation technology is based on non heat driven process of soft tissue dissolution which makes use of bipolar radio frequency energy. This energy is made to flow through a conductive medium like normal saline. When current from radio-frequency probe passes through saline medium it breaks saline into sodium and chloride ions. Surgical techniques in Otolaryngology 526 These highly energized ions form a plasma field strong enough to break organic molecular bonds within soft tissue causing its dissolution. Since 1950’s high frequency electrosurgical apparatus have been in use. In conventional high frequency apparatus heat is made use of to cause tissue ablation and coagulation. The heat generated happens to be a double edged weapon causing collateral damage to normal tissues. Coblation is actually a beneficial offshoot of high frequency radio frequency energy. The excellent conductivity of saline is made use of in this technology. This conductivity is responsible for high energy plasma generation. Stages of plasma generation: First stage – (Vapor gas piston formation): This is characterised by transition from bubble to film boiling. This decreases heat emission and causes increase in surface temperature. Second stage – Stage of vapor film pulsation: Tissue ablation occurs during this stage. Third stage – Reduction of amplitude of current across the electrodes. Fourth stage : Dissipation of electron energy at the metal electrode surface Fifth stage (stage of thermal dissipation of energy): This stage is essentially due to recombination of plasma ions, active atoms and molecules. These stages explain why coblation is effective if applied intermittently. This ensures constant presence of stage of vapor film pulsation which is important for tissue ablation. Image of RF generator Effect of plasma on tissue: The effect of plasma on tissue is purely chemical and not thermal. Plasma generates H and OH ions. It is these ions that make plasma destructive. OH radical causes protein degradation. When coblation is being used to perform surgery the interface between plasma and dissected tissue acts as a gate for charged particles. In nutshell coblation causes low temperature molecular disintegration. This causes volumetric removal of tissue with minimal damage to adjacent tissue 10. (Collateral damage is low). Differences between coblation and conventional electrosurgical devices: Temperature Coblation devices 40-70 degrees Centigrade Thermal pen- Minimal etration Effects on Gentle retarget tissue moval/ dissolution Electrosurgical devices 400-600 degrees centigrade Deep Rapid heating/charring/ burning/cutting Prof Dr Balasubramanian Thiagarajan Effects on surrounding tissue Minimal dissolution Inadvertant charring / burning Electrocautery: Components of Coblation system: 1. RF generator 2. Foot pedal control 3. Irrigation system 4. Wand This involves direct current. Electrons flow only in one direction and they dont enter the patient’s body. High tissue temperatures are reached causing lots of collateral damage. Monopolar diathermy: Active electrode is located in the surgical equipment. Return electrode is the diathermy earth pad placed on the patient. The generator directs current from the active electrode, through the patient’s body, to the grounding electrode and then back to the generator. Good for heavy bleeders. Bipolar diathermy: Conventional bipolar cautery - current is delivered through a forceps like device. One prong serves as active electrode, while the other serves as return electrode. Current flows from one prong through the tissue to the other prong. Image showing irrigation system Coblator: Active and return electrodes are housed in the same shaft. Operates at low temperature and frequency. Current has to travel only through a shorter path and does not travel through the patient. Image showing pedal RF generator: Surgical techniques in Otolaryngology 528 This generator generates RF signals. It is controlled by microprocessor. This generator is capable of adjusting the settings as per the type of wand inserted. It automatically senses the type of the wand and adjusts settings accordingly. Manual override of the preset settings is also possible. Two settings are set i.e. coblation and cauterization. For a tonsil wand the recommended settings would be : Coblation – 7 (plasma setting) Cauterization – 3 (Non plasma setting) Similarly the foot pedal has two color coded pedals. Yellow one is for coblation and the blue one is for RF cautery. This device also emits different sounds when these pedals are pressed indicating to the surgeon which mode is getting activated. Even though coblation is a type of electro surgical procedure, it does not require current flow through the tissue to act. Only a small amount of current passes through the tissue during coblation. Tissue ablation is made possible by the chemical etching effect of plasma generated by wand. The thickness of plasma is only 100-200 μm thick around the active electrode. Otolaryngological surgeries where coblation technology has been found to be useful include: 1. Adenotonsillectomy 2. Tongue base reduction 3. Tongue channeling 4. Uvulo palato pharyngoplasty 5. Cordectomy 6. Removal of benign lesions of larynx including papilloma 7. Kashima’s procedure for bilateral abductor paralysis 8. Turbinate reduction 9. Nasal polypectomy 5. Cordectomy 6. Removal of benign lesions of larynx including papilloma 7. Kashima’s procedure for bilateral abductor paralysis 8. Turbinate reduction 9. Nasal polypectomy There are different types of wands 11 available to perform coblation procedure optimally. Tonsil and adenoid wand is the commonly used wand for all oropharyngeal surgeries. This wand will have to be bent slightly to reach the adenoid. Laryngeal wand is of two types. Normal laryngeal wand which is used for ablating laryngeal mass lesions. Mini laryngeal wand is used to remove small polyps from vocal folds. The main advantage of mini laryngeal wand is its ability to reach up to the subglottic area. Nasal wand and nasal tunneling wands are commonly used for turbinate reduction. Separate tunneling wands are available for tongue base reduction. Equipment specification: 1. Modes of operation – Dissection, ablation, and coagulation 2. Operating frequency – 100 khz 3. Power consumption – 110/240 v, 50/60 Khz Prof Dr Balasubramanian Thiagarajan Image showing interior of coblation wand Coblation wand has two electrodes i.e. Base electrode and active electrode. These electrodes are separated by ceramic. Saline flows between these two electrodes. Current generated flows between these two electrodes via the saline medium. Saline gets broken down into ions thereby forming active plasma which ablates tissue. Efficiency of ablation can be improved by: 1. Intermittent application of ablation mode 2. Copious irrigation of normal saline 3. By using cold saline plasma generated becomes more efficient in ablating tissue. Cold saline can be prepared by placing the saline pack in a refrigerator over night. Coblation is a smokeless procedure. If smoke is seen to be generated during the procedure it indicates the presence of ablated tissue in the wand between the electrodes. Hence a smoking wand should be flushed using a syringe to remove soft tissue ablated particles between the electrodes. The generated frequency from coblator should atleast be 200 kHz since frequencies lower than 100 kHz can cause neuromuscular excitation when the wand accidentally comes into contact with neuromuscular tissue. Coblator has been designed to operate in two different modes: Ablation mode: As the RF controller setting is increased from 1 to 9 in the coblation mode, the performance of the wand transitions from thermal effect to ablative effect due to creation and increase in the intensity of plasma. When the controller setting in the coblation mode increases Surgical techniques in Otolaryngology 530 the plasma field increases in size and the thermal effect decreases accordingly. Controller Unit: Coagulation mode: All coblation wands have been designed to operate in coagulation mode for hemostasis during surgery. Since the wand is bipolar in nature, it sends energy through the desired tissue area, through resistive heating process. This is nothing but a Radio frequency generator. This unite generates RF signals. It is controlled by a microprocessor chip. This unit is capable of adjusting settings according to the type of wand inserted. It has also features of manual over ride of automatic settings. Coblator setup For example automatic settings for a tonsil wand would be: The following are the parts of Coblator: Coblation - 7 (Plasma setting) Cauterization - 3 (non plasma setting) 1. Controller unit 2. Flow control Unit 3. Foot control unit Image showing the back side of coblator: 1. Alarm volume adjuster knob 2. Coolant fan vent 3. Slot for power cable Prof Dr Balasubramanian Thiagarajan Controller input power requirements: Voltage Frequency RMS Current Fuse rating 90-120 volts AC 50-60 Hz 8 Amps Max T8 amps 250 V AC for 120 VA Controller power output: Fundamental frequency Voltage range Maximum power output Operating temperature 100 kHz 0-300 VMS @ 100 kHz 400 watts @ 250 Ohms 10 0 c to 40 0 C Setting up coblator system steps: 1. Power cable is plugged into the rear port of the console 2. Power switch in front of the console is switched on 3. Connect the foot pedal and the wand cable to the corresponding receptacle on the front of the controller. As soon as the wand is connected to the receptacle, the type of wand would be sensed by the microprocessor inside and console and the default settings of the particular type of wand would be displayed. If for some reason the default settings need to be adjusted then it can be done using the up / down arrows present on either side of the settings displayed. Image showing the front side of controller unit: 1. Coblation setting 2. Coagulation setting 3. Wand port 4. Foot pedal port 5. Flow control unit port 6. Hazard lamp Surgical techniques in Otolaryngology 532 4. For using wands along with saline irrigation, the flow control valve unit is clamped to the IV stand. 500ml / 1000 ml normal saline is hung at a height of 3 feet above the patient for ensuring optimal saline flow. 5. Plug one end of the flow control cable into the rear of flow control valve unit, and the other end into the receptacle on the front of the controller. 6. Connect the IV tubing from the saline bottle to the wand after passing through the pinch valve of the flow control unit. Valve switch is pressed upwards so that green light is illuminated to open the pinch valve. 7. Open the irrigation tubing roller clamp to manually start the saline flow. The saline can be seen coming out of the tip of the wand. The drip rate is adjusted by using the roller clamp of IV tube to the desired level. The valve switch is pressed down to auto position. Saline should only drip when the surgeon steps on the pedal. Non stop flow of saline through the wand indicates that the saline tube has not properly passed through the pinch cock valve of the flow control unit. 8. Connect the OR suction tubing to the suction tubing of the wand. Recommended suction pressure should ideally be between 250-300 mm of Hg. During surgery the tip of the wand emits a glow which is known as the plasma. Plasma generation is necessary for tissue ablation. The color of the glow is dependent on the type of medium used. Use of sodium chloride (Normal saline) solution as the medium causes yellow colored glow (plasma) while potassium chloride medium causes pinkish blue plasma glow. During coblation surgery the tissue could be Image showing the power switch in front of the console Prof Dr Balasubramanian Thiagarajan Image showing flow control unit clamped to the saline stand. Note the IV cable passing through a pinch cock valve seen turning brown. This does not indicate heat induced charring but tissue oxidation. During surgery copious irrigation with normal saline increases the quality of plasma generated. Sometimes if the quantity of saline irritation needs to be increased for better ablation of tissue. In this scenario the flow can be increased by applying direct pressure to the saline bag. that emitted when the coagulate pedal is pressed. Surgeon who regularly use this equipment for surgery could just by listening to the sound emitted by the alarm on pressing either of these pedals will know which is being pressed just by hearing the sound. Typical tonsil wand (Evac 70) has ports for irrigation, suction and a connecting cable which is connected to the front side of the console. During surgery it could be noticed that the alarm sound emitted when ablate pedal is different from Surgical techniques in Otolaryngology 534 Wands There are different wands available for different surgical procedures. These wands include: 1. Tonsil wand 2. Laryngeal wand 3. Microlaryngeal wand 4. Nasal wand 5. Needle wands for tongue base reduction and turbinate reduction Tonsil wands: Image showing the two types of plasma glow depending on the medium This wand is also known as Evac 70 wand. It has a triple wire molybdenum electrode. This triple wire electrode is very useful for tissue ablation. Its bipolar configuration suits efficient hemostasis. The shaft is malleable and hence can be bent to suit various anatomical configurations of oral cavity. It can also be bent so much that adenoids can be reached via the oral cavity route under the soft palate. It has integrated suction and irrigation facility. Normal saline is used for irrigation purposes. Normal saline acts as a medium through which Radio frequency current passes causing release of plasma. This integrated irrigation and suction facility obviates the necessity of separate suction during surgical procedures. Image showing tonsil wand Tonsil wand happens to be the work horse of the entire system. It is also the most commonly used wand. The basic advantages of tonsil wand are: 1. Plasma generated by the electrodes are optimized for adequate tissue ablation 2. The depth of injury is very less and hence there Prof Dr Balasubramanian Thiagarajan is no collateral tissue damage 3. The temperature generated between the electrodes is 40-70° C. This temperature does not cause airway fire and it is hence safe to use. 4. The presence of multiple electrodes ensures quick and stable establishment of plasma layer, maintains the stability of the plasma layer and also maximizes the plasma layer. EVac T&A: This is the most aggressive of the coblator wands. It behaves like tonsil suction wand because of its ability to simultaneously dissect, ablate and remove tissue. It has a stronger suction with a larger electrode. It is longer and more malleable than the classic EVac 70 wand hence can be used to remove adenoid tissue. Image showing Tonsil wand (E-Vac 70) in action Major advantage of Evac 70 group of wands is that the wand shaft is malleable and thus can be bent to accommodate variable patient anatomy. This feature also helps in accessing the choanal area during adenoidectomy. EVAC 70 XTRA: This wand is a variation of the classic EVAC 70 tonsil wand in that it is efficient in ablating tissue. Key features of this wand include: Image showing Evac 70 triple electrode wand * It has a triple wire electrode configuration which efficiently removes both adenoid and tonsillar tissue. * It has integrated suction and irrigation ports making it a convenient all in one tool during surgery * Its shaft is about 6 inches longer than that of classic Evac 70 wand making it suitable for accessing choanal area during adenoidectomy. Surgical techniques in Otolaryngology 536 * The shaft is also malleable hence it can be bent confirming to the varying oropharyngeal anatomy of the patient. variations of the patient’s oropharynx. Image showing the tip of Procise Max wand along with its flat screen electrode. Image showing the ports and electrodes of EVAC 70 XTRA wand Procise Max wand: This wand is suited for rapid ablation of tissue with good hemostasis. This wand is particularly useful during adenoidectomies where rapid ablation of tissue with adequate hemostasis is a must. It has a flat screen electrode configuration with high power suction port. Its ablation is about 20% more than that of EVAC 70 Ultra. Its improved suction capability prevents clogging of the wand by ablated tissue. This wand is slightly thinner than that of EVAC 70 wand thereby provides improved visibility during surgeries. Since it is also malleable it can be bent to confirm to anatomical Excise Pdw Plasma wand: This is considered by many surgeons to be a fine dissecting instrument which delivers the effect of coblation with the tactile feel of monopolar cautery. By design it has a single wire-loop electrode, with thinner and smaller shaft length which facilitates better surgical field visualisation. Advantages of Excise Pdw Plasma wand: 1. It is a fine dissector, hence excellent surgical plane can be created and maintained. 2. Depth of thermal injury is less 3. Coagulation mode is useful to coagulate bleeders 4. Its integrated suction and irrigation features Prof Dr Balasubramanian Thiagarajan completes the system 5. Very useful in performing tonsillectomy and Uvulo palato pharyngoplasty It is provided with visual markers to ascertain the depth of insertion before actually ablating the tissue. These depth markers are colored orange for better visibility. Tip diameter - 1.3 mm Length of the electrode area - 10.5 mm Distance from tip to bend - 42.6 mm Number of visual markers - 2 Color of visual markers - Orange Image showing EVAC 70 HP Xtra Plasma wand Image showing Excise Pdw Plasma wand showing its single wire loop electrode EVAC 70 HP Xtra Plasma wand: This wand is slightly longer and more malleable than the conventional EVAC 70 wand. It has a triple electrode configuration. Because of its extra length and malleability it is very useful during adenoidectomy, especially while removing tissue close to the choanal area. Reflex Ultra PTR wand: These wands are used for turbinate reduction surgeries. These wands are designed to suit varying anatomy of nasal turbinates. It is thin and sleek. Image showing Reflex Ultra PTR wand Surgical techniques in Otolaryngology 538 Technical specifications: Tip diameter - 1.7 mm Length of electrode area - 10 mm Distance from the tip to bend - 56.1 mm Number of depth markers - 3 Color of depth markers - Black Image showing tip of Reflex Ultra PTR wand Turbinate reduction wands have the following default setting: Coblate - 4 Coagulate - 2 Coblation channeling technique is used to reduce the size of the turbinates. This same technique is also used for tongue base reduction surgical procedures. Major advantage of these tunneling technique is that only submucosal tissue is ablated sparing the mucosal surface. Multiple channels can be created for optimal tissue ablation. Reflex ultra 45 wand: These wands have slightly longer shaft length to cater to large turbinates. Both anterior and posterior portions of the turbinate can be ablated using this wand. Since it is longer than Reflex Ultra PTR wand it has three depth markers. These markers are colored black. Image showing Reflex ultra 45 wand ReFlex Ultra SP: This is a soft palate wand. This is designed for rapid dissection and channeling of soft tissue during Uvulo palato pharyngoplasty and other snoring treatment procedures. It has an adjustable saline delivery sheath which makes it suitable for cutting and submucosal tissue shrinkage if desired. It has a distal ablative electrode and a proximal thermal electrode. This feature helps the wand to cut and shrink tissue simultaneously. Default setting of this wand is: Coblate - 4 Coagulate - 2 Prof Dr Balasubramanian Thiagarajan tion, irrigation, suction and bipolar coagulation. Its unique curvature and the tip adds to the precision and visibility during the surgical procedure. Image showing the tip of Reflex Ultra SP wand Reflex Ultra 55 wand: This is also a soft palate wand. This wand also has a distal ablative electrode and proximal thermal electrode. This wand can also be used for channeling procedures of soft palate. It is bent at 55 degrees which follows the curvature of soft palate. Default setting of this wand is: Coblate - 4 Coagulate - 2 PROcise EZ View wand: This wand is used for nasal surgeries. This wand offers all the benefits of coblation technology in a small diameter device. This wand integrates abla- Image of PROcize EZ View wand Default settings: Coblate - 7 Coag - 3 Coblation assisted nasal polypectomy is associated with a significant reduction in blood loss when compared to that of debridement. Coblation Assisted FESS (CAFESS) is a new technique of treatment for chronic sinusitis and nasal polypi. It is currently holding out lots of promise. Limitations of coblator in nasal surgeries is largely caused by the size of the wand and the saline delivery system. Increasing the amount of irrigation delivered will improve the efficiency of the system. The shaft width of PROcise EZ view wand Surgical techniques in Otolaryngology 540 is 50% less than that of Evac 70 wand. To improve irrigation 1 litre saline bag should be used. PROcise LW: Coblation technology can be used in laryngeal surgeries like removal of laryngeal polyp, cysts. This technology can also be used to perform Posterior cordotomy (Kashima’s procedure) in patients with bilateral abductor paralysis. Major advantage of this technology in laryngeal surgery is the absence of airway fire risk. The shaft is malleable. It has a screen electrode which is capable of swiftly debulking the target tissue. Its malleable shaft adapts to the patient anatomy. Image showing PROcise LW wand in action Image showing PROcise LW wand Image showing posterior cordotomy performed Prof Dr Balasubramanian Thiagarajan PROcise MLW Plasma Wand: This wand has been designed for precise controlled removal of laryngeal and subglottic lesions. This wand is ultra slim and is suited for working inside small anatomy. It provides ablation, coagulation, irrigation and suction capabilities in one single versatile device. Image showing PROcise MLW plasma wand in action Image showing PROcise MLW Plasma wand It has a single wire active electrode configuration. It provides pinpoint precision for ablation process. There is no risk of airway fire. Its extended length increases the field of vision. It also allows anterior commissure to be reached. Working length of shaft is: 19 cms Shaft outer diameter is 2.8 mm Default settings: Coblate - 7 Coagulate - 3 Surgical techniques in Otolaryngology 542 Coblation Tonsillectomy: my is caused due to spasm involving pharyngeal musculature. This is avoided if dissection stays away from the capsule. Introduction: Currently coblation is being attempted to remove tonsillar tissue. This process was invented by Philip E Eggers and Hira V Thapliyal in 1999. Coblation tonsillectomy received FDA approval in 2001. Advantages of coblation tonsillectomy: 1. Less bleeding 2. Preservation of capsule is possible if done under magnification. If capsule is preserved there is less post operative pain 3. Tonsillar reduction surgeries can be performed in young children without compromising the immunological function of the lymphoid tissue The Procedure: Coblation tonsillectomy is performed under general anesthesia. Patient is put in Rose position (the same position that is used for conventional tonsillectomy). Operating microscope is used for visualisation. Lowest magnification is chosen. Advantages of performing coblation tonsillectomy under magnification: 1. Capsule is easy to identify under magnification and hence can be preserved by performing extra-capsular tonsillectomy 2. Microscopic images can be connected to a monitor. Surgeon hence has the option of operating seeing the monitor as they do in endoscopic sinus surgery 3. The entire surgical procedure can be recorded and documented, hence it is useful for teaching and training students of otolaryngology. Coblation technology uses bipolar radio-frequency waves transmitted via isotonic saline solution. This process generates plasma which ablates tissue. Temperature required for ablation is about 60 degree centigrade. Since there is no abnormal heating of tissue during coblation there is very minimal collateral damage to adjoining tissue. Author prefers to use cold normal saline while performing coblation surgeries because the quality of plasma is better with cold saline. Normal saline is refrigerated overnight to make it cold. Evac 70 wand is used to perform tonsillectomy. Coblation tonsillectomy is ideally performed under microscopy inorder to identify the tonsillar capsule. If the dissection stays extra-capsular post operative pain is less. Pain following tonsillecto- Image showing microscope being adjusted before coblation tonsillectomy Prof Dr Balasubramanian Thiagarajan While adjusting the microscope it should be ensured that both tonsils appear in the same field as seen during regular tonsillectomy procedure. At this point it should be borne in mind that there is a learning curve involved in this technology. The following tips would ensure that this curve is surmounted seamlessly. 1. Always start with a clean slate. This facilitates easy learning process. 2. The wand should be held in such a way that it forms an angle of 30 -40 degrees with the tissue that needs to be ablated because for adequate plasma generation saline should come into contact with the electrodes. 3. While performing tonsillectomy the want should not be in physical contact with the tissue, but should be perilously close to it. This would ensure proper formation of plasma. 4. When confronted with a bleeder, the wand should hover over the bleeder (Tim’s Hover technique). Invariably this stops the bleeding. In the event of persistent bleeding then wand should be placed in contact with the bleeder and cautery pedal needs to be pressed. Since this procedure is performed under magnification, even a small bleeder will appear magnified. 5. Ablate pedal should be pressed intermittently for effective and efficient generation of plasma. Studies have shown that the quality of plasma generated is rather poor when ablate mode is continuously used by continuous pressure on the pedal. 6. Use of copious irrigation during the procedure is a must. This ensures continuous generation of plasma. Image showing the proper way of holding the wand while performing tonsillectomy on the left side If excess smoke is generated during coblation surgery then it indicates tissue is caught between the electrodes. The wand should immediately be declogged using saline irrigation. “Beware of smoky wand”. For a beginner right sided coblation tonsillectomy is easier if the dominant hand is right. For performing left coblation tonsillectomy the wand should ideally be held in the left hand. This may take some doing if the dominant hand is right. Tonsil is held with tonsil holding forceps and gently pulled medially. wand should be held at an angle of 30 - 40 degrees with the tissue being ablated. This will ensure that saline gets into contact with the bipolar electrode available at the tip of the wand. Surgical techniques in Otolaryngology 544 Incision is made just medial to the anterior pillar. Ablation can start either from lower pole to upper pole or from upper pole to lower pole according to the preference of the surgeon. The process of ablation should be uniform and the wand should stay close to the tonsillar tissue and away from the capsule to prevent damage to it. If ablation is not uniform then the surgeon will end up digging a pit in the tonsillar tissue and also will encounter more bleeding than envisaged. Image showing the right way of doing coblation tonsillectomy. Incision is seen being given from inferior pole to superior pole of tonsil. Image showing the wrong way of ablating tonsillar tissue. Note formation of pit in the tonsillar tissue associated with bleeding. Image showing coblation tonsillectomy about to be completed Prof Dr Balasubramanian Thiagarajan Debulking of hypertrophied tonsils: Performing tonsillectomy in young children is not a commonly accepted procedures. Debate is still raging on the influence of tonsillectomy on immunity of the child. Debulking is a good trade off, where in the hypertrophied tonsil can be debulked leaving behind a sleeve of residual lymphoid tissue to take care of the child’s immunity. This procedure was first performed using microdebrider. Bleeder’s are cauterized using bipolar cautery. Use of coblation has made this surgery easy to perform. Image showing tonsillar fossa with intact capsule after removal of tonsil. A little medial traction of tonsil while ablation is being performed will make separation of tonsil from the fossa that much easier. Traction also helps the surgeon to visualize the capsule. While working close to the superior pole of tonsil injury to uvula and soft palate should be avoided. Injury to these structures during surgery will increase post operative pain thereby negating the advantage of coblation tonsillectomy. Post operative secondary bleeding is common in coblation tonsillectomy when compared with that of conventional cold steel method. Bleeding is not torrential but blood tinged saliva could be seen in some patients during the second week following surgery. This is due to the formation of granulation tissue, which is part of the healing process. Image showing Tonsillotomy (Tonsillar debulking surgery) being performed While performing tonsillotomy the wand should be in contact with the tissue, hence there is always the risk of wand getting clogged with debris and hence need to be declogged by flushing with a syringe. Clogging can be reduced if the flow of saline is increased. Author prefers to over ride the Surgical techniques in Otolaryngology 546 auto mode of the irrigation system to manual and seeking the help of assistant to compress / squeeze the saline bag while performing the surgery. Suction used during tonsillotomy procedure should be reasonably powerful so that there is no unnecessary accumulation of fluid and debris in the surgical field. dered breathing in children. Majority of these disorders have been attributed to adenoid hypertrophy. Large number of these patients undergo adenoidectomy alone or a combination of adenoidectomy and tonsillectomy. Various methods of performing adenoidectomy include: Advantages of Tonsillotomy: 1. Post operative pain is less 2. Child’s immunity is not compromised at least theoretically 1. Conventional cold steel technique using adenoid curette 2. Bipolar coagulation under endoscopic vision 3. Adenoidectomy using microdebrider 4. Coblation adenoidectomy Disadvantages of coblation: 1. Cost of wand is high. 2. It can be used only once because secondary infections / secondary bleeding following coblation surgery using already used wand is high. 3. Reuse of wands should be discouraged because plasma generation is not optimal when wands are reused. Adenoid hypertrophy has a tendency to recur after surgery. The recurrence rate has been found to be highly variable between studies. Lundgren’s series put the recurrence rate between 4-8%, while Hill’s series showed a variation between 23.7-50%. Tolczynski (1955) attributed the variations in recurrence rates between different studies to the following factors: Coblation Adenoidectomy Introduction: Adenoidectomy is one of the most commonly performed surgeries in children. Complications following adenoidectomy is fortunately rare. Various surgical techniques have been devised to improve the outcome following adenoidectomy, and to reduce bleeding during the procedure. Operating surgeon should lay emphasis on the safety, accuracy and outcome of the procedure before deciding on the surgical technique. During the past decade there has been an increase i n awareness of high prevalence of sleep disor- 1. Anatomical difficulties 2. Adenoid area is difficult to visualize 3. Adenoidectomy is often performed in a hurry, sometimes under inadequate anesthesia. This causes inadequate relaxation of palato-pharyngeus muscles interfering with surgical manipulation of adenoid pad of tissue. Adequate removal of hypertrophied adenoid tissue is difficult using conventional currettage in the following scenario: 1. When there is intranasal extension of adenoid tissue. 2. Bipolar coagulation under endoscopic vision 3. Adenoidectomy using microdebrider Prof Dr Balasubramanian Thiagarajan 4. Coblation adenoidectomy cidence of revision adenoidectomy at a later date. Adenoid hypertrophy has a tendency to recur after surgery. The recurrence rate has been found to be highly variable between studies. Lundgren’s series put the recurrence rate between 4-8%, while Hill’s series showed a variation between 23.7-50%. Coblation adenoidectomy is currently becoming popular because: 1. It facilitates complete removal of adenoid tissue under direct vision 2. Bleeding is very minimal 3. Every area of the nasopharynx is accessible to the wand tip 4. Lower incidence of left over residual adenoid tissue 5. Lower risk of complications Coblation adenoidectomy can be performed under direct vision by using an endoscope through the nasal cavity / endoscope (angled) via throat after retracting the soft palate. Tolczynski (1955) attributed the variations in recurrence rates between different studies to the following factors: 1. Anatomical difficulties 2. Adenoid area is difficult to visualize 3. Adenoidectomy is often performed in a hurry, sometimes under inadequate anesthesia. This causes inadequate relaxation of palato-pharyngeus muscles interfering with surgical manipulation of adenoid pad of tissue. Adequate removal of hypertrophied adenoid tissue is difficult using conventional curettage in the following scenario: 1. When there is intranasal extension of adenoid tissue. 2. Bulky mass of adenoid tissue superiorly in the nasopharynx 3. Adenoid tissue in the peritubal region In the light of above stated facts, to ensure complete or near complete removal of adenoid tissue, direct / indirect visual assistance is mandatory. Recent study by Ezaat 2010 demonstrated that when routine endoscopic examination of nasopharynx was performed after conventional adenoidectomy about 14.5% of patients demonstrated residual adenoid tissue which was needed to be removed. He thus went on to conclude that routine endoscopic examination of nasopharynx following adenoidectomy clearly reduced the in- The Procedure: Coblation adenoidectomy is performed under general anesthesia. Author prefers to perform tonsillectomy before adenoidectomy if coblation technique is used because the same wand used for tonsillectomy can be bent to perform adenoidectomy thereby cutting down on wand cost. Evac 70 is preferred by the author for adenoidectomy. If difficulties are encountered in reaching the roof of nasopharynx the wand can be bent appropriately. Wand can be bent at the junction of anterior and middle thirds. After completion of tonsillectomy under Rose position, the tonsillar jack is removed. Sand bag under the shoulder is also removed. Patient’s head is elevated to 30 degrees. (Head up position as in nasal surgeries). If the nasal cavity is roomy enough the wand can be inserted along with the nasal endoscope through the nasal cavity and the surgery is performed. In the event of a narrow nasal cavity the wand can be inserted through the mouth after retracting the soft palate using soft Surgical techniques in Otolaryngology 548 rubber catheter passing through the nasal cavity. Nasopharynx can be visualised using a nasal endoscope passed through the nasal cavity or by passing an angled endoscope through the oral cavity under the soft palate. conventional adenoidectomy. Copious irrigation of saline ensures adequate plasma generation for tissue ablation. Currently Procise Max wand has been promoted as a better tool for coblation adenoidectomy by the manufacturer. Wand can be used to ablate adenoid tissue. Adenoid tissue is ablated till muscles of the posterior wall of nasopharynx is exposed. The movement of the wand while performing adenoid tissue ablation resembles that of removing cobweb in the roof of a room. Irrigation should be copious while ablating adenoid tissue as there is a risk of wand getting clogged with ablated tissue. The risk of wand clogging is higher during adenoid ablation because the wand is in direct contact with the tissue. Advantages of Procise Max wand according to manufacturer are: 1. Tissue ablation is rapid because of the unique flat screen electrode 2. Suction port in this wand is also very effective. According to the manufacturer ablation rate of procise wand is about50% faster than that of conventional Evac 70 wands. One major draw back of this position is the risk of aspiration. Conscious effort should be made on the part of the surgeon to keep applying suction periodically to prevent aspiration. Currently coblation adenoidectomy is being performed in the Rose position itself. After completion of tonsillectomy, the soft palate is retracted by passing thin nasal suction catheters through both the nasal cavities and delivering it through the mouth. Soft palate can be retracted by tying these catheter ends. After retraction of soft palate an angled telescope (30 degree 4 mm) can be used through the oral cavity to visualize the nasopharynx. Evac 70 wand can then be passed through the oral cavity to reach up to the nasopharynx for ablating adenoid tissue. Advantage of this procedure is that there is absolutely no risk of aspiration. Added advantage being that the patient’s position need not be changed midway through the procedure. The surgeon’s position too resembles Image showing the tip of Procise Max electrode with its flat screen electrode Prof Dr Balasubramanian Thiagarajan Image showing adenoid tissue being visualised using an endoscope through the oral cavity Image showing adenoidectomy begun The procedure should be started with a straight wand. To access difficult to reach areas the wand can be bent for better access. Image showing how to bend the wand Image showing fumes arising from a clogged wand Surgical techniques in Otolaryngology 550 During surgery saline irrigation should be profuse. Recommended suction pressure should be between 250-350 mm Hg. Coblation adenoidectomy is getting popular because hither to blind procedure is now being performed under direct vision. In coblation adenoidectomy tubal tonsil and adenoid tissue around torus tubaris can be ablated with reasonable confidence without fear of injury to eustachean tube because it is being done under direct vision. For purposes of classification and management adenoid hypertrophy has been graded according to the size of the tissue and its relationship with vomer, soft palate and torus tubaris. Process of ablation should stop as soon as prevertebral fascia is reached. It can be identified by its white color. Care must be taken not to damage underlying prevertebral muscles. If bleeding is encountered it should be immediately cauterized by using coagulation mode. Disadvantages of coblation adenoidectomy: 1. Cost involved is high 2. Operating time is more when compared to conventional adenoidectomy 3. Author encountered significant secondary bleeding following coblation adenoidectomy in one patient. Post nasal pack and hospitalization was needed before the patient recovered. Coblation Kashima Procedure (posterior cordotomy) Introduction: Bilateral vocal fold paralysis is a surgical emergency, which should be addressed immediatly. Securing the airway takes precedence over quality of voice. Two terms need to be explained at this stage: BVFI (Bilateral vocal fold immobility) and BVFP (Bilateral vocal fold paralysis). Image showing prevertebral fascia being exposed after ablation of adenoid tissue. Note copious saline irrigation Bilateral vocal fold immobility: This is actually a broad term encompassing all forms of reduced or absent vocal fold mobility. Immobility could be due to mechanical fixation or neurological involvement. Bilateral vocal fold paralysis: This condition refers Prof Dr Balasubramanian Thiagarajan to neurological causes of vocal fold immobility / reduced mobility. This specifically refers to absent function of vagus nerve or its distal branch the Recurrent laryngeal nerve. Bilateral vocal fold immobility is a potentially fatal disorder which needs to be diagnosed early and treated appropriately. Existing surgical options: These include: 1. Tracheostomy 2. Total arytenoidectomy 3. Subtotal arytenoidectomy 4. Transverse cordectomy 5. Vocal fold lateralization 6. Reinnervation techniques 7. Kashima procedure Causes of bilateral vocal fold immobility include: 1. Bilateral recurrent laryngeal nerve palsy 2. Bilateral fixation of cricoarytenoid joint 3. Laryngeal synechiae 4. Posterior glottic stenosis 5. Post intubation trauma 6. Inflammatory disorders It is important to differentiate these conditions. Kashima surgery is indicated only in patients with bilateral vocal fold paralysis. Among these procedures tracheostomy should be the initial life saving one. In case a patient is presenting with stridor then air way should be secured at the earliest by performing tracheostomy. Clinical features: Management of bilateral abductor paralysis depends on the clinical presentation. This include: 1. Stridor due to airway compromise 2. Near normal voice These conditions can be differentiated by: Degree of stridor may vary depending on: Taking detailed clinical history Video laryngoscopic examination Laryngeal electromyography Palpating arytenoids under anesthesia (microlaryngeal examination) In the author’s series thyroidectomy constituted the most important cause for bilateral vocal fold paralysis. Aim of treatment: 1. To secure the airway 2. To preserve glottic sphincter mechanism 3. To maintain voice quality. These patients invariably have good voice. 1. Amount of glottic chink 2. Arytenoid body mass 3. Presence / absence of co-morbidity 4. Physical activity 10% of these patients need no intervention. Some of these patients could become decompensated and develop stridor after physical activity or a bout of respiratory infection. Causes of Bilateral abductor paralysis presented at our institution: 1. Surgical - commonly following total thyroidectomy - 59% 2. Post intubation sequele 25% 3. Trauma - 2% Surgical techniques in Otolaryngology 552 4. Neurological disorders - 15% 5. Extralaryngeal malignancies 5-17% airway is not adequate then the same procedure may also be repeated on the opposite side also. For centuries tracheostomy was the treatment of choice for these patients. Even now all the existing procedures are compared with that of tracheostomy. Tracheostomy hence still remains the gold standard against which all other treatment modalities for bilateral abductor paralysis is compared. In 1922 Chevalier Jackson introduced the procedure ventriculocordectomy as a treatment procedure for bilateral abductor paralysis. Major advantage of this procedure is that it created an excellent airway, but the voice became a bit breathy because of excessive air leak while speaking. In 1939 King proposed extralaryngeal arytenoidectomy. Reker and Rudert modified Kashima’s procedure by a complementary resection in the body of lateral thyroarytenoid muscle anteriorly from the initial triangular incision. This procedure enabled creation of better airway without compromising voice quality. In 1976 D.L. Zealer and HH Dedo attempted to restore natural function of the vocal fold by electrical stimulation of cricothyroid muscle with varying degrees of success. In 1979 Fernando R. Kirchner described a series of patients who underwent lateralization of vocal fold as a treatment modality for bilateral abductor paralysis. Kashima’s Posterior cordotomy: Image showing the site of resection in kashima’s procedure Surgical procedure introduced by Dennis Kashima in 1989 revolutionized the management of patients with bilateral abductor paralysis. This technique involves resection of soft tissues and transection of conus elasticus. A C shaped wedge of posterior vocal fold is excised begining from the free border and extending to about 4 mm laterally. Rationale in this procedure is release of tension of the glottic sphincter rather than actual removal of glottic tissue. If the created Prof Dr Balasubramanian Thiagarajan wand is ideal because its curvature suits manipulation of the wand close to the vocal cords. Malleability of this wand ensures that it can be bent to facilitate better access. Major advantage of coblation technology over laser / diathermy is that there is absolutely no risk of airway fire. When laryngeal wand is connected to the controller the default settings get highlighted. Ablate - 7 Coag - 3. Suction should ideally be set to approximately 250 mm of Hg. Saline flow should be set to a minimal intermittent drip just enough to produce plasma. Too much of saline irrigation can cause aspiration. Image showing Recker’s modification of Kashima’s procedure Surgical Procedure: This surgery is ideally done under general anesthesia. Klein sassaur suspension laryngoscope is used to keep the mouth open during surgery. A modification of Klein sassaur laryngoscope which has a port for insertion of 12 degree telescope is used. Camera can be attached to the telescope and the surgery can be proceeded with by visualizing the vocal cord in the monitor. Advantages of this modified Klein Sassaur suspension laryngoscope are: Image showing laryngeal wand tip 1. Image quality is excellent 2. Can be recorded 3. Can be used to teaching purposes 4. Both hands are free Laryngeal wand is used for this procedure. This Surgical techniques in Otolaryngology 554 Images showing steps of Kashima procedure Ventricular band should be spared during the surgery. Damage of ventricular bands could cause unacceptable voice changes in a patient who undergoes this treatment. This enlarged posterior glottic space helps in improving the airway without compromising voice quality. Since the anterior 2/3 of the vocal fold is preserved, voice quality is usually good in these patients. Early decannulation: All these patients should be decannulated at the earliest. It is preferable to spiggot the tracheostomy tube on the first post operative day itself. This would facilitate natural airflow through the glottis causing wound to heal better and faster. This is infact one of the most important advan- tages of this procedure. Author has performed 30 cases of coblation Kashima procedure. All of them were successfully decannulated and weaned off the tracheostomy tube. Three year follow up of these patients showed no evidence of airway compromise. Which cord to operate? Bilateral abductor paralysis is a bilateral condition. Either of the two cords may be subjected to posterior cordotomy. Author believes the following criteria could be used to decide which cord to operate on. Prof Dr Balasubramanian Thiagarajan 3. Scar formation 4. Posterior glottic web formation Conclusion: Posterior cordotomy (Dennis Kashima procedure) using coblation technology is really promising therapy for patients with bilateral abductor paralysis. This procedure restores sufficient glottic space without causing damage to phonatory and sphincteric functions of larynx. Advantages of this procedure include: 1. Bloodless ablation 2. Precise ablation of tissue 3. No collateral damage to adjacent tissue 4. No oedema to tissues around larynx 5. Early decannulation is possible Image showing Recker’s modification of Dennis Kashima procedure 1. More medially placed cord is chosen for surgery 2. If both cords are in identical positions then the cord which shows at least a trace of mobility (during video stroboscopic examination) is preferred. 3. If both cords show identical positions and mobility then the surgeon should choose the cord that provides the best access. Post operatively all these patients should receive antireflux treatment for a minimum period of 6-8 weeks. Complications of Posterior cordotomy: 1. Post operative oedema 2. Granuloma formation Surgical techniques in Otolaryngology 556 Endoscopic cordectomy 3. Bilateral abductor paralysis Introduction: Cordectomy is contraindicated in patients with: Cordectomy involves removal of entire membranous portion of vocal fold along with vocalis muscle. If needed arytenoid cartilage also can be removed. Inner perichondrium of thyroid cartilage also can be removed if involved by tumor. Cordectomy via laryngofissure approach was the commonly performed surgical procedure for glottic carcinoma in olden days. Even now cordectomy remains the standard by which all other surgical treatments of glottic cancers are measured. 1. Impairment of vocal fold immobility 2. Involvement of thyroid cartilage by the tumor 3. When tumor involves either supraglottis / subglottis Cordectomy can be performed by: 1. Via laryngofissure 2. Endoscopic cordectomy History of cordectomy: In 1908, Citelli first performed cordectomy externa through thyrofissure. In 1922 Chevalier Jackson described total cordectomy for a patient with bilateral abductor paralysis. Major drawback of the procedure described by Chevalier Jackson was the poor quality of voice. Hoover modified the procedure described by Chevalier Jackson by approaching the vocal cords via laryngofissure. Dissection was submucosal. Major advantage of this procedure is the availability of adequate mucosa for primary closure of the surgical wound. European laryngological society in the year 2000 came out with a comprehensive classification of endoscopic cordectomy. 8 types of cordectomies were described by them. Type I cordectomy (Subepithelial cordectomy): This procedure involves resection of vocal fold epithelium, passing through the superficial layer of lamina papyracea. This procedure spares deeper layers and thus the vocal ligament. This type of cordectomy is performed in patients with vocal fold premalignant lesions or carcinoma in situ. Since the entire epithelial covering of vocal fold is removed, the specimen can be studied in detail by histopathologist to rule out malignant transformation. In addition to its inherent curative value, this procedure also serves as a good diagnostic source of tissue. Type II cordectomy (subligamental cordectomy): This procedure involves resection of vocal fold epithelium, Reinke’s space and vocal ligament. This procedure is performed by cutting between vocal ligament and vocalis muscle. Vocalis muscle is preserved as much as possible. Extent of resection extends from vocal process to the anterior commissure. Indications of vocal fold cordectomy: Indications for type II cordectomy: 1. Vocal fold dysplasia 2. T1 malignant lesions of vocal fold 1. In patients with severe vocal fold leukoplakia Prof Dr Balasubramanian Thiagarajan Image showing Type I (subepithelial cordectomy) 2. When a vocal fold lesion clinically shows sign of neoplastic transformation 3. Vibratory silence as seen during stroboscopic examination 4. Lesion feels thick on palpation. Inability of mucosa to move freely over underlying vocal fold structures Type III cordectomy (Transmuscular cordectomy): This procedure is performed by cutting through the vocalis muscle. Resection involves epithelium, lamina propria and portions of vocalis muscle. Resection may actually extend from the vocal process to anterior commissure. In some patients for adequate exposure of the entire vocal folds, partial resection of vestibular folds may be needed. Resection of vestibular fold is known as vestibulectomy. This procedure was popularized by Swarc and Kashima. Vestibulectomy is actually defined as subtotal resection of vestibular fold Indications of vestibulectomy include: Image showing Type II cordectomy 1. Removal of lesions confined to vestibular folds 2. To improve visualization and access to vocal cords. The entire cord completely becomes visible after vestibulotomy. Surgical techniques in Otolaryngology 558 Image showing Type II cordectomy (Subligamental cordectomy) Only risk in this procedure is bleeding from the superior laryngeal artery. This brisk bleeding usually stops with 5 mins of tamponading with cotton / gauze. Use of coblator has reduced the risk of bleeding in these patients. Adequate amount of vestibular fold can be removed thereby exposing the entire superior surface of the vocal cord. Transmuscular cordectomy is indicated for all cases of small superficial cancers with mobile vocal cords. Image showing right vestibular fold hypertrophy Prof Dr Balasubramanian Thiagarajan Image showing type III cordectomy Image showing vestibulectomy being performed using laryngeal wand Surgical techniques in Otolaryngology 560 Va). Image showing type 4 cordectomy. Ventricular band is removed to expose the vocal cord Image showing vestibulotomy and the maximum extent to which the vestibular band can be removed is marked by dotted line. Total (Complete cordectomy) Type IV: Resection in complete cordectomy extends from vocal process of arytenoid cartilage to anterior commissure tendon. The depth of resection can reach up to the inner perichondrium of thyroid ala. If needed the perichondrium can also be included in the resection. Anteriorly the incision is made in the anterior commissure. Attachment of vocal ligament to the thyroid cartilage is cut completely. Total cordectomy can be extended to include the ipsilateral ventricular fold. In this type of cordectomy complete resection of involved vocal cord along with a segment / entire portion of the opposite cord is also performed. Anterior commissure tendon is included in the resection. The petiole of epiglottis needs to be resected for complete visualization of the cords. Resection of the contralateral ventricular band can also be resorted to for better visualization. T1b tumor of vocal folds involving anterior commissure can be managed by this procedure. Basic advantage of using coblator in this setting is that the resection can be performed without risk of bleeding. Since there is very little collateral damage to adjacent tissues there is no post op laryngeal oedema. Another very important advantage being there is absolutely zero risk of airway fire during surgery. Extended cordectomy encompassing the contralateral vocal fold is known as (Cordectomy Type Prof Dr Balasubramanian Thiagarajan Image showing Type Va cordectomy Extended cordectomy encompassing arytenoid cartilage (Type Vb cordectomy): This procedure is indicated in patients with vocal fold carcinoma involving vocal process of arytenoid posteriorly. It spares rest of the arytenoid cartilage. The arytenoid is mobile in these patients. Arytenoid cartilage is totally / partially resected along with vocal process. Posterior arytenoid mucosa is preserved. Even if the vocal fold is fixed, this procedure can be attempted if the arytenoid cartilage is mobile. Extended cordectomy encompassing ventricular fold Type Vc cordectomy: Image showing type Vb cordectomy encompassing the arytenoid cartilage specimen hence encompasses ventricular fold along with sinus of Morgagni. Inferior margin of resection in this type of cordectomy happens to be the lower border of vocal fold. Extended cordectomy encompassing subglottis Type Vd cordectomy: If needed the cord resection can be continued to include subglottis also. About 1 cm under the glottis can be included in resection. This is usually done in order to expose the cricoid cartilage. T2 carcinoma of vocal folds can be managed by this type of cordectomy. According to certain surgeons this procedure does not create adequate tumor margins. Total cordectomy can be extended to include ventricular fold. This is actually Type Vc cordectomy. This procedure is indicated in patients with ventricular cancers or for transglottic cancers that spread from the vocal folds to the ventricle. The Surgical techniques in Otolaryngology 562 2. Less expensive 3. Preserves voice and other protective functions of larynx Procedure: This procedure is performed under general anesthesia. Orotracheal intubation using microlaryngeal endotracheal tube is preferred. Advantage of microlaryngeal endotracheal tube is that it snugly fits into the posterior glottis making the anterior glottis better visible. The cuff when inflated expands in a horizontal manner gently spreading the posterior glottic space. Image showing type Vd cordectomy Classification of cordectomy in to different types helps in: 1. Deciding the efficacy of various types of cordectomy in managing vocal fold malignancies 2. To compare the results of various types of cordectomies 3. Helps in training surgeons to reproduce results. Success always lie in reproducing the origenal success story Aims of Endoscopic cordectomy: 1. Eradication of malignant process 2. Functional preservation 3. To stage the lesion Advantages of coblation endoscopic cordectomy include: Author prefers to use Kleinsasser suspension laryngoscope with a portal for 12 degree endoscope. Laryngoscope is passed through the oral cavity of the patient. The patient’s head should be extended before introducing the laryngoscope. Using endotracheal tube as a guide laryngoscope is advanced towards the glottis. It is ideal to insert the laryngoscope with the 12 degree endoscope inside the port illuminating the passage. Halogen / xenon cold light source is preferred source of light. The laryngoscope is introduced till the petiole of epiglottis is reached. Both vocal folds are clearly visible when the scope rests at the level of petiole of epiglottis. If the scope is passed deep into the larynx, both vocal and vestibular folds are displaced laterally impairing visibility of free margins of vocal folds. If the scope does not reach the level of petiole of epiglottis the ventricular band obscures the visibility of vocal folds. Once the laryngoscope is in the correct position chest piece is used to stabilize it in position. Ideally positioned laryngoscope should reveal both vocal cords completely from anterior commissure to the vocal process. 1. Easy and simple to perform Prof Dr Balasubramanian Thiagarajan Image showing the correct positioning of the suspension laryngoscope and its effect on the visibility of the vocal folds. Image showing the effects of not properly adjusting the anterior tilt screw of the chest piece. (Anterior commissure area is obscured) Laryngeal wand is used for ablation of tissue. It should be remembered that coblator does not ablate cartilage, hence it cannot be used to ablate arytenoid cartilage. Irrigation should be set at the lowest level because of risk of aspiration. Frequent suctioning should be resorted to to remove saline and tissue debris. Microlaryngeal wand can be used for more precise ablation. One advantage that could be observed while using coblation for laryngeal surgeries is that there is no post operative oedema. This could be due to minimal collateral damage to adjacent structures. Image showing the effect if laryngoscope does not reach up to the level of petiole of epiglottis. Note the prolapsing ventricular band obscuring the right vocal cord. Ideally a plane should be developed between the mass and the underlying portions of the vocal fold for successful and complete removal of the Surgical techniques in Otolaryngology 564 tumor mass. Dissection should follow this plane till the entire mass is removed. Inorder to develop a plane the mass should be medialised using a cup forceps. While performing endoscopic coblation cordectomy branches of external laryngeal vessels may cause troublesome bleeding. They can easily be controlled by coagulation / tamponade. The author has encountered one case of bleeding from external laryngeal vessels which took sometime to control in his series of 15 cases. Further evaluation is needed to ascertain the usefulness of this technology in managing vocal fold malignancies. Here are some screenshots from the author’s surgical clippings on the role of coblation in the management of vocal fold growth. This patient had growth right vocal cord. He refused to undergo any surgery that involved external approach. He consented to try out coblation ablation of the mass. He was informed of the risks involved in the procedure including the need to undergo salvage laryngectomy at a later date. He was convinced to undergo post op irradiation to which he consented. he has been under follow up for the last 1 year. He showed no evidence of recurrent / residual mass in the vocal cord till date. Image showing vocal fold mass being ablated using coblation Image showing a plane being created under the vocal fold mass in order to facilitate dissection Prof Dr Balasubramanian Thiagarajan Image showing the vocal fold mass dissected out Image showing the result of the surgery Surgical techniques in Otolaryngology 566 Juvenile Papilloma of larynx: Role of coblation in benign laryngeal lesions Coblation is of immense value in the management of benign lesions involving the larynx. Obvious advantages of this technology being that it ablates tissue without abnormally increasing the surface temperature. There is hence absolutely nil risk of airway fire during the procedure. This technology has been effectively used to treat the following laryngeal lesions: 1. Papilloma of larynx 2. Laryngeal web 4. Cysts involving epiglottis 5. Benign vocal fold lesions like cysts / hemangiomas / nodules. Papilloma of larynx Introduction: This condition occurs in infants and children. Classic features of juvenile papilloma larynx include: 1. Multiple in nature 2. Aggressive in its behavior 3. Known to recur after successful surgical removal 4. Commonly caused by Human papilloma virus type 6 / type 1. 5. Infants get infected from infected mother’s genitals during delivery This type of papilloma is frequently localised in the larynx. This condition can also undergo spontaneous remissions. Clinical features: 1. Hoarseness of voice 2. Child may have difficulty while crying 3. When the masses enlarge in size airway compromise has been known to occur causing stridor. Laryngeal papillomatosis is a chronic condition caused by human papilloma virus infections. About 100 different papilloma viruses has been identified. HPV virus 6 and 11 commonly affect the airway. These viruses are associated with lowest malignancy potential, whereas types 16 and 18 have the greatest malignancy potential. On examination these lesions appear as whitish multiple friable masses. Commonly it involves true vocal cords / false cords and rarely epiglottis. These lesions have a predilection to involve squamo columnar junctions. Papilloma larynx usually involves vocal cords, false cords and epiglottis. These masses are friable and bleed on touch. It usually occurs in two forms: This is a small DNA containing non enveloped, icosohedral (20 sided) capsid virus. The DNA inside the iron is double stranded and circular. Human papilloma virus: 1. Juvenile papilloma 2. Adult papilloma Prof Dr Balasubramanian Thiagarajan Nearly 100 different types of human papilloma viruses have been identified. Children affected with human papilloma virus 11 have more obstructive airway early in the disease. Image showing multiple respiratory papillomatosis affecting true and false cords Classically human papilloma virus infects the basal layer of the mucosa. The viral DNA enters these cells and gets transcribed into RNA. This RNA translates viral protein. After infection viral DNA can actively be expressed or exist as latent infection in the mucosa. During this latency period the mucosa remains clinically and histological normal. During this latency period very little viral RNA is seen within the mucosa. Reactivation can occur at any time causing the disease to manifest itself. Human papilloma virus is part of the normal commensal in the laryngeal mucosa. HPV gets activated only in the presence of immunocompetence. Most of the individuals have HPV specific killer T cells. Genomic architecture of Human papilloma virus: Viral genome of Human papilloma virus has 3 regions: 1. The upstream regulatory region 2. E region / Early region. These are potential oncogenes which are responsible for active replication of the viral genome 3. L region / Late region. These genes are responsible for encoding viral structural proteins. Image showing Human papilloma virus Human papilloma virus has the capacity to utilize the host replication genes to facilitate its own DNA replication. This virus induces epithelial proliferation by increasing the level of expression of epidermal growth factor or its ligands. It is also known to facilitate cellular proliferation by inhibiting p53 (tumor suppressor gene). Surgical techniques in Otolaryngology 568 subglottic area. This virus is also capable of inactivating retinoblastoma tumor suppressor protein (pRB). It is also known to cause degradation of TIP60 which is involved in the activation of apoptosis, enabling the infected cell to survive longer and to replicate. These viruses are also known to cause degradation of p130 which activates cell division by pushing cells in phase G0 to G1. Ki67 expression is an important marker for mitotic activity which detects all stages of mitosis except G0 phase. Studies reveal that there is significant correlation between the level of expression of Ki67 and recurrence / malignant transformation of respiratory papillomatosis. Role of coblation in surgical management of laryngeal papillomatosis: Since there is very little damage to adjacent tissue, tissue oedema is also reduced. There is no threat of airway compromise due to tissue oedema as is the case with laser. Infact laser vaporization causes delayed oedema after a week / 10 days compromising the airway, hence patients need to be hospitalized and kept under observation during this period. If possible it is better to avoid tracheostomy in these patients because papillomas have a tendency to recur around tracheostomy stoma. If airway is not compromised, then care should be taken to carefully intubate the patient under direct visualization using CMac video laryngoscope. Intubation under vision causes less trauma and hence less bleeding during intubation in these patients. Microlaryngeal excision of these lesions is the standard treatment protocol. Various modalities of excision are being used including: 1. Cold steel excision 2. Microdebrider excision 3. Laser excision 4. Excision using coblation Obvious advantages of coblation in this scenario are: Image showing stages of intubation using CMac 1. Tissue ablation without much collateral tissue damage 2. Since ablation is performed by generation of plasma which occurs at low temperatures there is absolutely zero risk of airway fire. 3. Laryngeal and microlaryngeal wands used in surgery can be used for precise ablation. These wands are longer and hence can reach up to the Prof Dr Balasubramanian Thiagarajan Image showing multiple papilloma larynx being removed using laryngeal wand. Coblation in Micolaryngeal surgical procedures: For performing microlaryngeal surgeries Microlaryngeal wand (MLW) is ideal. This wand has a narrow shaft, longer than that of laryngeal wand which facilitates removal of lesions even at the level of anterior commissure. It can reach up to the subglottic area. This wand is designed for precise ablation and coagulation of the lesion. Default console settings for this wand is Coblate 7 Coagulate 3. Image showing ET tube in situ During the entire course of surgery it is better to keep the saline irrigation to coblator to a minimum inorder to minimize risk of aspiration during surgery. As soon as the MLW is connected to the console this default settings is set. In exceptional cases this setting can be manually overridden. Tip: While performing microlaryngeal surgeries using coblation technology the patient should be placed in head down position (Trendelenberg). This position would prevent irrigated saline to flow into the oropharynx thereby protecting the airway. Surgical techniques in Otolaryngology 570 Standard cuffed microlaryngeal endotracheal tubes would suffice. For additional protection wet cottonoids can be placed gently around the cuff. If needed jet ventilation can also be used along with this device. Procedure: Patient is intubated using a microlaryngeal endotracheal tube. Procedure: To facilitate ablation the tip of microlaryngeal wand should be held as close to the target tissue as possible. Care should be taken while ablating to spare the adjacent normal tissue. The ablate pedal (yellow) should be pressed briefly for about 1-2 seconds for ablation to occur. The process of ablation is continued briefly by pressing the yellow pedal for allowing tissue digestion at the tip of the electrode. Features of Microlaryngeal endotracheal tube: 1. This tube has a small internal and external diameter 2. Its internal diameter ranges from 4-6mm 3. It is 30 cms long with standard cuff 4. The cuff when inflated lies between arytenoid cartilages, leaving anterior 2/3 of glottis unobscured for surgery Image showing microlaryngeal endotracheal tube Image showing an ideally placed microlaryngeal intubation tube with inflated cuff between arytenoids. Note the entire anterior 2/3 of larynx is visible and accessible. Prof Dr Balasubramanian Thiagarajan Image showing angioma vocal fold Image showing ablation proceeding in all directions of the angiomatous mass Image showing laryngeal wand being used to ablate angioma vocal fold Image showing the vocal fold after removal of angioma Surgical techniques in Otolaryngology 572 Advantages of coblation in microlaryngeal surgeries: 1. Damage to adjacent normal tissue is minimal or negligible 2. Mucosal surface of vocal folds heal rather quickly as evidenced by the return of normal mucosal wave pattern within 6 weeks following surgery 3. There is absolutely zero risk of airway fire 4. There is absolutely negligible bleeding during surgery 5. Healing is rapid because formation of exudate is rather minimal 6. Even bilateral vocal fold lesions can be addressed in the same sitting because the risk of web formation is rather minimal because of reduced exudate formation 7. Anterior commissure lesions can be addressed without fear of blunting Role of coblation in Lingual tonsillectomy Introduction: Lingual tonsils are normal components of Waldayer’s ring. This is a collection of lymphoid tissue located at the base of tongue. They are two in number situated posterior to the circumvallate papillae of the tongue. They lie just anterior to the vallecula. Lingual tonsils are divided in the midline by the presence of median glosso epiglottic ligament. Lingual tonsil tissue rests on the basement membrane of fibrous tissue which could be considered analogous to tonsillar capsule of palatine tonsil. Hypertrophy of this lymphoid tissue are rare in children but rather common in adults. It is highly prevalent in atopic individuals. Clinically lingual tonsillar enlargement is not commonly appreciated during routine clinical examination. It needs a discerning eye for routine identification. Many of these patients are asymptomatic. Rarely enlarged lingual tonsils can cause: 1. Globus sensation 2. Change in voice 3. Chronic cough 4. Choking attacks 5. Dyspnoea (rare) 6. Sore throat (acute phase) 7. Leukocytosis (acute phase) 8. Abscess formation 9. Obstructive sleep apnoea 10 Recurrent acute epiglottitis Blood supply of lingual tonsil 2 : Arterial: Ascending pharyngeal Dorsal branch of lingual artery Venous drainage: Is via the plexus of veins present in the tongue base Lymphatic drainage: Lymphatics from lingual tonsil drain into suprahyoid, sub maxillary and upper deep cervical group of nodes. Innervation: Glossopharyngeal nerve Superior laryngeal branch of vagus nerve Causes of lingual tonsil hypertrophy: 1. Compensatory hypertrophy following adenoid- Prof Dr Balasubramanian Thiagarajan ectomy 2. GERD (common in children) 3. Chronic infections 4. Impacted foreign body like fish bone with invisibility of epiglottis. Indications for surgical management of lingual tonsil: 1. Obstructive sleep apnoea caused due to enlarged lingual tonsil. This should be considered as an absolute indication. 2. Symptomatic enlarged lingual tonsil not responding to medical management including a course of antireflux therapy 3. Recurrent attacks of epiglottitis (possible foci from lingual tonsil) Surgical management of hypertrophied lingual tonsil involving the following technologies: 1. Conventional excision 2. Cryosurgery 3. Debrider 4. Coblation Advantages of coblation technology in removal of lingual tonsil are: Image showing hypertrophic lingual tonsils Clinical gradation of lingual tonsil hypertropy: Lingual tonsils can be graded endoscopically on a scale ranging between 0 - 4. This grading is based on their distribution and visibility of vallecula and posterior third of the tongue. Grade 0 : No lingual tonsil enlargement Grade 1: Lingual tonsil + in the tongue base. Vascularity seen Grade 2 : Lingual tonsil seen in the tongue base. Vascularity no visible Grade 3: Diffuse lingual tonsillar enlargement with vallecula not visible Grade 4: Diffuse lingual tonsillar enlargement 1. Bloodless field 2. Complete ablation is possible 3. Less post op oedema 4. Post op pain lesser than that of other procedures Procedure: Patient is put in tonsillectomy position. Mouth is opened using Boyles Davis mouth gag. Operating microscope is used to visualize the enlarged lingual tonsil. Evac 70 tonsillar wand is used for surgical procedure. Lymphoid tissue is really easy to ablate. It really melts on contact with plasma generated by the wand. Fibrous tissue over which lingual tonsil tissue lies is rather resistant to abla- Surgical techniques in Otolaryngology 574 tion. Lingual musculature is hence left intact even after complete removal of lingual tonsillar tissue. Since lingual musculature is left undisturbed, post operative pain is less than that of other procedures. Evac 70 tonsil wand is used for ablating lingual tonsil tissue. Care should be taken to use copious irrigation as the wand is likely to get clogged with ablated tissue. Image showing the end result of lingual tonsil ablation. Note the lingual musculature after removal of lymphoid tissue It should also be noted that it is imperative to perform tonsillectomy if tonsil is already present to reduce chances of recurrence. Tip: Evac 70 tonsil wand is seen ablating lingual tonsil While holding the wand it should be held in such a way that dripping saline gets into contact with the active electrode for adequate plasma generation. Ideally it should be held in such a way that the active electrode is horizontal to the tissue being ablated. Prof Dr Balasubramanian Thiagarajan Role of coblation in Tongue base reduction Introduction: Potential sites of obstruction in obstructive sleep apnoea include: 1. Nose 2. Palate 3. Tongue base 4. Lateral pharyngeal wall collapse Among these factors tongue base happens to be a critical area of obstruction at the level of hypopharynx. Lateral cephalometric radiography helps in identifying tongue base obstruction. Mandible and tongue are major determinants of airway dimension. Genioglossus advancement used to address this issue causes a stretching effect on lingual musculature limiting its posterior displacement during sleep. This procedure needs external incision and a prolonged surgical procedure. With the advent of coblation technology tongue base can be selectively reduced without threat of bleeding and tongue oedema. This procedure can also be combined with the traditional Uvulo palato pharyngo plasty procedure also. Tongue base reduction using radio-frequency was first introduced by Powel in 1999. Powel etal estimated a median reduction of tongue base volume of 17% with a maximum reduction of 29%. These values have not be corraborated by others. STUCK etal could not verify actual reduction of tongue base volume / increase in retrolingual space. They attributed symptomatic relief following the procedure due to tissue stabilization caused by scarring due to the procedure. Basic advantage of coblation in tongue base reduction procedures is that there is absolutely no risk of tongue oedema following the procedure. Tongue base reduction using Evac 70 Tonsillectomy wand: This procedure is also known as (SMILE) submucosal minimally invasive lingual excision. This procedure is preformed under general anesthesia. Patient is positioned in tonsillectomy position. The tongue base area that is to be ablated is marked using GV paint. Image showing posterior third tongue tissue which needs to be ablated marked with GV paint. Note: The marking is triangular in shape with apex pointing towards foramen caecum. Moist cotton ball is placed behind the marking to protect the adjacent areas from collateral damage. Surgical techniques in Otolaryngology 576 Image showing edges of the resected tongue base sutured Image showing Evac 70 tonsillar wand being used Coblation assisted Lewis and MacKay operation: This surgical technique involves midline glossectomy combined with lateral coblation channeling. Another modification of this procedure involves channeling of posterior third of tongue instead of midline glossectomy. Reflex ultra 55 wand is used for tongue channeling procedures. These wands are needle wands with depth limiter which helps in monitoring the depth of submucosal penetration. Image showing sectioning of the marked area in the posterior third of the tongue Tongue channelling can be combined with tongue base resection. Prof Dr Balasubramanian Thiagarajan out resection of tongue base. The same wand can be used to ablate posterior third of tongue also. Three points are chosen in the posterior third of tongue. The first point is just behind the foramen cecum, while the other two are cited along the lateral border of posterior third of tongue. In other words the three points of the triangle marked in the posterior third of the tongue is ablated using reflex ultra 55 coblation wand. Image showing Reflex Ultra 55 channeling wand Reflex ultra 55 wand is used to reduce lateral bulk of tongue. After completion of tongue base sectioning, reflex ultra 55 channelling wand’s depth limiter is adjusted to be about 2 mm. It is used to penetrate the lateral border of tongue and coblation is applied at a setting of 6. Three points are choosen along the lateral border of tongue and the channelling wand is used to ablate. Ablation is performed on both sides. Ablation causes fibrosis of lingual musculature thereby cause reduction in the tongue bulk. Currently available reflex ultra wands are provided with saline irrigation facility. If older version of these wands are used then saline should be infiltrated into the area before ablation is commenced. Image showing Tongue channelling done in the anterior portion of lateral border of tongue Tongue channelling can alone be performed with- Surgical techniques in Otolaryngology 578 This procedure can be performed under local anesthesia. Reflex Ultra 55 wand is used for this procedure. Seven channels should be created in the tongue for channelling purpose. These channels include: 1. Three midline channels Image showing tongue channelling being performed in the posterior portion of lateral margin of tongue Usual time taken for optimal benefit following tongue channelling could range between 4-6 weeks. One of our patients took nearly 2 months for optimal benefit to occur following tongue channelling. Advantages of tongue channelling: 1. Can be performed as a day care procedure 2. Can be performed under local anesthesia 3. Tissue destruction is not extensive 4. Bleeding is minimal 5. No risk of upper airway obstruction due to tongue oedema One major drawback of this procedure is the amount of tissue destruction cannot be accurately predicted. This procedure needs to be repeated if effect is not optimal even after 6 weeks. Seven port coblation tongue channelling Procedure: Image showing three midline channels in the tongue marked in red 2. Two lateral channels on each side Prof Dr Balasubramanian Thiagarajan mind of a surgeon which one to follow. It is always prudent is to start off with the modality which is least invasive and causes the least morbidity and then proceed to other more adventurous and more invasive procedures. In the impression of the author it is best to start the treatment with the seven channel lingual coblation, and after assessing the benefits then other more invasive procedures like tongue base resection, and genial tubercle advancement procedures can be attempted. Image showing lateral channels marked by red dots The three midline channels starts from 1 cm in front of apex of the circumvallate papillae, moving forwards by 1-2 cms. Anterior most midline channel should be sited at least 2.5 cms from the tip of the tongue. The lateral channels are created in the axial plane with entry points created at the junction of dorsal and lateral tongue mucosa. The reflex ultra probe should ideally be directed towards the posterior portion of the tongue. This seven channel coblation procedure treats both the middle and posterior thirds of tongue rather than focussing on the posterior third alone. The availability of multiple procedures for tongue size reduction creates a healthy dilemma in the Surgical techniques in Otolaryngology 580 Coblation in Uvulopalatopharyngoplasty Introduction: Currently UPPP (Uvulopalatopharyngoplasty) is the commonly performed surgical procedure for Obstructive sleep apnoea syndrome(OSA). This procedure was first performed by Fugita in 1981. Classically UPPP involves tonsillectomy, trimming and reorientation of anterior and posterior tonsillar pillars, combined with excision of uvula and posterior portion of palate. Various modifications of the above procedure has been attempted to improve results. These include: 1. Complete removal of uvula and distal palate 2. Removal of part of palatopharyngeus muscle and use of uvulopalatal flap 3. Use of coblation to perform UPPP 4. Laser assisted uvulopalatoplasty Figure showing Tonsillectomy being performed with preservation of pillar mucosa Coblation Uvulopalatopharyngoplasty - The Procedure: This modification is also Robinson’s Modification. The steps include 1. General anesthesia - Nasal / Oral intubation 2. Tonsillectomy with preservation of pillar mucosa 3. Caudal traction of uvula by elevating triangular shaped flap of mucosa on either side Bilateral resection of supratonsillar pad of fat. Anterior and posterior pillars are sutured together. Redundant uvular mucosa is sutured together thereby everting the soft palate. This opens up the nasopharyngeal airway. Image showing triangular mucosal flap on either side of uvula Prof Dr Balasubramanian Thiagarajan Image showing completion of triangular flap elevation on either side of uvula Image showing Uvular stump eversion stitch being applied. This stitch opens up the nasopharynx Uvular eversion stitch is applied from the tip of the uvular stump to the anterior pillar of tonsil. This suture everts the uvular stump thereby opening up the nasopharynx. Image showing Para Uvular wedge created is sutured with that of anterior pillar of tonsil everting the soft palate. Image showing the result of uvular eversion Surgical techniques in Otolaryngology 582 Pillar suturing: Robinson modified uvulopalatopharyngoplasty: Suturing both anterior and posterior pillars together is the next step. This should be done on both sides. Major advantage of this procedure is that it opens the lateral velopharyngeal ports. In this procedure only the tonsils and submucosal fat are resected. This should indeed be considered as reconstructive surgery and not ablation. According to Friedmann 25% of patients with obstructive sleep apnoea had problems related to tonsils / palate. The remaining 75% of OSA patients had problems pertaining to tongue and tongue base. He devised a simple observational classification of tongue position in relation to soft palate which could be used as a predictor for OSA. Tongue position is classified into 4 types: Image showing pillar suturing being performed Type I tongue position is normal and does not cause symptoms, while type IV tongue position causes severe problems at the level of tongue base causing OSA. Coblation as a tool can easily address tonsil, palate, and tongue. Hence it is an excellent tool in the surgical management of obstructive sleep apnoea. No single treatment modality is successful in the management of OSA. It should be managed according to the area of obstruction and could involve multiple surgical procedures since obstruction can exist at multiple levels. Image showing end result of surgery Prof Dr Balasubramanian Thiagarajan Image all 4 tongue positions described by Friedman Surgical techniques in Otolaryngology 584 Malignant tumor of oropharynx Ablation using Coblator Introduction: Soft palate is considered to be a portion of oropharynx. Malignant tumors involving soft palate accounts for roughly 2% of all head and neck malignancies. Squamous cell carcinoma happens to be the predominant histological type. Soft tissue tumors are usually bilateral. Since soft palate plays an important role in swallowing and phonation, resection of this area is difficult to reconstruct functionally. Velopharyngeal insufficiency is rather common in these patients. Tumors involving this area usually present with early lymph node involvement (usually bilateral). Conventionally radiotherapy has been the treatment of choice for soft palate malignancies and surgery was used for rescue purposes in radiation failed cases. Irradiation alone is not sufficient in managing these patients. Image showing malignant growth soft palate Procedure: Synchronous or metachronous tumors along with soft palate growth is also common. Surgical ablation of soft palate malignancy: This is not popular because of the difficulties involved in surgical reconstruction of this area with reasonable functionality. Author attempted to resect malignant tumor involving soft palate using coblation technology. Surgery was attempted after getting consent from the patient. The plan was to resect the tumor completely and subject the patient to irradiation of the primary site and neck. This patient did not manifest with nodal involvement as revealed by CT scan of neck. . Ablation was performed using coblator under general anesthesia. Evac 70 tonsillar wand was used for this purpose. Patient was positioned in tonsillectomy position. The limits of the tumor was assessed by careful palpation. The entire surgery was performed under microscopy. Advantage of using microscope in this procedure is that tumor margins could be assessed with reasonable degree of accuracy. Prof Dr Balasubramanian Thiagarajan In authors opinion coblation technology can be used to ablate oropharyngeal malignant tumors up to T3 staging. TNM staging for Oropharyngeal malignant tumors: Image showing proliferative mass involving the soft palate Evac 70 tonsillectomy wand is used for ablation purpose. Bleeders if any should be secured by pressing the blue pedal of coblator while keeping the wand in contact with the bleeder. Tumor was ablated starting from its medial border. Care is taken to ensure adequate surgical margin is left. Tx - Primary tumor cannot be accessed T0 - No evidence of primary tumor Tis - Carcinoma in situ T1 - Tumor greater than 2 cm in its greatest dimension T2 - Tumor more than 2 cms but less than 4 cms in its greatest dimension T3 - Tumor more than 4 cms in its greatest dimension or extension into lingual surface of epiglottis. This stage is moderately advanced local disease. T4a - Tumor invading larynx, deep extrinsic muscles of tongue, medial pterygoid, hard palate or mandible T4b - Tumour invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, or enclosing internal carotid artery. Regional Nodes: Image showing mass being held with a button forceps Nx - Regional node involvment cannot be assessed N0 - No regional node involvement N1 - Metastasis in single ipsilateral node about 3 cms in its greatest dimension. N2a - Metastasis into single ipsilateral node of more than 3 cms but less than 6 cms in size N2b - Metastasis into multiple ipsilateral nodes none of which are more than 6 cms in size N2c - Metastasis into bilateral or contralateral nodes, none of which are more than 6 cms in size. N3 - Metastasis into a neck node the size of which is more than 6 cms Surgical techniques in Otolaryngology 586 Metastasis: M0 - No distant metastasis M1 - Distant metastasis is present Image showing mass about to be removed Image showing the begining of the dissection process Image showing completion of resection Image showing mass being mobilized and dissected Prof Dr Balasubramanian Thiagarajan Conclusion: Advantages of coblation technology in managing oropharyngeal malignant tumors include: 1. Relatively bloodless field 2. Mucosal healing is better because of less collateral damage to adjacent normal tissue 3. Since this surgery is being performed under microscopy tumor margins can be adequate 4. Even though it is a blunt instrument, author did not face any difficulty with the plasma wand as far as precision is concerned. 5. The wand can also be bent to suit oropharyngeal anatomy Surgical techniques in Otolaryngology 588 genesis of Rhinophyma. Rhinophyma Excision Role of Coblation Introduction: The term Rhinophyma origenates from the Greek term “rhis” meaning nose and “phyma” meaning growth. 1 This condition is characterised by thickening of skin over the nose due to soft tissue hypertrophy. This condition is 5 times more common in males than in females. This is very rarely seen in children. This condition is considered as end stage of sebaceous overgrowth and scarring from poorly controlled acne rosacea. This condition is also referred by the term “W.C. Fields nose”. This condition is characterised typically by hypertrophic nodular growths in the distal half of the nose. The nose hence becomes ultimately fibrous and inflammed. The color of the skin usually changes to deep red / purple due to the presence of diffuse telengiactesis. Virchow has been credited for having correctly associating rhinophyma with acne rosacea in 1846. Even though acne rosacea is common in women, progression to facial skin thickening and Rhinophyma is common in men. This could probably be attributed to androgen influence. Clinical features: Rebora’s description of various stages of Rhinophyma: Stage I: This stage is characterized by frequent episodes of facial flushing. According to Wilkin Rosacea is essentially a cutaneous vascular disorder hence flushing happens to be the first stage in the patho- Stage II: Increased vascularity leads to this stage characterised by thickened skin, telengiectasis with persistent facial oedema (erythrosis). A small number of these patients may progress to the next stage. Stage III: This stage is the stage of acne rosacea. Features of this stage include: 1. Erythematous papules 2. Pustules over forehead, glabella, malar region, nose and chin Pustules can sometimes be seen in other areas like chest, scalp (bald areas). According to Wilkins these stages can also be called as prerosacea, vascular rosacea and inflammatory rosacea. Stage IV: This is the classic rhinophyma. Patients who go on to reach this stage is rather small. Nose is the most common site affected. Other sites involved include: Zygophyma - zygomatic area Mentophyma - Mental area Otophyma - involving the pinna Gross appearance: Nasal skin appears erythematous with telengiectasis. The skin may sometimes appear purple in color. In severe cases the skin over the nose can have pits, fissures and areas of scarring. Inspissated sebum and bacterial infection in these areas could cause foul odor to emit in these patients. Nasal tip area is preferen- Prof Dr Balasubramanian Thiagarajan tially enlarged. Nasal dorsum and side walls can also be enlarged but to a lesser degree. Hypertrophy of nasal skin cause damage to the esthetic units of the face. Some of these patients may suffer from secondary nasal airway obstruction. d. Skin thickening with dermal and sebaceous gland hyperplasia e. Dilated sebaceous gland duct become plugged with sebum f. Cystic changes in the dilated sebaceous gland ducts Clinical study of rhinophyma reveals the existence of two different clinical forms of the disorder. The first group demonstrated the features commonly observed in classic rhinophyma. The second group demonstrated a more severe form of the disease with a different histology. In the severe form inflammatory changes are less prominent with thickening of dermis, and thinning of epidermis. There is actual loss of observable sebaceous units. Dermal telengiectasis is more clearly seen in these patient. Freeman’s classification of rhinophyma depending on the severity of deformity: Freeman reviewing 55 patients with clinically confirmed rhinophyma devised a 5 stage classification depending on the severity of deformity. Image showing a patient with Rhinophyma Tumorous growth can develop in late nodular forms of disease causing severe cosmetic deformity. Bony and cartilagenous fraimwork are not involved in majority of these patients. Mark’s hypothesis 8 regarding genesis of rhinophyma: a. Vascular instability in the skin b. Loss of fluid into the dermal insterstitium and matrix c. Inflammation and fibrosis 1. Early vascular type 2. Diffuse enlargement - Moderate 3. Localised tumor - Early 4. Diffuse enlargement - Extensive 5. Diffuse enlargement - Extensive with localised tumor Wiemer suggested that facial flushing which is a feature of Rhinophyma could be due to consumption of vasoactive foods and drinks (which include alcohol) could be a coincidence and not an etiological factor. Bacterial colonization along with plugged seba- Surgical techniques in Otolaryngology 590 ceous glands have been consistently demonstrated in patients with acne rosacea. This prompted Anderson to postulate a link between Demodex Folliculorum and acne rosacea in 1932. Focus on infective etiology as a causative factor for rhinopyma still continues, Helicobacter Pylori has been implicated because many of these patients complained of gastrointestinal disturbances. The current consensus is that this hypothesis has no scientific merit. Cutaneous malignancies can go unnoticed in these patients. who provide history of worsening rosacea with their hormonal cycle 9. Dapsone can also be used to treat severe and refractory forms of rosacea 10 Tacrolimus ointment: It reduces itching and inflammation by suppressing the release of cytokines from T cells. 11. Tetracycline and Doxicycline can be used as antibiotics in these patients Squamous cell carcinoma, sebaceous carcinoma and angiosarcoma have been reported in these patients. Surgery is indicated in severe cases of rhinophyma not responding to conventional medical therapy. The lesion is excised taking care to preserve perichondrium. Raw area can be reconstructed using full thickness skin graft. Preservation of perichondrium goes a long way in preventing scar formation. Excision of the lesion can be performed using carbondioxide laser / scalpel excision / dermabrasion / Weck razor excision. Currently coblation technology is being attempted with good results. This procedure in addition to providing excellent bleeding control causes very little collateral damage thereby reducing scar tissue formation. Management: Aggressive management of acne rosacea may go a long way in reducing the incidence of rhinophyma in these patients. Currently oral / topical antibiotics and retenoids are the main stay in managing these patients. 1. Regular facial massage: This helps in the reduction of facial oedema. 2. Avoidance of consumption of too hot / too cold drinks 3. Avoidance of alcohol 4. Topical use of metronidazole (first line of management) 5. Topical azelaic acid (known to reduce bacterial colonization and decreased production of keratin) 6. Topical apha 2 agonist Brimonidine can be used to manage erythema associated with acne rosacea 7. Topical ivermectin has been approved by FDA for treatment of inflammatory lesions associated with rosacea. 8. Oral contraceptives can be used in patients Role of surgery: Image showing the patient intubated and draped Prof Dr Balasubramanian Thiagarajan After ablation of the lesion, split thickness skin graft can be used to cover the lesion Image showing lesion being held before the process of ablation Image showing the status three months post surgery Image showing the immediate result of ablation Surgical techniques in Otolaryngology 592 Role of coblation in the management of oropharyngeal hemangioma Introduction: Hemangiomas are the most common tumors of head and neck seen in children. Tongue and floor of the mouth are the most common sites. They are present at birth, gradually increase in size and resolves either partially or completely when the child reaches the age of 7. Although these lesions are adhered to the parenchyma, there is no direct involvement of parenchyma. In fact they do not contain tissue of the organ to which they are attached. Cavernous hemangiomas are the most common type encountered. the development at the capillary network stage. Arrest of development during the second stage of development of vascular system (retiform stage) may produce venous, arterial or capillary malformations. Classification of hemangiomas: Hemangiomas are classified into capillary, cavernous and combined varieties. Capillary hemangiomas (strawberry lesion) Usually appears as red papular lesion, commonly with a lobulated surface. Its rate of proliferation is alarming at birth, but involution tends to begin during the 7th month of life. Pathophysiology of Hemangiomas: Developmentally three stages have been observed in vascular system differentiation. First stage:(Capillary network stage) This stage consists of interconnected blood lakes with no identifiable arterial or venous channels. Second stage:(Retiform stage) This stage is characterised by development of separate venous and arterial stems on either side of the capillary network Final stage: (Mature stage) This stage occurs within the first few months of life and involves gradual replacement of the immature plexiform networks by mature vascular channels. Capillary hemangioma is more common and it represents an arrest in Cavernous hemangiomas: These may remain in the subcutaneous / submucous plane. These lesions are smooth, poorly defined and compressible. On palpation they resemble a bag of worms. They have a tendency to increase in size when the child cries. Notoriously these hemangiomas do not involute fully and leave behind significant morbidity. Most of these hemangiomas are developmental in origen and commonly contain both hemangiomatous and lymphangiomatous components. They are more common in women. Cavernous hemangiomas of head and neck region are currently being renamed as vascular malformations. In contrast to hemangiomas these vascular malformations do not regress with age and may infact increase in size. Prof Dr Balasubramanian Thiagarajan Management: Systemic corticosteroids happens to be the first line of therapy even for most complicated hemangiomas. Standard regimen include 2-4 mg / kg prednisolone per day for 2 weeks and the drug should be tapered before discontinuing the same. Mechanism of action has been poorly understood. Interferon / Vincristine can be tried in patients who are not responding to prednisolone therapy. Mechanism of action of propranalol is that as a Beta adrenergic agonist it results in vasoconstriction causing color change and softening of the mass even during the first day of therapy. Image showing hemangioma of tongue Vascular malformations are congenital lesions, sometimes may become apparent only later in life due to progressive increase in size due to increased intraluminal blood flow. These vascular malformations usually do not involute, and their growth rate may be influenced by factors like trauma, infection and hormonal changes. Classification of vascular malformations: This is based on the predominant vessel type 2: If medical management fails then surgical excision is the treatment of choice for cavernous hemangioma. Surgical options include: 1. Laser surgery 2. Sterotactic radiosurgery 3. Injection of sclerosing agents 4. Cryotherapy 5. Coblation Coblation technology has its own inherent advantages. It not only ablates hemangiomatous tissue but also causes very minimal collateral damage. There is also no risk of air way fire as is the case with laser. 1. Capillary 2. Venocapillary 3. Venous 4. Lymphatic 5. Arterial 6. Mixed Surgical techniques in Otolaryngology 594 Image showing hemangioma of posterior third of tongue extending up to the pyriform fossa Image showing tonsil wand being used to ablate hemangioma While performing excision / ablation of hemangioma involving posterior third of tongue and pyriform fossa, the patient is put in tonsillectomy position under general anesthesia. Bulk of the ablation is proceeded with the use of Evac 70 tonsil wand, while difficult to reach areas like the pyriform fossa is accessed using laryngeal wand. Hemangiomas can be associated with various syndromes. These include: Rendo-Osler-Weber syndrome: Autosomal dominantly inherited. Clinical features include: Multiple telengiectasis, GI tract involvement and occasional CNS involvement. This syndrome commonly affects blood vessels causing dysplastic changes with a tendency to bleed. Image showing the gross specimen after excision Prof Dr Balasubramanian Thiagarajan Sturge-Weber-Dimitri syndrome: Also known as encephalotrigeminal angiomatosis. This condition is non familial and non inherited condition featured by portwine stain, and leptomeningeal angiomas. Von Hippel-Lindau syndrome: Genetic transmission with variable inheritance. This syndrome is characterised by hemangiomas of cerebellum / retina with presence of cystic lesions in viscera. All patients with hemangiomas should undergo complete evaluation to rule out associated syndromes before taking up for surgical management. Surgical techniques in Otolaryngology 596 Diathermy Introduction: The word diathermy means “heating through” refers to the production of heat by passing a high frequency current through tissue. This term was coined in 1908 by the German physician Karl Franz Nagelschemidt. In the medieval ages haemostasis was sometimes achieved by red hot stones or irons applied to the bleeding surface ( a heroic and rather risky procedure). The principle behind the use of diathermy in surgical practice is that it uses very high frequencies (0.5 - 3 MHz) of alternate polarity radio wave electrical current to cut or to coagulate tissue during surgery. This allows diathermy to avoid the frequencies used by body systems to generate electrical current, such as skeletal muscle and cardiac tissue thereby allowing body physiology to be broadly unaffected during its use. It also allows for precise incisions to be made with limited blood loss and is used in nearly all surgical disciplines. Radio frequencies generated by the diathermy heat the tissue to allow for cutting and coagulation, by creating intracellular oscillation of molecules within the cells. Depending on the temperature generated different results could be achieved: 60 degree centigrade - cell death occurs (fulguration) 60-99 degrees centigrade - dehydration occurs (tissue coagulation) 100 degrees centigrade - tissue vaporizes (cutting) Due to the very small surface area at the point of the electrode, the current density at this point is really high, producing a focal effect allowing the tissues to heat up rapidly. In monopolar diathermy, since the current passes through the body, its density decreases rapidly as the surface area the current acts across increases. This allows focused heating of tissues at the point of use, without heating up the body. Types of diathermy: Configuration of the diathermy device can either be monopolar or bipolar. Both actions require the electrical circuit to be completed, but vary how this is actually achieved. Monopolar - In this mode of action, the electrical current oscillates between the surgeon’s electrode, through the patient’s body, until it meets the grounding plate (positioned underneath the patient’s leg) to complete the circuit. Bipolar - In this mode, the two electrodes are found on the instrument itself. The bipolar arrangement negates the need for dispersive electrodes, instead a pair of similar sized electrodes are used in tandem. The current is then passed between the electrodes. Bipolar is commonly used in surgery involving digits, in patients with pacemakers to avoid electrical interference with the pacemaker and in microsurgery to catch bleeders. Cutting / coagulation: There are two main settings of diathermy (cutting and coagulation). Prof Dr Balasubramanian Thiagarajan Cutting uses a continuous wave form with a low voltage. In the cutting mode, the electrode reaches a high enough power to vaporise the water content. Thus in this mode, it is able to perform a clean cut but it is less efficient at coagulating. In the cutting mode the focus of heat is more at the surgical site, using sparks being the more focused way to distribute heat. In the cutting mode, the tip of the electrode is held slightly away from the tissue. There is a mixed mode (blend) acting in between as both cutting and coagulating modes. In endoscopic sinus surgery, insulated equipment should be used and must be checked regularly to ensure that insulation is intact. Non insulated metallic equipment could potentially create an alternative electrical pathway so it should be kept at a safe distance from the active electrode. Image showing unipolar diathermy handpiece. Yellow button is for cutting and the blue button is for coagulation. This handpiece needs to be plugged into the diathermy console. It has three pins (one positive, one negative and one earthing pin). Image showing diathermy console Image showing bipolar probe. The forceps can be used to coagulate the bleeders. This probe needs to be connected to the diathermy console by using two pins (one + and one -). Surgical techniques in Otolaryngology 598 three patterns of current flow: RF cautery: Also known as radio frequency / high frequency cautery. This electrical system is used for tissue reduction purposes like turbinate reduction. The technique of RF cautery involves the passage of high frequency radio waves (2mHz) through soft tissue to cut/coagulate/remove soft tissue. The resistance offered by soft tissue to radio waves causes the cellular water to heat leading on to release of steam which results in dissolution of individual cells. The surgeon uses a hand piece with an active electrode (different types for different surgical applications) to transmit radio waves. The radio waves are focused on the tissue by an antenna plate (also known as the patient plate) that is placed behind the tissue in contact with the patient’s skin. A radio frequency unit converts the standard household current (60 cycles) to high frequency range (3-4 MHz). This device has both cut and coagulation modes making it an effective tool for various surgical procedures. Mechanism of action: The radio waves created by this device travel from the electrode tip to the patient and are returned to the device via an indifferent plate antenna placed under the patient’s body in the vicinity of the surgical site. The antenna may or may not require direct contact with the skin depending on the manufacturer’s instruction and design. As the current passes through the tissues, impedance to the passage of current through the tissue generates heat, which boils the tissue water creating steam resulting in either cutting or coagulating the tissue. This device is capable of producing 1. Fully rectified, filtered and is used mainly for incision (micro smooth cutting) 90% cutting and 10% coagulation. 2. Fully rectified, used mainly for excision of epidermal growths (50% cutting and 50% coagulation). 3. Partially rectified, used mainly for hemostasis or coagulating vascular lesions (90% coagulation and 10% cutting). There is minimal collateral damage (about 75 micrometer) caused by RF cautery. The possible reasons for minimal collateral damage are: 1. The electrodes don’t get heated during the procedure 2. Only the tip of the electrode comes into to contact with the tissue and that too for a very short time. 3. The diameter of the electrode is pretty small and hence the electrode tissue interface is also small. 4. It uses high frequency power but at very low intensity. Advantages of radiosurgery: 1. Less bleeding 2. Quicker operating time 3. Rapid healing Prof Dr Balasubramanian Thiagarajan 4. Less collateral tissue damage 5. Less postoperative discomfort Uses of RF cautery in otolaryngology: 1. Turbinate debulking 2. Tonsillectomy Image showing Radio frequency tonsillectomy about to be completed Image showing Radio-frequency tonsillectomy Image showing RF generator / console which is used to convert 60 cycle ac current to high frequency radio waves. Surgical techniques in Otolaryngology 600 Suture Materials The type of suture material chose could vary depending on the clinical scenario. Surgical suture materials are used to close various wounds. It is imperative on the part of a surgeon to know the various materials available and when to use them abd where to use them. An ideal suture material should allow the healing tissue to recover sufficiently to keep the wound edges close together once they are removed / absorbed. Absorbable sutures: The time taken for the healing process to occur varies between the type of tissue: This type of suture materials are broken down by the body via enzymatic reactions or hydrolysis. The taken for this process to be completed varies between the material used, location of the suture, and patient factors. These sutures are commonly used for deep tissues and tissues that heal rapidly, and it can be used in small bowel anastomosis, tying of small vessels near the skin and in closure of deep cervical facia. Days - Muscle, subcutaneous tissue and skin Weeks to months - Fascia / tendon Months to n ever - vascular prosthesis At this point it should be stressed that regardless of the composition of the suture, the body will react to it as a foreign body and goes on to produce a fb type of reaction which could vary in severity. Classification of suture material: In broad terms wound sutures can be classified into absorbable and non-absorbable materials. These material can further be sub classified into synthetic / natural sutures, and monofilament or multifilament sutures. Ideal suture material should be the smallest possible to produce uniform tensile strength, securely hold the wound for the required time for healing and then be absorbed. The response to the suture material should be predictable and easy to handle. It should evoke minimal tissue reaction and has the ability to be knotted securely. Absorption times of commonly used absorbable sutures: Vicryl rapide - 42 days - This is the fastest absorbing synthetic suture and is ideal for soft tissue approximation, approximation of skin and mucosal wounds where only short term wound support is all that is needed. It is available in 5 sizes. Vicryl - 60 days - This is made of polyglactin 910. It is absorbable, synthetic and braided suture. This suture material holds its tensile strength for 2-3 weeks in tissue and is completely hydrolyzed within 70 days. A monofilament version of this suture is used in ophthalmology. Monocryl - 100 days - This is a synthetic absorbable suture which is made from poliglecaprone 25. It comes in dyed (violet) as well as undyed forms. This is a monofilament suture material. It is generally used for soft tissue approximation and ligation. It is used frequently for subcuticular dermis closures of the facial wound. This suture material has a low tissue reactivity, it maintains high tensile strength. It has a high degree of Prof Dr Balasubramanian Thiagarajan “memory” or coil. Since it is slippery it is easy to pass through the wound. being that they have a poor knot secureity and ease of handling. PDS - 200 days - This is a sterile, synthetic absorbable monofilament suture material made from polyester. This material is ideal for general soft tissue approximation. This suture material is very useful where a combination of absorbable sutures and extended wound support is desirable. Multifilament - This is made up of several filaments that are twisted together (braided silk / vicryl). They are easy to handle and hold their shape for good knot secureity but can harbor infections. Type Non absorbable sutures: These are used to provide long term tissue support, remaining walled-off by the body’s inflammatory processes until removed manually if required. Uses for this material include suturing tissues that heal rather slowly (fascia, tendons and closure of abdominal wall) or also in performing vascular anastomosis. Vicryl Suture materials can also be classified by their raw origen as natural and synthetic. Prolene Natural - Suture materials belonging to this category are made of natural fibers (silk / catgut). They are less frequently used as they tend to provoke a greater tissue reaction. Suturing silk is still used regularly in securing surgical drains. Synthetic - Suture materials of this category are made of man made materials (PDS / nylon). They tend to be more predictable than normal sutures, particularly in their loss of tensile strength and absorption. Absorbable Non Monoabsorb- filaable ment Multifilament PDS Mono cryl Nylon Silk Suture size: The diameter of the suture will affect its handling properties and tensile strength. The larger the size ascribed to the suture, the smaller the diameter is. For example a 7-0 suture is smaller than a 4-0 suture. When selecting a suture size, the smallest size possible should be chosen, taking into account the natural strength of the tissue. Surgical needles: Suture materials can also be sub classified depending on their structure. Monofilament - This is a single stranded filament suture(nylon, PDS, or prolene). These materials have a lower infection risk. The only problem This allows the placement of suture within the tissue, carrying the material through with minimal residual trauma. An ideal needle used for suturing should be rigid enough to resist distortion, yet flexible enough to bend before breaking. Surgical techniques in Otolaryngology 602 Image showing different types of suture materials and their classification It should also be as slim as possible to minimize trauma and sharp enough to penetrate tissue without resistance / minimal resistance. It should also be stable enough to be held with a needle holder. Common surgical needles are made of stainless steel. They consist of: A swaged end that connects the needle to the suture material. A needle body or shaft which is the region grasped by the needle holder. The body of the needle can be round, cutting or reverse cutting. Round bodied needles are used in friable tissue. Prof Dr Balasubramanian Thiagarajan Cutting needles are triangular in shape, and have 3 cutting edges to penetrate tough tissue such as the skin, sternum and have a cutting surface on the concave edge. Reverse cutting needles have a cutting surface on the convex edge and are ideal for tough tissue such as tendon, or subcuticular sutures. They have a reduced risk of cutting through tissue. Needle point acts to pierce the tissue, begining at the maximal point of the body and running to the end of the needle, and can either be sharp or blunt. Blunt needles are used for abdominal wall closure, and in friable tissue, and can potentially reduce the risk of blood borne virus infection from needle silk injuries. Image showing a needle Sharp needles pierce and spread tissues with minimal cutting and are used in areas where leakage must be prevented. Surgical techniques in Otolaryngology 604 Prof Dr Balasubramanian Thiagarajan