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

  1. Rigid Paediatric Bronchoscope of size 3.5mm,4mm.
  2. foreign body holding forceps : double action jaws width 7mm,working length 50 cm
  3. 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.

LEARNING POINTS:

  • 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