POST OP STAPEDOTOMY INCUS NECROSIS MANAGEMENT- PART 1
67 year old male, with history of right stapedotomy done 8 months back in a renowned centre in America came with complaints of hard of hearing following good hearing for 3 months. On examination, tympanic membrane was intact with minimal wax in external canal. CT temporal bone showed prosthesis in the posterior wall of external auditory canal. Exploratory tympanotomy showed necrosed long process of incus and live vein graft with central hole.
41 year old male who underwent stapedotomy with Causse piston 8 years back in our institution complained of decreased hearing. He had good hearing for 1 year after the surgery. Exploratory tympanotomy showed displaced piston and necrosis of incus long process.
In previous case which was discussed, incus necrosis happened before surgery and that may be the reason they used a bucket handle prosthesis. In the present case incus necrosis happened after surgery and was managed.
RESTORING AIRWAY WITH ACCEPATBLE VOICE IN BILATERAL VOCAL CORD PALSY
- Bilateral vocal cord palsy is a difficult situation for the surgeon and the patient.
- Tracheostomy is safe for the surgeon but undesirable from the patient’s point of view.
- A 55 year old female presented to us with noisy breathing occuring during sleep and which increased during exertion and attacks of URI , was a case of past hemithyroidectomy 10 years back (done elsewhere) following which the complaints started.
- VLS showed B/L vocal cord in paramedian position (bipahasic)
- After elective tracheostomy operation done was Posterior cordotomy with submucosal partial arytenoidectomy followed by cordoplasty
- Equipment used : Operating microscope, Weerda’s expanding MLS scope, 30 watt CO2 LASER with micromanipulator , Vocal cord separator, 5-0 Vicryl
- The tracheostomy tube was taken out at the end of 4 days.
- Postoperative voice is adequate to have conversation in the same room but not adequate to raise voice in anger !!!
- Further evaluation after 1 month postop awaited.
HOW TO ADDRESS DOUBLE VC PATHOLOGY AT THE SAME TIME?
- 35 yr woman with h/o voice abuse
- left vocal cord cyst addressed by a flap made on superior surface of vocal cord
- Right vocal cord polyp was excised from the medial surface of right vocal cord
- raw mucosal edge of right cord not allowed to get in contact with the other vocal cord
- Take home message:To stay away from anterior commissureand not allow two raw surfaces to contact each other
ENDOSCOPIC or OPEN Surgery for this Sinus lesion?
59yr old diabetic male presented with Left hemifacial pain & diplopia of 20 days duration. On examination-Left proptosis & infraorbital paraesthesia.
CT Scan – Irregular mass lesion in inferior aspect of Lt. Orbit with erosion of floor of Lt. Orbit & involvement of Lt. Maxillary sinus, Inferior rectus.
He was subjected to an Endoscopic biopsy through MMA, via which an incision using ball probe over infraorbital mucosa was made. Lesion was seen and biopsy was taken Submucosally using Navalakhe forceps (90o) which we suspected to be Aspergillus clinically. Hence we requested for special staining for detection of fungal sp.
HPE/ Silver Methenamine – Imp.: Invasive fungal lesion with Aspergillosis features.
Patient has been planned for Surgery. Follow up with treatment measures will be updated.
FOREIGN BODY BRONCHUS
15month old baby presented with history of ground nut aspiration 4 days ago with Expiratory stridor following xray and examination s/o absent air entry on right side.
As mandatory in such cases High risk consent was taken.
Foreign body(Nut) removed using Rigid Paediatric bronchoscope with right main bronchus under General Anaesthesia.
Basic Instruments needed to manage Tracheobronchial foreign body
- Rigid Paediatric Bronchoscope of size 3.5mm,4mm.
- foreign body holding forceps : double action jaws width 7mm,working length 50 cm
- 2F Flexible basket used for salivary stones
Learning Points :
- Method of Introducing Bronchoscope is just like passing Endotracheal tube with Anaesthetist Laryngoscope, even with a tiny bronchoscope one can see vocal cord structures which acts as guide to enter trachea.
- Once inside, Surgeon’s left hand index &middle finger is hooked around the upper tooth & the thumb is used to lift and push the scope.This method avoid damages to internal structures.
- Once the nut is identified scope is closed maximum oxygenation is given which allows 2min apnoea working interval during which forceps is used to grasp nut. Both Forceps and scope taken out together in one unit.Explore further for complete clearance.
Independence from facial nerve palsy for beginners
We do usually find facial nerve route post cortical mastoidectomy using nerve monitor,
This gives better understanding of anatomy without drilling facial canal and posterior tympanotomy levels for beginners.
Nerve Monitor for Mastoid surgeries needs three electrodes in orbicularis oculi ,oris ,grounding and additionally a stimulator and main console.
Increasing stimulus around 1.5 ma we can identify facial nerve pathway without drilling further in.
It is 3mm below and behind Fossaincudis lies the 2ND genu where horizontal part turns vertical.
Very useful device for beginners.
ENDOSCOPIC TRANS ANTRAL CLIPPING OF MAXILLARY NERVE IN TRIGEMINAL NEURALGIA
58 year old female presented with shock like pain in left eye and cheek since 1 year,not improving with medical management.
MRI brain showed mild indentation of 5th cranial nerve by loop of left superior cerebellar artery.
After removing posterior maxillary sinus wall,maxillary division of trigeminal nerve was isolated and vascular clips applied.
At 3 months post op patient reports almost complete recovery from symptoms(VAS 8 preop to 2 postop)
Compared to external approaches like peripheral neurectomy which are more invasive,this endoscopic technique is reversible and causes less post op morbidity.
INTRATYMPANIC THERAPY– OUR WAY FOR REFRACTORY MENIERE’S DISEASE.
Severe giddiness is a problem for the patient as well as the treating physician, especially when it comes without warning.
Patient’s lifestyle is grossly impaired.
A 49 year old female from Kerala presented to us with fluctuating hearing loss, tinnitus of 3 months history and vertigo of 10 days duration .
Out of the four components of Meniere’s she had all except ear block sensation.
Cervicogenic vertigo, Migraine, BPPV were excluded.
She underwent Audiometry, Impedance tympanometry and our modified glycerol test.
Modified glycerol test :
- 1.5 gm/kg orally
- Exclusion criteria:hypervolemia, confused mental states, congestive heart disease, diabetes or cardiac, renal, or hepatic disease.
- POINT TO REMEMBER: When administering glycerol orally, hypotonic fluids to relieve thirst and headache from glycerin-induced dehydration are not to be given as these will counteract osmotic effects.
- Patient was treated by intratympanic therapy (ITT) with gentamycin after no reponse with drugs.
- After flap elevation gelfoam is kept over the RWN which is then instilled with 4-5 drops of Gentamycin so as to provide a depot route.NO DILUENT is used.
PRIMARY TRACHEO-ESOPHAGEAL PUNCTURE FOLLOWING LARYNGECTOMY
Following Laryngectomy, loss of speech is not acceptable. Only a few can learn esophageal speech and most are uncomfortable with electrolarynx.Tracheal esophageal puncture ( TEP) with insertion of speech valve results in loud clear voice in 80% of patients.We advocate primary TEP during laryngectomy and important steps are described.
DISSECTION TIP FOR BEGINNERS-CHOLESTEATOMA CLEARANCE AND RECONSTRUCTION
Cholesterol granuloma if encountered at advancing end of cholesteatoma- separate dissection needed.Suctioning the keratin matrix from sac facilitates dissection.During dissection-
- use pushing movements
- avoid trauma to sac-decreases recurrence
- try to deliver sac intoto
Look out for asymptomatic lateral semicircular canal fistula-avoid suctioning over it.
Removing eroded malleus head helps in better anterior attic clearance-use the malleus nipper( House- Dieter ) above the tensor tympani attachment (for future ossiculoplasty stability)
Hypotympanic dissection may be difficult even after posterior tympanotomy unless the facial nerve is skeletonised.
Kenakort may be injected into thickened middle ear mucosa( possibility of bony dehiscence and accidental injection into major vascular structures to be kept in mind)
In this case,the facial nerve is limiting sinus tymani access ,hence ST and OW epithelium cleaned with diamond burr.
Do not touch the stapes suprastructure/ footplate.
Removing both the ossicular heads has weakened the attic necessitating a self retaining attic support.
Here reconstruction with fascia augmented with thin cartilage slice is done to prevent
- attic retraction
- PSQ retraction
- adhesion between neotympanum and medial wall
We have also used synthetic bioglass to isolate the attic above the horizontal facial nerve level.
SALIVARY STONE EXTRACTION WITH PAPILLOTOMY
A 71 year old gentleman presented to us with a 6 day h/o pain in the neck and was found to have a 3×4 mm sq calculus near the hilum of right submandibular gland in USG.
Sialoendoscopy revealed the same and tipless basket was used to lock and extract the calculus till the papilla.
As the calculus was too big to be taken out through the papilla, papillotomy was done while maintaining a constant traction with the basket wire, following which the calculus was extracted.
A stent was placed in the duct postoperatively.
- Maintaining a constant and gentle traction is important failing which the calculus may slip off in the duct
- USG with pictorial report is more valuable to assess whether calculus is endoscopically accessible.
MODIFIED SIALENDOSCOPIC TECHNIQUE FOR MOBILE PAROTID STONES
CASE- 57 year old, case of chronic left parotid sialadenitis with large mobile ductal calculus
Large fixed salivary calculi have standardised methods of removal but not large mobile ones running up and down a dilated duct but not coming into the mouth due to stricture
Here we have used a sialendoscope to dilate the stenosis with balloon and pass a tipless basket to grasp and fix the stone in one place.
Even this manoeuvre was not enough to dilate the duct and deliver the stone through the mouth,hence we located the stone with a needle,made a small stab incision parallel to the facial nerve and duct and extracted the stone.
After this a 4 Fr 3.5mm stent was passed to bridge across the stenosis which also acts as a surgical opening for proper duct healing.
If the same technique was done without dilatation and stenting there is high chance of a salivary fistula in the face
TRANSPOSITION OF LACRIMAL SYSTEM AND INFERIOR TURBINATE PRESERVATION TO AVOID POST OPERATIVE EPIPHORA , SECONDARY ATROPHIC RHINITIS AND EMPTY NOSE SYNDROME IN ENDOSCOPIC MEDIAL MAXILLECTOMY FOR BENIGN SINONASAL DISEASES
37 year old engineer presented with left sided nasal obstruction, recurrent left sided headache and facial pain since 3 months.Nasal endoscopy finding-Biopsy revealed Inverted papilloma. NECT scan findings-Homogenous opacification in the left maxillary sinus and nasal cavity. Intraoperatively it was identified that the sinus opacity was mainly constituted by retained secretions behind the tumour. Hence a CT with contrast or an MRI is recommended to differentiate tumour from secretions. Thick secretions were suctioned from sinus cavity. Nasolacrimal duct was exposed by drilling the bone anterior to it dividing the inferiormost attachment of duct to inferior meatus.In cases of malignant tumours the lacrimal duct will have to be sacrificed
Posterior part of inferior turbinte was pushed to the nasopharynx for visualisation of mass.after complete removal of mass inferior turbinate was brought forward and attached at medial maxillectomy using vascular clips. Nasal packing was not done post operatively. A cotton ball was placed in the anterior nare to prevent forceful blowing and to avoid injury to the delicate post op nasal cavity .Inferior turbinate was preserved using clips to avoid post op secondary atophic rhinitis and empty nose syndrome
ROLE OF FACIAL NERVE MONITORING IN REVISION EAR SURGERIES
- Reexploration surgery in a patient with h/o epidural absess as a complication of unsafe ear.
- Monopolar probe for facial nerve identification-initially at 2.00 milliAmp ,reduced to 1.00 milliAmp
- Evidence of biphasic curve on oscilloscope and dual tone sound suggest facial nerve/close proximity to it.
- Always use facial nerve monitor when anatomical landmarks are not present.
- Always maintain dry field to avoid false positive results and maintain a low current.
- Pseudo facial nerve like structures in the field may have other nerve fibres in it eg;chorda tympani which may confuse experienced surgeons and affect good clearance of the disease.
- For residents performing mastoidotympanoplasty the monitor gives an early indication of proximity and damage to facial nerve
In these days of medicolegal problems such monitors will be of great help to doctors.
DESTRUCTIVE MAXILLARY FOREIGN BODY GRANULOMA PRESENTING AS INVASIVE FUNGUS-A CASE REPORT
A 42 year old recently detected diabetic lady advised dental extraction for left upper molar was found to have mobile alveolus with multiple tooth with extensive destruction of maxilla.The patient had Root canal therapy on same side 4 years ago.
On examination In the hard palate the pathology stopped at the midline and infraorbital nerve was anesthetized. CT findings showed extensive bony destruction upto zygoma and ipsilateral hard palate.
Provisional diagnosis of invasive fungus was made.
Open surgery and maxillectomy preserving soft tissue of hard palate was done with primary suturing of cheek to alveolar margin . All infected bones were cleared. The bones had a moth eaten, friable , yellowish, non viable state and fungal culture sensitivity and biopsy were sent for a provisional diagnosis of invasive mycosis. Fearing the acute mucor we started on Amphotericin.
The biopsy revealed foreign body granuloma. Hence antifungal therapy was withdrawn , and patient was discharged and was advised strict diabetic control.
- Since soft tissue of hard palate was preserved there was no immediate fistula and the need of dental obturator was avoided.
- In these days of Invasive dental treatment with multiple materials, foreign body reaction and bacterial infections should also kept in mind till invasive fungus is proven by histopathology.
22 year old female patient presented with right sided facial swelling and fever since 1 month.history of similar episodes since 10 years on and off.treated conservatively at local hospital with poor response.
O/E-3 X 2 cm firm,tender,indurated swelling R parotid area
R stensons duct orifice indurated,no mucopus expressed from gland
- The parotid duct is easy to access with a sialendoscope but difficult to work with.
- Before introducing the scope the duct is treated with sensorcaine and adrenaline.
- throughout the procedure saline irrigation is done
The calculus was a linear one so a blunt ended basket was used
POST STAPEDOTOMY SN LOSS MANAGEMENT
50 year old female post Right Stapedotomy with hearing improvement after surgery, developed sudden onset of hearing impairment 1 month following surgery. Managed with IV steroids (Inj Solumedrol 500 mg slow IV ) followed by grommet insertion and steroid (Dexona) instillation . Following this hearing improvement occurred within 24 hours. Further improvement awaited.
FOREIGN BODY IN THE MIDDLE EAR
- 64 yr old man, with left csom (ttd) was taken up for mastoidotympanoplasty
- Intra op mucosa in antrum,middle ear was congested and hypertrophied(severe)
- Foreign body(?stalk of a plant) retrieved from near eustachian tube area
Take home message:We should be on the lookout for such foreign bodies in middle ear as many such patients have a h/o ear digging with foreign materials!
Surgically correctable causes of giddiness include Superior SCC Dehiscence (congenital), Lateral SCC Dehiscence (cholesteatoma/ Iatrogenic), etc.
All inner ear diseases – accurate diagnosis is more critical than the management.
Only HRCT is useful and Plain CT Brain will not pick it up. Caloric responses may be variable.
Case of a 67yr.old with recurrent vertigo lasting 2-3hrs for 5 months, triggered by bending down and getting up.
Our patient had a Transmastoid exposure of labyrinth, thinning of tegmen antri, followed by exposure of Superior SCC Arch under GA. Once dehiscence was exposed it was plugged with periosteum.
18 months old girl presented with swelling in Lt. Pre-auricular region, noticed since 2 months of age. There was a progressive increase in size of swelling & was not associated with pain. Child managed elsewhere with Beta-blocker (inderal – 5mg OD x 4 months) & 3 times Inj. Tricort. Tumour did not respond & continued to grow.
Approx 3.5×2.5 cm soft swelling with smooth surface, mobile, non-tender and with increased surface temperature and transmitted pulsation present.
- An EXCISION was performed
- Estimated blood loss wrt wt. of patient could only be 150ml
- ‘Suture Torniquet Technique’ (3-0 Prolene) was utilized
- Excision utilizing Bipolar scissors/cautery, with irrigation to prevent damage to underlying facial nerve.
- Post-op : Facial nerve function normal
- HPE : Hemangioma
31yr old teacher presented with voice change of 10 days. She was diagnosed with Rt. mid vocal cord cyst. We performed MLS + cyst excision under GA.The video attached shows the salient steps of an in toto excision of cyst.The picture depicts the importance of a Hand Stand at time of surgery.
Turbinoplasty using a 2.9mm xomed blade – microdebrider causes lesser post-op morbidity to patients. It is a safer, superior technique as the mucosal surface is not disturbed – Submucous Resection of turbinate is done.
Method: Turbinate is entered into with the sharp end of blade. A 180o turn is made within, such that the blade is towards the submucosal tissue and debridement of tissue is done. This is done all along the turbinate – ‘decompressing’ it in the process.
- No post-op nasal crusting/ burning sensation as with other turbinal reduction techniques.
- Complements the ‘no pack’ technique of septal surgeries (splint/ septal clip).
31 yr old female presented with Rt. Sided throat pain of 6 months duration.
She had an irregular lesion involving Rt. Tonsillar fossa, Rt.anterior & posterior pillars, uvula, with minimal extension towards Lt. Soft palate. Enlarged, hard, fixed Rt. level II lymph node detected.
CT Scan Neck : 4.2 x 1.9 x 2.4 cm. Rt. Tonsillar mass with anterior extension upto tonsillolingual sulcus, posteriorly parapharyngeal wall, superiorly upto palate and laterally limited by parapharyngeal fat. Level II A nodes – largest 12 x 13mm.
Surgery : Rt. Supraomohyoid neck dissection + CO2 Laser excision of Rt. Tonsillar malignancy – lateral resection upto carotid.
HPE : SCC infiltration positive at tonsillar bed (lateral extent), Level II nodes – extracapsular spread & Level III perinodal fibrous tissue.
Pt. planned for post-op RT
63 yr old male presented with Idiopathic B/L abductor palsy & mild stridor for past 8 years with sudden increase of breathlessness. Emergency tracheostomy performed elsewhere. CT Neck/Thorax normal.
Surgery : Left Laser Cordoplasty & Left Partial Arytenoidectomy .
Pt was decannualated on 6th postop day. Voice and airway both present post decannulation.
CSF Leak/ Foveal injury during Frontal sinus surgery by a young surgeon.
Lesson : To be close to the Anterior boundary of Frontal Recess at all times and anterior to Anterior Ethmoidal artery
37 year old male with h/o bilateral nose block,hyposmia and hyponasal voice -1 month
- Nasal endoscopy showed smooth surfaced globular mass with prominent surface vessels in nasopharynx obstructing both choanae
- CT scan imaging showed large hypodense cystic lesion(4×3.5x5cm)of sphenoid sinus with expansion and resorption of sinus walls
- Management plan:marsupialiasation of mucocele
Modified Tonsillectomy stand designed by late Dr.Velusamy 56 years back.
Advantage over Draffin’s bipod is that this stand is more stable and doesn’t slip.
NEW METHOD TO SAVE DISPLACED COCHLEAR IMPLANTS..
11 year old boy with congenital profound hearing loss and a Mondini malformation with single cavity cochlea underwent cochlear implant surgery for a limited auditory benefit in 2012. Post op Xray showed full insertion of all 22 electrodes.
Good ling six sounds detection noted immediately after switch on. CAP score revealed 4 as the maximum attained level out of 12. Two and half years later fluctuation in hearing , especially non detection of high frequency ling sounds ‘ss’ and ‘sh’ reported despise multiple mappings. Xray revealed electrode displacement, 13electrodes were extracochlear.
The standard advice in this situation is to take the implant out and fix a new one. Our patient couldnot afford this and we designed an off label technique to find out implant viability.The cochlear implant electrode is designed to be in a fluid environment and in middle ear air it was shown as open circuit. IMPEDANCE TELEMETRY ( NRT ) WAS DONE AFTER INSTILLING NORMAL SALINE INTO MIDDLE EAR TO RULE OUT ELECTRODE DAMAGE, where all the open circuit electrodes except 2 showed normal impedance values. So reinsertion of the same electrodes was done. Premorbid CAP score of 4 achieved immediately after mapping.
- A 39 year old came with an audiogram showing conductive loss and the classical 2K dip.
- Tympanometry showed As type with absent reflexes.
- After flap elevation ossicular mobility was checked and all ossicles were found fixed.(video) No evidence of Tympanosclerosis was found.
- PISA sign was strongly positive as evidence for anterosuperior otosclerotic foci.(picture) reference…
- Flap incisions were extended superiorly and anteriorly and scutum was exposed. 1 mm cutting burr was used to remove scutum (video) Incudostapedial joint was disarticulated to prevent SNHL.
- After full attic exposure , incudomalleal complex was cleared .Anterior malleolar ligament and tensor tympani were divided.
- Post clearance, mobility of Incus and Malleus were restored.
- Conventional stapedotomy was done with skeeter drill and 0.4 mm Nitinol -teflon piston was placed with fat seal and on-table hearing gain achieved.
- Otosclerosis with more than 40dB conductive loss , we prefer to use extended incision to expose malleus neck and anterior malleolar ligament. This is the third such case we have encountered.
23 years old male chronic smoker working as heavy motor vehicle driver developed sudden onset of painful swelling in right cheek with rapid spread to submandibular and sublingual space with airway compromise.
Radiographically ( CT scan with contrast ) showed a lytic lesion in the body of mandible around uninterrupted second and third molar teeth extending inferiorly into submandibular and sublingual space.
- Preliminary tracheostomy done.
- Transcervical incision made 2 cm below the inferior border of mandible.
- After layered dissection inferior border of mandible identified.
- A large mass with well defined sac found arising from within the body of mandible.
- Incision and drainage done, 50ml of cheesy material let out.
- Thickened wall of the mass is completely exenterated and further cleared by drilling of the mandible.
- An innovative approach by obliterating the empty space by bioglass done. This is done to avoid biografting with materials like fascia lata in the unknown pathological entity.
- Bioglass obliteration helps to combat infection by its antibacterial property and this is by virtue of its alkaline pH.
- HPE showed features of epidermoid cyst ( Infected Odontogenic keratocyst)
- As we hoped lesion healed without complications and patient went back to his work!
26 yr old pt presented with recurrent R submandibular swelling diagnosed R submandibular stone of 3mm. Stone engaged with basket & on withdrawl basket lockedup at narrow bifurcation of submandibular duct. Attempts to release stone not successful due to locking up of basket, duct approached through gingivolingual sulcus. Axial incision taken through the gingivolingual sulcus dissection done to identify duct and separated from lingual nerve, lockedup basket identified and stone removed and basket withdrawn through the natural submandibular orifice.
1.6mm Erlangen sialendoscope – note markings each 1cm apart. Comfortable removal of calculi upto 6mm.
2 contraindications : Intraglandular calculi and mega stone.
Presence of calculi for a long time causes multiple infective episodes which results in a fibrotic gland. At this stage gland will not function even after calculi removal.
Removal of stone upto 1yr after formation will restore function. Function of gland can be lost due to repeated infective episodes.
30 yr old male with h/o right submandibular sialolithiasis-1 month
- o/e:calculus palpable in the wharton’s duct approx 2cm from ductal orifice
- usg revealed a 8x5mm calculus in the duct close to orifice
- Calculus removed by incision of duct along its length.A Papillotomy was also done
- Perop sialendoscopy done to rule out presence of other stones/ductal strictures take home message:A experienced sonologist helps in decision making in salivary endoscopy/gland removal.
VOICE RESTORATION FOLLOWING LASER RESECTION OF HYPOPHARYNGEAL MALIGNANCY
66 year old male who underwent LASER resection of right sided pyriform fossa carcinoma( T3N0M0) followed by chemoradiation 1 year back presented with hoarseness and impaired voice quality.
Patient was planned for injection laryngoplasty (posterior commissure augmentation) with autologous fat.
Abdominal fat was harvested (image)
Fat was stripped with scissors and loaded in Arnold Breuning syringe (image)
Under DL visualization using Weerda’s expanding scope and jet ventilation , posterior commissure was augmented (video)
Postoperative voice was satisfactory.
Fat has to be stripped and NOT crushed to avoid breakage of adipocytes and absorption.
A 49year old male presented with history of left ear tinnitus, decreased hearing, deviation of angle of mouth to right and incomplete closure of left eye of 5years duration. MRI scan showed 2.4 cm lesion in left CP angle cistern with extension into internal auditory meatus. In this case, one can opt for surgical approaches or stereotactic radiosurgery.
Stereotactic radiosurgery can be used for lesions less than 3cm. But the cost is around 1.4lakhs which was not affordable for the patient. In this case, excision was done by translabyrinthine approach at a cost of Rs.75000. Though the 7th nerve did not improve, the patient’s severe tinnitus stopped post op.