Dekker Surgical Atlas of Pediatric Otolaryngology

Surgical Atlas
of
PEDIATRIC OTOLARYNGOLOGY
Surgical Atlas
of
PEDIATRIC OTOLARYNGOLOGY
with 900 illustrations
Eberly Professor of Pediatric Otolaryngology University of Pittsburgh School of Medicine Director, Department of Pediatric Otolaryngology Childrens Hospital of Pittsburgh Pittsburgh, Pennsylvania Professor of Clinical Otolaryngology SUNY Downstate Medical Center Director, Division of Pediatric Otolaryngology Department of Otolaryngology Long Island College Hospital and University Hospital of Brooklyn Brooklyn, New York
CHARLES D. BLUESTONE, MD
RICHARD M. ROSENFELD, MD, MPH
2002 BC Decker Inc Hamilton London
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BC Decker Inc
20 Hughson Steet South P. O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 1-800-568-7281 Fax: 905-522-7839; 1-888-377-4987 E-mail: info@bcdecker.com Website: www.bcdecker.com 2002 Charles D. Bluestone and Richard M. Rosenfeld All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. 02 03 04 / FP / 6 5 4 3 2 1 ISBN 1-55009-133-6 Printed in Canada
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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check recent publications and the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs.
P REFACE
Surgical Atlas of Pediatric Otolaryngology is a unique and comprehensive reference for clinicians who care for infants and children with disorders of the ears, nose, throat, head, neck, and related structures. Over 200 procedures are described in 650 figures in 900 parts, with step-by-step instructions for patient preparation, surgical techniques, postoperative care, and prevention of complications. Major sections cover all relevant procedures including otologic, rhinologic, oral and pharyngeal, and head and neck surgeries, endoscopy and airway surgery, and plastic and reconstruction surgery. Osler once quipped, There are only two sorts of doctors: those who practice with their brains, and those who practice with their tongues. A third sort had been recruited for this book: those who practice with their hands. We are fortunate to have recruited the leading experts in the field to describe in detail how they achieve successful outcomes. All authors are active surgeons, culled from major childrens hospitals, academic training programs, and pediatric otolaryngology fellowship programs. Their combined wisdom has been distilled and organized to promote optimal surgical results. The Surgical Atlas builds upon a superb foundation established by Atlas of Pediatric Otolaryngology, published in 1995 as a companion to the twovolume classic text Pediatric Otolaryngology. This self-contained work contains 15 new chapters on topics including ossiculoplasty, sphenoid sinus surgery, nasal and septal deformities, surgery to correct drooling, velopharyngeal insufficiency, soft tissue surgery, and maxillofacial trauma. More than 40 additional procedures are illustrated with new artwork, and existing illustrations have been redrawn as needed for improved clarity. The text is completely revised and updated, with extensive reorganization and reformatting for easy access.
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Preface
A unique feature of the Surgical Atlas is that technical descriptions are balanced by in-depth discussions of decision making, patient selection, and clinical management. We emphasize not only how to cut, but also when to cut and when not to cut. Anesthetic considerations, patient preparation, and postoperative care are discussed in detail because they differ in infants and children as compared with adults. Children have special needs related to changes in anatomy, physiology, and psychosocial adjustment during growth and development, and an understanding of these differences can improve surgical outcomes. We have structured this book to meet the needs of a diverse audience. Physicians in training will benefit from ready access to how to information on the gamut of procedures they are likely to encounter in their residence or fellowship. Junior clinicians will have a one-stop refresher for common and uncommon procedures needed for everyday patient care, with advice and clinical pearls from leading surgical authorities. Senior clinicians will find the book a useful reference for complex or esoteric procedures, with literature citations for additional details. The beautiful line illustrations are a superb didactic aid for clinicians and patients. We are pleased to have had Jon Coulter prepare most of the artwork that describes in detail the surgical techniques. His expertise has added consistency and clarity to the text. We are also indebted to our excellent editorial assistants, Deborah Hepple and Billy Tang, for their secretarial support and help in collating the manuscripts. Mr. Tangs efforts and the cost of illustrations were supported, in part, by Faculty Development Awards from the State University of New York Downstate Medical Center in Brooklyn. Last, we thank Sylvan Stool for his invaluable editorial efforts in the precursor, Atlas of Pediatric Otolaryngology. We hope the reader will benefit from the fine contributions made by the authors of this text, and that this atlas will enhance the care of infants and children who require otolaryngologic surgery. Charles D. Bluestone, MD Pittsburgh, PA Richard M. Rosenfeld, MD, MPH Brooklyn, NY January 2002
C ONTRIBUTORS
George Alexiades, MD Department of Otolaryngology New York University Medical Center New York, New York Chapter 9: Cochlear Implants Cuneyt M. Alper, MD Associate Professor of Otolaryngology University of Pittsburgh School of Medicine Department of Pediatric Otolaryngology Childrens Hospital of Pittsburgh Pittsburgh, Pennsylvania Chapter 26: Tracheotomy James S. Batti, MD Assistant Professor of Pediatric Otolaryngology University of Connecticut Department of Otolaryngology Connecticut Childrens Medical Center Hartford, Connecticut Chapter 4: Ossiculoplasty Charles D. Bluestone, MD Eberly Professor of Pediatric Otolaryngology University of Pittsburgh School of Medicine Director, Department of Pediatric Otolaryngology Childrens Hospital of Pittsburgh Pittsburgh, Pennsylvania Chapter 1: Tympanostomy Tubes and Related Procedures Chapter 2: Approaches to the Middle Ear and Mastoid Chapter 3: Myringoplasty and Tympanoplasty Chapter 4: Ossiculoplasty Chapter 5: Mastoidectomy and Cholesteatoma Chapter 6: Perilymphatic Fistula and Eustachian Tube Surgery Chapter 31: Otoplasty for the Prominent Ear
Margaretha L. Casselbrant, MD, PhD Professor of Otolaryngology University of Pittsburgh School of Medicine Department of Pediatric Otolaryngology Childrens Hospital of Pittsburgh Pittsburgh, Pennsylvania Chapter 26: Tracheotomy Kenny H. Chan, MD Professor of Otolaryngology University of Colorado School of Medicine Chairman, Department of Pediatric Otolaryngology Childrens Hospital Denver, Colorado Chapter 25: Endoscopy of the Upper Aerodigestive Tract Noel L. Cohen, MD Professor of Otolaryngology New York University School of Medicine Chairman, Department of Otolaryngology New York University Medical Center New York, New York Chapter 9: Cochlear Implants William S. Crysdale, MD Professor of Otolaryngology University of Toronto Otolaryngologist-in-Chief Hospital for Sick Children Toronto, Ontario Chapter 11: Nasal and Septal Deformities Chapter 19: Surgery for Drooling
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Contributors
Michael J. Cunningham, MD Associate Professor of Otolaryngology Harvard Medical School Department of OtolaryngologyHead and Neck Surgery Massachusetts Eye and Ear Infirmary Boston, Massachusetts Chapter 20: Cervical Adenopathy Chapter 23: Salivary Gland Surgery Chapter 24: Thyroidectomy Robin A. Dyleski, MD Assistant Professor of Pediatric Otolaryngology University of Arkansas for Medical Sciences Vice Chief, Department of Pediatric Otolaryngology Arkansas Childrens Hospital Little Rock, Arkansas Chapter 33: Cleft Lip and Cleft Palate Roland D. Eavey, MD Associate Professor of Otolaryngology Harvard Medical School Director of Pediatric Otolaryngology Department of OtolaryngologyHead and Neck Surgery Massachusetts Eye and Ear Infirmary Boston, Massachusetts Chapter 30: Auricular Repair for Microtia Jose N. Fayad, MD Department of Otolaryngology Manhattan Eye Ear and Throat Hospital Lenox Hill Hospital New York, New York Chapter 8: Ear Canal Stenosis and Atresia Norman Friedman, MD Assistant Professor of Otolaryngology University of Colorado School of Medicine Denver, Colorado Chapter 25: Endoscopy of the Upper Aerodigestive Tract Ari J. Goldsmith, MD Associate Professor of Otolaryngology SUNY Downstate Medical Center Division of Pediatric Otolaryngology Department of Otolaryngology Long Island College Hospital and University Hospital of Brooklyn Brooklyn, New York Chapter 17: Tonsillectomy, Adenoidectomy, and UPPP
Carlos Gonzalez, MD Clinical Associate Professor of Otolaryngology University of Puerto Rico School of Medicine Chief, Department of Surgery San Jorge Childrens Hospital San Juan, Puerto Rico Chapter 16: Surgery of the Tongue Charles W. Gross, MD Professor of Otolaryngology University of Virginia Health System Department of OtolaryngologyHead and Neck Surgery University of Virginia Medical Center Charlottesville, Virginia Chapter 29: Soft Tissue Surgery Gady Har-El, MD Professor of Clinical Otolaryngology SUNY Downstate Medical Center Vice Chairman, Department of Otolaryngology Long Island College Hospital and University Hospital of Brooklyn Brooklyn, New York Chapter 15: Sphenoid Sinus Surgery Gerald B. Healy, MD Professor of Otology and Laryngology Harvard Medical School Otolaryngologist-in-Chief, Department of Otolaryngology Childrens Hospital Boston Boston, Massachusetts Chapter 27: Surgery of the Larynx and Trachea Raymond L. Hilsinger Jr, MD Chief, Department of Head and Neck Surgery Kaiser Permanente Medical Center Oakland, California Chapter 7: Facial Nerve Exploration and Repair Andrew J. Hotaling, MD Professor of Otolaryngology and Pediatrics Chief, Pediatric Otolaryngology Department of OtolaryngologyHead and Neck Surgery Loyola University Medical Center Chicago, Illinois Chapter 14: Inflammatory Sinonasal Disease
Contributors
ix
Kevin J. Hulett, MD Department of OtolaryngologyHead and Neck Surgery Loyola University Medical Center Chicago, Illinois Chapter 14: Inflammatory Sinonasal Disease Glenn Isaacson, MD Professor of Otolaryngology Chairman, Department of OtolaryngologyHead and Neck Surgery Temple University School of Medicine Philadelphia, Pennsylvania Chapter 13: Endoscopic Ethmoidectomy and Antrostomy Robert M. Kellman, MD Professor of Otolaryngology Chairman, Department of Otolaryngology and Communication Sciences SUNY Health Science Center at Syracuse Syracuse, New York Chapter 32: Maxillofacial Trauma Margaret A. Kenna, MD Associate Professor of Otology and Laryngology Harvard Medical School Department of Otolaryngology Childrens Hospital Boston Boston, Massachusetts Chapter 12: Congenital Nasal Malformations John Kim, MD Department of OtolaryngologyHead and Neck Surgery University of Michigan Health System Ann Arbor, Michigan Chapter 34: Craniosynostosis Charles F. Koopman Jr, MD Professor of Pediatric Otolaryngology University of Michigan Medical Center Chief, Division of Pediatric Otolaryngology Department of OtolaryngologyHead and Neck Surgery C.S. Mott Childrens Hospital Ann Arbor, Michigan Chapter 21: Deep Neck Infections Greg R. Licameli, MD Assistant Professor of Otology and Laryngology Harvard Medical School Department of Otolaryngology Childrens Hospital Boston Boston, Massachusetts Chapter 27: Surgery of the Larynx and Trachea
Scott C. Manning, MD Associate Professor of Otolaryngology University of Washington Chief, Pediatric OtolaryngologyHead and Neck Surgery Department of Otolaryngology Childrens Hospital & Medical Center Seattle, Washington Chapter 10: Epistaxis Lawrence J. Marentette, MD Associate Professor of Otolaryngology and Neurosurgery Director, Cranial Base Program Department of OtolaryngologyHead and Neck Surgery University of Michigan Health System Ann Arbor, Michigan Chapter 34: Craniosynostosis Khosrow Mojdehi, MD Assistant Professor of Anesthesiology SUNY Downstate Medical Center Director, Division of Pediatric Anesthesiology Department of Anesthesiology Long Island College Hospital and University Hospital of Brooklyn Brooklyn, New York Chapter 36: Pediatric Anesthesia Simon C. Parisier, MD Chairman Emeritus, Department of Otolaryngology Manhattan Eye Ear and Throat Hospital Lenox Hill Hospital New York, New York Chapter 8: Ear Canal Stenosis and Atresia Stephen S. Park, MD Associate Professor of Otolaryngology University of Virginia Health System Director, Division of Facial Plastic and Reconstructive Surgery Department of OtolaryngologyHead and Neck Surgery University of Virginia Medical Center Charlottesville, Virginia Chapter 29: Soft Tissue Surgery David M. Polaner, MD Associate Professor of Anesthesiology University of Colorado School of Medicine Denver, Colorado Chapter 25: Endoscopy of the Upper Aerodigestive Tract
Contributors
Reza Rahbar, DMD, MD Instructor in Otology and Laryngology Harvard Medical School Department of Otology and Laryngology Childrens Hospital Boston Boston, Massachusetts Chapter 12: Congenital Nasal Malformations Mark A. Richardson, MD Professor and Chairman Department of OtolaryngologyHead and Neck Surgery Oregon Health and Science University Portland, Oregon Chapter 22: Congenital Malformations of the Neck Keith H. Riding, MD Clinical Professor University of British Columbia Staff Otolaryngologist British Columbia Childrens Hospital Vancouver, British Columbia Chapter 25: Endoscopy of the Upper Aerodigestive Tract J. Thomas Roland Jr, MD Department of Otolaryngology New York University Medical Center New York, New York Chapter 9: Cochlear Implants Richard M. Rosenfeld, MD, MPH Professor of Clinical Otolaryngology SUNY Downstate Medical Center Director, Division of Pediatric Otolaryngology Department of Otolaryngology Long Island College Hospital and University Hospital of Brooklyn Brooklyn, New York Chapter 17: Tonsillectomy, Adenoidectomy, and UPPP Chapter 22: Congenital Malformations of the Neck Chapter 35: Information for Parents and Caregivers Robert W. Seibert, MD Professor of Pediatric Otolaryngology University of Arkansas for Medical Sciences Department of Pediatric Otolaryngology Arkansas Childrens Hospital Little Rock, Arkansas Chapter 33: Cleft Lip and Cleft Palate
Christopher E. Stevens, MD Department of OtolaryngologyHead and Neck Surgery University of Virginia Health System Charlottesville, Virginia Chapter 29: Soft Tissue Surgery Sylvan E. Stool, MD Emeritus Professor of Otolaryngology University of Colorado School of Medicine Denver, Colorado Chapter 25: Endoscopy of the Upper Aerodigestive Tract Sherard A. Tatum, MD Associate Professor of Otolaryngology Director, Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology and Communication Sciences SUNY Health Science Center at Syracuse Syracuse, New York Chapter 32: Maxillofacial Trauma Jon B. Turk, MD Assistant Professor of Otolaryngology SUNY Downstate Medical Center Director, Facial Plastic and Reconstructive Surgery Department of Otolaryngology Long Island College Hospital Brooklyn, New York Chapter 11: Nasal and Septal Deformities Jay A. Werkhaven, MD Associate Professor of Otolaryngology Department of Otolaryngology Vanderbilt University Medical Center Nashville, Tennessee Chapter 28: Laryngotracheal Laser Surgery J. Paul Willging, MD Associate Professor of Otolaryngology University of Cincinnati College of Medicine Department of Otolaryngology Childrens Hospital Medical Center Cincinnati, Ohio Chapter 18: Velopharyngeal Insufficiency
C ONTENTS
OTOLOGIC SURGERY 1. Tympanostomy Tubes and Related Procedures...............................................................................1 a. Tympanocentesis ..............................................................................................................1 b. Myringotomy ...................................................................................................................4 c. Grommet-type tympanostomy tube insertion...................................................................6 d. Permanent tympanostomy tube insertion .........................................................................11 e. Removal of tympanostomy tubes and myringoplasty........................................................16 2. Approaches to the Middle Ear and Mastoid ..................................................................................21 a. Transcanal approach .........................................................................................................21 b. Endaural approach............................................................................................................26 c. Postauricular approach......................................................................................................32 3. Myringoplasty and Tympanoplasty ................................................................................................39 a. Myringoplasty with medial fascia or fat-plug graft............................................................41 b. Transcanal medial fascia or fat-plug graft tympanoplasty ..................................................49 c. Postauricular medial fascia graft tympanoplasty ................................................................49 d. Endaural medial fascia graft tympanoplasty ......................................................................52 e. Lateral fascia graft tympanoplasty .....................................................................................58 f. Cartilage graft tympanoplasty ...........................................................................................66 4. Ossiculoplasty................................................................................................................................75 a. Advancement flap .............................................................................................................78 b. Incus interposition............................................................................................................81 c. Partial ossicular replacement prosthesis.............................................................................82 d. Total ossicular replacement prosthesis...............................................................................83 5. Mastoidectomy and Cholesteatoma ...............................................................................................91 a. Simple mastoidectomy......................................................................................................91 b. Modified radical mastoidectomy.......................................................................................96 c. Radical mastoidectomy.....................................................................................................98 d. Congenital cholesteatoma.................................................................................................103 e. Posterosuperior quadrant acquired cholesteatoma.............................................................111 f. Pars flaccida attic cholesteatoma .......................................................................................117
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6. Perilymphatic Fistula and Eustachian Tube Surgery .......................................................................123 a. Congenital perilymphatic fistula.......................................................................................123 b. Obliteration of the eustachian tube ..................................................................................129 c. Patulous eustachian tube: catheter obstruction .................................................................132 7. Facial Nerve Exploration and Repair .............................................................................................137 a. Intratemporal exploration and decompression ..................................................................139 b. Intratemporal repair, rerouting, and grafting ....................................................................150 c. Extratemporal exploration and repair for lesions...............................................................157 d. Extratemporal exploration and repair after trauma ...........................................................171 e. Extratemporal repair, rerouting, and grafting....................................................................176 8. Ear Canal Stenosis and Atresia.......................................................................................................185 a. Reconstruction of the external ear canal ...........................................................................186 b. Skin grafting of the external auditory canal ......................................................................207 c. Congenital aural atresia ....................................................................................................211 9. Cochlear Implants .........................................................................................................................221 RHINOLOGIC SURGERY 10. Epistaxis.........................................................................................................................................251 a. Local cautery ....................................................................................................................253 b. Anterior packing...............................................................................................................253 c. Endoscopic-guided cautery ...............................................................................................254 d. Posterior packing ..............................................................................................................255 e. Arterial ligation.................................................................................................................257 11. Nasal and Septal Deformities.........................................................................................................259 a. Closed reduction of nasal fracture.....................................................................................260 b. Internal approach for septoplasty......................................................................................264 c. External approach for septoplasty .....................................................................................268 d. Endonasal approach for rhinoplasty..................................................................................282 e. External approach for rhinoplasty.....................................................................................291 12. Congenital Nasal Malformations ...................................................................................................299 a. Transnasal repair of choanal atresia ...................................................................................300 b. Transpalatal repair of choanal atresia ................................................................................306 c. Lateral rhinotomy.............................................................................................................312 d. Sublabial approach............................................................................................................315 13. Endoscopic Ethmoidectomy and Antrostomy................................................................................319 14. Inflammatory Sinonasal Disease ....................................................................................................339 a. Drainage of septal abscess or hematoma ...........................................................................339 b. Antral aspiration and lavage..............................................................................................341 c. Caldwell-Luc procedure....................................................................................................342 d. External ethmoidectomy...................................................................................................344 e. Frontal sinus trephination.................................................................................................346 f. Dacryocystorhinostomy ....................................................................................................348
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15. Sphenoid Sinus Surgery .................................................................................................................353 a. Transnasal transethmoidal sphenoidotomy .......................................................................355 b. Direct transnasal sphenoidotomy......................................................................................358 ORAL AND PHARYNGEAL SURGERY 16. Surgery of the Tongue....................................................................................................................367 a. Anterior tongue lesions.....................................................................................................367 b. Macroglossia .....................................................................................................................369 c. Base of tongue lesions.......................................................................................................372 d. Frenuloplasty ....................................................................................................................376 17. Tonsillectomy, Adenoidectomy, and UPPP ....................................................................................379 a. Adenoidectomy.................................................................................................................381 b. Tonsillectomy ...................................................................................................................388 c. External carotid artery ligation .........................................................................................397 d. Uvulopalatopharyngoplasty (UPPP) .................................................................................402 18. Velopharyngeal Insufficiency .........................................................................................................407 a. Superiorly based pharyngeal flap.......................................................................................408 b. Rolled pharyngeal flap ......................................................................................................415 c. Posterior pharyngeal wall augmentation ...........................................................................417 d. Sphincteroplasty ...............................................................................................................419 e. Lateral port revision, narrowing........................................................................................422 f. Lateral port revision, enlarging .........................................................................................424 19. Surgery for Drooling......................................................................................................................427 a. Submandibular duct relocation with sublingual gland excision.........................................427 b. Submandibular duct relocation.........................................................................................433 c. Parotid duct ligation .........................................................................................................436 d. Tympanic neurectomy ......................................................................................................438 e. Submandibular duct ligation ............................................................................................438 HEAD AND NECK SURGERY 20. Cervical Adenopathy .....................................................................................................................441 a. Percutaneous needle biopsy...............................................................................................442 b. Cervical lymph node biopsy .............................................................................................448 c. Functional (modified) neck dissection ..............................................................................452 21. Deep Neck Infections ....................................................................................................................465 a. Submandibular space drainage..........................................................................................468 b. Pharyngomaxillary (lateral pharyngeal) space drainage .....................................................472 c. Masticator space drainage .................................................................................................475 d. Parotid space drainage ......................................................................................................477 e. Peritonsillar space drainage ...............................................................................................480 f. Visceral space drainage .....................................................................................................482 g. Retropharyngeal space drainage ........................................................................................482 h. Prevertebral space drainage ...............................................................................................486 i. Vascular (carotid) space drainage ......................................................................................487 j. Danger space drainage...................................................................................................488
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22. Congenital Malformations of the Neck a. Thyroglossal duct cyst ......................................................................................................491 b. Cystic hygroma (lymphangioma)......................................................................................496 c. First branchial cleft fistula.................................................................................................499 d. Pre-auricular pit or fistula .................................................................................................502 e. Second and third branchial cleft fistula.............................................................................504 f. Fourth branchial pouch sinus ...........................................................................................507 g. Fibromatosis colli .............................................................................................................512 23. Salivary Gland Surgery ..................................................................................................................515 a. Parotidectomy...................................................................................................................515 b. Submandibular gland excision ..........................................................................................526 c. Plunging ranula excision...................................................................................................532 d. Intraoral ranula excision ...................................................................................................536 24. Thyroidectomy ..............................................................................................................................539 ENDOSCOPY AND AIRWAY SURGERY 25. Endoscopy of the Upper Aerodigestive Tract .................................................................................556 a. Pharyngoscopy..................................................................................................................562 b. Laryngoscopy....................................................................................................................563 c. Bronchoscopy ...................................................................................................................569 d. Esophagoscopy .................................................................................................................578 26. Tracheotomy..................................................................................................................................587 a. Tracheotomy.....................................................................................................................587 b. Tracheocutaneous fistula closure .......................................................................................593 27. Surgery of the Larynx and Trachea.................................................................................................597 a. Arytenoidectomy ..............................................................................................................597 b. Supraglottoplasty ..............................................................................................................602 c. Glottic web excision .........................................................................................................604 d. Posterior glottic stenosis repair..........................................................................................606 e. Laryngeal separation .........................................................................................................608 f. Laryngeal decompression (cricoid split) with hyoid interposition .....................................612 g. Augmentation laryngoplasty with cartilage graft ...............................................................616 h. Augmentation laryngoplasty with cartilage stent...............................................................620 i. Segmental tracheal resection .............................................................................................624 j. Cricotracheal resection......................................................................................................626 28. Laryngotracheal Laser Surgery .......................................................................................................633 a. Epiglottic cysts..................................................................................................................642 b. Vallecular cysts..................................................................................................................644 c. Ventricular cysts................................................................................................................646 d. Intracordal cysts................................................................................................................648 e. Vocal process granulomas .................................................................................................650 f. Laryngeal papillomatosis...................................................................................................652 g. Laryngeal webs .................................................................................................................654 h. Vocal cord nodules ...........................................................................................................658 i. Reinkes edema and vocal cord polyps ..............................................................................660
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j. Laryngeal and subglottic hemangiomas ............................................................................663 k. Subglottic stenosis ............................................................................................................665 l. Tracheal stenosis ...............................................................................................................668 PLASTIC AND RECONSTRUCTIVE SURGERY 29. Soft Tissue Surgery ........................................................................................................................671 a. Lip repair..........................................................................................................................678 b. Auricular repair.................................................................................................................682 c. Nasal repair ......................................................................................................................686 d. Periorbital repair ...............................................................................................................688 e. Parotid duct repair............................................................................................................694 f. Facial nerve repair.............................................................................................................694 g. Scar revision .....................................................................................................................695 30. Auricular Repair for Microtia ........................................................................................................701 31. Otoplasty for the Prominent Ear ...................................................................................................717 32. Maxillofacial Trauma .....................................................................................................................727 a. Coronal incision ...............................................................................................................732 b. Superior lid crease incision ...............................................................................................734 c. Transconjunctival incision ................................................................................................736 d. Vestibular or canine fossa incision ....................................................................................738 e. Extraoral mandibular exposure .........................................................................................740 f. Intraoral mandibular exposure ..........................................................................................744 g. Maxillomandibular fixation ..............................................................................................746 h. Rigid internal fixation.......................................................................................................750 i. Nasoethmoid, naso-orbital ethmoid, and skull base trauma..............................................753 j. Bone grafting....................................................................................................................758 33. Cleft Lip and Cleft Palate Repair...................................................................................................763 a. Unilateral cleft lip repair...................................................................................................765 b. Bilateral cleft lip repair .....................................................................................................770 c. Unilateral lip adhesion......................................................................................................775 d. Bilateral lip adhesion ........................................................................................................778 e. V to Y pushback palatoplasty............................................................................................782 f. Two-flap palatoplasty........................................................................................................785 g. Double reversing Z-plasty (Furlow palatoplasty)...............................................................788 34. Craniosynostosis ............................................................................................................................791 a. Unilateral coronal craniosynostosis ...................................................................................794 b. Bicoronal craniosynostosis ................................................................................................796 c. Metopic craniosynostosis ..................................................................................................798 d. Sagittal craniosynostosis....................................................................................................800 e. Lambdoidal craniosynostosis ............................................................................................802 PATIENT EDUCATION AND ANESTHESIA 35. Information for Parents and Caregivers .........................................................................................807 36. Pediatric Anesthesia .......................................................................................................................823 Index....................................................................................................................................................829
CHAPTER 1
T YMPANOSTOMY T UBES AND R ELATED P ROCEDURES

Charles D. Bluestone, MD
In this chapter, I provide my indications and surgical techniques for the following procedures: tympanocentesis, myringotomy, grommet-type tympanostomy tube placement, permanent tube (T-tube) placement, and tympanostomy tube removal and paper-patch myringoplasty. Tympanocentesis is a needle aspiration of the middle ear and is indicated to identify the causative organism when a middle-ear effusion is present.1 Myringotomy is performed when drainage of the middle-ear cleft is required. Insertion of a tympanostomy tube into a myringotomy incision is indicated when prolonged ventilation, drainage, or both are desired.
TYMPANOCENTESIS Indications Tympanocentesis is performed when any of the following are present: Otitis media in children who are seriously ill or have toxic signs or symptoms Unsatisfactory response to antimicrobial therapy Onset of otitis media in a patient who is receiving antimicrobial agents Presence or suspicion of suppurative complications Otitis media in the newborn, the very young infant, or the immunologically deficient patient, in each of whom an unusual organism may be suspected Anesthetic Considerations The procedure can usually be performed without general anesthesia. In certain cases, premedication with a combination of a short-acting barbiturate and either morphine or meperidine, or even a general anesthetic, is advisable. For older children and adolescents, a small amount of phenol can be used on the tympanic membrane before the needle is inserted.
Surgical Atlas of Pediatric Otolaryngology
Procedure Aspiration can be carried out using an otoscope with a surgical head or with an otomicroscope. Adequate immobilization of the patient is essential when a general anesthetic is not used. The needle is inserted through the inferior portion of the tympanic membrane, using an 18-gauge spinal needle attached to a syringe or collection trap. The following method is recommended for tympanocentesis and aspiration of a middle-ear effusion for microbiologic assessment:
!
A culture of the external auditory canal can be obtained with a Calgiswab that is moistened with trypticase soy broth if an unusual middle-ear organism is suspected. The external canal is filled with 70% ethyl alcohol for 1 minute (Figure 11). The alcohol is removed from the ear canal by aspiration when an unusual middle-ear organism is suspected.
Figure 11 Ethyl alcohol (70%) is instilled in the external canal for 1 minute.
Tympanostomy Tubes and Related Procedures
Tympanocentesis is performed in the inferior portion of the tympanic membrane with an Alden-Senturia trap with a needle attached (Figure 12). Care is taken not to close the suction hole in the trap before entering the middle ear. A tuberculin syringe with an 18-gauge needle attached is an alternative. A myringotomy can be performed after tympanocentesis to provide more effective drainage.
Postoperative Care The middle-ear aspirate should be sent to the microbiology laboratory for Gram stain, culture, and antibiotic susceptibility studies. Even though the tympanocentesis defect is small, postoperative otorrhea may develop, the treatment of which is described in detail later in this chapter (see Tympanostomy Tube Insertion).
Figure 12 Alcohol is removed from the ear canal by aspiration, and tympanocentesis is performed with an Alden-Senturia trap (Storz Instrument Co, St. Louis, MO) with a needle attached.

MYRINGOTOMY Indications Myringotomy is performed for the following indications: Presence or suspicion of suppurative complications of otitis media, such as facial paralysis or mastoiditis Relief of severe otalgia at the onset of the illness, or persistent signs and symptoms of acute middle-ear (mastoid) infection Note that myringotomy is useful primarily to provide drainage of the middle ear and frequently the mastoid. As previously discussed, tympanocentesis with needle aspiration should precede the myringotomy when microbiologic assessment is indicated. Myringotomy as a routine adjunct to antimicrobial therapy is not required;2 however, the procedure is helpful for relief of otalgia. Furthermore, in selected cases, a tympanostomy tube may be indicated to provide adequate drainage, such as when a suppurative complication or chronic otitis media with effusion is present, or when the child has had recurrent otitis media in the recent past. The use of a laser to perform the myringotomy is an experimental procedure,3 which awaits appropriate clinical trials comparing laser myringotomy (with or without insertion of a tympanostomy tube) with the standard knife myringotomy. Anesthetic Considerations The anesthetic considerations and immobilization of the child are similar to those described for tympanocentesis. Procedure A wide-field incision (Figure 13A) is made in the inferior portion of the pars tensa (instillation of 70% alcohol for 1 minute precedes the procedure if an unusual bacterial organism is suspected). A radial incision is made in the anterosuperior quadrant of the pars tensa (Figure 13B) if a tympanostomy tube is to be inserted (an incision in the anteroinferior quadrant is a reasonable alternative).
Figure 13 A, A wide-field incision is made in the inferior portion of the pars tensa. B, A radial incision is made in the anteroposterior (or anteroinferior) quadrant of the pars tensa.
Middle-ear effusion is aspirated with a small Baron or Fraser aspirator (Figure 14A). When a wide-field inferiorly placed myringotomy is indicated, a larger aspirator is used (Figure 14B). If, during myringotomy, the effusion is too viscid to be aspirated through the anterosuperior radial myringotomy, a counter incision myringotomy can also be performed and the thick effusion aspirated through the inferiorly placed incision. Postoperative Care The patient (or a family member) should be warned that otorrhea might become a problem. When otorrhea is profuse, external otitis may develop. Cotton should be placed in the external auditory canal, and ototopical antibiotic drops (with or without hydrocortisone) are usually helpful in preventing dermatitis and chronic suppurative otitis media that could result from bacterial organisms from the external canal entering and contaminating the middle ear through the myringotomy incision.4 The cotton should be changed at least once a day or whenever it becomes wet. Postoperative otorrhea is discussed in detail below (see Grommet-Type Tympanostomy Tube Insertion).
Figure 14 A, A small Baron or Fraser aspirator is used for aspiration of middle-ear effusion. B, When a wide-field inferiorly placed myringotomy is indicated, a larger aspirator is used.

GROMMET -TYPE TYMPANOSTOMY TUBE INSERTION Of the many types of tubes currently available, the biflanged Armstrongtype grommet tube is preferred for routine placement. Our studies have shown that it remains functional for approximately 12-18 months (range 6-24 months). 57 Indications The following are indications for the placement of a grommet-type tympanostomy tube:8 Chronic middle-ear effusion that is relatively asymptomatic, does not respond to medical management, is not improving, and has persisted for at least 3 months when bilateral or 6 months when unilateral. Insertion at an earlier time would be reasonable when there is significant hearing loss (eg, >25 dB), speech or language delay, a severe retraction pocket, disequilibrium or vertigo, or when tinnitus is present. Recurrent acute otitis media, especially when antimicrobial prophylaxis fails to prevent frequent, severe, and long-lasting disease. Minimum frequency for considering tympanostomy tube insertion would be three or more episodes during the previous 6 months or four or more attacks during the previous year, with one being recent. Recurrent otitis media with effusion in which the duration of each episode does not meet the criteria for chronic disease, but the cumulative duration is considered to be excessive (eg, 6 to 12 months). When a suppurative complication is suspected or is present. Insertion of a tympanostomy tube at the time of tympanocentesis or myringotomy can provide more prolonged drainage and aeration of the middle-ear cleft. Eustachian tube dysfunction, even in the absence of middle-ear effusion, when the patient has persistent or recurrent signs and symptoms that are not relieved by medical treatment. Signs and symptoms would include tinnitus, hearing loss (usually fluctuating), and vertigo or disequilibrium. Also, tympanostomy tube placement may be required when there is a need for hyperbaric oxygen therapy. When atelectasis of the middle ear (with or without retraction pocket) is present, and is chronic and unresponsive to medical management. When a tympanoplasty (with or without a mastoidectomy) is performed and eustachian tube function is thought to be poor, such as when an acquired cholesteatoma is present in an infant or young child (see Chapter 4).
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Eustachian tube function testing is usually not feasible prior to surgery for cholesteatoma unless a tympanostomy tube is in place or a perforation is present. If a tube or perforation is present, the middle ear should not be infected. Tympanostomy tube insertion at the time of the cholesteatoma surgery can help prevent postoperative atelectasis, retraction pocket, and recurrent cholesteatoma.
Anesthetic Considerations In children, the procedure is performed under general anesthesia. In some older cooperative teenagers, local infiltrative anesthesia (1% lidocaine with 1:100,000 epinephrine) can be used successfully (see Chapter 2, Figure 21 for injection sites), or a small amount of topical phenol can be applied to the myringotomy site, or both methods of local anesthesia can be used. Procedure A myringotomy is performed as previously described, in the anterosuperior or anteroinferior quadrant of the pars tensa. A radial incision is made that is small enough to prevent premature extrusion but is long enough to permit the tube to be easily inserted. If the indication for tube placement is a suppurative complication (ie, mastoiditis), a wide-field myringotomy (see Figure 13A) should also be performed in the inferior portion of the tympanic membrane to provide adequate drainage. The tympanostomy tube is inserted through a second incision in the anterosuperior (or anteroinferior) quadrant. Middle-ear effusion, if present, is aspirated. ! When purulent or mucopurulent fluid is aspirated, a culture of the middle-ear effusion is recommended using a Quik-Cath (Baxter Healthcare Corporation, Deerfield, IL) attached to an Alden-Senturia trap. ! If the middle-ear effusion is too mucoid to be effectively aspirated through the myringotomy incision, a counter incision should be made in the inferior portion of the tympanic membrane, which is large enough for the viscous effusion to be aspirated with a large-bore suction aspirator. Instillation of saline through the myringotomy has also been advocated to enhance the suctioning of extremely viscous middle-ear effusions. The tympanostomy tube is inserted using alligator forceps (Figure 15); the Armstrong-type grommet tube is preferred.
Figure 15 An alligator forceps is used to insert the tympanostomy tube into the previously performed myringotomy in the anterosuperior quadrant of the pars tensa.
Forceps with a serrated (not smooth) edge are recommended to permit better control of tube position and angulation during insertion. The tube is placed in either the anterosuperior or anteroinferior quadrant (Figure 16); there is no consensus regarding the safest and most effective position for tube placement. Placement in the anterosuperior may be associated with a longer duration, however, if a chronic perforation occurs following extrusion, repair of the tympanic is somewhat more difficult than when the perforation develops in the anteroinferior quadrant. Nevertheless, these perforations, irrespective of site, can be successfully repaired in most children (see Chapter 3).
Figure 16 Tympanostomy tube in place.
When the external auditory canal is small, such as in young infants, a smaller-bore grommet tube may be more feasible than the traditional tube. However, in these infants, as well as those children who have stenosis of the ear canal (eg, Down syndrome), the tympanostomy tube will have to be inserted into the ear canal prior to insertion of speculum, since the grommet will not usually pass through smaller specula (Figure 17). If a longer period of ventilation is desired, however, a T-tube can generally be passed through a small speculum.
Ototopical drops (preferably non-ototoxic, eg ofloxacin) are instilled into the external auditory canal when a middle-ear effusion is aspirated, and instillation is continued if otorrhea occurs. Saline irrigation of the middle ear (when middle-ear effusion is present) at the time of tympanostomy tube insertion has been reported to be effective in preventing postoperative otorrhea.9 Postoperative Care Otorrhea that occurs after surgery is usually treated effectively with an ototopical medication, such as ofloxacin.10 Culture and susceptibility testing of the effusion at the time of tympanostomy tube placement can be helpful in selecting oral antimicrobial agents. The need to protect the ears when the child with tympanostomy tubes is bathing or swimming is controversial. This author prefers routine use of earplugs, but others advise earplugs only when swimming deep under water or if the child complains of ear pain upon head submersion (see Chapter 35). Patients are re-examined approximately 2 weeks after insertion of the tube, at which time an audiogram is obtained to determine if, indeed, the hearing is normal when the tympanostomy tubes are in place and patent. If the hearing is normal and the tympanostomy tubes are functioning, the child can be re-examined in 6-12 months and then every
Figure 17 A, When the external canal is too small or is stenotic, the grommet, attached to the alligator forceps, is inserted into the canal prior to the speculum, since the speculum is too small to pass the grommet. B, Once the grommet is in the canal, it can then be inserted into the myringotomy incision.
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6 months until spontaneous extrusion occurs. Ideally, periodic examination of the child by the surgeon is advised, but this recommendation is not always followed in this cost-conscious era. 11 Rosenfeld and Isaacson12 (and this author concurs) suggest that children be referred back to the otolaryngologist every 4-6 months after insertion, 6-12 months after the tubes extrude, whenever recurrent or chronic otorrhea occurs, when the tube becomes occluded, and when a chronic perforation develops after the tube extrudes. They strongly recommend referral for a postoperative audiogram, whenever the tube can not be visualized, bloody otorrhea occurs or when otorrhea is not controlled by antibiotics, the hearing worsens, persistent otalgia occurs, granulation is present, or when the tube is retained longer than 2 years. Postoperative Complications and Sequelae Because episodes of acute otorrhea are common during the life of indwelling and patent tympanostomy tubes, early treatment of these infections with an ototopical agent, with or without a systemic antimicrobial agent (depending upon the severity of the otitis media and the underlying upper respiratory tract infection), appears to not only decrease the duration and severity of the infection but also to prevent progression to the chronic stage, ie, chronic suppurative otitis media.13 Premature extrusion of the tympanostomy tube occasionally occurs, and if it does so prior to 6 months, this author usually recommends re-insertion, since prevention of recurrent disease will most likely require 12 or more months with the tube in place. Spontaneous extrusion in the immediate postoperative period may be due to the presence of acute otitis media, with otorrhea, at the time of tube placement. To avoid this complication, place the patient on prophylactic antibiotics (eg, amoxicillin, 20 mg/kg/day) until the day of the procedure. In addition, if acute otitis media is present when the tubes are inserted, vigorously treat the acute infection with either oral antibiotics, ototopical agents, or both, which can be culture-directed following the results of the Gram stain and culture and susceptibility studies of the middle-ear aspirate obtained at the time of the myringotomy and tube placement. On rare occasions, the tympanostomy tube may fall into the middle ear, either at the time of placement, or at any time during the postoperative period.
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When this occurs during the procedure, instillation of saline through the myringotomy incision will float the tube to the level of the ear drum and then suctioning at the site of myringotomy incision will bring the tube into view, at which time the tube can be either properly repositioned or extracted and re-inserted. If the tympanostomy tube is found to be behind the tympanic membrane during the postoperative period and the child requires re-insertion of the tube, then the procedure described above can be performed. However, if the tympanic membrane has healed with the tympanostomy tube in the middle ear, but the child does not have an indication for re-insertion of tympanostomy tubes, then inform the
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parents that the tube is biocompatible, should not be associated with a foreign body reaction, and will not cause otitis media. Thus it can remain indefinitely in the middle ear, since the child will otherwise require a general anesthetic in order to retrieve the tube. Following spontaneous extrusion (or removal) of tympanostomy tubes, a permanent perforation can occur. When grommet-type tubes are used, the perforation rate is between 0.5 and 1%, but when permanent tubes are used the rate can be as high as 40%.14,15 These perforations can usually be prevented when tubes are surgically removed if a myringoplasty is performed at the time of removal (see below), however, if a chronic perforation is found after spontaneous extrusion, a myringoplasty or tympanoplasty may be indicated (see Chapter 3). Other common sequelae of tympanostomy tubes are myringosclerosis, and localized atrophy of the tympanic membrane resulting in a dimeric membrane that can develop into a retraction pocket if the child continues to have chronic eustachian tube dysfunction. The presence and extent of myringosclerosis increases with increasing number of tube insertions, but does not commonly cause hearing loss, ie, it is a cosmetic problem but not a functional one. The presence of a chronic retraction pocket, however, is more problematic since an iatrogenic cholesteatoma can occur. Thus, management of these defects is indicated and may include re-insertion of a tympanostomy tube at another site, tympanoplasty, or both, depending upon the site, extent, and the presence or absence of adhesive otitis media. If the portion of tympanic membrane involved in the retraction pocket returns to the normal position following tympanostomy tube placement, then tympanoplastic repair of the defect may be avoided (see Chapter 3). Even though a relatively uncommon occurrence, a cholesteatoma can develop at the site of the tympanostomy tube placement (either as result of a retraction pocket, or following invagination of epithelium around the tube, or at the margin of a chronic perforation that occurs after the tube extrudes), especially if the child is not frequently observed during the postoperative period.13 PERMANENT TYMPANOSTOMY TUBE INSERTION When ventilation of the middle ear is desirable for a period of time longer than 12-18 months, a permanent tube may be more appropriate than a grommet tympanostomy tube. The incidence of chronic perforation following permanent tube extrusion or removal, however, is higher than that of short-acting grommet tubes. Therefore, this author rarely recommends permanent tympanostomy tubes for infants and young children. Candidates for permanent tympanostomy tube insertion include older children and adolescents who have had several (three or more) recent insertions of grommet-type tubes. In this situation, placement of permanent tubes may reduce the need for frequent future operations. In general, a permanent tympanostomy tube is recommended when a permanent (chronic) perforation is desirable. This author uses one of two types: the Per-Lee tube (XomedTreace Inc, Jacksonville, FL)16 or the Richards T-Tube (Smith-Nephew Inc, Bartlett, TN). 15
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Indications The following are indications for placement of a permanent tympanostomy tube: Otitis media or atelectasis of the middle ear is determined to be permanent (ie, caused by eustachian tube dysfunction) and not likely to improve with advancing age For conditions such as congenital or acquired eustachian tube stenosis, fracture through the eustachian tube following skull-base surgery, or benign or malignant neoplasms These conditions are relatively rare but can lead to chronic and potentially life-long eustachian tube dysfunction. Anesthetic Considerations Aspects of anesthesia are similar to those described for myringotomy and placement of grommet-type tympanostomy tubes. Procedure (see also Myringotomy and Grommet-Type Tympanostomy Tube Insertion procedures) When a Per-Lee tube is to be used, an incision is made with a myringotomy knife immediately anterior to the body of the malleus (Figure 18).
Figure 18 An incision is made anterior to the body of the malleus.
13
A Per-Lee tube is preferred:

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The tube should be shortened and a wide flange cut to fit posterior to the malleus. The wide flange is posterior behind the malleus, and a shorter anterior flange is cut to fit behind the anterior quadrant of the tympanic membrane (Figure 19). The tube is inserted using alligator forceps. Compression of flanges with alligator or cup forceps aids in insertion of the tube (Figure 110). The tube is in place. Note the posterior flange behind the malleus (Figure 111).
Figure 19 A Per-Lee tube is shortened.
Figure 110 The tube is inserted using an alligator forceps.
Figure 111 The tube in place.
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A Richards T-tube may also be used:

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The tube shaft is trimmed (Figure 112) to prevent contact with the ear canal, but should be kept long enough to prevent the tube from falling into the middle ear. A myringotomy incision is made in the anteroinferior quadrant of the tympanic membrane.
Figure 112 The Richards T-tube is cut short (similar to Figure 19) and grasped by the tips of the alligator forceps so that the two flanges are folded backwards inside the forceps.
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Both flanges of the T-tube are pressed by the forceps (see Figure 112), inserted through the myringotomy incision (Figure 113A), and allowed to spring out behind the tympanic membrane (Figure 113B). Alternatively, the tube can be grasped with the flanges pressed forward, rather than back against the tube shaft. A properly placed tube permits a clear view of the middle-ear mucosa through the tube lumen. When one or both flanges are not in an ideal position, they can be repositioned with an otologic pick. The shaft should be positioned so that the lumen can be easily seen, which enhances postoperative follow-up. The tube may easily become blocked if it is placed against the canal wall.
Postoperative Care Postoperative care is similar to that described for myringotomy and grommet-type tympanostomy tube insertion. When ototopical medication is prescribed, the patient should use sufficient amounts to fill the ear canal in order that the drops penetrate the tube, since these two types of permanent tympanostomy tubes are longer than the grommet types.
Figure 113 A, The T-tube is inserted with the forceps through the myringotomy incision far enough that the two flanges are behind the tympanic membrane. B, The forceps releases the tube and is withdrawn so that the flanges spring out behind the eardrum.
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REMOVAL OF TYMPANOSTOMY TUBES AND MYRINGOPLASTY Tympanostomy tubes can be removed as an office procedure without the aid of either local or general anesthesia, especially when the tube is partially extruded or if there is chronic infection involving the tympanic membrane. In children, however, tympanostomy tubes are usually removed under general anesthesia in the operating room since the procedure is painful and the rim of the perforation can be denuded of epithelium. This also allows the defect to be closed (ie, myringoplasty) following removal of the tube. This method, although not tested in a clinical trial, appears to result in a higher rate of closure of the perforation than when the tube is removed with no attempt to close the defect. Case Selection Our studies of tympanostomy tubes indicate that the Armstrong-type tube usually lasts about 12 to 18 months, with the range being 6 to 24 months.57 Tubes that remain in place longer than that period may require removal on an individualized basis depending on several factors, such as the following: Age of the child Amount of time that the tube has remained in place Unilateral versus bilateral tubes Status of the contralateral ear when that tympanic membrane is intact Eustachian tube function Presence or absence of recurrent or chronic otorrhea (and frequency, severity, and duration of otorrhea) Patency of the tube Season of the year The age of the child is one of the most important factors, because most epidemiological studies of otitis media show that the disease peaks in infancy and declines rapidly after about 6 years of age. In addition, the structure and function of the eustachian tube as well as the childs immunity are usually more mature after 6 years of age. Therefore, removal of tubes in children 6 years of age and older is more desirable than in younger children. However, removal of the tube in select younger children may be beneficial, for example, in cases of unilateral recurrent otorrhea through a tube (apparently owing to reflux of nasopharyngeal secretions into the middle ear) that is not medically controlled. Tube removal may also be beneficial when the contralateral tympanic membrane is intact (no tube is present) and that ear has been free of middle-ear disease for 1 year or more. Indications Presence of a retained unilateral tympanostomy tube in children who are 6 years of age or older, when the contralateral tympanic membrane is intact and the middle ear has been free of disease for 1 year or more Select children younger than 6 years of age, depending on the factors listed above
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Presence of retained bilateral tympanostomy tubes in children in whom eustachian tube function is now considered within normal limits owing to either growth and development, nonsurgical management (eg, allergy control or treatment), or surgery (eg, adenoidectomy, repair of cleft palate) Presence of frequently recurrent otorrhea through a tympanostomy tube that is not prevented by antimicrobial prophylaxis Important factors in decision-making are frequency, severity, and duration of the episodes; age of the patient; and duration that the tube has been in place. Following chronic otorrhea, especially when the criteria described in the first two points are met When the tympanostomy tube is imbedded in granulation tissue, which is unresponsive to medical treatment Anesthetic Considerations In children, general anesthesia is usually required. For select children, especially teenagers, no anesthesia is needed. Procedure The myringotomy tube is gently removed using an alligator forceps (Figure 114). Epithelium from the rim of the perforation is removed using a rightangled pick, or using a gently curved pick to split the layers of tympanic membrane and a cup forceps to remove the tissue (Figure 115).
Figure 114 The myringotomy tube is gently removed using an alligator forceps.
Figure 115 Epithelium from the rim of the perforation is removed using a right-angled pick.
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A circular portion of Steri-Strip is cut and placed over the perforation (Figure 116). The operative site must be free of any bleeding prior to placement of the patch; application of epinephrine via Gelfoam for 5 minutes is adequate. An antibiotic ointment (eg, polymyxin B sulfate, zinc bacitracin, neomycin sulfate) is instilled into the external auditory canal using a syringe and a plastic needle tip (Figure 117).
Figure 116 A circular portion of Steri-Strip (Medical-Surgical Division/3M, St. Paul, MN) is cut and placed over the perforation.
Figure 117 Instillation of an antibiotic ointment into the external auditory canal using a syringe and a plastic needle tip (Quik-Cath, Baxter Healthcare Corporation, Deerfield, IL).
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Postoperative Care The patient is re-examined after 4 to 6 weeks. At that time, the SteriStrip patch has usually come off the tympanic membrane and the perforation is healed. If the patch is not displaced, an ototopical agent is instilled for several days and the child is re-examined. Confirmation of closure of the tympanic membrane can be achieved using pneumatic otoscopy, or more precisely, with the aid of the otomicroscope and a Bruening otoscope with a nonmagnifying lens. A microscopic defect, however, may still be present despite seemingly good tympanic mobility as observed during pneumatic otoscopy. Tympanometry is the most sensitive method to confirm that the tympanic membrane is intact.
REFERENCES
Bluestone CD, Klein JO. Otitis Media in Infants and Children. St. Louis, (MO): WB Saunders; 2001. p. 1623, 25269. 2. Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics 1991;87:46673. 3. Brodsky L, Brookhauser P, Chait D, et al. Office-based insertion of pressure equalization tubes: the role of Laser-assisted tympanic membrane fenestration. Laryngoscope 1999;109:200914. 4. Bluestone CD. Efficacy of ofloxacin and other ototopical preparations for chronic suppurative otitis media in children. Pediatr Infect Dis J 2001;20:1115. 5. Casselbrant ML, Kaleida PH, Rockette HE, et al. Efficacy of antimicrobial prophylaxis and tympanostomy tube insertion for prevention of recurrent acute otitis media: results of a randomized clinical trial. Pediatr Infect Dis J 1992;11:27886. 6. Mandel EM, Rockette HE, Bluestone CD, et al. Myringotomy with and without tympanostomy tubes for chronic otitis media with effusion. Arch Otolaryngol Head Neck Surg 1989;115:121724. 7. Mandel EM, Rockette HE, Bluestone CD, et al. Efficacy of myringotomy with and without tympanostomy tubes for chronic otitis media with effusion. Pediatr Infect Dis J 1992;11:2707. 8. Bluestone CD, Klein JO, Gates GA. Appropriateness of tympanostomy tubes. Setting the record straight. Arch Otolaryngol Head Neck Surg 1994; 120:10513. 9. Gross RD, Burgess LP, Holtel MR, et al. Saline irrigation in the prevention of otorrhea after tympanostomy tube placement. Laryngoscope 2000; 110:24651. 10. Dohar JE, Garner ET, Nielson RW, et al. Topical ofloxacin treatment of otorrhea in children with tympanostomy tubes. Arch Otolaryngol Head Neck Surg 1999;125:53745. 11. Derkay CS, Carron JD, Wiatrak BJ, et al. Postsurgical follow-up of children with tympanostomy tubes: results of the American Academy of Otolaryngology-Head Neck Surgery Pediatric Otolaryngology Committee National Survey. Otolaryngol Head Neck Surg 2000; 122:3138. 12. Rosenfeld RM, Isaacson GC. Tympanostomy tube care and consequences. In: Rosenfeld RM, Bluestone CD, editors. Evidence-based otitis media. Hamilton, Ontario: BC Decker Inc; 1999. p. 31336. 1.
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13. Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J 2000;19 Suppl:3746. 14. Buckley WJ, Bowes AK, Marlowe JF. Complications following ventilation of the middle ear with Goode T tubes. Arch Otolaryngol Head Neck Surg 1991;91:8958. 15. Goode RL. Long-term middle-ear ventilation with T-tubes: the perforation problem. Otolaryngol Head Neck Surg 1996;115:5001. 16. Per-Lee JH. Long-term middle ear ventilation. Laryngoscope 1981;91:106373.
CHAPTER 2
A PPROACHES TO THE M IDDLE E AR AND M ASTOID

The three most commonly used surgical approaches to the middle ear and mastoid are: transcanal, endaural, and postauricular. The most feasible approach to the mastoid is through a postauricular incision. Even though the endaural incision can be used to approach the mastoid, it does not provide as good exposure of the mastoid as the postauricular incision.
TRANSCANAL APPROACH The transcanal (transmeatal, endomeatal) approach to the middle ear is not used as commonly in children as it is in adults owing to the relatively small ear canal in infants and young children. When the external canal is too small, the endaural or postauricular approach is used; however, in older children and adolescents, the canal is usually large enough to use a transcanal approach to the middle ear. The tympanomeatal flap that is developed provides excellent exposure of the mesotympanum. This approach was described by Rosen.1 Indications Tympanoplasty: Repair of tympanic membrane perforations when the canal is large enough for adequate exposure (an endaural or postauricular approach is indicated when the canal is too small) and when there is a need to examine the middle ear (see Chapter 3) Cholesteatoma surgery: When a congenital or acquired cholesteatoma is localized to the tympanic membrane, mesotympanum, and hypotympanum. Also, cholesteatoma that is localized to the attic can be removed using this approach if the superior portion of the tympanomeatal incision is elongated into the superior and anterosuperior portions of the canal wall (see Figure 22B ). Second look tympanotomy: This procedure is usually performed approximately 6 months after surgery for cholesteatoma, in which the tympanic membrane is present and prevents adequate postoperative examination to determine if there is residual cholesteatoma. On occasion, a
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third look is indicated 6 months after the second procedure if that operation uncovers a residual cholesteatoma; rarely, a fourth look is required (see Chapter 5).2 Ossiculoplasty: Repair of congenital or acquired defects of the ossicular chain (see Chapter 4) Otosclerosis surgery: When stapedectomy or stapedotomy is to be performed and the external canal is large enough to provide adequate visualization of the operative site Exploratory tympanotomy: When an examination of the middle ear is indicated to determine the cause of diseases and disorders of the middle ear that are not evident by other diagnostic methods, such as when there is a conductive or mixed hearing loss of undetermined origin, or when a perilymphatic fistula is suspected (see Chapter 6) Other procedures: These include labyrinthectomy, obliteration or closure of the eustachian tube (see Chapter 6), and section of the tensor tympani or stapedius muscles, which are rarely indicated in children. Anesthetic Considerations In children, the procedure is performed under general anesthesia. Local anesthetic (1% lidocaine with 1:100,000 epinephrine) is infiltrated into all four quadrants of the ear canal (6, 9, 12, and 3 oclock) just lateral to the bony-cartilaginous junction and the graft site, for hemostasis and to enhance the anesthesia (Figure 21). When intraoperative monitoring of the facial nerve is indicated, such as when a middle-ear cholesteatoma is in close approximation to the nerve, only epinephrine is used to avoid temporarily blocking the facial nerve during the procedure.
Figure 21 Injection sites (x) for transcanal approach.
Approaches to the Middle Ear and Mastoid
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Preparation If a temporalis graft is to be used, a small portion of hair is shaved just above the pinna. If a large speculum does not fit snugly into the external canal so that both of the surgeons hands are free to perform the procedure, a speculum holder attached to the operating table can be used. A speculum holder is frequently not needed, however, because the canal usually dilates when a smaller speculum is initially used, after which a larger speculum can be inserted. Procedure This incision is used when the mesotympanum and hypotympanum are the surgical sites (Figure 22A). The flap includes skin over the medial two-thirds of the bony external auditory canal. An extended incision is made when greater exposure of the epitympanum is desired, such as when disease involves the attic (ie, superior tympanomeatal flap) (Figure 22B). The incision is made more lateral and anterior.
Figure 22 A, This incision (dashed line) is used when the mesotympanum and hypotympanum are surgical sites. B, An extended incision (dashed line) is made when greater exposure is desired, such as when the disease is in the attic and an atticotomy may be performed.
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The tympanomeatal flap is elevated to the annulus. Bleeding, if present, is controlled at this stage by application of cotton pledgets or by a Super Sorb Micro Eye Sponge (Storz Ophthalmics Inc, St. Louis, MO) soaked in epinephrine prior to entering the middle ear (Figure 23). The middle ear is entered by elevating the annulus with a curved pick just below the chorda tympani nerve (Figure 24).
Figure 23 The tympanomeatal flap is elevated to the annulus with a moon elevator.
Figure 24 The middle ear is entered by elevating the annulus.
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The superior portion of the tympanomeatal flap is completed using microscissors (Figure 25). Curettage of the posterosuperior canal wall scutum to visualize the long process of the incus, stapes, and stapedius tendon may be necessary in many cases (Figure 26).
Figure 25 The superior portion of the tympanomeatal flap is completed using microscissors.
Figure 26 Curettage of the scutum.
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The tympanomeatal flap is completed when the posterior edge of the long process of the malleus, the long process of the incus, the stapes, the stapedius tendon, and the round window are visible, and the flap is reflected anteriorly without tension (Figure 27).
Figure 27 The tympanomeatal flap is completed when the posterior portion of the malleus is exposed and the flap extends to at least both 6 and 12 oclock; the flap should be able to be reflected forward and completely out of the operative field.
Postoperative Care Postoperative care depends on the final procedure performed. For example, if only a tympanoplasty was performed, the canal is filled with an antibiotic ointment, as described in Chapter 1 (see Removal of Tympanostomy Tube and Myringoplasty). In such cases, the child can be re-examined 4 to 6 weeks later. ENDAURAL APPROACH The endaural approach is commonly used in infants and young children because their ear canals are often too small to permit adequate exposure for the transcanal approach. Another advantage of the endaural approach is the accessibility of the epitympanum and anterosuperior portion of the mesotympanum; as well, a fascia graft can be easily obtained from the temporalis muscle, since this tissue is in the operative field. Indications Tympanoplasty: Repair of perforation in the anterosuperior quadrant of the pars tensa (see Chapter 3) Attic retraction pocket: When the extent of the retraction pocket cannot be fully visualized using the otomicroscope, when there has been recurrent infection within it, when the pocket is progressively enlarging, or when placement of a tympanostomy tube fails to reverse an extensive pocket
27
Distinction among these types of retraction pockets and acquired cholesteatoma is frequently difficult (see Chapter 3). Congenital and acquired cholesteatoma: When the disease is localized to the anterior epitympanum and the mesotympanum (see Chapter 5) Closure or obliteration of the eustachian tube: When adequate access is not possible employing the transcanal approach and anterior tympanomeatal flap (see Chapter 6) Anesthetic Considerations General anesthesia is almost always required, and local infiltrative anesthesia is also used. Injection sites are the same as those described for a transcanal approach (see Figure 21), but additional injections are placed in the incisura of the pinna. Preparation Because the incision is carried into the incisura of the pinna, a small area of scalp hair may have to be shaved anterosuperior to the pinna. Procedure The procedure described below is a modification of the one described originally by Lempert.3 Compared to the classical endural approach, my method differs in the canal incisions, the incision in the incisura of the pinna is shorter and only a small portion of the mastoid bone is exposed, since this approach is not feasible, as is the postauricular approach, when a mastoidectomy is planned. A Lempert speculum exposes the bony-cartilaginous junction (Figure 28). Injection sites are just lateral to the junction but directed toward the bony canal and into the incisura of the pinna.
Figure 28 A Lempert speculum exposes the bony-cartilaginous junction for injection of a local anesthetic agent. x = injection sites
28
A posterior canal incision with a Rosen flap knife (a Bard-Parker blade is too large) is made slightly medial to the bony-cartilaginous junction, so that the medial (ie, tympanomeatal) flap is thin (Figure 29). The incision is continued into the incisura of the pinna but superficial to the temporalis muscle, using a No 15 Bard-Parker knife blade (Figure 210); the No 15C blade, which is smaller than the standard one, can be used in infants to make the incision in the incisura.
Figure 29 A posterior canal incision is made with the Rosen flap knife.
Figure 210 The incision is continued into the incisura of the pinna but superficial to the temporalis muscle.
29
An anterior incision in the canal is connected to, and is a continuation of, the posterior canal incision (Figure 211). The lateral posterior and anterior flaps are elevated with a periosteal elevator to permit insertion of the self-retaining retractor (Figure 212). The tympanomeatal flap, tympanic membrane, and temporalis muscle are exposed (Figure 213).
Figure 211 An anterior relaxing incision in the canal.
Figure 212 The lateral posterior and anterior flaps are elevated.
Figure 213 The tympanomeatal flap, tympanic membrane, and temporalis muscle are exposed with the aid of a selfretaining retractor.
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The tympanomeatal flap is elevated (Figure 214). When indicated, the flap is dissected off the malleus (Figure 215).
Figure 214 The tympanomeatal flap is elevated.
Figure 215 Dissection of the flap off the malleus using a curved pick.
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The flap is elevated, exposing the middle ear (Figure 216).
Figure 216 The middle ear is exposed.
Postoperative Care Following a procedure that uses the endaural approach, the ear canal is packed with two strips (one medial and one lateral) of Adaptic gauze (Johnson & Johnson Medical Inc, Arlington, TX) impregnated with an antibiotic ointment. Two strips are used to prevent accidental removal of all the packing by the child during the postoperative period. A Glasscock dressing (Glasscock Ear Dressing Kit, Oto-Med, Lake Havasu City, AZ) is used for the first postoperative day, and for a few days afterward if the child prefers. The Adaptic packing is removed after 1 week and cotton is inserted into the meatus. The cotton is changed at least once a day or whenever it becomes soiled, and may be left out once there is no further drainage. Application of an antibiotic ointment into the edge of the wound in the incisura prevents the cotton from adhering to it. The child is re-examined in about 1 month.
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POSTAURICULAR APPROACH The postauricular approach is frequently used in children. Since it facilitates exposure of the middle ear, a fascia graft can be readily obtained from the temporalis muscle, and it is the preferred approach when a mastoidectomy is to be performed. Indications The postauricular incisions and approach are indicated when there is disease that involves the mastoid, but it is also used to provide access to the middle ear when neither the transcanal approach nor the endaural approach is feasible. This approach is also used when tympanoplasty is required for a large perforation; both medial and lateral graft techniques can use this approach (see Chapters 3 and 5). Anesthetic Considerations The anesthesia is the same as that described for the transcanal approach, but additional injection sites are required in the postauricular area (Figure 217).
Figure 217 Injection sites (x) in the postauricular area in addition to those in the canal.
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Preparation A small area of hair is shaved posterior and superior to the planned postauricular incision. Procedure An incision is made a few millimeters posterior to the postauricular crease (Figure 218A). In children younger than 4 years of age, the incision is made away from the stylomastoid foramen and the facial nerve; injection sites are altered accordingly (Figure 218B).
Figure 218 A, An incision is made just a few millimeters posterior to the postauricular crease. B, An incision used for children younger than 4 years of age to avoid potential injury to the facial nerve.
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The postauricular soft tissue is exposed (Figure 219). A transcanal incision is made from the 6 to 12 oclock position about onethird of the distance from the annulus to the meatus to create a Koerner flap (the transcanal incision usually precedes the postauricular incision) (Figure 220).
Figure 219 The postauricular soft tissue is exposed.
Figure 220 A transcanal incision is made with a Rosen flap knife to create a Koerner flap.
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Canal incisions are extended laterally (Figure 221). A Koerner flap is back-elevated a few millimeters laterally in the canal to facilitate identification of the incisions and elevation of the flap from the postauricular approach (Figure 222). A piece of Super Sorb Micro Eye Sponge large enough to fill the canal medial to the incisions also aids in identifying the canal incision, and prevents inadvertently and prematurely entering the middle ear.
Figure 221 Canal incisions are extended laterally.
Figure 222 The Koerner flap is elevated a few millimeters laterally in the canal.
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A T incision is made in postauricular soft tissue and the periosteum is elevated (Figure 223). The superior limb of the incision is placed just below the inferior edge of the temporalis muscle. If a mastoidectomy is not planned, the T incision may be replaced by a semicircular incision parallel to the lateral concavity of the external auditory canal. The Koerner flap is elevated through postauricular exposure (Figure 224).
Figure 223 A T incision is made in postauricular soft tissue and is elevated with a periosteal elevator.
Figure 224 The Koerner flap is elevated.
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The tympanic membrane, tympanomeatal flap, and mastoid are exposed (Figure 225). A Penrose drain is used to retract the Koerner flap anteriorly, which is fastened to the surgical drape in front of the ear. The Penrose drain also protects the Koerner flap when a self-retaining retractor is inserted (Figure 226).
Figure 225 The tympanic membrane, tympanomeatal flap, and mastoid are exposed.
Figure 226 A Penrose drain is used to retract the Koerner flap anteriorly to protect the flap when the retractor is inserted.
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The tympanomeatal flap is elevated and reflected anteriorly to expose the mesotympanum, similar to that described for the transcanal approach (Figure 227).
Figure 227 The tympanomeatal flap is elevated and reflected anteriorly to expose the mesotympanum.
Postoperative Care The postauricular incision is closed with an absorbable suture; a drain is optional. Two strips of Adaptic gauze impregnated with antibiotic ointment are used to pack the ear canal. A Glasscock pressure dressing is applied for 1 day. The packs are removed in 1 week, and the child is re-examined in about 1 month. REFERENCES
1. 2. 3. Rosen S. Mobilization of the stapes to restore hearing in otosclerosis. NY J Med 1953;53:26503. Rosenfeld RM, Moura RL, Bluestone CD. Predictors of residual-recurrent cholesteatoma in children. Arch Otolaryngol Head Neck Surg 1992;118:38491. Lempert J. Endaural, antauricular surgical approach to the temporal bone: principles involved in this new approach. Summary report of 1,780 cases. Arch Otolaryngol Head Neck Surg 1937;27:55587.
CHAPTER 3
M YRINGOPLASTY AND T YMPANOPLASTY

In this chapter, I describe operative procedures for repairing a perforation or a retraction pocket of the tympanic membrane with myringoplasty or tympanoplasty. The tissue technique for myringoplasty and tympanoplasty may be medial (underlay) or lateral (overlay, onlay), and the approach may be transcanal (transmeatal), endaural, or postauricular (see Chapter 2).
SELECTION OF APPROACH AND TECHNIQUE Myringoplasty is used when there is no need to enter the middle ear, whereas tympanoplasty is indicated when the middle ear requires inspection. The myringoplasty is usually performed utilizing the transcanal approach and a medial fascia or fat-plug graft technique. The tympanoplasty approach and graft procedure depend upon the location and extent of the defect: When the perforation is small and central (usually in one of the inferior quadrants), a transcanal approach is used, employing a tympanomeatal flap to enter the middle ear, and repairing the drum defect with a medial fascia graft or fat-plug. When the perforation is larger and in one or both posterior quadrants, especially when it is a marginal perforation, a postauricular approach is employed with a medial fascia graft. When a retraction pocket is in this portion of the tympanic membrane, the same approach is used, but a cartilage graft is placed medial to the fascia graft to batten the tympanic membrane. When the perforation is in the anterosuperior quadrant, an endaural approach is used with a medial fascia graft. The same approach is used for a retraction pocket in this quadrant, but a medial cartilage graft is also employed to batten the eardrum. When the perforation involves most or all of the tympanic membrane (eg, subtotal or total), a postauricular approach and a lateral fascia graft are used.
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Myringoplasty Myringoplasty is a procedure used to repair a tympanic membrane perforation, without the need to examine the middle-ear. The procedure should be limited to patients who satisfy all of the following four criteria: 1. Relatively small central perforation of the tympanic membrane 2. Translucent tympanic membrane 3. No middle-ear disease is present or suspected 4. Hearing is within normal limits When these conditions are not met, a tympanoplasty is indicated to facilitate the repair and to explore the middle ear, as described later in this chapter. In Chapter 1, the indications and technique for removal of a retained tympanostomy tube and a paper-patch (Steri-Strip) myringoplasty were described. In the absence of a tympanostomy tube, the same paper-patch myringoplasty technique is used when a chronic small perforation is present secondary to a previously extruded tympanostomy tube, as a complication of otitis media, or following trauma to the eardrum. The surgical procedure is the same as that described in Chapter 1, and the indications are similar to those described below, when a myringoplasty is performed using a medial graft. When the Steri-Strip technique is used, the perforation should be no larger than the defect made by a grommet-type tube, because this technique has a poor success rate with larger perforations. Saito and colleagues,1 however, reported a 99% success rate in 108 patients, aged 2 to 68 years, using this patch. Tympanoplasty There is no consensus on the optimal ages for tympanoplasty (or myringoplasty) and suggestions have ranged from 2 or 3 years to puberty. Paparella2 states that tympanoplasty can be performed in children of almost any age, but Sheehy and Anderson3 do not recommend elective tympanic membrane grafting in children younger than 7 years of age because of potential postoperative otitis media. More recently, other surgeons4,5,6 have reported tympanoplasty outcomes that agree with the recommendation of Sheehy and Anderson.3 In a recent review of the long-term outcomes of tympanoplasty by Tos and associates,7 however, the success rate was 86% after 15 to 27 years. A recent meta-analysis of tympanoplasty in children from 1966 to 1997 by Vrabec and colleagues8 revealed that the success rate increased with advancing age and that none of the other parameters studied was shown to be a significant predictor of success. For a more detailed discussion of this controversy, the reader is referred to Bluestone and Klein.9 In general, the indications for tympanoplasty are similar to those described in Chapter 1 when removal of a tympanostomy tube with a paper-patch myringoplasty is being considered and, as described above, when a medial graft tympanoplasty is indicated. A relatively small central perforation can be repaired successfully using the Steri-Strip technique, as described in detail in Chapter 1. A tympanoplasty, as opposed to only a myringoplasty, should be performed when there is a need to examine the middle ear, such as when there
Myringoplasty and Tympanoplasty
41
is conductive hearing loss that cannot be attributed to the size and position of the perforation (eg, ossicular discontinuity or fixation), when a retraction pocket is present, or when an occult middle-ear cholesteatoma is suspected. Additional indications would be when the perforation is large, when its location makes it difficult to repair using a myringoplasty procedure (eg, anterosuperior quadrant), or when it is a marginal perforation. When the perforation is in the posterosuperior quadrant and is marginal, a tympanoplasty provides not only a higher success rate, but also an opportunity to inspect the ossicular chain and middle ear, especially the sinus tympani and facial recess, to rule out cholesteatoma. The classification of tympanoplasty related to ideal and theoretical postoperative hearing outcomes, based on middle-ear mechanics, consists of five types, each of which is based on the most lateral intact structure that remains connected to the inner ear: Type I: Tympanoplasty (or myringoplasty) when all three ossicles are normal, which should result in normal hearing. Type II: Tympanoplastic graft (or tympanic membrane) is in contact with the incus and the stapes is present, both of which are connected and mobile, which ideally should result in a minimal hearing loss of only 2.5 dB. Type III: Tympanoplastic graft (or tympanic membrane) is in direct contact with the suprastructure of the stapes (columella effect), which should result in a hearing loss of only 2.5 dB; also known as myringostapediopexy. Type IV: Ossicular chain is absent and the tympanic membrane is in contact with a mobile stapes footplate, which theoretically should result in a 27.5 dB hearing loss; also known as a cavum minor. Type V: A window is surgically made in the horizontal semicircular canal, which should result in hearing similar to a Type IV; also known as a fenestration. MYRINGOPLASTY WITH MEDIAL FASCIA OR FAT -PLUG GRAFT Indications Case selection and indications for myringoplasty with a medial fascia or fat graft are similar to those described in Chapter 1 for removal of a tympanostomy tube and paper-patch (Steri-Strip) myringoplasty, however, there are a few notable differences: Site of the perforation: The perforation should not be in the anterosuperior quadrant of the pars tensa unless the defect is very small, in which case the simpler Steri-Strip technique is usually successful. When the defect is not very small, placement of a medial graft through an anterosuperior perforation is difficult owing to the constricted space. Perforations in this quadrant are repaired more effectively using the endaural tympanoplastic technique described later (see Endaural Medial Fascia Graft Tympanoplasty).
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Etiology: Chronic traumatic perforations can be repaired in infants and young children, as well as in older children and adolescents, as long as recurrent or chronic middle-ear infection does not coexist. A more detailed discussion of the indications and outcomes of this operation is included in the following section (see Postauricular Medial Fascia Graft Tympanoplasty). Selection of Tissue for the Graft The tissue graft that can be used is either perichondrium removed from the tragus, fascia removed from the temporalis muscle, or a fat graft from the lobule of the ear. Myringoplasty outcomes using any of these tissues are highly successful (with the appropriate case selection), but the fat-plug technique is the most desirable, since the fat can be rapidly harvested and the middle ear does not have to be filled with Gelfoam. In addition, the fat-plug graft may be more stable since it is half in the middle ear and half on the outer surface of the tympanic membrane. Anesthetic Considerations In children, the procedure is performed under general anesthesia. In addition, infiltration of a local anesthetic (1% lidocaine with 1:100,000 epinephrine) into the ear canal and the graft site is preferred. Preparation If a large speculum does not fit snugly into the external canal so that both of the surgeons hands are free to perform the procedure, a speculum holder attached to the operating table can be used. A speculum holder, however, is frequently unnecessary because the canal usually dilates when a smaller speculum is initially used, after which a larger speculum can be inserted. A small portion of the hair is shaved just above the pinna, if a temporalis graft is to be used. Procedure Sites of injection of the local anesthetic agent are just lateral to the bonycartilaginous junction at 3, 6, 9, and 12 oclock (Figure 31). The anesthetic agent is also injected above the pinna, the tragus, or the lobule, when a graft is to be harvested from one of these sites. When a fascia graft is desired, an incision is made superior to the pinna just above the hairline (Figure 32A), and the graft is excised (Figure 32B).
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Figure 31 Sites of injection (x) of the local anesthetic agent.
Figure 32 A, An incision for a fascia graft is made superior to the pinna just above the hairline. B, The fascia graft is excised.
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As an alternative to a fascia graft, a perichondrial graft can also be used. An incision for the perichondrial graft is made in the tragus, slightly toward the meatus, which leaves the tiny scar hidden (Figure 33A), and the perichondrial graft is excised (Figure 33B).
Figure 33 A, An incision for a perichondrial graft is made in the tragus. B, The graft is excised from the posterior surface of the tragus.
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Still another highly successful alternative is to remove a small piece of fat from the ear lobule. The incision is made on the posterior surface of the lobule to hide the scar, but caution should be exercised while dissecting the fat with scissors so as to prevent a button hole perforation of the lobule (Figure 34). A small central perforation is ideal for this procedure (Figure 35).
Figure 34 A fat graft is taken from the lobule through an incision on the posterior surface.
Figure 35 A small central perforation is present.
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The rim of the epithelium at the edge of the perforation is removed with a pick. A cup forceps will also facilitate this stage (Figure 36).
Figure 36 The rim of the epithelium at the edge of the perforation is removed with a pick.
When a fascia or perichondrial graft is used to repair the perforation The middle ear is filled with Gelfoam (Figure 37) and the graft is placed medial to the tympanic membrane (Figure 38).
Figure 37 The middle ear is filled with absorbable gelatin sponge (Gelfoam) (The Upjohn Company, Kalamazoo, MI).
Figure 38 A tissue graft is placed medial to the tympanic membrane.
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A Steri-Strip is placed over the perforation and tissue graft (Figure 39). If any bleeding occurs in the operative site, epinephrine applied to a piece of Micro Eye Sponge (Storz Ophthalmics, Inc, Clearwater, FL) is used prior to placement of the Steri-Strip. An antibiotic ointment is instilled into the external auditory canal using a syringe and plastic needle tip (Figure 310).
Figure 39 A Steri-Strip is placed over the perforation and tissue graft.
Figure 310 An antibiotic ointment is instilled into the external auditory canal using a syringe and plastic needle tip.
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When a fat-plug graft is used to repair the perforation: The graft is inserted tightly into the perforation (Figure 311A), with half of the fat in the middle ear and half on the outer surface of the tympanic membrane (Figure 311B). No Gelfoam is needed in the middle ear, but a Steri-Strip is applied to the outer surface of the graft and antibiotic ointment is instilled into the ear canal similar to that shown in Figure 310. Postoperative Care Postoperative care is similar to that described in Chapter 1 under Removal of Tympanostomy Tube and Myringoplasty.
Figure 311 A, A fat-plug graft is tightly inserted into the perforation. B, The plug should be half in the middle ear and half out on the lateral surface of the tympanic membrane.

TRANSCANAL MEDIAL FASCIA OR FAT -PLUG GRAFT TYMPANOPLASTY
49
When the perforation is central and relatively small but exploration of the middle ear is desired, a transcanal approach can be used and a medial tissue graft can be employed in a manner similar to that described above for a myringoplasty; however, the graft is more precisely placed medial to the perforation than is possible when only a myringoplasty is performed. The middle ear is opened and explored using a tympanomeatal flap as previously described in Chapter 2 (see Figures 21 to 27). POSTAURICULAR MEDIAL FASCIA GRAFT TYMPANOPLASTY In my experience, when the perforation is in one or both of the posterior quadrants (including the so-called marginal perforation) of the pars tensa of the tympanic membrane, the defect can be repaired in children with a very high success rate using a medial graft and the postauricular approach. When a subtotal or total perforation is present, however, this author prefers to repair the tympanic membrane with a lateral graft, which also utilizes the postauricular approach (see Lateral Fascia Graft Tympanoplasty below). The problem of using a medial graft with these large defects, even when the middle ear is fully exposed through a postauricular approach, is securing the graft onto the anterior canal wall. Conversely, when the perforation is limited to the posterosuperior, posteroinferior, or both quadrants, a medial graft can be utilized. The graft is placed over the superior, posterior, and inferior portions of the canal wall, and also anteriorly over the malleus; the tympanic membrane remnant must be elevated off of the malleus. Thus, the medial graft will have all four portions of the graft secured. Indications Perforations limited to the posterior quadrants of the tympanic membrane Retraction pocket of the posterior quadrants that are chronic but mild (as opposed to severe), however, even these pockets are best repaired using a cartilage graft, in addition to a fascia graft (see Cartilage Graft Tympanoplasty below) Anesthetic Considerations and Preparations The anesthesia for the ear canal is shown in Figure 31, and the postauricular anesthesia is shown in Chapter 2, Figure 217. Procedure The epithelium is cleaned off the margin or rim of the perforation as shown in Chapter 1, Figure 115. The canal and postauricular incisions and approach are shown in Chapter 2, Figures 218 to 227.
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Following elevation of the tympanomeatal flap off the malleus (Figure 312A), the middle ear is filled with Gelfoam, and the fascia graft, which has been harvested from the temporalis muscle, is placed anteriorly over the malleus, and onto the superior, posterior, and inferior medial portions of the ear canal (Figure 312B).
Figure 312 A, The tympanomeatal flap is elevated and dissected off the malleus so that the graft can be placed over it and the entire middle ear can be explored. B, The fascia graft is placed medially overlying the superior, posterior, and inferior canal walls, and over the malleus.
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The tympanomeatal flap is replaced to its original position (Figure 313A), and the Koerner flap is then replaced to its original position (Figure 313B), making certain that the medial edge of the flap is not curled under, but lies completely unfurled; if it is not, a postoperative iatrogenic cholesteatoma may occur in the posterior ear canal. Gelfoam is placed lateral to the flaps in the medial one-third of the ear canal, and two adaptic (Johnson & Johnson Medical Inc, Arlington, TX) strips, impregnated with an antibiotic ointment, are inserted into the outer two-thirds of the ear canal. The postauricular wound is closed with absorbable suture and a Glasscock pressure dressing (Glasscock Ear Dressing, Oto-Med, Lake Havasu City, AZ) is then applied. Postoperative Care The postoperative care is described in Chapter 2 under Postauricular Approach.
Figure 313 A, The tympanomeatal flap is replaced. B, The Koerner flap is replaced.
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ENDAURAL MEDIAL FASCIA GRAFT TYMPANOPLASTY Attempts to close perforations in the anterosuperior portion of the pars tensa of the tympanic membrane using traditional transcanal myringoplasty or tympanoplasty procedures frequently fail because they are difficult to perform in the constricted space between the anterosuperior portion of the scutum and the malleus. Even though some surgeons have reported success using a medial graft via a postauricular approach,10 this method usually does not adequately expose the anterosuperior canal wall to enhance a complete take of the graft and closure of the perforation. This author has found the endaural approach to be the most feasible and successful method to repair perforations in the anterosuperior quadrant of the pars tensa because it provides excellent access to the area and the exposure provides an opportunity to visualize the mesotympanum as well as place a medial graft on three areas of attachment: the anterior and superior canal walls, and the malleus. In addition, the fascia graft from the temporalis muscle can be harvested from the operative site. This technique is also used to repair a retraction pocket in the anterosuperior quadrant of the pars tensa, which is usually a sequela of spontaneous extrusion of a tympanostomy tube (see Cartilage Graft Tympanoplasty below). Also, this approach is used for small congenital cholesteatomas that are in the anterosuperior portion of the mesotympanum; when there is extension into, but limited to, the anterior attic, an atticotomy can be performed (see Chapter 5). The endaural approach described below is a modification of the one originally described by Lempert.11 Indications Perforation in the anterosuperior quadrant of the pars tensa Retraction pocket in the anterosuperior quadrant of the pars tensa that is chronic but mild (as opposed to severe), but even these pockets are best repaired using a cartilage graft, in addition to a medial fascia graft (see Cartilage Graft Tympanoplasty below) Congenital cholesteatoma limited to the anterosuperior mesotympanum Anesthetic Considerations and Preparation The anesthesia and the preparations for this procedure are described in Chapter 2 under Endaural Approach.
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Procedure Perforation occurs in the anterosuperior quadrant of the pars tensa (Figure 314). The epithelium at the rim of the perforation is removed with a pick, and a cup forceps is also used (Figure 315).
Figure 314 Perforation in the anterosuperior quadrant of the pars tensa.
Figure 315 The epithelium at the rim of the perforation is dissected with a pick.
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An endaural incision and approach are completed (see Chapter 2 under Endaural Approach); the anterior relaxing incision is extended inferiorly on the anterior canal wall (Figure 316). The fascia graft is harvested from the temporalis fascia (Figure 317).
Figure 316 An endaural incision and approach are completed.
Figure 317 A fascia graft is harvested from the temporalis fascia.
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The tympanomeatal flap is elevated from the superior portion of the posterior canal wall, the superior canal wall, and the superior portion of the anterior canal wall (Figure 318). The tympanomeatal flap is elevated and dissected off the malleus; depending upon the lower extent of the perforation and the extent of the middle ear to be assessed, the flap can either be partially or totally dissected from the malleus; when totally separated from the malleus, the flap can be reflected inferiorly to visualize the mesotympanum and the rest of the ossicular chain (Figure 319).
Figure 318 The tympanomeatal flap is elevated from the canal walls.
Figure 319 The tympanic membrane is elevated, partially dissected off the malleus to the umbo, or totally off the malleus, so it can be reflected inferiorly to visualize the mesotympanum.
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A fascia graft is placed over the superior and anterosuperior canal walls and the malleus; Gelfoam fills the middle ear prior to placement of the graft (Figure 320). The tympanomeatal flap is replaced (Figure 321).
Figure 320 A fascia graft is placed over the superior and anterosuperior canal walls and the malleus.
Figure 321 The tympanomeatal flap is replaced noting that the perforation is completely covered medially by the fascia graft.
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Adaptic packing is inserted into the external canal; a layer of Gelfoam is placed over the tympanic membrane (Figure 322). The endaural incision is closed with an absorbable suture (Figure 323). Postoperative Care The postoperative care is described earlier in Chapter 2 under Endaural Approach.
Figure 322 A layer of Gelfoam is placed over the tympanic membrane, and two strips of antibiotic-impregnated adaptic packing (Johnson & Johnson Medical Inc, Arlington, TX) are inserted into the external canal.
Figure 323 The endaural incision is closed with absorbable suture.
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LATERAL FASCIA GRAFT TYMPANOPLASTY The lateral graft tympanoplasty is primarily employed to close relatively large perforations, and this author has found this method to be more successful in children than any of the medial graft techniques for subtotal or total perforations. The reason why the lateral graft technique has a better long-term success rate than the medial graft technique is wider attachment of the lateral graft to all four portions of the canal wall. Also, persistent or recurrent negative middle-ear pressure, which is usually present in children who have middle-ear disease, is probably deleterious to a medial graft during the immediate postoperative period, whereas negative middle-ear pressure is an advantage when a lateral graft is used. An additional application for the lateral graft occurs when there is generalized atelectasis of the pars tensa. This procedure uses the postauricular incision and approach, but the Koerner flap is longer than that described in Chapter 2 under Postauricular Approach. The posterior canal incision is made only a few millimeters from the annulus, because the skin adjacent to the annulus and the outer epithelial layer of the tympanic membrane are discarded; as little skin as possible is removed from the external canal, to facilitate rapid postoperative healing. The procedure is designed to create two laterally based pedicle flaps, one posterior (ie, the long Koerner flap) and one anterior. The entire external canal is exposed, which facilitates the procedure. Also, if needed, a canaloplasty can be performed. Indications Large central perforations of the pars tensa Extensive atelectasis of the pars tensa, for which most of the tympanic membrane is replaced with tissue graft Anesthetic Considerations and Preparation The anesthesia and preparations for this procedure are described in Chapter 2 under Postauricular Approach. Procedure This procedure is ideal for a large central perforation (Figure 324).
Figure 324 This is the typical size of a perforation to be repaired.
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An incision for a long Koerner flap is made closer (approximately 2 mm) to the posterior annulus than the usual incision (Figure 325). The postauricular incision and approach are completed (see Chapter 2 under Postauricular Approach), and a fascia graft is taken from the temporalis muscle (Figure 326).
Figure 325 An incision for a long Koerner flap is made closer to the posterior annulus.
Figure 326 The postauricular incision and approach are completed, and a fascia graft excised.
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A T incision is made in the postauricular soft tissue (Figure 327). A Penrose drain is placed for retraction of the Koerner flap (Figure 328).
Figure 327 A T incision in the postauricular soft tissue.
Figure 328 A Penrose drain is placed for retraction of the long Koerner flap.
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An anterior incision for the anterior flap is made approximately 2 mm lateral to the anterior annulus and is connected to the Koerner flap incision (Figure 329). If the ear canal is too narrow to visualize the anterior canal wall and annulus, a canaloplasty (primarily in the lateral portion of the posterior canal wall), using an air drill, is helpful; the canaloplasty is readily performed, since the two pedical flaps are retracted out of the field and the bony canal is completely exposed. The anterior flap is elevated, rolled, and tucked laterally out of the medial portion of the canal (Figure 330).
Figure 329 An anterior incision is made approximately 2 mm lateral to the anterior annulus.
Figure 330 The anterior flap is elevated.
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A medial strip of canal skin is adjacent to the annulus, and the entire outer epithelial layer of the tympanic membrane is elevated using a moon elevator and discarded (Figure 331). The canal wall is curetted to remove any remnants of canal skin; a microdrill is another option. When indicated, a canaloplasty can be performed at this stage (Figure 332).
Figure 331 The remaining medial strip of canal skin and the entire outer epithelial layer of the tympanic membrane are removed.
Figure 332 The canal wall is curetted to remove any remnants of canal skin.
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The annulus is elevated to examine the mesotympanum and the ossicles (Figure 333). The middle ear is filled with Gelfoam (Figure 334).
Figure 333 The annulus is elevated to examine the mesotympanum and the ossicles.
Figure 334 The middle ear is filled with Gelfoam.
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A fascia graft is placed over the tympanic membrane remnant, overlapping onto the medial canal wall; four pieces of Surgicel are placed over the edge of the graft and onto the canal wall to fix the graft (Figure 335). The anterior pedicle flap is replaced and overlaps the lateral edge of the anterior portion of the fascia graft (Figure 336).
Figure 335 A fascia graft is placed over the medial canal wall; four pieces of Surgicel (Johnson & Johnson Medical Inc, Arlington, TX) are placed over the edge of the graft and onto the canal wall.
Figure 336 The anterior pedicle flap is replaced and overlaps the outer anterior edge of the graft.
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The Penrose drain is removed, and the Koerner flap, which overlaps the lateral edge of the posterior portion of the fascia graft, is replaced (Figure 337). A layer of Gelfoam is placed over the tympanic membrane remnant and graft, and two strips of Adaptic gauze impregnated with antibiotic ointment are inserted into the external canal (Figure 338).
Figure 337 The Penrose drain is removed, and the Koerner flap is replaced.
Figure 338 A layer of Gelfoam is placed over the graft and medial portions of the two flaps, and two strips of Adaptic are inserted into the external canal.
Postoperative Care The postauricular wound is closed with an absorbable suture, and a Glasscock pressure dressing is applied. The postoperative care is described in Chapter 2 under Postauricular Approach. Postoperative blunting in the anterior sulcus and lateralization of the graft are rarely observed, but an iatrogenic implantation cholesteatoma,
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between the graft and the remnant of the tympanic membrane or in the canal wall, is not an uncommon postoperative sequela; occurrence is frequently related to the inexperience of the surgeon. When lateralization of the graft is a postoperative complication, it usually can be attributed to external otitis, otitis media, or both, that occur in the postoperative period. Compared to a medial graft, a lateral graft may require up to several months longer for the tympanic membrane to assume a normal appearance. CARTILAGE GRAFT TYMPANOPLASTY Cartilage graft tympanoplasty is indicated whenever a defect in the tympanic membrane or canal wall requires a stronger support than just a softtissue (eg, fascia) graft to prevent future retraction. A cartilage graft is required if an atticotomy is performed for a retraction pocket or cholesteatoma in the pars flaccida, which is described in detail in Chapter 5. The most common reason for requiring a cartilage graft is a retraction pocket (with or without cholesteatoma) of the tympanic membrane middle ear that is to be excised and a tympanoplasty performed. Although some surgeons favor simple excision of a retraction pocket of the pars tensa in conjunction with placement of a tympanostomy tube, persistent perforation and recurrence of the retraction pocket are potential unfavorable outcomes.12 Also, tympanostomy tube insertion does not reverse the process in the attic when the pars flaccida is involved.13,14 The cartilage graft prevents the retraction pocket (and subsequent cholesteatoma) from recurring.15 Retraction pockets can occur in any portion of the tympanic membrane, but, when not associated with a healed perforation or as a sequela of tympanostomy tube placement, they usually occur in the posterosuperior quadrant of the pars tensa or in the pars flaccida. When a retraction pocket develops at the site of a healed perforation or following extrusion (or removal) of a tympanostomy tube, the pocket can be anywhere in the pars tensa; usually a dimeric membrane is present at the site prior to the development of the retraction pocket. Retraction pockets develop in middle ears that become atelectatic, and are classified based on location, extent (localized vs. generalized), duration (acute vs. chronic), and severity (mild, moderate, or severe).16 These defects can progress into a cholesteatoma, and the two are often indistinguishable. Retraction pockets are most likely the result of two major factors: anatomy of the tympanic membrane, and eustachian tube dysfunction. A pars flaccida retraction pocket is related to the highly compliant (floppy) nature of the normal tympanic membrane in this location and to eustachian tube dysfunction. A pars tensa retraction pocket usually occurs in the posterosuperior quadrant, which is the most compliant17 because of the long distance between the attachment of the tympanic membrane to the anterior edge of the malleus and the posterosuperior portion of the annulus. Persistent high negative middle-ear pressure could cause retraction in this area, with potential adherence of the tympanic membrane to the underlying stapes and long process of the incus.
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Using the endaural approach, repair of a retraction pocket of the pars flaccida or the anterosuperior portion of the pars tensa using a cartilage graft is essentially the same as when a cholesteatoma is present in these areas, which is described in detail in Chapter 5. POSTAURICULAR MEDIAL CARTILAGE-FASCIA GRAFT TYMPANOPLASTY The most effective approach to perform a cartilage graft for a retraction pocket in the posterosuperior quadrant is postauricular. Elevation of the Koerner and tympanomeatal flaps provides adequate exposure to visualize a small retraction pocket, but if there is an extension into the facial recess and sinus tympani, as is commonly encountered, a 2.7-mm 70 Hopkins rod-lens telescope is placed in the hypotympanum to visualize these areas; the telescope is positioned in the middle ear in the area least likely to injure the ossicles, but can be rotated to inspect all areas of the middle ear. A less effective alternative is the use of the Buckingham mirror. A medial fascia graft is placed to close the defect. To prevent a recurrence of the retraction pocket, a conchal cartilage-perichondrial graft is also used, since it is in the surgical field. A tympanostomy tube is usually also inserted, since eustachian tube dysfunction has been found to be present in children who have retraction pockets.18 Indications The indications for surgical repair of a retraction pocket are as follows: Inability to fully visualize the extent of the pocket with the otomicroscope Inability to expand the pocket using the Bruening otoscope, with the nonmagnifying lens and the otomicroscope Failure to expand the pocket during nitrous oxide anesthesia Failure of the tympanic membrane at the site of the pocket to return to a normal position 2-4 weeks following the insertion of a tympanostomy tube placed in another site Recurrent or chronic infection within the pocket Difficulty in determining whether a cholesteatoma is present Anesthetic Considerations and Preparation The anesthesia and the preparations for these procedures are described in Chapter 2 under Postauricular Approach. If relatively extensive disease is anticipated, a facial nerve monitor is used during the procedure.
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Procedure A retraction pocket defect is identified in the posterosuperior quadrant of the pars tensa, with a probable extension into the facial recess and the sinus tympani (Figure 339). Using a postauricular approach (see Chapter 2), incisions for the Koerner flap are made (Figure 340).
Figure 339 Retraction pocket defect in the posterosuperior quadrant of the pars tensa; the degree of posterior extension is unknown (?).
Figure 340 Incisions for the Koerner flap.
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The postauricular approach is completed, and the Koerner flap is retracted anteriorly (Figure 341). The tympanomeatal flap and retraction pocket are elevated (Figure 342).
Figure 341 The postauricular approach is completed, and the Koerner flap is retracted anteriorly.
Figure 342 The tympanomeatal flap is elevated.
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A portion of the posterosuperior scutum is removed with a curette to visualize the ossicles and the surrounding area. The tympanic membrane and the retraction pocket are dissected from attachments medial and posterior to the annulus (Figure 343). A 2.7-mm 70 Hopkins rod-lens telescope (Hopkins-Karl Storz, Endoscopy-America Inc, Culver City, CA) is placed in the hypotympanum to visualize the facial recess and the sinus tympani for residual epithelium (Figure 344). A Buckingham mirror is used as an alternative to the telescope (Figure 345).
Figure 343 A portion of the scutum of the posterosuperior canal wall is removed with a curette to adequately visualize the posterior mesotympanum.
Figure 344 A 70 rod-lens telescope is placed in the middle ear to visualize the facial recess and the sinus tympani.
Figure 345 A Buckingham mirror can be used as an alternative to the telescope.
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A cartilage-perichondrial graft is taken from the conchal cartilage (Figure 346). The conchal cartilage graft is placed over the long process of the malleus and overlapping the posterior canal wall. A fascia graft is also used to repair the defect and is lateral to the cartilage graft, but medial to the tympanic membrane (Figure 347).
Figure 346 A portion of conchal cartilage is exposed and a cartilage-perichondrial graft is harvested.
Figure 347 The conchal cartilage-perichondrial graft is placed over the long process of the malleus, and onto the superior and posterior canal walls.
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The tympanomeatal flap is replaced. A tympanostomy tube is inserted into the tympanic membrane if eustachian tube function is still poor in order to prevent middle-ear effusion or another portion of the tympanic membrane from retracting (Figure 348). A layer of Gelfoam is placed over the tympanic membrane and graft. Two strips of Adaptic gauze impregnated with antibiotic ointment are inserted into the external canal.
Figure 348 A tympanostomy tube is inserted into the tympanic membrane.
Postoperative Care The postoperative care is the same as that described in Chapter 2 under Postauricular Approach.

REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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Saito H, Kazama Y, Yazawa Y. Simple maneuver for closing traumatic eardrum perforation by micropore strip tape patching. Am J Otol 1990;11:42730. Paparella MM. Otologic surgery in children. Otolaryngol Clin North Am 1977;10:14551. Sheehy JL, Anderson RG. Myringoplasty: a review of 472 cases. Ann Otol Rhinol Laryngol 1980;89:3314. Koch WM, Friedman EM, McGill TJI, et al. Tympanoplasty in children. The Boston Childrens Hospital Experience. Arch Otolaryngol Head Neck Surg 1990;116:3540. Smyth GD. Tympanic reconstruction. Otolaryngol Clin North Am 1972;5:11125. Shih L, de Tar T, Crabtree JA. Myringoplasty in children. Otolaryngol Head Neck Surg 1991;105:747. Tos M, Orntoft S, Stangerup SE. Results of tympanoplasty in children after 15 to 27 years. Ann Otol Rhinol Laryngol 2000;109:1723. Vrabec JT, Deskin RW, Grady JJ. Meta-analysis of pediatric tympanoplasty. Arch Otolaryngol Head Neck Surg 1999;125:5304. Bluestone CD, Klein JO. Otitis media in infants and children. WB Saunders; 2001. p. 3137. Potsic WP, Winawer MR, Marsh RR. Tympanoplasty for the anterior-superior perforation in children. Amer J Otol 1996;17:1158. Lempert J. Endaural, antauricular surgical approach to the temporal bone: principles involved in this new approach. Summary report of 1,780 cases. Arch Otolaryngol Head Neck Surg 1937;27:55587. Blaney SPA, Tierney P, Bowder DA. The surgical management of the pars tensa retraction pocket in the childresults following simple excision and ventilation tube insertion. Int J Pediatr Otorhinolaryngol 1999;50:1337. Palva T, Johnsson L-G, Ramsey H. Attic aeration in temporal bones from children with recurring otitis media: tympanostomy tubes did not cure disease in Prussaks Space. Am J Otol 2000;21:48593. Hasebe S, Takahashi H, Honjo I, Sudo M. Organic change of effusion in the mastoid in otitis media with effusion and its relation to attic retraction. Int J Pediatr Otorhinolaryngol 2000;53:1724. Gerber MJ, Mason JC, Lambert PR. Hearing results after primary cartilage tympanoplasty. Laryngoscope 2000;110:19949. Bluestone CD. Definitions, terminology, and classification. In: Bluestone CD, Rosenfeld RM, editors. Evidence-based otitis media. Hamilton, Ontario: B C Decker Inc; 1999. p. 946. Khanna SM, Tonndorf J. Tympanic membrane vibration in cats studied by time-averaged holography. J Acoust Soc Am 1972;51:190420. Chan KC, Sculerati N, Casselbrant ML, et al. Comparison of eustachian tube function tests between children with cholesteatoma/retraction pocket and those with chronic otitis media with effusion. In: Tos M, Thomsen J, Peitersen E, editors. Cholesteatoma and Mastoid Surgery; 1989; Amsterdam: Kugler & Ghedini; 1989. p. 4857.
12.
13.
14.
15. 16. 17. 18.
CHAPTER 4
O SSICULOPLASTY
James S. Batti, MD Charles D. Bluestone, MD
This chapter reviews methods for reconstructing the ossicular chain from tympanic membrane to oval window, with emphasis on specific techniques for children with ossicular fixation or discontinuity. Information is also provided regarding outcomes and prognostic factors, with the caveat that most published data relate to adults. Lastly, the major reasons for failure are discussed and the current knowledge of ossiculoplasty in children is summarized.
OSSICULAR RECONSTRUCTION Etiology of Ossicular Abnormalities Ossicular-related causes of conductive hearing loss can be congenital or acquired, and are mainly due to discontinuity or fixation: Ossicular discontinuity occurs in the following scenarios presented in order of decreasing frequency: eroded incudostapedial joint, absent incus, absent incus and stapes superstructure, and absent incus and stapes including the footplate.1 Austin2 defined four groups in the absence of an intact incus: (1) malleus handle present, stapes superstructure present, (2) malleus handle present, stapes superstructure absent, (3) malleus handle absent, stapes superstructure present, and (4) malleus handle absent, stapes superstructure absent. Ossicular fixation most commonly occurs when the malleus head is ankylosed to the attic wall or when tympanosclerosis of the attic is present. Kartush3 modified Austins classification of ossicular defects by adding two other groups related to ossicular fixation: (1) ossicle head fixation with all ossicles present, and (2) stapes fixation with all ossicles present. Moretz4 added still another category, nonclassifiable, to describe unusual situations requiring ossiculoplasty that are not easily included in the other categories. These include lateralized tympanic membrane and some congenital abnormalities.
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Options for Ossicular Reconstruction The many options for ossicular chain reconstruction can be classified into three groups: 1. Autograft prostheses include tissue harvested from the patient and used for reconstructing the ossicular chain. Examples include the patients own ossicles or cartilage. 2. Homograft prostheses are derived from human donor tissue, screened and treated to avoid transmission of disease, and preserved for later use. Examples include tympanic membrane, ossicles, and cartilage. 3. Allograft prostheses are synthetic and biocompatible. Examples include high density polyethylene sponge (Plasti-Pore), aluminum oxide, ceramic, and hydroxyapatite.5 Recommended methods of ossicular chain reconstruction are listed in Tables 41 to 43. Many of the preferred methods attempt to utilize the patients own tissue; however, when this is not possible, prosthetic devices can be used depending on the remaining ossicle(s). Prosthetic devices are classified according to the desired reconstruction: Incus prostheses are used when the malleus and stapes are present. Incus-stapes prostheses are used when the stapes footplate is present along with an intact malleus. Partial ossicular replacement prostheses (PORPs) are used when the stapes superstructure is intact. Total ossicular replacement prostheses (TORPs) are used when only the stapes footplate is available.
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Table 41 Reconstructive options for ossicular chain discontinuity with ossicles present
Site of discontinuity Recommended reconstructive options
Tympanic membrane / malleus Malleus / incus Incus / stapes Stapes superstructure / footplate Stapes footplate / oval window
Advancement flap Incus interposition Incus interposition Cartilage autograft Mobilization Stapedectomy, tissue graft, and prosthesis
Table 42 Reconstructive options for ossicular chain discontinuity with ossicles absent
Absent ossicle(s) Recommended reconstructive options
Malleus Incus
Autograft incus Type II tympanoplasty* Autograft cartilage Incus prosthesis Type III tympanoplasty* Autograft incus Incus-stapes prosthesis Autograft cartilage Type III tympanoplasty* PORP Autograft cartilage Incus-stapes prosthesis Autograft cartilage TORP
Stapes superstructure Malleus and incus
Incus and stapes superstructure Malleus, incus, and stapes superstructure
PORP = partial ossicular replacement prosthesis; TORP = total ossicular replacement prosthesis * See Chapter 3
Table 43 Reconstructive options for ossicular chain fixation

Site of fixation Recommended reconstructive options
Malleus / incus Incus / stapes Stapes superstructure / footplate Stapes footplate / oval window
Incus interposition Mobilization Incus interposition Mobilization Mobilization Stapedectomy with prosthesis Mobilization Stapedectomy with prosthesis
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ADVANCEMENT FLAP Indications Lateralized tympanic membrane following any method of tympanoplasty, but more often following the lateral graft technique (see Chapter 3 under Tympanoplasty) Anesthetic Considerations In children, the procedure is performed under general anesthesia. Local anesthetic (1% lidocaine with 1:100,000 epinephrine) is infiltrated into all four quadrants of the ear canal (6, 9, 12, and 3 oclock) just lateral to the bony-cartilaginous junction for hemostasis and to enhance the anesthesia. Procedure Coronal view demonstrating the lateralized tympanic membrane (Figure 41). A transcanal incision is made just medial to the bony-cartilaginous junction (Figure 42A). The wide tympanomeatal flap is elevated (Figure 42B). The middle ear is entered by elevating the annulus (Figure 43A). The tympanomeatal flap and lateralized tympanic membrane are elevated to expose the entire middle ear space; the flap is attached only to the anterior canal wall (Figure 43B).
Figure 41 Advancement flap for lateralized tympanic membrane. Coronal view showing that the grafted tympanic membrane does not connect to the malleus, which usually results in mild to moderate conductive hearing loss.
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Figure 42 A, A wide tympanomeatal flap incision (dashed line) is made just medial to the bony-cartilaginous junction (right ear). B, The tympanomeatal flap is elevated.
Figure 43 A, Middle ear is entered. B, Tympanomeatal flap and lateralized tympanic membrane are elevated to expose the entire middle ear; the flap is only attached to the anterior canal wall.
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The tympanomeatal flap is advanced medially against the malleus, leaving bare bone in the ear canal medial to the bony-cartilaginous junction (Figure 44). Gelfoam is placed lateral to the flap and two strips of Adaptic (with antibiotic ointment) are inserted into the medial and lateral canal as packing (Figure 45). An addition to the method described above is to incise part of the tympanomeatal flap and insert the handle of the malleus through the incision. This holds the flap against the malleus, but the incision is generally unnecessary if the packing in the external canal rests firmly against the flap. Postoperative Care The packs are removed in 1 week, and the child is re-examined in about 1 month.
Figure 44 Tympanomeatal flap is advanced medially against the malleus, which leaves exposed bone in the canal wall medial to the bony-cartilaginous junction.
Figure 45 Coronal view showing tympanomeatal flap advanced onto the tympanic membrane; Gelfoam is placed lateral to the flap and two strips of Adaptic (with antibiotic ointment) are inserted into the medial and lateral ear canal.
Ossiculoplasty
INCUS INTERPOSITION
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Indications The most commonly encountered abnormality with the ossicular chain involves the incus. The incus interposition procedure can be utilized when there is either discontinuity or fixation involving the incudomalleal or incudostapedial joint. Anesthetic Considerations The anesthesia is the same as that described for the advancement flap. Procedure A transcanal incision is made just medial to the bony-cartilaginous junction (see Figure 42A). The wide tympanomeatal flap is elevated (see Figure 42B). The middle ear is entered by elevating the annulus (see Figure 43A). Utilizing a right angle or curved needle, the incus is disarticulated from any remaining attachments in the attic. The incus is removed and sculpted (Figure 46A). A groove for the malleus handle is created in the articulating surface of the incus body. The facet for the stapes is then created in the body of the incus near its junction with the long process. The incus is inserted between the malleus and stapes superstructure, completing the interposition (Figure 46B). Gelfoam is placed lateral to the flap and the ear canal is filled with antibiotic ointment. Postoperative Care After an initial postoperative visit, the child is followed up in 1 month.
Figure 46 Incus interposition. A, The incus is removed and sculpted. B, The sculpted incus is inserted between the malleus and head of the stapes.
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PARTIAL OSSICULAR REPLACEMENT PROSTHESIS (PORP) Indications Ossicular chain abnormality in which an intact stapes superstructure is bridged with a synthetic biocompatible prosthesis to the tympanic membrane, graft, or malleus Anesthetic Considerations The anesthesia is the same as that described for the advancement flap. Procedure A transcanal incision is made just medial to the bony-cartilaginous junction (see Figure 42A). The wide tympanomeatal flap is elevated (see Figure 42B). The middle ear is entered by elevating the annulus (see Figure 43A). The PORP is inserted on the stapes (Figure 47). A notch can be made in the prosthesis to secure the PORP and accommodate the stapedial tendon. A cartilage graft can be placed lateral to the prosthesis to aid in prevention of extrusion of the prosthesis. Gelfoam is placed lateral to the flap and the ear canal is filled with antibiotic ointment. Postoperative Care After an initial postoperative visit, the child is followed up in 1 month. A postoperative audiogram is obtained in 2-3 months.
Figure 47 Placement of a partial ossicular replacement prosthesis (PORP). A, Surgeons view of PORP in place. B, Lateral view of the PORP positioned on the stapes head.
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TOTAL OSSICULAR REPLACEMENT PROSTHESIS (TORP) Indications Ossicular chain abnormality in which an intact stapes footplate is bridged with a synthetic biocompatible prosthesis to the tympanic membrane, graft, or malleus Anesthetic Considerations The anesthesia is the same as that described for the advancement flap. Procedure A transcanal incision is made just medial to the bony-cartilaginous junction (see Figure 42A). The wide tympanomeatal flap is elevated (see Figure 42B). The middle ear is entered by elevating the annulus (see Figure 43A). The TORP is inserted on the stapes footplate (Figure 48).
Figure 48 Placement of a total ossicular replacement prosthesis (TORP). A, Surgeons view of TORP in place. B, Lateral view of the TORP positioned on the stapes footplate.
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A cartilage graft is placed between the TORP and tympanic membrane to reduce the chance of extrusion (Figure 49). Gelfoam is placed lateral to the flap and the ear canal is filled with antibiotic ointment. Postoperative Care After an initial postoperative visit, the child is followed up in 1 month. A postoperative audiogram is obtained in 2-3 months.
Figure 49 Cartilage graft between the TORP and tympanic membrane.
Ossiculoplasty
OUTCOMES AND PROGNOSTIC FACTORS
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Table 44 presents a summary of the published data on hearing level and extrusion rate outcomes for various methods of ossicular reconstruction.2,521 Several trends are apparent. Successful closure of the air-bone gap to less than 20 dB hearing level is achieved by less than 80% of authors, with TORP results being generally poorer than those for PORP or incus interposition. Furthermore, hearing results tend to worsen with time in nearly all studies that reported serial outcome data. This observation, combined with the nontrivial extrusion rates in some studies, suggests a need for long-term follow-up of all patients after ossiculoplasty. Several prognostic factors for ossiculoplasty success have been reported. Bellucci22 noted a relationship between outcomes and middle-ear status (never infected, intermittent discharge, unremitting discharge, and cleft palate or nasopharyngeal deformity) and Austin2 emphasized the availability of the malleus handle and stapes superstructure. Black23 proposed a combined system using the acronym SPITE for preoperative predictive factors of poor outcome: (S) Surgical complexity of surgery; necessity of scutum and drum repair (P) Prosthetic absence of malleus or stapes; presentation of a 50 dB airbone gap (I) Infection chronic otorrhea; myringitis (T) Tissue poor general condition of tissue, referring to extremes of youth (under 5 years) or advanced age (over 70 years); meatoplasty required; poor mucosa of the middle ear (E) Eustachian tube dysfunctioneustachian tube dysfunction / middleear effusion present; severely collapsed tympanic membrane Factors that failed to show statistically significant adverse effects in audiologic results included any prior failed surgery, scutum defect repair without tympanic membrane repair, myringoplasty, and staged surgery. Loss of the stapes superstructure was found by both Mills24 and Smyth and Patterson25to be associated with a poorer outcome in ossiculoplasty. In order to achieve success in ossiculoplasty, Smyth and Patterson25 concluded that the average postoperative air conduction over the speech frequencies (0.5, 1.0, 2.0, and 4.0 kHz) must be < 30 dB, or the interaural difference must be reduced to < 15 dB. Fifteen dB corresponds to the cross-attenuation effect of the skull.26 If these criteria are not met, the patient will likely be unaware of any audiometric improvement. Reasons for Ossiculoplasty Failure Ossiculoplasty failure may occur because of problems with the prosthesis, middle ear, or eustachian tube. A common cause of ossiculoplasty failure is inadequate contact between the prosthesis and the graft, which may be caused by sliding or reabsorption of the cartilage. Additional causes of functional failure include: (1) improperly sized prosthesis (too short), (2) sliding of the prosthesis, (3) fracture of the stapes crura, and (4) contraction and movement of the healing tympanic membrane. Each of these results in poor contact between the footplate and the graft.27
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Table 44 Clinical outcomes of ossicular reconstruction

Achievement rate of hearing levels < 20 dB (%) Type of prosthesis First author of paper After ! 1 year After > 1 year Extrusion rate (%)
Autograft Incus interposition PORP Incus replacement, hydroxyapatite Incudostapedial joint Plasti-Pore
Nikolaou6 Jackson7 Grote8 Wehrs9 Schwetschenau10 Colletti11 Bayazit12 Goldenberg13 Jackson7 Brackmann14 Smyth15 Slater16 Nikolaou6 Daniels17 Nikolaou6 Chole5 Macias Chole5 Black19 Chole5 Grote8 Colletti11 Brackmann20 Goldenberg13 Bayazit12 Nikolaou6 Slater16 Nikolaou6 Chole
5 5 18
74 68 85 77 63 49 73 81 40 78 89 43 71 50 68 84 43 61 68 65 30 73 75 61
83 91 48 73 43 75 89 65 48 0 76 46 55 54 65 21 71 60 55
13 0 0 4 6 10 7 11 1 50 0 5 0 4 4 7 4 0 23 8 4 14 1 9 4 0 0 0 2
Polyethylene
Ceramic Cartilage Hydroxyapatite and Plasti-Pore TORP Incus / stapes, hydroxyapatite and Plasti-Pore Incus / stapes, hydroxyapatite Plasti-Pore
Polyethylene Ceramic Cartilage Hydroxyapatite and Plasti-Pore Malleus / footplate, hydroxyapatite TM / footplate, hydroxyapatite Hydroxyapatite and fluoroplastic
Chole Macias18 Colletti21 Colletti21 Daniels17
PORP = partial ossicular replacement prosthesis; TM = tympanic membrane; TORP = total ossicular replacement prosthesis
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Middle-ear disease may also cause ossiculoplasty failure. There are many uncertainties in the hostile biological environment associated with surgery for chronic ear diseasemucosal disease, middle-ear adhesions, and eustachian tube dysfunctionthat contribute to failure of the surgery. These abnormalities promote middle-ear effusion, retraction of the tympanic membrane, atelectasis of the middle ear, and extrusion of the graft or prosthesis. Perforation of the tympanic membrane, with or without extrusion of the prosthesis, may also occur. Eustachian tube dysfunction is also a common cause of tympanic membrane perforation and prosthesis extrusion, because of graft retraction and increased tension against the prosthesis. Sustained tension may break the prosthesis, or result in partial or complete extrusion. One proposed method to decrease failure is to cut the tensor tympani tendon during ossicular reconstruction. This may flatten and slightly lateralize the tympanic membrane, thereby facilitating placement of the prosthesis and decreasing the tendency of the tympanic membrane to medialize in patients with eustachian tube dysfunction.16 RECOMMENDATIONS FOR OSSICULOPLASTY IN CHILDREN Few studies of ossicular reconstruction in children have been reported. Silverstein et al28 reported 18 cases using Plasti-Pore PORPs and TORPs, but obtained poor results with a 44% failure rate and 17% extrusion rate. Conversely, Sheehy29 and Kessler et al30 reported using PORPs and TORPs in children with success rates similar to those in adults. In Kesslers study, for example, the mean patient age was 9.8 years and hearing results of an airbone gap < 20 dB were noted in 54% of cases with an extrusion rate of 13%. Tos and Lau31 evaluated autografts and homografts in children and found 58% had hearing results of an air-bone gap < 20 dB which remained stable. Due to the lack of long-term use of middle-ear prostheses in children, autograft materials are primarily used to reconstruct the ossicular chain whenever possible.32 The most effective method of managing ossicular chain abnormalities is disease prevention, ie, tympanic membrane retraction treated with placement of a ventilation tube, cartilage graft, or both (see Chapters 1 and 3). The hesitancy to perform ossiculoplasty in children is primarily related to eustachian tube dysfunction with difficulty in controlling middle-ear disease and cholesteatoma. With some reported failure rates higher in children than in adults, many argue that ossicular reconstruction should be be postponed.10 The principles of successful tympanoplasty, however, are similar for adults and children. Once the childs ear is made safe and stable, ossicular reconstruction is the next goal and completes the restoration of normal middle-ear function. Some claim that children differ only in that they may be more likely to require postsurgical tympanostomy tube insertion to maintain a stable ear.31,33 Despite a paucity of studies that have evaluated short- and long-term outcomes of ossiculoplasty in children, the surgeon must have some guidelines for procedure timing. A useful rule of thumb is that eustachian tube function may be considered adequate for ossiculoplasty when there has
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been no otitis media (in an ear with an intact tympanic membrane) for at least four consecutive seasons (12 months). This should minimize the incidence of postoperative atelectasis or middle-ear effusion, which can result in failure or extrusion. Similarly, ossicular reconstruction in children who have had a cholesteatoma removed from the middle ear is usually withheld until the middle ear is found to be free of disease (eg, at the time of second look tympanotomy), because residual or recurrent cholesteatoma at the site of the reconstruction will usually result in failure of the graft or prosthesis. Nonetheless, the timing and treatment option chosen should be individualized for each child.
REFERENCES
1. 2. 3. 4. 5. 6. Hough J. Incudostapedial joint separation: etiology, treatment and significances. Laryngoscope 1959;69:64453. Austin DF. Ossicular reconstruction. Otolaryngol Clin North Am 1972;5:14560. Kartush JM. Ossicular chain reconstruction: capitulum to malleus. Otolaryngol Clin North Am 1994;27:689715. Moretz WH Jr. Ossiculoplasty with an intact stapes: superstructure versus footplate prosthesis placement. Laryngoscope 1998;108:112. Chole RA, Skarada DJ. Middle ear reconstructive techniques. Otolaryngol Clin North Am 1999;32:489503. Nikolaou A, Bourikas Z, Maltas V, Aidonis A. Ossiculoplasty with the use of autografts and synthetic prosthetic materials : a comparison of results in 165 cases. J Laryngol Otol 1992;106: 6924. Jackson CG, Glasscock ME III, Nissen AJ, et al. Ossicular chain reconstruction: the TORP and PORP in chronic ear disease. Laryngoscope 1983;93:9818. Grote J. Reconstruction of the middle ear with hydroxyapatite implants: long-term results. Ann Otol Rhinol Laryngol 1990;144 Suppl:126. Wehrs RE. Incus interposition and ossiculoplasty with hydroxyapatite prostheses. Otolaryngol Clin NA 1994;27:67788. Schwetschenau EL, Isaacson G. Ossiculoplasty in young children with the Applebaum incudostapedial joint prosthesis. Laryngoscope 1999;109:16215. Colletti V, Fiorino FG, Sittoni, V. Minisculptured ossicle grafts versus implants: long-term results. Am J Otol 1987;8:5539. Bayazit Y, Goksu N, Beder L. Functional results of Plasti-Pore prostheses for middle-ear ossicular chain reconstruction. Laryngoscope 1999;109:70911. Goldenberg RA. Hydroxylapatite ossicular replacement prostheses: preliminary results. Laryngoscope 1990;100:693700. Brackmann DE, Sheehy JL, Luxford WM. TORPs and PORPs in tympanoplasty: a review of 1042 operations. Otolaryngol Head Neck Surg 1984;92:327. Smyth GD. Five year report on partial ossicular replacement prostheses and total ossicular replacement prostheses. Otolaryngol Head Neck Surg 1982;90:3436. Slater PW, Rizer FM, Schuring AG, Lippy WH. Practical use of total and partial ossicular replacement prostheses in ossiculoplasty. Laryngoscope 1997;107:11938.
7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
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17. Daniels RL, Rizer FM, Schuring AG, Lippy WL. Partial ossicular reconstruction in children: a review of 62 operations. Laryngoscope 1998;108:167481. 18. Macias JD, Glasscock ME III, Widick MH, et al. Ossiculoplasty using the Black hydroxyapatite hybrid ossicular replacement prostheses. Am J Otol 1995;16:71821. 19. Black B. Design and development of a contoured ossicular replacement prosthesis: clinical trials of 125 cases. Am J Otol 1990;11:859. 20. Brackmann DE, Sheehy JL. Tympanoplasty with TORPs and PORPs. Laryngoscope 1979;89:10814. 21. Colletti V, Fiorino FG. Malleus to footplate prosthetic interposition: experience with 265 patients. Otolaryngology Head Neck Surg 1999;120:43744. 22. Bellucci RJ. Dual classification of tympanoplasty. Laryngoscope 1973;83:17548. 23. Black B. Ossiculoplasty prognosis: the SPITE method of assessment. Am J Otol 1992;13:54451. 24. Mills RP. The influence of pathological and technical variables on hearing results in ossiculoplasty. Clin Otolaryngol Allied Sciences 1993;18:2025. 25. Smyth GD, Patterson CG. Results of middle ear reconstruction: do patients and surgeons agree? Am J Otol 1985;6:2769. 26. Browning G. Clinical Otology and Audiology. London, England: Butterworths; 1986. 27. Sellari-Franceschini S, Piragine F, Bruschini P, Berrettini S. TORPS and PORPS: causes of failure. Am J Otol 1987;8:5512. 28. Silverstein H, McDaniel AB, Lichtenstein R. A comparison of PORP, TORP, and incus homograft for ossicular reconstruction in chronic ear surgery. Laryngoscope 1986;96:15965. 29. Sheehy JL. Cholesteatoma surgery in children. Am J Otol 1985;6:1702. 30. Kessler A, Potsic WP, Marsh RR. Total and partial ossicular replacement prostheses in children. Otolaryngol Head Neck Surg 1994;110:3023. 31. Tos M, Lau T. Stability of tympanoplasty in children. Otolaryngol Clin N Am 1989;22:1528. 32. Bluestone CD, Stool SE, Kenna M. Pediatric Otolaryngology. 3rd ed. Philadelphia: WB Saunders; 1996. 33. Chandrasekhar SS, House JW, Devgan U. Pediatric tympanoplasty. A 10 year experience. Arch Otolaryngol Head Neck Surg 1995;121:8738.
CHAPTER 5
M ASTOIDECTOMY AND C HOLESTEATOMA

In the first section of this chapter, I describe my indications and surgical technique for mastoidectomy. In the next section, I describe specific surgical procedures for cholesteatoma (depending upon the site and extent of the disease), which may or may not include a mastoidectomy.
MASTOIDECTOMY Many procedures include a mastoidectomy, but the most common indications in infants and children are mastoiditis (acute and chronic), cholesteatoma, or coexistence of these diseases. There are three traditional procedures: 1. Simple (cortical, complete) mastoidectomy 2. Modified radical mastoidectomy 3. Radical mastoidectomy A fourth procedure, tympanomastoidectomy, combines the simple mastoidectomy with a middle-ear procedure, maintaining the posterior and superior canal walls. The basic steps in performing the three standard mastoidectomy procedures are described below. The approach in all cases is postauricular (see Chapter 2), and intraoperative monitoring of facial nerve function is used routinely.1 SIMPLE (CORTICAL, COMPLETE) MASTOIDECTOMY A simple or complete mastoidectomy, which is more appropriately called a cortical mastoidectomy, is indicated for acute mastoid osteitis.2,3 An important distinction is acute mastoiditis without osteitis (with or without periosteitis), which generally does not require surgical management. When surgery is needed, the term acute coalescent mastoiditis is commonly
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used, but a more consistent term related to the underlying pathology is acute mastoid osteitis. The term acute surgical mastoiditis is also used, but again does not appropriately describe the pathology. Another indication for cortical mastoidectomy, which is more common in the antibiotic era than acute mastoid osteitis, is in conjunction with surgery for middle-ear disease. When performed in this manner, the procedure becomes a canal wallup tympanomastoidectomy (see Tympanomastoidectomy later in this chapter). Indications Acute mastoid osteitis, with or without subperiosteal abscess (or other extensions into the temporal bone and deep neck) Chronic suppurative otitis media (and mastoiditis), when nonsurgical management fails Cholesteatoma (with or without chronic suppurative otitis media), when the cholesteatoma extends into the mastoid gas cells (see Cholesteatoma later in this chapter) Cochlear implant, in which a posterior tympanotomy is part of the procedure (see Chapter 9) Other reasons, such as facial nerve decompression, translabyrinthine labyrinthectomy, neoplasm, and mastoid trauma, which are relatively uncommon indications in infants and children Anesthetic Considerations The anesthesia and the preparation for this procedure are described in Chapter 2. Procedure A postauricular approach and a drill are used to uncover the mastoid antrum (Figure 51). The mastoid antrum is identified (Figure 52).
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Figure 51 A postauricular approach and drill are used to uncover the mastoid antrum.
Figure 52 The mastoid antrum is identified.
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A curette removes the thinned bone over the incus (Figure 53); drilling at this stage could injure the incus and result in conductive, sensorineural (due to acoustic trauma), or mixed hearing loss. Dissection is complete when the anterior epitympanum, zygomatic cells, body of the incus, and head of the malleus are identified (Figure 54), and there is free flow of the irrigant from the mastoid into the middle ear. Specimens for culture and antibiotic susceptibility are taken from the mastoid mucosa and bone, and also from the middle ear and mastoid purulent material. A tympanostomy tube (with or without the addition of a wide-field myringotomy) is placed when acute mastoid osteitis is an indication for surgery (Figure 55). The postauricular wound is closed with an absorbable suture. The need for drainage, if any, relates to the primary indication for surgery:
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For acute mastoid osteitis, a plastic drain with holes cut into the portion that lies within the mastoid cavity, is placed in the mastoid cavity (Figure 56). For chronic suppurative otitis media, a rubber band or Penrose drain is used. For cholesteatoma, without acute or chronic infection, placement of a drain is optional.
When the procedure is performed for acute mastoid osteitis, no packing is inserted into the external canal. Postoperative Care The child is maintained on intravenous antimicrobial therapy, which can be adjusted after the results of the culture and susceptibility studies are available. The drain is removed when there is no further drainage from the wound. The child can be discharged on a culture-directed, oral antimicrobial agent when afebrile and when there is no further discharge from the middle ear or mastoid wound.
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Figure 53 A curette removes the thinned bone over the incus.
Figure 54 Dissection is complete when the epitympanum, zygomatic cells, and heads of the incus and malleus are identified.
Figure 55 Tympanostomy tube and wide-field myringotomy.
Figure 56 The postauricular wound is closed with an absorbable suture and drain is inserted.
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MODIFIED RADICAL MASTOIDECTOMY A modified radical mastoidectomy is most commonly performed for congenital or acquired cholesteatoma, chronic suppurative otitis media with mastoiditis, or both. The mastoid cavity, the epitympanum, and the external canal are exteriorized into a common cavity, but the tympanic membrane is either maintained or grafted. In a study of 232 Pittsburgh children with cholesteatoma, there were 244 surgical procedures, of which 24% were modified radical mastoidectomies.4 A Bondy modified radical mastoidectomy was performed in selected cases (eg, small, constricted mastoid) in which cholesteatoma was localized to the epitympanum and lateral to the ossicles. Today, however, a canal wallup tympanomastoidectomy, if possible, is preferred over a modified radical mastoidectomy for cholesteatoma (see Cholesteatoma later in this chapter). When chronic suppurative otitis media and mastoiditis fail to improve following intensive medical management, a tympanomastoidectomy is usually the next step in management (see Tympanomastoidectomy later in this chapter).5 If, during surgery, there appears to be a persistent obstruction between the middle ear and the mastoid cavity when the simple mastoidectomy is completed (ie, irrigation fluid fails to flow freely between the two areas), then the canal wall may have to be removed and the operation converted into a modified radical mastoidectomy. An alternative would be a posterior tympanotomy approach to the facial recess, but this technique is not as effective in controlling and preventing the infection as removing the canal wall. An alternative to removing the posterior canal wall in a child would be to remove the incus. Neither removal of the posterior canal wall nor the incus is desirable in a child, thus the surgeon should make every effort to be conservative by removing as much disease (eg, granulation tissue) as possible from the facial recess and attic, to promote adequate drainage from the aditus ad antrum and mastoid into the middle ear. Indications Cholesteatoma: When the disease extends to the mastoid air cells and cannot be effectively managed using the more preferred method of an intact canal wallup tympanomastoidectomy (see Cholesteatoma later in this chapter) Chronic suppurative otitis media and mastoiditis: When nonsurgical methods fail and a simple mastoidectomy will most likely be, or has been, unsuccessful in providing adequate aeration between the middle ear and the mastoid cavity Anesthetic Considerations and Preparation The anesthesia and the preparation for this procedure have been described in Chapter 2 under Postauricular Approach. When chronic suppurative disease (with or without cholesteatoma) is present, perioperative antimicrobial therapy is usually administered; an agent effective against Pseudomonas aeruginosa is usually recommended, because it is the most commonly isolated organism.
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Procedure A simple mastoidectomy is usually performed first (Figure 57). The posterior canal wall is taken down to the facial ridge (Figure 58). The tympanic membrane is replaced (Figure 59); the epitympanum and the mastoid cavity are exteriorized.
Figure 57 A complete simple mastoidectomy is usually performed first.
Figure 58 The posterior canal wall is taken down to the facial ridge.
Figure 59 The tympanic membrane is replaced.
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In children, the mastoid cavity is usually not grafted or obliterated because residual disease may be obscured, and the cavity frequently becomes smaller with advancing age. A layer of Gelfoam is placed on the tympanic membrane/graft, and two strips of Adaptic gauze (Johnson & Johnson Medical, Inc, Arlington, TX) are lightly packed into the external canal; the mastoid cavity may or may not require packing depending upon the degree of bleeding encountered when performing the mastoidectomy. A drain in the postauricular wound is usually unnecessary, since the mastoid (and the wound) is in continuity with the external canal. Postoperative Care The postoperative care is similar to that described for the Postauricular Approach discussed in Chapter 2. When the indication is chronic suppurative otitis media and mastoiditis, perioperative and postoperative intravenous antimicrobial therapy is usually administered. Cavity care is more difficult in the infant and young child, and the procedure may have to be performed in the operating room with the patient under general anesthesia, especially when residual cholesteatoma is present. Thus, one of the goals of cholesteatoma surgery at this age should be to make every effort to avoid a cavity by preserving the canal wall (see Cholesteatoma later in this chapter). RADICAL MASTOIDECTOMY Radical mastoidectomy creates a common cavity that consists of the middle ear, epitympanum, mastoid cavity, and external canal. The operation is not performed as frequently today as it was in the preantibiotic era; however, it is performed when extensive cholesteatoma, which cannot be controlled with a less radical procedure, is present. In children, an extensive rapidly growing cholesteatoma is not uncommon, and radical mastoidectomy is still performed in selected cases. In our series of 244 surgical procedures for cholesteatoma, 26% were radical mastoidectomies.4 In the past, radical mastoidectomy was advocated when a suppurative intracranial complication developed in a patient who had acute or chronic otitis media and mastoiditis, but today, a lesser procedure is usually safe and effective in individualized patients, especially when cholesteatoma is absent. Even when cholesteatoma is present, the availability of the telescope frequently allows a canal wallup tympanomastoidectomy, which is a more desirable procedure in children than a radical mastoidectomy (see Cholesteatoma later in this chapter). Closure of the eustachian tube at the bony (protympanic) portion can prevent troublesome postoperative recurrent or chronic otorrhea caused by reflux of nasopharyngeal secretions (see Chapter 6). This author does not routinely perform this part of the procedure, because all patients do not have postoperative drainage. Moreover, future reconstruction of an aerated middle-ear space may not be possible unless a tympanostomy tube is inserted or a perforation is present in the reconstructed tympanic membrane.
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Indications Extensive congenital or acquired cholesteatoma, when a less radical procedure is not possible. For suppurative intracranial complications of cholesteatoma, on an individualized basis, or for selected children who have chronic suppurative otitis media (and mastoiditis), when a less radical procedure (eg, canal wallup tympanomastoidectomy) is not likely to control the disease process. Anesthetic Considerations and Preparation When suppurative disease is present within the middle-ear cleft, intravenous antimicrobial therapy is frequently administered perioperatively (and postoperatively) and should be given when there is a suppurative complication of middle-ear mastoid disease. The anesthesia and preparation for this procedure are the same as described earlier in this chapter. If an intracranial procedure is to be performed in conjunction with the mastoidectomy, the patient should also be prepared for that procedure. Procedure The posterior external auditory canal is taken down and a facial ridge is created as in a modified radical mastoidectomy (Figure 510). The tympanic is removed. Removal of the malleus and incus is included in the classic operation, but depends upon the extent of the disease (Figure 511). A meatoplasty, in which soft tissue and a portion of conchal cartilage are removed through the postauricular wound, is usually performed. Postoperative Care The postoperative care is similar to that described above following a modified radical mastoidectomy.
Figure 510 The posterior ear canal is taken down, and a facial ridge is created.
Figure 511 The tympanic membrane, malleus, and incus are removed.
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TYMPANOMASTOIDECTOMY A tympanomastoidectomy combines a simple mastoidectomy with a middle-ear surgical procedure, which frequently includes a tympanoplasty, ie, tympanomastoidectomy with tympanoplasty. The goals of this procedure, in addition to eradication of the disease, are to maintain an intact canal wall, and to maintain, or reconstruct, the tympanic membrane and ossicular chain. For children, this procedure should be the goal of the operation, since it is much more desirable than a radical modified radical mastoidectomy. Tympanomastoidectomy is used when chronic suppurative otitis media (and mastoiditis), or cholesteatoma, or both, are present (see Cholesteatoma later in this chapter). When chronic suppurative otitis media (without cholesteatoma) is unresponsive to medical management, including intravenous antimicrobial therapy, a tympanomastoidectomy is indicated, which includes a simple mastoidectomy (see Simple Mastoidectomy above).5 The middle ear is entered as described in Chapter 2 under Postauricular Approach. CHOLESTEATOMA Classification and Etiology Aural cholesteatoma can be congenital or acquired. Congenital cholesteatoma is caused by a congenital rest of epithelial tissue within the middle ear (including intratympanic), or in other portions of the temporal bone, which may appear as a white cyst-like structure or as sheets of tissue. The tympanic membrane is usually intact, and the cholesteatoma is apparently not a sequela of otitis media or eustachian tube dysfunction; however, Tos6 recently proposed that a congenital cholesteatoma may be acquired and may be a sequela of otitis media. The most common site of congenital cholesteatoma, in the early phase, is within the middle ear in the anterosuperior quadrant of the mesotympanum. Disease frequently extends into the anterior attic, or into the posterosuperior portion of the mesotympanum, and can also invade the facial recess, sinus tympani, and the attic. Also, the site can be in the posterosuperior portion of the mesotympanum. More advanced congenital middleear cholesteatoma can extend into the aditus ad antrum, mastoid, petrous apex, labyrinth, and can even spread outside the temporal bone, such as into the intracranial cavity. The tympanic membrane may not be intact if the disease is extensive. Acquired cholesteatoma can be a sequela of middle-ear disease or may arise from implantation of epithelium, caused by trauma or surgery (ie, iatrogenic) of the middle ear (including the tympanic membrane), ear canal, or mastoid. Acquired cholesteatoma can be present anywhere in the middleear cleft, can extend to any portion of the temporal bone, and can spread outside the temporal bone. Often the cause of the cholesteatoma, either congenital or acquired, is uncertain, especially when the disease is far advanced and the tympanic membrane is not intact. Of 232 children operated on at the Childrens Hospital of Pittsburgh between 1973 and 1990, 43 (18%) had a congenital cholesteatoma (excluding intratympanic), 83 (36%) had an acquired cholesteatoma, and in 106 (46%) children, the cholesteatoma could not be distinguished as
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either congenital or acquired.4 Of 59 children who had a cholesteatoma treated in Switzerland between 1981 and 1996, 18 (29%) were congenital and 41 (71%) were acquired.7 Cholesteatoma Surgery in Children vs. Adults The ideal goals of surgery for cholesteatoma in children are similar to those in adults: 1. Eradicate disease 2. Preserve or reconstruct the anatomic structures 3. Preserve or restore hearing 4. Prevent residual and recurrent disease Many surgical procedures have been advocated to achieve these goals, but, unfortunately, none have been subject to randomized clinical trials. The lack of rigorously designed trials relates to many factors, but primarily to the variation in site, extent, and severity of the disease, and the rather limited number of pediatric cases at any one individual center. As well, most otologic surgeons have their own preferences based on their skills, training, and experience. Therefore, controversy remains over the optimal procedures to treat and prevent residual cholesteatoma (disease remaining after surgical attempts to eradicate it) and recurrent cholesteatoma (development of new disease). Canal WallUp vs. Canal WallDown Mastoidectomy Controversy exists over whether to perform a canal wallup or canal walldown procedure when the extent of cholesteatoma requires mastoidectomy. In infants and children, every effort should be made to avoid a canal walldown mastoidectomy because it is especially desirable to maintain or reconstruct the anatomy in this age group. Among the many disadvantages of having a potentially life-long open mastoid cavity, is the fact that children usually require a general anesthetic for the periodic cleaning and debridement that ensues. The cavity is more difficult to clean postoperatively for children than in adults because children are frequently apprehensive during the procedure. Furthermore, since swimming is a common activity in youngsters, they are more susceptible to infection when an open mastoid cavity is exposed to water. Therefore, whenever possible, perform a canal wallup tympanomastoidectomy and additional tympanoplasty, if needed. Since the middle ear and mastoid are not directly visible following these procedures, a second look operation is performed approximately 6 months later to detect any residual cholesteatoma. Exploration is recommended at 6 months because cholesteatoma is more aggressive in children than adults. Waiting 12 months, as advocated for adults, can result in more extensive residual disease than is desirable. If a residual cholesteatoma is encountered at the second look, it is removed and the child is re-explored in another 6 months. These repeat procedures are performed until there is no further residual cholesteatoma. In our study of 232 children who had 244 surgical procedures, residual or recurrent cholesteatoma developed in 38% of cases and 23% of those cholesteatomas were detected at the time of the second look procedure.4
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Residual or recurrent disease was significantly associated with ossicular erosion at the time of the original surgery, in direct proportion to the number of ossicles involved. In a Japanese review of children operated on for cholesteatoma, residual cholesteatoma was uncovered at the second look tympanotomy in 64% of cases.8 During the second look exploratory tympanotomy this author uses the 70 Hopkins rod-lens telescope to inspect the middle ear for residual and recurrent disease. Currently, a canal walldown mastoidectomy is performed for: 1. Suppurative complications (intratemporal or intracranial) of cholesteatoma, with cholesteatoma in the mastoid. The decision for or against removing the canal wall, however, should be individualized, based on the site, extent, and severity of the complication, as well as other factors below. 2. Cholesteatoma in inaccessible areas (by transmastoid approach) of the temporal bone, such as the retrolabyrinthine region or the petrous apex. 3. Children with another medical condition (eg, severe congenital heart disease) which would make a re-operation (eg, second look tympanotomy) a potential health hazard. 4. Children who are unable (eg, living in remote areas) or unlikely (eg, poor compliance) to return for a second look tympanotomy. This applies not only to developing countries, but also to certain populations in the United States. 5. Second look procedures revealing aggressive extensive residual cholesteatoma that is unlikely to be controlled in the future without a canal walldown procedure. Otologic Telescope The most significant factor in the preservation of the posterior and superior canal walls in most children is the relatively recent availability of an optical telescope, which enhances visualization of the middle-ear cleft. I use the 2.7-mm 70 Hopkins rod-lens telescope (Hopkins-Karl Storz, EndoscopyAmerica Inc, Culver City, CA). With this instrument, the surgeon can directly visualize the facial recess and the attic; whereas in the past, the superior canal wall (medial portion) would have to be removed to ensure that cholesteatoma was not attached to the lateral attic wall. The telescope can be placed in the attic following the tympanomastoidectomy, and focused inferiorly to determine whether or not there is persistent disease. Although not related to performing a canal wallup versus a canal walldown procedure, the telescope also greatly enhances examination of the middle ear in areas not visible with the otomicroscope (especially when the canal walls remain intact), such as the osseous portion of the eustachian tube, the sinus tympani, and the hypotympanum. Timing of Ossiculoplasty If an ossiculoplasty is required to restore the hearing, it is delayed until there is no residual or recurrent cholesteatoma, and otitis media and eustachian tube dysfunction (including atelectasis) are absent and unlikely to recur. Persistent or recurrent middle-ear problems can result in an unfa-
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vorable outcome of ossiculoplasty, such as postoperative extrusion of the prosthesis (see Chapter 4). Residual cholesteatoma found during second look at the site of ossiculoplasty not only inhibits attempts at removal of the cholesteatoma, but the ossiculoplasty may have to be disassembled. Since children are more likely than adults to have recurrent or persistent otitis media and eustachian tube dysfunction, prevention of these middleear problems is a required part of cholesteatoma surgery. Placement of a tympanostomy tube, cartilage batten, or both, may be necessary not only at the time of the surgery, but for as long as middle-ear or eustachian tube problems persist. Postoperative formation of a retraction pocket is often associated with cholesteatoma recurrence (see Chapter 3). Follow-up Visits Following surgery for cholesteatoma that involves the middle ear, with or without extension into the mastoid gas cell system, children are re-examined periodically for at least 5 years. There are two major concerns: 1. Residual cholesteatoma that remains following the initial surgical procedure 2. Recurrent cholesteatoma (new disease) because of persistent eustachian tube dysfunction, and a new retraction pocket in an anatomic site similar to the original one, or in another area of the tympanic membrane4,912 Recurrent cholesteatoma is most effectively prevented in children with a tympanostomy tube, cartilage graft tympanoplasty, or both, as described in Chapter 3 under Cartilage Graft Tympanoplasty. In addition, implantation (iatrogenic) cholesteatoma can develop following this type of middle-ear and mastoid surgery. This author usually follows children every 3 months during the first postoperative year, every 6 months during the second and third postoperative years, and then yearly for another 5-7 years. CONGENITAL CHOLESTEATOMA In general, the surgical procedures for removing a congenital cholesteatoma are similar to those employed when an acquired cholesteatoma is diagnosed. There are two additional procedures for congenital cholesteatoma, however, that are not described in the section on Acquired Cholesteatoma: (1) removal of intratympanic membrane cholesteatoma, and (2) removal of cholesteatoma in the anterosuperior quadrant of the middle ear. Cholesteatoma is encountered relatively frequently in both of these anatomic sites in infants and children. Another commonly encountered site is the posterosuperior portion of the mesotympanum, which is approached in a similar manner as that described for acquired cholesteatoma. In our study of 45 surgical procedures for congenital cholesteatoma performed in the 1970s and 1980s (excluding intratympanic disease), 56% were limited to the middle ear (with or without atticotomy), 13% were canal wallup tympanomastoidectomies, 9% were modified radical mastoidectomies, and 20% were radical mastoidectomies.4 The present trend, however, is to maintain the posterior canal wall, and avoid a postoperative open cavity (radical or modified radical mastoidectomy) whenever possible.
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Indications Intratympanic membrane congenital cholesteatoma. Congenital cholesteatoma medial to the intact tympanic membrane in the anterosuperior quadrant of the middle ear Anesthetic Considerations and Preparation The anesthesia and the preparation depend on the site and the approach. For an intratympanic membrane cholesteatoma, the anesthesia and preparation are similar to those described in Chapter 2 under Transcanal Approach. For a congenital cholesteatoma that is within the anterosuperior portion of the middle ear and epitympanum, the anesthesia and preparations are the same as described in Chapter 2 under Endaural Approach. A facial nerve monitor is used when the disease is in the middle ear. Procedures No 1. Intratympanic membrane congenital cholesteatoma Congenital cholesteatoma is seen within the intact tympanic membrane (Figure 512). The cholesteatoma is removed with a pick; a cup forceps is also used (Figure 513). A Steri-Strip patch is placed over the defect if a small perforation is present (Figure 514). If the perforation is large, a tissue graft myringoplasty is performed, as shown in Chapter 3.
Figure 512 Congenital cholesteatoma within the intact tympanic membrane.
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Figure 513 Cholesteatoma is removed with a curved pick.
Figure 514 A Steri-Strip patch is placed over the defect.
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No 2. Anterosuperior middle-ear congenital cholesteatoma A congenital cholesteatoma is visualized in the middle ear, medial to the anterosuperior quadrant of the intact tympanic membrane (Figure 515). The choice of approach (see Chapter 2) depends on the extent of cholesteatoma and the size of the childs ear canal: ! An endaural approach (Figure 516A) is used for disease localized to the anterosuperior mesotympanum, but with inadequate direct access or visualization because of a narrow ear canal. Only a short incision is needed in the incisura, because the mastoid will not be entered. ! A transcanal approach (Figure 516B) is used for disease localized to the anterosuperior mesotympanum, with a large enough ear canal to permit adequate visualization and access to the anterosuperior canal wall. ! A postauricular approach is used for disease extending into the posterior attic, aditus ad antrum, and mastoid (see Acquired Cholesteatoma below). The tympanomeatal flap is elevated off the malleus to completely expose the cholesteatoma. Although the tympanic membrane can often be maintained intact, any portion that appears penetrated by the cholesteatoma should be excised to prevent recurrence and the tympanic membrane grafted. Cholesteatoma extension into the anterior epitympanum is common and can be visualized on the preoperative computed tomography (CT) scan. An anterior atticotomy is done with a microdrill (Figure 517), and the cholesteatoma is removed (for more extensive disease, see Acquired Cholesteatoma below).
Figure 515 A congenital cholesteatoma is visualized in the middle ear, medial to anterosuperior quadrant of the intact tympanic membrane.
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Figure 516 A, Endaural incisions and approach when the cholesteatoma is localized to the anterior mesotympanum and the anterior epitympanum. B, Transcanal approach is used, if feasible.
Figure 517 An anterior atticotomy is done with a microdrill, and cholesteatomas are removed.
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The tympanomeatal flap is replaced (Figure 518). A defect, if present, is repaired using a medial fascia graft as described in Chapter 2. If the endaural approach was used, the incision is closed with 2-3 absorbable sutures. Postoperative Care The postoperative care is dependent on the approach used (see Chapter 2). A second look exploratory tympanotomy is usually performed 6 months after the procedure to remove any residual middle-ear or epitympanic cholesteatoma. The site and extent of the cholesteatoma, the status of the hearing, and the degree of translucency of the tympanic membrane are key factors in recommending a second look operation (see Acquired Cholesteatoma below).
Figure 518 A tympanomeatal flap is replaced.

ACQUIRED CHOLESTEATOMA
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The most common type of cholesteatoma is acquired, which is a sequela of middle-ear disease (eg, eustachian tube dysfunction, otitis media). Acquired cholesteatoma can also occur as an unwanted sequela of otologic surgery, such as tympanostomy tube placement.13 The most frequent anatomic site in which an acquired cholesteatoma is encountered in children is the posterosuperior quadrant of the pars tensa; the second most common site is the pars flaccida area. In a study of 1024 patients (adults and children), a cholesteatoma of the attic was seen in 42% of cases and a cholesteatoma of the posterosuperior quadrant in 31% of cases. A cholesteatoma was present in 18% of patients when there was a total perforation, in 6% when there was a central perforation, and in 3% when there was no perforation (possibly congenital).14 However, it is possible that the patients in whom the cholesteatoma was associated with a total perforation originally had involvement of the posterosuperior portion of the pars tensa. In children, the most common defect in the tympanic membrane (ie, retraction pocket) develops first in the posterosuperior quadrant of the pars tensa, or less commonly, in the pars flaccida. The term marginal perforation has been used to describe the defect in the posterosuperior quadrant, and the defect in the pars flaccida has been called an attic perforation. These are frequently not true perforations, however, but rather retraction pockets or cholesteatomas that otoscopically appear as perforations; no continuity between the defect and the middle ear occurs until later in the disease process. Selection of Procedure Related to Site and Extent of Disease Each childs final procedure should be individualized based on several factors. One surgical procedure is not advocated for all cholesteatomas. The following factors are important in the preoperative planning and the intraoperative decision-making process: Anatomic site Extent of disease Condition of ossicular chain and tympanic membrane Presence or absence of chronic suppurative otitis media and mastoiditis Presence or absence of suppurative or nonsuppurative complications Anatomy of the temporal bone and the middle-ear cleft Status of eustachian tube function Age and general health of the child Findings of CT scans Availability of postoperative follow-up care As stated above, the long-standing goals of cholesteatoma surgery are to eradicate disease, reconstruct the tympanic membrane, maintain the anatomy of the middle-ear cleft, and preserve (restore) hearing. In addition, try to preserve the external auditory canal to prevent the potential morbidity of an exposed mastoid cavity. Unfortunately, this is not always possible,
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because cholesteatoma in children is frequently more invasive, grows more rapidly, and is associated with a higher residual and recurrence rate than cholesteatoma in adults. Other factors that may be related to this difference are the higher rate of recurrent and chronic middle-ear disease and poor eustachian tube function in the pediatric population. Of the 199 procedures performed for acquired cholesteatoma (or cholesteatoma of uncertain etiology) at Childrens Hospital of Pittsburgh from 1973 to 1990, 28% involved only a middle-ear procedure, 20% were canal wallup tympanomastoidectomies, 25% were modified mastoidectomies, and 28% were radical mastoidectomies.4 The current trend, however, is to maintain the posterior canal wall and avoid a postoperative open cavity (radical or modified radical mastoidectomy) whenever possible. Staging of Acquired Cholesteatoma It is appropriate to stage cholesteatomas for management, reporting, and research. When staging cholesteatoma, the presence or absence of infection should be noted, and if present, the duration of the otitis media. This author has proposed the following classification:15 Cholesteatoma without infection is a cholesteatoma that is not associated with infection, either within the cholesteatoma itself, or in any other portion of the middle-ear cleft. Cholesteatoma with infection is a cholesteatoma that is associated with infection, which can be either acute (with or without otorrhea) or chronic. The most common infection associated with cholesteatoma is chronic suppurative otitis media. Cholesteatoma is further classified based on its site and extent: Stage 1. Cholesteatoma confined to the middle ear (hypo- and mesoepitympanum), without erosion of the ossicular chain Stage 2. Same as Stage 1, but with erosion of one or more ossicles Stage 3. Middle ear and mastoid gas cell system involved, without erosion of ossicles Stage 4. Same as Stage 3, but with erosion of one or more ossicles Stage 5. Extensive cholesteatoma of the middle ear, mastoid, and other portions of the temporal bone, the extent of which is not totally accessible to surgical removal (eg, medial to labyrinth), with one or more ossicles involved; fistula of the labyrinth may or may not be present Stage 6. Same as Stage 5, but cholesteatoma extends beyond the temporal bone Surgical Planning The following examples (posterosuperior quadrant and pars flaccida/attic cholesteatomas) describe the two most common types of acquired cholesteatoma encountered in children. Each example includes the common sites of extension of the cholesteatoma and the final procedure selected, depending on the extent of the disease. There is a logical progression of the operation, and the reader can follow the decision-making process. Preoperative evaluation of the CT scans can be helpful in planning the proce-
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dure and discussing the risks versus the benefits (ie, informed consent) with the parents. The CT scans do not have a high enough sensitivity to accurately identify the extent of the cholesteatoma in all patients, but they are a valuable diagnostic aid.16 The following procedures are not only reserved for presumed acquired cholesteatoma, but can also be used for cholesteatoma of congenital or uncertain etiology. POSTEROSUPERIOR QUADRANT ACQUIRED CHOLESTEATOMA Cholesteatoma that occurs in the posterosuperior quadrant of the pars tensa of the tympanic membrane has been called a marginal perforation, but this is in almost all cases a misnomer or misconception, because there is no perforation, at least when encountered in children. It is most likely the result of recurrent or persistent middle-ear negative pressure, due to eustachian tube functional obstruction, and immediately preceded by a retraction pocket.17 The following surgical procedures describe an acquired cholesteatoma according to four possible extensions: 1. Confined to the posterior mesotympanum, facial recess, and sinus tympani 2. Extending into the superior portion of the facial recess and epitympanum 3. Extending into the aditus ad antrum and mastoid gas cells 4. Extending into the remaining portion of the middle ear, in addition to other areas Indications Cholesteatoma in the posterosuperior quadrant, with or without extension into the epitympanum, mastoid gas cells, and middle ear (Figure 519)
Figure 519 Posterosuperior quadrant cholesteatoma of uncertain extension into one or more of four possible areas, numbered one through four as referenced above.
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Anesthetic Considerations and Preparation The anesthesia and the preparation for this procedure are the same as for a postauricular approach (see Chapter 2). A facial nerve monitor is used during the procedure. Procedures Incisions for a Koerner flap and postauricular approach are completed (Figure 520) as described in Chapter 2 under Postauricular Approach. No 1. Cholesteatoma in the posterior mesotympanum, facial recess, and sinus tympani The tympanomeatal flap is elevated to reveal a cholesteatoma confined to the posterior mesotympanum, facial recess, and sinus tympani (Figure 521). The posterosuperior portion of the canal wall scutum is removed with a curette to further visualize the cholesteatoma (Figure 522). Alternatively, a microdrill can be used. Cholesteatoma in the facial recess is removed, and visualization of the sinus tympani is enhanced with the aid of a 2.7-mm 70 Hopkins rod-lens telescope (Hopkins-Karl Storz, Endoscopy-America Inc, Culver City, CA). (See Chapter 3, Figure 344). An ossiculoplasty, if indicated, can be performed at this time (see Chapter 4). Gelfoam is placed in the middle ear and a cartilage-perichondrial graft is placed over the defect (Figure 523). The graft is harvested from the conchal cartilage through the postauricular wound, as described in detail in Chapter 3 under Cartilage Graft Tympanoplasty. A tympanostomy tube is inserted into the anterior portion of the tympanic membrane (Figure 524) to prevent cholesteatoma recurrence.18
Figure 520 Incisions for a Koerner flap are made approximately one third of the distance from annulus to meatus.
Figure 521 The tympanomeatal flap is elevated to reveal a cholesteatoma confined to the posterior mesotympanum, facial recess, and sinus tympani.
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Figure 522 The posterosuperior portion of the canal wall scutum is removed with a curette.
Figure 523 A cartilage-perichondrial graft is placed over the defect.
Figure 524 A tympanostomy tube is inserted into the anterior portion of the tympanic membrane.
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No 2. Cholesteatoma extending into the epitympanum The tympanomeatal flap is elevated to reveal cholesteatoma extending into the epitympanum (Figure 525). An atticotomy is performed with a microdrill and the incus is removed (Figure 526). Incus interposition is one reconstructive option (see Chapter 4), but removal of the entire malleus and a myringostapediapexy is an alternative. A cartilage-perichondrial graft and a fascia graft are placed medial to the tympanic membrane remnant (Figure 527).
Figure 525 The cholesteatoma extends into the epitympanum.
Figure 526 Atticotomy is performed.
Figure 527 A cartilage-perichondrial graft and a fascia graft are placed medial to the tympanic membrane remnant.
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No 3. Cholesteatoma extending into the mastoid gas cells Atticotomy reveals cholesteatoma extending superiorly and posteriorly into the attic and the aditus ad antrum (Figure 528). The mastoid cortex is entered (Figure 529) and, if a cholesteatoma can be removed without taking the canal wall down, a simple mastoidectomy is performed as described earlier. A cartilage-perichondrial graft and a fascia graft are placed medial to the tympanic membrane remnant (see Figure 527). Thus, a canal wallup mastoidectomy with tympanoplasty is performed.
Figure 528 The cholesteatoma extends posterosuperiorly.
Figure 529 Simple mastoidectomy is completed.
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No 4. Extensive cholesteatoma Mastoidectomy and middle-ear examination reveal extensive cholesteatoma that cannot be adequately excised without removing the posterior and superior canal walls (Figure 530). A modified radical mastoidectomy can be successful in selected cases with this extent of disease. However, as stated earlier, the use of the telescope enhances removal of the cholesteatoma even when the disease is extensive, and may obviate the need for a canal walldown procedure. A canal wallup tympanomastoidectomy (see Figure 529) is safe and effective in many children even when the disease is extensive. A radical mastoidectomy (Figure 531) is reserved for only those cholesteatomas that are so extensive that a canal wallup procedure, or even a modified radical mastoidectomy, will not safely control the disease (see Cholesteatoma Surgery in Children vs. Adults earlier in this chapter). Postoperative Care The postoperative care and follow-up are as for the procedures described earlier in this chapter.
Figure 530 Mastoidectomy and middle-ear examination reveal extensive cholesteatoma in the mastoid and entire middle ear.
Figure 531 A radical mastoidectomy is performed when disease is too extensive to perform a less radical procedure.

PARS FLACCIDA ATTIC CHOLESTEATOMA
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A cholesteatoma that is otoscopically visualized in the pars flaccida area has been inappropriately termed an attic perforation, when in reality there is no perforation but simply a cholesteatoma (or retraction pocket). The etiology and pathogenesis are most likely similar to cholesteatoma that develops in the posterosuperior quadrant of the pars tensa, and as described earlier, a retraction pocket precedes the cholesteatoma.15 The following surgical procedures describe a cholesteatoma in the pars flaccida according to three possible extensions: 1. Confined to the anterior epitympanum 2. Extending into the aditus ad antrum and mastoid 3. Extensive cholesteatoma Preoperative CT scans can be helpful in the decision to use an endaural or postauricular approach, since the scans usually determine if the disease extends into the mastoid gas cell system. If the cholesteatoma appears confined to the epitympanum, the endaural approach is used. In contrast, a postauricular approach is used when the cholesteatoma has most likely extended into the mastoid. If the cholesteatoma does indeed extend into the mastoid, then a classical Bondy modified radical mastoidectomy is performed in selected cases; however, if there is extensive disease in the mastoid, the postauricular approach is more feasible. Also, as stated before, a canal wallup tympanomastoidectomy should be the goal in children, not a modified radical or radical mastoidectomy. Indications Cholesteatoma in the pars flaccida, with or without extension into mastoid air cells and middle ear (Figure 532)
Figure 532 Cholesteatoma in the pars flaccida with three possible extensions, numbered one through three as referenced above.
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Anesthetic Considerations and Preparation The anesthesia and the preparation are dependent on the surgical approach, which will be endaural when the cholesteatoma is relatively small and confined to the epitympanic space. If the cholesteatoma is thought to extend into the mastoid, as evaluated preoperatively on the CT scans, the postauricular approach is used (see Chapter 2). Procedures No 1. Attic cholesteatoma confined to the anterior epitympanum Using an endaural approach (see Chapter 2), the middle ear is exposed (Figure 533). An anterior atticotomy is completed (Figure 534). An incision is made in the tragus (the incision is made slightly medial to the outside edge of the targus) to harvest a cartilage-perichondrial graft (Figure 535) and the graft is excised leaving the outer portion of the targus intact to prevent cosmetic deformity (Figure 536). The cartilage graft is positioned (Figure 537) to batten the tympanic membrane and prevent postoperative retraction into the attic defect, which can result in a recurrent cholesteatoma. A tympanostomy tube is inserted into the anteroinferior quadrant of the tympanic membrane (Figure 538) if persistent eustachian tube dysfunction, otitis media, or both, are anticipated in the postoperative period.
Figure 533 Endaural incisions and approach are completed when the cholesteatoma is confined to the anterior epitympanum.
Figure 534 An anterior atticotomy is completed.
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Figure 535 An incision is made in the tragus to harvest a cartilage-perichondrial graft.
Figure 536 The tragal cartilage-perichondrial graft is excised.
Figure 537 Defect is repaired using tragal cartilageperichondrial and fascia grafts.
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No 2. Attic cholesteatoma extending into the mastoid An endaural approach and atticotomy reveal that cholesteatoma extends posteriorly into the aditus ad antrum and possibly into the mastoid gas cells (Figure 539). For mastoid disease, however, an initial postauricular approach is more feasible. The preoperative CT scan is usually helpful in determining disease extension, and may determine if an endaural or postauricular approach should be used. If the cholesteatoma is lateral to the ossicles, and is not in the middle ear but in the mastoid, a modified radical approach mastoidectomy is one option (Figure 540). However, a canal wallup tympanomastoidectomy with a cartilage graft (from the conchal cartilage, placed over the attic defect) tympanoplasty, similar to that described in Figure 527, is more desirable.
Figure 539 An endaural approach and atticotomy reveal that cholesteatoma extends posterior toward the mastoid air cells.
Figure 540 A modified radical mastoidectomy is one option, but a canal wallup tympanomastoidectomy with a cartilage graft tympanoplasty is preferred.
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No 3. Extensive attic cholesteatoma Extensive cholesteatoma is anticipated from the CT scan (Figure 541). A postauricular approach is indicated, and the final procedure is dependent on the extent of the cholesteatoma. A canal wallup tympanomastoidectomy and cartilage graft tympanoplasty are preferred (see Figures 527 and 529), reserving a canal walldown procedure for those children and cholesteatomas decribed above (see Cholesteatoma Surgery in Children vs. Adults earlier in this chapter). Postoperative Care The postoperative care is as described in Chapter 2 under Endaural Approach and Postauricular Approach.
Figure 541 Extensive cholesteatoma is anticipated from the CT scans.
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REFERENCES
1. 2. 3. Noss RS, Lalwani AK, Yingling CD. Facial nerve monitoring in middle ear and mastoid surgery. Laryngoscope 2001;111:8316. Bluestone CD, Klein JO. Otitis media in infants and children. Philadelphia: WB Saunders; 2001. p. 32940. Bluestone CD. Acute and chronic mastoiditis and chronic suppurative otitis media. In: Feigin RD, editor, Wald ER, Dashefsky B, guest editors. Seminars in pediatric infectious diseases. Vol 9. Philadelphia: WB Saunders; 1998;9:1226. Rosenfeld RM, Moura RL, Bluestone CD. Predictors of residual-recurrent cholesteatoma in children. Arch Otolaryngol Head Neck Surg 1992;118:38491. Kenna MA, Rosane BA, Bluestone CD. Medical management of chronic suppurative otitis media without cholesteatoma in children-update 1992. Am J Otol 1993;14:46973. Tos M. A new pathogenesis of mesotympanic (congenital) cholesteatoma. Laryngoscope 2000; 110:18907. Soldati D, Mudry A. Cholesteatoma in children: techniques and results. Int J Pediatr Otorhinolaryngol 2000;52:26976. Mishiro Y, Sakagama M, Okumura S, et al. Postoperative results for cholesteatoma in children. Auris Nasus Larynx 2000;27:2236. Sivola J, Palva T. Long-term results of pediatric primary one stage cholesteatoma surgery. Int J Pediatr Otorhinolaryngol 1999;48:1017. Stangerup SE, Drozdziewicz D, Tos M, Tabalzini E. Surgery for acquired cholesteatoma in children: long-term results and recurrence of cholesteatoma. J Laryngol Otol 1998;112:72449. Stangerup SE, Drozdziewicz D, Tos M. Cholesteatoma in children: predictors and recurrence rates. Int J Pediatr Otorhinolaryngol 1999;49:6973. Sivola J, Palva T. One stage surgery for pediatric cholesteatoma: long-term results and comparison with primary surgery. Int J Pediatr Otorhinolaryngol 2000;56:1359. Golz A, Goldenberg D, Netzer A, et al. Cholesteatomas associated with ventilation tube insertion. Arch Otolaryngol Head Neck Surg 1999;125:7547. Sheehy JL, Brachman DE, Graham MD. Complications of cholesteatoma: a report on 1024 cases. In: McCabe BF, Sad J, Abramson M, editors. Cholesteatoma: First International Conference, 1977; Iowa City, Iowa; New York: Aesculapius; 1977. p. 4209. Bluestone CD. Definitions, terminology, and classification. In: Rosenfeld RM, Bluestone CD, editors. Evidence-based otitis media. Hamilton, Ontario: BC Decker Inc; 1999. p. 85103. Bluestone CD. Invited comments: Clinical forumroutine preoperative imaging in chronic ear surgery. Am J Otol 1998;19:5367. Bluestone CD, Klein JO. Intratemporal Complications and Sequelae of Otitis Media. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology. Philadelphia: WB Saunders; 1996. p. 60414. Rakover Y, Keywan K, Rosen G. Comparison of the incidence of cholesteatoma surgery before and after using ventilation tubes for secretory otitis media. Int J Pediatr Otorhinolaryngol 2000;56:414.
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
15. 16. 17.
18.
CHAPTER 6
PERILYMPHATIC F ISTULA AND E USTACHIAN T UBE S URGERY

Perilymphatic fistula (PLF) is an abnormal communication between the inner ear and the middle-ear cleft (ie, eustachian tube, middle ear and mastoid). The communication can extend to the brain, in which case cerebrospinal fluid (CSF) may be identified in the middle ear. PLF can be congenital or acquired, and may occur in any portion of the labyrinth adjacent to the middle-ear cleft; labyrinthine fistula is also an acceptable term. Acquired PLF is caused by trauma, cholesteatoma, infection, neoplasm, or iatrogenic injury. Congenital PLF is present at birth, and commonly associated with middle-ear malformations. PLF is diagnosed more often in adults than children.13 In this chapter, I describe the repair of congenital PLF, but the principles also apply to acquired PLF. If the stapes is subluxed due to trauma, it may have to be either repositioned in the oval window, or removed and a prosthesis inserted (see Chapter 4), depending upon the severity of the trauma.
CONGENITAL PERILYMPHATIC FISTULA We originally described this condition in children in 1978 and subsequently in 1983.4,5 More recently, we reported on 94 children who had an exploratory tympanotomy for possible fistula between 1980 and 1989.6 Of these 94 children, 60 (64%) had a fistula identified at the time of surgery, and 86% had a congenital malformation of the middle ear (visualized at surgery), the inner ear (identified on CT scan), or both. The most common malformations identified in the middle ear involved the stapes, round window, or both. Otitis media can be associated with a congenital PLF, producing nystagmus during an acute episode, in addition to the mixed hearing loss. The sensorineural component is most likely due to labyrinthitis. In a review of 47 infants and children who had exploratory tympanotomy for possible fistula at the Childrens Hospital of Pittsburgh, 30 children (64%) had a past history of otitis media, and of these 30 patients, 28 (93%) had a fistula diagnosed at surgery.7
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Preoperative Evaluation If the child has a middle-ear effusion with a presumed congenital PLF, the effusion must be eliminated (medically or with a tympanostomy tube) several weeks prior to exploratory tympanotomy. Effusions should also be avoided in the postoperative period. CT scans can be very specific when a malformation of the middle or inner ear is identified, but otherwise, they are not very sensitive.8 When disequilibrium or vertigo is present, tests of balance function can help document labyrinthine dysfunction; however, a PLF can be present despite normal labyrinthine function tests. Although there currently is no available preoperative test that is both highly sensitive and specific,3 an intraoperative beta-2 transferrin test aids in confirming some, but not all, of the observed leaks (the test is highly specific, but not sensitive).9,10
!
Beta-2 transferrin testing can only identify CSF leaks and not those in which perilymphatic fluid is found in the middle ear.11 Nevertheless, when the test is positive, CSF is present in the middle ear.12 Even though the test results are only available postoperatively, a positive test will confirm the presence of a CSF leak, which can be helpful if the contralateral ear is suspected to have a similar defect.13
Indications Congenital perilymphatic fistula is suspected preoperatively from the history, physical findings, serial audiometry, CT scans, and also from balance testing when vertigo or disequilibrium is present. Sensorineural hearing loss of uncertain etiology, that is either fluctuating, progressive, or both, is the most common indication for exploration; although a relatively uncommon presenting symptom in children, a congenital PLF may be the cause of sudden sensorineural hearing loss in this age group. Mixed conductive and sensorineural hearing loss, in which the sensorineural component is fluctuating, progressive, or both; the conductive component may be either stable (eg, malformation of the ossicular chain), fluctuating due to otitis media, or both. Vertigo or disequilibrium of uncertain etiology, with or without hearing loss, may be caused by a congenital PLF; tests of balance function can help confirm if the labyrinth is involved. Anesthetic Considerations and Preparation The usual approach is transcanal, and the anesthesia and the preparation are as described in Chapter 2 under Transcanal Approach. In infants and young children, the external canal may be too narrow for a transcanal approach, in which case the endaural approach is used (also described in Chapter 2).
Perilymphatic Fistula and Eustachian Tube Surgery
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When the transcanal approach is used, a small area of hair is shaved above the pinna where the temporalis muscle graft is to be obtained; for the endaural approach, the muscle graft can be taken directly through the wound. Procedure The tympanomeatal flap is elevated for an exploratory tympanotomy (Figure 61). Three types of malformed stapes are frequently encountered: posteriorly positioned anterior crus, no anterior crus, or a monopod stapes (Figure 62). ! A malformed round window is also frequently found, which is usually laterally faced with an abnormal niche. ! Also, the long process of the incus can be malformed with an anterior facing concavity.
Figure 61 The tympanomeatal flap is elevated for an exploratory tympanotomy.
Figure 62 Three types of stapes malformations are frequently encountered as described above.
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Because the anatomy of the stapes superstructure is difficult to visualize, a 90 pick is used to palpate the crura and obturator foramen to determine if an abnormality is present (Figure 63). A leak is frequently seen in the anterior footplate area. A small pledget of Gelfoam is placed over the stapes footplate, and another is placed over the round window; both remain in place for a few minutes and then are sent to the immunopathology laboratory for beta2 transferrin testing (Figure 64).
!
An alternative to Gelfoam is the use of a micro-pipette to collect the fluid. A Valsalva maneuver, performed by the anesthetist, may enhance the identification and collection of the leak.
Figure 63 A 90 pick is used to palpate the crura and obturator foramen.
Figure 64 Small pledgets of Gelfoam are placed over the stapes footplate and the round window.
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An incision is made slightly above the hairline to remove a small piece of temporalis muscle for a graft (Figure 65). The donor site is closed with absorbable suture. Mucosa around the stapes footplate and the round window niche is denuded for the graft (Figure 66). Small pieces of muscle are laid over the stapes footplate and in and around the round window niche (Figure 67). A layer of Gelfoam is placed over the muscle grafts, and the tympanomeatal flap is replaced; muscle grafts are placed even if a leak is not visualized.
Figure 65 An incision is made slightly above the hairline to remove a small piece of temporalis muscle for a graft.
Figure 66 The mucosa around the stapes footplate and the round window niche is denuded for the graft site.
Figure 67 Small pieces of muscle are laid over the stapes footplate and in and around the round window niche.
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Postoperative Care If a perilymphatic fistula is identified at surgery, the child is kept at bed rest overnight, and the patient and parents are counseled about the type of physical activity permitted in the future to prevent a recurrence of the fistula. In general, this author recommends avoiding activities that grossly elevate cerebrospinal fluid pressure (eg, weight lifting, pushups, situps), and activities that rapidly alter middle-ear pressure, such as diving in water (especially scuba) and flying in unpressurized cabins of airplanes. Postoperatively, patients usually have no further hearing loss. If vertigo was present preoperatively, patients are frequently asymptomatic postoperatively if a fistula is found during surgery and repaired.14 Recurrence A small number (usually less than 10%) of children will have recurrent PLF, frequently due to vigorous activity, which is suspected when their symptoms recur, such as fluctuating or progressive sensorineural hearing loss, vertigo or disequilibrium, or both. Recurrence signals the need for a re-exploration of the middle ear, and repair of the defect; the procedure is identical to the primary operation described above, but any residual muscle should be left undisturbed, and only the portions of the stapes or round window, that are exposed should be re-grafted with muscle.

EUSTACHIAN TUBE SURGERY
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Eustachian tube dysfunction can be simply classified as the tube being either too closed (obstruction) or too open (patulous); obstruction can be further classified as being either anatomic (mechanical) or a failure of the tubal opening mechanism (functional).15 Unfortunately, there are no current surgical procedures to correct the most common type of eustachian tube dysfunctionfailure of the opening mechanism: 1. Functional obstruction and its attendant middle-ear disease, are most common in infants and young children, but the condition usually improves with advancing age. 2. For adolescents and adults whose functional obstruction persists, a definitive operative procedure to improve function is a goal of future research. Presently, we have only a bypass procedure for this type of dysfunctiontympanostomy tube insertion (see Chapter 1). Anatomic obstruction, however, may be corrected by surgery, depending upon the etiology, such as excising a cholesteatoma that involves the middle-ear end of the eustachian tube (see Chapter 5). Although we do not have a surgical procedure to create a functioning eustachian tube, we do have surgical procedures to obstruct the tube: 1. Obliteration of the eustachian tube when chronic or recurrent otorrhea is a problem in patients who have a radical mastoid cavity 2. Closure of the tube when it is chronically, abnormally patulous OBLITERATION OF THE EUSTACHIAN TUBE Otorrhea is a common problem following mastoidectomy and is seen most frequently when there is a large perforation of the tympanic membrane, or when the eardrum has been removed completely as part of a radical mastoidectomy. The discharge can usually be controlled medically or by repairing the tympanic membrane, which provides a closed middle-ear space (see Chapter 3). In the absence of contamination from water entering the external canal, the ear discharge is caused by unwanted nasopharyngeal secretions refluxing through the eustachian tube into the middle ear, resulting from the lack of the middle-ear gas cushion. Occasionally, a patient (usually after radical mastoidectomy) has significant morbidity from otorrhea, and medical management fails to prevent the recurrent or chronic discharge. Reconstructing the middle ear is an unlikely possibility. Obliteration of the eustachian tube, however, is a reasonable alternative, as long as the patient and parents are fully informed of the benefits (ie, prevention of otorrhea) and costs (eg, inability to reconstruct a functioning gas-filled middle ear with an intact eardrum) of the surgery. The most likely candidates are those who have no serviceable hearing in the affected ear, and for them, obliteration of the entire middle-ear cleft should be considered.16
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Indications Presence of postoperative recurrent or chronic otorrhea following radical mastoidectomy, which is unresponsive to medical management, and reconstruction of the middle ear and tympanic membrane is not feasible or indicated, especially when the patient has no serviceable hearing in the ear. Anesthetic Considerations and Preparation The anesthesia and preparation for this procedure are the same as those described in Chapter 5. Procedure The middle ear and the mastoid are approached through a postauricular incision, since the mastoidectomy cavity usually needs to be revised. Bone pt is harvested with a drill from an uninvolved area of the cortex and is collected in a Luki Disposable Aspirator trap (Sherwood Davis and Geck, St. Louis, MO) (Figure 68).
Figure 68 Bone pt is harvested and aspirated into a trap.
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A small piece of temporalis muscle, bone pt, and a temporalis fascia graft are used to obliterate the protympanic (ie, osseous or middle-ear) portion of the eustachian tube (Figure 69). Careful removal of mucosa of the eustachian tube precedes obliteration. A layer of Gelfoam is placed over the fascia graft and in the middle ear, and two strips of Adaptic gauze impregnated with an antibiotic ointment are placed in the ear canal. Postoperative Care Ear canal packing is removed after 1 week.
Figure 69 A small piece of temporalis muscle, bone pt, and temporalis fascia are used to obliterate the middle-ear end (osseous, protympanic) of the eustachian tube.
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PATULOUS EUSTACHIAN TUBE: CATHETER OBSTRUCTION A continuously open eustachian tube is termed patulous, and some patients (most frequently adults) complain of autophony and of hearing their own breathing. Rapid weight loss is often the predisposing factor in some, but by no means all, patients. In 1981, we reported a successful surgical procedure to obstruct the tube in selected patients who had failed medical management.17 More recently, we reported on nine patients who had the procedure and whose follow-up ranged from 4 months to 15 years; six of the nine patients had no further or infrequent symptoms, but three reported no relief.18 The procedure has undergone some modifications during the last 10 years and now has a better chance of success than the technique originally described.19 1. When the external auditory canal is relatively small, an endaural approach is employed. 2. If the anterior canal wall and tympanic membrane are completely seen, the transcanal approach is used and an anterior tympanomeatal flap is elevated to visualize the middle-ear orifice of the eustachian tube. We now use a pressure manometer intraoperatively. Prior to replacing the tympanomeatal flap, the manometer (or tympanometer) is used to assess the opening pressure of the surgically-occluded eustachian tube. 1. A sterile olive tip probe is introduced into the external auditory canal, and the pressure is raised to 400-600 mm H2O. 2. Maintenance of pressure in this range represents adequate occlusion of the tubal lumen. 3. If there is a low opening pressure, there is usually an open space around the tube, and a small amount of tissue is used to fill the gap.20 Indications Patulous eustachian tube, with debilitating symptoms unrelieved by nonsurgical measures and despite placement of a tympanostomy tube.19,20 Anesthetic Considerations and Preparation As described in Chapter 2 for the transcanal or endaural approach. Procedure An incision is made for an anterior tympanomeatal flap (Figure 610). If the anterior canal wall obscures adequate visualization of the operative site, a microdrill is used for an anterior canaloplasty, or the endaural approach is used instead. The anterior tympanomeatal flap is elevated, and the orifice of the eustachian tube is identified (Figure 611).
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Figure 610 An incision is made approximately 8 mm lateral to the anterior annulus for an anterior tympanomeatal flap, which is similar to the standard flap made on the posterior canal wall.
Figure 611 The anterior tympanomeatal flap is elevated, and the orifice of the middle-ear end of the eustachian tube is identified.
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A small-bore polyethylene tube (eg, No 90) is introduced into the orifice of the eustachian tube to determine the site, direction, and approximate length of the Medicut angiocatheter to be inserted (Figure 612). A small length of Medicut catheter is cut; a portion of the flared tip of the catheter is maintained (Figure 613). Bone wax is inserted into the lumen of the catheter (Figure 614).
Figure 612 A small-bore polyethylene tube is introduced into the orifice of the eustachian tube to confirm the location and direction in which the catheter is to be inserted.
Figure 613 A small length of Medicut angiocatheter (Argyle Medicut, Sherwood Medical Industries, St. Louis, MO) is cut.
Figure 614 Bone wax is inserted into the lumen of the catheter.
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The narrow end of a Medicut catheter is inserted into the orifice of the eustachian tube until it is tightly in place and the flared end is in the middle ear but not touching the malleus (Figure 615). ! An intraoperative test of eustachian tube function with a manometer attached to a tympanometer ear canal earpiece is helpful in determining if the tube is effectively closed. ! If not, a piece of muscle, fascia, or perichondrium should be inserted into the lateral side of the eustachian tube between the catheter and the bony wall of the tube. A tympanostomy tube is inserted into the anteroinferior portion of the tympanic membrane (Figure 616). Postoperative Care The immediate postoperative care is as described in Chapter 2 for either a transcanal or endaural approach. The tympanostomy tube should be left in place until it spontaneously extrudes. Some patients will not require replacement of the tympanostomy tube if their middle ear remains aerated and they are without middle-ear symptoms; apparently, there is sufficient gas passing from the nasopharynx around the catheter and into the middle ear, however, their eustachian tube is no longer patulous. If there is any postoperative problem with the catheter (eg, otorrhea) it can be removed, but this requires elevating an anterior tympanomeatal flap in an operative procedure.
Figure 615 A Medicut catheter is inserted into the orifice of the eustachian tube. A pressure manometer tests whether the eustachian tube is obstructed at this stage.
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REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. Healy GB, Friedman JM, Strong MS. Vestibular and auditory findings of perilymphatic fistula: a review of 40 cases. Trans Am Acad Ophthalmol Otolaryngol 1976;82:449. Shelton C, Simmons FB. Perilymphatic fistula: the Stanford experience. Ann Otol Rhinol Laryngol 1988;97:1058. Goto F, Ogawa K, Kunihiro T, et al. Perilymphatic fistula45 case analysis. Auris Nasus Larynx 2001;28:2933. Grundfast KM, Bluestone CD. Sudden or fluctuating hearing loss or vertigo in children due to perilymph fistula. Ann Otol Rhinol Laryngol 1978;87:76171. Supance JS, Bluestone CD. Perilymph fistula in infants and children. Otolaryngol Head Neck Surg 1983;91:66371. Weber PC, Perez BA, Bluestone CD. Congenital perilymphatic fistula and associated middle ear abnormalities. Laryngoscope 1993;103:1604. Bluestone CD. Otitis media and congenital perilymphatic fistula as a cause of sensorineural hearing loss in children. Pediatr Infect Dis J 1988;7 Suppl:S1415. Weissman JL, Weber PC, Bluestone CD. Congenital perilymphatic fistula: computed tomography appearance of middle ear and inner ear anomalies. Otolaryngol Head Neck Surg 1994;111:2439. Weber PC, Kelly RH, Bluestone CD, Bassiouny M. Beta-2 transferrin confirms perilymph fistula in children. Otolaryngol Head Neck Surg 1994;110:3816. Weber PC, Bluestone CD, Kenna MA, Kelly RH. Correlation of beta-2 transferrin and middle ear abnormalities in congenital perilymphatic fistula. Am J Otol 1995;16:27782. Buchman CA, Luxford WM, Hirsch BE, et al. Beta-2 transferrin assay in the identification of perilymph. Am J Otol 1999;20:1748. Bluestone CD. Implications of beta-2 transferrin assay as a marker for perilymphatic versus cerebrospinal fluid labyrinthine fistula. Am J Otol 1999;20:1748. Bluestone CD. Perilymphatic fistula in children. In: Gates GA, editor. Current therapy in otolaryngology-head and neck surgery. 6th ed. Hamilton, Ontario: BC Decker Inc; 1998. p. 6771. Weber PC, Bluestone CD, Perez B. Outcome of hearing and vertigo following surgery for congenital perilymphatic fistula in children (Abstract). Annual meeting of the American Society of Pediatric Otolaryngology; April 21, 1993; Los Angeles, CA; 1993. Bluestone CD. Eustachian tube function and dysfunction. In: Rosenfeld RM, Bluestone CD, editors. Evidence-based otitis media. Hamilton, Ontario: BC Decker Inc; 1999. p. 13756. Supance JS, Bluestone CD. How I do it Medical management of the chronic draining ear. Laryngoscope 1983;93:6612. Bluestone CD, Cantekin EI. Management of the patulous eustachian tube. Laryngoscope 1981;91:14952. Magit AE, Bluestone CD. Catheter occlusion of the patulous eustachian tube (Abstract). Proceedings of the American Otological, Rhinological, and Laryngological Society, Western Section Meeting; January 13, 1992; Los Angeles, CA; 1992. Bluestone CD, Magit AE. The abnormally patulous Eustachian tube. In: Brackmann DE, Shelton C, Arriaga MA, editors. Otologic surgery. Philadelphia: WB Saunders; 1994. p. 1039. Bluestone CD. Management of the abnormally patulous eustachian tube. In: Myers EN, Bluestone CD, Brackmann DE, Krause CJ, editors. Advances in otolaryngology-head and neck surgery. St. Louis (MO): Mosby, Inc; 1998. p. 20534.
9. 10. 11. 12. 13. 14.
15. 16. 17. 18.
19. 20.
CHAPTER 7
FACIAL N ERVE E XPLORATION AND R EPAIR

Raymond L. Hilsinger Jr, MD
Surgical procedures of or around the facial nerve epitomize much of what is challenging and intriguing about otolaryngologyhead and neck surgery. To be successful, the head and neck surgeon must have a precise knowledge of anatomy; the ability to handle traumatic, neoplastic, infectious, idiopathic, and congenital diseases; the skills to manage emergent, urgent, and routine situations; and the technical expertise to do both macroscopic and microscopic surgery in an open operative field as well as in a confined space. Editors Note: This chapter complements others describing management of the facial nerve for specific disorders or disease processes. Related chapters include Chapter 5, Mastoidectomy and Cholesteatoma, Chapter 22, Congenital Malformations of the Neck, and Chapter 23, Salivary Gland Surgery.
FACIAL NERVE ANATOMY For surgical purposes, the facial nerve can be classified into three segments: intracranial, intratemporal, and extratemporal (Figure 71). Intracranial Segment The intracranial segment of the motor branch of the facial nerve emerges from the inferior border of the pons between the olive and the inferior cerebellar peduncle and medial to the vestibulocochlear nerve and the nervus intermedius (intermediate nerve).13 The nerve then courses laterally in the cerebellopontine angle. Intratemporal Segment The intratemporal segment consists of four subsegments (see Figure 7-1): meatal (internal auditory canal), labyrinthine (petrous), tympanic (horizontal), and mastoid (vertical).1 The meatal subsegment begins as the nerve enters the internal auditory meatus at the medial end of the internal auditory canal.
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The facial nerve occupies the anterosuperior area of the canal and courses laterally in a horizontal plane just superior to the cochlear nerve and anterior to the nervus intermedius.
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Figure 71 Schematic anatomy of right facial nerve.
In its most lateral aspect, the facial nerve is separated from the cochlear nerve by the falciform crest and from the superior vestibular nerve by the vertical crest just before passing through the orifice of the facial (fallopian) canal.13
The labyrinthine subsegment begins medially at the orifice of the facial canal and continues laterally but angles slightly anteriorly and inferiorly for 3 to 5 mm to the first turn (genu) just posterior to the geniculate fossa and geniculate ganglion.13 The tympanic subsegment begins after the facial nerve bends 75 to course posteriorly and slightly laterally, running inferiorly for about 1 cm at a 10 angle from horizontal.
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From anterior to posterior, the tympanic subsegment is positioned just superior and posterior to the cochleariform process, superior to the oval window, and inferior and slightly medial to the lateral semicircular canal.13
Facial Nerve Exploration and Repair
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The mastoid subsegment begins at the second turn (genu) of the facial nerve at the posterior end of the tympanic subsegment (just posterior to the oval window) and bends from 95 to 125 just inferior to the lateral semicircular canal. ! The mastoid subsegment runs inferiorly at an angle from 5 to between 30 and 35 from the vertical, and it usually runs slightly laterally until exiting the stylomastoid foramen. The length depends on development of the mastoid process and location of the stylomastoid foramen, from which the facial nerve exits the temporal bone. ! In neonates, infants, and small children, the second turn of the nerve is more acute and courses more laterally because of the incompletely developed mastoid bone. The stylomastoid foramen may be at the level of the mastoid antrum because, as the squamous portion of the mastoid process grows, the foramen moves inferiorly and always posterior to the styloid process.13 Extratemporal Segment The extratemporal segment of the nerve begins where the facial nerve exits the stylomastoid foramen. The extratemporal segment courses anteriorly and slightly laterally to enter the parotid gland and then passes lateral to the mandible and masseter muscle within the gland, separating the gland into superficial and deep portions. In small children the nerve enters the parotid gland in a more anterior location because the parotid gland is smaller and located more anteriorly.4 Branches At about the posterior border of the mandible, the facial nerve divides into temporofacial and cervicofacial branches. The temporofacial branch further divides into temporal (frontal), zygomatic, and buccal branches; the cervicofacial branch further divides into buccal, mandibular, and cervical branches. Many anatomic variations as well as multiple cross-anastomoses can be found (particularly between the buccal branches); this interconnecting plexus of branches is called the pes anserinus. INTRATEMPORAL EXPLORATION AND DECOMPRESSION An intracranial, intratemporal, extratemporal, or combined approach can be used to expose the facial nerve surgically. This chapter describes surgical approaches to the facial nerve from the geniculate ganglion peripherally. Good discussions of other approaches (including cranial nerve VII surgery in the internal auditory canal or medial to internal genu, the middle cranial fossa approach, and the translabyrinthine approach for sensorineural hearing loss with facial paralysis) may be found in Otologic Surgery by Brackmann et al5 and in Otoneurosurgery by Pellet et al.6 Intratemporal procedures are done to explore and visualize the course of the facial nerve or to decompress the nerve by removing the lateral bony facial canal wall. In cases of acute or chronic infection, a drainage procedure (mastoidectomy with enlargement of the aditus ad antrum, with or without wide myringotomy, and a large tympanostomy tube) may suffice. Modified or radical mastoidectomy may be required for removal of bony
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fragments, cholesteatoma, or extrinsic neoplasms compressing the nerve. When exploration reveals a missing nerve segment or when a facial nerve neuroma is excised, an interposition graft often is required. Indications Intratemporal exploration of the facial nerve, with or without decompression, is indicated for peripheral facial nerve paralysis caused by Blunt or penetrating head trauma (usually resulting in temporal bone fracture and immediate paralysis) for which computed tomography (CT) scan or magnetic resonance imaging (MRI) shows disruption of the facial canal and compression or disruption of the facial nerve Iatrogenic injury sustained during or after middle ear or mastoid surgery, regardless of whether the facial nerve was visualized Prolonged labor, difficult vaginal delivery, or both (with or without use of forceps), associated with hemotympanum, other evidence of temporal bone fracture, and either complete immediate facial nerve paralysis or progression to complete loss of facial function Acute otitis media persisting for 4 to 6 weeks after antibiotic therapy, wide myringotomy, and simple mastoidectomy with enlargement of the aditus ad antrum Chronic suppurative otitis media with tympanic membrane perforation persisting after mastoidectomy, enlargement of the aditus ad antrum, and use of topical and parenteral antibiotic agents Chronic suppurative otitis media with cholesteatoma Congenital cholesteatoma or neoplasm in the temporal bone Facial nerve neuroma Anesthetic Considerations For maximum safety and efficiency, anesthesia should be administered in a surgical suite strategically arranged to accommodate the specific tasks and materials needed during surgery. General endotracheal anesthesia is used without anesthetic agents that interfere with nerve testing and monitoring. Fluid intake is carefully controlled with a volume-control chamber, infusion pump, or similar device. Neonates and some young infants require a fluid warmer and either a warming blanket, warming lights, or both. Appropriately sized breathing circuits, blood pressure cuffs, masks, laryngoscopes, and endotracheal tubes also are necessary. The anesthesiologist is stationed across the table from the surgeon and inferior to the patients shoulder, to facilitate coordination and communication among the surgical team. The endotracheal tube is taped to the patients mouth on the side closest to the anesthesiologist (Figure 72). An angled sidebar is attached to the operating table on the side of the anesthesiologist to ensure easy access to the endotracheal tube and airway.
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Figure 72 Operating room (OR) arrangement for intratemporal bone facial nerve procedure on right ear.
Preparation The operating table can be reversed to more easily accommodate both the microscope base and the surgeons legs. The patient is placed in the supine position as close as possible to the surgeon. The patients head can be placed in a foam-sponge head holder so that the top of the patients head is positioned flush with the end of the operating table and the patients chin is flexed on the neck to bring the ear into a vertical position. Alternatively a Juers head holder can be attached to the end of the table and the patients head taped to the head holder (or to the table) for maximum immobilization. If this arrangement is selected, the anesthesiologist or circulating nurse rotates the table toward the surgeon for posterior visualization, and away from the surgeon for anterior visualization. Nerve integrity monitor electrodes are placed in the orbicularis oculi and orbicularis oris muscles and are connected to the unit. The electrodes are tested and activated before surgery. The ear canal and tympanic membrane are examined under the microscope. The canal skin and proposed postauricular incision are injected with a 1:100,000 epinephrine solution (0.1 mL of 1:1,000 epinephrine in 10 mL of sterile saline) for vasoconstriction, which improves visualization.
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If a fascia graft is necessary, access to the temporalis fascia may require shaving a sufficient amount of hair superior to the auricle, posterior to the auricle, or both. The entire auricle, ear canal, side of the face, and neck are sterilized with a surgical preparation. A 3M 1030 Steri-Drape (3M, St. Paul, MN) is placed with the fenestration over the ear and the long end draped over the angled sidebar. A thyroid sheet is then placed over the patient. The sidearm for viewing is positioned on the side of the microscope closest to the scrub table for the assistants ease of viewing and retraction. The video camera attachment is positioned on the opposite side toward the patients feet. Draped with a sterile cover, the microscope is positioned at the level of the patients head; for stability, the long extension of the microscopes base is pointed toward the surgeon. Video camera attachments are connected to the video recorder and viewing screen. The scrub table extends from the top of the operating table, and both tables are of equal height. The scrub nurse sits beside the scrub table, facing the surgeon (see Figure 72). Procedure Figure 73 overviews the intratemporal surgical procedure. The ear canal and tympanic membrane are examined for anatomic deformity. Wax and debris are removed. The ear canal is irrigated with sterile saline if the tympanic membrane is intact. If the facial nerve is suspected to be in an abnormal position and the paralysis has been present less than 72 hours, a nerve stimulator can be used to map the approximate position of the main trunk and branches of that nerve. The course of the facial nerve can then be marked with an indelible surgical marker.
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Figure 73 Intratemporal exploration and decompression of the facial nerve.
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No 1. Mastoidectomy The mastoid tip is palpated, and an incision is made 1 to 2 cm posterior to the retroauricular fold, from the superior attachment of the auricle to the mastoid tip. If a great auricular nerve graft is needed, the incision can be continued in a gradual curve onto the neck about 2 cm inferior to the margin of the mandible (Figure 74). In infants in whom a mastoid tip has not yet developed, or in anyone whose facial nerve has an anomalous course, an incision is made 1.5 to 2 cm posterior to and not inferior to the auricular attachment (Figure 75). The skin is elevated by sharp and blunt dissection until either the nerve is identified or the lateral extent of the external bony canal wall is reached.4 The postauricular skin and fibrofascial tissues are elevated anteriorly to identify the suprameatal spine (spine of Henle) at the superoposterior aspect of the lateral bony canal wall (Figure 7-6). Further elevation can be done anterosuperior to the canal to expose the zygomatic root and inferiorly to expose the mastoid tip. If the facial nerve is located in an anomalous lateral position, nerve preservation should be a primary goal during tissue elevation and dissection. To locate the mastoid air cells, an otosurgical drill with large burs is used in a horizontal direction just inferior to the temporal line; to enlarge the opening, the drill is used in a vertical direction from the temporal line to the mastoid tip. This use of the drill in horizontal and vertical directions creates a T-shaped opening (Figure 77). During any mastoid and middle ear surgical drilling, suction irrigation is used constantly to improve visualization and drill performance and to prevent thermal injury to the facial nerve and inner ear.
Figure 74 If a graft of the great auricular nerve is needed, postauricular incision 1 cm to 2 cm posterior to retroauricular sulcus may be continued to the upper portion of the neck (ie, to a point 2 cm inferior to the mandible).
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Figure 75 In neonates and young infants, a postauricular incision is made 1.5 to 2 cm posterior to the retroauricular sulcus and not inferior to the auricular attachment.
Figure 76 Postauricular elevation done to expose the spine of Henle, zygomatic root, temporal line, and mastoid process.
Figure 77 T-shaped opening made to begin mastoidectomy.
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The tegmen is located posterosuperior to the external canal at the temporal line. The dissection is continued medially along the tegmen to identify Krners septum and, more medially, the aditus ad antrum, the lateral (horizontal) semicircular canal, and the short process of the incus. To enlarge the mastoid cavity, the sinodural angle is drilled posteriorly and superiorly, the mastoid tip and digastric ridge are drilled inferiorly, the zygomatic root is drilled anteriorly, and the sigmoid (lateral) sinus is delineated posteriorly (Figure 78). The posterior bony external canal wall is thinned to expose more of the posterior and superior surfaces of the incus and the facial recess. To aid visualization the skin of the posterior canal wall can be elevated. An exploratory tympanotomy incision can be made before or after mastoidectomy if the middle ear must be entered to localize the facial nerve or to visualize or manipulate the ossicular chain. No. 2. Nerve identification If the facial nerve has not been identified after the mastoid cavity is surgically enlarged and the posterior canal is thinned, the facial nerve can be identified at either its superior or inferior aspect in the mastoid cavity. Superiorly the facial nerve can be identified just inferior to the fossa incudis as well as anterior (and, usually, medial) to the lateral semicircular canal. The facial nerve can be identified or further delineated by using smaller burs to make a triangular opening in the facial recess and by drilling parallel to the expected course of the nerve (Figure 79). A small bridge of bone inferior to the fossa incudis is left intact to protect the short process of the incus at the base of the facial recess triangle. The lateral side of the triangle is the annulus; the medial side is the facial nerve. The chorda tympani nerve originates at the apex of the triangle and continues as part of the lateral side. If located, the chorda tympani nerve can be followed inferiorly and posteriorly to the mastoid subsegment of the facial nerve (Figure 710). Enlarging the facial recess and the epitympanum and working through the tympanotomy incision facilitates exposure of the tympanic subsegment of the facial nerve. This approach can help determine continuity of the ossicular chain, extent of the cholesteatoma or neoplasm, or extent of the temporal bone fracture or trauma. Achieving maximum visualization in some cases may require the surgeon to disarticulate the incudostapedial and incudomalleolar joints and either rotate the incus (ie, medially or laterally) or remove it. Small burs are used to expose the tympanic subsegment of the facial nerve, usually by a facial recess approach but sometimes through the external canal. At the end of the procedure, the incus is either returned to its anatomic position or is interposed between the malleus and stapes and stabilized with small pieces of absorbable gelatin sponge.7
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Figure 78 Exposure of the lateral semicircular canal, short process of incus, sinodural angle, lateral sinus, and digastric ridge.
Figure 79 Facial recess approach to locate the facial nerve.
Figure 710 Facial recess approach to the chorda tympani nerve and the facial nerve canal.
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The nerve also can be located inferiorly at the stylomastoid foramen by following the digastric ridge anteriorly and superiorly along the lateral margin of the nerve. No 3. Exploration and Decompression For patients with traumatic paralysis, the mastoidectomy procedure can be terminated if no fracture or trauma site is seen. If a trauma site is identified, the facial nerve is explored proximally and distally using the largest diamond bur available; a thin bony covering is left to protect the nontraumatized nerve in the facial canal.
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At a location several millimeters proximal and distal to the site of injury, bony fragments are lifted carefully off the damaged nerve area using angled picks and elevators (Figure 711). To minimize nerve trauma and to maintain as much normal blood supply as possible, nerve exposure is limited to the trauma site. To enable the nerve sheath to serve as a protective layer for the nerve and thus facilitate axonal regeneration, the nerve sheath is not incised.
For avulsed nerve segments or for excision of facial nerve neuroma, interposition grafting is necessary (see Intratemporal Repair, Rerouting, and Grafting, below). After completion of drilling and before any grafting procedure, saline solution is used to irrigate the surgical site (ie, the mastoid cavity with or without the middle ear). If a tympanotomy flap has been elevated, it is replaced. The auricle and the skin of the posterior canal wall are repositioned. The postauricular incision is closed in two layers by using a 3-0 or 4-0 chromic catgut suture and a 4-0 or 5-0 nylon suture. An absorbable cutaneous suture or a subcuticular stitch can be used if the surgeon expects suture removal to be difficult. The ear canal is packed with absorbable gelatin sponge, an expandable ear wick, or gauze strips. A mastoid compressive dressing is applied. Mittens can be placed on the hands of young children to prevent them from removing the dressing. Postoperative Care The mastoid dressing is re-inforced to absorb bloody drainage during the night and is changed or removed the next day. If paralysis or paresis affects the orbicularis oculi muscle, artificial tears or eyedrops are used. To prevent inadvertent corneal irritation, the eyelid is closed manually while the patient is recumbent. The stitches and ear canal pack are removed 5 to 7 days postoperatively. Recovery of facial muscle function depends on the extent of denervation:
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If no denervation has occurred, recovery may be expected within 3 to 6 weeks.
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If compression has caused minimal or moderate denervation, recovery should take 4 to 12 weeks. If denervation is severe, recovery will take at least 8 to 12 weeks.
Figure 711 Bone fragments lifted to expose facial nerve (n).
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INTRATEMPORAL REPAIR, REROUTING, AND GRAFTING In cases of facial nerve laceration, the severed nerve endings must be exposed and approximated. Loss of less than 50% of the nerve fibers results in acceptable recovery, which includes midface contracture and synkinesis; this result is better than that produced by nerve grafting. Loss of 75% or more fibers results in unacceptable recovery. Consequently when cross-sectional avulsion of the nerve exceeds 50%, intratemporal interposition nerve grafting or rerouting of the facial nerve with primary anastomosis is probably indicated, depending on the surgeons clinical judgment. Possible nerve graft donor sites include the ipsilateral or contralateral great auricular nerve and the sural nerve. Choice of the donor site depends on the length of the defect, size of the nerve, and condition of donor sites.8 Principals of Facial Nerve Repair Grafting is successful only if the entire neurovascular system has residual vitality. The proximal nerve and nuclei must be intact and functioning, the portion of nerve distal to the dehiscence must be able to accept neural regeneration, and the facial muscles must be able to contract.9 Before deciding when and whether to operate and what technique to use, the surgeon may need to learn the cause and duration of the paralysis, obtain CT and/or MRI scans of the nerve and temporal bone, and use electrophysiologic tests. If treatment has been delayed for 1 year or more after onset of the condition, muscle biopsy may be necessary. The skin and sensory function over the donor site also must be checked: nonfunctional nerve may be fibrotic and thus unacceptable for grafting.10 Informed consent is extremely important because patients and their families must understand possible procedures, alternatives, risks, and complications. In particular the surgeon must clearly articulateand make sure that patients and their families understand the following:
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Recovery of facial function will not be evident for at least 3 months because the rate of facial nerve regeneration is 0.5 to 1 mm/day. Improvement may take more than a year. Recovery will not be total and is always associated with synkinesis.
Many current standards exist for the equipment as well as the technique used in nerve repair. Essential equipment includes an operative microscope, a sharp blade (razor blade or 6500 Beaver Mini-Blade [R Beaver Inc, Waltham, MA]) for nerve transection, and the fewest nonreactive 90 or 10-0 monofilament sutures necessary to maintain coaptation; use of atraumatic technique is critical.9,10 The recipient nerve stump and nerve graft bed should be prepared or irrigated before graft harvesting. The graft should be long enough to preclude suture line tension, and it should be placed in position with no delay. Possibly because it is less traumatic to the nerve, epineural suturing in the trunk seems more conducive to maximal nerve regeneration than does perineural suturing. When anastomosing nerves of different sizes, creation of an epineural-perineural anastomosis may be indicated.
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Nonstandard suggestions include cutting the nerve at a 45 angle instead of a 90 angle to increase surface exposure for healing (although the same number of neural tubules will still be present); reversing the graft orientation to facilitate neural ingrowth; and using tissue adhesives such as fibrin glue and laser welding. A controversial suggestion for minimizing synkinesis is to clip nonessential facial nerve branches to increase regeneration in the unclipped branches. Some authors believe that re-innervation of the zygomatic and buccal branches is most important for orbital and oral movement, particularly because return of function is rare in the frontal branch and is poor in the marginal branch. In contrast other authors believe that the frontal and marginal branches are more important for good cosmesis because the zygomatic and buccal branches often recover after crossanastomosis or masseter neurotization. Advocates of both these theories clip specific branches and/or tie the clipped ends by using a nonabsorbable suture.911 Indications Facial nerve approximation is indicated for acute intratemporal facial nerve laceration without separation of the nerve endings if affected nerve endings can be approximated and will remain in apposition without other stabilization. Facial nerve suturing is indicated for acute intratemporal facial nerve laceration, with or without separation of the nerve endings. If no separation exists, the nerve endings will not remain in an unsupported approximated position; if minimal nerve ending separation exists, the nerve endings can be approximated using tensionless sutures. Facial nerve rerouting may be elected when the nerve endings are under tension after suturing, regardless of temporal bone development. Moreover, for persons with fully developed temporal bones, facial nerve rerouting may be elected if the maximum space between nerve endings is as large as 1 cm; for persons with less-developed temporal bones (ie, small children), this distance must be smaller: the smaller the child, the smaller the distance needed.
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The advantage of successful rerouting is that only one suture line is needed, whereas two suture lines are needed for nerve grafting. The disadvantages of rerouting include limited length to be gained, additional trauma directed to the nerve by required circumferential exposure and elevation, interruption of the nerves blood supply, loss of the facial canal as a stent, possible surgical damage to the ossicular chain (with subsequent conductive hearing loss), and loss of the posterior bony canal wall. In children, the disadvantages of rerouting seem to outweigh the advantages because the mastoid segment of the facial nerve in children is shorter than that in adults.
Interposition nerve grafting is indicated when direct approximation of the separated nerve is impossible or when direct approximation can be achieved only with the nerve under tension. Compared with rerouting,
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interposition nerve grafting has the advantages of being less traumatic to the facial nerve and less disruptive to the middle ear anatomy and the conductive mechanism. Interposition nerve grafting has the disadvantage of necessitating two suture lines and an additional surgical site. Nerve grafting is contraindicated in the presence of infection. Grafting in an open cavity is problematic because of the lack of protection and possible contamination. Anesthetic Considerations General endotracheal anesthesia is used as described above Intratemporal Exploration and Decompression. Before anesthesia is administered, the ipsilateral and contralateral sides of the neck are tested for sensation. Preparation The patient is prepared as described above see Intratemporal Exploration and Decompression. The neck, ear, and side of the face are prepared for possible grafting of the great auricular nerve. If placement of a sural nerve graft is anticipated, the lower leg, ankle, and foot are similarly prepared. A surgical glove is placed over the toes, and the foot and leg are draped with a sterile stockinette and placed on a sterile sheet. An extremity drape is used to cover the leg. Procedure Figure 712 overviews intratemporal repair, rerouting, and grafting of the facial nerve. Simple mastoidectomy is always done (see Figures 75 to 78), with or without exploratory tympanotomy. If necessary (ie, to locate facial nerve, extent of neuroma, or trauma), a facial recess approach (see Figure 79 and 710) may be attempted for easier access to the nerve; if that approach fails, modified radical or radical mastoidectomy may be necessary. Facial nerve exploration is done, exposing the nerve for several millimeters proximal and distal to the site of trauma. All bone fragments are carefully lifted from the nerve (see Figure 711). In a simple nerve laceration, sutures may not be necessary if the severed edges are in approximation or can be positioned and maintained in approximation (Figure 713). If the nerve edges will not lie in an approximated position, they are sutured with enough 9-0 or 10-0 monofilament nylon sutures in the epineurium to maintain coaptation.
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Figure 712 Intratemporal repair, rerouting, and grafting of facial nerve.
Figure 713 Facial canal exploration and exposure of facial nerve proximal and distal to laceration of facial nerve.
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For rerouting, the entire facial nerve must be exposed from the geniculate ganglion to the stylomastoid foramen. The posterior bony canal wall is removed, and the nerve is elevated out of the facial canal and sutured with the fewest 9-0 or 10-0 monofilament nylon sutures needed to achieve coaptation (Figure 714).12 A neofacial nerve canal can be drilled for nerve stability but only if additional injury to the ear will not result. In patients with total ipsilateral sensorineural hearing loss, however, the ossicles can be removed, and additional space can be gained by removing the cochlea. This procedure is not done if cochlear implantation is an option. For interposition grafting, the nerve is explored and exposed with diamond burs for several millimeters proximal and distal to the avulsed or lacerated section. Drilling must expose half to two-thirds of the circumference of the nerve. Once the bony lining is thinned, it can be removed with picks and elevators (see Figure 711). The ends of the nerve are freshened with the sharpest possible blade (razor blade or 6500 Beaver Mini-Blade) to expose healthy nerve. In cases of delayed repair and neuroma, the nerve endings are submitted for frozen section to confirm viable nerve tissue. The ipsilateral great auricular nerve is a desirable choice for interposition grafting because this nerve is located within the surgical field and has appropriate length and caliber; however, to achieve a maximally successful outcome, the viability of both the facial nerve and the donor nerve should be confirmed by frozen section. The contralateral great auricular nerve or the sural nerve also can be used as a graft. To expose the great auricular nerve, the postauricular incision can be continued onto the neck approximately 2 cm inferior to the mandible:
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The great auricular nerve (C2, C3) is the sensory branch of the cervical plexus and courses from medial to lateral around the posterior border of the sternocleidomastoid muscle (Erbs point). The nerve ascends toward the inferior auricle and mastoid tip, proceeds along the lateral surface of the sternocleidomastoid muscle, and usually terminates in three branches (Figure 715A). The great auricular nerve bisects an imaginary straight line extending between the mastoid tip and the angle of the mandible (Figure 715B).
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Figure 714 Facial nerve rerouted and sutured with fewest sutures needed to achieve coaptation. (Adapted from Hilsinger RL Jr. The facial nerve. In: Bluestone CD, Stool SE, editors. Atlas of pediatric otolaryngology. Philadelphia: WB Saunders; 1995. p. 145.)
Figure 715 A, The great auricular nerve before a graft is taken. B, Before the grafting procedure is begun, the approximate position of nerve is located by drawing a vertical line bisecting a straight line between the mastoid tip and the angle of the mandible.
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Sufficient length of nerve graft is obtained through elevation, sharp and blunt dissection, and sharp incision with either a razor blade or a 6500 Beaver Mini-Blade. The graft is interposed in the facial canal and may stay in position without suturing. One to three 9-0 or 10-0 nylon monofilament sutures in the epineurium are placed to hold the graft in position (Figure 716). The postauricular incision is closed in two layers with 3-0 to 4-0 catgut and 4-0 to 5-0 nylon sutures. The neck skin may be approximated with staples. Antibiotic ointment is applied to the incision line. Fluffed gauze sponges and 10 cm " 10 cm dressing gauze sponges are used as a compression dressing. A mastoid, Barton, or nylon tubular net dressing can be applied for pressure. Postoperative Care The dressing is reinforced to absorb bloody drainage during the night and is changed or removed the next day. Eyedrops or artificial tears are used, and the eyelid is closed manually while the patient is recumbent to prevent inadvertent corneal irritation. The stitches and ear canal pack are removed after 5 to 7 days. The patient should begin to notice recovery after 4 to 6 months. Improvement in facial function may continue for 12 months or longer.
Figure 716 Nerve graft sutured in position in the facial canal.

EXTRATEMPORAL EXPLORATION AND REPAIR FOR LESIONS
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In children, neoplastic disease in the parotid area is uncommon, and hemangioma is more common than lymphangioma; pleomorphic adenoma is the most common benign solid tumor. Of the malignant tumors, mucoepidermoid carcinoma is the most common, and adenocarcinoma is the next most common. Malignant parotid gland disease tends to occur later in childhood; sarcoma can occur at an early age. Non-neoplastic disease occurs infrequently. Congenital anomalies of the first branchial cleft are rare.7,1316 Complete examination for disease of the parotid area includes obtaining an accurate medical history and physical examination with radiographic studies (including CT, MRI, or both) and with or without fine-needle aspiration biopsy. Conducting these tests may be difficult in younger children and thus may necessitate sedation or general anesthesia for the child. Because these tests cannot ensure accurate diagnosisin children or in adultsexcisional biopsy (superficial or total parotidectomy) usually is indicated for a nonresolving or enlarging growth. If possible, hemangioma is left to regress spontaneously. Similarly, unless complications occur, surgery for other suspected nonmalignant disease can be delayed until the child is well developed.7,1417 Indications Parotid gland cysts, neoplasms, and chronic parotitis Nonparotid neoplasms that invade or are contiguous with the parotid gland (ie, when the facial nerve is at risk during surgery) Cysts and fistulas of the first branchial cleft Anesthetic Considerations General endotracheal anesthesia is used as described abovesee Intratemporal Exploration and Decompression. Nasotracheal intubation is used to increase the distance between the mastoid tip and the ascending ramus of the mandible and thus to facilitate location of the facial nerve trunk. The entire side of the face (including the auricle, ear canal, and neck) is sterilized with a surgical preparation. A nasal endotracheal tube can be attached to the forehead with Tegaderm transparent adhesive dressing (3M, Salt Lake City, Utah) and immobilized with a head wrap to allow manipulation of the head with less risk of extubation. The nasal endotracheal tube is covered with a towel so that when a 1050 Steri-Drape (3M, Salt Lake City, Utah) is applied to the side of the face and neck, the drape does not attach to the endotracheal tube. Use of the plastic drape enables exposure of the chin, corner of the lips, nasofacial junction, eye, and forehead. The anesthesiologist is positioned on the side of the operating table opposite the surgeon and inferior to the patients contralateral shoulder so that the surgeon and surgical assistants have easy access to the patients entire head and each side of the patients neck (Figure 717).
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Figure 717 Operating room (OR) arrangement for extratemporal bone facial nerve procedure on right ear.
Preparation The patient is placed in the supine position with the top of the head flush with the edge of the operating table and with the body positioned closest to the side of the table at which the surgeon stands. The patients head is turned away from the operating surgeon and toward the anesthesiologist so that the affected parotid is exposed. A rolled towel is placed underneath the patients shoulders to accentuate the operative field. The patients hair is taped away from the surgical field with Hy tape (Hy Tape Surgical Products Corp, Yonkers, NY). In patients who have no facial paralysis or who have had paralysis for less than 72 hours, a nerve stimulator can be used to determine the approximate position of the facial nerve and its branches. Nerve integrity monitor electrodes are placed in the orbicularis oculi and orbicularis oris muscles and are then connected to the monitor unit, tested for function, and activated. The proposed incision line is injected with a 1:100,000 epinephrine solution (0.1 mL of 1:1,000 epinephrine in 10 mL of sterile saline) for increased vasoconstriction and for improved visualization.
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If placement of a sural nerve graft is anticipated, the lower leg, ankle, and foot are similarly prepared. A surgical glove is placed over the toes, and the foot and leg are draped with a sterile stockinette and placed on a sterile sheet. An extremity drape is used to cover the leg. A thyroid or a split sheet is used to cover the patient and to drape the entire surgical field. The scrub nurse stands next to the surgeon and in front of the back scrub table. Surgical loupes and the microscope should be available to help the surgeon locate and dissect along the nerve. Procedure Figure 718 overviews extratemporal exploration and repair for lesions.
Figure 718 Extratemporal exploration and repair for parotid and nonparotid lesions.
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No 1. Incision and exposure The proposed preauricular incision (Figure 719) is marked with a surgical marker.
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In older children and adolescents, the incision will be less noticeable if curved posteriorly to conform to the anatomic indentation just superior to the tragus, inferior to the tragus, or both. The incision continues just inferior to the earlobe and posteriorly onto the mastoid process and is then curved inferiorly and anteriorly about 2 cm inferior to the mandible rim, preferably within a skin crease (see Figure 719A). Alternatively, the postauricular portion of the incision can be continued into the hairline or directly posteriorly into the hair as in a facelift incision. In infants (in whom the mastoid tip has not yet developed) and in patients in whom the course of the nerve is considered anomalous, an upper neck incision is made 2 cm inferior to the rim of the mandible and curving onto the postauricular area. After the skin incision is made, the skin flap is elevated superiorly with sharp and blunt dissection until the facial nerve is located. The incision can then be extended superiorly, if necessary (see Figure 719B).4
Figure 719 A, Incision line for parotidectomy. Incision may be extended (arrows) as necessary to the neck, hairline, or into the hair. B, Incision line for parotidectomy in infant with undeveloped mastoid tip. After the facial nerve is identified, the incision can be extended along the dotted line as necessary. (Reproduced and adapted [A only], with permission from Farrior JB, Santini H. Facial nerve identification in children. Otolaryngol Head Neck Surg 1985;93:1746.)
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The skin flap is elevated using sharp and blunt dissection to a point about 1 cm superior, anterior, inferior, and posterior to the parotid gland. Elevation usually is continued until the zygomatic arch, the buccal fat pad, the upper one-third of the neck, and the mastoid tip are exposed (Figure 720). The anterior border of the sternocleidomastoid muscle is identified. The great auricular nerve is located at the posterior border of the upper midportion of the sternocleidomastoid muscle and is exposed superiorly until it branches just inferior to the auricle. The nerve is kept in position as long as possible. In smaller infants, transecting the great auricular nerve may be unnecessary because the parotid gland is more anterior than it is in older children and adults.4
Figure 720 Elevation of parotidectomy skin flaps to expose zygoma, buccal fat pad, masseter muscle, and sternocleidomastoid muscle.
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The anterior border of the sternocleidomastoid muscle is dissected medially until the posterior belly of the digastric muscle is located (Figure 721). The inferior border of the parotid gland is retracted superiorly, and the digastric muscle is followed to its origin, medial to the mastoid tip (the digastric muscle originates at the level of and inferior to the stylomastoid foramen, through which the facial nerve exits). This dissection in infants may suffice to locate the main trunk of the facial nerve, because the parotid gland in infants is more anterior (Figure 722).4 The preauricular area is dissected medially along the external canal perichondrium. The parotid gland is retracted anteriorly. Sharp and blunt dissection is continued medially until the cartilaginous pointer is identified at the bony cartilaginous junction of the external auditory canal (Figure 723). This dissection plane is continued superiorly to the level of the zygomatic arch. The preauricular dissection is continued medially, both superior and inferior to the expected location of the facial nerve. This technique facilitates eventual visualization of the nerve by widening the surgical field.
Figure 721 Retraction of inferior parotid gland and sternocleidomastoid muscle to locate posterior belly of digastric muscle.
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Figure 722 Location of facial nerve in infant with anteriorly placed parotid gland. (Adapted and reproduced with permission from Farrior JB, Santini H. Facial nerve identification in children. Otolaryngol Head Neck Surg 1985;93:1746.)
Figure 723 Posterior border of parotid gland retracted anteriorly to dissect external canal medially toward cartilaginous pointer. (Adapted from Hilsinger RL Jr. The facial nerve. In: Bluestone CD, Stool SE. editors. Atlas of pediatric otolaryngology. Philadelphia: WB Saunders; 1995. p. 151.)
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No 2. Identifying the facial nerve The facial nerve is located about 1 cm medial to the tympanomastoid suture line and the cartilaginous pointer at the external auditory canalbony cartilaginous junction, just anterior to the stylomastoid foramen (Figure 724).
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This area is separated with blunt dissection parallel to the expected course of the nerve. Bleeding is controlled with clamps, 3-0 absorbable suture ties, bipolar cautery, a Shaw scalpel, or light pressure using small or large moist dissecting sponges.
Figure 724 Exposure of main trunk of facial nerve and its temporofacial and cervicofacial divisions.
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Proper surgical technique is essential when working near the facial nerve:
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The surgeon should minimize any contact with the facial nerve and its branches. Visualization obscured by blood can be improved by lightly touching the facial nerve with small and large moist dissecting sponges. Minimal pressure should be applied, and the nerve should not be rubbed or suctioned. In most cases, knowledge of the anatomy of the facial nerve should obviate the need for a facial nerve stimulator, which can further traumatize the nerve. In revision surgery, post-traumatic exploration, and certain patients with extensive neoplastic disease and infection, however, the nerve may be identified through judicious use of a facial nerve stimulator at its lowest setting.
If the main trunk cannot be identified or if it is incorporated in scar tissue or tumor, peripheral branches must be located and dissected in retrograde fashion to the main trunk in the following areas: the mandibular branch, temporal branch, buccal branches, and zygomatic branch. The mandibular branch, or ramus mandibulae, is located in the neck lateral to the facial vessels and just superior to the submandibular gland.
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In many infants this branch is located more superiorly, lateral to the mandible. In older children, if the mandibular branch is not located easily, the fascia of the submandibular gland can be incised and elevated superiorly along the posterior facial vein until the cervical or mandibular branch is identified.
The temporal branch is usually found overlying or just superior to the zygomatic arch deep to the superficial fascia, about halfway between the anterior border of the auricle and the lateral bony orbital rim. A buccal branch can be found coursing near and parallel to the parotid duct about 1 to 1.5 cm inferior to the zygomatic arch. The zygomatic branch can often be identified between the anterosuperior border of the parotid gland and the lateral inferior orbital rim. Rarely, for large neoplasms or when severe scarring has resulted from prior surgery or trauma, mastoidectomy is indicated. In that circumstance the facial nerve is explored to locate the nerve and follow it through the stylomastoid foramen. Once the main trunk has been identified, blunt dissection is continued anteriorly along the trunk until its bifurcation is located; the facial nerve is then identified conclusively, and the parotid tissue lateral to the nerve can be incised with a Shaw scalpel or with a No 11, 12, or 15 blade.
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Dissection along the nerve can be facilitated initially with a fine hemostat such as a McCabe facial nerve dissector. Once the proper plane has been established, curved mosquito-type forceps and small Kelly clamps suffice. Each branch is dissected to a point distal to the parotid gland (Figure 725). No 3. Superficial and deep parotidectomy If possible, the parotid gland between the branches is removed with the pathologic specimen. As large a margin of normal parotid tissue as is possible is included around any tumor or cyst. If, after the superficial portion of the parotidectomy has been completed, the disease process is medial to the facial nerve, the nerve is elevated gently with sharp and blunt dissection. The main trunk and each of the cervicofacial branches are retracted with vascular loops to expose the underlying parotid tissue (Figure 726). The masseter muscle is identified anteriorly and medially to expose and remove the tissue medial to the facial nerve. Dissection is begun in a plane lateral to the masseter fascia and is continued to the posterior border of the masseter muscle at the ascending ramus of the mandible. A second dissection plane is begun on the mastoid tip inferior to the stylomastoid foramen and the main trunk of the facial nerve. This plane is continued medially and is connected with a plane beginning on the bony canal superior to the facial nerve trunk. The remaining parotid tissue, which may be in the parapharyngeal space, can be removed by advancing along the dissection planes.
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If necessary to protect the facial nerve, this portion of the excision can be done in segments from between the branches of the nerve or superior or inferior to the main trunk and to the superior or inferior branches of the nerve. When dissecting superior to the trunk and posterior to the frontal branch, care should be taken to avoid injuring the auriculotemporal branch of the third division of the trigeminal nerve. This branch lies near the superficial temporal artery between the auricle and the mandible.
In patients with large tumors of the parapharyngeal space, anterior traction on the mandible may provide adequate additional operating space. Otherwise, mandibular osteotomy and mandibular swing may be necessary to adequately visualize and access the site so as to sufficiently facilitate removal of tumor or parotid tissue.
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Figure 725 Exposure of the zygomatic branch of facial nerve with a curved hemostat before severing parotid tissue lateral to the facial nerve.
Figure 726 Main trunk and cervicofacial branch of facial nerve retracted to expose underlying parotid gland tissue.
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Once the pathology specimen has been removed, the nerve is inspected to ensure that it is intact:
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If transected at the trunk or at the temporalis, zygomatic, or mandibular branches, the nerve is reapproximated using the fewest 9-0 or 10-0 monofilament nylon sutures needed to achieve coaptation (Figure 727). Anastomosis of severed buccal branches is usually unnecessary because of the rich interanastomosis of buccal branch nerve fibers. The cervical branch is routinely sacrificed during parotidectomy, and it does not require repair because loss of function is minimal.
If a segment of the nerve has been removed, an immediate interposition nerve graft can be sutured in place (Figure 728).
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If delay of grafting is elected, the severed proximal and distal ends should be marked with nonabsorbable (nylon) sutures to facilitate localization at subsequent repair. Instead of using an interposition graft, less important branches may be severed and anastomosed to more valuable branchesfor example, the buccal to the temporal or zygomatic branch, or the buccal or cervical to the mandibular branch (Figure 729).18
Figure 727 Sutured laceration of main trunk of facial nerve.
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Figure 728 Interposition nerve grafts sutured into zygomatic and marginal branch defects.
Figure 729 Transposition (A) and anastomosis (B) of cervical branch to avulsed mandibular branch and of buccal branch to avulsed zygomatic branch. (Adapted and reproduced with permission from Tucker HM. The management of facial paralysis due to extracranial injuries. Laryngoscope 1978;88:34854.)
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The wound is irrigated with saline solution, and the facial nerve is reexamined for continuity. A Penrose or vacuum drain is placed inferior to the trunk, posterior to the branches, and through either the inferior neck incision or a separate incision. The preauricular skin can be approximated with 3-0 to 4-0 catgut and 4-0 to 5-0 nylon sutures. The neck incision can be approximated with staples. Antibiotic ointment is applied to the incision. Fluffed gauze sponges and 10 cm " 10 cm dressing gauze sponges are used for a pressure dressing. A Barton or nylon tubular net dressing can be applied for pressure. Postoperative Care Facial function is checked when the patient is awakened from anesthesia.
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If paresis or paralysis is present and the nerve was left intact, the patient is observed. If paralysis is present immediately after surgery and was not present preoperatively, and if the status of the nerve was not checked, the nerve should be explored to establish continuity, and any lacerations should be repaired.
The patient is observed for hematoma, seroma, salivary fistula, corneal irritation, or new facial paralysis. Gustatory sweating may be a late complication. Artificial tears are used, and if the eye is affected by facial paresis or paralysis, the eyelid is closed before sleep. The dressing is re-inforced overnight to absorb bloody drainage. The drain is removed on the first or second postoperative day or when drainage is minimal or nonexistent. The pressure dressing is applied for 4 to 7 days, and the sutures or staples are removed on the seventh postoperative day. If the nerve was intact at the end of surgery, any postoperative paresis should resolve in 4 to 6 weeks. If paralysis is present, recovery should begin within 3 months and should continue for 12 months.
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EXTRATEMPORAL EXPLORATION AND REPAIR AFTER TRAUMA Penetrating wounds of the face may affect the main trunk of the facial nerve as well as any or all of its branches. Because facial nerve injury may be part of more massive trauma, assessment of the patients airway and cardiovascular status is important. Neurologic evaluation should be done after the patients condition has stabilized and should include assessment of the facial nerve. Computed tomography scans are appropriate when the temporal bone has been traumatized. An MRI may help to locate injury to either the nerve trunk or the larger nerve branches. The type of trauma and duration of paralysis are also important. Differentiating partial from complete facial paralysis may be difficult when facial edema, ecchymosis, or lacerations exist and particularly if the patient is uncooperative.9,10,19 Any nerve branch lacerated anterior to the masseter muscle is usually too small to approximate; in addition, function often returns because of cross-anastomoses or neurotization. A completely severed facial nerve continues to conduct impulses for about 72 hours.810 Wound exploration within 72 hours can thus be facilitated by use of nerve stimulation to help find the severed nerve branches. The nerve stimulator is of no help if the patient is evaluated after 72 hours; nonetheless, exploration and repair should be done as soon as it is feasible. Dissection is facilitated when delayed until scarring has matured.810 Nerve grafts should be done before 18 months, by which time fibrosis of the neural tissues and subsequent atrophy of muscle fibers is sufficiently advanced to preclude a successful result from grafting. Indications Facial paralysis immediately after a penetrating wound anterior or inferior (or both) to the auricle and posterior to the anterior border of the masseter muscle (repair is unnecessary for branches severed anterior to the masseter muscle). Facial paralysis immediately after blunt trauma to the head and neck. Anesthetic Considerations General nasotracheal anesthesia is used as described abovesee Extratemporal Exploration and Repair for Lesions. Preparation Preparation is made for possible parotidectomy, mastoidectomy with facial nerve exploration, and grafting of the great auricular nerve or sural nerve as described above see Intratemporal Exploration and Decompression and Extratemporal Exploration and Repair for Lesions. The surgeon should have access to a nerve integrity monitor, facial nerve stimulator, and microscope or surgical loupes.
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Procedure Figure 730 outlines extratemporal exploration and repair for facial nerve trauma. For more peripheral cutaneous lacerations accompanied by segmental paralysis, exploration of the wound and approximation of the severed nerve endings may be possible. A parotidectomy approach is necessary to locate the facial nerve:
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If the lacerated peripheral branches cannot be located or approximated In more proximal facial lacerations In total facial nerve paralysis In cases of blunt trauma with no external laceration
Figure 730 Extratemporal exploration and repair after trauma.
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As with the procedures described earlier in this chapter, a facial nerve stimulator may facilitate locating the nerve if the surgical approach is done within 72 hours after onset of paralysis. If the facial nerve trunk and its branches are intact, or if lacerations are found only in the cervical or distal buccal branches, the nerve can be left as is and the wounds can be cleaned, debrided, and sutured. In acute cases, once a nerve laceration or avulsion is locatedand if the ends can be approximated without causing tensionthe nerve endings are mobilized and sutured with the fewest number of 9-0 or 10-0 monofilament nylon sutures necessary to achieve coaptation. If the ends cannot be approximated without the use of tension, underlying parotid tissue may be removed to allow approximation without adding tension to the suture line (Figure 731A and B).18 When the laceration is situated at the stylomastoid foramen or at a posterior location on the main trunk so that suturing of the proximal stump is impossible, mastoidectomy with facial nerve exposure is necessary to locate and mobilize the proximal nerve for reapproximation or grafting.
Figure 731 A, Avulsed parotid tissue and facial nerve. B, Superficial and underlying parotid tissue is removed to enable approximation of nerve branch ends after avulsion. n = nerve; m = muscle. (Adapted and reproduced with permission from Tucker HM. The management of facial paralysis due to extracranial injuries. Laryngoscope 1978;88:34854.)
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In cases of delayed repair, the nerve endings are mobilized, freshened with a razor blade or with a 6500 Beaver Mini-Blade, and sutured with the fewest 9-0 or 10-0 monofilament nylon sutures needed to achieve coaptation (Figure 732A to C). As in acute cases, underlying parotid tissue may be removed to allow approximation without adding tension to the suture line. Interposition nerve grafting is necessary if the severed segments cannot be approximated or can be closed only under tension (see Extratemporal Repair, Rerouting, and Grafting, below). If immediate grafting is impossible or inadvisable (eg, when gross contamination or anesthetic complication is present), the severed proximal and distal ends should be tagged with nonabsorbable nonreactive (nylon) sutures for easier localization at subsequent repair. In cases of delayed repair, a frozen section of nerve margin should be analyzed to determine whether neural fibrosis has occurred. If neural fibrosis is detected, further nerve resection is needed until viable nerve tissue is located. A Penrose or vacuum drain is placed inferior to the trunk and posterior to the branches of the nerve, and it is passed either through the inferior part of the incision or through a separate incision. Any wound lacerations are freshened; these lacerations, as well as the parotidectomy incision, are approximated using 3-0 to 4-0 chromic catgut subcutaneous sutures and 4-0 to 5-0 nylon cutaneous sutures. Antibiotic ointment is placed on the incision(s). Fluffed gauze sponges and 10 cm " 10 cm dressing gauze sponges are applied with either a Barton or nylon tubular net compression dressing. Postoperative Care Postoperative care and nerve recovery time after surgical exploration and repair are the same as discussed in the previous section on Extratemporal Exploration and Repair for Lesions.
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Figure 732 A, Similar-sized nerve and nerve graft ends are cut at a 90 angle with a sharp blade and then sutured. B, When a smaller-diameter graft is needed, 5 mm of epineurium is stripped from the end and the perineurium is sutured to recipient nerve. C, Two nerve grafts of smaller diameter are sutured to a larger-diameter nerve trunk.
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EXTRATEMPORAL REPAIR, REROUTING, AND GRAFTING Extratemporal facial nerve rerouting or grafting is done when primary approximation of the nerve endings is impossible or cannot be done without causing tension at the suture line. Extratemporal facial nerve rerouting is done by removal of the existing parotid gland to enable approximation without tension at the suture line.8 Depending on length of defect, size of the nerve, and condition of donor sites, nerve graft donor sites may include the ipsilateral or contralateral great auricular nerve and the sural nerve. Various nerve transfers, predominantly the hypoglossal-facial (XII-VII) but also the cross-facial (VII-VII) and spinal accessoryfacial (XI-VII), have been advocated. The simplest and least debilitating nerve transfer can be done by severing cervical or buccal branches and by approximating them to the distal stump of the mandibular, zygomatic, or temporal branches.911,18 Indications Approximation and suturing are indicated in any laceration at the trunk or main branch posterior to the anterior border of the masseter, if this approximation and suturing can be done without causing tension at the suture line. Rerouting of the extratemporal facial nerve is indicated if lacerated nerve segments cannot be approximated without causing tension at the suture line and in the presence of residual parotid tissue, which, if removed, will enable approximation without causing tension at the suture line. For interposition nerve grafting to be done, viable neural tissue must be present at the proximal and distal segment margins. Grafting is indicated in three circumstances: 1. Extratemporal facial nerve laceration in which primary approximation and suturing are not possible 2. Primary approximation and suturing are achieved and the laceration is under tension 3. Avulsion of more than 50% of the nerve has occurred Nerve transfer of a cervical or buccal branch is indicated when lacerations of mandibular, zygomatic, or temporal branches cannot be approximated without causing tension at the suture line and when sufficient length and appropriate diameter of cervical or buccal branch are available for primary anastomosis without causing tension at the suture line. Nerve transfer from another cranial nerve (XII, XI, or contralateral VII) may be indicated as a last resort in patients with a flaccid face, functioning distal nerve and neuromuscular junction, and no viable proximal nerve. An interposition nerve graft may be necessary to bridge the gap. Because of the additional cranial nerve deficit that results after nerve transfer, this procedure must not be undertaken unless the patient has first given informed consent that takes into account not only the result of nerve transfer but also the deficit that the patient should expect after the loss of donor nerve.
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Anesthetic Considerations General nasotracheal anesthesia is used as described abovesee Extratemporal Exploration and Repair for Lesions. Preparation Preparation is made for possible parotidectomy, mastoidectomy with facial nerve exploration, and grafting of the great auricular nerve or sural nerve as described abovesee Intratemporal Exploration and Decompression and Extratemporal Exploration and Repair for Lesions. The surgeon should have access to a nerve integrity monitor, facial nerve stimulator, and microscope or surgical loupes. Procedure The extratemporal facial nerve is sutured and rerouted as described in the two previous sections on Extratemporal Exploration and Repair for Lesions and Repair After Trauma. Exposure and preparation of the proximal and distal facial nerve sites before nerve grafting are done as described in the four previous sections. The nerve graft should be obtained after the recipient site is prepared. If grafting is delayed after the nerve graft is obtained, the nerve should be placed in Ringers lactate solution. The great auricular nerve (ipsilateral or contralateral) or the sural nerve may be used. No 1. Great auricular nerve graft Before grafting the great auricular nerve, the surgeon should test the skin of the neck for sensation in the area of the C2/C3 distribution on both the ipsilateral and the contralateral sides of the neck. The cervical portion of a parotidectomy incision can be used to locate the great auricular nerve. Otherwise a horizontal incision is made parallel to (or, preferably, in) a skin crease about 2 cm inferior to the mandibular margin and centered on the posterior border of the sternocleidomastoid muscle. One long incision or two smaller stair-step incisions can be made. Once isolated, the nerve can be dissected proximally toward its origin in the cervical plexus to gain as much as 10 cm of additional length. The cervical incision can be approximated in two layers by using 3-0 to 4-0 chromic catgut sutures and 4-0 to 5-0 nylon sutures. If the ipsilateral great auricular nerve is smaller than the severed branch of the facial nerve, the contralateral great auricular nerve or one or more fascicles of the sural nerve also can be grafted (see below). Use of the great auricular nerve as a graft leaves a cutaneous sensory deficit over the mastoid process and auricle. No 2. Sural nerve graft The sural nerve is formed by the junction of the communicating ramus of the lateral sural cutaneous nerve and the medial sural cutaneous nerve in the middle of the leg.
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The sural nerve is usually located just medial to the small saphenous vein; it then continues inferiorly and curves anteriorly, inferior to the lateral malleolus, where it divides into several branches. The sural nerve ends as the lateral dorsal cutaneous nerve. ! The sural nerve is easiest to locate just posterior to the lateral malleolus and next to the saphenous vein (Figure 733). The sural nerve can be exposed through a vertical incision that bisects the plane between the lateral malleolus and the Achilles tendon. The incision is then curved inferior to the lateral malleolus and onto the lateral aspect of the foot (Figure 734A). An alternative, more cosmetically acceptable way to expose the sural nerve, is to first make a horizontal incision at the level of the lateral malleolus and posterior to it (Figure 734B). Lateral traction on the vein and the sural nerve reveals the nerves superior and inferior course and thus allows easier dissection. Horizontal incisions are then made at appropriate intervals to obtain a longer graft. Up to 35 cm of nerve, consisting of two to four fascicles, can be used. The leg incision is approximated in two layers by using 3-0 to 4-0 chromic catgut sutures and 4-0 to 5-0 nylon sutures. A compressive leg dressing is applied using 10 cm " 10 cm dressing gauze sponges and elastic tape.
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Figure 733 The sural nerve, located adjacent to the saphenous vein in the lower part of leg.
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Figure 734 The sural nerve can be identified through (A) a vertical incision bisecting the distance between lateral malleolus and the Achilles tendon and curving inferiorly to gain additional length or branches, or (B) a horizontal incision made just posterior to the lateral malleolus with stairstep incisions above and below to obtain additional length.
No 3. Interposition grafting When ready for use, the great auricular or sural graft is laid in position to determine the length needed. Slightly more graft than is needed should be taken to allow for contraction and to avoid tension on suture lines. The ends are prepared by using a sharp razor to sever the nerve at an angle between 45 and 90. If the diameter of the graft is too large, epineurium may be removed as is necessary from the last 5 mm of the nerve graft at either or both ends.
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An appropriate number of 9-0 or 10-0 monofilament nylon sutures is used to approximate the perineurium of the graft to the epineurium of the nerve (Figure 735). Depending on the width of the proximal and distal nerve stump or stumps, either the entire nerve or one or more fascicles can be used. No 4. Hypoglossal facial anastomosis For hypoglossal facial anastomosis, the cervical portion of a parotidectomy incision is made after the distal nerve stump has been located. The hypoglossal nerve is found 1.5 cm superior to the carotid bifurcation, where the nerve courses laterally to the internal and external carotid arteries and medially to the posterior belly of the digastric muscle. To maximize the length of nerve available for transfer, the nerve is dissected anteriorly as far as is possible before transection. Interposition nerve grafts may be necessary for approximation without tension. Both the distal facial nerve segment and the hypoglossal stump are prepared for perineural or epineural anastomosis, and the stump is sutured to the recipient facial nerve by using an appropriate number of 9-0 or 10-0 monofilament nylon sutures (Figure 736). Sacrifice of the hypoglossal nerve results in paralysis of the ipsilateral side of the tongue and ipsilateral facial contraction during deglutition. Facial function can be relearned. The wound is irrigated with sterile saline, and the skin incision is approximated with 3-0 or 4-0 chromic catgut sutures and with 4-0 or 5-0 nylon sutures. Staples can be used to close the cervical portion of the incision. Antibiotic ointment is applied to the incision line. To create pressure over the wound, a compressive Barton or tubular net dressing or elastic tape is applied over fluffed gauze sponges and 10 cm " 10 cm dressing gauze sponges. Postoperative Care The facial and cervical dressings are re-inforced overnight to absorb bloody drainage. The dressing is removed on the first or second postoperative day, and a fresh compressive dressing is applied and is left in place for 4 to 7 days. The compressive leg dressing applied after the sural nerve grafting is removed 1 to 3 days postoperatively; sutures or staples in the leg and neck are removed 7 to 10 days postoperatively. Recovery of facial function should begin within 4 to 6 months postoperatively and may be expected to continue for at least 12 months postoperatively.
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Figure 735 Two grafts or fascicles sutured to a facial nerve trunk larger in diameter than are available donor grafts.
Figure 736 Hypoglossal nerve transected and sutured onto previously prepared distal facial nerve.
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ELECTROPHYSIOLOGIC TESTING Electrophysiologic (EP) testing can be used either to stimulate the affected nerve-muscle complex or to record volitional muscle action potentials, including fibrillation or defibrillation potentials. In patients with facial paralysis, EP testing is sometimes used clinically to assess degree of nerve damage, to help establish prognosis for recovery, and to determine need for surgical intervention. However, because patients with partial paralysis have complete recovery, EP testing can be useful only for patients who have complete facial nerve paralysis. In addition, nerve action potentials remain nearly normal for as long as 72 hours, so nerve stimulation tests are useful only after 72 hours and for no more than 2 or 3 weeks after injury. Volitional muscle testing is not reliable until at least 2 or 3 weeks after injury.20,21 EP Testing Procedures Types of EP testing include nerve excitability testing, maximal stimulation testing, electroneurography, electromyography, magnetic stimulation, and testing of the stapedial muscle reflex. Nerve excitability testing. Nerve excitability testing (NET) subjectively compares movement of each side of the face after the facial nerve is stimulated with the minimal amount of current necessary to elicit muscle contraction. A difference of at least 3.5 mA in stimulation intensity at the facial nerve trunk or over its branches indicates progressive or impending degeneration.22 As a clinical test, NET has largely been replaced by either maximal stimulation testing (MST) or electroneurography (ENOG). Maximal stimulation testing. Maximal stimulation testing is a subjective test in which branches of the facial nerve are stimulated to determine the level of current needed for maximal muscle contraction. The amount of facial motion on each side of the face is compared subjectively, and the response is recorded as a percentage of function of the unaffected side.20 Electroneurography. Electroneurography consists of bipolar electrical stimulation of the facial nerve trunk as well as bipolar recording (at peripheral branches) of two parameters: stimulation level needed for a maximal response, and size and configuration of the compound muscle action potential (CMAP). Electroneurography can be performed using either of two methods. In the standard method, electrodes for nerve stimulation and recording are placed at fixed (standard) points on the face. In the optimized method, the electrodes are moved to various points on the face to obtain the greatest CMAP. Both techniques enable comparison between the CMAP on each side of the face regardless of stimulation level. The latent period between application of the stimulus and the start of CMAP testing is sometimes used to indicate functional status of the facial nerve. The recorded end point can be measured and compared statistically with that of the other side. Use of ENOG varies from clinic to clinic, and interpretation differs on the basis of both the pathology expected and the treatment selected. Amplitude reduction of 90% or more within 1 to 3 weeks is interpreted as indicating need for surgical intervention.20,21
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Electromyography. When administered at least 2 to 3 weeks after nerve injury, electromyography (EMG) can be useful for assessing facial re-innervation. Volitional EMG can be used to monitor facial nerve recovery; if no recovery is seen at a 2- to 3-week follow-up, fibrillation potentials become established. Regeneration potentials become visible after about 12 weeks and occur before facial motion becomes visible. In patients with acute incomplete facial nerve paralysis, electromyographic evidence of fibrillation potential is considered an indication of tumor, until this diagnosis is otherwise disproved. Magnetic stimulation. Magnetic stimulation is a technique in which stimulation generated by a magnetic coil is applied at the stylomastoid foramen and is recorded retrograde at the vertex. Results of this test can indicate facial nerve degeneration and damage.21 Stapedial muscle reflex testing. Testing of the stapedial muscle reflex can also be considered an electrophysiologic test because, as the first motor branch of the facial nerve, the stapedial nerve is the first facial nerve branch to recover. Recovery of an absent stapedius reflex within 21 days suggests an excellent prognosis. Appropriate Use Basing treatment on the results of electrical tests alone is problematic for two main reasons: Any indicated surgery will be delayed 3 days because a 3-day delay exists between the time of injury and the time when nerve action potentials become abnormal. Abnormal results of electrical tests remain abnormal and cannot be used to monitor nerve regeneration. Although electrical tests can be used to assess the prognosis and can accurately indicate inappropriateness of surgical intervention, results of these tests are not timely indicators for treatment. Members of our department have used the clinical history, results of physical examination and, when necessary, results of radiologic studies to assess the physical state of the nerve and thus to serve as a guide toward surgical exploration of the facial nerve. ACKNOWLEDGMENTS For reviewing an earlier draft of the manuscript, the author thanks Frederick M. Byl, MD, E. Lila Jordan, RN, and Kedar K. Adour, MD, who also helped with the Electrophysiologic Testing section for this edition. Jon Coulter, MA, CMI, and Juan Domingo provided the illustrations. The Medical Editing Department of Kaiser Foundation Research Institute provided editorial assistance.
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REFERENCES
1. Proctor B. The anatomy of the facial nerve. Otolaryngol Clin North Am 1991;24:479504. 2. Clemente CD, editor. Grays anatomy of the human body. 30th ed. Philadelphia: Lea & Febiger; 1985. 3. Hollinshead WH. Anatomy for surgeons. 3rd ed. I. The head and neck. Philadelphia: Harper & Row; 1982. 4. Farrior JB, Santini H. Facial nerve identification in children. Otolaryngol Head Neck Surg 1985;93:1736. 5. Brackmann D, Shelton C, Arriaga M, editors. Otologic surgery. 2nd ed. Philadelphia: WB Saunders; 2001. 6. Pellet W, Cannoni M, Pech A, et al. Otoneurosurgery. New York: Springer-Verlag; 1990. 7. May M. Facial paralysis in children. In: Bluestone CD, Stool SE, Arjona SK, editors. Pediatric otolaryngology. Philadelphia: WB Saunders; 1983. p. 24970. 8. Adkins WY, Osguthorpe JD. Management of trauma of the facial nerve. Otolaryngol Clin North Am 1991;24:587611. 9. Johns ME, Crumley RL. Facial nerve injury, repair, and rehabilitation [Otorhinolaryngology self-instructional packages, 79200]. Washington (DC): American Academy of Otolaryngology; 1979. 10. Papel ID. Rehabilitation of the paralyzed face. Otolaryngol Clin North Am 1991;24:72738. 11. Fisch U, Lanser MJ. Facial nerve grafting. Otolaryngol Clin North Am 1991;24:691708. 12. Hilsinger RL Jr. The facial nerve. In: Bluestone CD, Stool SE, editors. Atlas of pediatric otolaryngology. Philadelphia: WB Saunders; 1995. p. 12966. 13. Batsakis JG. Tumors of the head and neck: clinical and pathological considerations. 2nd ed. Baltimore: Williams & Wilkins; 1979. p. 914, 646. 14. Gates GA. Diseases of the salivary glands. In: Bluestone CD, Stool SE, Arjona SK, editors. Pediatric otolaryngology. Philadelphia: WB Saunders; 1983. p. 102336. 15. McRae RG, Lee KJ, Goertzen E. First branchial cleft anomalies and the facial nerve. Otolaryngol Head Neck Surg 1983;91:197202. 16. Schuller DE, McCabe BF. Salivary gland neoplasms in children. Otolaryngol Clin North Am 1977;10:399412. 17. Harris JP, Davidson TM, May M, Fria T. Evaluation and treatment of congenital facial paralysis. Arch Otolaryngol 1983;109:14551. 18. Tucker HM. The management of facial paralysis due to extracranial injuries. Laryngoscope 1978;88:34854. 19. Olsson JE, Shagets FW. Blunt trauma of the temporal bone [Otorhinolaryngology self-instructional package, 80386]. 2nd ed. Washington (DC): American Academy of OtolaryngologyHead and Neck Surgery; 1986. 20. Adour KK. Facial nerve electrical testing. In: Jackeler RK, Brackmann DE, editors. Neurotology. St. Louis (MO): Mosby; 1994. p. 12839. 21. Dobie RP. Tests of facial nerve function. In: Cummings CW, Frederickson JM, Harker LA, et al, editors. OtolaryngologyHead & Neck Surgery. 3rd ed. St. Louis (MO): Mosby; 1998. p. 275766. 22. Laumans EP, Jongkees LB. On the prognosis of peripheral paralysis of endotemporal origin. Part II: Electrical tests. Ann Otol Rhinol Laryngol 1963;72:62136.
CHAPTER 8
E AR C ANAL S TENOSIS AND ATRESIA

Simon C. Parisier, MD Jose N. Fayad, MD
Inadequate attention to the external ear canal may cause an otherwise successful tympanomastoid operation to fail. When performing ear surgery, a narrow canal or overhangs that prevent adequate exposure may compromise the desired results. An understanding of the ear canal anatomy, with analysis and correction of the structures producing narrowing or obstruction, permits a systematic operative approach resulting in a patent meatus and canal. A common iatrogenic complication of operations involving the external ear canal is partial postoperative stenosis. A narrow meatal opening defeats the self-cleaning mechanism of the external ear canal, leading to the problem ear. Following a canal walldown mastoidectomy, the mastoid cavity, which becomes marsupialized into the external ear, must be accessible. Failure to provide good access to the mastoid recess frequently results in problem ears that are difficult to manage.
PRINCIPLES OF EAR CANAL SURGERY Otologic surgery involving the ear canal is ideally performed when the skin is not inflamed, and after any acute infectious processes are controlled. Draining ears should be medically treated prior to surgery: Meticulous debridement of the ear canal is performed as an office procedure using an operating microscope and appropriate delicate instruments. Wax, retained keratin debris, and secretions are cleansed to expose the underlying skin and eardrum remnant. Granulation tissue is removed and sent for pathologic examination. The resulting bleeding base is chemically cauterized. A culture of the ear canal may be obtained in selected refractory cases. Appropriate antifungal or antibiotic topical drops and systemic oral antibiotics are prescribed. The importance of preventing water entry into the ear when bathing or swimming must be emphasized to the patient and family. Patients are instructed to plug the affected ear with commercially available soft silicone plugs or petroleum-impregnated lambs wool.
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Parents and patients are admonished not to use cotton-tipped applicators, which can impact debris in the canal and irritate the skin. Occasionally, when a patient is unable to comply with the recommended instructions or is refractory to the treatment, hospitalization is recommended for intravenous antibiotic and intensive local therapy. Most wet ears can be converted to a dry state in 4 to 6 weeks using the above recommendations. Surgery can be performed when the acute inflammatory ear process is quiescent. Occasionally, despite intensive therapy, suppuration persists. In these cases, the indicated ear surgery might be required, in spite of active drainage, in order to create a noninfected ear. Generally, surgery performed in an actively inflamed ear may be accompanied by increased bleeding that may obscure the underlying anatomy and consequently compromise the surgical outcome. Also, in a small child, blood loss may be significant, requiring blood transfusions. Audiometric evaluations should always be performed prior to surgery on an ear. The indications for obtaining radiographic imaging are determined by the underlying existing clinical findings. RECONSTRUCTION OF THE EXTERNAL EAR CANAL Indications Reconstruction of the external ear canal requires preserving the specialized, cerumen-producing, migratory skin lining and managing its two anatomic portions: lateral (cartilaginous) and medial (bony). Lateral Cartilaginous Ear Canal Skin lining: contains hair follicles, sebaceous glands, and dermal layer. This is the thicker layer of ear canal skin. Procedure overview: perform meatoplasty by removing constricting cartilage from the anterior edge of the concha and by resecting cartilage that forms the floor of the canal. The skin lining is preserved. Medial Bony Ear Canal Skin lining: the lamina propria of the epidermis merges with the bony periosteum. This is the thinner layer of ear canal skin. Procedure overview: develop pedicled canal wall skin flaps posteriorly and anteriorly. Expose bony overhangs, which are drilled away. Replace the meticulously preserved canal wall skin, maintaining an epidermis-lined canal. In cases for which the canal wall skin is deficient, use a split-thickness skin graft to provide a stable epidermal canal lining. Surgical Anatomy In the tympanic part of the temporal bone, two prominent suturesthe anterior tympanosquamous suture and the posterior tympanomastoid suturemay protrude and encroach on the canal lumen (Figure 81). The resulting overhangs can prevent the eardrum margin and related pathologic changes from being visualized. The suprameatal spine (see Figure 81), when prominent and anteriorly oriented, can further narrow the canal at the bony-cartilaginous junction.
Ear Canal Stenosis and Atresia
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Figure 81 Tympanic portion of the temporal bone showing the anterior tympanosquamous suture (a), posterior tympanomastoid suture (b), and the suprameatal spine (c).
The anterior and inferior portions of the tympanic bone vary in bulk. The glenoid fossa is anterior to the ear canal. The mastoid bone and the air cell system are posterior to the ear canal. Anesthetic Considerations and Preparation General anesthesia is usually required for children. Local anesthesia may be feasible for short procedures in adolescents. Standard and routine draping should be used, providing exposure of the ear. Facial nerve monitoring may be applicable. If facial nerve monitoring is used, muscle relaxants are avoided.
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Procedure The described approach is applicable to a wide variety of otologic procedures, including tympanoplasty, mastoidectomy (wallup or walldown), and repair of ear canal stenosis (acquired or congenital). The ear canal surgical methods described include endaural and postauricular approaches (Figures 82 and 83). Table 81 lists the advantages and limitations of each approach.
Figure 82 An endaural approach. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 83 A postauricular approach. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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Table 81 Endaural vs. postauricular approach for ear canal reconstruction

Approach Advantages Disadvantages
Endaural
! Precise incision placement ! Facilitates development of a rectangularly shaped, laterally based conchal-meatal skin flap ! Pedicled flap promotes healing, reduces granulations, and eliminates stenosis formation
" Inadequate exposure to eradicate disease in a large pneumatized mastoid cavity " Cartilage resection, especially from the canal floor, is technically difficult while preserving canal wallmeatal skin; this may hamper construction of a large meatal opening " Anterior sulcus area is more difficult to access, especially when there is a canal wall overhang
Postauricular
! Best exposure of extensively " Imprecise placement of canal skin pneumatized mastoid bone incisions may result in skin loss, ! Enhanced visualization of the delayed healing, and partial stenosis anterior canal-tympanic " Additional surgical exposure membrane sulcus and time are needed ! Direct exposure of conchal and inferior canal cartilages facilitates elevation of meatal and canal wall skin ! Permits harvesting of areolar tissue and temporalis fascia grafts, which allow bone resurfacing after a canal walldown mastoidectomy
No 1. Endaural approach The ear canal is injected with 1:100,000 epinephrine solution.
!
Using a 25-gauge needle, the injection is placed into the dermal portion of the ear canal where the last hair cells are located. Injection into the skin of the osseous canal results in blebs and tears of the thin epidermis and should be avoided. The needle bevel is directed towards the bone. Fluid is injected using digital pressure, forcing the anesthetic to hydrodissect towards the eardrum. The skin is observed to blanch and thicken as the anesthetic is slowly injected. The initial injection is made superiorly at 12 oclock into the loosely attached superior canal skin where the spread of the solution is limited by the skins fibrous attachments to the tympanosquamous and tympanomastoid sutures. The second injection is made into the skin inferiorly at 6 oclock, the spread of the solution being confined to the tightly adherent skin overlying the tympanic bone.
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Through an ear speculum, using a stapes knife, a horizontal incision is made in the ear canal 2-3 mm lateral and parallel to the annulus (Figure 84). The incision extends from above the lateral process of the malleus (12 oclock) to the floor of the external canal. The meatal opening is widely dilated using a Lempert endaural speculum (Figure 85). Two vertical incisions are made using an electrosurgical unit with a needlepoint tip to minimize bleeding and enhance visibility: 1. The first incision is made superiorly in the notch between the tragus and the anterior root of the helix (12 oclock) (Figure 86). This incision is not carried down to the horizontal one; a bridge of skin is initially maintained for stability. Working through this incision, a duckbill elevator is used to elevate the superior and posterior canal wall skin off the underlying bone (Figure 87).
Figure 84 A horizontal incision is made using a stapes knife through an ear speculum. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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Figure 85 Dilation of the meatal opening with a Lempert endaural speculum. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 86 The first incision is made using an electrosurgical unit with a needle point tip at the 12 oclock position. (Reproduced with permission from Johnson JT, editor. American Academy of Otolarygology-Instruction Courses. Vol. 4. St. Louis (MO): CV Mosby; 1991.)
Figure 87 A duckbill elevator lifts the skin of the superior and posterior canal wall off the underlying bone. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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This exposes the tympanosquamous suture anteriorly (Figure 88), the canal bone, the suprameatal spine, and if possible, the tympanomastoid suture posteriorly. 2. In the same fashion as the previous step, an incision is made at the 6 oclock position beginning at the horizontal incision and extending laterally to the conchal opening (Figure 89). Using a duckbill elevator, the inferior posterior canal wall skin is dissected from the underlying bony canal (Figure 810). The bridge of the skin that was initially preserved superiorly is now cut using a Bellucci scissors, completing the mobilization of the rectangular-shaped meatal canal skin flap (Figure 811).
Figure 88 Undermining reveals a tympanosquamous suture (arrow). (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 89 A second incision is made at the 6 oclock position. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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Figure 810 The skin of the inferior posterior canal wall is elevated. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 811 Preserved skin is cut with a Bellucci scissors to form the meatal canal skin flap. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
The rectangular skin flap is elevated retrograde out of the canal to the meatus (Figure 812A and B). The meatal opening can be further enlarged by extending the vertical incisions into the conchal area, and by excising cartilage under the concha and canal wall floor via the postauricular approach.
Figure 812 A and B, The flap is elevated out of the canal to the meatus. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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No 2. Postauricular approach The skin is incised just posterior to the skin crease using an electrosurgical unit with a needlepoint tip (Figure 813). The dissection separating the tissues that connect the auricle to the scalp is facilitated by pulling the ear laterally, thus opening up the tissue planes. Cutting the auricularis muscle bundle mobilizes the auricle and facilitates visualization of the temporalis area. The ear is retracted forward (Figure 814). The ear is retracted forward (see Figure 814) and grafts are harvested from the temporalis fascia and the overlying prefascial (areolar) connective tissue layer.
!
The thin areolar tissue is incised parallel to the superior temporal line (see Figure 814, inset). The areolar tissue is grasped, dissected from the underlying muscle with a Freer elevator (Figure 815), and excised with a scissors (Figure 816). The graft is spread out and allowed to dry on a Teflon block for later use in resurfacing the bone when performing a canal walldown mastoidectomy.
Figure 813 Using a postauricular approach, an incision is made using electrocautery. (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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Figure 814 The ear is retracted forward, and an incision is made through the areolar tissue (inset). (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 815 The incised tissue is lifted and dissected with a Freer elevator. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 816 Areolar tissue is excised. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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The temporalis fascia graft is obtained by making a circular incision through the fascial layer (Figure 817). The size of the graft should be dictated by its purpose. For repair of a drum defect, a relatively small graft is harvested; for a canal walldown mastoidectomy, a larger graft is harvested to repair the tympanic membrane and cover exposed bone. The superior edge of the graft is grasped with a pickup and is bluntly freed off the temporalis muscle (Figure 818).
The mastoid periosteum is incised in a T-like fashion (Figure 819). The first incision (1) is carried down to and parallel to the superior temporal line. A second incision (2) is made at a right angle and carried down to the mastoid tip. Using the Freer elevator and the electrosurgical knife, the periosteum is elevated to expose the mastoid cortex. Large, self-retaining retractors are inserted to enhance operative exposure.
Figure 817 A temporalis fascia graft is obtained by making a circular incision through the fascial layer (inset). (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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Figure 818 The graft is removed from the temporalis muscle. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 819 A T-shaped incision is made in the mastoid periosteum. The first incision (1) is made parallel to the superior temporal line and is followed by another incision (2), which is made at a right angle to the mastoid tip. (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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The cartilage of the canal floor in the tympanomastoid sulcus area is identified and dissected using a Stevens scissors (Figure 820A). This cartilage is known by parotid surgeons as the pointer and is used as a landmark for finding the facial nerve. The inferior canal wall skin is dissected off this cartilage to visualize the previously made endaural inferior 6 oclock incision. The block of cartilage, freed from its adjacent connective tissue, is amputated from its remaining anterior attachment, which is continuous with the tragal cartilage (Figure 820B, arrow). The inferior portion of the cartilaginous canal can now be enlarged. The excised cartilage is placed in saline and can be used later for ossicular reconstruction or to repair a defect in the lateral attic wall. To complete the meatoplasty, a crescent-shaped segment of the anterior edge of the conchal cartilage is excised (Figure 821). The auricle is held with the surgeons thumb and index finger while the third or fourth finger is inserted into the lumen to dilate and stabilize the meatal opening. This facilitates incising the cartilage and developing a tissue plane between the cartilage and the meatal skin (Figure 822).
Figure 820 A, Cartilage is dissected from the floor of the canal in the tympanomastoid sulcus area and is removed from the remaining anterior attachment. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.) B, Space created from its removal (arrow) enables enlargement of the inferior portion of the cartilaginous canal.
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Figure 821 The conchal cartilage segment is excised. (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 822 The tissue plane between the cartilage and the meatal skin is established. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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The mobilized, rectangular, conchal-based posterior meatal canal wall skin is debulked. The skin is grasped with a forceps and supported on the surgeons finger (Figure 823), and then thinned using a Stevens scissors until ceruminous glands are visible. The debulked flap is more pliable and easier to reposition into the canal, especially in cases where the canal has been preserved. An adequate meatus is approximately 1.5 to 2.0 cm in diameter, which should easily admit the surgeons index finger. If the meatus is too small, the vertical 12 and 6 oclock incisions may be extended laterally into the concha, and additional soft tissue and cartilage resected (see the discussion on Figures 819 and 820).
Figure 823 The conchal-based skin of the posterior meatal canal wall is debulked. (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
No 3. Eliminating anterior bony canal overhangs and obstructions An incision is made through the anterior canal skin with a stapes knife parallel to the plane of the eardrum in the protruding area (Figure 824A). The skin is raised in a retrograde fashion until the tympanic bonycartilaginous junction (arrow) is reached (Figure 824B). The skin is usually firmly attached at the tympanic bony-cartilaginous junction. The cartilage is separated from the rough bony surface using a duckbill elevator, thus mobilizing the skin and gaining adequate exposure of the entire tympanic ring (Figure 825).
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Figure 824 A, An incision is made through the anterior canal skin and is elevated, B, until the tympanic bone cartilage junction (solid arrow) is reached. (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 825 A duckbill elevator separates the cartilage from the rough bony surface. (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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The bony overhangs are removed with constant suction irrigation and appropriate burs (Figure 826A). Removal of the laterally positioned bony overhangs allows visualization of the more medial structures. The distal skin lining the anterior and inferior medial bony canal skin is elevated down toward the fibrous annulus (arrow). Great care is taken to preserve the skin that lines the anterior sulcus. Sponges are placed over the distal skin to protect it from the suctioning and drilling (Figure 826B). The remaining bony overhangs are removed using diamond burs, which will not displace the protective sponges. Anteriorly, the bone is thinned until it becomes translucent, thus allowing detection of the color of the glenoid periosteum, which can be appreciated through the intact layer of bone. Inferiorly, the floor of the canal is enlarged until the drum margin is visible. Posteriorly, when performing a procedure in which the canal is preserved, it is important not to enter the mastoid air cells. Prominent bony protuberances obscuring the drum margin are drilled away. Circumferential drilling of the tympanic bone is completed when the tympanic annulus and pars flaccida are clearly visible and permit adequate exposure for removal of pathology and to perform the necessary surgery. Upon completing the ear surgery, the anterior sulcus skin is repositioned and the area stented with Gelfoam (Figure 827). The angle formed by the eardrum and canal wall skin must be preserved to prevent blunting. The laterally raised anterior canal wall skin is replaced to resurface the bony canal. The meatal opening is enlarged, the canal is packed, and the wound is closed after either a canal wallup or a canal walldown procedure.
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Figure 826 A, Bony overhangs are removed using suction and a drill while the distal skin is elevated and protected by sponges, B. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
A B
Figure 827 The anterior sulcus skin is repositioned, and the area is stented with Gelfoam. (Reproduced with permission from Johnson JT, editor. American Academy of OtolaryngologyInstruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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No 4. Canal walldown procedure The mastoid periosteum is turned into the posterior portion of the mastoid recess. A 2-0 catgut suture is used to approximate the area where the conchal cartilage had been excised to the mastoid periosteum (Figure 828A). This enlarges and stabilizes the meatal opening (Figure 828B). The posterior canal wall skin is turned into the posterior mastoid recess, creating an epithelial pedicle flap. This flap helps resurface the posterior mastoid recess and enhance epidermization of the cavity.
Figure 828 A, A suture is used to approximate connective tissue, resulting in enlargement and stabilization of the meatal openings, B. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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Absorbable gelatin sponge (Gelfoam) is used to pack the temporalis fascia and areolar tissue grafts are packed against the bony surfaces. Medium thick (0.05) Silastic sheeting is positioned to line the cavity and the ear canal, which is packed with additional Gelfoam. Bismuth-impregnated petrolatum gauze strips (Xeroform) are packed into the Silastic-lined meatal opening. The postauricular incision is closed and a mastoid dressing is applied. The diameter of the meatal opening affects the size of the mastoid recess. When the meatus is small, the area to the sinodural angle becomes longer and the cavity becomes larger (Figure 829A). A large meatus reduces the area to the sinodural angle, and consequently the mastoid cavity is smaller (Figure 829B).
Figure 829 The size of the diameter of the meatal opening affects the size of the mastoid recess. A, A small diameter. B, A large diameter. (Reproduced with permission from Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
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No 5. Canal wallup procedure The mastoid periosteum is sutured to the temporalis muscle using 2-0 chromic catgut. The area where the crescent of conchal cartilage had been excised is approximated to the edge of the mastoid periosteum enlarging and stabilizing the meatal opening. Working endaurally, the posterior canal wallmeatal skin flap is replaced into the canal to resurface the posterior canal wall. The lumen is lined with medium thick (0.05) Silastic sheeting to stent the canal, and serve as a nonadherent dressing that prevents ingrowth of granulation tissue. The lumen is packed with absorbable gelatin sponges (Gelfoam) and bismuth-impregnated petrolatum gauze strips (Xeroform). The postauricular incision is closed and a mastoid dressing is applied. Postoperative Care The mastoid dressing is removed after 48 hours and an aqueous suspension of antibiotic eardrops, to be used three times a day, is prescribed. The nonadherent Silastic sheeting, within which the packing had been placed, is removed after 10 to 14 days. If properly inserted, the removal of this nonadherent packing is painless and bloodless. The topical eardrops are continued until the Gelfoam has either dissolved or been removed and the ear canal and mastoid skin lining has healed.
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SKIN GRAFTING OF THE EXTERNAL AUDITORY CANAL The purpose of skin grafting is to restore an epithelial lining to the external auditory canal in cases where there is congenital atresia or where the skin has been lost (ie, trauma, previous ear surgery). To ensure a patent lumen, the existing meatalcanal wall skin is used to stabilize the meatal opening and thin split-thickness skin grafts are used to line the bony canal. Indications Split-thickness skin grafting is required for reconstruction of the ear canal in cases of congenital or acquired atresia and stenosis. Acquired etiologies include iatrogenic, post-traumatic, and after surgical excision of exostoses or ear canal neoplasms. Preparation The lower abdomen should be draped appropriately, and the following equipment should be available: ! Dermatome ! Silicone sheeting, 0.001" thickness ! Benzoin-type adhesive ! Absorbable gelatin sponge (Gelfoam) ! Bismuth-impregnated petrolatum gauze strips (Xeroform) ! 5-0 plain gut suture Procedure A thin, split-thickness skin graft approximately 6 cm by 2 cm is harvested from the lower abdomen, between the inguinal crease and the umbilicus. This site is easily hidden by a bikini-style bathing suit (Figure 830).
Figure 830 The lower abdomen skin graft site.
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The donor site is dressed with Xeroform and an occlusive dressing. A composite skin-silicone graft is prepared: 1. A 0.001" silicone sheeting square slightly larger than the harvested skin graft is smoothed out by placing clamps at its four corners to prevent curling (Figure 831A). 2. Benzoin adhesive is applied to the thin silicone sheeting, which is allowed to dry and become sticky (Figure 831B). 3. The epidermal side of the skin graft is glued to the adhesive on the silicone sheeting to form a composite graft (Figure 831C). 4. The composite graft is trimmed to the necessary size (Figure 832). The dermal surface of the skin graft can now be applied to the bony surface of the canal. 5. Slits are cut at the end of the graft so as to overlap the temporalis fascia, which has been used to construct the tympanic membrane (see Figure 832). The graft is positioned into the ear canal with the slit end medially (Figure 833A), and then placed over the reconstructed tympanic membrane (Figure 833B). The lateral end may be sutured into the concha.
Figure 831 Silicone sheeting is unfurled (A) and treated with benzoin adhesive (B) before a skin graft is applied to it (C).
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Figure 832 The skin-silicone graft is trimmed (A), and slits are cut (B and C) in order to overlap the temporalis fascia.
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Figure 833 A, The graft is positioned into the canal. B, The graft is placed over the reconstructed tympanic membrane.
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Gelfoam is carefully inserted into the composite graft and packed snugly. Artificial sponges (microspheres) are used to suction the Gelfoam, thus compacting it into the canal and ensuring that the skin grafts become apposed to the bony surfaces (Figure 834). Postoperative Care The occlusive donor site dressing is removed after several days, and the patient is advised to bathe daily in a half-filled tub. The Xeroform will peel off spontaneously, and the skin will heal in about 10 days. The patient should avoid getting water into the canal for at least 3 months and possibly as a routine. Swimming may be allowed 6 months after surgery, but usually with ear protection (ie, disposable silicone ear plugs). Grafted skin is not as hardy as normal external canal skin; it does not migrate laterally and has no pilosebaceous cerumen glands. Therefore, regular orifice cleaning of accumulated keratin debris is performed about every 6 months, or as required. Grafted bony ear canals are more likely to develop external otitis.
Figure 834 Artificial sponges are used to suction Gelfoam and ensure that grafts become apposed to bony surfaces.

CONGENITAL AURAL ATRESIA
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Because atresias are associated with temporal bone and other organ system developmental abnormalities, potential accompanying disorders must be identified and investigated before correcting the atresia. The following should be looked for: Middle ear and mastoid: hypoplastic or absent tympanic cavity; reduced aeration of the middle ear and mastoid; anomalies of the carotid artery and jugular bulb; and anomalous course of the facial nerve, which may preclude a successful hearing reconstruction. Inner ear: dysplasia of the cochlea, vestibular structures, or auditory canal. Extratemporal: malformations of other organ systems that develop synchronously with the ear, such as the genitourinary tract. Other aspects of the preoperative evaluation include 1. Computed tomography (CT) 1.5 mm axial and coronal slices of the temporal bone are mandatory. Three-dimensional CT scanning offers further information, such as the relation of the atretic plate to the tegmen tympani and the glenoid fossa. The radiographic examination should demonstrate the following:
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Thickness and shape of the atretic plate Extent of the external canal development and the presence (or absence) of cholesteatoma if the canal is stenotic Size and pneumatization of the mastoid and the middle ear Status of the ossicles, facial nerve, and inner ear structures
2. Audiometric evaluation Hearing acuity in both ears must be assessed even if one ear has a normal appearance. In newborns, auditory brainstem-evoked potential testing can be performed with bone conduction testing to quantify the conductive loss and any sensorineural component. Potential coexisting sensorineural hearing loss, which would not be corrected by atresia surgery, should be identified and discussed with the family prior to surgery. Bilateral hearing loss must be treated with appropriate amplification at the earliest possible age. Indications Timing of surgery If the atresia is bilateral, the child is fitted with a bone-conductive hearing aid at the earliest age possible. Canal reconstruction can be performed when the child is 4 to 5 years of age. If atresia is unilateral, reconstruction is elective. The parents can elect to surgically restore hearing or defer the procedure until the patient is able to participate in the decision-making process.
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Congenitally stenotic canals may be more urgent to repair because retained debris and keratin may form a cholesteatoma. Controversy exists regarding the order of correction when atresia is accompanied by microtia. Auricular reconstruction generally precedes the atresia surgery to prevent scar tissue and compromised vascularity from jeopardizing the cosmetic results. The microtia repair must be delayed until about age 6 years, to allow adequate development of the costochondral cartilage for sculpting the auricular cartilaginous scaffold. The risks and realistic expected benefits of this complicated surgery must be discussed with the family relative to the individual surgeons operative results. Contraindications A significant neurosensory hearing loss or inner ear malformation. Limited middle earmastoid pneumatization or a significantly hypoplastic middle-ear cleft. Anomalous facial nerve or aberrant major vascular structure. Middle cranial fossa tegmen sagging, which would restrict anatomic access to the middle-ear cleft. Procedure Continuous facial nerve monitoring, though not essential, is recommended. The risk of iatrogenic injury to the nerve may increase because of an anomalous course in the temporal bone. A skin incision is made posterior to the rudimentary or the reconstructed auricle (Figure 835). Palpation of the temporomandibular joint may help to orient the surgeon in the patient with an aberrant, low-set, deformed auricle. The incision is carried down to the temporalis fascia, and a graft is obtained to reconstruct the eardrum (see Figures 814 to 818). The periosteum is incised in a T-like fashion as described earlier (Figure 836). The mastoid cortex is exposed, and the glenoid fossa is identified (Figure 837). Occasionally, a rudimentary imperforate tympanic ring or a cribrose area (circle) is present. Alternatively, there may be no marks identifying where the canal should have developed. The level of the middle cranial fossa (cranium) roughly corresponds to the superior temporal line (dashed).
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Figure 835 A skin incision is made posterior to the reconstructed auricle.
Figure 836 A T-shaped incision is made on the periosteum.
Figure 837 The mastoid cortex is exposed. The superior temporal line (dashed line) approximates the level of the tegmen. Drilling is begun in the rudimentary tympanic bone (circle). TMJ = temporomandibular joint
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Drilling between the glenoid fossa and the tegmen plate (see Figure 837) creates the ear canal. In some cases, a core of dense bone represents the obliterated external canal. The surgeon should attempt to drill a circular canal-like opening toward the middle-ear cleft (Figure 838). It is important to avoid entering the mastoid air cells; however, the atresia plate itself is occasionally pneumatized. Frequently, a dense periosteal membrane is identified at the medial end of the atresia plate (Figure 839). In these malformed ears, the deformed malleus and incus are frequently fused into a single bony mass that is attached to the atresia plate. This ossicular mass may be continuous with a mobile stapes. Consequently, it is important not to inadvertently drill on these ossicles, which become mobilized when the atresia plate is removed. To avoid a vibratory inner ear injury, the atresia plate should be thinned down to an eggshell translucent thickness, which is then curetted away from the periosteal membrane. The periosteal membrane is then incised, and the middle ear is entered (Figure 840). An opening that is similar in dimension to a normal tympanic membrane must be made. Frequently, the vertical portion of the facial nerve is encountered posteriorly. It is desirable, though not always possible, to identify the round window niche (Figure 841). Occasionally, a forward-lying facial nerve prevents this.
Figure 838 A circular canallike opening is made with a drill. TMJ = temporomandibular joint
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Figure 839 Dense periosteal membrane.
Figure 840 The middle ear is entered after an incision of the periosteal membrane has been made.
Figure 841 Round window niche.
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If air cells have been entered, they can be plugged using bone dust pt (Figure 842A) collected in the Sheehy bone pt collector (Figure 842B). An ossicular reconstruction is performed when the chain is not continuous; observing a round window reflex may help decide if the chain is intact (Figure 843). Silastic sheeting is used to prevent bony fixation of the reconstructed ossicles. A temporalis fascia graft is inserted as an underlay medial to the endosteal membrane, which can frequently be preserved (Figure 844). A meatal opening is created. An anteriorly based pedicle flap using the imperforate skin from the conchal area is elevated from the underlying cartilage or connective tissue. (Figure 845A). The flap is debulked, removing cartilage and connective tissue (Figure 845B), thereby creating a rectangular full-thickness flap.
Figure 842 A, Bone dust pt is used to plug air cells. B, Sheehy bone pt collector.
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Figure 843 Silastic sheeting prevents bony fixation of the reconstructed ossicles.
Figure 844 A temporalis fascia graft is inserted medial to the endosteal flap (arrow).
Figure 845 A, The flap is elevated (arrow) and debulked, creating a rectangular full-thickness flap. B, Cartilage and/or connective tissue is excised (arrow) to create a lumen in the soft tissue atresia.
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The flap is rotated into the canal and is sutured anteriorly (arrows) to the soft tissue in the area of the glenoid fossa (Figure 846). This provides a vascular pedicled skin graft to resurface the lateral half of the anterior canal. The remainder of the canal is resurfaced using composite grafts of thin split-thickness skin and Silastic sheeting (see the previous section on skin grafting, Figures 830 to 832). Slits are made in the composite grafts so that they drape onto the temporalis fascia graft. Gelfoam is packed snugly into the lumen. The postauricular incision is closed with absorbable sutures (Figure 847). A mastoid dressing is applied. Postoperative Care The postoperative care is similar to that described above. The mastoid dressing is removed after 48 hours. Aqueous topical eardrops are prescribed. After 2 weeks, the first of the Gelfoam is removed in the office using the microscope. The remainder of the Gelfoam packing is gradually removed over several visits spaced at 10-14 day intervals. The canal heals in 4 to 6 weeks.
Figure 846 The lateral half of the anterior canal is resurfaced with a skin graft.
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Figure 847 A Penrose drain.
BIBLIOGRAPHY
Andrews JC, Anzai Y, Mankovich NJ, et al. Three-dimensional CT scan reconstruction for the assessment of congenital aural atresia. Am J Otol 1992;13:23640. Beck DL, Benecke JE. Intraoperative facial nerve monitoring-technical aspects. Otolaryngol Head Neck Surg 1990;102:2702. Bellucci RJ. Tympanoplasty, the malleus, stapes wire and total defect skin graft. Laryngoscope 1996;76:143958. Bellucci RJ. Congenital malformations of the ear. Otolaryngol Clin North Am 1981;14:95124. Bellucci RJ, Converse JM. The problem of congenital auricular malformation. Trans Am Acad Ophthalmol Otolaryngol 1960;64:840. Curtin HD. Congenital malformations of the ear. Otolaryngol Clin North Am 1988;21:31736. Jahrsdoerfer RA, Yeakley JW, Hall JW, et al. High resolution CT scanning and auditory brainstem response in congenital aural atresia: patient selection and surgical correction. Otolaryngol Head Neck Surg 1985;93:2928. Johnson JT, editor. American Academy of Otolaryngology-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991. Lambert PR. Major congenital malformations: surgical management and results. Ann Otol Rhinol Laryngol 1988;97:6419. Leonetti JP, Matz GJ, Smith PG, Beck DL. Facial nerve monitoring in otologic surgery: clinical indications and intraoperative technique. Ann Otol Rhinol Laryngol 1990;99:9118. Molony TR, De La Cruz A. Surgical approaches to congenital atresia of the external auditory canal. Otolaryngol Head Neck Surg 1990;103:9911001.
CHAPTER 9
C OCHLEAR I MPLANTS
Noel L. Cohen, MD J. Thomas Roland Jr, MD George Alexiades, MD
Cochlear implants are for patients with bilateral severe, profound, or total deafness, who derive little or insufficient benefit from amplification. Most adult implantees lost their hearing subsequent to speech acquisition, but a much smaller group had prelingual deafness. Outcomes, in general, are much better for the former group. Conversely, most pediatric implantees have congenital hearing impairment. Consequently, there is more experience in children with prelingual than postlingual deafness. Treatment is often unnecessarily delayed, however, because of a missed diagnosis or an unrealistic attitude by parents or physicians regarding the outlook for improvement. Cumulative results after a decade of experience indicate significant benefit to all the above groups, especially if the children were implanted at a young age or shortly after losing hearing. Contrary to earlier expectations, congenitally deaf children receive as much benefit from cochlear implants as post-lingually deaf children, can learn to hear, achieve normal speech, and read and attend mainstream schools as long as they are implanted early, receive the necessary rehabilitation, and study and live in a hearing and speaking environment. As the child matures, uses the implant, and participates in rehabilitation and education, performance will continue to improve. COCHLEAR IMPLANTATION Cochlear implants have been configured as single-channel, multichannel, intracochlear, or extracochlear, but the overwhelming majority of devices currently in use (October 2001) are multichannel, intracochlear systems. A multichannel device offers an advantage over the single-channel, since the cochlea is tonotopically organized. Comparative data have demonstrated the superiority of multichannel devices. An extracochlear device has the theoretic advantage of avoiding cochlear damage by using an extracochlear series of electrodes, but these devices have been difficult to design, and have failed to demonstrate either safety or efficacy in the past. Three devices are available in the United States for use in children (October 2001): the Clarion and CII devices manufactured by the Advanced Bionics Corporation, the Nucleus 24 K and Contour series from Cochlear Corporation, and the Combi-40+ by Med-El. A fourth device manufactured by the MXM company, is available in other countries, but
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not in the US. More than 20,000 children have received cochlear implants world-wide. The House AllHear single-channel implant is rarely used for either adults or children. Indications General criteria Bilateral severe to total deafness with little or no benefit from amplification Cochlea and cranial nerve VIII must be present. Overall health is satisfactory for general anesthesia. Age-related criteria Child age 12 months or older for the Nucleus Contour device Child age 18 months or older for the Clarion, CII, and Med-El Combi-40+ devices Child age 6 months or older with labyrinthitis ossificans. Deafness caused by meningitis should lead to an expeditious workshop, including both computed tomography (CT) and magnetic resonance imaging (MRI) scans to detect early changes of labyrinthitis ossificans, and to allow surgery before there is significant obstruction to electrode insertion into the scala tympani. Impact of otitis media Otitis media with effusion (OME) is not a contraindication to implantation. Acute or chronic ear infection (other than OME) is a contraindication; the timing of surgery may be difficult for the otitis-prone child. Tympanostomy (ventilating) tubes are generally removed prior to, or during, cochlear implant surgery to preclude contamination of the middle ear. Other considerations Appropriate educational and family setting (mainstream, oral/aural, total schooling, and family environment) Older children and adolescents must desire implantation. Parents must understand the need for continuing programming, rehabilitation, and education in an appropriate communication environment. Anesthetic Considerations and Preparation General endotracheal anesthesia is required; muscle relaxants are not used. A pediatric anesthesiologist is preferred for young children or those with airway problems. Electrophysiological monitoring is required, such as stapedial reflex, neural response telemetry (NRT), or auditory brainstem response (ABR). Facial nerve monitoring is used. Perioperative antibiotics are administered.
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Procedure The operation is performed in the conventional otologic position, with perioperative antibiotics (second generation cephalosporin) being given at the time of incision and repeated if the surgery should take more than 4 hours. The surgical technique for children is similar to that for adults, with the size of the child and skull, the lack of mastoid development, and thin nature of the scalp and skull forming the critical differences. For children well below the age of 24 months, the small airway and lesser toleration of blood loss are also considerations. Positioning the implant Sufficient hair is shaved from the side of the head to allow draping around the periphery of the incision. The shave need not be extensive. The dummy device is placed on the head and its position is marked in ink (Figure 91). The device should be slightly behind the edge of the auricle, allowing space for a behind-the-ear speech processor. ! The tip of the implant is above the canthomeatal line. ! The posterior part of the device is angled 45 or more above the horizontal, increasing the angle toward the vertical in the smallest children. After the position of the device and the center of the well are marked, an incision is drawn on the skin (Figure 92). Unless there is a preexisting scar, the incision takes the shape of a lazy S or inverted J.
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Planning the flap The incision begins in the postauricular sulcus near the mastoid tip, ascends to the attachment of the auricle, and then, in a curved fashion, extends posteriorly and superiorly, allowing at least 15 mm around the position of the implant. The incision for the Advanced Bionics and Med-El implants extends further posteriorly to allow drilling a well for the entire device (see Figures 92B and C). This incision allows reflection of the flap sufficient for mastoidectomy and drilling of the well without strong retraction. In most cases, fishhooks without barbs are used for retraction: selfretaining retractors are rarely needed. Incisions The skin is prepared with an organic iodine solution and thoroughly draped.
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If the posterior portion of the device will be placed deep to the scalp, as well as the temporalis muscle and pericranium, (as for the Nucleus 24 and Contour devices), the shave, prep, and drape are less extensive (see Figure 92A). If the entire device is to be placed in the well (Clarion and Combi40+), the shave, draping, and incision are somewhat more extensive (see Figure 92B and Figure 92C).
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Figure 91 The implant is positioned on the side of the head, allowing sufficient room for the behind-the-ear speech processor. A, Nucleus and Contour. B, Clarion and CII. C, Med-El Combi-40+.
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Figure 92 The incision is marked (dashed line), and the area is prepped and draped. A needle with methylene blue is inserted to the bone, marking the center of the well. A, Nucleus and Contour. B, Clarion and CII. C, Med-El Combi-40+.
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A 22-gauge needle is dipped in methylene blue to mark the center of the proposed well by depositing a droplet on the surface of the bone. The line of the incision is infiltrated with 1:200,000 epinephrine. The incision is made with the cutting and coagulation current to limit blood loss from the scalp. The flap is elevated deep to the galea, allowing the pericranium to remain in place. The pericranium is incised to form a large anteriorly based Palva flap, which will be closed over the device, affording a second layer of closure and interposing the flap between the electrode and the incision. The pericranium is further elevated to accommodate tie-down holes and the specific device (Figures 93A and B). Nontraumatic fishhooks without barbs are used to gently retract both the scalp and Palva flaps. The flaps should be kept moist with gauze sponges throughout the procedure. For the Nucleus devices, a large pocket is elevated for the body of the device deep to the pericranium, angled posterosuperiorly, and a smaller pocket is elevated deep to the temporalis muscle for the ground electrode (Figure 94).
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Figure 93 The scalp and Palva flaps are elevated and retracted with barbless fishhooks. A, Nucleus. B, Clarion and Med-El Combi-40+.
Figure 94 Two pericranial pockets (dashed lines) are elevated for the Nucleus devices: posterosuperiorly for the body of the device, and anterosuperiorly for the ground electrode.
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Creating the well A well is created for the electronics package. Drilling is begun with cutting burs (Figure 95A) and is then finished with diamond burs (Figure 95B). The well should be large enough to accommodate the electronics of the Nucleus device or the entire Med-El or Advance Bionics implant (Figures 95C and D), and should have a flat floor and vertical sides. The device-specific metal die is used to ensure the proper shape and size. For small children, it is necessary to drill down to the dura, or to create an island of bone by thinning the floor of the well and cutting around the periphery with a small diamond bur (see Figure 95B).
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Figure 95 A well is drilled with cutting and diamond burs to accommodate the pedestal of the Nucleus devices (A and B), the entire Clarion or CII (C), or the Med-El Combi-40+ body (D). The well will expose dura in small children; a bony island may be preserved (B).
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Tie-down holes Holes are drilled above and below the anterior and posterior parts of the receiver-stimulator. These are cut with a 3-mm bur, creating a series of grooves that, for the older child, are then connected with a 2-mm diamond bur, leaving a bridge of bone intact (Figures 96A and B). For the younger child, the holes are carried to the surface of the dura, which is then elevated from the inner surface of the bone with a whirlybird to facilitate easy passage of the tie-down suture (Figure 96C). The Nucleus devices require only one tie-down of the anterior portion since the posterior portion is placed in a tight pericranial pocket. A special technique is used to tie the ceramic Med-El and Advanced Bionics devices as flush as possible with the bone surface: 1. Four vertical 2-mm holes are drilled above and below the well (Figure 97A) with the dura protected by a Freer elevator or similar tool. 2. Sutures are then passed through the holes (Figure 97B), forming loops around the implant. 3. When the loops are tightened, the implant is recessed flush with the surface of the skull (Figures 97C and D).
C Figure 96 Tie-down holes are drilled horizontally for Nucleus devices (A). In the older child, a tunnel can be created between the inner and outer tables (B); in younger children, the holes are drilled down to the dura (C).
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Figure 97 A-D, Vertical holes are drilled for the sling suture of the Clarion, CII, and Med-El Combi-40+ implants.
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4. We advise two tie-downs for these devices since they require a larger well (Figures 98A and B). Mastoidectomy The goal of mastoidectomy is to approach the facial recess and accommodate the redundant proximal electrode. Therefore, it is unnecessary to create an extensive cavity below the area of the antrum. A conventional mastoidectomy is performed, keeping in mind the lack of mastoid tip development in a small child. The posterior and superior edges of the cavity should not be saucerized, but should be allowed to overhang to retain the proximal electrode (Figure 99). For infants, it is often necessary to drill into marrow to create a sufficiently large cavity; this can cause annoying oozing, which is readily controlled with a diamond bur or bone wax. A channel is then drilled to connect the well with the posterior edge of the mastoid cavity, allowing the proximal wire leads to be recessed below the bone surface (Figure 910).
Figure 98 Two sets of holes are drilled above and below the well for the ceramic devices. A, Clarion and CII. B, Med-El Combi-40+.
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Figure 99 The mastoidectomy is performed, and a channel is drilled connecting it to the well.
Figure 910 Mastoidectomy and facial recess with: (A) ghost outline of facial nerve and chorda tympani nerve, as well as (B) overhang of superior wall (Adapted from Cochlear Corporation. Surgical Procedure Manual. Englewood (CO): Cochlear Corporation; 1987).
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Facial recess The facial recess is a triangular space bounded posteriorly by the upper vertical portion of the facial nerve, superiorly by the short process of the incus, and anteriorly by the chorda tympani nerve (see Figure 910). This space must be opened adequately to visualize the round window area and the electrode placement (Figure 911A). Drilling begins by exenterating mastoid cells and thinning the posterior canal wall. This is important to allow visualization from the lateral to the medial parts of the posterior mesotympanum. The facial nerve is identified in its vertical segment, but bone is allowed to remain on the nerve. Drilling of the facial recess begins superiorly, where the triangular facial recess is widest.
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The chorda tympani nerve is identified and can usually be spared. The tympanic membrane annular ligament should always be spared. The posterior canal wall should be preserved. Perforation, if present, must be repaired with soft tissue and bone.
Often, a cell tract will lead through the bone of the facial recess into the middle ear. As the bone is removed, care is taken to not allow the rotating shaft of the bur to rub against the posterior wall of the facial recess. Contact with the rotating bur may heat the bone and cause edema of the underlying facial nerve with resulting weakness of the face. Once the facial recess is opened superiorly, the area of the oval window can usually be identified. The facial recess is then gradually opened inferiorly in order to visualize the round window niche (see Figure 911A).
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It is occasionally necessary to sacrifice the chorda tympani in order to visualize the niche, which is never more than 3 mm from the inferior border of the oval window. Care is taken to not mistake a hypotympanic air cell for the round window niche (Figure 911B). Membranous adhesions over the round window niche, if present, can be removed for better visualization. Pumping the stapes for a round window reflex may also help.
Cochleostomy The shape of the cochlea deep to the promontory should be understood since this influences the cochleostomy location and direction of electrode insertion (Figure 911C).
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Figure 911 A, The facial recess is opened, showing, from superior to inferior, the short process of the incus, the incus bar, the oval window, promontory, and round window niche. B, The relationship of the round window membrane, niche, and a hypotympanic cell. C, The cochlea is viewed through the promontory (Adapted from Cochlear Limited. Surgeons Guide for the CI24R(CS) Cochlear Implant. Sydney, Australia: Cochlear Limited; 2000).
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The scala tympani of the cochlea may be opened by either taking down the round window membrane or by direct cochleostomy immediately anterior to the round window niche (Figures 912A and B). We prefer cochleostomy, but the round window approach is also acceptable. 1. Round window approach. The tegmen of the niche is removed in order to visualize the membrane, which is reflected inferiorly with a sharp pick. Bone is drilled away inferiorly to allow easier access past the hook area, which is the most proximal and strongly curved portion of the scala tympani (Figure 912C). 2. Direct cochleostomy approach. Cochleostomy is performed immediately anterior to the round window niche using a 1.5-mm diamond bur (Figure 912D). It should be remembered that the scala tympani is aligned in a lateral to medial position, more or less parallel with the thinned posterior canal wall.
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Figure 912 A, Opening of the scala tympani using the round window membrane approach. B, Anteroinferior fenestration (transpromontory cochleostomy). C, Hook is drilled. D, Cochleostomy is completed. (Adapted from Cochlear Limited. Surgeons Guide for the CI24R(CS) Cochlear Implant. Sydney, Australia: Cochlear Limited; 2000).
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When the bone over the scala tympani is thinned, the white endosteum is visualized. This should be removed with rightangled picks or stapes footplate instruments to avoid drilling directly into the scala tympani with resultant trauma and deposition of bone dust (Figure 913A). ! The cochleostomy should be more than adequate for introducing the electrode array, which varies among the several devices. The perimodiolar electrodes tend to be of greater diameter and require a slightly larger cochleostomy. If necessary, proximal bony obstruction may be perforated with a diamond bur (Figure 913B); fibrous tissue or osteoid may be removed with picks.
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When the CT scan shows an obstruction of the cochlea, the surgeon should be prepared to attempt a scala vestibuli insertion or drill out the scala tympani to a sufficient depth to allow electrode insertion.
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If a free lumen cannot be located, drilling should continue in the axis of the scala tympani for up to 8 mm to allow partial electrode placement. Care must be taken not to expose or traumatize the internal carotid artery, which may be located just anterior to the junction of the pars inferior and the pars ascendens of the scala tympani. Alternate techniques for dealing with labyrinthitis ossificans include (1) using a split or double electrode to allow placement of electrodes in the lower basal and either the upper basal or second turns, and (2) the circumferential drill-out described by Balkany et al.
Occasionally, on opening the cochlea, there may be a profuse flow of perilymph and cerebrospinal fluid (CSF). This is similar to the feared perilymph gusher sometimes seen in stapes surgery.
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In both cases, the etiology is an abnormal communication between the scala tympani and the CSF space, such as is seen with major Mondini and common cavity dysplasias and the Large Vestibular Aqueduct Syndrome. The treatment is to elevate the head of the table, wait for the fluid flow to diminish, insert the electrode, and pack strips of pericranium or temporalis fascia tightly (like a champagne cork) into the cochleostomy around the electrode. A spinal drain is rarely necessary.
Device placement and electrode insertion Prior to insertion, the wound is liberally irrigated to remove bone dust. We prefer to place the body of the Clarion and the Nucleus Contour devices in the well and pericranial pocket prior to electrode insertion. The Nucleus 24K device and Med-El (both with straight electrodes) may be placed either before or following electrode insertion. Prior to insertion, a lubricant may be placed into the cochleostomy. Two substances used have been 50% glycerine and hyaluronic acid (Healon).
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Figure 913 A, Removal of bone debris; smoothing sharp edges of the cochleostomy. B, Drilling through bony obstruction (Adapted from Cochlear Limited.Surgeons Guide for the CI24R (CS) Cochlear Implant. Sydney, Australia: Cochlear Limited; 2000).
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The electrode is inserted into the scala tympani using the specially designed insertion tool, claw, or other atraumatic instrument such as fine jewelers forceps (Figures 914 and 915): 1. The receiver-stimulator, if not previously placed in the well or pocket, is grasped in the surgeons nondominant hand, and the tip of the electrode array is presented to the cochleostomy. 2. The tip is guided into the cochleostomy with the appropriate instrument (see Figures 914A and 915A). Ordinary alligator forceps should not be used since they are potentially damaging. 3. The straight electrode arrays of the Nucleus 24K and the Med-El Combi-40+ usually advance easily, with steady pressure from both hands. If it appears to impact, the electrode should be withdrawn one or two rings, rotated 90 degrees or more (counterclockwise for the right ear and clockwise for the left ear) to disimpact the array tip, and then gently reinserted (see Figure 914B).
Figure 914 A straight electrode is inserted (A) and rotated (B) inside the scala tympani (Adapted from Cochlear Limited. Surgeons Guide for the CI24R(CS) Cochlear Implant. Sydney, Australia: Cochlear Limited; 2000).
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Figure 915 A, Insertion of Nucleus Contour (or Med-El Combi-40+) electrode with jewelers forceps. The special claw may also be used. B, Insertion of Clarion High Focus I or CII HFII electrode using special insertion tool.
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4. If the electrode array appears to buckle, force should never be used; the surgeon should be satisfied with a partial insertion. 5. Some curved or perimodiolar electrodes require a dedicated insertion tool (see Figure 915B) which places the electrode in the scala tympani. The perimodiolar electrodes may also require a second maneuver, such as removing a stylet for the Contour device to allow the electrode to flex closer to the modiolus (Figure 916), or adding a mechanical positioner for the Clarion device to actively move the electrode in that direction. The newer CII electrode has a positioner attached to the electrode, allowing simultaneous insertion of both. The surgeon should consult the manufacturers surgical manual for details of technique for each device. As soon as the implant is in contact with the patient, the monopolar cautery should be turned off and disconnected from the patient. Securing the implant Once the electrode has been inserted, the receiver-stimulator is sutured down with nonabsorbable material (2-0 Tevdek on a CV 136 needle) taking care that the knot is at the edge of the implant rather than over its center (Figures 917A, B, and C). The ground electrode of the Nucleus and Med-El devices is placed under the temporalis muscle (see Figures 917A and C).
Figure 916 Removing the Nucleus Contour stylet.
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Figure 917 A, The Nucleus Contour or CI24K in pockets and tied down. B, The Advanced Bionics Clarion or CII tied down. C, Med-El Combi-40+ tied down. Ground electrode is under the temporalis muscle.
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Soft tissue is packed between the electrode and the walls of the cochleostomy to prevent perilymph leakage, taking care not to damage the electrode lead wire (Figure 918). Electrophysiological testing is performed. This differs from device to device, but in general, electrode impedances are measured, electrical stapedius reflex is tested, and back telemetry (eg, Neural Response Telemetry) is performed. Soft tissue is packed in the facial recess, and the wound is thoroughly irrigated to remove blood and bone dust. Closure The anteriorly based Palva pericranial flap is sutured over the proximal electrode lead with absorbable sutures. A drain is rarely needed; meticulous hemostasis is achieved with bipolar cautery. The incision is closed in layers with absorbable sutures, subcuticular sutures, and tape strips for the skin (Figures 919A and B). Staples are used for the older child.
Figure 918 Soft tissue packed between the electrode and edge of the cochleostomy.
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Figure 919 A, Younger child subcuticular suture. B, Older child suture or staples.
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An intraoperative portable X-ray is strongly advised to verify electrode placement while the patient is still asleep. The patients head is straightened on the table, preferably prior to application of the dressing. A single anteroposterior transorbital view (slightly over-penetrated) is taken (Figure 920). An incorrectly placed or compressed electrode should be discovered in the operating room rather than weeks later when the child is found to be nonstimulable. A gentle mastoid dressing is applied.
Figure 920 An intraoperative transorbital X-ray is taken to verify electrode position. A, Straight electrode. B, Perimodiolar electrode.
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Postoperative Care The dressing is removed the morning following surgery. Staples are generally removed in 10 days; no specific aftercare is necessary. Ventilation tubes should not be placed in an ear that has received a cochlear implant. Certain sports and activities are best avoided after cochlear implant surgery, including wrestling, rugby, and heading the ball in soccer. Children engaging in contact sports, cycling, horseback riding, etc, should always wear protective headgear. MRI must be avoided unless the magnet can be removed (as with the Nucleus CI 24 series); there is no contraindication to CT scanning. Monopolar cautery should never be used in the vicinity of the cochlear implant or in cases where the implant lies between the active and the ground electrodes. Other forms of radiant energy (eg, diathermy) should also be avoided, as well as plastic playground slides while the external hardware is being worn. Complications No deaths or life-threatening surgical complications have been reported after cochlear implantation, and the complication rate has decreased over the years (Table 91). Complications for children are less than for adults (Table 92).
Table 91 Cochlear implant complications over time (for both adults and children)
Type of complication 1991 (N=459) (%) 1993 (N=2,751) (%) 1995 (N=4,969) (%) 1998 (N=9,221) (%) 2000 (N=12,300) (%)
Flap Electrode Facial nerve
5.4 1.7 1.7
3.0 1.5 0.7
2.7 1.2 0.6
2.1 1.0 0.4
0.9 0.9 0.1
Table 92 Cochlear implant complications in adults vs. children

Type of complication Adults (%) Children (%)
Flap Electrode Facial nerve Extrusion, receiver-stimulator Extrusion, electrode
2.70 1.20 0.43 1.47 0.17
1.40 0.76 0.39 0.37 0.22
Data for tables collected by authors from Cochlear Corporations. Compilations, summaries and charts adapted from Cohen NL, Hoffman RA. Complications of cochlear implant surgery. In Eisele DW, editor. Complications in Head and Neck Surgery. St. Louis: Mosby-Year; 1993. p. 7229 and Hoffman RA, Cohen NL. Complications of cochlear implant surgery. Ann Otol Rhinol Laryngol 1995;166 Suppl 4202.
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Major complications include facial palsy and others requiring re-hospitalization for surgery or intravenous antibiotics. The most common major complications include flap necrosis or infection, migration of the device and/or electrode, and electrode misplacement or damage, many of which might have been avoided by more appropriate planning and surgical technique. ! A displaced cochlear implant electrode detected by an intraoperative X-ray would be replaced without delay or a second operation. ! Most cases of facial palsy occur shortly after surgery, but others may be delayed until well after discharge. Most are probably caused by thermal injury from the bur-shaft when drilling the facial recess or cochleostomy, rather than direct trauma to the nerve. Most resolve completely. Minor complications are those handled in an outpatient setting; no significant increase in morbidity occurs.
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Finally, there has not been an increased incidence of otitis media in children who have received cochlear implants, complications caused by the presence of the implant, or the loss of an implant secondary to otitis media. CONCLUSIONS Cochlear implant surgery in children can be accomplished satisfactorily and safely in the overwhelming majority of properly selected candidates. The surgery requires some modifications from the adult technique, especially in the child under age 2 years, but the complication rate is not greater. After more than a decade of experience, there does not appear to be a deleterious effect on the middle or inner ear from implanting a multichannel cochlear implant in children. The benefit of these devices, on the other hand, has been even greater than anticipated, even in the very young congenitally deaf child. Unexpectedly, many older congenitally deaf children have also received significant demonstrable benefit from cochlear implantation. BIBLIOGRAPHY
Balkany T, Gantz BJ, Stevenson RL, et al. A sysematic approach to electrode insertion in the ossified cochlea. Otolaryngol Head Neck Surg. 1996 Jan;114(1):411. Bielamowicz SA, Coker MJ, Jenkins HA, Igarashi M. Surgical dimensions of the facial recess in adults and children. Arch Otolaryngol Head Neck Surg 1988;114:5347. Cochlear Corporation. Surgical procedure manual. Englewood (CO): Cochlear Corporation; 1987. Cochlear Limited. Surgeons guide for the CI24R (CS) cochlear implant. Sydney, Australia: Cochlear Limited; 2000. Clark GM, Cohen NL, Shepherd RK. Surgical and safety considerations of multichannel cochlear implants in children. Ear Hear 1991:12 Suppl 4:15S24S. Cohen NL, Hoffman RA. Complications of cochlear implant surgery. In: Eisele DW, editor. Complications in head and neck surgery. St Louis: Mosby-Year Book; 1993. p. 7229. Cohen NL. Surgical techniques to avoid complications of cochlear implants in children. Adv OtoRhino-Laryngol 1997;52:1613.
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Cohen NL. Surgical techniques for cochlear implants. In: Waltzman SB, Cohen NL, editors. Cochlear implants. New York: Thieme; 2000. p. 1516. Fishman AJ, Holliday RA. Principles of cochlear implant imaging. In: Waltzman SB, Cohen NL, editors. Cochlear implants. New York: Thieme; 2000. p. 79107. Hoffman RA, Downey LL, Waltzman SB, Cohen NL. Cochlear implantation in children with cochlear malformations. Am J Otol 1997;18:1847. Hoffman RA, Cohen NL. Complications of cochlear implant surgery. Ann Otol Rhinol Laryngol 1995;166 Suppl:4202. Kveton J, Balkany TJ. Status of cochlear implantation in children. American Academy of Otolaryngology Head and Neck Surgery Subcommittee on Cochlear Implants. J Pediatr 1991;118:17. Lenarz T, Battmer RD, Bertram B. Cochlear implantation in children under 2 years of age. In: Waltzman SB, Cohen NL, editors. Cochlear Implants. New York: Thieme; 2000. p. 1635. Roland JT Jr, Fishman AJ, Alexiades G, Cohen NL. Electrode to modiolus proximity: a fluoroscopic and histologic analysis. Am J Otol 2000;21:21825. Roland JT Jr, Fishman AJ, Waltzman SB, et al. Stability of the cochlear implant in children, Laryngoscope 1998;108:111923. Shpizner BA, Holliday RA, Cohen NL, et al. Postoperative imaging of the multichannel cochlear implant. Am J Neuroradiol 1995;16:151724. Waltzman SB, Cohen NL. Cochlear implantation in children younger than 2 years old. Am J Otology 1998;19:15862. Webb RL, Lehnhardt E, Clark GM, et al. Surgical complications with the cochlear multiple-channel intracochlear implant: experience at Hannover and Melbourne. Ann Otol Rhinol Laryngol 1991;100:1316.
C H A P T E R 10
E PISTAXIS
Scott C. Manning, MD
Most epistaxis in children is caused by anterior septal trauma from digital manipulation, nose rubbing (allergic salute), or blunt injury. Predisposing factors include dry winter air, frequent upper respiratory infections, and allergic, viral, or bacterial rhinitis. Unilateral epistaxis and nasal obstruction in a young child should prompt a careful examination for a foreign body. Infrequently, obstruction from septal deviation or polyps may create focal areas of mucosal drying and ulceration. Vascular tumors, such as rhabdomyosarcomas in young children or angiofibromas in adolescent boys, are a rare cause of dramatic difficult-to-control epistaxis. Appropriate radiographic evaluation, such as computed tomography, is indicated when tumors are suspected. Local cautery is sufficient to control most epistaxis in children; posterior packing and direct vessel ligation are rarely necessary. For extremely refractory epistaxis, especially in patients with primary or acquired coagulopathies, selective embolization of involved vessels can be performed by an experienced interventional radiologist. The most common complication of selective embolization is transient facial nerve weakness; tissue ischemia is rare.
ANATOMY The most common site of nasal bleeding in children is the anterior septum, where several terminal branches of both the internal and external carotid systems come together under a thin delicate mucosa. Kiesselbachs or Littles area is also the part of the nose that is most likely to be adversely affected by trauma and dry air (Figure 101). Superior epistaxis usually involves terminal branches of the anterior or posterior ethmoidal arteries (Figures 101 and 102), which are branches of the ophthalmic arteries from the internal carotid system. The anterior ethmoidal artery supplies the anterior third of the lateral nasal wall and adjacent septum, whereas the posterior ethmoidal artery supplies the superior turbinate, posterior superior lateral nasal wall, and septum. These arteries may be injured during endoscopic sinus surgery.
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Figure 101 Arteries supplying the nasal septum. (Modified from Culbertson MC, Manning SC. Epistaxis. In: Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saunders; 1990. p. 673.)
Figure 102 Arteries supplying the lateral nasal wall. (Modified from Culbertson MC, Manning SC. Epistaxis. In: Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saunders; 1990. p. 673.)
Posterior epistaxis usually involves terminal branches of the sphenopalatine artery, which arises from the internal maxillary artery and enters the nose just posterior to the posteroinferior tip of the middle turbinate. A medial branch supplies much of the septum (see Figure 101), and a lateral branch supplies the inferior and middle turbinates (see Figure 102). The medial branch may be injured during endoscopic sinus surgery as it crosses the anterior inferior face of the sphenoid sinus.
Epistaxis
LOCAL CAUTERY Indications Identified focal bleeding site on the anterior septum
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Bleeding unresolved with 5 minutes of continuous local pressure via nose pinching Bleeding refractory to medical therapy, including allergy management and application of petroleum-based ointment to the anterior septum Anesthetic Considerations and Preparation Topical anesthesia and vasoconstriction are achieved with cotton pledgets or applicators soaked in lidocaine and oxymetazoline; alternatively, 4% cocaine solution can be sprayed. The nasal cavity is inspected carefully with a headlight and speculum, microscope, otoscope, or rigid endoscope. Gentle suctioning and nose blowing are performed to remove all blood and clots. Procedure The bleeding site or vessel is identified and limited cautery is performed with silver nitrate or an electrocautery. When electrocautery is necessary, bipolar cautery with an insulated bipolar device is less traumatic to the septum than is monopolar cautery. Repeated or bilateral cautery of the nasal septum (eg, in patients with a hereditary hemorrhagic telangiectasia) can lead to avascular cartilage necrosis and septal perforation. Antibiotic ointment is applied to the cautery site. ANTERIOR PACKING Indications Failure of local cautery Diffuse mucosal bleeding sites Coagulopathy Anesthetic Considerations and Preparation As described abovesee Local Cautery. Procedure Working from inferior to superior with a headlight and pediatric nasal speculum, small strips of absorbable packing (oxidized cellulose or gelatin sponge) coated with small amounts of antibiotic ointment are placed. Alternatively, ointment-coated gauze or cotton strips are layered from inferior to superior. This method may cause further mucosal irritation when the gauze is removed. When possible, permanent packing should not be used in patients with severe coagulopathy because inflammation and mucosal trauma when the packing is removed are likely to result in further bleeding.
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Postoperative Care Following successful management of routine anterior septal bleeding, preventive measures include humidification with topical nasal saline and/or room humidifiers and application of petroleum-based ointments to the distal septum. Steroid-containing ointments can be used for up to 2 weeks to more rapidly control inflamed vessels in the caudal septum. General management of suspected allergic rhinitis can help prevent recurrent epistaxis by reducing trauma from facial rubbing and by reducing mucosal inflammation. ENDOSCOPIC-GUIDED CAUTERY Indications Failure of anterior packing Cooperative patient Anesthetic Considerations and Preparation As described abovesee Local Cautery. Procedure The bleeding site is visualized with an endoscope in a cooperative patient (Figure 103) young children may require general anesthesia. Nasal septoplasty may be necessary to allow an endoscopic view of the bleeding areas around septal deviations. Focal cautery of the bleeding site is done with an insulated sinus bipolar cautery or suction cautery. Antibiotic-coated absorbable gelatin sponge or oxidized cellulose is applied to the cautery site.
Figure 103 Demonstration of the rigid endoscope used to visualize the posterior nasal cavity.
Epistaxis
POSTERIOR PACKING
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Indications Epistaxis caused by an identified posterior (sphenopalatine area) bleed Posterior epistaxis caused by facial fractures, severe coagulopathies, or sinus surgery Anesthetic Considerations and Preparation As described abovesee Local Cautery. Procedure Manufactured nasal balloons may be placed in the nasal cavity and inflated as per instructions below (Figure 104). A posterior pack can be fashioned from a 15-mL urinary catheter:
!
! !
Cut a 1- to 2-cm length segment of endotracheal tube of a size that will slide over the urinary catheter back to the insufflation ports. Place the urinary catheter through the nose so that its tip is visualized just beyond the soft palate on oral examination. Inflate the balloon with 5 to 10 mL of sterile saline. Place an anterior nasal pack around the catheter with either gauze or absorbable hemostatic material (see Anterior Packing, above). Slide the sleeve forward so that it fits within the nostril and puts pressure against the anterior pack. Put tension on the posterior balloon by pulling the catheter forward while placing countertraction against the sleeve. Add further saline to the posterior balloon as necessary to stop all bleeding. Fix the catheter in place by placing a C clamp (or other type of clamp) on the catheter just in front of the sleeve.
Figure 104 Demonstration of a manufactured epistaxis balloon. The posterior balloon in the nasopharynx provides an anchor for the anterior balloon to apply pressure to the posterior nasal cavity.
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Gauze packs also can be used for posterior packing (Figure 105): ! Fix a gauze pack to a catheter passed through the nose and retrieved through the mouth. ! Pull the gauze pack, via a suture, firmly against the posterior choanal opening. ! Place an anterior nasal layered gauze pack and fix the posterior pack suture to a soft rubber or gauze bolster outside the nares. ! In young children it may be advisable to use absorbable packing, as surgical gauze may adhere and be difficult to remove in the uncooperative child. An endoscopic-guided direct cautery can be attempted, as described above. Postoperative Care For unusually severe posterior bleeding episodes requiring bilateral nasal packing, the child is admitted to the hospital, if not already hospitalized. Continuous pulse oximetry monitoring is used to detect hypoxia, particularly during sleep. Supplemental oxygen is used as needed. Nasal packs may injure the septal mucosa, with resultant bleeding when packs are removed (especially for children with systemic coagulopathies). The packs are checked for excessive pressure to the columella nasi and ala nasi, which may result in ischemic injury if prolonged.
Figure 105 A, Fixing of a suture attached to a posterior gauze pack to a catheter placed around the palate. B, An anterior pack of layered antibiotic-coated gauze. A suture from a posterior pack is affixed to a soft bolster outside the nares. (Modified from Culbertson MC, Manning SC. Epistaxis. In: Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saunders; 1990. p. 675.)
Epistaxis
ARTERIAL LIGATION
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Older techniques of transantral approach to the internal maxillary artery or transethmoidal approach to the anterior and posterior ethmoidal arteries are being replaced by endoscopic approaches to the terminal branches of the respective arteries. Indications Epistaxis refractory to more conventional treatment Epistaxis caused by severe facial fractures Epistaxis caused by neoplasms of the face or paranasal sinuses Anesthetic Considerations and Preparation General anesthesia with a hypotensive technique is used if possible. Local injection of the greater palatine foramen can allow for better visualization by temporarily reducing the bleeding. Anterior and posterior packs are removed, and the nasal cavities are suctioned and treated with oxymetazoline. Procedure Lateral endoscopic procedures involve raising a mucosal flap posterior to the natural ostium of the maxillary sinus, exposing the terminal branches of the sphenopalatine artery (see Bibliography for sources of surgical details). The branches can then be directly cauterized or clipped with vascular clips. Medial trans-septal approaches to the distal sphenopalatine branches also have been described.
BIBLIOGRAPHY
El-Guindy A. Endoscopic transseptal sphenopalatine artery ligation for intractable posterior epistaxis. Ann Otol Rhinol 1998;107:10337. Fairbanks DNF. Complication of nasal packing. Otolaryngol Head Neck Surg 1986;94:4125. Lund VJ, Howard DJ. A treatment algorithm for the management of epistaxis in hereditary hemorrhagic telangiectasia. Am J Rhinol 1999;13:31922. Moreau S, DeRugy MG, Babin E, et al. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope 1999;108:8878. Murthy P, Nilssen EL, Rao S, McClymont LG. A randomized clinical trial of antiseptic basal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis. Clin Otolaryngol 1999;24:22831. Murray AB, Milner RA. Allergic rhinitis and recurrent epistaxis in children. Ann Allergy Asthma Immunol 1995;74:303. Wormald PJ, Weed TH, van Hasselt CA. Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis. Am J Rhinol 2000;14:2614.
C H A P T E R 11
N ASAL AND S EPTAL D EFORMITIES

Jon B. Turk, MD William S. Crysdale, MD
Pediatric nasal surgery is performed for functional, aesthetic, and reconstructive reasons. Contrary to certain widely held beliefs, nasal surgery can be performed safely at almost any age if appropriate cartilage-sparing and suture-control maneuvers are employed. Failure to treat symptomatic pathology because of concerns over interrupting facial growth can prolong functional and aesthetic problems. Whereas a healthy respect for facial growth centers should accompany any otolaryngologic intervention in children, surgical correction of structural nasal obstruction and deforming injuries should not be deferred until the late teen years.
PRINCIPLES OF NASAL SURGERY Older teenagers (males age 16 years or older, females age 14 years or older) are treated no differently than adults because beyond this age there is very little significant facial skeletal growth. Adolescents being considered for aesthetic nasal surgery must also have psychological and emotional factors addressed with both themselves and their families. Children younger than age 15 years should have surgery performed using the least destructive techniques to accomplish the surgical goal; nasal and septal cartilage should be reshaped and repositioned rather than removed. Techniques that rely on sutures to reposition and control the nasal tip are often performed through the external approach, and are especially useful in pediatric rhinoplasty, owing to their nondestructive nature and reversibility. Bony osteotomies, when necessary, should be performed with small sharp osteotomes to minimize bone loss and trauma to surrounding tissues. The periosteum overlying the nasal bones should always be preserved to prevent collapse of the nasal bones with resultant pyriform aperture and internal nasal valve stenosis.
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Computed tomography (CT) scanning is the preferred radiographic method for nasal pathology. Plain radiographs are not recommended because fractures and cartilaginous deformities are poorly visualized. In contrast, CT scans demonstrate bony and cartilaginous deformities and provide information on the orbit, facial bones, and paranasal sinuses. Although not every patient requires radiographic imaging for diagnosis, CT scans serve to document pathology, aid surgical planning, and survey adjacent structures. The otolaryngologist performing septal and nasal surgery should maintain a dedicated septorhinoplasty tray with sharp rasps and osteotomes. A lightweight adjustable headlight with a halogen or xenon light source should be routinely worn because overhead lights are inadequate for intranasal visualization. Finally, a dry operative field is essential for all nasal procedures, which is best accomplished by infiltrating the nose and septum with local anesthetic and vasoconstrictor 10-15 minutes before the start of surgery. CLOSED REDUCTION OF NASAL FRACTURE Closed reduction is a minimally invasive technique used to reduce simple laterally displaced nasal fractures within 2 weeks of the onset of injury. Closed reduction is ideally performed when swelling has subsided, but before fibrosis and bony union has begun. This window of opportunity is typically between 5-10 days following the injury. While it may be appropriate to wait several days to reduce a nasal fracture, the nose must be examined professionally prior to that time to detect septal hematoma. If a septal hematoma is diagnosed it should be incised and drained immediately (Figure 111), usually under general anesthesia. A septal quilting stitch is placed (Figures 112A and B) and nasal packs are inserted bilaterally. This may prevent more serious sequelae such as septal abscess and saddle nose deformity.
Figure 111 The mucoperichondrium is incised with a No 11 scalpel blade.
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Figure 112 A, A short Keith needle on a 4-0 plain gut suture is passed back and forth through the septum. B, Final appearance of quilted septum.
Indications Simple nasal fractures that produce lateral displacement of the nasal pyramid, within 10 days after onset of injury. Closed reduction is not the treatment of choice when anterior-posterior (ie telescoping) injuries occur or when there are concomitant fractures of the nasal septum. Open reduction should be considered when the injury involves both cartilage and bone, is complicated or comminuted, or if treatment must be deferred beyond 2 weeks. Anesthetic Considerations Although closed reduction is a rapid and simple procedure and is often performed under local anesthesia in adults, deep intravenous sedation or mask general anesthesia are preferred for children. Deep intravenous sedation or general anesthesia makes the procedure painless for the patient, but also eliminates the need for local anesthesia infiltration which otherwise may distort the nose significantly. This allows for a safer, more comfortable, and more accurate procedure. Preparation Closed reduction of a nasal fracture under deep intravenous or general anesthesia should only be performed in the operating room setting. This allows maximum control of the airway along with patient and operator comfort. The patient is positioned supine with his or her head towards the anesthesiologist, and the surgeon (if right-handed) stands to the patients right. A pediatric closed reduction tray and a small Frazier tip suction are prepared as the anesthesiologist begins induction.
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Procedure Well wrung-out pledgets sprayed with oxymetazoline are gently inserted into the patients nose after anesthesia induction is begun. No local anesthesia is injected into the nose so as to prevent distortion. A small Goldman displacer, or other blunt instrument such as the back of a knife handle, is gently inserted into the nostril on the side of the inwardly displaced fracture (ie, the side where the nasal bone is fractured toward the septum) (Figure 113A). The surgeons contralateral hand is placed on the skin overlying the outwardly displaced fracture (ie, the side where the nasal bone is fractured away from the septum). Depending on which way the nose is fractured, the surgeon will rest the thumb or forefingers of the contralateral hand on the external surface of the patients nose. With both the displacer and the contralateral thumb or fingers moving in unison, the surgeon performs a fluid two-part movement (Figure 113B): 1. A downward movement (towards the patients toes) is used to distract the fractured nasal bones. 2. A sideways movement is used to simultaneously outfracture the inwardly displaced nasal bone and infracture the outwardly displaced nasal bone; a click is often heard as the nasal pyramid moves into proper position. While considerable force may be necessary to reposition the fractured segments, the operator should be careful not to use so much force as to fracture or displace the nasal septum or upper lateral cartilages. By carefully inserting, manipulating, and withdrawing the Goldman displacer, mucosal laceration can be avoided and the procedure remains essentially bloodless. A nasal splint is then applied to the newly aligned nasal bones; intranasal packing is utilized only if there has been significant bleeding, which is extremely rare if closed reduction has been performed correctly. Postoperative Care If utilized, nasal packing is removed on the first postoperative day. Ice packs over the eyes are recommended for the first 48 hours. The nasal splint can be removed on the seventh postoperative day. Gentle nasal exercises are begun in order to maintain bony alignment. These are accomplished by having the patient (or a parent) gently squeeze the nasal bones together a few times a day for the first seven days after the splint comes off. Pressure should be light, and the patient should not experience pain during this maneuver. The patient may resume light aerobic activity after 2 weeks, running and jumping at 4 weeks, and has no restrictions after 6 weeks.
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Figure 113 A, A small displacer is introduced into the nose on the side of the medially displaced fracture, while fingers from the contralateral hand are placed on the side of the laterally displaced fracture. B, After distracting the fractured segments (vertical arrow), gentle pressure is used to reduce the fracture (horizontal arrow).
Complications Complications following closed reduction are exceedingly rare. Inadequate fracture reduction may occur, and can be corrected with an open reduction performed at least 3 months after the failed closed reduction. Iatrogenic cartilage displacement is a rare complication, which is best avoided by judicious use of force and by proper instrument placement during closed reduction.
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SEPTOPLASTY Septoplasty eliminates nasal septal pathology interfering with normal nasal function. Most children with nasal septal pathology have nasal obstruction, which is a nonspecific and common complaint. The differential diagnosis of pediatric nasal obstruction also includes sinusitis, allergic rhinitis, and adenoid hyperplasia, which may coexist with a septal problem. In addition to anterior rhinoscopy, the diagnostic evaluation may require rhinometry, flexible endoscopy, or imaging studies to determine the etiology of nasal obstruction. Septoplasty can either be completed using an internal approach or an external approach. The internal approach offers low morbidity, but is suitable only for pathology limited to the posterior inferior aspect of the nasal septum. The external approach has higher morbidity, but facilitates primary or revision surgery for all types of septal pathology, including large cartilaginous defects (ie, necrosis after a septal abscess). INTERNAL APPROACH FOR SEPTOPLASTY Indications Nasal obstruction caused by septal pathology posterior and inferior to a line from the anterior nasal spine to the caudal aspect of the nasal bones (Figures 114A and B). To facilitate access to the nasal cavity when completing other nasal surgery (ie, polypectomy, endoscopic sinus surgery).
Figure 114 A, The stippled area represents the location of the septal pathology. Note that it is posterior to a line joining the anterior nasal spine and the anterior aspect of the nasal bones. B, The view of septal pathology with anterior rhinoscopy. QC = Quadrilateral cartilage
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Contraindications Mucosal disease such as allergic rhinitis. Systemic disease that places the patient at significant risk from general anesthesia. Anesthetic Considerations General anesthesia with a cuffed oral endotracheal tube stabilized on the chin of the supine patient. The anesthetic machine is on the patients left side to permit the surgeon (may be opposite if surgeon left handed) to stand on the patients right side. Preparation The head is placed on a ring for stability, and a small roll is under the shoulders to achieve a neutral position. The surgeon wears a headlight to facilitate visualization. Pledgets soaked in oxymetazoline solution are placed in both sides of the nasal cavity. Procedure The membranous septum and the submucoperichondrial layer of the anterior aspect of the quadrilateral cartilage (QC) are infiltrated with 5-10 mL of 1% lidocaine with 1:200,000 epinephrine solution using a 25-gauge needle. Using a No 15 scalpel blade, a right hemi-transfixion incision is used to expose the caudal end of the QC. The incision is made from anterior to posterior to avoid damaging the alar rim (Figure 115).
Figure 115 Completing the right hemi-transfixion incision.
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On the concave side of the nasal septum, the mucoperichondrium is dissected back 4-5 mm from the edge of the QC using Converse scissors (Figure 116). A Beaver blade is used to gently incise the perichondrium layer; the incision area is rubbed with an applicator stick to gain access to the exact plane beneath the perichondrium for further dissection. The mucoperichondrium is dissected with a Freer elevator (Figure 117) posteriorly and inferiorly until the anterior aspect of the vomer and the junction with the nasal crest of the maxilla is exposed. Dissection is now completed in a more measured fashion as one proceeds past the junction of the QC with the nasal crest of the maxilla to the floor of the nose. Using the Freer elevator or a Beaver blade on a long scalpel handle, an incision is made in the inferior aspect of the QC parallel to, but 5-6 mm from, the junction of the QC with the nasal crest of the maxilla. This incision must not extend anteriorly to the anterior nasal spine. This strip of cartilage is mobilized and ideally removed without damaging the mucous membrane on the opposite side of the septum (the occurrence of a linear tear in the mucous membrane on the convex side of the septum is not problematic as this will now serve as the drainage site). The Freer elevator is inserted from the concave side into the subperichondrial area on the convex side; the mucous membrane on the convex side is elevated off the QC and the vomer as required, permitting removal of all areas that are significantly off the midline. The QC is not disarticulated from the ethmoid plate; in fact, there is as little dissection superiorly as possible. To preserve the integrity of the dorsal strut, no cartilage is removed anterior to a line from the anterior nasal spine to the nasal bones. When excision of cartilage and bone (Figure 118) is complete, the hemi-transfixion incision is closed with 3 or 4 interrupted stitches of absorbable suture (4-0 chromic catgut). The septum is usually quilted using absorbable suture (4-0 plain catgut) mounted on miniature Keith needles: 1. The suture has a needle at each end; one needle is cut off, and a knot is placed in the suture close to that end. 2. The remaining needle is driven back and forth through the septum starting 2-3 cm from the anterior naris and working anteriorly. 3. The quilting is continued for about six passes of the needle. The tension on the suture is maintained by placing a knot when the quilting has been completed. Occasionally, there will be persistent bleeding. A small amount of Vaseline gauze packing is inserted to achieve hemostasis. Postoperative Care Packing, if used, is removed the next morning. The patient is seen 1 week later to ensure that a septal hematoma has not occurred. The family is cautioned at the time of discharge that normal activity can be resumed 2 weeks after surgery.
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Figure 116 Dissecting the perichondrium back in a posterior direction.
Figure 117 Using the Freer elevator to carry the dissection below the perichondrium more posteriorly.
Figure 118 The view after removing adequate amounts of cartilage and bone.
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EXTERNAL APPROACH FOR SEPTOPLASTY The external approach for septoplasty allows a wide variety of techniques to be employed based on the type of septal deformity: If the pathology is posterior, excision of cartilage only can be utilized (the indication for the external approach has been the rhinoplasty part of the procedure). If the pathology is anterior, the posterior aspect of the QC can be used as a free graft to replace the area that is crucial to the support of the nose and cannot be excised. This procedure is described below. If the case is a revision surgery, only fragments of cartilage may remain and may need to be filleted and sewn together to make a large enough free graft to be reinserted to provide mid-third support. If the cartilage is missing (the situation after a nasal septal abscess), endogenous cartilage from the rib (first choice) or auricle can be used to create a free graft for insertion. The versatility of this approach is offset by increased morbidity and complexity of postoperative care (see below). Late complications, such as stitch granuloma, are more common because a nonabsorbable suture is used to fix the free graft in place. Moreover, salvage surgery can be challenging if further trauma to the nose occurs. Lastly, the correct insertion of a septal free graft is a difficult procedure to master if nasal surgery is done only occasionally. Indications Anterior septal pathology interfering with nasal valve function; the deformity is caudal to a line from the anterior nasal spine to the nasal bones (Figures 119 and 1110). Posterior septal pathology when an external approach is needed for a coexisting problem, such as an asymmetric nasal deformity in a cleft lip or palate patient. Revision septoplasty. Contraindications Mucosal disease significantly interfering with nasal function. Systemic disease putting the patient at significant risk from general anesthesia. Lack of parental insight as to degree of septal pathology requiring this type of operative approach. Anesthetic Considerations and Preparation General anesthesia is required with a cuffed oral endotracheal tube stabilized on the chin of the supine patient. Pledgets soaked in oxymetazoline solution are placed in both sides of the nasal cavity. The anesthetic machine is on the patients left side to permit the surgeon (if right-handed) to stand on the patients right side.
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The patients head is placed on a ring for stability, and a small roll is placed under the shoulders to achieve a neutral position. The surgeon wears a headlight to facilitate visualization.
Figure 119 Gentle thumb pressure readily reveals anterior nasal septal pathology.
Figure 1110 Location of the septal pathology (stippled area) obstructing the nasal valve and anterior to a line from the nasal bones to the anterior nasal spine. QC = Quadrilateral cartilage
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Procedure The face is prepped and a towel is wrapped tightly about the head just above the eyebrows to facilitate holding a miniature Aufricht retractor in place when the nose has been decorticated. A full body drape is applied. The soft tissues of the nose are injected with 1% lidocaine and 1:200,000 epinephrine solution. More solution is injected in the membranous septum, beneath the anterior aspect of the perichondrium of the QC, and in the pyriform aperture area if medial and lateral osteotomies are to be completed. Usually, about 10 mL are injected. The transcolumellar incision is drawn on the skin with a reverse gull wing silhouette to minimize the impact of any scar retraction (Figure 1111). The incision is placed outside of the feet of the medial crura so that the crura base is undisturbed. Rim incisions are made with a No 15 blade 1-2 mm inside the nostril sill, from the apex of the external naris of the nostril to the lateral aspect of the transcolumellar incision (Figure 1112). Converse scissors are used through the right rim incision to create a plane of dissection outside the medial crura towards the left rim incision (Figure 1113): 1. The tips of the scissors are pushed through the left rim incision. 2. Next, through the right rim incision, dissection is carried up over the left dome area. 3. Then, through the left rim incision, dissection is carried over the right dome area. 4. Lastly, through the right rim incision, the skin is undermined inferiorly beyond the transcolumellar incision.
Figure 1111 The location and form of the transcolumellar incision.
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Figure 1112 Completing the right rim incision.
Figure 1113 Using the Converse scissors to dissect across the columella external to the medial crura into the left rim incision.
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The transcolumellar incision is completed using a No 11 blade held at right angles to the skin (Figure 1114) using a sawing motion. Only 2 mm of the blade tip are inserted to minimize any damage to the underlying medial crura. The rim incisions are then advanced on each side along the caudal border of the lateral crura. For this maneuver, it is crucial that an assistant apply counter traction to the dome of the lower lateral cartilage using a skin hook (Figure 1115). Once the rim incisions are of adequate length, dissection is carried over the domes until the upper lateral cartilages (ULCs) are encountered. Dissection is then carried superiorly in the midline over the ULCs and nasal bones creating a pocket in which the miniature Aufricht retractor can be inserted. The retractor is inserted to hold the skin out of the surgical field, and is stabilized on the towel above the eyebrows with a Kelly clamp. Next, the operator and assistant each pick up the medial crura with a Brown forceps. The operator divides the medial crura with a Beaver blade, cutting through the membranous septum until the caudal end of the QC is encountered and delineated down to the level of the anterior nasal spine (Figure 1116). Gordon hooks are hung on the medial crura to keep them out of the surgical field. Converse scissors are used to begin the dissection under the mucous membrane on the concave side of the nasal septum. It is important that this initial dissection be 4-5 mm from the attachment of the ULCs to the QC. A Beaver blade is used to gently incise the perichondrium, and the incision is rubbed with an applicator stick so the proper plane is entered with the Freer elevator.
Figure 1114 The No 11 blade is utilized to complete the transcolumellar incision.
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Figure 1115 The lower lateral cartilages are exposed with advancing rim incisions.
Figure 1116 The caudal strut of the quadrilateral cartilage is exposed after dividing tissue between the medial crura.
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Dissection will be limited because of the attachment of the ULCs to the QC. This attachment is divided under direct vision in a progressive fashion with a Beaver blade until the nasal bones are encountered. Dissection can now be carried posteriorly until the vomer is encountered; superiorly until the junction of the ethmoid plate and the undersurface of the nasal bones is reached; and inferiorly to the floor of the nose from the anterior nasal spine to beyond the juncture with the vomer bone. Ideally, this is accomplished while keeping the mucous membrane intact. Returning to the anterior aspect of the QC, a Converse scissors elevates the mucous membrane on the convex side of the septum away from the edge of the dorsal strut, again remaining 4-5 mm from the attachment of the ULCs with the QC. Dissection will be facilitated by the progressive release of the ULCs from the QC. Care must be taken when going around the septal spur towards the nasal floor, because the QC must usually be dislocated from the nasal crest of the maxilla towards the concave side of the nose to permit adequate access. Again, the mucoperichondrium is elevated off the entire QC to the undersurface of the nasal bones, onto the perpendicular plate of the ethmoid, and onto the vomer bone. The connective tissue at the junctions of the QC with nasal crest of the maxilla, the vomer, the perpendicular plate of the ethmoid, and the undersurface of the nasal bones are divided using the Freer elevator. Particular attention must be paid to the fibrous bands attaching the QC to the anterior spine and these may need to be divided with a Beaver blade. The QC can now be removed in its entirety (Figure 1117). The QC is then kept moist in sterile saline until remodeling. Bone off the midline is now removed from the vomer and the nasal crest of the maxilla, while maintaining the perpendicular plate of the ethmoid intact. The upper surface of the anterior spine is trimmed to take off any irregular spicules of bone, but caution is exercised to not remove any significant amount of bone in this area. The inferior fixation suture (4-0 Mersilene) to be used later is placed through the anterior nasal spine (Figure 1118): 1. With a firm, rotatory motion, an 18-gauge needle is driven in the midline from the anterior-inferior face of the anterior nasal spine up to the superior aspect. 2. The needle is used to guide the suture needle through the bone. 3. Care is taken to place the first knot (a double throw) on the upper surface of the anterior nasal spine exactly in the midline. 4. Two (single throw) knots secure this suture position. This suture is now put aside for future use. The distance from the anterior nasal spine to the nasal bones is measured with surgical calipers (Figure 1119). This distance has varied from 1933 mm in 85 patients (aged 4 to 16 years) for whom data are available.
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Figure 1117 The entire quadrilateral cartilage removed intact; the instrument points to a fracture line in the anterior aspect.
Figure 1118 A nonabsorbable suture is placed through the anterior nasal spine.
Figure 1119 Surgical calipers measure distance from the anterior nasal spine to the nasal bones.
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The template for the free graft is now made: 1. The QC is placed on a paper drape and the outline of the dorsal strut and the caudal strut is traced past the approximate junction with the anterior nasal spine. 2. One end of the surgical calipers (set at the distance determined from the anterior nasal spine to the nasal bones) is placed on the approximate position where the QC articulates with anterior nasal spine. The other end then determines where the free graft will meet the nasal bones (Figure 1120). 3. A notch is drawn into the template (Figure 1121), as this will be the part of the free graft that fits under the nasal bones. 4. Finally, one end of the calipers is placed on the paper where the nasal bones meet the free graft, and the other end is used to draw an arc in the template so that the position of the inferior fixation suture can be altered as required when one completes the sagittal swing maneuver. The template is now cut out of the paper drape. The QC is now remodeled to create the free graft. The QC is examined and the template is positioned on it to determine the best part to use, ideally the straightest and strongest area (Figure 1122). The anterior pathology is trimmed away, saving the excised cartilage for possible later use (ie dorsal graft, columellar strut graft, tip graft, etc). With the template as a guide, a No 15 blade is used to carve out the free graft (Figure 1123).
Figure 1120 The distance determined by the surgical calipers is transferred to the paper template.
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Figure 1121 The completed drawing for the free graft. (A) indicates where the free graft will be attached to anterior nasal spine. (B) is where the free graft will meet the nasal bones.
Figure 1122 The cut out paper template lying on the posterior aspect of the excised quadrilateral cartilage.
Figure 1123 The finished cartilage free graft.
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The free graft is placed between the mucous membrane flaps with the notch under the nasal bones. Two interrupted sutures of the 4-0 Mersilene are placed through the ULCs and the edge of the free graft 1 and 3 mm from the nasal bones (Figure 1124). The first knot of each suture is a double throw, as this will maintain tension until the second knot (a single throw) is placed and tightened. The skin of the nose is loosely draped in its normal position. Through the incision, the free graft is grasped in Brown forceps and rotated forward in the sagittal plane (the sagittal plane swing maneuver) until the correct support of the supratip region is obtained. The suture inserted earlier at the anterior nasal spine is used to fix the free graft in place (Figure 1125). The first knot receives a double throw, and subsequent throws are single. When in doubt, fix the free graft too far in the anterior position as the septal angle area of the free graft can always be shaved down to the correct level. Using Keith needles, two transfixion sutures of 2-0 chromic catgut are placed through the free graft for additional stability (Figure 1126). If the nasal bridge is asymmetric, medial and lateral osteotomies are completed at this time. For the medial osteotomies, the osteotome is placed by direct vision so that it engages the nasal bones but misses the upper fixation sutures. Medial and lateral osteotomies have been completed in 20% of 169 patients (mean age 12 years, youngest age 6 years) that have had the free graft procedure during the past 14 years.
Figure 1124 The free graft being sewn to the upper end of the upper lateral cartilages.
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Figure 1125 The inferior aspect of the graft being fixed to the anterior nasal spine following the sagittal plane swing maneuver.
Figure 1126 A transfixion suture further stabilizes the free graft position.
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Other rhinoplasty-type maneuvers (see below) tip grafts, dorsal grafts, ULC augmentation, etc) are completed at this time. The lower lateral cartilages are sutured back together with interrupted Vicryl sutures. The skin edges of the columellar incision are gently opposed with 5-7 interrupted sutures of 5-0 Prolene; it is important that these are not tight so that they can be easily removed. The rim incisions from their lateral extent to the midline are closed with interrupted sutures of 4-0 chromic catgut. A drainage incision approximately 1 cm in length is made in the inferior aspect of the nasal septum, 2-3 cm posterior to the anterior nasal spine; any accumulated blood is suctioned. Two strips of Vaseline gauze are inserted into each side of the nose, taking care to not pack the nose tightly as pain will result. An overlying adhesive dressing is now applied. A premanufactured splint is also applied to the nose if medial and lateral osteotomies were done. A moustache dressing is used for 2 days to catch any material that seeps from the nose. Postoperative Care The nasal packing is removed early in the morning 2 days following surgery, and the patient is discharged from hospital later the same day. The parent is instructed to apply antibiotic ointment to the columellar incision area twice each day until dressing removal. Nasal packs remain in place for 2 days, during which time the patient is hospitalized. Sutures must be removed from the columellar incision after surgery, which may very occasionally require a general anesthesia in young children. Further office visits are needed at 1 and 3 months postoperatively to ensure satisfactory healing. At the time of discharge, the parents are instructed to call or return to the hospital if there is any fever, increased facial pain or swelling, or increased difficulty breathing through the nose. All of the latter may indicate the development of a postoperative infection. The overlying adhesive dressing and cast are removed 7 to 8 days following surgery. The patient remains at home until this visit and returns to school the Monday after this visit. Full activities can be resumed 1 month after surgery. Special Considerations Completing a reduction rhinoplasty at the same time that a free graft procedure is done is a technically difficult and high-risk procedure. Therefore, the patient and family are warned that a second procedure may be required at some time in the future if such a goal is appropriate. Postoperative nasal airflow studies are ideally completed 1 year following surgery. Ongoing follow-up with respect to the appearance and subsequent growth of the nose is very much dependent on the age of the child at the time of surgery. Patients may be safely discharged from care at age 16 years.

RHINOPLASTY
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Although often carrying a cosmetic connotation, rhinoplasty can also be performed for reconstructive and functional reasons. Open reduction of nasal fractures, the correction of dorsal septal deformities, and additive or reductive changes to the nasal framework may all be considered forms of rhinoplasty. As noted above, rhinoplasty can be performed at any age if conservative techniques are utilized. Surgery for strictly aesthetic purposes, however, should not be performed prior to age 15 years. Rhinoplasty may be performed via an endonasal approach or a transcolumellar incision (external or open approach), each method offering specific advantages and disadvantages (Table 111). When functional and cosmetic deformities coexist, techniques that simultaneously address the septum and external nasal framework may be combined to offer a singlestage return to form and function. Finally, because of its central location on the face, an aesthetically displeasing nose can be the source of much emotional and psychological discomfort for the teenage patient. Indications Reduction of a complicated nasal fracture (ie, involving both bony and cartilaginous structures or one that occurs in primarily an anterior-posterior direction). Reduction of a nasal fracture not initially treated or inadequately reduced by closed techniques. In these cases, rhinoplasty should be deferred at least 3 months from the time of original injury or failed closed reduction. Simultaneous functional and cosmetic repair of a traumatically or congenitally deformed nose (see also External Approach for Septoplasty-Indications). Alteration of an aesthetically displeasing nose.
Table 111 Endonasal vs. external approach for rhinoplasty

Approach Advantages Disadvantages
Endonasal
! Allows better intraoperative visualization of final result ! Preferred for simple tip maneuvers or if no tip surgery is necessary ! No visible scar ! Allows more precise tip surgery ! Affords excellent access to the dorsal septum, if affected ! Less destructive to existing nasal support mechanisms
! More difficult to judge symmetry during tip maneuvers ! Cannot address or reconstruct dorsal septum, if affected
External
! Potentially visible external scar ! Difficult to judge or visualize final result ! Slightly more time consuming
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Anesthetic Considerations All pediatric rhinoplasty surgery is performed under general endotracheal anesthesia to ensure maximal airway control and safety. Local anesthesia consisting of 1% lidocaine with 1:100,000 epinephrine is utilized to ensure a dry operative field and to diminish the requirements for general anesthesia. If using general anesthesia with local infiltration, there is no reason to use topical cocaine and this practice has been abandoned. Preparation The patient is positioned as for closed reduction. A lightweight headlight with halogen light source and 2.5x surgical loupes are used. Following intubation, a throat pack is fashioned by tying a piece of tie from a surgical mask around the sponge portion of a no detergent scrub brush. The pack is inserted transorally into the oropharynx to prevent blood from entering the trachea or esophagus, and to help to avoid postoperative aspiration or nausea. Procedure Two approaches are described: endonasal and external. No 1. Endonasal approach for rhinoplasty Surgical exposure Well wrung-out cotton pledgets sprayed with oxymetazoline are inserted into the nose with bayonet forceps. If the septum is also going to be addressed, it is infiltrated with local anesthesia. Further injections of local anesthesia are made at the planned incision sites and along the nasomaxillary groove and nasal dorsum. After allowing 10-15 minutes for vasoconstriction, a hemi-transfixion incision is made with a No 11 blade (Figure 1127). If concomitant septoplasty is to be performed (see section on septoplasty), it is addressed at this point of the operation. A contralateral hemi-transfixion incision is made after septoplasty is complete (if performed), and the two incisions are connected with a fine blunt scissors. The resulting transfixion incision crosses the midline, but is not carried all the way down to the anterior nasal spine. Intercartilaginous incisions are made bilaterally with the No 15 blade, remaining close to the scrolled edge of the upper lateral cartilage (Figure 1128). A fine blunt scissors is inserted into the intercartilaginous incision and spread three times until a pop is felt (fibers connecting the upper and lower lateral cartilages). A slightly heavier scissors (small Metzenbaum) is introduced through the incision, and with the contralateral hand pinching up the dorsal skin and musculature, the scissors is opened and closed several times as it is advanced towards the radix (Figure 1129). By utilizing the contralateral hand to pull up the nasal superficial musculoaponeurot-
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ic system (SMAS), and by digging the blunt scissors into the nasal bones and overlying periosteum, the correct plane is entered. The maneuver is then repeated on the opposite side. The Metzenbaum scissors is next used to connect the intercartilaginous incisions to the transfixion incision. By carefully dividing the intervening fibers, the surgeon should now be able to pass the scissors along the dorsum, over the anterior septal angle, and down the caudal aspect of the septum without impedance.
Figure 1127 A transfixion incision is made between the medial crura of lower lateral cartilages and the caudal edge of septum.
Figure 1128 An intercartilaginous incision is made between the caudal margin of the upper lateral cartilage and the cephalic border of the lateral crus of the lower lateral cartilage.
Figure 1129 Skeletonizing the dorsum is facilitated by pinching up the nasal skin and SMAS with the contralateral hand.
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Correction of dorsal and bony deformities An Aufricht retractor is inserted between the nasal bone and cartilage, below, and the skin and muscle, above. The dorsal septum is immediately visible from the anterior septal angle back to the rhinion. If a cartilaginous dorsal hump exists, it can now be trimmed with a No 11 or No 15 blade (Figure 1130). The trimming should be incremental, constantly monitoring the profile after each sliver of cartilage is removed; it is easier to prevent an over-resected dorsum than to correct one. Bony humps or spicules can be addressed by inserting a fine diamond rasp over the bony dorsum, and by rasping with a to-and-fro motion (Figure 1131). This should be performed equally from each side so as not to create asymmetry. When withdrawing the rasp out of the dorsal pocket, first lift the rasp off the nasal bones so as not to catch and avulse the adjoining upper lateral cartilages. The rasp should be rinsed frequently with saline to remove bone dust and other debris. After checking to make sure that the profile is properly aligned (small modifications can, and often should, be left until after the tip work is completed), bilateral pyriform incisions are made with the electrocautery just lateral to the anterior end of the inferior turbinates. If a sizeable bony hump has been removed, medial osteotomies are seldom necessary. If indicated, however, they are performed by inserting a curved guarded osteotome up through the nasal mucosa at the junction of the upper lateral cartilages and nasal bones on either side of the bony nasal septum. A short oblique osteotomy is created by having the surgical assistant tap the osteotome with a mallet, while directing the osteotome in the direction of the medial canthus (Figure 1132). Curved guarded osteotomes are then inserted through the pyriform incisions and locked into place on the pyriform rim; proper placement is confirmed by the ability to rock the head back and forth with the handle of the osteotome. A high-low-high lateral osteotomy is performed: (1) high up on the pyriform rim, then (2) low down into the nasomaxillary groove, then (3) high up towards the radix at the level of the medial canthus. By continually palpating the blunt guard of the osteotome under the skin, the path of the osteotomy can be precisely controlled (see Figure 1132). The nasal bones are gently infractured with manual digital pressure. By keeping the majority of the periosteum over the nasal bones intact, there is much less chance of nasal bone collapse following osteotomy. In performing osteotomies earlier, rather than later, in the rhinoplasty, there is generally less bleeding encountered.
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Figure 1130 The cartilaginous hump is reduced incrementally with a No 11 scalpel blade.
Figure 1131 The bony hump is reduced with a fine rasp.
Figure 1132 Path of medial (dotted line) and lateral (dashed line) osteotomies.
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Correction of nasal tip deformity The nasal tip is now addressed and three situations exist that are amenable to simple endonasal tip plasty: 1. If the tip shape is acceptable, but its position in space is deemed undesirable, modifications of the underlying septum (caudally or dorsally) may alter rotation or projection. Reduction of the dorsal portion of the caudal septum or the nasal spine area will result in tip deprojection. A triangle of septal cartilage may be trimmed from the most caudal part of the septum (via the transfixion incision) to allow the nasal tip to slightly rotate up. 2. If the tip is slightly bulbous, but the domes of the lower lateral cartilages are close together, a retrograde cephalic trim may be performed via the intercartilaginous incision with aid of an assistant: A fine blunt scissors is used to dissect on both sides of the lateral crus of the lower lateral cartilage (Figure 1133A). The cartilage is thereby freed from the overlying nasal skin and the underlying vestibular lining. With an assistant helping to evert the lateral crus, a conservative strip from the cephalic margin can be directly excised (Figure 1133B). This should be performed evenly on both sides, generally removing only 3-4 mm of cartilage. 3. If the tip is bulbous and the domes are far apart or asymmetric, the lower lateral cartilages should be delivered prior to modification: Bilateral infracartilaginous (marginal) incisions are performed with a No 15 blade (Figure 1134). A blunt fine scissors is used to dissect directly over the top of the lateral crus and exits at the intercartilaginous incision.
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Figure 1133 A, A fine scissors is used to dissect superficial and deep to the inverted cephalic edge of the lateral crus of the lower lateral cartilage. B, Conservative retrograde cephalic trim may now be performed with a No 15 scalpel blade.
Figure 1134 An infracartilaginous (marginal) incision is made with a No 15 scalpel blade and a sharp double hook at the caudal margin of the lower lateral cartilage.
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The resulting bipedicled flap of lower lateral cartilage and vestibular skin is delivered through the marginal incision in anatomic configuration (Figure 1135). The cephalic margin of the lateral crus is trimmed under direct vision, making sure to leave at least 6-7 mm of intact lateral crura (Figure 1136). The domes are bound together with 5-0 Prolene suture, thereby narrowing the nasal tip and creating a small degree of projection and rotation (Figure 1137):
"
One of the domes is passed under the nasal tip skin and out through the contralateral marginal incision. Once both domes are delivered to one side, a free 25-gauge needle is used to skewer them and hold them symmetrically. The suture may now be passed in a mattress fashion to unite the domes. The 25-gauge needle is removed and the newly created tip is returned to its anatomic position beneath the skin and checked for symmetry.
"
"
Figure 1135 The lower lateral cartilage is delivered as a bipedicled chondrocutaneous flap.
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Figure 1136 Conservative resection of the cephalic portion of the lateral crus of the lower lateral cartilage is performed preserving at least 6 mm of intact lateral crus.
Figure 1137 A horizontal mattress suture of 5-0 clear Prolene is used to narrow the interdomal distance.
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Incision closure A dorsal augmentation graft (Figure 1138), if indicated, is placed prior to incision closure by tenting up the dorsal skin with the Aufricht retractor and inserting the graft with a bayonet forceps. Fixation can be performed percutaneously with a suture passed through the dorsal skin, the graft, back through the skin, and then tied over a Telfa bolster. Alternately, the caudal end of the implant can be sutured to the dorsal septum with an absorbable suture. The marginal and transfixion incisions are closed with chromic suture, and if a septoplasty was performed, a quilting suture is placed. Two folded Telfa packs are coated with antibiotic ointment and inserted into each nasal passage with a bayonet forceps (Figure 1139). Paper tape is cut to size and placed over the entire nasal dorsum, with an additional piece wrapped around the nasal tip for support in the early postoperative period. A splint made from Aquaplast is trimmed to size, dipped in hot water, and applied to the nose for 2 minutes (Figure 1140).
Figure 1138 Correct position of dorsal onlay graft.
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Figure 1139 Folded Telfa nasal packs are inserted bilaterally.
Figure 1140 Nasal splint.
No 2. External approach for rhinoplasty Surgical exposure Well wrung-out cotton pledgets sprayed with oxymetazoline are inserted into the nose with bayonet forceps. If the septum is also going to be addressed, it is infiltrated with local anesthesia. Further injections of local anesthesia are made at the planned incision sites and along the nasomaxillary groove and nasal dorsum. An inverted V incision is marked at the waist of the columella and infiltrated with local anesthesia using a 30-gauge needle.
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Marginal incisions are made at the caudal margin of the lower lateral cartilages as in the endonasal delivery technique. 1. A fine-tipped delicate scissors is inserted in front of the medial crura, from one marginal incision site to the other (Figure 1141). 2. The scissors is spread vertically to separate the columellar skin from the perichondrium in the precrural space. 3. Following this important maneuver, the point of a No 11 blade is used to complete the inverted V incision, taking care not to lacerate the underlying medial crura. The paired columella arteries are coagulated with a fine tip cautery and the subperichondrial plane is entered with fine scissors. By remaining in this plane, a bloodless dissection can be achieved as the nasal tip cartilages are skeletonized. Dissection proceeds medially up over the domes towards the anterior septal angle (Figure 1142) and laterally up over the lateral crura (Figure 1143). From this point on, the dorsal dissection is identical to that for the endonasal approach (see Figures 1129 to 1132). The sub-SMAS plane is entered at the anterior septal angle, and with the contralateral hand pinching up the nasal skin and musculature, a Metzenbaum scissors is spread several times while advancing towards the nasion. Septoplasty, if indicated, is performed now. The septum can be easily accessed by dividing the medial crura, entering the membranous columella, and palpating the caudal edge of the quadrangular plate. The technique for this procedure is covered in detail in the preceding section, Septoplasty.
Figure 1141 Bilateral infracartilaginous incisions (1) are made with the No 15 blade. A fine scissors (2) is used to connect the medial portions of both infracartilaginous incisions in the precrural plane. The transcolumellar incision (3) is then completed with a No 11 blade.
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Figure 1142 A fine scissors is used to dissect over the medial crura and domes in the subperichondrial plane.
Figure 1143 The dissection continues laterally over the lateral crus in the subperichondrial plane.
Correction of dorsal and bony deformities Dorsal reduction and osteotomies are performed as described in the preceding section, Endonasal approach for rhinoplasty. Correction of nasal tip deformity Tip modifications may now be made and generally proceed from the bottom up, ensuring a well-supported nasal tip.
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A bulbous tip or excess lateral crura, if present, are corrected with a cephalic trim as described in the preceding section, Endonasal approach for rhinoplasty. Next, a straight rigid piece of septal cartilage (previously harvested during septoplasty or for grafting purposes) is inserted between the medial crura (Figure 1144). The domes are aligned in exact symmetric apposition, and held by passing a 4-0 Polydioxanone (PDS) suture through the crura and columellar strut in a mattress fashion (the knot is buried). The strut is utilized in almost every external rhinoplasty to prevent buckling of the medial crura, provide added tip support, and to set the stage for further tip modification. The next four tip maneuvers may be used alone or in combination and allow the surgeon to tailor the repair to the exact tip pathology encountered. All of these maneuvers are reversible, nondestructive, and rely solely on cartilage suture techniques. 1. A dome-spanning suture (Figure 1145) is placed if the domes are too far apart or if a small amount of projection is needed. A 5-0 Prolene suture is placed between the two domes in a symmetric fashion and slowly tightened until the desired width between the domes is achieved. The net result of this popular maneuver is to narrow the nasal tip and project and rotate it slightly. 2. A lateral crural spanning suture (Figure 1146) is used if the supratip area is still too full following conservative cephalic trim. This suture of 5-0 Prolene is placed in a mattress fashion behind the domes, but should not be overly tightened to prevent postoperative airway obstruction caused by internal nasal valve compromise.
Figure 1144 A cartilaginous strut is sutured between the medial crura.
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Figure 1145 The interdomal distance is narrowed with a 5-0 clear Prolene horizontal mattress suture.
Figure 1146 The supratip area is narrowed with a 5-0 clear Prolene horizontal mattress suture. Note the placement of the suture behind the domes.
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3. The tip complex may now be set to the proper height with several millimeters of projection or deprojection achievable utilizing the recession projection control suture (Figure 1147). Both medial crura are grasped with a forceps and positioned at the desired height along the caudal septum. Next, a 4-0 PDS suture is placed from the midway point on the caudal margin of the septum to the posterior edges of the medial crura. By tying this suture tightly, the tip complex is now fixed at the appropriate level of projection or recession. 4. Finally, if further tip rotation is desired, a tip rotation suture (Figure 1148) may be utilized. This suture of 4-0 PDS is placed from just behind the anterior septal angle on the dorsum of the septum to the posterior edges of the superior aspect of the medial crura. As the suture is slowly tightened, the tip complex will be rotated around the anterior septal angle. When the desired degree of tip rotation is achieved, the knot is secured. Incision closure A dorsal augmentation graft (see Figure 1138), if indicated, is placed prior to incision closure by tenting up the dorsal skin with the Aufricht retractor and inserting the graft with a bayonet forceps. Fixation can be performed percutaneously with a suture passed through the dorsal skin, the graft, back through the skin, and then tied over a Telfa bolster, or alternately, by suturing the caudal end of the implant to the dorsal septum with an absorbable suture. The marginal and transcolumellar incisions are closed with chromic and proline suture, respectively (Figure 1149); if a septoplasty was performed, a quilting suture is placed.
Figure 1147 A recession projection control suture is placed between the caudal edge of the septum and posterior edges of the medial crura.
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Figure 1148 A rotation control suture is placed between the dorsal edge of the anterior septum (anterior septal angle) and the superior posterior edges of the medial crura.
Figure 1149 The transcolumellar incision is meticulously closed using a 6-0 Prolene suture on a fine needle.
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Two folded Telfa packs are coated with antibiotic ointment and inserted into each nasal passage with a bayonet forceps (see Figure 1139). Paper tape is cut to size and placed over the entire nasal dorsum; additional tape should not be placed around the nasal tip as this may compromise blood supply. A splint made from Aquaplast is trimmed to size, dipped in hot water, and applied to the nose for 2 minutes. Postoperative Care Nasal packing is removed on the first postoperative day. Ice packs over the eyes are recommended for the first 48 hours. The nasal splint can be removed on day 7 (along with sutures if the external approach has been employed). Gentle nasal exercises are begun in order to maintain bony alignment, by having the patient (or a parent) gently squeeze the nasal bones together a few times a day for the first 7 days after splint removal. Pressure should be light and the patient should not experience pain during this maneuver. At 2 weeks, the patient may resume light aerobic activity; at 4 weeks, running and jumping are allowed; and at 6 weeks, full activity may be resumed. Complications Complications following rhinoplasty are rare, but include excessive bleeding, septal hematoma, nasal valve compromise, and over- or undercorrection of deformities. Many such deformities are minor and can be corrected with a small revision procedure after an appropriate healing time (usually a minimum of one year following primary rhinoplasty).
BIBLIOGRAPHY
Crysdale WS, Djupesland P. Nasal obstruction in children and infants: evaluation and management. In: Myers EN, editor. Advances in otolarygology. Volume XIII. CV Mosby; 1999. Crysdale WS. Clinical challenges in otolaryngology (commentary): septoplasty in childrenyes, but do the right thing. Arch Otolaryngol Head Neck Surg 1999;125:701. Crysdale WS. External septoplasty in children. J Otolaryngol 1996;25:25760. Tardy ME. Rhinoplasty; the art and science. Philadelphia: WB Saunders; 1997. Tebbetts JB. Primary rhinoplasty: A New Approach to the Logic and Techniques. CV Mosby (St. Louis, MO); 1998. Toriumi DM. Open structure rhinoplasty: featured technical points and long-term follow-up. Facial Plastic Clin N Am 1993;1:122. Walker P, Crysdale WS. External septorhinoplasty in childrenpatient selection and surgical technique. J Otolaryngol 1994; 23:2831. Walker P, Farkas L, Crysdale WS. External septoplasty in children: outcome and effects on growth. Arch Otolaryngol Head Neck Surg 1993;119:9849.
C H A P T E R 12
C ONGENITAL N ASAL M ALFORMATIONS

Margaret A. Kenna, MD Reza Rahbar, DMD, MD
Diagnosis of congenital nasal malformations requires an adequate history, complete physical examination, and nasal endoscopy. Computed tomography (CT) or magnetic resonance imaging (MRI) is often required to further define the bony and soft tissue abnormalities. When these malformations are associated with a significant nasal obstruction, repair or bypass of the obstruction must be undertaken. Timing of the surgical intervention depends on the degree of the nasal obstruction, general medical condition, and the presence or absence of other associated anomalies.
OVERVIEW OF MALFORMATIONS This section provides a brief overview of the most common causes of nasal obstruction for which surgery is indicated. The remainder of the chapter describes the relevant surgical procedures. Choanal Atresia Choanal atresia results from nonrupture of the nasobuccal membrane, with a defect in the region of the nasal and palatal process.1,2 Choanal atresia is present in approximately 1:7,000 live births, with a female to male ratio of 2:1, and a unilateral to bilateral ratio of 2:1. Bilateral choanal atresia is often associated with other congenital anomalies, most commonly CHARGE association.3,4 Unilateral cases are often relatively asymptomatic, while bilateral cases usually present with respiratory distress at birth. Repair of bilateral choanal atresia can be done at any time after the airway is secure and the initial workup for evaluation of possible associated anomalies has been completed. If there are no critical airway issues, repair of unilateral cases is usually elective. Diagnosis involves nasal endoscopy and CT scan of the paranasal sinuses and nasopharynx.
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Pyriform Aperture Stenosis The etiology of pyriform aperture stenosis is overgrowth of maxillary ossification at the area of the nasal process of the maxilla.5,6 Associated abnormalities such as holoprosencephaly, pituitary abnormalities, mega uni-central incisor, and cardiac anomalies are sometimes seen in infants with congenital pyriform aperture stenosis.7,8 Pyriform aperture stenosis is best evaluated by CT of the nasal cavity. Most common presentation is nasal airway obstruction, most often seen with bilateral aperture stenosis. Dermoids, Gliomas, Teratomas Many congenital nasal malformations can be grouped by their embryology.1,9 Nasal dermoids, gliomas, and encephaloceles result from the abnormal closure of the foramen cecum. These anomalies may have either a fibrous connection (stalk) or an actual extension to the central nervous system, presenting either externally or intranasally. Dermoid is the most common congenital midline nasal mass, and contains mesodermal elements (hair follicles, sebaceous glands, and sweat glands).10 Teratomas are comprised of elements of all three embryonic layers and can occur anywhere in the midline. CT s or MRIs are essential to help determine whether these lesions have any intracranial extension.4,10 TRANSNASAL REPAIR OF CHOANAL ATRESIA Indications Bilateral choanal atresia often presents with airway distress at, or shortly after, birth. Repair or bypass of nasal obstruction must be performed immediately.11 Unilateral atresia may not be symptomatic at birth; therefore, repair can be done later in childhood. The transnasal approach is suitable for all types (membranous, mixed, bony) of atresia, as long as adequate transnasal access is present.12 Thick bony atresias with medialized pterygoid plates, however, are better suited to a transpalatal approach (next section). If there is lack of adequate nasal access due to other anomalies (nasal, facial), or there is a thick bony atresia with medialized pterygoid plates, the transpalatal repair may need to be considered.13 If the patient is otherwise medically stable, the transnasal approach can be performed as early as the first few days of life. Anesthetic Considerations This procedure should be performed under general anesthesia using either an oral endotracheal or tracheotomy tube.
Congenital Nasal Malformations
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Preparation The nasal cavity is suctioned to remove all secretions. Neuropledgets with topical vasoconstriction (ie, 0.5% oxymetazoline) are placed intranasally. After removing the pledgets, the largest 0 rigid telescope (2.7 or 4.0 mm) that fits comfortably into the nose is used to examine the nasal cavity and atretic plate. Contents of the entire cavity, including the turbinates and nasal septum, are evaluated for any obvious abnormality. The posterior septum, lateral nasal wall, middle turbinate, and atresia plate are infiltrated with 0.5% lidocaine with 1:200,000 epinephrine solution, taking care not to exceed the maximum dose for age and weight. Gauze packs are placed in the nasopharynx to prevent blood from being swallowed or aspirated. Procedure Examination of the posterior choana and atresia plate is performed with a rigid 0 endoscope (preferred method) as described above, or with a nasal speculum (Figure 121) and magnification (microscope, loupe). The atresia plate is palpated using a straight No 5 suction or No 6 French metal dilator to further assess the degree of bony or membranous component. Findings on palpation are correlated with the axial and coronal CT scan. A small opening is made in the most inferior medial aspect of the atresia plate at the junction of the atresia plate and the posterior septum. A small straight suction sound dilator, or a 25-gauge spinal needle can be used for this purpose.
Figure 121 The posterior choanal atresia mucosa is exposed with a nasal speculum.
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The position of the instrument in the nasopharynx is confirmed: 1. In unilateral cases, the position is confirmed using a 0 or 30 endoscope through the contralateral nasal passage. 2. In bilateral cases, a Davis mouthgag is slightly opened permitting the nasopharynx to be visualized with a mirror or a 120 endoscope. Many techniques have been proposed for making a mucosal flap in the atretic area: 1. A sickle knife may be used to incise the mucosa at the junction of the posterior septum and the atretic plate, and a mucosal flap is elevated off the atresia plate. 2. Alternatively, a vertical incision is made along the anterior face of the atretic area, followed by elevation of medial and lateral flaps (Figure 122). The authors prefer this method. 3. In revision cases, and in some primary cases, it is often difficult to elevate the mucosal flaps. Care should be taken, however, to preserve as much mucosa as possible. Bone removal may be accomplished with mastoid curettes, the carbon dioxide laser, or powered instrumentation.14-16 A powered microdebrider with a covered (guarded) drill of appropriate size is used to remove the remaining pterygoid lamina, atresia plate, and part of the vomer in order to widen the opening. A 120 endoscope is placed transorally to permit precise visualization of the bone removal.
Figure 122 The anterior mucosa is incised vertically, and flaps are elevated medially and laterally.
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Figure 123 A and B, Removal of atretic bone inferiorly and medially.
A backbiting forceps removes further portions of the vomer and bony septum. The forceps is inserted on the atretic side, and appropriate position is confirmed with a 0 endoscope on the contralateral side. This is an important step in gaining an adequate opening for the choana. Preliminary results have shown that topical application of mitomycin C may be helpful in decreasing scar formation and increasing the success rate: 1. Mitomycin C is an antibiotic with antitumor activity, which selectively inhibits the synthesis of deoxyribonucleic acid (DNA). The drug has been topically used by ophthalmologists to inhibit scarring since the mid-1980s, and later by otolaryngologists. 2. Although the Food and Drug Administration (FDA) has approved mitomycin C for use as a chemotherapeutic agent, topical use is an off-label application (August 2001). When handling any chemotherapeutic agent, double gloves are used and drug is diposed of in a special waste bag. 3. Approximately 1.0 mL of mitomycin C (premixed by the pharmacy to 0.4 mg/mL) is applied topically to the surgical site for 4 minutes, which is then irrigated with 20 mL of saline.17,18 Whether to stent, the ideal material for stenting, its method of placement, and the duration of stenting remain controversial:19,20 1. We recommend stenting with a 3.5 or 4.0 endotracheal tube in neonates, and a 4.0 or larger endotracheal tube for older children.
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2. If the choanal atresia is bilateral, the endotracheal tube is bent into a U-shape, and an opening is made posteriorly facing the lumen of the nasopharynx in the part of the tube that loops around the vomer (Figure 124). 3. Red rubber catheters are passed nasally and retrieved orally. Each end of the stent is secured to a red rubber catheter using a 0 silk suture. 4. The catheters are lubricated with water-soluble gel, and are withdrawn from the nose, bringing with them the ends of the stent. If passage is difficult, the stent is removed and the choanal openings are dilated with lubricated urethral sounds. A finger is placed in the nasopharynx to ensure proper passage and position of the sound after each pass. 5. Proper positioning of the stent opening against the vomer (Figure 125) is confirmed orally using a dental mirror or a 120 endoscope. Several methods of securing the stents anteriorly can be utilized. A suture can be passed medially inside the stent (Figure 126), through the cartilaginous septum to the medial portion of the contralateral stent, and then back again. This keeps the stent firmly in place but allows for unimpeded passage of the suction catheter. If stents are used, it is important to make sure intraoperatively that a suction catheter can be passed through the stent into the nasopharynx, as it is difficult to correct this once the child is awake.
Figure 124 A flexible endotracheal tube is fashioned into a stent for the posterior choanae.
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Figure 125 A stent is used to keep the choanae open bilaterally. The stent passes behind the vomer, and suction catheters can be passed from anterior to posterior into the nasopharynx.
Figure 126 The anterior ends of the stent protrude from the nares and are sutured in position.
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Postoperative Care Meticulous attention to the stents is necessary to prevent plugging and displacement. Soft catheters are used for suctioning every few hours, and normal saline can be used for irrigation of the stents. While the stents are in place, the anterior septum and nares are inspected regularly for any signs of pressure from the stent, and broad-spectrum antibiotics and antireflux medications are recommended. Duration of stent placement remains controversial: 1. For difficult bilateral cases, we recommend stent placement for 3-4 weeks. 2. For children with craniofacial anomalies (ie, CHARGE association), we again stent for 3-4 weeks because of a higher possible failure rate. 3. For unilateral cases, we recommend stent placement for a shorter period of time (2-3 days). Some surgeons do not employ stents after unilateral surgery. Stent removal is performed under general anesthesia, at which time nasal endoscopy is performed to inspect the surgical site and remove discrete granulation tissue. Complications Reported complications include palatal flap dehiscence or necrosis; stent displacement or plugging; choanal restenosis; maxillary hypoplasia and anterior crossbite;21 pressure necrosis from stents; and cerebrospinal fluid (CSF) leak. TRANSPALATAL REPAIR OF CHOANAL ATRESIA Indications The major advantage of the transpalatal approach is improved visualization. A deviated septum, large turbinates, other anatomical abnormalities, or simply the small size of the nose, can make it difficult to see the posterior nasal cavity for sufficient bone removal.22,23 The transpalatal approach may allow wider surgical exposure, improved access to the posterior vomer, and creation of a larger initial opening. If otherwise medically stable, the transpalatal procedure can be performed as early as the first few days of life. Anesthetic Considerations The procedure is performed under general anesthesia with the airway secured by an endotracheal or tracheotomy tube. The palate is injected with 0.5% lidocaine solution with 1:200,000 epinephrine, taking care not to exceed the maximum dose for age and weight. Neuropledgets with a topical vasoconstrictor (ie, 0.5% oxymetazoline) are placed intranasally. Preparation The Dingman mouth gag provides excellent exposure of the palate and posterior pharynx.
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Surgical endoscopes and the operating microscope (with a 300 mm lens) are used for magnification and visualization. Procedure Several palatal incisions have been described (Figure 127), of which the Owens incision is recommended. Both the Owens and Steinzeug incisions permit maximal exposure of the superior lateral nasal wall, which may need to be drilled for optimal posterior choanal size. The other incisions in Figure 127 are not recommended, because of an increased fistula rate when the incision overlies the site of bone removal. The Owens incision starts behind the maxillary tuberosity and is carried medially along the palatal-alveolar ridge junction to the canine region, where it then continues to the nasopalatine foramen. A similar incision is made on the other side. Adequate mobile mucosa must be preserved along the alveolar side of the incision to allow for proper closure.
Figure 127 Incisions used in the transpalatal approach: (1) Steinzeug, (2) Owens, (3) Wilson, (4) Brunk, and (5) Ruddy. The stippled area represents the atresia plate.
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The mucoperiosteal flaps are elevated posteriorly to the edge of the hard palate (Figure 128A). Care must be taken to preserve the neurovascular bundle coming out of the greater palatine foramen (Figure 128B). This bundle should remain within the flap as it is elevated. If further length of the flap is needed, the posteromedial wall of the greater palatine foramen and canal can be removed to mobilize the greater palatine artery. Additional techniques that are rarely necessary include sectioning the tensor veli palatini muscle or fracturing the hamulus of the pterygoid bone. The soft palate is separated from the posterior edge of the hard palate (Figure 129) with a releasing incision where they join. The soft palate is retracted posteriorly and superiorly to expose the nasopharynx and posterior edge of the hard palate. Prior to removing bone (Figure 1210), the nasal mucosa must be preserved and elevated from the nasal surface of the hard palate. The posterior edge of the hard palate is then removed using a cutting bur (Figure 1211) or a Kerrison punch. A diamond cutting bur may be used to remove the posterior edge of the hard palate while preserving the underlying nasal mucosa. Care must be taken not to damage the neurovascular bundles.
Figure 128 The mucoperiosteal flap is elevated (A) while preserving the greater palatine vessels, (B).
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Figure 129 The mucoperiosteal flap has been elevated. Dashed lines indicate the incision between the hard and soft palates.
Figure 1210 Dashed lines indicate areas of bone removal for bilateral atresia.
Figure 1211 The posterior edge of the hard palate is removed with a cutting bur.
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Bone and abnormal soft tissue should be removed to the roof of the nasal cavity. Then the posterior portion of the hard palate, vomer, and bony septum are thinned or removed for adequate choanal size. If necessary, bone removal laterally between the lateral nasal wall, maxillary sinus, and pterygopalatine fossa can be considered for increased choanal size. The CT scan should be examined first, however, to determine the amount of bone that can be safely removed without risk of neurovascular injury. Although sometimes impossible to do, an attempt should be made to preserve nasal mucosa, which can be used to line the new choanal opening (Figure 1212). Throughout the procedure, urethral sound dilators of various sizes are used to determine the dimensions of the choanal opening. At the end of the procedure, it should be possible to pass at least a No 14 French catheter through the opening (in a newborn) without difficulty. After adequate enlargement of the choana, topical application of mitomycin C may be used to help decrease scar formation and increase the success rate (see preceding section). Different techniques for stenting have been proposed. The authors prefer the use of an endotracheal tube in the U shape as described earlier (see Figure 124). The stent is placed, and proper position confirmed by direct visualization through the palatal incision (Figures 1213A and B). Palatal closure is done with an absorbable suture in an interrupted fashion and the stent is secured to the nasal septum (Figure 1213C).
Figure 1212 Technique for obtaining a mucoperiosteal flap from the membranous atresia.
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Figure 1213 A, The stent is inserted into the nasopharynx via the nares. B, The mucosal flaps (if preserved) are placed on the inferior aspect of each tube before the palatal flap is replaced. C, A suture is placed through the nasal septum behind the columella to prevent displacement of the tubes; the palatal incision has been closed.
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Postoperative Care Meticulous attention to the stents is necessary to prevent plugging and displacement. Soft catheters are used for suctioning every few hours, and normal saline can be used for irrigation of the stents. While the stents are in place, the anterior septum and nares are inspected regularly for any signs of pressure from the stent, and broad-spectrum antibiotics and antireflux medications are recommended. Stent removal is performed after 3-4 weeks under general anesthesia, at which time nasal endoscopy is performed to inspect the surgical site and remove any polypoid or obstructing granulation tissue. Complications Reported complications include palatal flap dehiscence or necrosis; stent displacement or plugging; choanal restenosis; maxillary hypoplasia and anterior crossbite; pressure necrosis from stents; and CSF leak. LATERAL RHINOTOMY Indications Exposure for intranasal lesions such as dermoid, glioma, encephalocele, or lesions involving the septum, lateral nasal wall, or floor of the nasal cavity. Exposure for lesions involving the maxilla and ethmoid sinuses. Anesthetic Considerations The procedure should be performed under general anesthesia with a secure airway (endotracheal or tracheotomy tube). The incision line is infiltrated with 0.5% lidocaine solution with 1:200,000 epinephrine, taking care not to exceed the maximum dose for age and weight. Neuropledgets with a topical vasoconstrictor (0.5% oxymetazoline solution) are placed intranasally. Preparation The entire face should be surgically prepared, leaving entire nose and midface exposed. A tarsorrhaphy suture of 5-0 silk is placed to approximate the upper and lower eyelids on the side of the procedure. The bipolar electrosurgical forceps are available for hemostasis. Procedure A curvilinear incision is planned (Figure 1214). Hatch marks are placed along the nasal incision and the alar rim to allow exact skin closure; a broken line at the level of the medial canthus may be used to prevent postoperative webbing. The incision begins just below the medial aspect of the eyebrow, extending inferiorly in a plane approximately one-half the distance between the medial canthus and the nasion. The incision should be carried anteriorly to the nasomaxillary sulcus, then continue to the alar sulcus and nasal vestibule.
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The incision is performed in layers, using the bipolar electrosurgical forceps for meticulous hemostasis. The alar incision is carried through all layers of tissue until the bony edge of the maxillary process is reached (Figure 1215). The nasal ala is detached and mobilized by dividing the vestibular mucosa to complete the alar sulcus incision. A suture placed in the lateral alar region is helpful for retraction, and will expose lesions of the anterior nasal floor and septum (Figure 1216).
Figure 1214 Nasal incision for lateral rhinotomy.
Figure 1215 An alar incision is carried through all layers of tissue.
Figure 1216 A lesion is visible on the septum and anterior nasal floor.
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Additional procedures may be performed to improve exposure: 1. The periosteum of the nasal bone and ascending process of the maxilla may be elevated in order to remove the underlying bone. 2. The periosteum on the anterior face of the maxilla may be elevated, and a lateral osteotomy of the nasal pyramid may be performed along the frontal process of the maxilla using curved chisel or oscillating saw to outfracture the bone. Care is taken not to injure the inferior orbital nerve. 3. Skin incisions and facial skeleton osteotomies may be required for further exposure. Skin closure is done in layers. The periosteal layer is closed first (4-0 absorbable suture), followed by closure of the subcutaneous layer (4-0 absorbable suture). Special attention should be given to the closure of the medial canthal and alar regions. Skin closure is done with 6-0 nylon or 6-0 plain gut suture. Nasal packing is used, when necessary, for hemostasis. Postoperative Care Antimicrobial ointment is applied daily to the skin incisions. If nasal packing is employed, broad-spectrum systemic antibiotics and salt water nasal spray should be used until the packing is removed. Suture removal from the skin on the fifth postoperative day. Complications Reported complications include epiphora, telecanthus, vestibular stenosis, nasal valve collapse, and infraorbital nerve injury.

SUBLABIAL APPROACH Indications Exposure for repair of pyriform aperture stenosis. Exposure for removal of anterior nasal floor lesions.
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Preparation Use of magnification (operating microscope with 300-mm lens, or surgical endoscope) is highly recommended. Anesthetic Considerations The procedure should be performed under general anesthesia with airway secured by endotracheal or tracheotomy tube. The sublabial area is infiltrated with 0.5% lidocaine with 1:200,000 epinephrine, taking care not to exceed the maximum dose for age and weight. Neuropledgets with topical vasoconstrictor (0.5% oxymetazoline solution) are placed intranasally. Procedure A standard sublabial incision is made, bridging the right and left canine fossae (Figure 1217A). The mucosa and mucoperiosteum are elevated to expose the pyriform aperture (Figure 1217B), taking care to avoid injuring the tooth buds. The anterior nasal spine is left attached to the septal cartilage. Mucosa is elevated off the nasal floor, lateral nasal cavity, and the pyriform aperture. Dissection continues until the lesion is adequately exposed, or the area of pyriform stenosis is passed.
Figure 1217 A, Incision for sublabial approach. B, The anterior nasal spine is left attached to septal cartilage.
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A diamond cutting bur or mastoid curettes may be used to remove the lateral bony aspect of the pyriform (Figure 1218). Bone removal from the nasal floor, when necessary, is performed judiciously to avoid injuring the maxillary tooth buds. The final nasal aperture should be wide enough to allow easy passage of a 3.5 endotracheal tube stent (in an infant) on both sides. The length of the stents should be fashioned to pass the stenotic area and sutured anteriorly to the anterior septum. Duration of stenting is controversial, ranging from 24 hours to 4 weeks. The authors recommend 3-4 days of stenting. The sublabial incision is closed using an absorbable suture in an interrupted fashion (Figure 1219). Postoperative Care Stent care and removal are performed as described earlier for Choanal Atresia. Complications Reported complications include injury to the tooth buds or nasolacrimal duct; naso-oral fistula; hypoplasia of the nose or midface; and restenosis of the pyriform aperture.
Figure 1218 Bone is removed from the pyriform aperture laterally and anteriorly.
Figure 1219 The sublabial incision is closed. Placement of a small drain (as shown) is rarely necessary.

REFERENCES
1.
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2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
Hengerer AS, Newburg JA. Congenital malformations of the nose and paranasal sinuses. In: Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saunders; 1990. p. 71828. Hengerer AS, Strome A. Choanal atresia: a new embryologic theory and its influence on surgical management. Laryngoscope 1982;92:91321. Bergstrom L, Owens O. Posterior choanal atresia: a syndromal disorder. Laryngoscope 1984;94:12736. Lowe LH, Booth TN, Joglar JM, Rollins NK. Midface anomalies in children. Radiographics 2000;20:90722. Brown OE, Myer CM, Manning SC. Congenital nasal pyriform aperture stenosis. Laryngoscope 1989;99:8691. Godil MA, Galvin-Parton P, Monte D, et al. Congenital nasal pyriform aperture stenosis associated with central diabetes insipidus. J Pediatr 2000;137:2602. Lo FS, Lee YJ, Lin SP, et al. Solitary maxillary central incisor and congenital nasal pyriform aperture stenosis. Eur J Pediatr 1998;157:3944. Huang JK, Cheng SJ, Lin JC, Sheu CY. Congenital nasal pyriform aperture stenosis and single central maxillary incisor: CT and MRI findings. Clin Imaging 1998;22:3937. Hughes GB, Sharpino G, Hunt W, Tucker HM. Management of the midline nasal mass: a review. Otolaryngol Head Neck Surg 1980;2:22233. Pensler JM, Bauer BS, Naidich TP. Craniofacial dermoids. Plast Recon Surg 1988;82:9538. Stahl RS, Jurkiewicz MJ. Congenital posterior choanal atresia. Pediatrics 1985;76:42936. Stankiewicz JA. The endoscopic repair of choanal atresia. Otolaryngol Head Neck Surg 1990;103:9317. Osguthorpe JD, Singleton GT, Adkins WY. The surgical approach to bilateral choanal atresia. Arch Otolaryngol Head Neck Surg 1982;108:3669. Lantz HJ, Birch HG. Surgical correction of choanal atresia in the neonate. Laryngoscope 1981;91:162934. Muntz H. Pitfalls to laser correction of choanal atresia. Ann Otol Rhinol Laryngol 1987;96:436. Healy GB, McGill TJ, Jako GJ, et al. Management of choanal atresia with the carbon dioxide laser. Ann Otol Rhinol Laryngol 1987;87:65862. Rahbar R, Valdez TA, Shapshay SM. Preliminary results of intraoperative Mitomycin C in the treatment and prevention of glottic and subglottic stenosis. J Voice 2000;14:2826. Rahbar R, Shapshay SM, Healy GB. Mitomycin: effects on laryngeal and tracheal stenosis, benefits and complications. Ann Otol Rhinol Laryngol 2001;110:16. Grundfast KM, Thomsen JR, Barber CS. An improved stent method for choanal atresia repair. Laryngoscope 1990;100:11323. Gleeson MJ, Hibbert J. A stent for the corrective management of bilateral choanal atresia. Laryngoscope 1985;95:140910. Freng A. Growth in width of the dental arches after partial extirpation of the mid-palatal suture in man. Scand J Plast Recon Surg 1978;12:26772. Krespi YP, Husain S, Levine TM, Reede DL. Sublabial transeptal repair of choanal atresia or stenosis. Laryngoscope 1987;97:14026. Resouly A, Barnard JDW, Purnell AN. Access by Lefort I osteotomy for correction of unilateral choanal atresia. Clin Otolaryngol 1990;15:2812.
C H A P T E R 13
E NDOSCOPIC E THMOIDECTOMY AND A NTROSTOMY

Glenn Isaacson, MD
There are no prospective clinical trials comparing medical management of sinusitis to any surgical technique, nor are there published studies comparing endoscopic surgery to classical techniques in comparable situations. Over a decade of experience with endoscopic techniques, however, has shown that well-trained otolaryngologists can perform this surgery safely, with a low incidence of revision surgery, and a high degree of child and family satisfaction.1
Indications Endoscopic sinus surgery is not considered until medical therapies have been exhausted, including long courses of oral antibiotics, intranasal or systemic steroids, and complete allergy management.2 Some surgeons prefer to correct septal deviations prior to endoscopic surgery, and most would perform an adenoidectomy alone prior to operating on the sinuses if the adenoids were obstructing or if there was sufficient tissue to serve as a bacterial reservoir. Endoscopic sinus surgery works well for 1. Recurrent acute sinusitis that responds to antibiotics, but rapidly recurs 2. Decreasing nasal obstruction from polyposis, allergy, or cystic fibrosis3 3. Providing surgical drainage of ethmoid mucoceles4 4. Treating acute sinusitis complicated by orbital subperiosteal abscess or nonadjacent intracranial abscesses5 Endoscopic sinus surgery may have a role in 1. Managing chronic sinusitis, especially when anatomic abnormalities are present 2. Symptomatic control in sinusitis with cystic fibrosis, especially for those children with headache 3. Establishing diagnosis for certain sinus pathology including atypical mucous retention cysts, fibrous dysplasia, and soft tissue masses
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4. Obtaining reliable material for culture in critical situations such as immunosuppression 5. Controlling allergic fungal sinusitis 6. Decreasing the need for systemic steroids in children with asthma and chronic sinusitis Endoscopic sinus surgery does not 1. Provide permanent control of sinus disease in cystic fibrosis6 2. Improve pulmonary function in children with cystic fibrosis7 3. Work reliably for children with immunosuppression8 or primary ciliary dyskinesia9 4. Remove the need for continuing medical management in most children Sinus surgery is inappropriate treatment for allergic rhinitis without sinusitis, or for purulent nasal discharge secondary to intranasal foreign bodies or adenoid hyperplasia. The value of surgery for preschoolers with chronic or recurrent sinusitis remains controversial, because many will outgrow their disease within a short period of time. Lastly, endoscopic ethmoidectomy is rarely appropriate for a child with chronic headaches and normal computed tomography (CT) of the sinuses. Preoperative Evaluation History and physical examination should establish the frequency, severity, duration, and cause of sinusitis. A family or personal history of inhalent allergy, cystic fibrosis, or immunosuppression will help guide decisionmaking and establish appropriate surgical expectations. Additional preoperative considerations include Anterior rhinoscopy and nasal endoscopy (rigid or flexible) to assess septal deviation and nasal cavity size, and to rule out other causes of nasal symptoms including tumors, choanal atresia, enlarged adenoids, and intranasal foreign bodies. A complete blood count, prothrombin time, and partial thromboplastin time, to screen for anemia and coagulopathies. CT with high resolution axial and coronal images to establish the diagnosis of sinusitis and to serve as a surgical road map. Some centers incorporate intraoperative computerized image guidance, especially for revision cases. Consultation with appropriate specialists for any pre-existing pulmonary, cardiac, renal, or hematologic disorders. One month of appropriate oral antibiotics and one week of systemic oral corticosteroids just prior to surgery. Anesthetic Considerations Endoscopic sinus surgery is performed under general anesthesia in young children. Propofol and narcotics, instead of potent inhalational agents, have been shown to decrease intraoperative bleeding and improve visualization in a bloodless field.10
Endoscopic Ethmoidectomy and Antrostomy
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Local anesthesia with sedation may be feasible for unusually mature teenagers. Older patients with cystic fibrosis and poor pulmonary function may benefit especially from this approach. Oxymetazoline solution (0.5%) is used as a topical vasoconstrictor to avoid potential adverse effects associated with cocaine and pseudoephedrine.11 The middle turbinate, uncinate process, and greater palatine foramen are injected with 1% lidocaine solution with 1:100,000 epinephrine. Instrumentation Many fine surgical instruments are available. The Lusk endoscopic sinus surgery set,12 produced by Karl Storz, is recommended as basic equipment. This set includes 0, 30, and 70 telescope (2.7 and 4 mm outer diameter) Lusk double-balled ostium seeker Pediatric size backbiting forceps 0, 45, and 90 Blakesley forceps (pediatric and adolescent size) Graduated 3, 5, and 7 cm suction tubes Bellucci scissors Two angled antral suction tubes Sickle knife Double-ended J-curette These are supplemented with Cottle elevator 1 mm Kerrison forceps Parsons miniature backbiting forceps Parsons push-pull knife Kuhn-Bolger frontal sinus instruments 0 and 45 throughbiting forceps Powered microdebrider with aggressive straight and curved 4 mm tips
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Preparation The patient is placed in supine position with the head slightly elevated. The eyes are left uncovered and are kept moist with a water-based emulsion (Lacri-Lube). The surgeon sits during the procedure with the nondominant elbow resting on a Mayo stand. A beam splitter between the endoscope and the surgeons eye shares the view with a video camera also supported by the nondominant hand (Figure 131). Procedure A young childs nose is much narrower than that of a teen or adult (Figure 132). 1. The ethmoid sinuses, while present from the embryonic period, are small compared to the orbit, both in width and height. 2. The lateral wall of the inferior meatus is thick and the maxillary sinus is small. Unerupted teeth occupy the floor of the maxillary antra. 3. The uncinate process, the lamina papyracea, and the ethmoid roof are thin and fragile, as in the adult.
Figure 131 The patient is supine with head slightly elevated. The surgeon sits with instruments in the dominant hand, and the telescope (with camera and beam splitter) in the nondominant hand.
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4. The anterior border of the maxillary natural ostium is only a few millimeters from the lacrimal duct, placing the duct at risk during enlargement of the ostium. A key to success when operating in the narrow confines of a childs nose is maintaining a bloodless field. These preparatory maneuvers take about 10 minutes, but are essential for good visualization. 1. The nasal cavity is initially vasoconstricted with neuropledgets impregnated with 0.5% oxymetazoline, which are advanced into the middle meatus with the spatulated end of a Cottle elevator (Figure 133).
Figure 132 Comparison of four-year-old sinuses (A) and adult sinuses (B). In the child, the orbit is relatively large and the maxillary sinus small and surrounded by thick bone. An unerupted tooth presents in the maxillary floor. There is little frontal sinus development.
Figure 133 A pledget, impregnated with oxymetazoline, is introduced into the middle meatus with the spatulated end of a Cottle elevator.
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2. Trauma to the mucosa of the middle turbinate must be avoided because synechiae form easily between the turbinate and lateral nasal wall. If the turbinate is positioned too far laterally to allow the entry of instruments, neuropledgets are packed into the middle meatus to displace the turbinate medially, thereby avoiding mucosal trauma. 3. Injection of the greater palatine foramen is performed because the sphenopalatine vessels are difficult to reach transnasally in a child. The foramen can be found in children of any size or dentition by locating the junction of the hard and soft palate (Figure 134). About 1 cm anterior to this junction, and halfway between the median raphe of the hard palate and the alveolar ridge, a shallow depression is typically seen. A 27-gauge needle bent at a 45 angle 1.0 cm from the tip is inserted into this dimple and directed slightly laterally. 4. The needle should enter the foramen easily. Slight resistance is encountered with injection of 1.0 mL of 1% lidocaine solution with 1:100,000 epinephrine. If there is no flow, or if marked blanching of the palate occurs, the foramen has been missed. If there is no resistance to flow, the needle is through the soft palate and is injecting the nasopharynx. An uncinectomy is performed to gain access to the middle meatus. The following maneuvers assure a low uncinectomy and prevent stripping of mucosa at the root of the middle turbinate, which can lead to scarring. 1. Mucosa at the root of the middle turbinate and inferior curve of the uncinate is injected with 1% lidocaine solution with 1:100,000 epinephrine. 2. The posterior edge of the uncinate is identified and mobilized with a Lusk double-balled seeker (Figure 135). 3. An inferior incision is made in the uncinate with a small backbiting forceps (Figure 136), and an anterior incision at the break point with a 1-mm Kerrison forceps (Figure 137). Alternatively, the pull side of a Parsons push-pull knife can make both incisions. These techniques are preferred over the small sickle knife described by Messerklinger,13 because the orbit is in close proximity. 4. After the uncinate incisions are complete, the uncinate is demucosalized with a straight microdebrider and the denuded bone is removed.
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Figure 134 A dimple in the soft tissue overlies the greater palatine foramen, which is located 1 cm anterior to the junction of hard and soft palate, halfway between the median raphe of the hard palate and the alveolus.
Figure 135 A Lusk double-balled seeker is placed behind the posterior edge of the uncinate process to rotate it medially and to identify the break point.
Figure 136 A small backbiting forceps makes an inferior incision in the uncinate.
Figure 137 A 1-mm Kerrison forceps makes an anterior incision along the break point to the insertion of the middle turbinate.
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Once the uncinate is removed, the natural ostium of the maxillary sinus is easily found near the floor of the middle meatus (Figure 138). If the ostium is not apparent, the usual flaw is incomplete removal of the most inferior portion of the uncinate. A few snips with the backbiting forceps will remove this obstruction and reveal the ostium.
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If ostium is patent, it is not enlarged, because circumferential injury can lead to stenosis. If the ostium is closed, a wide antrostomy is created: 1. The position of the natural ostium is confirmed with the Lusk seeker. 2. One blade of the Bellucci scissors is introduced into the ostium and the fontanelle is incised from front to back. The resultant flap of fontanelle tissue is removed using the microdebrider to create a large opening. 3. A backbiting forceps should not be used to enlarge the ostium in small children in order to prevent lacrimal duct injury.14
Preserving anatomic landmarks during dissection is particularly important in pediatric sinus surgery. The ethmoid bulla is usually apparent once the uncinate process has been removed. If there is a question about its location, the maxillary natural ostium, the middle turbinate, and the floor and medial walls of the orbit serve as guides. Ethmoidectomy is performed next: 1. The ethmoid bulla is entered inferiorly and medially, usually with a J-curette (Figures 139 and 1310). A single eggshell of bone is removed and the contents of the ethmoid cell are inspected to guard against accidental orbital or cranial entry.
Figure 138 Paramedial sagittal section through an infant skull. AN= agger nasi cells, AE = anterior ethmoid cells, PE= posterior ethmoid cells, MT= middle turbinate, EB= ethmoid bulla, GL= ground lamella of middle turbinate, MO= maxillary ostium.
PE
AE
}
GL MO EB
AN
MT
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Figure 139 A J-curette opens the ethmoid bulla inferiorly and medially (intranasal view).
Figure 1310 A J-curette opens the ethmoid bulla inferiorly and medially (sagittal view).
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2. The anterior ethmoid cells are arranged in two vertical rows, while the posterior cells are taller and usually occupy the full height of the ethmoid labyrinth (see Figure 138). The lower row of anterior ethmoid cells is cleaned first, advancing from anterior to posterior. 3. After penetrating the ground lamella of the middle turbinate, the most posterior ethmoid air cell is identified. The roof of this cell is a landmark for the upper limit of surgery. 4. Dissection proceeds from posterior to anterior along the ethmoid roof, fracturing the ethmoid partitions with the 90 end of the Jcurette (Figure 1311). 5. The dangling mucosa of the ethmoid cells is removed with a straight microdebrider tip (Figures 1312 and 1313) to avoid stripping the lining of the ethmoid cavity. Residual bone fragments are removed with Blakesley forceps (Figure 1314). 6. The most anterior of the ethmoid cells are the agger nasi cells. These are opened when diseased, or to improve access to the frontal recess.
Figure 1311 The right angle end of the J-curette sweeps gently along the roof of the ethmoids from posterior to anterior (sagittal view).
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Figure 1312 Dangling mucosa is removed using the straight microdebrider to avoid stripping (sagittal view).
Figure 1313 Dangling mucosa is removed using the straight microdebrider to avoid stripping (intranasal view).
Figure 1314 Remaining bony fragments are removed with Blakesley forceps (intranasal view).
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To prevent granulation and synechiae formation in the narrow ethmoid cavity, a stent is placed in the ethmoid cavity at the conclusion of surgery. Two options exist: 1. Gelatin film. Two to three sheets of rolled gelatin film are softened in saline solution, rolled up, and placed in the ethmoid cavity. The tail end of the roll is used to separate the middle turbinate from the lateral nasal wall (Figure 1315). 2. Hyaluronic acid. A MeroGel sinus stent (Medtronic Xomed, Jacksonville, FL) is rolled up and placed in the ethmoid cavity. The stent is hydrated by injection with saline solution, which gradually transforms the biopolymer into a muco-adhesive gel after 24-48 hours. The stent position is checked to ascertain that it is not obstructing the maxillary antrostomy. The pharynx and stomach are suctioned of blood and secretions; during suctioning, the stents are observed with an endoscope to ensure they are not displaced by passage of the nasogastric suction tube. Postoperative Care Children are placed on a broad-spectrum antibiotic for 2-3 weeks until the ethmoid stent absorbs or is removed. Saline nasal spray is used as needed for dryness. Most children do not permit significant nasal manipulation in the office after surgery. Office debridement is restricted to removing very large or obstructing crusts, or blood clots. The gelatin film does not dissolve and must be removed 2 weeks later. In teenagers, this is often accomplished in the office with topical anesthesia. For younger children, it is removed under anesthesia using a setup similar to that for the primary surgery: 1. Any granulation tissue covering the maxillary ostium is removed with Blakesley forceps. 2. Triamcinolone cream (0.1%) and a folded sheet of gelatin film are placed in the ethmoid cavity during the clean-out procedure. This sheet comes out spontaneously in most cases. In contrast to gelatin film, the hyaluronic acid (MeroGel) stent will separate from mucosal surfaces and dissolve gradually after approximately 2 weeks. A clean-out procedure is generally unnecessary. Hydrating the stent as described above facilitates resorption. Children are maintained on oral antibiotics for 2-4 weeks after surgery and steroid nasal sprays are restarted as soon as nasal crusting permits.
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Figure 1315 Rolled gelatin sheeting is placed in the ethmoid cavity. A flap separates the middle turbinate from the lateral nasal wall.
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Complications of Sinusitis Among the complications of acute sinusitis, orbital involvement is most common, followed by intracranial extension. Preseptal cellulitis secondary to ethmoid sinusitis (Figure 1316) responds well to antibiotic therapy and seldom requires surgery. Visual impairment and decreased extraocular motility occur if infection breeches the lamina papyracea and forms a subperiosteal abscess (Figure 1317). Selected cases of orbital subperiosteal abscess may be treated with antibiotics and close observation, but severe cases require surgical drainage. External approaches produce a facial scar and do not optimally address the underlying ethmoid disease. In contrast, endoscopic ethmoidectomy provides wide drainage of the ethmoid sinus and orbital extension. The endoscopic approach, however, requires additional experience. The intraconal complications of ethmoid sinusitisorbital cellulitis and orbital abscessrequire open approaches to safely drain the soft tissue surrounding the globe. Acute ethmoid sinusitis may produce a parenchymal brain abscess by hematogenous spread. In this life-threatening condition, most neurosurgeons request surgical drainage of the sinuses, which can be accomplished endoscopically. When acute frontal sinusitis leads to contiguous epidural, subdural, or parenchymal brain abscesses, open surgical drainage at the time of craniotomy is generally preferred to endoscopic approaches. Opening the frontal recess by an endoscopic approach provides access to the frontal sinus, but not with the same certainty as the Lynch external frontoethmoidectomy.
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Figure 1316 Orbital preseptal cellulitis.
Figure 1317 Coronal view of orbital subperiosteal abscess. Inflammation in the ethmoid labyrinth penetrates the lamina papyracea and is trapped beneath the orbital periosteum. The medial rectus muscle is thickened from inflammation and the globe is displaced anteriorly, producing proptosis.
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CYSTIC FIBROSIS Most children with cystic fibrosis have chronic sinusitis, though many are asymptomatic. Clinically important disease falls into two categories: (1) headache with chronic inflammatory changes, and (2) polyposis with or without mucocele formation. Before endoscopic techniques, intervention was restricted to children with massive polyposis and expansion of the nasal bones. In skilled hands, however, children with lesser degrees of symptomatic disease can benefit from endoscopic polypectomy if the following pointers are observed: Pulmonary function should be optimized before surgery. Polyps usually fill the nasal cavity arising from the ethmoid cells and maxillary antra (Figure 1318). Some of the anterior polyps must often be removed with a microdebrider before the uncinate process can be located. The uncinate is often demineralized, floppy, and rotated into the nasal cavity by protruding maxillary polyps. A microdebrider is used to remove the uncinate process. In contrast to the techniques above, ethmoidectomy is performed before antrostomy, because the maxillary sinus contents often bleed vigorously. Ethmoid polyps are removed in a controlled fashion with the microdebrider (Figure 1319). Ethmoid mucoceles are occasionally encountered during polyp dissection; marsupialization into the nose is curative. The natural ostium of the maxillary sinus is usually widely patent, but filled with polyps. A curved microdebrider tip is used to remove polyps at the mouth of the maxillary antrum, and to remove the soft tissue of the fontanelle (Figure 1320).
Figure 1318 Polyps arise from the ethmoid air cells and maxillary antrum, and protrude into the nose.
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Figure 1319 Bulky ethmoid polyps are removed with the microdebrider.
Figure 1320 The fontanelle is enlarged with the curved microdebrider.
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The contents of the maxillary sinus are tenacious and cannot be suctioned out. To clean the sinus, the curve of the microdebrider tip must be increased to about 70 (Figure 1321). A small aluminum pipe bender (available at most plumbing supply stores) is used to avoid kinking (Figure 1322). Thick secretions and hyperplastic mucosa are removed from the antrum using the 30 and 70 endoscopes for visualization (Figure 1323). Oxymetazoline-impregnated pledgets are placed into the antrum to control bleeding. If bleeding is excessive, expanding nasal sponges (Merocel) are left in the sinus cavities overnight and removed at the bedside. For cystic fibrosis without polyps, surgery is performed as described previously for chronic sinusitis. Of note, ethmoid partitions are often very thick secondary to chronic osteitis and must be removed with throughbiting forceps instead of the J-curette to avoid injuring the ethmoid roof.
Figure 1321 Microdebrider tips. (A ) Straight. (B ) Curved. (C ) Curved reversed and augmented.
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Figure 1322 The curve of a microdebrider tip is reversed and augmented with a small aluminum pipe bender.
Figure 1323 The augmented curve allows removal of polyps and tenacious debris.
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DEDICATION I acknowledge Rodney P. Lusk, MD and David S. Parsons, MD who, in collaboration with other fine otolaryngologists, developed the techniques of pediatric endoscopic sinus surgery and taught them to the rest of us.
REFERENCES
1. 2. 3. 4. 5. 6. Parsons DS, Phillips SE. Functional endoscopic surgery in children: a retrospective analysis of results. Laryngoscope 1993;103:899903. Clement PA, Bluestone CD, Gordts F, et al. Management of rhinosinusitis in children. Int J Pediatr Otorhinolaryngol 1999;49 Suppl 1:S95100. Gentile VG, Isaacson G. Patterns of sinusitis in cystic fibrosis. Laryngoscope 1996;106:10059. Alvarez RJ, Liu NJ, Isaacson G. Pediatric ethmoid mucoceles in cystic fibrosis: long-term follow-up of reported cases. Ear Nose Throat J 1997;76:5389 and 5436. Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal orbital abscess formation: diagnosis and treatment. Otolaryngol Head Neck Surg 1993;109:88694. Nishioka GJ, Barbero GJ, Konig P, et al. Symptom outcome after functional endoscopic sinus surgery in patients with cystic fibrosis: a prospective study. Otolaryngol Head Neck Surg 1995;113:4405. Madonna D, Isaacson G, Rosenfeld RM, Panitch H. Effect of sinus surgery on pulmonary function in patients with cystic fibrosis. Laryngoscope 1997;107:32831. Lusk RP, Polmar SH, Muntz HR. Endoscopic ethmoidectomy and maxillary antrostomy in immunodeficient patients. Arch Otolaryngol Head Neck Surg 1991;117:603. Parsons DS, Greene BA. A treatment for primary ciliary dyskinesia: efficacy of functional endoscopic sinus surgery. Laryngoscope 1993;103:126972. Blackwell KE, Ross DA, Kapur P, Calcaterra TC. Propofol for maintenance of general anesthesia: a technique to limit blood loss during endoscopic sinus surgery. Am J Otolaryngol 1993;4:2626. Riegle EV, Gunter JB, Lusk RP, et al. Comparison of vasoconstrictors for functional endoscopic sinus surgery in children. Laryngoscope 1992;102:8203. Lusk RP, Muntz HR. Endoscopic sinus surgery in children with chronic sinusitis: a pilot study. Laryngoscope 1990;100:6548. Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247:6376. Bolger WE, Parsons DS, Mair EA, Kuhn FA. Lacrimal drainage system injury in functional endoscopic sinus surgery. Incidence, analysis, and prevention. Arch Otolaryngol Head Neck Surg 1992;118:117984.
7. 8. 9. 10.
11. 12. 13. 14.
C H A P T E R 14
I NFLAMMATORY S INONASAL D ISEASE

Andrew J. Hotaling, MD Kevin J. Hulett, MD
A variety of inflammatory nasal disorders in children may require surgery, but many are amenable to endoscopic management. The decision to use an external or intranasal approach depends on the amount of exposure needed and the surgeons training and experience. The exposure gained by an external approach to the maxillary sinus may be helpful in removing a large cyst or tumor; however, an experienced surgeon can manage a subperiosteal orbital abscess endoscopically.
DRAINAGE OF SEPTAL ABSCESS OR HEMATOMA Indications The primary cause of a septal hematoma is trauma, often secondary to a nasal fracture. An undetected hematoma may progress to abscess formation. A septal abscess or hematoma must be treated when detected because the blood supply to the septal cartilage is interrupted. Untreated abscess or hematoma may result in necrosis, perforation, or septal collapse with saddle nose appearance. Anesthetic Considerations The procedure usually is performed under general anesthesia. Neuropledgets moistened with 0.05% oxymetazoline solution are placed intranasally for topical decongestion.
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Procedure An incision is made over the abscess or hematoma, usually in the dependent portion to assist drainage. If pus is encountered, a culture may be taken (Figure 141). After evacuating the abscess or hematoma, a light nasal pack is placed along the traumatized site to prevent a recurrence. One-quarter-inch plain gauze with topical antibiotic ointment is used for packing. Postoperative Care The pack is removed in the office after 2 or 3 days. The site is re-inspected after 5 to 7 days to ensure that healing is satisfactory. Normal saline solution (1 or 2 sprays or 2 to 4 drops) is placed in each naris every 4 hours while the patient is awake to keep the nasal cavity lubricated and to minimize crusting and scabbing.
Figure 141 Drainage of a septal abscess.
Inflammatory Sinonasal Disease

ANTRAL ASPIRATION AND LAVAGE
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Indications Acute maxillary sinusitis unresponsive to medical management Aspiration of culture specimen in immunocompromised patient with maxillary sinusitis Anesthetic Considerations The procedure is performed under general anesthesia or topical anesthesia with intravenous sedation. Procedure After induction of anesthesia, the nose is decongested. Two small cottonoids soaked in oxymetazoline are placed along and under the inferior turbinate. The maxillary sinus is entered by one of several approaches: ! Inferior meatal approach. A trocar is inserted into the posterior half of the inferior meatus, posterior to the nasolacrimal duct. The trocar is aimed toward the ipsilateral lateral canthus (Figure 142). If the trocar does not enter the sinus with moderate pressure, it is repositioned several millimeters posteriorly. The bone is often thinner posteriorly along the inferior meatus.
Figure 142 Aspiration of the maxillary sinus with a trocar. The trocar is aimed toward the ipsilateral lateral canthus.
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Middle meatal approach. The middle meatus is identified with the 0 endoscope, and the natural ostium of the maxillary sinus in the posterior infundibulum is identified by a ball-tipped seeker. The seeker should fall into the opening with gentle probing. A curved antral suction cannula is then inserted into the ostium for irrigation. This may not be feasible if the uncinate process is large or the middle meatus is constricted. Canine fossa approach. This approach is not recommended in young children because the unerupted tooth buds will interfere with passage of the trocar. In older children care must be taken to avoid harming dentition.
Once entered, the contents of the sinus can be aspirated with a syringe attached to the trocar or suction cannula. If the contents cannot be aspirated, instillation of nonbacteriostatic saline into the sinus and subsequent aspiration may be helpful. Aspirated material is sent for culture and sensitivity testing. Antral irrigation is performed next, using a syringe attached to the trocar or cannula by intravenous extension tubing. The ipsilateral globe and cheek should be palpated while irrigating. Displacement of the globe or soft tissue swelling indicates placement of the trocar within the orbit or into the soft tissues of the cheek. After aspiration and washing, placement of a small dry piece of absorbable gelatin sponge under the inferior turbinate will assist in hemostasis. If required a nasoantral window can be constructed using a rasp or a Cottle elevator. Postoperative Care Normal saline solution (1 or 2 sprays or 2 to 4 drops) is placed in each naris every 4 hours while the patient is awake to keep the nasal cavity lubricated and to minimize crusting and scabbing. CALDWELL-LUC PROCEDURE Indications Presence of a mass within the sinus, such as a cyst or a suspected neoplasm Recurrent antrochoanal polyp, refractory to endoscopic management The operation is not recommended for chronic sinusitis; maxillary sinusitis usually improves following adequate medical or surgical treatment of ethmoid disease. Anesthetic Considerations The procedure usually is performed under general anesthesia. A 0.05% lidocaine solution with 1:200,000 epinephrine is injected into the gingivobuccal sulcus. Neuropledgets moistened with 0.5% oxymetazoline solution are placed intranasally for topical decongestion.
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Procedure The incision is placed above the secondary dentition. A plain sinus radiograph can be helpful in determining this level. The periosteum is elevated until the infraorbital nerve is seen (Figure 143A). An osteotome is used to outline a window into the antrum. After the bony cuts are made, the window can be elevated with a Freer elevator. A maxillary sinus culture is obtained through the antral window. Once the limits of the sinus have been established by inspection and palpation, the window can be enlarged with Kerrison forceps, taking care to protect the infraorbital nerve and dentition. The contents of the sinus are removed. If required the mucosal lining can be elevated and removed using ring curettes. A nasoantral window is constructed using a curved hemostat to enter the sinus from the nose through the inferior meatus. The window is enlarged as necessary to provide adequate aeration (Figure 143B ). The nose is packed with a folded sheet of Telfa gauze coated with antibiotic ointment. Alternatively a Foley catheter can be placed into the sinus through the nose via the nasoantral window and the balloon filled with saline. The mucosal incision is closed with an absorbable suture.
Figure 143 Caldwell-Luc procedure. A, An incision is made over the secondary dentition and the periosteum is elevated. B, Using a curved hemostat, a nasoantral window is created through the inferior meatus.
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Postoperative Care The packing or Foley catheter is removed after 1 or 2 days. Normal saline solution (1 or 2 sprays or 2 to 4 drops) is placed in each naris every 4 hours while the patient is awake to keep the nasal cavity lubricated and to minimize crusting and scabbing. EXTERNAL ETHMOIDECTOMY Indications Acute or chronic ethmoid sinusitis unresponsive to medical management Orbital complication of sinusitis, such as subperiosteal abscess Endoscopic sinus techniques can be used for orbital complications of ethmoid sinusitis; however, unless the surgeon is skilled in this technique, an external approach is recommended. Anesthetic Considerations The procedure usually is performed under general anesthesia. Neuropledgets moistened with 0.05% oxymetazoline solution are placed intranasally for topical decongestion. Procedure A tarsorrhaphy is performed on the ipsilateral eye for protection. The curvilinear incision is outlined easily using the thumbnail to make an impression midway between the medial canthus and the midline of the nose. The resultant incision line is then marked and injected with 0.05% lidocaine solution with 1,000,000 epinephrine (Figure 144A). The incision is made with a No 15 scalpel blade. The periosteum is elevated medially to aid in closure. Lateral elevation of the periosteum will lift the lacrimal sac from its fossa, along with its attachments superiorly and inferiorly (Figure 144B). The orbital contents and lacrimal apparatus are protected during further dissection by gentle lateral retraction using a thin malleable retractor. The periosteum is elevated posteriorly into the orbit until the anterior ethmoidal artery is identified, or more posteriorly if required. If a subperiosteal infection is present, pus will be encountered as the periosteum is elevated. Cultures are taken. Orbital contents can be inspected if required. Using an osteotome, the ethmoid complex is entered through the lacrimal fossa or through the lamina papyracea, if it is not already dehiscent. The ethmoid complex can easily be drained into the nose using a mosquito hemostat through the incision into the ethmoid sinus. The nose is viewed with a nasal speculum, and the hemostat is delivered into the middle meatus. An unfolded 10 cm " 10 cm surgical sponge can then be pulled from the nose into the external wound and used as a rasp to open the ethmoid cells. The sponge is removed.
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The incision is closed in two layers and drained externally with a rubber band, leaving an untied suture at the drain site to be tied when the drain is removed. A rubber band also can be used to drain the ethmoid internally (Figure 144C). An eye pad is an excellent dressing for the external incision.
Figure 144 External ethmoidectomy. A, The incision is marked by tracing the impression of the thumbnail midway between the medial canthus and the midline of the nose. B, Once the periosteum has been elevated off the medial orbital wall, the ethmoid complex is entered using an osteotome. Inset, Orbit showing the location of the lacrimal sac and direction of dissection. C, The ethmoid complex can be drained internally using a rubber band.
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FRONTAL SINUS TREPHINATION Indications Acute frontal sinusitis unresponsive to medical management Intracranial complication of frontal sinusitis Anesthetic Considerations The procedure is performed under general anesthesia. Procedure An ipsilateral tarsorrhaphy will help to protect the globe. The incision line is just superior to the orbital rim in the superomedial aspect of the orbit (Figure 145A). A preoperative Caldwell radiograph is useful to determine the exact size and location of the frontal sinus. The incision is marked and injected with 0.5% lidocaine solution with 1:200,000 epinephrine. Once the incision is made, the periosteum is elevated inferiorly and superiorly. A cutting bur is used to make the trephination. Care is taken to open only the anterior table (Figure 145B). A culture is taken through the opening, after which a lacrimal probe is used to palpate gently all the walls of the sinus (Figure 145C). The opening is made large enough to accept a small endotracheal tube, through which a smaller red rubber catheter is placed (Figure 145D). The catheter extends beyond the end of the endotracheal tube. The proximal end of the red rubber catheter is fitted with a blunt needle so that sinus irrigation can be performed with outflow between the catheter and the endotracheal tube. The red rubber catheter is sewn to the endotracheal tube, which is sewn to the skin. The incision is closed, leaving an untied suture at the drain site, which is subsequently tied when the drain is pulled. Postoperative Care Irrigations are performed with sterile saline every 4 hours until the patient has consistent flow into the pharynx or nose. When the drain is pulled, the untied suture is tied to complete wound closure.
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Figure 145 Frontal sinus trephination. A, The incision is marked. B, The anterior table is opened using a cutting bur. C, A culture is taken, and the sinus is palpated with a lacrimal probe. D, A drain is sewn into place.
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DACRYOCYSTORHINOSTOMY Indications Epiphora caused by traumatic or infectious obstruction of the lacrimal sac or nasolacrimal duct; an obstruction can be identified with punctal probing and irrigation or dye studies Anesthetic Considerations and Preparation Dacryocystorhinostomy (DCR) usually is performed under general anesthesia. Neuropledgets moistened with 0.05% oxymetazoline solution are placed intranasally for topical decongestion. A tarsorrhaphy is performed on the ipsilateral eye for protection. Procedure No 1. External dacryocystorhinostomy The curvilinear incision is outlined easily using the thumbnail to make an impression midway between the medial canthus and the midline of the nose. The incision line is marked and injected with 0.5% lidocaine solution with 1:200,000 epinephrine (Figure 146A). A similar injection is performed intranasally on the lateral nasal wall, anterior to the middle turbinate. The skin and periosteum are incised. Bipolar cautery is useful for hemostasis. Using a small periosteal elevator, the lateral periosteum is elevated to the level of the anterior lacrimal crest. When the entire lacrimal crest is exposed, the adherent periosteum along this landmark is elevated carefully, care must be taken not to puncture the lacrimal sac. Once the periosteum is elevated from the lacrimal crest, the sac can be lifted easily to expose the lacrimal fossa. A small malleable retractor can help to hold the lacrimal sac out of the fossa. The bone of the lacrimal fossa is fractured gently using a small chisel. The entire bony fossa is then removed using back-biting rongeurs. Local anesthetic with epinephrine should be injected into the underlying nasal mucosa. Vertical incisions are made into the nasal mucosa and the medial wall of the lacrimal sac creating anterior- and posterior-based flaps from both the sac and the nasal mucosa (Figure 146B). The posterior based flaps are resected at the margin of the bony defect. A thin Silastic stent can be placed from the sac into the nasal cavity. It is secured to the anterolateral aspect of the sac with a 5-0 chromic suture. The nasal extent can be secured with a 5-0 nylon suture. The anterior-based flaps are sutured together carefully using interrupted 4-0 chromic sutures (Figure 146C). The skin and subcutaneous tissue are closed in two layers. The Silastic stent is removed after 7 to 10 days.
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Figure 146 Open dacryocystorhinostomy. A, The incision is marked by tracing the impression of the thumbnail midway between the medial canthus and the midline of the nose. B, Vertical incisions are made in the lacrimal sac and the nasal mucosa. C, The anterior-based flaps are sutured together to allow drainage into the nasal cavity.
350
No 2. Endoscopic dacryocystorhinostomy A 0.5% lidocaine solution with 1:200,000 epinephrine is injected just anterior to the middle turbinate. A 0 rigid endoscope is used to visualize the lateral wall of the nasal cavity. The head of the middle turbinate may require trimming for proper exposure of the lacrimal bone. Anterior to the middle turbinate, a sickle knife or a Freer elevator is used to make a vertical incision. Using a straight Blakesley forceps or a microdebrider, 1.0 to 1.5 cm2 of mucosa is removed to expose the lacrimal bone. Using a small diamond bur, the lacrimal bone is drilled to expose a small section of the bulging lacrimal sac (Figure147). To ensure proper identification of the sac, a lacrimal probe can be introduced through the inferior canaliculus and visualized with the endoscope pushing against the wall of the lacrimal sac. A Kerrison rongeur is used to remove the bone surrounding the medial and anterior wall of the lacrimal sac. Along the anterior face of the sac, a vertical incision is made, and a straight Blakesley forceps is used to remove the entire medial wall. A lacrimal probe can be used to check the patency of the DCR. Silicone stents are placed into each canaliculus extending into the nasal cavity and are tied together. A small nasal pack may be necessary for hemostasis. Postoperative Care Nasal packs, if placed, are removed within 24 to 48 hours. Normal saline solution (1 or 2 sprays or 2 to 4 drops) is placed in each naris every 4 hours while the patient is awake to keep the nasal cavity lubricated and to minimize crusting and scabbing. Antibiotic ophthalmic drops used three times daily will help if purulent conjunctivitis is present. The silicone stents are removed after 4 to 6 weeks.
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Figure 147 Endoscopic dacryocystorhinostomy. The fossa of the lacrimal sac is located just anterior to the middle turbinate. After elevating the mucosa, the fossa is exposed by drilling the lacrimal bone.
BIBLIOGRAPHY
Cunningham MJ, Woog JJ. Endonasal endoscopic dacryocystorhinostomy in children. Arch Otolaryngol Head Neck Surg 1998;124:32833. Sprekelsen MB, Barberan MT. Endoscopic dacryocystorhinostomy: surgical technique and results. Laryngoscope 1996;106:1879.
C H A P T E R 15
S PHENOID S INUS S URGERY

Gady Har-El, MD
The sphenoid sinus originates in the sphenoethmoidal recess, which develops during the third and fourth fetal months. Extension of the recess and pneumatization within the sphenoid bone, however, is not present at birth. Penetration into the sphenoid bone occurs gradually during the first four or five postnatal years and then accelerates during years five to seven. The sphenoid sinus usually reaches the sella turcica by age 7 years, but continues to develop and enlarge, especially anterior and posterior to the sella turcica, until adolescence.14
Indications The most common indication for sphenoidotomy in children is an acute or chronic inflammatory process, with or without orbital, visual, or intracranial complication. Sphenoid sinus surgery is quite uncommon in young children, and is almost unheard of before 4-5 years of age. Indications for sphenoidotomy or sphenoidectomy include Sphenoid sinusitis (acute, chronic, fungal) Sphenoid mucocele Cerebrospinal fluid (CSF) leak, with or without encephalocele Tumor removal Biopsy of tumor (sphenoid, adjacent structure) Pituitary surgery APPROACHES TO THE SPHENOID The approach to the sphenoid sinus may be external or transnasal. Whereas all approaches are discussed briefly below, only the transnasal are described in detail. The approaches are Transorbital transethmoidalexternal Transantral transethmoidal
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Transnasal, transseptal 1. sublabial 2. with alotomy 3. external rhinoplasty
Transnasal, nontransseptal Transethmoidal ! Direct Transpalatal

!
External Transorbital Transethmoidal Approach For years this has been the most popular surgical approach for acute inflammatory disease of the sphenoid disease, without impending or existing orbital complications.57 It is especially helpful when both ethmoid and sphenoid sinus disease coexist. This approach provides excellent control of the orbit, which is important for managing intraorbital extension and avoiding orbital complications. With the increased popularity of endoscopic intranasal approaches, this technique is now used less frequently; however, it may still be the gold standard for managing acute infection. This approach is not very useful for isolated sphenoid sinus disease, because it requires ethmoidectomy whether or not ethmoid sinus disease is present. Transantral Transethmoidal Approach This approach is mentioned mainly for historical perspective. It was more popular when the Caldwell-Luc procedure was the standard approach for chronic maxillary and ethmoid sinus disease. Since the Caldwell-Luc procedure is no longer used for inflammatory disease, sphenoidotomy is rarely performed via this approach. After complete posterior ethmoidectomy is performed through the maxillary antrum, the sphenoid sinus may be entered. As with other external approaches, this route is not useful for isolated sphenoid sinus disease. Transpalatal Approach This approach is not suitable for managing infections, but is used for sphenoid and skull base tumors. If the tumor extends beyond the sphenoid sinus into the nasopharynx and the pterygopalatine space, the transpalatal approach provides excellent exposure. The transpalatal route is excellent for managing small and medium size juvenile angiofibromas, with or without sphenoid sinus involvement. In contrast, tumors isolated to the sphenoid and sella turcica are better approached transnasally. Transseptal Approaches The transseptal route is a relatively safe and avascular approach to the sphenoid sinus. Since the size of the nostril is usually an important factor in limiting the exposure, most transnasal transseptal approaches include an additional incision line (most often sublabial) for wider exposure. Other incisions include external rhinoplasty and alotomy. Sinus endoscopes augment the view and exposure via the transseptal approach, especially for pituitary lesions.
Sphenoid Sinus Surgery
355
The main disadvantage of the transseptal approach is that it is not suitable for infections. It does not provide the sphenoid sinus with a permanent opening into the nasal cavity, especially when the natural ostium is blocked as a result of, or as a cause of, infection. The approach is still used, however, for noninflammatory processes such as pituitary lesions, CSF leak, and for biopsy of tumors. The transseptal approach is used infrequently in children because of the above factors, plus concerns over a potential detrimental impact on future septal growth. We have used this route in very few adolescents for pituitary tumors or traumatic CSF leak. Since the vast majority of children undergoing sphenoidotomy require the procedure for acute or chronic infections, and since the surgery produces reliable drainage into the nasal cavity, the transnasal nontransseptal approaches are generally preferred. Transnasal Nontransseptal Approaches This group of approaches includes the transnasal transethmoidal and the direct transnasal approaches. With the introduction of endoscopic sinus techniques and instrumentation, intranasal sphenoidotomy has become increasingly popular. The most commonly used approach is transnasal transethmoidal, which is appropriate when the ethmoid and the sphenoid sinuses require simultaneous exploration (ie, ethmoid and sphenoid sinusitis). If the sphenoid sinus is the only sinus that requires exploration,810 violating the ethmoid complex can be avoided by using the direct transnasal approach. Intranasal ethmoidectomy, although a common procedure, is not without complications and sequelae. Possible immediate serious complications of intranasal ethmoidectomy are well known, but fortunately, uncommon. However, delayed sequelae are not uncommon and may result in significant morbidity including synechiae, nasal obstruction, ethmoid sinusitis, frontal outflow tract obstruction (with possible frontal sinusitis), maxillary outflow obstruction (with possible maxillary sinusitis), and prolonged ethmoid cavity dryness and crusting. TRANSNASAL TRANSETHMOIDAL SPHENOIDOTOMY Using this route, the surgeon approaches the sphenoid sinus after complete anterior and posterior ethmoidectomy.1120 The technique of ethmoidectomy was described in Chapter 13. At the conclusion of complete ethmoidectomy, the surgeon identifies the 1. Skull base, superiorly 2. Middle turbinate, medially 3. Orbital wall and maxillary ostium, laterally 4. Anterior sphenoid wall and choana, posteriorly The location of the anterior sphenoid wall may be verified with an intraoperative C-arm image intensifier or with more sophisticated intraoperative navigation systems. For routine nonrevision cases, however, imaging is usually not required.
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Measurements with a marked probe, or with color-coded instruments, will also assist the surgeon. In a mature adolescent, the anterior sphenoid wall is about 7 cm from the anterior nasal spine, at about an angle of 30 from the nasal floor (Figure 151A). The safest location to enter the sphenoid sinus will be as medially as possible, closer to the nasal septum; the sphenoid sinus should not be entered laterally. As the surgeon moves medially on the anterior wall of the sphenoid sinus, the superior turbinate may need to be removed. When necessary, this is done posterior to the middle turbinate. Conversely, there is no need to remove the middle turbinate for transethmoidal sphenoidotomy. The natural ostium of the sphenoid sinus is located medially, close to the posterior insertion of the nasal septum. It is usually found 0.5 to 1.5 cm above the choana, depending on age. Parsons et al21 described the technique of gentle displacement and fracture of the superior turbinate from lateral to medial, which will result in a near-vertical fracture line on the anterior sphenoid wall. They termed this line the ridge. The natural sphenoid ostium is consistently found medial to this ridge. If the natural ostium cannot be located because of the disease process, entry to the sphenoid sinus can be accomplished safely if it is done inferomedially on the anterior sphenoid wall. Again, intraoperative fluoroscopy can verify the entry into the sphenoid sinus. Once the sphenoid sinus is entered, the opening can be enlarged with a sphenoid punch and with different sizes and angles of Kerrison rongeurs (Figure 151B). Enlarging the opening laterally is done cautiously. A curved instrument, such as a small upbiting forceps or neurosurgical nerve hook, is routinely placed in the sinus to palpate laterally before removing bone (Figure 152). A 70 telescope can be introduced into the sinus and the amount of bone removal in a lateral direction can be determined before it is actually done. The 70 telescope can be also used to positively identify the structures on the lateral wall (carotid artery and optic nerve).
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Figure 151 Transnasal transethmoidal sphenoidotomy. A, Sagittal view. B, Surgeons view. Note complete anterior and posterior ethmoidectomy has been done.
Figure 152 Palpation within the sinus before proceeding with lateral bone removal.
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DIRECT TRANSNASAL SPHENOIDOTOMY The direct transnasal approach is preferred for isolated sphenoid sinus disease to avoid the potential complications and sequelae of ethmoidectomy.2226 In children, the procedure is usually done under general anesthesia. After appropriate intranasal vasoconstriction, the inferior aspect of the middle turbinate is gently displaced laterally under 0 telescopic guidance. Only the inferior part of the middle turbinate is displaced; pushing on the turbinate close to its skull base attachment may result in CSF leakage. In about 20 to 30% of cases, the size or curvature of the middle turbinate or nasal septum may not allow enough lateral displacement.
!
When necessary, a limited middle turbinectomy is performed. Only the free, inferior aspect of the middle turbinate is removed. The ethmoid complex is not entered. The procedure is done with endoscopic scissors after appropriate infiltration with a vasoconstricting solution. Bipolar cautery may be used before transecting the turbinate to reduce bleeding (Figure 153).
After displacement or partial resection of the middle turbinate is completed, the superior meatus is now exposed and the superior turbinate is seen. Additional vasoconstriction may be achieved by inserting neurosurgical pledgets soaked with a vasoconstricting solution. They are removed after 5 minutes. Depending on the exposure provided, and the level of skill and comfort of the surgeon, a self-retaining speculum may be inserted (long selfretaining nasal speculum or the Hardy transsphenoidal pituitary speculum). However, if only limited intrasphenoid work is needed, (eg, decompression for acute sphenoiditis), a speculum is unnecessary. A long bayonette forceps connected to a bipolar cautery unit is now inserted.
!
The forceps jaws are introduced on both sides of the superior turbinate, thus hugging the turbinate, as superior as possible and as posterior as possible. Bipolar electrocautery current is then applied close to the insertion of the superior turbinate to the skull base (Figure 154). Alternatively, the newer endoscopic coaxial bipolar instruments can be also used for this purpose.
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Figure 153 A, Partial middle turbinectomy. Bipolar cautery may be used before transection to reduce bleeding. B, Only the free inferior part of the turbinate is removed. The ethmoid complex is not entered.
Figure 154 Bipolar cauterization of the superior turbinate close to the skull base.
360
Next, endoscopic scissors are used to transect the superior turbinate superiorly, close to its skull base attachment, through the cauterized area (Figure 155). The tip of the turbinate is pulled down gently, and with the combination of bipolar bayonette forceps and endoscopic scissors, the posterior attachment of the superior turbinate to the anterior sphenoid wall is released without significant bleeding (Figure 156). A 90 bipolar forceps may be used to control bleeding from the transected attachments of the superior turbinate to the anterior sphenoid wall and to the skull base (Figure 157). If the sphenoid sinus ostium has not been identified before it is usually apparent now.
!
Sphenoidotomy is performed with fine Kerrison rongeurs or a sphenoid punch. It is safer to start from the natural ostium moving laterally, superiorly, and inferiorly (Figure 158). If the ostium is difficult to identify, however, the sphenoid sinus may be penetrated medially, about halfway between the skull base and the choana. Rarely, a drill may be required to penetrate a very thick anterior sphenoid wall.
The posterior division of the sphenopalatine artery (the nasoseptal division) runs across the anterior wall of the sphenoid sinus from lateral to medial,27 and then becomes the posterior septal artery. Depending on the extent of sphenoidotomy required, it is safer to cauterize the inferior aspect of the anterior sphenoid wall before using the Kerrison rongeurs to remove it. The extent of removal of anterior sphenoid sinus wall depends on the exact disease process and the planned procedure. By approaching the sphenoid sinus after removing the superior turbinate, there is usually enough room for an 8 mm " 12 mm opening. This is certainly sufficient for decompression or limited biopsy. If additional exposure is required, the surgeon may extend the sphenoidotomy laterally or medially.
361
Figure 155 The superior turbinate is transected close to the skull base through the cauterized area.
Figure 156 The superior turbinate is removed.
Figure 157 The posterior attachment of the superior turbinate to the anterior sphenoid wall is cauterized.
Figure 158 Transnasal sphenoidotomy.
362
Lateral extension of the sphenoidotomy 1. Lateral exposure is achieved by performing limited posterior ethmoidectomy through the superior meatus. This is followed by additional removal of anterior sphenoid wall in a lateral direction (Figure 159). 2. Before removing bone, it is safer to insert an upbiting forceps or a right angle nerve hook to palpate behind the piece of bone about to be removed. 3. Introducing a 70 telescope to examine the lateral aspect of the sinus will help to determine how much anterior wall can be removed safely without risking injury to the optic nerve or carotid artery. Medial extension of the sphenoidotomy 1. A backbiting bone punch can be inserted into the sphenoid sinus to remove the posterior aspect of the nasal septum in a posterior-toanterior direction. 2. Alternatively, (this is especially helpful when the intrasphenoidal septum is thick and does not allow the surgeon to use the backbiting forceps), the sharp blade of a Freer elevator is used to penetrate through the posterior septum, about 3-5 mm anterior to the sphenoid sinus, into the contralateral posterior nasal cavity (Figure 1510). Heavy straight forceps are then used to remove the remaining strut of nasal septum, and proceed into the sphenoid sinus by removing the sphenoid rostrum and the intrasphenoidal septum (Figure 1511). 3. Both of these techniques will result in a very wide exposure of the sphenoid sinus and the sella turcica. They are usually unnecessary for inflammatory diseases of the sinus. At the conclusion of the procedure, a small piece of MeroGel or Gelfilm is placed between the nasal septum and the middle turbinate. Packing is placed, only if necessary, to control bleeding. Postoperative Care Packing, if present, is removed in 24 hours. Postoperative care is the same following endoscopic ethmoidectomy, including humidification and the intranasal moisturizing spray. Antibiotics or antifungal medications are given in cases where the procedure was done to treat an infectious process. They may be changed according to the results of intraoperative cultures.
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Figure 159 Lateral enlargement of the sphenoidotomy through the superior meatus.
Figure 1510 The posterior attachment of the nasal septum to the sphenoid rostrum is penetrated.
Figure 1511 After the posterior septal strut has been removed, both sphenoid sinuses are exposed and the surgeon now removes the intrasphenoid septum (if needed).
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REFERENCES
1. 2. Anon JB, Rontal M, Zinreich SJ. Anatomy of the paranasal sinuses. New York: Thieme; 1996. p. 311, 258. Levine HL, May M, Rontal M, Rontal E. Complex anatomy of the lateral nasal wall: simplified for the endoscopic sinus surgeon. In: Levine HL, May M, editors. Endoscopic sinus surgery. New York: Thieme; 1993. Rice DH. Embryology. In: Donald PJ, Gluckman JL, Rice DH, editors. The Sinuses. New York: Raven Press; 1995. p. 1523. Tom LWC. Structure and function of the nose, paranasal sinuses, and nasopharynx. In: Wetmore RF, Muntz HR, McGill TJ, editors. Pediatric Otolaryngology-principles and practice pathways. New York: Thieme; 2000. p. 40921. Donald PJ. Conventional surgery for ethmoid and sphenoid sinusitis. In: Donald PJ, Gluckman JL, Rice DH, editors. The sinuses. New York: Raven Press; 1995. p. 23346. Portmann G. Trephination of the sphenoid sinus. In: Portmann G, editor. A treatise on the surgical technique of otorhinolaryngology. Baltimore: Williams & Wilkins; 1939. p. 37089. Weiss, RL, Bailey BJ. Approaches to the sphenoid. In: Bailey BJ, editor. Head and neck surgeryotolaryngology. Vol. 1. Philadelphia: JB Lippincott; 1993. p. 40212. Cakmak O, Shohet MR, Kern EB. Isolated sphenoid sinus lesions. Am J Rhinol 2000; 14:1319. Ruoppi P, Seppa J, Pukkila M, Nuutinen J. Isolated sphenoid sinus disease. Arch Otolaryngol Head Neck Surg 2000;126:77781. Sethi DS. Isolated sphenoid lesions: diagnosis and management. Otolaryngol Head Neck Surg 1999;120:7306. Bolger WE, Keyes AS, Lanza DC. Use of the superior meatus and superior turbinate in the endoscopic approach to the sphenoid sinus. Otolaryngol Head Neck Surg 1999;120:30813. Janowsky R. Endoscopy pituitary surgery. In: Stankiewicz JA, editor. Advanced endoscopic sinus surgery. St. Louis (MO): Mosby; 1995. p. 95102. Lanza DC, Kennedy DW. Endoscopic sinus surgery. In: Bailey BJ, editor. Head and neck surgery-otolaryngology. Vol.1. Philadelphia: JB Lippincott; 1993. p. 389401. May M, Levine HL, Mester SJ, Porta M. Endoscopic sinus surgery. In: Levine HL, May M, editors. Endoscopic sinus surgery. New York: Thieme; 1993. p. 10575. Muntz HR. Diagnosis and management of chronic sinusitis. In: Wetmore RF, Muntz HR, McGill TJ, editors. Pediatric otolaryngology-principles and practice pathways. New York: Thieme; 2000. p. 47585. Rosen FS, Sinha UK, Rice DH. Endoscopic surgical management of sphenoid sinus disease. Laryngoscope 1999;109:16016. Stankiewicz JA. Sphenoid sinus surgery. In: Stankiewicz JA, editor. Advanced endoscopic sinus surgery. St. Louis (MO): Mosby; 1995. p. 2531. Stankiewicz JA. The endoscopic approach to the sphenoid sinus. Laryngoscope 1989;99:21821. Wigand MA. Endoscopic surgery of the paranasal sinuses and anterior skull base. New York: Thieme; 1990, p. 1267. Cheung DK, Martin GF, Rees J. Surgical approaches to the sphenoid sinus. J Otolaryngol 1992;21:18.
3. 4.
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
16. 17. 18. 19. 20.
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21. Parsons DS, Bolger WE, Boyd EM. The ridge - a safer entry to the sphenoid sinus during functional endoscopic sinus surgery in children. Oper Tech Otolaryngol Head Neck Surg 1994;5:434. 22. Gopal HV. Endoscopic transnasal transsphenoidal pituitary surgery. Cur Opin Otolaryngol Head Neck Surg 2000;8:438. 23. Har-El G, Swanson RM. The superior turbinectomy approach to isolated sphenoid sinus disease and to the sella turcica. 2001;15:14956. 24. Kelly TF, Stankiewicz JA, Chow JM, Origitano TC. Endoscopic transsphenoidal biopsy of the sphenoid and clival mass. Am J Rhinol 1999;13:1721. 25. Orlandi RR, Lanza DC, Bolger WE, et al. The forgotten turbinate: the role of the superior turbinate in endoscopic sinus surgery. Am J Rhinol 1999;13:2519. 26. Sethi DS, Pillay PK. Endoscopic management of lesions of the sella turcica. J Laryngol Otol 1995;109:95662. 27. Har-El G. The anterior wall of the sphenoid sinus. Ear Nose Throat J 1994;73:4468.
C H A P T E R 16
S URGERY
OF THE
TONGUE
Carlos Gonzalez, MD
Oral tumors constitute approximately 3% of all tumor-like growths in the oral cavity, jaws, and salivary glands in children of all ages. The overwhelming majority of oral tumors are benign; however, a wide variety of congenital and acquired oral and pharyngeal neoplasms occur. Malignant lesions must also be considered, because 5-10% of childhood malignancies involve the head or neck (excluding the central nervous system). Most of these lesions are sarcomas (rhabdomyosarcoma is most common) or epidermoid carcinomas. ANTERIOR TONGUE LESIONS Tumors and cysts of the anterior two-thirds of the tongue are usually benign, and include hemangiomas, lymphangiomas, cystic lesions, fibrous tumors, epithelial tumors, and hamartomas. Surgery is usually limited to excisional biopsy. Indications Suspected malignancy Articulation disorder Bleeding Anesthetic Considerations Oral intubation is performed for most small lesions of the anterior tongue. The tube is retracted out of the surgical field. For larger lesions, or when the CO2 laser is to be used, nasotracheal intubation can be considered. A laser-safe or foil-wrapped tube is used when necessary. Preparation The patient is supine with a shoulder roll in place, or is in a semi-sitting position. When the CO2 laser is used ! All operating room personnel should wear appropriate eye protection. ! A separate suction line should be available to remove the laser plume. ! Moistened towels and sponges should be placed on all surrounding exposed skin and mucosal surfaces to avoid inadvertent laser burns.
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Procedure A mouth retractor, without a tongue blade, such as the Jennings or a bite block, is placed. A silk suture is placed in the midline of the tongue for retraction. The lesion and surrounding soft tissue are removed with a scalpel, a needle-tip monopolar cautery, or a laser. When using the laser vaporization technique, laser energy can be applied using a hand piece or the operating microscope. For excisional biopsy, an elliptical incision is made around the lesion (Figure 161A). Dissection is carried down through the tongue surface into the tongue musculature if necessary. The defect is closed in layers approximating the tongue musculature, followed by the mucosal edges, using absorbable suture material (Figure 16-1B). Postoperative Care Feeding can resume shortly after surgery. Initially, a soft diet is better tolerated. Oral hygiene with normal saline solution increases the patients comfort postoperatively.
Figure 161 Excisional biopsy of a tongue lesion. A, Proposed elliptical incision (dashed line) allowing a cuff of normal tissue. B, Closure of the resulting defect (adapted from Lor).1
Surgery of the Tongue

MACROGLOSSIA
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Macroglossia is defined as abnormal enlargement of the tongue causing tongue protrusion at rest. Multiple causes have been described, including hypothyroidism, mucopolysaccharide and lipid storage diseases, lymphangioma, hemangioma, neurofibroma, and muscular macroglossia. Persistent chronic macroglossia should be differentiated from acute parenchymatous glossitis, due to various causes, that often results in rapid tongue enlargement causing airway distress.2 Indications Chronic airway obstruction Maxillofacial deformity and malocclusion Recurrent hemorrhage from drying effects of chronic tongue protrusion Articulation disorder Cosmetic deformity Anesthetic Considerations Nasotracheal intubation or fiberoptic-guided intubation may be useful. Orotracheal or nasotracheal intubation may be difficult due to tongue size. A tracheotomy may be necessary prior to surgical treatment of the tongue. Preparation The patient is supine with a shoulder roll in place, or is in a semi-sitting position. When the CO2 laser is used
!
All operating room personnel should wear appropriate eye protection. A separate suction line should be available to remove the laser plume. Moistened towels and sponges should be placed on all surrounding exposed skin and mucosal surfaces to avoid inadvertent laser burns.
Procedure A mouth retractor, without a tongue blade, such as the Jennings or a bite block, is placed. A silk suture is placed in the midline of the tongue for retraction.
370
Wedge resection of the tongue (Figure 162) can be fashioned in several forms, depending on the amount of tongue that needs to be excised. One advantage of wedge resection is that more lateral tongue can be preserved, thus preserving taste and sensation.
!
Simple wedge excision is shown in Figure 162A. Extended wedge excision is shown in Figure 162B. Keyhole wedge excision is shown in Figure 162C.
Wedge resection may result in a tongue that is too thin and pointed. In these cases, a tip reduction technique can be used (see Figure 162D). Incision of the tongue surface and musculature is carried out using a surgical blade or an electrocautery, cutting deep toward musculature in order to have more mucosal surface to re-approximate, and to decrease tension on the suture line. The tongue is closed in layers, using an absorbable suture, to re-approximate tongue musculature and mucosal surfaces (see Figures 162E and F). Postoperative Care Postoperative edema of the tongue during the first 24 to 48 hours may cause significant airway distress. Overnight nasotracheal intubation versus tracheotomy must be considered. Patients and parents should be counseled for recurrent macroglossia, especially in cases of lymphangioma.
Figure 162 A, Simple wedge incision. B, Extended wedge incision.
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Figure 162 C, Keyhole wedge incision. D, Tip reduction. E and F, Closing technique (adapted from Lor).1
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BASE OF TONGUE LESIONS Mucoceles are commonly occurring lesions of the oral cavity. These lesions are usually painless, freely mobile, smooth, soft, fluctuant masses that vary in size from a few millimeters to several centimeters. Larger lesions are usually located in the floor of the mouth or in the substance of the tongue. Mucoceles involving the base of the tongue region can enlarge enough to cause airway compromise. Histologically, the walls of most of the specimens consist of granulation tissue, and an epithelial lining is rarely identified. Indications Upper airway obstruction Hemorrhage or risk of hemorrhage Dysphagia Speech impediment Anesthetic Considerations Nasotracheal intubation is performed. Orotracheal or nasotracheal intubation may be difficult due to the base of the tongue mass and size. A tracheotomy may be necessary prior to surgical treatment of the tongue. Preparation The patient is supine with a shoulder roll in place, or is in a semi-sitting position. Procedure No 1. Intraoral approach A mouth retractor, without tongue blade, such as the Jennings or a bite block, is placed. A silk suture is placed in the midline of the tongue for retraction. The dome of the cyst is incised, and contents of the cyst are aspirated (Figure 163A). The entire dome of the cyst is removed (marsupialized), leaving a granulation bed exposed to heal by second intention (Figure 163B). Primary closure can also be performed if the lesion can be completely excised.
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Figure 163 A and B, Intraoral marsupialization of a base of the tongue lesion.
374
No 2. Transcervical approach An external approach to a lesion of the tongue base is usually reserved for large cystic masses in which the inferior margin of dissection (vallecula) would be poorly visualized from an oral approach. Large thyroglossal duct cysts and mucoceles, as well as lingual thyroids, can be adequately excised using this approach. Computed tomography or magnetic resonance imaging may be beneficial to assess the true extent of a mass that appears in the oral cavity.3 Landmarks should be identified as follows: (1) suprasternal notch, (2) cricoid cartilage, (3) laryngeal cartilage, and (4) hyoid bone. A transverse incision is made in the neck fold over the hyoid bone (Figure 16-4A ). Subplatysmal superior and limited inferior flaps are developed. Suprasternal musculature is dissected and transected from the hyoid bone.
!
Hyoid bone dissection should be carried out in the midline to avoid injury to lateral structures such as the hypoglossal nerve or superior laryngeal nerve. Dissection is carried down into the pre-epiglottic fat pad (Figure 164B). In cases of lingual thyroglossal duct cyst or lingual thyroid, the midportion of the hyoid bone can be freed of infrahyoid musculature and removed with the specimen; this is done with a Sistrunk procedure.
The pharyngeal mucosa is identified, and the pharynx is entered above the epiglottis (Figure 164C). The tongue base lesion is identified and dissected free of the tongue musculature. The pharynx is closed with a running Connell suture technique to invert the mucosal edges. Strap muscles are re-approximated, and the wound is closed in layers over a drain. Postoperative tongue edema for 24-48 hours may cause significant airway distress. Overnight nasotracheal intubation (versus tracheotomy) must be considered. Postoperative Care Feeding can resume shortly after intraoral surgery. In cases of base of tongue lesions, feeding should start with liquids and can advance as tolerated. Feeding can resume within 48 to 72 hours after transcervical surgery, depending on the amount of tongue base dissected and reliability of the pharyngeal closure.
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Figure 164 External approach to a base of the tongue lesion. A, Transverse incision over the hyoid bone. B, Surgical field identifying the supra- and infrahyoid musculature, which is transected to gain access to the base of the tongue region. C, Visualization of the base of the tongue region through a midline neck approach.
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FRENULOPLASTY Restrictive ankyloglossia can contribute to feeding and speech problems in some children. Surgical release, with or without tissue rearrangement, may be beneficial in appropriately selected cases. Indications Difficulty with breast-feeding in the neonate Articulation disorder Bleeding due to trauma against teeth Anesthetic Considerations Mask or endotracheal anesthesia may be used. For mask anesthesia, the surgeon alternates with the anesthesiologist for access to the oral cavity. This technique is appropriate if minimal bleeding is anticipated and a simple horizontal-to-vertical plasty is planned. For endotracheal anesthesia, oral or nasal intubation may be used; an orally placed tube should be taped to one side of the mouth. This technique is appropriate if bleeding is anticipated (eg, very thick frenulum) or tissue transposition (eg, Z-plasty) is planned. Preparation The patient is supine with a shoulder roll in place to extend the neck fully. Procedure A mouth retractor, without a tongue blade, such as the Jennings or a bite block, is placed. A silk suture is placed in the midline of tongue tip for retraction. A grooved tongue retractor is positioned to isolate the lingual frenulum as the mobile tongue is stretched (Figure 165A). The restrictive lingual frenulum is incised using cold dissection or a needle-tip monopolar cautery (Figure 165B). Dissection is carried down to the tongue musculature with care to prevent injury to the submandibular salivary ducts or papilla. This releases the tongue and leaves a defect on the tongues ventral surface extending to the floor of the mouth (Figure 165C). The resulting defect can be left to close by secondary intention or closed using interrupted absorbable sutures (horizontal-to-vertical plasty). When the released frenulum is very thick, or is a recurrence, tissue rearrangement techniques (ie, Z-plasty) can also be used to close the defect. Postoperative Care Feeding can resume shortly after surgery.
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Figure 165 Release of restrictive lingual frenulum. A, Tongue retractor in position, tethering the lingual frenulum. B, Electrocautery is used to release the lingual frenulum. C, Surgical defect on the ventral surface of tongue. Tongue musculature is exposed; salivary ducts and papilla are protected and preserved.
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REFERENCES
1. 2. 3. Lor J. An Atlas of head and neck surgery. Philadelphia: WB Saunders; 1988. Gupta OP. Congenital macroglossia. Arch Otolaryngol Head Neck Surg 1971;93:37883. Sistrunk WE. Technique for removal of cysts and sinuses of the thyroglossal duct. Surg Gynecol Obstet 1928;46:10912.
C H A P T E R 17
TONSILLECTOMY, A DENOIDECTOMY, AND UPPP

Ari J. Goldsmith, MD Richard M. Rosenfeld, MD, MPH
Tonsillectomy and adenoidectomy (T&A) is the most common major surgery in children, despite a significant reduction in procedures from the 1970s to 1990s. Although initially performed for infections (otitis media and tonsillitis), upper airway obstruction is the main current indication. T&A are often grouped together, but are separate operations with distinct indications. The astute clinician must distinguish between disease due to tonsils and disease due to the adenoid. This chapter describes T&A in detail, including newer adenoidectomy techniques using the suction coagulator and powered instrumentation. Regardless of technique, about 1-2% of children bleed after tonsillectomy; therefore, management of complications is emphasized, ranging from prevention strategies to external carotid ligation. Uvulopalatopharyngoplasty (UPPP) is also described, because selected children may require UPPP in addition to T&A to relieve obstructive sleep apnea syndrome (OSAS).
GENERAL CONSIDERATIONS Preoperative Evaluation Dental consultation is obtained for any child with potentially loose teeth. Sleep studies are usually unnecessary for children with upper airway obstruction, unless the diagnosis or need for surgery is in question. Cardiac evaluation for cor pulmonale or right-sided heart failure is necessary for children with known or suspected obstructive sleep apnea syndrome (OSAS). Coagulation tests remain controversial. There is no consensus on the benefit of preoperative studies such as platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time. Any child with a personal or family history of easy bruising or extensive bleeding (nasal, dental) is tested.1,2 1. von Willebrand disease requires aggressive preoperative hematological optimization, including desmopressin and cryoprecipitate. Patients who receive desmopressin need careful fluid and electrolyte management after surgery.3
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2. Sickle cell disease requires preoperative transfusion and intravenous hydration, which should be coordinated by a pediatric hematologist.4 Down syndrome children should have lateral neck films to evaluate for C1-C2 (atlantoaxial) instability. Cardiac disease is also common and must be assessed prior to surgery. The endotracheal tube size should be 1 2 to 1 size smaller than predicted based on age and weight, because a smaller subglottis may predispose to edema with a standard size tube. Preparation Children and families may benefit from viewing educational movies or books about T&A prior to surgery. In addition, children should visit the hospital surgical suite prior to surgery to help alleviate anxiety. Coexisting medical problems such as asthma, heart disease, and seizures should be evaluated and optimized prior to surgery. A postoperative intensive care unit (ICU) or observation bed is reserved for children with OSAS, significant medical problems, neurologic delay, or craniofacial abnormalities. No aspirin or ibuprofen-containing products are permitted for 10 days prior to surgery. Anesthetic Considerations General anesthesia is administered via a curved RAE endotracheal tube, which is placed in the midline of the lower lip and taped securely. The laryngeal mask has been evaluated for T&A and adenoidectomy, but is not considered a standard of care. The risk of perioperative aspiration of blood, vomitus, and secretions precludes routine use until definitive studies establish safety. Narcotic premedications are avoided in children with OSAS. Intra-operative corticosteroids may decrease postoperative pain and emesis and improve recovery following tonsillectomy. Dexamethasone (0.5 mg/kg) can be given intravenously at the start of surgery (maximum dose of 16 mg).5 Ketorolac tromethamine is a parenteral nonsteroidal anti-inflammatory drug that should be avoided, because it may increase bleeding. Surgical Exposure A headlight is mandatory for adequate visualization. The table is positioned so that the surgeon has nonobstructed access to the patients head, while the anesthesiologist has access to the intravenous and anesthesia tubing. A shoulder roll is placed between the scapulae, the head is placed on a head doughnut, and a head drape is placed. The face should not be injured when placing the towel clamp, or alternatively, a piece of tape can be used to hold the head drape. The patient is placed in Roses position by lowering the head, unless there is Down syndrome or other conditions affecting the cervical spine.
Tonsillectomy, Adenoidectomy, and UPPP
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An appropriately sized Crowe-Davis, McGiver, or Dingman mouth gag is carefully inserted, avoiding dental injury, and then suspended on a Mayo stand brought into the field. A wet tonsil sponge is placed in the hypopharynx to prevent leakage of anesthetic gases that can cause an intraoperative fire.6 Red rubber catheters are used to retract the soft palate. The catheters are lubricated with soapy water, and placed along the floor of the nose until they pass into the pharynx. The catheters are brought out the oral cavity and clamped to elevate the palate. Adenoidectomy, tonsillectomy, or UPPP is performed as described below. ADENOIDECTOMY Indications Infection: recurrent or chronic sinusitis (adenoiditis); otitis media persisting after extrusion of tympanostomy tubes; primary therapy of otitis media when combined with myringotomy Obstruction: nasal airway obstruction; OSAS; chronic mouth breathing; hyponasal speech Anesthesia, Preparation, and Exposure As described earlier under General Considerations Velopharyngeal examination is performed prior to adenoidectomy to detect weakness that may predispose to velopharyngeal insufficiency (VPI). This includes a history of nasal regurgitation when young, the presence of palatal abnormalities, short palate on oral examination, and absence of a uvular bulge on nasopharyngoscopy.
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Procedure The hard palate is inspected and digitally palpated for a submucous cleft (bifid uvula, zona pellucida, notching of the posterior hard palate). The palate length should also be inspected (Figure 171). A laryngeal mirror (dipped in soapy water to prevent fogging) is used to inspect the nasopharynx (Figures 172 A and B). Pulsations may indicate an aberrant internal carotid artery or ascending pharyngeal artery. The adenoid size is noted. Depending on the type of adenoidectomy to be performed, one or more techniques can be used for tissue removal:
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Primary adenoidectomy can be performed using a curette, suction coagulator, or a microdebrider. The suction coagulator is ideal for small adenoids, although it can be used routinely regardless of adenoid size. Secondary (revision) adenoidectomy can also be performed using curette, suction coagulator, or microdebrider; however, greater precision is achieved by the latter two methods. The suction coagulator generally results in the least bleeding. Partial superior adenoidectomy is performed in children at risk for VPI (see above). The suction coagulator and microdebrider are best suited for this procedure.7
Figure 171 The palate is inspected and palpated for evidence of a submucous cleft: bifid uvula (a), zona pellucida (b), and/or notching of the posterior hard palate (c).
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Figure 172 A and B. A laryngeal mirror is used to visualize the adenoid, assess the degree of obstruction, and select the appropriate instrument for adenoidectomy.
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No 1. Curette adenoidectomy A curette is chosen based on mirror inspection and should fit snugly between the tori. Using the mirror for direct visualization, the curette is inserted superiorly up to the septal vomer (Figure 173A ). The curette is swept inferiorly with a side-to-side rocking motion to completely remove all adenoid tissue (Figure 173B ). Care is taken to avoid deep muscular or vertebral injury, injury to the torus region, and injury to the choana. A smaller curette or a St Clair adenoid forceps is used to remove any retained tissue noted on repeat mirror examination. Tonsil packs are placed in the nasopharynx for 5 minutes, or until tonsillectomy is completed. When necessary, oxymetazoline can be used for topical vasoconstriction. Phenylephrine is avoided because of cardiac toxicity.8 The packs are individually removed and the suction cautery (30 watts) is used for hemostasis and to remove retained adenoid tissue, especially at the choana where tissue is often missed by the curette (Figure 174A ). No 2. Suction coagulator (liquefaction) adenoidectomy A 10 Fr suction coagulator (Valleylab #E2505-10Fr, Boulder, CO) is used at a power setting of 30-45 watts, depending on child age. The electrosurgery unit is set to monopolar coagulation, and is used in spray (not pinpoint) mode with foot control. Using a laryngeal mirror to visualize the nasopharynx, the suction tip is inserted within (not on top of ) the central bulk of the adenoid pad. Current is applied for a few seconds, and the tip is gradually withdrawn as the tissue liquefies. When performed properly, the adenoid tissue liquefies but does not cauterize; the suction tip should rarely require cleaning. In contrast, when the tip is applied too superficially there is excessive heat, smoke, crusting, and cauterization. Remaining tissue is liquefied while drawing the lateral adenoid tissue (near the torus) medially and the superior adenoid tissue (near the choana and vomer) inferiorly. The adenoidectomy is complete when the choanae are completely visible and the nasopharynx has a smooth level contour. There should be no burns on the vomer, nasal turbinates, soft palate, or lateral nasopharyngeal walls. No 3. Microdebrider (shaver) adenoidectomy Microdebrider adenoidectomy is performed using a special adenoid attachment for the powered shaver device with mirror visualization (Figure 174B ).9 Adenoid tissue is removed, taking care not to injure adjacent structures, particularly the torus tubarius and lateral nasopharynx.
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Figure 173 A, The adenoid curette contacts the nasal septum superiorly to ensure complete removal of adenoid tissue. B, The curette is swept inferiorly with a side-to-side motion.
B Figure 174 A, The suction coagulator may be used for hemostasis after curettage, or as a primary modality for tissue removal. B, Use of the microdebrider (powered shaver) for adenoid removal.
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For a partial superior adenoidectomy, the microdebrider (or suction cautery) is used to remove superior adenoid tissue adjacent to the choana, while maintaining an inferior adenoid remnant to aid in velopharyngeal closure (Figure 175). As noted above, the suction coagulator can also be used to achieve this effect.7 If necessary, hemostasis is obtained using the suction cautery (30 watts). Deep or excessive cauterization of the posterior wall of the nasopharynx is avoided to prevent delayed recovery caused by persistent fetor oris and stiff neck. The nasopharynx is irrigated, the red rubber catheters are removed, and an appropriately sized nasogastric tube is used to empty the stomach. The mouth gag should be removed with the thumb pressing down on the lip area, to prevent premature extubation. Postoperative Care A normal diet and activity are resumed as soon as the child and family desire. Antibiotics, typically amoxicillin or amoxicillin and clavulanate, are given for seven days to reduce odor and stiff neck caused by bacterial colonization of the adenoid bed. Acetaminophen is sufficient for pain relief; narcotics are unnecessary, and medications containing aspirin or ibuprofen should be avoided for 7 days. Complications Noniatrogenic complications after adenoidectomy include10 Regrowth of adenoid tissue, particularly in very young children, which may require revision (secondary) adenoidectomy. Hypernasality, because of temporary pain splinting. Persistent hypernasality is rare and probably caused by unrecognized pre-existing velopharyngeal weakness. Management includes speech therapy or a sphincter pharyngoplasty, if refractory (see Chapter 18). Atlantoaxial subluxation (Grisels syndrome), which presents with persistent torticollis 1-2 weeks after surgery. Neurological or orthopedic consultation may be required. Iatrogenic complications after adenoidectomy include Dental injury, from intubation or the mouth gag. Dentition should be checked prior to inserting and removing the mouth gag. Urgent laryngoscopy and bronchoscopy must be performed for any newly discovered missing teeth. Nasopharyngeal stenosis, caused by excessive tissue removal. Repair is difficult and may include dilation, steroid injection, or a tissue flap (rotational, advancement, or free flap).11 Eustachian tube injury, if the torus tubarius is cauterized or denuded.
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Meningitis, after injecting lidocaine and epinephrine into the posterior nasopharynx prior to adenoidectomy. Injections are unnecessary and should be avoided. Lingual nerve palsy, caused by pressure from the tongue blade of the mouth gag. Cautery burns, caused by operator error or equipment malfunction.12
Figure 175 Patients at risk for velopharyngeal insufficiency undergo a partial adenoidectomy, whereby an inferior adenoid remnant is left to aid in velopharyngeal closure.
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TONSILLECTOMY Tonsillectomy is a major surgery with potential morbidity and mortality. Recent studies suggest that aggressive antibiotic regimens aimed at resistant organisms in the tonsils or adenoid may avoid surgery; therefore, careful preoperative management and evaluation are necessary. Indications Infection: recurrent tonsillitis, peritonsillar abscess Obstruction: upper airway obstruction; obstructive sleep apnea syndrome (OSAS); poor feeding and failure to thrive; muffled speech caused by enlarged tonsils Miscellaneous reasons: asymmetric enlargement with suspicion of neoplasm; recurrent hemorrhagic tonsillitis; velopharyngeal insufficiency caused by enlarged tonsils Anesthesia, Preparation, and Exposure As described earlier under General Considerations. Procedure Tonsillectomy can be performed via cold dissection technique or hot electrocautery technique. Many studies have debated the merits of each technique, but electrocautery dissection offers the advantages of decreased intraoperative bleeding, and if carefully performed, avoids the potential risk of greater postoperative pain.13 Laser dissection has not been shown to be superior to electrocautery. Radiofrequency submucosal tissue volume reduction has been described in adults, but is presently (August 2001) not recommended as a standard approach. The superior pole of one tonsil is pulled medially with an Allis clamp, which grasps the tonsil with the tines in a superior to inferior orientation (Figure 176). The mucosa overlying the superior pole is then incised with a protected straight electrosurgery tip (15-20 watts) at the junction between the tonsil and mucosal fold.
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Once the incision is made, the cautery is used to identify the avascular plane between the tonsillar capsule and tonsillar fossa. Correct identification of this plane is essential. If the plane is not easily identified, a Metzenbaum scissors or tonsil clamp can be placed through the incision to help identify the plane (Figure 177). After the plane is identified, the Allis clamp can then regrasp the tonsil capsule and mucosal fold for the rest of the procedure.
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Figure 176 The tonsil is grasped with the Allis clamp tines in a superior to inferior orientation, and pulled medially while superior tonsillar pillar is incised.
Figure 177 A small scissors or clamp can be used to identify the appropriate avascular dissection plane in scarred or fibrotic tonsils.
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Dissection between the tonsillar capsule and fossa proceeds from superior to inferior, while an assistant suctions the plume. 1. Medial traction is applied to the tonsil so that the cautery can gently lyse the intervening fibers without deeply penetrating the muscular fossa (Figure 178). 2. Traction on the tonsil is continually re-assessed to provide maximum visualization of fibers and blood vessels between the tonsil capsule and fossa. 3. Dissection is performed with only the tip of the cautery, as close to the capsule as possible, to limit delivery of current to surrounding tissues. 4. Muscular penetration by the cautery tip can result in increased postoperative pain and possibly a greater risk of postoperative bleeding. The cautery continues around the inferior pole of the tonsil until the tonsil can be completely removed (Figure 179). The plane between the inferior palatine and lingual tonsil must be established to prevent overaggressive removal of lingual tonsil, which is accomplished by sweeping the cautery from lateral to medial when cauterizing at the inferior pole. After tonsil removal, hemostasis is established with a suction cautery (15-30 watts), and a Hurd dissector to retract the anterior and posterior tonsillar pillars.
Figure 178 The tonsil is stretched medially and the cautery is used to gently divide the fibers between the tonsillar capsule and the tonsillar fossa.
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Figure 179 The cautery can be used more aggressively to locate the plane between the inferior tonsil and lingual tonsil by medial traction (arrow), while cauterizing from lateral to medial until the tonsil separates from the lingual tonsil and base of tongue.
1. The cautery should not burn deeply, rather the bleeding tissue should be pulled into the suction lumen and then cauterized (Figure 1710A). 2. The superior pole of the tonsil can be visualized with a laryngeal mirror to allow hemostasis in this region (Figure 1710B).
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C Figure 1710 A, Bleeding tissue is pulled into the lumen of the suction cautery and then cauterized in order to prevent deep cauterization. B, A laryngeal mirror is used to visualize a bleeding site in the superior pole. C, Figure eight stitches of 2-0 plain or chromic gut are placed on any bleeding vessels despite initial cauterization.
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3. Visible vessels or persistent bleeding may require a figure eight stitch using a 2-0 plain or chromic gut suture on a semicircular needle (Figure 1710C). Hemostatic sutures must be placed superficially to prevent deeper vascular injury (Figure 1711). 4. Other hemostatic techniques include prolonged packing, ties, bismuth, bipolar cautery, Avitene, and topical thrombin. Before excising the contralateral tonsil, the mouth gag should be taken down for one minute between sides to minimize the chances of tongue edema. The nasopharynx and oropharynx are irrigated to assure hemostasis, and to identify residual adenoid or tonsil tissue that could be aspirated. The red rubber catheters are removed. An appropriately sized nasogastric tube is used to empty the stomach.
Figure 1711 Atial view through plane of oropharynx. Cautery and suturing must be done carefully to avoid injuring the internal carotid artery (a), located 5-30 mm posteriorly and laterally to the tonsillar fossa (b).
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The mouth gag should be removed with the thumb pressing down on the lip area, to prevent premature extubation (Figure 1712). The child is then extubated by the anesthesiologist, though the surgical team should supervise the process and ensure that there is no excessive bleeding or other difficulties.
Figure 1712 To prevent accidental extubation, the endotracheal tube is held down at the lip while removing the mouth gag.
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Postoperative Care While most patients can be safely discharged 4-6 hours after surgery, observation overnight in the inpatient ward or intensive care unit is recommended for16
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Children less than age 3 years Children with OSAS Children with significant associated medical problems, neurological delay, or craniofacial abnormalities Children who live far from the hospital, or have questionable caregiver support at home
Antibiotics, typically amoxicillin or amoxicillin and clavulanate, are given for 7-10 days to reduce odor and stiff neck caused by bacterial colonization of the tonsil and adenoid beds. There is no consensus on activity resumption after T&A, though general principles include avoiding strenuous activity for one week and returning to school or day care after one week (to allow for bleeding observation under caregiver supervision). There are many approaches to postoperative diet after T&A, ranging from liquid or soft diet for 1-2 weeks (most common), to resumption of normal diet on the same day as surgery. Hard foods, or foods that cause discomfort, should be avoided for at least 7 days. Analgesia is provided with acetaminophen, with or without codeine. Codeine is usually avoided in children with OSAS to prevent respiratory depression. Medications containing aspirin or ibuprofen should be avoided for 7 days.17 Sucralfate gargles (1 g per 60 mL water) have been shown in adults and older children to decrease postoperative pain following T&A.18 Complications Noniatrogenic complications after tonsillectomy include10 Bleeding in 1-2% of children, which is typically delayed (5-7 days); bleeding in the first 24 hours is less common. Most bleeding will stop spontaneously, but generally requires 24 hours of inpatient observation. Initial adjuvant techniques for hemostasis include clot removal, gargling with salt water or hydrogen peroxide, local cautery with silver nitrate sticks, and injection of epinephrine 1:200,000.2 Persistent bleeding, requiring control in the operating room 1. Rapid sequence anesthesia is used for induction. 2. Bleeding vessels are cauterized or suture ligated (see Figure 1710). 3. Refractory hemorrhage requires external carotid artery embolization by an interventional neuroradiologist. 4. When embolization is unavailable, external carotid artery ligation (described below) is performed while packing the oral cavity to tamponade the bleeding.
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Dehydration, requiring re-admission for hydration with isotonic solutions (to prevent hyponatremia) while monitoring electrolytes. Airway obstruction, requiring observation in an intensive setting, parenteral steroids, racemic epinephrine, careful insertion of a nasopharyngeal airway of appropriate length, and consideration for re-intubation if necessary. Postobstructive pulmonary edema, which may result from increased intrathoracic venous and hydrostatic pressure relieved by intubation or surgery. Presenting signs include oxygen desaturation and pink frothy secretions. Diuretics and re-intubation may be needed. Atlantoaxial subluxation (Grisels syndrome), presenting with persistent torticollis 1-2 weeks after surgery. Neurological or orthopedic consultation may be required. Depression, which must be considered in children with persistent postoperative character change beyond the typical recovery time.19 Iatrogenic complications after tonsillectomy include Dental injury, from intubation or the mouth gag. Dentition should be checked prior to inserting and removing the mouth gag. Urgent laryngoscopy and bronchoscopy must be performed for any newly discovered missing teeth. Oropharyngeal stenosis, caused by excessive removal of the deep lower tonsil pole and adjacent lingual tonsil tissue. Surgical repair is very difficult and includes dilation, steroid injection, and tissue flaps.20 Internal carotid artery injury, after deep cautery, suturing, or dissection, because the artery lies within 5-30 mm of the lateral tonsil fossa (see Figure 1711).14 Lingual nerve palsy, caused by pressure from the tongue blade of the mouth gag. Cautery burns, caused by operator error or equipment malfunction.

EXTERNAL CAROTID ARTERY LIGATION
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Indications Post-tonsillectomy hemorrhage, persisting despite the measures listed above, including embolization of the external carotid artery (if available). Anesthetic Considerations and Preparation General anesthesia with endotracheal intubation is mandatory. The pharynx is packed with gauze pads or sponges, as needed, to tamponade hemorrhage from the tonsil fossae; an assistant applies direct manual pressure. Procedure A skin incision is made along the anterior border of the sternocleidomastoid muscle (Figure 1713). The anterior muscle border is identified and cleaned of fascial attachments.
Figure 1713 A skin incision is made along the anterior border of the sternocleidomastoid muscle.
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The carotid sheath is exposed by dissection between the sternocleidomastoid muscle posteriorly, and the strap muscles anteriorly (Figure 1714A). A large blunt clamp is spread in the direction of the sheath until the contents are identified (Figure 1714B). The internal jugular vein, ansa hypoglossi, and vagus nerve are retracted posteriorly, while a vessel loop retracts the common carotid anteriorly (Figure 1715). The common carotid artery is followed superiorly above the bifurcation, avoiding injury to the hypoglossal nerve as it crosses superficially.
Figure 1714 A, The carotid sheath is exposed between the sternocleidomastoid muscle posteriorly, and the strap muscles anteriorly. B, A large blunt clamp is used to open the sheath by spreading in the same direction.
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Figure 1715 The internal jugular vein (a), ansa hypoglossi and vagus nerve are retracted posteriorly, while the common carotid artery (b) is retracted anteriorly with a vessel loop. The common carotid artery is traced superiorly past the bifurcation, where the external carotid division (c) has multiple branches and typically lies anterior.
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The external carotid division is identified by its usual anterior location, though it should be definitively identified by the presence of branches. A ligature of 2-0 silk is placed around the external carotid artery, above the superior thyroid artery division, which is the first branch above the bifurcation (Figure 1716). Persistent bleeding is probably due to collateral flow and will require selective ligation of the ascending pharyngeal, lingual, and facial branches, which are the next three above the superior thyroid artery branch. Following cessation of oral bleeding, the wound is closed in layers, over a small Penrose drain that can be removed on postoperative day one (Figure 1717).
Figure 1716 The external carotid artery (a) is ligated with a 2-0 silk tie placed above the first superior thyroid division (b).
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Figure 1717 The wound is closed in layers over a small Penrose drain.
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UVULOPALATOPHARYNGOPLASTY (UPPP) Indications Refractory OSAS persisting despite T&A OSAS without tonsillar or adenoid enlargement OSAS in a child with an abnormally long or redundant soft palate Alternative to tracheotomy in children with craniofacial abnormalities, neuromuscular hypotonia, or severe obesity Anesthesia, Preparation, and Exposure As described earlier under General Considerations Preoperative nasopharyngoscopy or video fluoroscopy should demonstrate that the obstruction is at the level of the oropharynx, not at the hypopharynx or laryngeal level. All patients undergoing UPPP have OSAS, and therefore, require preoperative cardiac evaluation and postoperative observation in the ICU. Parents must be advised that if UPPP fails to alleviate OSAS, tracheotomy will be necessary. Procedure A tonsillectomy is performed first (see above), though some surgeons perform the tonsillectomy in continuity with the UPPP. Choosing the palatal incision site is somewhat subjective:
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Pulling the uvula superiorly and anteriorly will help identify the junction between the mucosa and musculature of the soft palate, which is typically the correct incision site. The incision should never be superior to the point where the soft palate contacts the posterior pharyngeal wall.
While tensing the uvula, the anterior mucosal incision is made with a protected flat electrosurgery tip (20 watts), extending bilaterally from the midline to the anterior tonsillar pillars (Figure 1718).
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The incision is stepped in the midline, creating a longer mucosal flap posteriorly, which can be pulled forward to allow closure around the palatal musculature (Figures 1719 A and B). Only the uvula is removed; remaining palatal musculature is preserved.
After removing the redundant anterior and posterior palatal mucosa with the attached uvula, hemostasis is achieved using the suction cautery.
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Figure 1718 The uvula is tensed and pulled inferiorly and anteriorly, while an incision is made into the palatal mucosa. This incision is carried down laterally towards the anterior tonsillar pillars.
Figure 1719 The incision is carried through the uvular musculature (A, operative view), and stepped posteriorly so that a longer mucosal flap is left posteriorly (B, lateral view).
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The mucosal edges are approximated using interrupted 3-0 Vicryl sutures: 1. The midline mucosal edges are closed from posterior to anterior, by pulling the posterior flap forward around the palatal musculature to meet the anterior flap (Figures 1720 A and B). 2. The lateral mucosal edges can be closed by suturing from anterior mucosa to posterior mucosa through a small bite of intervening lateral musculature. This will aid in lateralizing the newly formed pillars. Once mucosal closure is complete, a nasopharyngeal airway is placed under direct vision and taped to the face with benzoin solution. The tube should extend below the newly created palate and towards the base of the tongue region. An appropriately sized nasogastric tube is used to empty the stomach. The mouth gag should be removed with the thumb pressing down on the lip area, to prevent premature extubation (see Figure 1712). The child is then extubated by the anesthesiologist, though the surgical team should supervise the process and ensure that there is no excessive bleeding or other difficulties.
Figure 1720 Closure is performed with interrupted sutures (A, operative view) that pull the posterior flap around the palatal musculature to meet the anterior flap (B, lateral view).
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Postoperative Care Diet, medications, and activity are the same as described above for tonsillectomy. The patient must be admitted overnight to the ICU and observed closely for respiratory compromise. Patients may be discharged the following morning if they have good oral intake and no respiratory compromise. A nasopharyngeal airway should be maintained for the first postoperative night, and this should be specified on a sign placed over the bed. Parenteral dexamethasone (up to 0.5 mg/kg per dose) is given every 6-8 hours for 24 hours. Prolonged overnight intubation may be necessary in children with severe OSAS or significant postoperative swelling. Complications Airway obstruction, caused by pre-existing OSAS combined with postoperative edema, respiratory depression from anesthetics, and possible pulmonary edema. Bleeding is less common than after tonsillectomy, probably because of mucosal closure. Hypernasality is often seen temporarily, with normal competence returning in 6-8 weeks. Persistent hypernasality is very difficult to repair following UPPP since the operation violates the tissues that can subsequently be used for flap surgery. Prevention by conservative palatal resection is therefore critical. Velopharyngeal stenosis, caused by excessive tissue removal and scarring between the posterior tonsillary pillars and posterior pharyngeal wall. Repair is difficult and may include dilation, steroid injection, or a tissue flap (rotational, advancement, or free flap).21 Persistent OSAS, requiring continuous positive airway pressure or tracheotomy.
REFERENCES
1. 2. 3. 4. 5. Hartnick CJ, Ruben RJ. Preoperative coagulation studies prior to tonsillectomy. Arch Otolaryngol Head Neck Surg 2000;126:6846. Wei JL, Beatty CW, Gustafson RO. Evaluation of posttonsillectomy hemorrhage and risk factors. Otolaryngol Head Neck Surg 2000;123:22935. Allen GC, Armfield DR, Bontempo FA, et al. Adenotonsillectomy in children with von Willebrand disease. Arch Otolaryngol Head Neck Surg 1999;125:54751. Halvorson DJ, McKie V, McKie K, et al. Sickle cell disease and tonsillectomy. Arch Otolaryngol Head Neck Surg 1997;123:68992. Goldman AC, Govindaraj S, Rosenfeld RM. A meta-analysis of dexamethasone use with tonsillectomy. Otolaryngol Head Neck Surg 2000;123:6826.
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6.
Keller C, Elliott W, Hubbell RN. Endotracheal tube safety during electrodissection tonsillectomy. Arch Otolaryngol Head Neck Surg 1992;118:6435. 7. Kakani RS, Callan ND, April MM. Superior adenoidectomy in children with palatal abnormalities. Ear Nose Throat J 2000;79:3005. 8. Jones J, Greenberg L, Groudine S, et al. Phenylephrine advisory panel report. Int J Pediatr Otorhinolaryngol. 1998;45:9799. 9. Stanislaw P, Koltai PJ, Feustel PJ. Comparison of power-assisted adenoidectomy vs. adenoid curette adenoidectomy. Arch Otolaryngol Head Neck Surg 2000;126:8459. 10. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998;118:618. 11. Giannoni C, Sulek M, Friedman EM, Duncan NO. Acquired nasopharyngeal stenosis. Arch Otolaryngol Head Neck Surg 1998;124:1637. 12. Zinder DJ, Parker GS. Electrocautery burns and operator ignorance. Otolaryngol Head Neck Surg 1996;115:1459. 13. Nunez DA, Provan J, Crawfoird M. Postoperative tonsillectomy pain in pediatric patients. Electrocautery vs. cold dissection and snare tonsillectomya randomized trial. Arch Otolaryngol Head Neck Surg 2000;126:83741. 14. Deutsch MD, Martich Kriss V, Willging P. Distance between the tonsillar fossa and internal carotid artery in children. Arch Otolaryngol Head Neck Surg 1995;121:14102. 15. Steward DL, Chung SJ. The role of adjuvant therapies and techniques in tonsillectomy. Cur Opin Otolaryngol Head Neck Surg 2000;8:18692. 16. Gabalski EC, Mattucci KF, Setzen M, Moleski P. Ambulatory tonsillectomy and adenoidectomy. Laryngoscope 1996;106:7780. 17. Moir MS, Bair E, Shinnick P, Messner A. Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Laryngoscope 2000;110:18247. 18. Ozcan M, Altuntas A, Unal A, et al. Sucralfate for posttonsillectomy analgesia. Otolaryngol Head Neck Surg 1998;119:7004. 19. Klausner RD, Tom LWC, Schindler PD, Potsic WP. Depression in children after tonsillectomy. Arch Otolaryngol Head Neck Surg 1995;121:1058. 20. Ghorayeb BY. Cicatricial velopharyngeal stenosis. Arch Otolaryngol Head Neck Surg 1988;114:1924. 21. Krespi Y, Kacker A. Management of nasopharyngeal stenosis after uvulopalatoplasty. Otolaryngol Head Neck Surg 2000;123:6925.
C H A P T E R 18
V ELOPHARYNGEAL I NSUFFICIENCY
J. Paul Willging, MD
Closure of the velopharyngeal sphincter is essential for normal speech intelligibility and resonance; incomplete closure distracts the listener and interferes with communication. Velopharyngeal insufficiency (VPI) reduces oral pressure resulting in weak consonants and speech that often sounds muffled and unclear. The ability to project the voice is also limited by inadequate oral pressure. With small openings, turbulent airflow through the velopharyngeal opening can be appreciated as an audible nasal rustle.1 VELOPHARYNGEAL CLOSURE PATTERNS Nasopharyngoscopy is essential in managing VPI, because it precisely determines the level and pattern of velopharyngeal closure. Additional information is obtained concerning the size and location of the area of velopharyngeal escape and the presence of medialized carotid arteries on the posterior pharyngeal walls. Three patterns of velopharyngeal closure exist: 1. Nearly one-half of patients will demonstrate a coronal pattern of velopharyngeal closure, with the free edge of the soft palate approximating the posterior pharyngeal wall. 2. The circular pattern of closure is exhibited by 40% of patients. Passavants ridge (specialized fibers of the superior pharyngeal constrictors) may occasionally contribute to velopharyngeal closure, but generally the ridge is well below the level of closure. 3. The sagittal pattern closure is found in 15% of the population, in which the soft palate contributes little to closure, with the lateral walls medializing to accomplish primary velopharyngeal closure.2 A speech pathologist skilled in assessing velopharyngeal function is also necessary in the team evaluation of patients with hypernasality. Phonemespecific VPI (a specific articulation error) presents with hypernasality but responds to speech therapy, whereas surgery is required by and reserved for structural or neurologic deficits of velopharyngeal function. Apraxia and other speech disorders caused by underlying illness may also have nasal emission, which, if properly diagnosed by the speech therapist, can avoid unnecessary surgery.
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SUPERIORLY BASED PHARYNGEAL FLAP The superiorly based pharyngeal flap is the workhorse for velopharyngeal surgery. A musculocutaneous flap is placed as an obturator within the area of velopharyngeal closure. Lateral ports are maintained for nasal respiration by sewing the flap around stents of known diameter. Indications Central gaps are most amenable to restoration with a pharyngeal flap. The side walls of the velopharynx need to buttress against the inset flap to affect velopharyngeal closure. Lateral wall motion will often improve (develop) after flap placement with postoperative speech therapy. Anesthetic Considerations General endotracheal anesthesia is required. There is a high prevalence of velo-cardio-facial syndrome (chromosomal microdeletion of 22q11.2) in VPI patients. Phenotypic expression includes VPI, submucous cleft palate, learning disabilities, cardiac anomalies, retrognathia, malar flattening, pharyngeal hypotonia, slender hands and fingers, small stature, and medialized carotid arteries.3 Cardiac status should be investigated. Antibiotic prophylaxis is often necessary to prevent subacute bacterial endocarditis. Preparation Adenotonsillar hyperplasia may require tonsillectomy and adenoidectomy before flap placement to prevent postoperative obstructive apnea. A 4- to 6-week interval for healing should elapse between procedures. A videotape of the nasopharynx during connected speech is obtained during the preoperative evaluation of the patient. The videotape is viewed immediately before the operation to determine the level of attempted velopharyngeal closure. Anatomic landmarks are identified on the tape that can be used to locate this level in the patient. The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure A mouth gag is inserted, and the patient is placed into suspension. The posterior pharyngeal wall is visualized and palpated to identify any significant vessels in the operative field. The internal carotid arteries may be medialized in velo-cardio-facial syndrome patients. These vessels will be deep to the prevertebral fascia and not interfere with the operation, but increased care in raising the flap is necessary. Proposed posterior pharyngeal wall incision lines are infiltrated with 1% lidocaine with 1:100,000 units of epinephrine to affect vasoconstriction and ease the raising of the flap. The standard flap width generally runs from a point approximating the posterior tonsillar pillars (Figure 181).
Velopharyngeal Insufficiency
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The inferior extent of the flap should be near the midpoint of the tonsil. The length of the flap can be checked by estimating the distance from the posterior pharyngeal wall to the free margin of the soft palate, and then measuring down from the level of velopharyngeal closure. The problem of raising a flap that is too long is that the base of the flap will settle and adhere to the posterior pharyngeal wall, dropping the level of the flap away from the proper level of velopharyngeal closure.
The posterior aspect of the soft palate is infiltrated with 1% lidocaine with 1:100,000 units of epinephrine. The superiorly based pharyngeal flap is elevated by incising down to the prevertebral fascia. This fascial layer is bright white in color, and the plane will be essentially avascular. Hemostasis can be accomplished with monopolar electrosurgery. The lateral limbs of the incision are curved slightly laterally near the base of the flap to assist with creating the lateral ports.
Figure 181 Incisions for a superiorly based pharyngeal flap.
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Flap elevation needs to be high into the nasopharynx, to the natural level of velopharyngeal closure. Failure to raise the flap high enough will result in an inferior tethering of the free edge of the soft palate, further compromising velopharyngeal function. This will also cause the flap to be located in a position precluding its participation in velopharyngeal closure. The donor site is closed with 3-0 Vicryl suture.
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Undermining of the surrounding mucosa is rarely necessary. Suturing the mucosa directly to the prevertebral fascia will prevent tenting of the mucosa and the creation of dead space. Superiorly, the donor site is left to granulate. Overzealous closure of the donor site superiorly can lead to nasopharyngeal stenosis. Traction sutures placed on the nasal surface of the free edge of the soft palate can improve visualization for this incision (Figure 182). Care is taken to incise the mucosa with an adequate area of separation to allow the flap to be inset. The incision should be horizontal across the posterior soft palate, avoiding the natural tendency to make a curvilinear incision toward the posterior tonsillar pillar.
An incision is made on the nasal surface of the posterior soft palate.

!
If visualization is difficult, the posterior soft palate may be divided in the midline. Nasal stents are placed transnasally into the hypopharynx to size the lateral ports. Smaller endotracheal tubes, 3.5, are used for children, and 4.0 endotracheal tubes are used for adolescents. 4-0 Vicryl sutures are used to sew the oral mucosa and muscle of the flap to the anterior nasopharyngeal mucosa of the soft palate (Figure 183). A mirror is used to evaluate the lateral ports. If the port is too large (the flap is loose around the stent), additional sutures are placed to wrap the flap around the nasal stent. The lateral port closure should not be under tension.
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Figure 182 An incision is made horizontally on the nasopharyngeal surface of the soft palate to create a pocket to inset the transposed pharyngeal flap.
Figure 183 The pharyngeal mucosa of the pharyngeal flap is sewn to the anterior nasopharyngeal mucosa of the soft palate, anchoring the flap into position.
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To alleviate tension on the mucosal suture line in the nasopharynx, two additional 3-0 Vicryl sutures are used to roll the muscular component of the flap into the soft palate incision (Figure 184). These sutures begin 2 cm from the free margin of the soft palate, one on either side of the midline, passing through the substance of the soft palate and exiting the soft palate incision. In horizontal mattress fashion, the muscular layer of the flap is grasped to turn into the soft palate. At the conclusion of the procedure, the pharyngeal flap should not be visible in the oropharynx; it must be high in the nasopharynx (Figure 185). If the palate was divided for improved exposure, it is closed in three layers. Meticulous technique is necessary to minimize fistula formation. The nasal stents are positioned with their distal end in the midoropharynx, and are then secured with tape to the nose. Suction catheters are fashioned to extend 1 cm beyond the end of the stent. Postoperative Care The patient is admitted for postoperative observation. Perioperative oral antibiotics are prescribed for 1 week. The nasal stents are irrigated with normal saline and suctioned as necessary. The nasal stents are removed the following morning if no airway obstruction occurred overnight. The patient is observed in the hospital without the nasal stents for an additional night. Patients return for a postoperative check at 3 weeks. Speech therapy begins 1 month postoperatively. A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hypernasality or nasal emission is detected.
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Figure 184 Horizontal mattress sutures are placed through the substance of the soft palate and through the musculature of the pharyngeal flap to pull the flap into the soft palate recipient incision and minimize tension on the mucosal sutures.
Figure 185 Superiorly based pharyngeal flap in final position
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Complications Adenotonsillar hyperplasia must be addressed prior to performing a pharyngeal flap to prevent obstructive sleep apnea. Snoring is expected, but obstructive events need treatment. Continuous positive airway pressure (CPAP) can alleviate the problem until postoperative edema subsides. Stenosis of the lateral ports may cause hyponasality and obstructive breathing. Revision surgery may be necessary if symptoms continue beyond 3 months. Continued VPI secondary to failure of the lateral ports to close may be identified. Patients will frequently require a short course of speech therapy to learn how to use their flap. Failure to improve by 3 months suggests that further surgery will be necessary. Narrowing of the flap may cause inadequate obturation of the velopharyngeal defect. In some patients, the secondary intention healing of the raw surface of the flap causes the flap to narrow. If a wide flap is determined to be necessary preoperatively, an additional step of lining the flap with mucosal flaps, based on the free margin of the soft palate, minimizes the raw surface of the flap left to granulate, and can more predictably maintain the width of the flap (Figure 186). This requires splitting the palate to elevate the soft palate nasal flaps.4
Figure 186 Elevating the mucosa off the nasopharyngeal surface of the posterior soft palate allows lining of the pharyngeal flap to minimize flap narrowing.
ROLLED PHARYNGEAL FLAP
415
The rolled superiorly based pharyngeal flap is an augmentation technique of the posterior pharyngeal wall. It offers a buttress for the free edge of the soft palate in patients with coronal or circular closure patterns.5 Indications Small velopharyngeal gaps Narrow gaps that run across the posterior pharyngeal wall Anesthetic Considerations General endotracheal anesthesia is required. There is a high prevalence of velo-cardio-facial syndrome.3 Cardiac status should be investigated in such patients. Antibiotic prophylaxis is often necessary to prevent subacute bacterial endocarditis. Preparation A videotape of the nasopharynx during connected speech is viewed immediately before the operation to determine the level of attempted velopharyngeal closure. Anatomic landmarks are identified on the tape that can be used to locate this level in the patient. The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure A mouth gag is inserted, and the patient is placed into suspension. The posterior pharyngeal wall is visualized and palpated to identify any significant vessels in the operative field. The internal carotid arteries may be medialized in velo-cardio-facial syndrome patients. These vessels will be deep to the prevertebral fascia and not interfere with the operation, but increased care in raising the flap is necessary. Proposed posterior pharyngeal wall incision lines are infiltrated with 1% lidocaine with 1:100,000 units of epinephrine to affect vasoconstriction and ease the raising of the flap. The standard flap width generally runs from a point approximating the posterior tonsillar pillars (see Figure 181). The inferior extent of the flap should be near the midpoint of the tonsil. The superiorly based pharyngeal flap is elevated by incising down to the prevertebral fascia. This fascial layer is bright white in color, and the plane will be essentially avascular. Hemostasis can be accomplished with monopolar electrosurgery. Flap elevation needs to be high into the nasopharynx, to the natural level of velopharyngeal closure. Failure to raise the flap high enough will result in the flap being located in a position precluding its participation in velopharyngeal closure. The donor site is closed with 3-0 Vicryl suture; undermining of the surrounding mucosa is rarely necessary. Suturing the mucosa directly to the
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prevertebral fascia will prevent tenting of the mucosa and the creation of dead space. Superiorly, the donor site is left to granulate. The inferior edge of the flap is sewn to the prevertebral fascia at the base of the flap (Figure 187). Lateral release incisions are made 7 mm below the attachment of the flap to the prevertebral fascia to allow additional mucosa to be advanced in order to close the donor site immediately beneath the sutured flap. Postoperative Care The patient is discharged after recovery from general anesthesia. Perioperative oral antibiotics are prescribed for 1 week. Patients return for a postoperative check at 3 weeks. Speech therapy begins 1 month postoperatively. A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hypernasality or nasal emission is detected. Complications VPI may continue if contracture of the flap occurs or there is inadequate posterior displacement of soft palate. VPI may persist if the flap is not positioned at the level of velopharyngeal closure.
Figure 187 A pharyngeal flap can be rolled onto itself and used to augment the posterior pharyngeal wall.
POSTERIOR PHARYNGEAL WALL AUGMENTATION
417
Biocompatible or homologous tissues are used to augment irregularities or deficiencies in the posterior pharyngeal wall that create areas of velopharyngeal escape of air and sound energy. Indications Small gaps along the posterior pharyngeal wall Size of gap less than 4 mm Touch closure of the velopharyngeal mechanism that cannot withstand increased intraoral pressure Anesthetic Considerations General endotracheal anesthesia is required. There is a high prevalence of velo-cardio-facial syndrome.3 Cardiac status should be investigated in such patients. Antibiotic prophylaxis is often necessary for subacute bacterial endocarditis. Preparation A videotape of the nasopharynx during connected speech is viewed immediately before the operation to determine the level of attempted velopharyngeal closure. Anatomic landmarks are identified on the tape that can be used to locate this level in the patient. The material to be injected must be available. Medical grade Teflon carries the risk of infection, granuloma formation, inferior displacement over time,6 or theoretically, embolization.7 ! Commercially available collagen products are available from manufacturers, but little experience exists concerning their use in the posterior pharyngeal wall. ! Homologous fat may be injected and can be harvested from the abdomen or buttock. The amount of absorption and tissue viability vary, and the need for repeat procedures should be discussed with patients and families. The patient is positioned on a shoulder roll to maintain hyperextension of the neck.
!
Procedure A mouth gag is inserted, and the patient is placed into suspension. The posterior pharyngeal wall is visualized and palpated to identify any significant vessels in the operative field. The internal carotid arteries may be medialized in velo-cardio-facial syndrome patients. Red rubber catheters are placed transnasally and brought out through the mouth to retract the soft palate symmetrically. Landmarks on the videotape that localize the exact site of nasopharyngeal escape are identified. A Bruening syringe is loaded with Teflon or fat; a spinal needle is used to inject collagen. The needle is inserted into the exact site of deficiency
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and introduced to the level of the prevertebral fascia. The fascia offers increased resistance compared to the overlying mucosa and muscle. A single-needle puncture per injection site is important to minimize the amount of material escaping during the injection. A metal tongue blade is pushed against the posterior pharyngeal wall immediately inferior to the injection site (Figure 188). This creates a broad barrier to displacement of the injected material in an inferior direction. The augmentation material is slowly injected onto the prevertebral fascia. Generally 1 to 2 cc of material are injected at each site. Over-correction is necessary. After the material has been deposited, the needle should not be removed for an additional 1 minute to allow the pressure in the tissues to disperse, thus minimizing the amount of material expelled through the injection puncture site. Additional sites are injected as required. Central defects will require 2 injections, one on either side of the median raphe that prevents the material from crossing the midline. Postoperative Care The patient is discharged after recovery from general anesthesia. Perioperative oral antibiotics are prescribed for 1 week. Postoperative neck pain is expected because the prevertebral fascia has been irritated. Patients return for a postoperative check at 3 weeks. Speech therapy begins 1 month postoperatively. A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hypernasality or nasal emission is detected. Complications VPI may persist if the injection is not positioned at the level of velopharyngeal closure. VPI may re-develop if resorption of the injected material re-opens an area for nasal escape.
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Figure 188 Implanted material should be placed on the prevertebral fascia.
SPHINCTEROPLASTY A sphincteroplasty (sphincter pharyngoplasty) transposes myocutaneous flaps into the site of velopharyngeal closure to narrow the lateral ports of the velopharyngeal sphincter.8 There is potential for this to be a dynamic sphincter, as both blood and nerve supply enter the flaps from the superior pedicle. The major benefit of this procedure results from the static narrowing produced by transposing the flaps. Additional benefit is realized from the added bulk of the flaps to the posterior pharyngeal wall, augmenting this area and improving closure. Indications Central velopharyngeal closure can be accomplished, but nasal escape arises from wide lateral fornices Poor or absent lateral wall motion Very deep fossa of Rosenmller Anesthetic Considerations General endotracheal anesthesia is required. There is a high prevalence of velo-cardio-facial syndrome.3 Cardiac status should be investigated in such patients. Antibiotic prophylaxis is often necessary for subacute bacterial endocarditis.
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Preparation A videotape of the nasopharynx during connected speech is viewed immediately before the operation to determine the level of attempted velopharyngeal closure. Anatomic landmarks are identified on the tape that can be used to locate this level in the patient. The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure A mouth gag is inserted, and the patient is placed into suspension. The posterior pharyngeal wall is visualized and palpated to identify any significant vessels in the operative field. Red rubber catheters are placed transnasally and brought out through the mouth to symmetrically retract the soft palate. Landmarks identified on the videotape that localize the exact site of nasopharyngeal escape are identified in the patient. Proposed incision lines are infiltrated with 1% lidocaine with 1:100,000 units epinephrine to affect vasoconstriction. The incisions entail rectangular flaps encompassing each posterior tonsillar pillar. A horizontal incision is made connecting the medial limbs of the incisions at the level of velopharyngeal closure (Figure 189). The soft palate may be split in the midline to facilitate visualization within the nasopharynx. The mucosa is incised to the prevertebral fascia on the medial incisions. The palatopharyngeus muscle is incorporated into the flap. Lateral dissection is limited in the area of the tonsil. After making the transverse incision at the level of velopharyngeal closure, the surrounding tissue is elevated superiorly to create a bed within which the flaps may be inset. Inferior dissection is avoided to prevent insetting the flaps below the level of velopharyngeal closure. The base of each flap is undermined superiorly and laterally to effectively narrow the lateral velopharyngeal walls when the flaps are rotated medially. The donor sites are closed with interrupted 3-0 Vicryl sutures. The inferior edge of each flap is medially rotated and sewn to the lateral limit of the recipient horizontal incision of the opposite side (Figure 1810). One flap will reside above the other. If the palate was divided for improved exposure, it is closed in three layers. Meticulous technique is necessary to minimize fistula formation. Postoperative Care The patient is discharged after recovery from general anesthesia. Perioperative oral antibiotics are prescribed for 1 week. Postoperative neck pain is expected as the prevertebral fascia has been irritated.
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Patients return for a postoperative check at 3 weeks. Speech therapy begins 1 month postoperatively. A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hypernasality or nasal emission is detected. Complications VPI may persist if the sphincteroplasty is not positioned at the level of velopharyngeal closure. VPI may continue if inadequate narrowing of the lateral nasopharynx was achieved.
Figure 189 The posterior tonsillar pillars are incorporated into the musculocutaneous flaps for the sphincteroplasty.
Figure 1810 The transposed flaps should be high in the nasopharynx, at the level of velopharyngeal closure.
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LATERAL PORT REVISION - NARROWING The goal of the operation is to create local advancement flaps to narrow the lateral ports. Indication Continued VPI following placement of a pharyngeal flap through an incompetent lateral port Anesthetic Considerations and Preparation General endotracheal anesthesia is required. Preoperative nasopharyngoscopic evaluation during connected speech has identified the lateral ports that require revision. The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure A mouth gag is inserted, and the patient is placed into suspension. Red rubber catheters are placed transnasally and brought out through the mouth to retract the soft palate symmetrically. The posterior and lateral mucosa of the lateral velopharyngeal port are infiltrated with 1% lidocaine with 1:100,000 units epinephrine to affect vasoconstriction. A Y-to-V advancement flap is created where the lateral margin of the port is advanced medially (Figure 1811). The advancement is on the posterior lateral pharyngeal wall, extending into the nasopharynx, adjacent to the pedicle of the flap. Bilateral port procedures may be necessary.
Figure 1811 Y-V advancement flap to close a lateral port that is excessively wide.
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Postoperative Care The patient is discharged after recovery from general anesthesia. Perioperative oral antibiotics are prescribed for 1 week. Patients return for a postoperative check at 3 weeks. Speech therapy begins 1 month postoperatively. A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hypernasality or nasal emission is detected. Complications VPI may persist if the advancement flaps did not effectively narrow the lateral ports. Hyponasality or obstructive breathing may arise if lateral port stenosis occurs.
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LATERAL PORT REVISION - ENLARGING A local advancement flap is used to open and reline the stenotic lateral port. Indication Stenosis of the lateral port with obstructive respiration, hyponasality, or both Anesthetic Considerations and Preparation General endotracheal anesthesia is required. Preoperative nasopharyngoscopic evaluation during connected speech has identified the lateral ports that require revision. The patient is positioned on a shoulder roll to maintain hyperextension of the neck. Procedure A mouth gag is inserted, and the patient is placed into suspension. An endotracheal tube is passed transnasally through the stenotic port. A vertical incision of the soft palate in the midportion of the lateral port is made to release the stenosis (Figure 1812). Mucosa from the nasal surface of the soft palate is advanced to cover the raw surface created by the incision. If the resulting size of the port is inadequate, multiple incisions can be made to adequately open the ports. Postoperative Care The patient is discharged after recovery from general anesthesia. Perioperative oral antibiotics are not generally required. Patients return for a postoperative check at 3 weeks. Speech therapy begins 1 month postoperatively. A repeat office evaluation for objective resonance testing occurs at 3 months. Repeat nasopharyngoscopy is performed if continued hypernasality or nasal emission is detected.
Figure 1812 Enlargement of a stenotic lateral port.
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Complications Hyponasality or obstructive breathing may occur if the lateral port stenosis persists or re-develops. VPI may develop if the advancement flaps opened the lateral ports beyond that which could be closed by lateral wall movement. SURGICAL OUTCOMES Revision surgery for VPI is possible. It is important to investigate the reasons for the previous surgical failure so precautions can be taken to minimize their recurrence. Pharyngeal flaps can be raised a second time if 6-12 months are permitted to elapse. Unilateral sphincteroplasties may be performed in patients who fail to develop adequate lateral wall motion following pharyngeal flap placement. Patients must have an objective evaluation 3-6 months following reconstructive procedures to assess their nasal resonance. Precise terminology is necessary to judge outcome; normal is not the same as acceptable. A familys satisfaction with the results of surgery does not equate to normal or acceptable resonance. Without objective scrutiny of postoperative outcomes, improvement in surgical judgment cannot occur. Not all patients with continued hypernasality need revision surgery. Developmental delays, compensatory articulation errors, and underlying syndromes will affect speech outcomes. Creating the structural elements necessary for velopharyngeal closure is the essential goal of surgery. Collaboration with speech pathologists is mandatory for maximal outcome.
REFERENCES
1. Kummer AW, Curtis C, Wiggs M, et al. Comparison of velopharyngeal gap size in patients with hypernasality, hypernasality and nasal emission, or nasal turbulence (rustle) as the primary speech characteristic. Cleft Palate Craniofac J 1992;29:1526. Croft C, Shprintzen R, Rakoff S. Patterns of velopharyngeal valving in normal and cleft palate subjects: a multi-view videofluoroscopic and nasendoscopic study. Laryngoscope 1981;91:26571. Shprintzen R, Goldberg R, Lewin M, et al. A new syndrome involving cleft palate, cardiac anomalies, typical facies, and learning disabilities: velo-cardio-facial syndrome. Cleft Palate J 1978;15:5662. Hogan V. A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control (l.p.c.) pharyngeal flap. Cleft Palate J 1973;10:33145. Gray SD, Pinborough-Zimmerman J, Catten M. Posterior wall augmentation for treatment of velopharyngeal insufficiency. Otolaryngol Head Neck Surg 1999;121:10712. Smith J, McCabe B. Teflon injection in the nasopharynx to improve velopharyngeal closure. Ann Otol Rhinol Laryngol 1977;86:55963. Borgatti R, Tettamanti A, Piccinelli P. Brain injury in a healthy child one year after periureteral injection of Teflon. Pediatrics 1996;98:2901. Jackson I, Silverton J. The sphincter pharyngoplasty as a secondary procedure in cleft palates. Plast Reconst Surg 1977;59:51824.
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C H A P T E R 19
S URGERY
FOR
D ROOLING
William S. Crysdale, MD
Persistent troublesome drooling occurs in patients with neurologic deficits, but has a particularly high prevalence (10-20%) among children with cerebral palsy. Management decisions are best made using a team approach. Surgery is indicated when nonsurgical measures are ineffective, and may include one or more of the procedures listed in Table 191.
SUBMANDIBULAR DUCT RELOCATION WITH SUBLINGUAL GLAND EXCISION Indications Operation of choice1 for chronic significant drooling in the neurologically impaired patient unresponsive to nonsurgical measures, such as therapy to improve oral-motor skills of the tongue, lips, and pharynx.2 Contraindications Neurologic dysfunction that is not static (for which deterioration or improvement is anticipated within 12 months) Chronic significant aspiration Anesthetic Considerations General anesthesia is maintained through a nasotracheal tube that is stabilized on the patients forehead. A bolster is placed under the shoulders to moderately extend the neck. Draping around the head encompasses the endotracheal tube, but leaves access to the mouth. The anesthetic machine is towards the foot of the operating table and to the left of the patient so that the surgical team has ample access to the patients head. Preparation The patient is placed in a slight reverse Trendelenburg position. A headlight is necessary for visualization. The surgeon and the assistant sit at the head of the operating table. If a tonsillectomy has not been done previously, the tonsillar fossae are examined and the tonsils are removed if they are filling the fossae.
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Table 191 Comparison of surgical procedures for drooling

Procedure Advantages Disadvantages
Submandibular duct relocation with sublingual gland excision
! ! ! !
Result is usually maintained Oral cavity remains moist Dentition remains healthy Complications requiring surgery (ie ranula) have not occurred Result is usually maintained Oral cavity remains moist Dentition remains healthy Short procedure Sublingual glands are not removed
" Significant morbidity " Hospital stay of 3-4 days " About 2% require a secondary procedure for persistent drooling " Long-term result may not be better than submandibular duct relocation alone Significant morbidity Hospital stay of 3-4 days Ranula incidence of 8% within 6 months About 2% require a secondary procedure for persistent drooling " About 1% of ducts obstruct, forming a retention cyst requiring external excision of the ipsilateral submandibular gland " " " " " Xerostomia may occur when used as a secondary procedure " Sialorrhea frequently returns to preoperative levels within 6 months " Xerostomia may be problematic when combined with parotid duct ligation " Ranula formation secondary to disruption of sublingual gland tissue
Submandibular duct relocation
! ! ! ! !
Parotid duct ligation
! Short procedure ! Low morbidity ! Hospital stay of 1-2 days ! Short hospital stay ! Low morbidity ! Minimally invasive procedure
Tympanic neurectomy Submandibular duct ligation
Procedure Exposure of the floor of the mouth is facilitated by inserting a twopronged self-retaining retractor between the upper and lower teeth, and by suturing the tip of the tongue to the soft palate. The floor of the mouth anterior and posterior to the submandibular papillae is infiltrated with 5 mL of anesthetic agent containing 1:200,000 epinephrine. An island of mucosa 2 cm wide and 1 cm deep, encompassing the submandibular papillae, is created (Figure 191A). 1. For the right-handed surgeon it is easiest to identify the left submandibular duct first; conversely, for the left-handed surgeon, it would be the right submandibular duct. 2. The duct is identified by grasping the posterior edge of the island with forceps about 1 cm from the midline, and then rolling the tissue towards the lower dentition. With a sharp scissors, the dissection proceeds laterally from the midline, just underneath the edge of the mucosal island (Figure 191B). 3. The right duct (or the left duct for the left-handed surgeon) is found with lateral to medial scissors dissection, keeping in mind the position of the already displayed contralateral duct.
Surgery for Drooling
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Figure 191 A, Creating an island of mucosa. B, Identifying the left submandibular duct.
Once both ducts have been found, they are freed of their attachments to the adjoining tissues down to the anterior aspect of the submandibular gland by blunt dissection along the axis of the duct, utilizing large blunt scissors (Boyd).
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For this maneuver, appropriate retraction is crucial: the anterior retractor pulls laterally, holding the sublingual gland away from the duct, while the posterior retractor pushes the genioglossus muscle medially. Usually, dissection is adequate if the ducts, when gently held, will reach the vermillion border of the lower lip (Figure 192A).
A 4-0 chromic catgut suture is attached to both lateral corners of the mucosal island; the island is then sutured to the undersurface of the tongue to keep the ducts in view while the sublingual glands are excised (Figure 192B). An incision is made through the floor of mouth mucosa 3-4 mm from, but parallel to, the lower alveolus, starting from the pre-existing anterior incision and continuing posteriorly for 3-4 cm.
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The anterior aspect of the sublingual gland is mobilized off the inner aspect of the mandible with blunt scissors dissection (Figure 193A). The gland is then firmly grasped by a clamp, and via blunt dissection, is stripped posteriorly off the underlying muscles: the mylohyoid deep and genioglossus medially (Figure 193B). Next, the gland is freed of its attachment to the tongue. Scissors are used to create a tunnel between the gland and the tongue, avoiding large veins. The mucosa is then divided (Figure 194A). The lingual nerve is identified medially, and the sublingual gland is then dissected off the lingual nerve back to where the submandibular duct and the lingual nerve cross (Figure 194B). ! Hemostasis is crucial during this dissection; electrocautery is essential. ! Particular care is required on the deep aspect of the gland laterally, about midway back, because this is where the arterial supply enters the gland from the lingual artery and from branches of the submental artery; this artery is always anterior to the lingual nerve. ! It is also crucial not to dissect too deep to the lingual nerve plane as large veins will be encountered, resulting in significant bleeding. Excessive ligation of such veins will result in significant tongue edema, which may persist for months.
Figure 192 A, Both submandibular ducts are dissected free. B, The island of mucosa temporarily sutured to the tongue.
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Figure 193 A, The anterior aspect of the sublingual gland is mobilized. B, Sublingual gland is mobilized posteriorly.
Figure 194 A, Division of the mucous membrane close to the tongue. B, Mobilization of the sublingual gland off the lingual nerve.
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Once the sublingual glands have been excised, the submandibular ducts can be relocated into the tonsillar fossae. 1. The mucosal island containing the submandibular papillae is freed off the tongue and the suture holding the tip of the tongue is removed. 2. The mucosal island is divided in the midline (Figure 195A). 3. Leaving the self-retaining retractor in place, the tongue is pulled forward and a Negus clamp is passed forward from the tonsillar fossa into the operative area, staying in the submucous space (Figure 195B). 4. The suture on the lateral edge of the mucosal island is grasped, and the island with the duct is pulled into the tonsillar fossa. Once both ducts have been pulled into the tonsillar fossae, a tonsil gag is inserted. The individual ducts are sutured to the posterior aspect of the anterior tonsillar pillar with a single mattress stitch using absorbable suture (3-0 chromic catgut). At this point, the tonsillar fossae are inspected closely to ensure complete hemostasis. The Boyle Davis gag is removed and the self-retaining retractor is reinserted; the floor of mouth is examined closely to ensure complete hemostasis. The anterior incision is closed with five or six simple interrupted stitches of absorbable suture material (4-0 chromic catgut). Postoperative Care Airway obstruction requiring 24-48 hours of nasotracheal intubation may (rarely) occur if swelling of the tongue is excessive. This should be anticipated in patients with retrognathia who were difficult to intubate. Good pain control is essential to make the patient comfortable and manageable during the first 24-48 hours after surgery. Morphine intravenous drip is utilized routinely. Intravenous fluids are necessary for 24-48 hours postoperatively. Prophylactic antibiotics are recommended. Systemic steroids for 2 doses (immediately postoperative and 8 hours later) are administered. Antiemetic medications are used as required. Parental (or other caregiver) involvement in nursing care is encouraged because management problems are frequent during the first 48 hours. Special Considerations The floor of mouth may take 4 weeks to heal completely if closure of the anterior incision has been difficult. The result usually becomes apparent within 6 weeks.
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Figure 195 A, Division of the mucosal island between the two papillae. B, Instrument is inserted to pull the duct into the tonsillar fossa.
SUBMANDIBULAR DUCT RELOCATION Indications This operation was used frequently during the 1980s, but is now uncommon. Submandibular duct relocation may be indicated if one is concerned, from an anatomical technical point of view, of excising the sublingual glands. Contraindications Neurologic dysfunction that is not static (for which deterioration or improvement is anticipated within 12 months) Chronic significant aspiration Anesthetic Considerations General anesthesia is maintained through a nasotracheal tube that is stabilized on the patients forehead. A bolster is placed under the shoulders to moderately extend the neck. Draping around the head encompasses the endotracheal tube, but leaves access to the mouth.
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The anesthetic machine is at the foot of the operating table and to the left of the patient so that the surgical team has ample access to the patients head. Preparation The patient is placed in a slight reverse Trendelenburg position. A headlight facilitates visualization. The surgeon and the assistant sit at the head of the operating table. If a tonsillectomy has not been done previously, the tonsillar fossae are examined and the tonsils are removed if they are filling the fossae. Procedure Exposure of the floor of the mouth is facilitated by inserting a twopronged self-retaining retractor between the upper and lower dentition, and by suturing the tip of the tongue to the soft palate. The floor of the mouth anterior and posterior to the submandibular papillae is infiltrated with 5 mL of anesthetic agent containing 1:200,000 epinephrine. An island of mucosa 2 cm wide and 1 cm deep, encompassing the submandibular papillae, is created (see Figure 191A). 1. For the right-handed surgeon it is easiest to identify the left submandibular duct first; conversely, for the left-handed surgeon, it would be the right submandibular duct. 2. The duct is identified by grasping the posterior edge of the island with forceps about 1 cm from the midline, and then rolling the tissue towards the lower dentition. With a sharp scissors, the dissection proceeds laterally from the midline, just underneath the edge of the mucosal island (see Figure 191B). 3. The right duct (or the left duct for the left-handed surgeon) is found with lateral to medial scissors dissection keeping in mind the position of the already displayed contralateral duct. Once both ducts have been found, they are freed of their attachments to the adjoining tissues down to the anterior aspect of the submandibular gland by blunt dissection along the axis of the duct, utilizing large blunt scissors (Boyd). For this maneuver, appropriate retraction is crucial: the anterior retractor pulls laterally, holding the sublingual gland away from the duct, while the posterior retractor pushes the genioglossus muscle medially. ! Usually, dissection is adequate if the ducts, when gently held, will reach the vermillion border of the lower lip (see Figure 192A). A 4-0 chromic catgut suture is attached to both lateral corners of the mucosal island; the island is then sutured to the undersurface of the tongue to keep the ducts in view while the sublingual glands are excised (see Figure 192B).
!
With a towel clip in the lateral aspect of the tongue for countertraction, a mucosal tunnel is created from the anterior aspect of the sub-
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mandibular gland to the tonsillar fossa by pushing a Kelly clamp through from the anterior incisional area (Figure 196A). The Kelly clamp is then used to pull a No 10 suction catheter from the tonsillar fossa into the anterior incisional area. The sutures attached to the mucosal islands are threaded through the catheters (Figure 196B), and then pulled through the submucosal tunnels into the tonsillar fossae. A single mattress suture attaches the mucosal island to the posterior aspect of the anterior tonsillar pillar close to the base of the tongue. Difficulty in relocating the duct posterior to the tonsillar fossa indicates that the anterior dissection of the submandibular duct off the adjacent tissues was not carried far enough posteriorly. The anterior incision is closed with five or six simple interrupted stitches of absorbable suture material (4-0 chromic catgut). Postoperative Care Same as described above for Submandibular Duct Relocation with Sublingual Gland Excision. Special Considerations Ranula formation occurs in 8% of patients having this procedure. The parents, or other caregivers, need to be forewarned about this problem, and follow-up will be necessary for at least 1 year.
Figure 196 A, Pulling a catheter into the anterior incisional area. B, Threading of the suture through the catheter.
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PAROTID DUCT LIGATION Indications Patients with chronic significant sialorrhea after submandibular duct relocation, with or without sublingual gland excision Patients with chronic significant sialorrhea and limited access to the oral cavity (ie, temporal mandibular joint ankylosis), thus making it technically impossible to complete submandibular duct relocation with or without sublingual gland excision Patients with chronic significant sialorrhea who are appropriate surgical candidates, but in whom aspiration is significant and of concern This procedure may be done in combination with submandibular duct ligation. Contraindications Failure to cannulate the parotid duct at the outset of the procedure Anesthetic Considerations An oral endotracheal tube is adequate and permits access to both parotid ducts. Preparation The patients head is in a neutral position with a slight reverse Trendelenburg position. The surgeon wears a headlight for visualization. The operation is easier if the surgeon stands to the side of the head opposite the duct having surgery (ie, on the left if the right side is being completed). The assistant is positioned on the controlateral side. Procedure The parotid duct is located and cannulated with a lacrimal probe. With the probe held in place, the soft tissues immediately anterior to the duct orifice are infiltrated with 2 to 3 mL of anesthetic agent containing 1:200,000 epinephrine. With the lacrimal probe held in place, an elliptical incision 1.5 cm in length is made 0.5 cm anterior to the duct orifice (Figure 197A). This incision should not be too far anterior to the duct orifice, or the duct will be difficult to locate. The duct quickly travels obliquely lateral and posterior to the gland; thus, dissection must be done close to the duct orifice until the duct (with the probe inside) is identified. When the duct is identified, it is cleared of excessive soft tissue for approximately 1 cm. A Mixter clamp is inserted around the duct so that the ligatures can be grasped and pulled into place (Figure 197B). Two separate ligatures of nonabsorbable suture (3-0 Mersilene) are placed around the duct (2 turns in each ligature). Buccal mucous membrane is closed with interrupted absorbable sutures.
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Postoperative Care Prophylactic antibiotics are recommended. Morbidity is minimal, and discharge from hospital is usually possible within 24 hours. Special Consideration Fistulization of the duct with failure of the procedure if the duct is inadvertently divided
Figure 197 A, Location of the incision anterior to the parotid duct orifice. B, Instrument around the parotid duct to grasp the nonabsorbable ligature.
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TYMPANIC NEURECTOMY Indications Chronic sialorrhea when risk of any intraoral procedure is significant Persistent sialorrhea following all intraoral procedures Contraindications Active middle ear disease Preparation The patients head is draped for access to both ear canals (if a bilateral procedure is to be completed). Procedure Tympanotomy is completed using an endomeatal flap (see Chapter 2). The chorda tympanic nerve, which contains the parasympathetic secretomotor fibers to the submandibular gland, is divided upon entering the middle-ear space. The parasympathetic fibers to the parotid gland are in the tympanic plexus located just anterior to the round window niche. They are covered in bone approximately 25% of the time. Nerve fibers in the tympanic plexus are interrupted using an instrument such as the Rosen needle. About 2-3 mm of the nerve are removed. The endomeatal flap is repositioned and held in place with pieces of Gelfoam. The contralateral ear is now completed in a similar fashion. Postoperative Care Morbidity is minimal, and discharge from hospital may be possible the same day. Special Considerations This procedure is rarely performed, and is done only as a final measure that has little promise of success. SUBMANDIBULAR DUCT LIGATION Indications Chronic sialorrhea with significant aspiration Submandibular duct ligation is usually combined with parotid duct ligation.3 Contraindications Severe retrognathia, making access to this area problematic Anesthetic Considerations A nasotracheal tube facilitates completing the procedure. Preparation The surgeon wears a headlight to improve visualization.
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Procedure Exposure of the floor of the mouth is facilitated by inserting a twopronged self-retaining retractor between the upper and lower dentition, and by suturing the tip of the tongue to the soft palate. The floor of the mouth anterior and posterior to the submandibular papillae is infiltrated with 5 mL of anesthetic agent containing 1:200,000 epinephrine. A 2.5 cm mucosal incision is made approximately 1 cm posterior to the orifices of the submandibular papillae (Figure 198A). The left submandibular duct is found first (see Figure 191B) by grasping the posterior edge of the island and by elevating those tissues toward the lower dentition. The duct is then dissected with sharp scissors in a lateral direction from the midline, just underneath the edge of the mucosal island. The right duct is then identified. A Mixter clamp is passed around each duct in succession and used to grasp the nonabsorbable suture (Mersilene 3-0) used to ligate the ducts (Figure 198B). The incision in the floor of mouth is closed with interrupted absorbable sutures.
Figure 198 A, Location of incision posterior to the submandibular papillae. B, Instrument around the submandibular duct to grasp the nonabsorbable ligature.
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Postoperative Care Morbidity is minimal, and discharge from hospital may be possible the same day. Special Considerations This procedure may become the operation of choice, because the morbidity is significantly less than submandibular duct relocation with sublingual gland excision.
REFERENCES
1. 2. 3. Crysdale WS, Greenberg J, Koheil R, Moran R. The drooling patient: team evaluation and management. Int J Pediatr Otorhinolaryngol 1985;9:2418. Klem C, Mair EA. Four-duct ligation: a simple and effective treatment for chronic aspiration from sialorrhea. Arch Otolaryngol Head Neck Surg 1999;125:796800. Crysdale WS, Raveh E, McCann C, et al. Management of drooling - surgical experience from 1,103 patients assessed. Dev Med and Child Neur 2001;43(6):37983.
C H A P T E R 20
C ERVICAL A DENOPATHY
Michael J. Cunningham, MD
Neck masses in children may be congenital, inflammatory, or neoplastic. Although pediatric neck masses are rarely malignant, about 5-10% of primary malignancies originate in the head and neck, and one of every four malignant lesions eventually manifest in this region. A noninflammatory firm neck mass in a child should be considered of potential neoplastic etiology until proven otherwise. Worrisome historical factors include (1) family history of childhood cancer, (2) previous primary neoplasm, (3) known predisposition to systemic cancer, (4) previous radiation therapy, and (5) prior exposure to carcinogenic or immunosuppressive drugs. Clinical findings suggesting a need for urgent biopsy include (1) rapid or progressive growth, (2) fixation of the mass to the skin or deep neck structures, (3) supraclavicular mass or adenopathy, and (4) firm neck mass in a child with weight loss or prolonged fever for whom a specific diagnosis is uncertain. Additional criteria for concern include (1) firm masses of any size in neonates, (2) firm masses greater than or equal to 1 cm in children aged 6-12 months, and (3) firm masses greater than or equal to 3 cm in diameter in children over 1 year of age. In the absence of the above findings, observation with serial measurements over several weeks is a reasonable method of discriminating less worrisome underlying pathology such as benign reactive lymphadenopathy from potential neoplastic disease processes. Subsequent elective biopsy for diagnostic confirmation is recommended if the mass in question progressively increases in size or fails to decrease in size by 4-6 weeks follow-up. The child suspected of having a cervicofacial neoplasm based on the above historical and clinical features requires a complete otolaryngologic and systemic examination. Additional laboratory and imaging studies are performed as indicated. Computed tomography (CT) and magnetic resonance imaging (MRI) are the radiologic studies of choice; in specific clinical circumstances, radioisotope scans and angiographic procedures may supply additional information.
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Although, with few exceptions, the physical examination and laboratory evaluation may suggest a diagnosis, biopsy is required for diagnostic confirmation. Biopsy can be performed in either percutaneous or open fashion. The choice between these two techniques is dictated by several factors described below. PERCUTANEOUS NEEDLE BIOPSY Percutaneous needle biopsy may be used to evaluate cystic and solid childhood cervicofacial masses. A close working relationship between the surgeon and pathologist is essential for success. The principal role of percutaneous needle biopsy as a diagnostic tool is to determine whether the mass in question is benign or malignant. An aspiration biopsy analyzed by an experienced cytopathologist can also be highly accurate in predicting the specific type of tumor. Sampling errors do occur, and a negative finding on a percutaneous needle biopsy should never be considered definitive when there is clinical suspicion of malignancy. A subsequent open surgical biopsy is necessary. Indications A preliminary histopathologic diagnosis is desired to better select, modify, or eliminate definitive operative intervention. Clinically unresectable cervicofacial mass Anesthetic Considerations Needle biopsy of superficial lesions in older children and adolescents can be performed under local anesthesia using topical lidocaine 2.5% and prilocaine 2.5% (EMLA) cream and/or injected 1 or 2% lidocaine with 1:100,000 epinephrine solution. General anesthesia is often necessary for infants and young children. Concomitant endoscopic evaluation of the aerodigestive tract or biopsy of deep cervical lesions may require general anesthesia regardless of age. Preparation Percutaneous needle biopsy can be performed by large bore cuttingneedle technique or by fine-needle aspiration (FNA) technique. 1. Large-bore cutting needles provide core tissue fragments from which fixed sections for histopathologic examination can be obtained. The VIM-Silverman (12-gauge) needle (Figure 201A) or the disposable TRU-Cut (14-gauge) needle (Figure 201B) may be used. 2. The FNA technique uses much smaller 22- to 25-gauge needles from 1 12 to 3 12 inches in length, depending on the lesion depth (Figure 201C). An 18- to 20-gauge needle may be needed to aspirate cystic lesions containing thick mucoid material.
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Figure 201 A, Vim-Silverman (12-gauge) needle. B, TRU-Cut biopsy needle. C, 22-gauge 3 12 needle.
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Procedure The child is positioned and draped with the proposed biopsy site readily available to the surgeon, and the surrounding anatomic landmarks easily visualized (Figure 202). If only local anesthesia is planned, the topical anesthetic cream is placed over the skin in the region of the planned biopsy tract approximately 30 minutes beforehand; in large bore cutting-needle biopsy, infiltration of anesthetic solution into the skin and immediate subcutaneous tissues is also recommended. These steps are unnecessary with general anesthesia. The biopsy site is identified:
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For superficial lesions, the mass is stabilized with the thumb and the index finger of the opposite hand (Figure 203). For deep cervical lesions, either specific measurements for needle localization and depth placement should have been preoperatively calculated from radiologic studies, or the biopsy should be performed under radiologic guidance.
No 1. Large bore cuttingneedle biopsy A 1-2 mm skin incision is made with a No 11 scalpel blade prior to needle insertion (Figure 204). The biopsy technique varies with the type of large-bore needle used; the TRU-Cut needle, for example, comes with its own specific instructions.
Figure 202 The patient is positioned so that the biopsy site is easily accessible to the surgeon.
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Figure 203 Superficial lesions can be stabilized with the thumb and index finger.
Figure 204 A large-bore needle biopsy requires that a 1- to 2-mm skin incision be made prior to needle insertion.
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In general, the needle is advanced into the mass using a smooth rapid motion. At least two passes are recommended; the second biopsy attempt should be made through the same incision but at a different angle. The specimens obtained are expelled onto filter paper and placed into saline, formalin fixative, or another special medium, depending on the suspected pathology. Pressure is applied to the biopsy site; a small compression dressing may be necessary. No 2. Fine-needle aspiration No skin incision is necessary. The needle chosen is attached to a 20 mL syringe holder. A constant vacuum is applied while the needle is passed at least twice, at different angles, into the mass (Figure 205). The vacuum is then released slowly to avoid aspirating material into the syringe. The needle is withdrawn. The syringe is separated from the needle, filled with air, and reattached. The material within the needle is then expelled onto glass slides, spread over a small area, and quickly air-dried. Ideally, such slides are passed immediately to the pathologist. In the absence of readily available pathology consultation, slides are immediately fixed by placement in 95% alcohol solution. Lymph node aspirates should additionally be placed into saline or special cell culture media for flow cytometry and lymphocyte marker analysis. Pressure is immediately applied to the biopsy site, followed by a plastic adhesive bandage. Complications The potential dissemination of malignancy from mechanical trauma is a major concern in large bore cuttingneedle biopsy. This implantation problem has theoretically been eliminated by the FNA technique. Bleeding with hematoma formation is a potential complication, particularly for vascular masses or in patients with coagulopathies. This risk is reduced with FNA. There are additional site-specific risks, such as pneumothorax when biopsying supraclavicular masses.
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Figure 205 Fine-needle aspiration technique is shown.
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CERVICAL LYMPH NODE BIOPSY In adults, open surgical excisional or incisional biopsy is typically contraindicated due to the high likelihood of a cervical mass representing metastatic carcinoma. Open biopsy is much more frequently performed in children and adolescents due to the relatively high incidence of reactive lymphadenopathy and benign neoplasms. Excisional biopsy is favored; incisional biopsy is reserved for clinically unresectable lesions. Indications The childs age or level of cooperation dictates general anesthesia for biopsy performance. More sufficient quantities of pathologic tissue than those obtainable by percutaneous biopsy are required for definitive histopathologic diagnosis (for example, suspected lymphoma). There is a clinical suspicion of malignancy despite a negative percutaneous biopsy. Excision is likely the definitive treatment of the cervical mass in question. Anesthetic Considerations and Preparation The procedure is performed under general anesthesia. The need for intraoperative frozen section histopathologic assessment is determined before surgery. Frozen section ensures that adequate tissue has been obtained for permanent section diagnosis, but is not recommended to make a definitive intraoperative diagnosis. Preoperative pathology consultation is also important in suspected lymphoma cases so that fresh tissue preparations can be made for cell culture and lymphoma marker studies. Specific clinical situations may dictate preoperative oncology consultation to coordinate additional studies (lumbar puncture, bone marrow biopsy) while the child is anesthetized. Procedure The child is positioned and draped with the mass and surrounding anatomic landmarks easily visualized. The planned incision is outlined in a cervical skin crease near the mass (Figure 206). Subcutaneous infiltration of 1% lidocaine with 1:100,000 epinephrine solution provides hemostasis. The skin, subcutaneous tissues, and platysma muscle are transected down to the level of the superficial layer of the deep cervical fascia (Figure 207). Detailed knowledge of the regional anatomy is necessary to avoid neurovascular injury.
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Figure 206 The incision is outlined in a cervical skin crease.
Figure 207 The mass beneath the superficial layer of the deep cervical fascia.
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The mass is carefully delineated before removal (Figure 208). If feasible, the entire mass or the largest of multiple masses should be removed to maximize the chances of successful histopathologic diagnosis. Frozen section examination is requested when appropriate. Tissue specimens are obtained for microbiology and special stains if clinically indicated. After irrigation and hemostasis, a rubber band or small Penrose drain may be placed if extensive or deep dissection was required. Closure is performed in two layers using interrupted absorbable sutures for platysma muscle and subcutaneous tissue approximation, and either interrupted or a single subcuticular nylon suture in the skin (Figure 209). A pressure dressing is applied to complete the procedure. Complications Hemorrhage with secondary hematoma or seroma formation reflects inadequate hemostasis or drainage. Additional postoperative sequelae relate to the specific biopsy site. Particular care is necessary near the tail of the parotid or submandibular triangle, and in the posterior triangle of the neck, to avoid potential injury to the facial nerve and spinal accessory nerve, respectively.
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Figure 208 Removal of the cervical nodal mass.
Figure 209 The incision is closed after placement of a small Penrose drain.
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FUNCTIONAL (MODIFIED) NECK DISSECTION The lymph nodes of the neck are anatomically localized into six levels (Figure 2010): Level 1: Submental and submandibular group Level 2: Upper jugular group Level 3: Middle jugular group Level 4: Lower jugular group Level 5: Posterior triangle group Level 6: Anterior compartment group Neck dissections are classified based on which level(s) of lymph nodes are removed and which contiguous structures of the neck are excised. In a radical or classic neck dissection, all nodes in levels 1 through 5 are resected in continuity with the ipsilateral sternocleidomastoid muscle, internal jugular vein, spinal accessory nerve, submandibular gland, and, occasionally, the tail of the parotid gland. This extensive procedure is rarely indicated in children. A complete functional neck dissection also removes all lymph nodes within levels 1 through 5; however nonlymphatic structures, particularly the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve, are preserved. For comparison, cross section anatomical dissections are shown at the levels of the hyoid bone and thyroid cartilage for both a radical neck dissection and a complete functional neck dissection, respectively (Figures 2011 and 2012). Limiting the procedure to specific node levels can further modify a functional neck dissection. For example, a supraomohyoid neck dissection selectively removes the lymphatic tissue from levels 1 through 3, a posterolateral
Figure 2010 Cervical lymph node groups by anatomic levels.
2 3 5 4 6
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Mandible Mylohyoid muscle Anterior belly digastric muscle
Facial vein Hyoid bone Submaxillary gland Parotid gland Facial artery Internal carotid artery Internal jugular vein Sternocleidomastoid muscle CN X Posterior digastric muscle Levator scapulae muscle
Mandible Mylohyoid muscle
Anterior digastric muscle
Facial vein Hyoid bone Submaxillary gland Parotid gland Facial artery Internal carotid artery
Figure 2011 Structures removed (stippled area) at the level of the hyoid in a radical neck dissection (A) compared to a functional neck dissection (B).
Internal jugular vein Sternocleidomastoid muscle Vagus nerve Posterior digastric muscle Levator scapulae muscle
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Thyroid cartilage Omohyoid muscle Sternocleidomastoid muscle Internal carotid artery Internal jugular vein Scalenus medius muscle Levator scapulae muscle
Thyroid cartilage Omohyoid muscle Sternocleidomastoid muscle Internal carotid artery Internal jugular vein Scalenus medius muscle Levator scapulae muscle
Figure 2012 Structures removed (stippled area) at the level of the thyroid in a radical neck dissection (A) compared to a functional neck dissection (B). (Reprinted with permission from Surgical Anatomy of the Head and Neck, Philadelphia: Lippincott Williams Wilkins; 2001:61624.)
neck dissection involves levels 2 through 5, and a lateral neck dissection involves levels 2 through 4; these are all ipsilateral procedures. In contrast, an anterior neck dissection involves bilateral removal of level 6 lymph nodes. Indications A functional neck dissection is considered when An adolescent or young adult has cervicofacial squamous cell carcinoma with documented cervical nodal metastases or a high likelihood of cervical metastases due to the location of the primary lesion An adolescent or young adult has undifferentiated nasopharyngeal carcinoma with documented or suspected lymph node metastases A modified anterior neck dissection is considered when A child, adolescent, or young adult has confirmed thyroid gland malignancy with documented or suspected lymph node metastases A modified supraomohyoid or lateral neck dissection is a consideration when A child, adolescent, or young adult has an extensive nodal inflammatory process such as atypical mycobacterial infection unresponsive to medical management A child, adolescent, or young adult has a non-neoplastic lymphoproliferative disorder with symptomatic airway and/or great vessel compromise, or when there is suspicion of an increased risk of neoplastic transformation
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Anesthetic Considerations and Preparation The procedure is performed under general anesthesia. The patient is positioned with an inflatable thyroid bag under the shoulders so the head can be turned and extended with the occiput resting against the upper end of the operating table. Similar draping is used for all neck dissection procedures except modified anterior neck dissection. A head drape is used leaving the lobule of the ear uncovered. Four additional towels are placed: (1) from the chin to the mastoid over the body of the mandible, (2) horizontally across the upper chest from the midline to the shoulder, (3) from the mastoid tip to the shoulder, and (4) in the midline vertically. Procedure A wide variety of neck dissection incisions and flap designs have been described. A modified Conley incision allows excellent access to both the superior and inferior neck (Figure 2013). The S-shape of the vertical component of the modified Conley incision also heals well with minimal contracture and comparatively good cosmesis. The incision is infiltrated with 1% lidocaine with 1:100,000 epinephrine for hemostasis.
Figure 2013 Child draped in surgical position with modified Conley incision outlined.
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Surgical exposure and orientation The skin flaps are elevated deep to the platysma muscle. The rationale for leaving the platysma muscle with the skin is to provide better blood supply to the flaps. The flaps are raised (Figure 2014):
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! ! !
superiorly to the lower border of the mandible, extending to the mastoid tip inferiorly to the upper border of the clavicle anteriorly to the midline posteriorly to the anterior border of the trapezius muscle
If a concurrent tracheotomy is planned, care is taken not to communicate the anterior flap elevation with the tracheotomy site. This avoids contaminating the neck with peristomal secretions, and will enhance the effectiveness of postoperative suction drainage. The surgeon must identify and preserve several major anatomical structures:
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Structures routinely preserved during all neck dissections, including radical procedures, are the carotid artery, brachial plexus, phrenic nerve, vagus nerve, hypoglossal nerve, lingual nerve, and ramus mandibularis branch of the facial nerve (Figure 2015). Structures additionally preserved during all functional neck dissections include the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve (Figure 2016).
Figure 2014 Elevation of cervical flaps with identification of important superficial anatomical structures.
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Figure 2015 Completed radical neck dissection with identification of important deep anatomical structures.
Figure 2016 Completed functional neck dissection with identification of the principal anatomical structures to be preserved.
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Intimate knowledge of the fascial layers of the neck is mandatory in order to perform an adequate functional neck dissection (see also Chapter 21): 1. The superficial fascia incorporates the subcutaneous fat and the platysma muscle. 2. The deep fascia is divided into three layers: (1) the superficial layer envelops the trapezius and sternocleidomastoid muscles, (2) the middle layers surround the strap muscles and the viscera, and (3) the deep layer covers the deep neck musculature (Figure 2017). 3. These fascial layers delineate a large lateral space on each side of the tracheoesophageal visceral column containing the cervical lymph nodes, associated areolar tissues, carotid arteries and their branches, internal jugular veins and their branches, and numerous nerves. 4. The carotid sheath envelops the carotid artery, internal jugular vein, and vagus nerve; it divides the lateral space on each side of the neck into a smaller anterior space and a larger posterior space. The arterial and venous branches of the great vessels, as well as the muscles of the neck, further subdivide the anterolateral and posterolateral spaces into the various smaller compartments or cervical triangles (Figure 2018). 5. Successful functional neck dissection entails careful excision of all lymphatic and areolar tissues while preserving the vessels, nerves, and muscles traversing these compartments. Neurovascular preservation A complete step-by-step description of the various modifications of functional neck dissection is beyond the scope of this subsection. Specific intraoperative points will be highlighted to emphasize preservation of important neurovascular structures. The standard functional neck dissection requires significant retraction of the sternocleidomastoid muscle to access the anterolateral and posterolateral cervical compartments. At the junction of the superior one-third and inferior two-thirds of the sternocleidomastoid muscle, the spinal accessory nerve can often be identified. It is typically located 1 cm deeper than Erbs point, where the greater auricular nerve turns over the posterior border of the sternocleidomastoid muscle. The upper level 2, middle level 3, and lower level 4 jugular lymph nodes are excised by careful dissection along the internal jugular vein and the carotid sheath; the takeoff of the occipital vessels off the carotid artery marks the upper limit of the dissection. The vagus, spinal accessory, and hypoglossal nerves are at risk and must be identified during the superior portion of this dissection. Dissection of the level 1 lymph nodes within the submental and submandibular triangles requires identifying and preserving the lingual nerve, hypoglossal nerve, and the ramus mandibular branch of the facial nerve as reviewed in detail in Chapter 23.
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Figure 2017 Fascial layers of the neck.
Figure 2018 Triangles of the neck.
Submandibular triangle Submental triangle Occipital triangle Posterior triangle Omoclavicular triangle (Greater supraclavicular fossa) Superior carotid triangle Inferior carotid or muscular triangle Anterior triangle
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During removal of the level 5 lymph nodes within the posterolateral cervical compartment, care must be taken to identify and preserve the brachial plexus and the phrenic nerve. The phrenic nerve should be identified along the anterior scalene muscle; this nerve is partially intraaponeurotic and can be easily torn. Careful dissection is also necessary in the supraclavicular fossa in the region of the junction of the subclavian and internal jugular vein in order to avoid injury to either the left thoracic duct or the right lymphatic duct. A variation of the standard functional neck dissection is to divide and mobilize the sternocleidomastoid muscle (Bocca procedure) instead of retracting it. ! The sternocleidomastoid muscle is divided at the junction of its inferior one-third and superior two-thirds, and is elevated superiorly to enhance clearance of the lymphatic tissues from levels 2 through 5 (Figure 2019). ! Once the neck dissection is complete, the sternocleidomastoid muscle is re-approximated with absorbable mattress sutures. ! No significant loss of muscle function is reported with this technique. Closure Following completion of a functional neck dissection, the integrity of the various neurovascular structures within each cervical compartment operated upon is reassessed, and the neck is irrigated with antibiotic saline solution. A suction catheter is placed via a separate stab incision prior to flap replacement. Continuous suction drainage avoids the need for pressure dressings, and facilitates postoperative monitoring of flap viability. The platysma muscle and superficial fascial layer are closed with 3-0 chromic or Vicryl suture in interrupted fashion. Skin closure is accomplished with interrupted stitches of 4-0 and 5-0 nylon suture or metallic clips. Particular care must be taken in closing the triangle where the flaps intersect in order to avoid strangulating the flaps blood supply (Figure 2020). Postoperative Care and Complications Hemorrhage with secondary hematoma or seroma formation reflects inadequate hemostasis or drainage. Injury to the spinal accessory nerve may result in inability to lift the shoulder, inferior displacement of the shoulder with a winged scapula, and predisposition to chronic shoulder pain. The spinal accessory nerve is most commonly injured during dissection either within the superior neck near the internal jugular vein or where it enters the sternocleidomastoid muscle. Injury of the phrenic nerve during posterolateral neck dissection results in ipsilateral paralysis of the diaphragm. Visual identification and stimulation of the nerve will intraoperatively verify its anatomical integrity. For medicolegal reasons, preoperative documentation of diaphragmatic function is valuable.
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Figure 2019 Division of the sternocleidomastoid muscle in a Bocca functional neck dissection.
Figure 2020 Cervical incision closure and suction drain placement.
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Injury of the vagus nerve low in the neck causes hoarseness; vagal nerve injury high in the neck causes severe hoarseness and aspiration. The vagus nerve is most commonly injured during dissection in the superior neck near the internal jugular vein. Brachial plexus injury may cause altered motion and sensation of the shoulder, scapula, arm, and hand. Injury to the brachial plexus is fortunately rare due to its anatomical location beneath the deep layer of the deep cervical fascia. Injury to the ramus mandibularis branch of the facial nerve results in an asymmetric smile and, if severe, may cause oral incompetence with drooling from the corner of the mouth. Blunt trauma from stretching of the ramus mandibularis during surgical retraction can cause a temporary paralysis or paresis that typically resolves within several months. Conversely, severing the nerve causes permanent facial asymmetry due to absence of lower lip innervation. Occasionally, paresis of the lower lip is due to denervation of the platysma muscle and not marginal mandibular nerve injury; this condition resolves with progressive compensation by adjacent facial musculature. Unilateral hypoglossal nerve injury may cause moderate speech and masticatory difficulties secondary to unilateral tongue paralysis. Visual identification and confirmatory stimulation of this nerve within the floor of the submandibular triangle should be performed intraoperatively. The cervical sympathetic chain can be injured during superior neck dissection. The resulting Horners syndrome is characterized by ipsilateral ptosis, anhydrosis, and pupil constriction. Aggressive dissection in the supraclavicular fossa may result in injury to the left thoracic duct or the right lymphatic duct. Failure to intraoperatively recognize this injury will result in a chylous leak. Increased suction drainage of milky secretions is observed, and, if voluminous, electrolyte and nutritional imbalance can result. A chylous leak will sometimes respond to conservative postoperative measures such as a fat-free diet, continued suction drainage, and the application of pressure dressings; often a formal surgical re-exploration of the neck is required to stop the chylous flow. Pneumothorax is a rare complication of neck dissection. The anesthesiologist may notice an intraoperative change in the respiratory pattern or signs of circulatory failure. Alternatively, immediate postoperative (postextubation) respiratory distress may occur. Chest X-ray confirms the diagnosis. Treatment consists of immediate chest tube insertion. Carotid rupture is a rare event during or following functional neck dissection in a nonirradiated field. Careful attention to appropriate flap design and meticulous surgical technique decrease the risk of carotid injury.
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BIBLIOGRAPHY
Bain G, Bearcroft BW, Berman LH, Grant JW. The use of ultrasound-guided cutting-needle biopsy in paediatric neck masses. Eur Radiol 2000;10:5125. Bocca E. Functional neck dissection. In: English GM, editor. Otolaryngology. Vol V. Philadelphia: JB Lippincott Company; 1994. Chapter 44:113. Cunningham MJ. Neoplastic disorders: benign and malignant. In: Cotton RT, Myer CM III, editors. Practical pediatric otolaryngology. Philadelphia: Lippincott-Raven Publishers; 1999. p. 68191. Janfaza P, Fabian RL. Anatomy of the neck; general considerations. In: Janfaza P, Nadol JB Jr., Galla RJ, editors. Surgical anatomy of the head and neck. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 597627. Knight PJ, Mulney AF, Vassey LE. When is a lymph node biopsy indicated in children with enlarged peripheral nodes? Pediatrics 1982;69:3916. Knight PJ, Reiner CB. Superficial lumps in children: what, when and why? Pediatrics 1983;72: 14753. Montgomery WW. Surgery of the neck. In: Montgomery WW, editor. Surgery of the upper respiratory system. Vol II. 2nd ed. Philadelphia: Lea & Febiger; 1989. p. 83124. Mobley DL, Wakely PE Jr, Frable MAS. Fine needle aspiration biopsy: application to pediatric head and neck masses. Laryngoscope 1991;101:46972. Robbins KT, VanSonnenberg E, Casola G, Varney RR. Image-guided needle biopsy of inaccessible head and neck lesions. Arch Otolaryngol Head Neck Surg 1990;116:95761. Tunkel DE, Baroody FM, Sherman ME. Fine needle aspiration biopsy of cervicofacial masses in children. Arch Otolaryngol Head Neck Surg 1995;121:5536.
C H A P T E R 21
D EEP N ECK I NFECTIONS

Charles F. Koopman Jr, MD
Deep neck infections may be broadly classified as involving the suprahyoid spaces, infrahyoid space, or spaces involving the entire neck. This chapter describes the surgical approaches for incision and drainage of infections involving one or more of the following spaces: Suprahyoid spaces: submandibular space, pharyngomaxillary (lateral pharyngeal) space, masticator space, parotid space, and peritonsillar space Infrahyoid space: visceral space Spaces involving the entire neck: retropharyngeal space, prevertebral space, vascular (carotid) space, and danger space A thorough knowledge of the superficial and deep cervical fascial layers is a prerequisite to any surgical drainage procedure for deep neck infection. Appropriate imaging studies (eg, contrast enhanced computed tomography) are obtained before surgery unless the airway is unstable.
FASCIAL LAYERS OF THE NECK Superficial Cervical Fascia The superficial cervical fascia encloses the voluntary muscles in its deepest portion (the platysma muscle) and surrounds the neck, being continuous with the superficial fascia of the muscles of facial expression superiorly, and the deltoid, back, and pectoral areas inferiorly. Superficial lymph nodes on the external jugular vein also lie within this region. Deep Cervical Fascia Superficial layer. The superficial layer of the deep cervical fascia is connected to the vertebral spinous processes and ligamentum nuchae. It completely encircles the neck and divides to surround the trapezius muscle (Figure 211). Anteriorly, the fascia divides again to enclose the sternocleidomastoid muscle. The fascia forms a single layer anterior to the sternocleidomastoid muscle and meets its counterpart from the opposite side. This layer is attached to the hyoid bone and is important because it divides the neck into the areas above
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(suprahyoid) and below (infrahyoid). The superior part of this fascia encloses the submandibular and parotid glands and forms the stylomandibular ligament, which runs from the styloid process to the hyoid bone. The infrahyoid portion of the superficial layer attaches to the anterior and posterior portions of the sternum and forms the suprasternal space (space of Burns), where the anterior jugular veins and lymph nodes are found. Middle (pretracheal) layer. The superficial muscular layer of the pretracheal layer encloses the strap muscles (omohyoid, thyrohyoid, sternohyoid, and sternothyroid). This layer also passes in front of the trachea, esophagus, and thyroid gland, and as it courses inferiorly along the infrahyoid muscles behind the sternum, it fuses with the fibrous pericardium. The carotid sheath (surrounding the internal jugular vein, common carotid artery, and vagus nerve) is found between the superficial layer, the pretracheal layer, and the prevertebral layer (see Figure 211). The lateral portion of the pretracheal fascia fuses with the outer superficial fascia layer. The visceral layer of the pretracheal fascia surrounds the constrictor muscles and attaches to the base of the skull, where it forms the anterior portion of the retropharyngeal space. This part of the fascia is sometimes called the buccopharyngeal portion. Deep (prevertebral) layer. The prevertebral or deep layer of the deep cervical fascia may be thought of as originating from the cervical spinous processes and ligamentum nuchae. Anteriorly, it encloses the prevertebral muscles, brachial plexus, and subclavian artery. A danger space exists near the posterior part of the trapezius muscle and the upper posterior triangle of the neck where the prevertebral layer splits into two definite layers anterior to the vertebral column (Figure 212). Both the anterior and posterior portions of this space originate at the base of the skull. The anterior layer blends with the fascia of the esophagus in the superior mediastinum and is considered the posterior wall of the retropharyngeal space. The posterior portion extends inferiorly to the coccyx.
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Figure 211 Cross section of the neck illustrating visceral structures and fascial planes. (Adapted from Barrett G, Koopman CF, Coulthard SW. Retropharyngeal abscessa ten year experience. Laryngoscope 1984;94:45563.)
Figure 212 Lateral neck emphasizing retropharyngeal, prevertebral, and danger spaces. (Adapted from Barrett G, Koopman CF, Coulthard SW. Retropharyngeal abscessa ten year experience. Laryngoscope 1984;94:45563.)
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SUBMANDIBULAR SPACE DRAINAGE The submandibular space (Figure 213) is divided into the sublingual (supramylohyoid) space and the submaxillary (inframylohyoid) space. The anterior belly of the digastric muscle forms a central component called the submental space, which is bounded by the mucosa of the floor of the mouth, the mandible, and the superficial layer of the deep cervical fascia. The sublingual and submaxillary spaces are frequently involved in odontogenic infections. Indications Ludwigs angina. The symptoms of infection include inflamed swollen tissues of the floor of the mouth; displacement of the tongue upward and backward toward the soft palate; trismus; marked induration initially confined to the submandibular compartment but then spreading; and, if the angina is untreated, dyspnea. Poor response to antimicrobial therapy. Surgical intervention is needed to avoid respiratory tract infection, aspiration pneumonia, progressive dehydration, or spread of infection from the lateral pharyngeal space to the carotid sheath, and then to the superior mediastinum. Anesthetic Considerations and Preparation General anesthesia is needed to control the airway and avoid aspiration. Nasotracheal or oral endotracheal anesthesia is preferred, but may be difficult because of trismus and superior and posterior displacement of the tissues of the floor of the mouth. Tracheostomy is performed under local anesthesia or insufflation general anesthesia, when necessary, if nasotracheal or oral endotracheal intubation is not possible. The skin is prepared with an antiseptic scrub of the surgeons choice if an external approach is needed. The throat is packed with gauze.
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Figure 213 Submandibular and masticator space fascial planes. (Adapted from Hollinshead WH. Anatomy for surgeons. Vol 1. 2nd ed. New York: Hoeber; 1968.)
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Procedure An abscess in the sublingual space may respond adequately to intraoral drainage. For bilateral submandibular space infections, especially Ludwigs angina, a submental incision is necessary (Figure 214A): A horizontal incision is placed approximately 1 cm above the hyoid bone (this may vary depending on the region of maximal induration) and extends laterally sufficiently below the angle of the mandible to avoid injuring the marginal mandibular nerve. ! The horizontal incision (preferably in a skin crease) is carried through the skin, subcutaneous tissue, and the platysma muscle to the deep cervical fascia, which is then incised. ! The neck is explored bilaterally using the area between the anterior bellies of the digastric and mylohyoid muscles. Blunt and sharp dissection is used, as necessary, to identify, enter, and drain the abscess cavity (Figure 214B). ! The wound is irrigated copiously with saline or an antibiotic and saline solution (bacitracin). ! Drains are placed (Penrose or suction drains, such as Jackson-Pratt) (Figure 214C). The suction drains may also be used for wound irrigation if necessary. Postoperative Care Intravenous antibiotics are used for 4-5 days, followed by oral antibiotics for 2-3 weeks.
!
The drains are advanced slowly over several days.
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Figure 214 Incision and drainage of a submental space abscess or Ludwigs angina infection. A, Limited midline skin incision. B, Dissection between the geniohyoid muscles after the mylohyoid muscle has been incised. C, Muscle closure and placement of a Penrose drain. (Adapted from Lor J. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988.)
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PHARYNGOMAXILLARY (LATERAL PHARYNGEAL) SPACE DRAINAGE This space is bounded by the petrous portion of the temporal bone superiorly; the superior constrictor muscle medially; the pterygoid muscles, mandible, and parotid gland laterally; the pterygomandibular raphe anteriorly; the buccopharyngeal and prevertebral fascia posteriorly; and the hyoid bone inferiorly. Infection may originate from the teeth, tonsils, peritonsillar space, penetrating wounds to the lateral pharyngeal wall, or dental injections or other oral local anesthetics. Signs and symptoms include toxicity (fever and chills), trismus, swelling of the lateral pharyngeal wall in the region posterior to the tonsils with occasional displacement of the tonsil medially or anteriorly, edema, and in some patients, generalized sepsis. Indications Pharyngomaxillary abscess Unsatisfactory response to antibiotic therapy Impending respiratory obstruction Extension of the abscess along the carotid sheath with impending rupture of the internal carotid artery Anesthetic Considerations and Preparation General anesthesia is used, preferably nasotracheal anesthesia in which a tube is placed in the contralateral naris. Oral endotracheal anesthesia is acceptable if the trismus is not too great; however, because of the swelling and trismus, a tracheostomy under local anesthesia or under general insufflation may be necessary. The skin is prepared with an antiseptic scrub of the surgeons choice. The surgeon should have a nerve stimulator available. Procedure A horizontal incision or apron incision is made in the neck in the region of the infection, taking care to avoid the marginal mandibular nerve (Figure 215A). The dissection is carried through the skin and platysma to identify the anterior border of the sternocleidomastoid muscle and the posterior and inferior aspects of the submandibular gland (Figure 215B). The anterior border of the sternocleidomastoid muscle is retracted posteriorly and the carotid sheath structures are identified opposite the tip of the hyoid bone greater cornu.
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Figure 215 Drainage of the pharyngomaxillary (lateral pharyngeal) space (A) Illustration depicting planned external incision (B) Dissection illustrating important, relavant structures (C) Illustration depicting approach used to retract structures prior to drainage of abcess. (Adapted from Lor J. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988.)
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The pharyngomaxillary space includes two compartments, separated by the styloid process, which must both be adequately drained (Figure 216): 1. The posterior compartment contains the carotid sheath cranial nerves IX to XII. 2. The anterior compartment contains fat, connective tissue, muscle, and lymph nodes. The abscess is drained by blunt finger dissection along the anterior carotid sheath, retracting the sheath laterally and posteriorly. An elevator beneath the angle of the mandible facilitates exposure (Figure 215C). Dissection extends superiorly to the cranial base. The area of purulence is drained, cultures are taken for aerobic and anaerobic bacteria, and the wound is copiously irrigated with sterile saline with or without antibiotic solution. A Penrose or a wall-suction drain (Jackson-Pratt) is placed. The JacksonPratt system may be used if multiple drains are placed for concurrent irrigation and suction. Postoperative Care Intravenous antibiotics are given for 5-7 days, followed by oral antibiotics for 2-3 weeks. The drains are advanced slowly over 5-7 days.
Figure 216 Axial section of the nasopharynx showing major fascial layers and anatomic structures. The styloid process divides the lateral pharyngeal space into prestyloid and poststyloid portions, which are separated from the retropharyngeal space by a thin anteroposterior layer of fascia (cloison sagitalle). (Adapted from Yellon RF, Bluestone CD. Head and neck space infections in children. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology. Vol 2. 3rd ed. Philadelphia: WB Saunders; 1996. p. 1532.)

MASTICATOR SPACE DRAINAGE
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The deep cervical fascia forms the masticator space as it covers the masseter muscle laterally and the pterygoid muscles medially (see Figure 213). Contents include the masseter muscle, pterygoid muscles, and mandibular ramus. Masticator space infection is most often odontogenic, but may be caused by injections of oral anesthesia, especially attempts to block the inferior alveolar nerve. Infections from the zygoma, temporal bone, or mandible may spread to this region. The signs and symptoms of masticator space infection include general toxicity of acute onset, severe trismus, dysphagia, induration over the angle and ramus of the mandible externally, and oral swelling near the angle and ramus of the mandible, which may push the tonsil medially. Indications Masticator space abscess Unsatisfactory response to antibiotic therapy Impending airway obstruction or asphyxia Anesthetic Considerations General anesthesia is necessary. Nasotracheal or oral endotracheal anesthesia is preferred, although the trismus may preclude use of an oral tube. When necessary, the airway is secured by tracheotomy. Preparation If an external incision is necessary, the neck and facial skin are prepared with an antiseptic scrub of the surgeons choice. If intraoral drainage is planned, the hypopharynx is packed with a gauze pack. Procedure External drainage is used if there is marked lateral swelling and the infection is in the lateral portion of the masticator space: 1. An incision is made 2-3 cm below and parallel to the angle of the mandible. 2. Dissection is carried out in a plane beneath the mandibular ramus branch of the facial nerve. The mandibular periosteum is incised to enter the space. 3. The platysma muscle and the fascia overlying the submandibular gland are transected. The facial vein, and if necessary, the facial artery, are ligated and elevated along with the fascia of the submandibular gland to protect the marginal mandibular nerve. 4. The masticator space is entered and drained with a curved hemostat. 5. The wound is irrigated copiously with saline or a saline and antibiotic solution, and a Penrose drain or suction drain is inserted and advanced slowly.
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Internal drainage may be performed if there is minimal or moderate external swelling to protect the marginal mandibular nerve and avoid an external incision. 1. The incision is made via an intraoral approach medial to the ascending ramus of the mandible at the level of the retromolar trigone. Injury to the ductal system of the parotid gland is avoided. 2. Blunt dissection with a curved hemostat is carried to the region of the abscess, and the abscess is drained intraorally. 3. A drain may be sutured in the intraoral wound (Penrose type). If the infection extends to the most superior aspect of the masticator space, it may be necessary to make an incision in the hairline to approach the temporalis fascia. 1. The temporalis fascia is incised parallel to the course of the facial nerve and the dissection is carried to the abscess cavity (which is lateral to the temporalis muscle). 2. If the abscess is medial to the muscle, then the dissection is carried through the muscle into the abscess cavity. 3. The wound is then irrigated with antibiotic solution and a drain (Penrose) is placed and advanced slowly over several days. Alternatively, Betadine-impregnated packing may be placed and advanced over several days. Postoperative Care Intravenous antibiotics are given for 5-7 days, followed by oral antibiotics for 2-3 weeks. The drains are advanced over 4-7 days and, if the infection is extremely severe, the wound is packed with iodoform gauze soaked in Betadine solution. Additional Betadine solution is placed on the gauze as it is advanced over 3-4 days.

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The superficial layer of the deep cervical fascia forms the parotid space (Figure 217) as it covers the parotid gland, facial nerve, and parotid lymph nodes. The medial portion of the fascia is not complete and communicates with the pharyngomaxillary space. This allows for spread of parotid space abscesses into the pharyngomaxillary space and then to the prevertebral space. Parotid space infections are most commonly caused by stasis of the parotid gland, dehydration after surgery or severe chronic or acute illness, salivary gland calculi, oral infections, or severe otitis externa. The causative bacterium is most commonly coagulase-positive Staphylococcus aureus. Signs and symptoms include generalized toxicity, dehydration (especially in postoperative or cachetic patients), painful swelling over the parotid gland, and, in the latter stages, pitting edema and erythema of the overlying skin. Indications Parotid space abscess Unsatisfactory response to antibiotic therapy Anesthetic Considerations and Preparation The procedure is usually performed under general oral endotracheal anesthesia. The skin is prepared with an antiseptic scrub of the surgeons choice.
Figure 217 Parotid space. (Adapted from Hollinshead WH. Anatomy for surgeons. Vol 1. 2nd ed. New York: Hoeber; 1968.)
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Procedure An incision is made in the standard fashion used for a parotidectomy, with curved pre-auricular and infra-auricular portions (Figure 218A). Skin and subcutaneous tissue are elevated over the parotid fascia. If there is an isolated abscess cavity (very rarely the case), the surgeon should 1. Detach the parotid fascia from the anterior surface of the tragal cartilage and sternocleidomastoid muscle. 2. Incise the abscess and drain with a curved hemostat opened in a direction parallel to the course of the facial nerve. 3. Drain the wound with a Jackson-Pratt suction drain. If there are multiple abscess cavities (most often the case), the surgeon should 1. Leave the parotid fascia attached to the anterior tragal cartilage unless the surgeon feels that identification of the facial nerve main trunk is required. 2. Puncture the parotid fascia in multiple areas with a curved pointed mosquito hemostat, and spread the hemostat parallel to the course of the facial nerve and its branches (see Figure 218B). Multiple openings are made in this fashion to drain the infected fluid and eliminate any loculations. 3. Drain the wound with a Penrose drain. If the patient has a bleeding diathesis, liposuction can avoid a long skin incision and flap elevation: 1. Make a small incision in the usual parotidectomy area (see Figure 218A) to accommodate a small liposuction cannula. 2. Insert the liposuction cannula and drain the multilocular areas. Always drain parallel to facial nerve branches to avoid injury. 3. Place a compression dressing over the drainage sites. Postoperative Care Intravenous antibiotics are given for 4-5 days, followed by oral antibiotics for 1-2 weeks. The drains are advanced over 4-5 days.
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Figure 218 Incision and drainage for parotid space abscess. A, Parotidectomy-type skin incision. B, The hemostat is spread parallel to the facial nerve (ghost outline) to open the parotid capsule. (Adapted from Lor J. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988.)
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PERITONSILLAR SPACE DRAINAGE The peritonsillar space is bounded by the capsule of the tonsil medially, the superior constrictor muscle laterally, and the tonsillar pillars anteriorly and posteriorly. Abscesses in the midportion may go through the superior constrictor into the lateral pharyngeal space. The signs and symptoms of infection include dysphagia; trismus; swelling of the tonsillar pillars, the soft palate, and often the uvula, with displacement of the uvula to the contralateral side; displacement of the tonsil (also to the contralateral side); and a hot potato voice. Indications Peritonsillar abscess Unsatisfactory response to antibiotic therapy Airway compromise Anesthetic Considerations and Preparation In younger children, a general anesthetic is necessary. In older children and teenagers, topical and local anesthesia is usually adequate for needle aspiration. However, one must incise the area and place a hemostat for drainage. If an acute tonsillectomy is to be performed, general anesthesia is usually necessary. If the patient requires a general anesthetic, the throat should be packed with a gauze pack. Procedure The initial method of diagnosing and treating a peritonsillar abscess is with aspiration (Figure 219). A syringe with a 16- or 18-gauge needle is inserted at the junction of the soft palate and superior tonsillar pillar (the area most likely to have purulence and also the area that is least dangerous for aspiration). If there is pointing in another area, or if the initial aspiration in this area fails, then drainage is attempted inferiorly and more medially. Incision of the tonsillar pillar (if performed) is done over the most fluctuant area or at the site of a purulent needle aspirate. When general anesthesia is necessary, a tonsillectomy is done with electrosurgical dissection to reduce bleeding. The contralateral tonsil is also removed if bleeding from the abscessed tonsil is not copious. Postoperative Care If only aspiration has been used, the patient may be given intravenous antibiotics until oral intake is satisfactory to ensure compliance with oral antibiotics. If a tonsillectomy or incision and drainage were performed, intravenous antibiotics are given until oral intake is satisfactory for discharge from the hospital.
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Figure 219 Aspiration, incision, and drainage of a peritonsillar abscess. (Adapted from Myer CM, Cotton RT. A practical approach to pediatric otolaryngology. Chicago: Year Book Medical Publishers; 1988.)
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VISCERAL SPACE DRAINAGE The anatomic boundaries of this space are the visceral fascia (the superior border of which is the thyroid gland) and the inferior border, which is the mediastinum at the region of the aortic arch. Posteriorly, there is a communication with the posterior visceral space. Visceral space infection may be caused by purulent thyroiditis, progression of pharyngitis, foreign body in the cervical esophagus, or esophageal perforation from a foreign body. Signs and symptoms include odynophagia, erythema and edema in the hypopharynx, dyspnea, and anterior neck swelling in the region of the thyroid glands and midline cervical lymph nodes. Indications Visceral space abscess Unsatisfactory response to antibiotic therapy Anesthetic Considerations and Preparation General anesthesia is usually used via the oral endotracheal route. The skin is prepared with an antiseptic scrub of the surgeons choice. Procedure Surgical drainage uses an anterior horizontal skin incision similar to that of a tracheostomy. The skin and subcutaneous tissues are incised, and the dissection is carried through the midline fascia between the strap muscles. If the infection is lateral to the midline, dissection is carried to the involved side, and the abscess cavity is entered. Cultures are taken and the cavity is drained. The wound is irrigated with saline or a saline and antibiotic solution. A Penrose or wall-suction drain is placed. Postoperative Care Intravenous antibiotics are given for 4-5 days, followed by oral antibiotics for 2-3 weeks. The drains are slowly advanced daily to allow the wound to close medially to laterally. RETROPHARYNGEAL SPACE DRAINAGE The retropharyngeal space (see Figures 211 and 212) is bounded posteriorly by the alar fascia, anteriorly by the posterior pharyngeal wall, and superiorly by the base of the skull. The space extends inferiorly to the superior mediastinum at the level of T1, where the middle and deep cervical fascia layers fuse. Retropharyngeal space infection may be caused by regional purulent disease (nasopharynx, middle ear, nose and paranasal sinuses, or oral cavity) or by trauma (penetrating foreign body wounds or iatrogenic endoscopy). Signs and symptoms include dysphagia, odynophagia, toxicity (fever, chills,
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malaise), nuchal rigidity, occasionally a hoarse or soft voice, and potentially progressive airway obstruction. Lateral neck X-rays may be positive, with a widening at the C2 level of more than 7 mm in both children and adults. At the C6 level, a widening of 14 mm occurs in children younger than 14 years of age, and a widening of 22 mm occurs in adults. Indications Retropharyngeal space abscess Neurologic findings are compatible with progressive spinal cord compression Progressive airway obstruction Unsatisfactory response to antibiotic therapy Some practitioners treat cellulitis and abscesses (as diagnosed by contrast-enhanced CT scans) with parenteral antibiotics, reserving surgical drainage for patients with airway compromise or clinical deterioration. The author agrees with medical management of cellulitis, where the presence of an abscess is in doubt, or where there is a small lateral abscess in a nontoxic patient. However, surgical drainage is strongly recommended for toxicity, abscess, airway obstruction, or failure to improve within 24 to 36 hours of antibiotic therapy. The complications associated with neurological sequelae, regional extension along fascial planes, or spread to the mediastinum are much more serious than a well-planned drainage procedure. Anesthetic Considerations This procedure must be performed under general anesthesia with protection of the airway by an endotracheal tube (cuffed in older children or teenagers, and hypopharyngeal packing in uncuffed tubes). If possible, an oral endotracheal tube is preferred; however, on rare occasions, a tracheostomy may be necessary. If an oral tube is used, it may be necessary to change to a nasotracheal tube after drainage if edema requires intubation in the postoperative period. An experienced anesthesiologist should perform the intubation. Preparation Contrast CT scans will detect extension into adjacent structures, fascial planes, and the mediastinum, and will rule out concomitant complications such as epidural abscesses (which are not unusual in severe cases of retropharyngeal space abscesses), osteomyelitis of the vertebrae, and atlanto-axial subluxation. If an intraoral drainage is planned, the throat is packed with a gauze pack. If an external incision is planned, the skin is prepared with an antiseptic scrub of the surgeons choice. The patient is placed in Roses position to prevent aspiration of the abscess contents.
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Procedure If there is a question concerning the presence of purulence, aspiration with an 18-gauge needle into the upper retropharyngeal space is indicated (Figure 2110A). Intraoral aspiration and drainage are recommended if the abscess is limited to the upper retropharyngeal space: 1. The incision is carried through the posterior pharyngeal wall mucosa vertically through the edematous mucosa. The author prefers to make this incision with the coagulation cautery to reduce blood loss (Figure 2110B). 2. Dissection is then carried bluntly into the cavity. The cavity is cultured and drained completely, and an incision is made overlying the space. 3. Intravenous antibiotics are administered. External drainage is used when the abscess extends inferiorly to the hyoid bone: 1. The incision is made in a modified apron-like fashion (Figure 2110C) with a horizontal limb at the midportion of the abscess cavity (judged on a lateral X-ray and CT scan), and the vertical portion is carried along the anterior border of the sternocleidomastoid muscle superiorly. 2. The dissection is carried down to the sternocleidomastoid muscle, which is retracted laterally. The carotid sheath is identified, and most commonly its contents are reflected laterally, with the dissection into the abscess cavity continued anterior to the sheath. Occasionally, when there is a large amount of induration and adhesions, it is technically more feasible to use a retrocarotid sheath dissection with the sheath being retracted anteriorly and the cavity drained posterior to the sheath. However, if the approach is anterior to the carotid sheath, the sheath contents are retracted laterally, and the larynx, trachea, and thyroid gland are retracted medially. 3. The dissection is then carried down to the prevertebral muscles behind the inferior constrictors. The cavity is opened with blunt dissection superiorly to inferiorly, and the contralateral extent is identified. 4. The abscess cavity is irrigated with a saline and bacitracin solution, and wall-suction (Jackson-Pratt) drains are inserted, both superiorly and inferiorly. The author also likes to use a third, and possibly a fourth, drain for irrigation, and all drains are marked according to their desired function (eg, superior suction, inferior suction, superior irrigation, inferior irrigation). Antibiotic ointment (Betadine ointment) is applied to gauze packing (in the most severe cases) to pack the wound in addition to irrigation. 5. The wound is dressed with a Montgomery dressing so that the gauze, which is used to soak up excess irrigation, can be changed easily.
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C Figure 2110 Intraoral aspiration (A) and incision (B) of a retropharyngeal abscess. C, Incision (dashed line) for external approach to the retropharyngeal space. (Adapted from Lor J. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988.)
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Postoperative Care Betadine solution is added to the packing twice daily until all packing has been removed. The packing is advanced over 3-5 days. The irrigation drains are removed after 24-48 hours. The suction drains are advanced slowly beginning on the third to fourth postoperative day. Intravenous antibiotics are given for 7-10 days, followed by oral antibiotics for 2-3 weeks. The antibiotic coverage should empirically cover gram-negative, beta-lactamase producing, gram-positive, and anaerobic organisms. PREVERTEBRAL SPACE DRAINAGE The prevertebral space (see Figure 212) is found between the prevertebral layer of the deep cervical fascia and the osseous bodies of the cervical vertebrae extending from the base of skull to the coccyx. Infections are most commonly caused by distal disease, such as tuberculosis or cutaneous infections. The symptoms of prevertebral space infection may be very subtle and include only localized or vague pain, torticollis of varying degrees, and malaise. If the cervical vertebrae are significantly infected, there may be neurologic symptoms. Imaging studies confirm the diagnosis (CT scans, magnetic resonance imaging, or lateral radiographs of the neck and cervical spine). Indications Abscess or infection of the prevertebral space Anesthetic Considerations and Preparation General endotracheal anesthesia (oral or nasal) is required. If the edema is severe, the endotracheal tube should be maintained until the swelling has receded to allow a stable airway. Occasionally a tracheostomy is needed. The skin is prepared with an antiseptic scrub of the surgeons choice. Procedure The treatment is directed at cervical drainage via a lateral approach in a fashion similar to that for the external method of treating retropharyngeal space abscesses (preceding section). Concomitant medical management with appropriate antibiotics (eg, antituberculosis drugs if tuberculosis is involved, or anti-staphylococcal drugs if Staphylococcus aureus is present). The wound should be drained with a Penrose or Jackson-Pratt drain and packed in a fashion similar to that used for the retropharyngeal space abscess. Postoperative Care The postsurgical care is similar to that of the retropharyngeal space abscess.

VASCULAR (CAROTID) SPACE DRAINAGE
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The vascular space is a potential space within the carotid sheath (Figure 2111) extending from the base of the skull to the superior mediastinum. All three layers of the deep cervical fascia contribute to the boundaries. Consequently, infections in any of the other spaces (but especially the lateral pharyngeal space) may extend into the carotid sheath. Carotid space infection may be caused by necrosis of a deep cervical lymph node or spread from other neck spatial planes, especially the lateral pharyngeal space. The signs and symptoms include fever, limited neck motion, profound swelling of the anterior or lateral neck, possibly with pitting edema. A purplish discoloration may indicate hemorrhage. Spiking fevers and severe chills may indicate thrombosis of the internal jugular vein with septic emboli. Horners syndrome is occasionally seen.
Figure 2111 Vascular (carotid sheath) space. (Adapted from Everts EC, Echevarria J. The pharynx and deep neck infections. In: Paparella MM, Shumrick DA, editors. Otolaryngology. Vol. 3. 2nd ed. Philadelphia: WB Saunders; 1980. 2313.)
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Indications Abscess of the vascular (carotid) space Risk of spontaneous carotid artery hemorrhage Internal jugular vein thrombosis with septic emboli and potential spread to the brain by way of the lateral sinus Cranial nerve deficits or Horners syndrome Unsatisfactory response to antibiotic therapy Anesthetic Considerations General oral endotracheal anesthesia is required. If the edema is severe, the tube must be left in place postoperatively to protect the airway. Occasionally, a tracheostomy is needed. The skin is prepared with a surgical scrub of the surgeons choice. Procedure An external approach is mandatory. The incision is placed along the anterior border of the sternocleidomastoid muscle in a fashion similar to the vertical limb of the apron incision (see Figure 2110C). Dissection is carried down to the carotid sheath, and the abscess cavity is drained. If the internal jugular vein shows evidence of thrombosis, ligation is required to avoid spread to the lateral sinus and prevent distal abscesses or meningitis. The wound is drained with a Jackson-Pratt or Penrose drain. Good muscle coverage of the carotid sheath is essential to limit the risk of vascular erosion and hemorrhage. This wound is usually not packed with gauze. Postoperative Care The drains are advanced slowly over 5-10 days. Postoperative systemic antibiotic therapy is similar to that of the retropharyngeal space abscess. DANGER SPACE DRAINAGE The danger space (see Figure 212) lies between the alar layer of the deep cervical fascia (anteriorly) and the prevertebral layer of deep cervical fascia (posteriorly). Infections usually originate in the nose, paranasal sinus, nasopharynx, oropharynx, and hypopharynx. Signs and symptoms include odynophagia, dysphagia, spiking fevers, nuchal rigidity, a muffled voice, and swelling in the posterior pharyngeal wall. Indications Danger space abscess Unsatisfactory response to antibiotic therapy Risk airway obstruction, spread to the mediastinum or diaphragm, or involvement of the vertebrae or neural structures including an epidural abscess
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Anesthetic Considerations and Preparation The procedure is performed under general oral endotracheal anesthesia, if possible. If airway obstruction is impending, a tracheostomy must be performed. The skin is prepared with an antiseptic scrub of the surgeons choice. Procedure A transoral approach is used for swelling in the upper neck. Aspiration is performed prior to making an incision in the posterior pharyngeal wall with electrosurgery. Dissection is carried through the prevertebral fascia to drain the space from the base of the skull to the most inferior aspect. The extent of the involvement is determined by CT scans (enhanced) and possibly by MRI. An external approach is used for abscesses lower in the neck that are inaccessible orally or for infections that extend to the lower cervical vertebrae. The approach is as described above for the retropharyngeal space. The wound is cared for in a similar fashion to the retropharyngeal space abscess with drains, irrigation, packing, and Montgomery strap dressings. Postoperative Care Postoperative systemic antibiotic therapy is similar to that of the retropharyngeal space abscess. BIBLIOGRAPHY
Ballenger JJ. Diseases of the nose, throat, and ear. 12th ed. Philadelphia: Lea & Febiger; 1977. Barrett G, Koopmann CF, Coulthard SW. Retropharyngeal abscessa ten year experience. Laryngoscope 1984;94:45563. Cunnington P, Mongia S. Pharyngeal abscess in a small infant presenting as upper airway obstruction and atlanto-axial subluxation. Anesthesia 2000;55:9278. Everts EC, Echevarria J. The pharynx and deep neck infections. In: Paparella MM, Shumrick DA, editors. Otolaryngology. Vol 3. 2nd ed. Philadelphia: WB Saunders; 1980. p. 2302-22. Gauthier M. Deep neck infections of the head and neck. In: Katz A, editor. Manual of otolaryngologyhead and neck therapeutics. Philadelphia: Lea & Febiger; 1986. p. 359-73. Hollinshead WH. Anatomy for surgeons. Vol 1. 2nd ed. New York: Hoeber; 1968. Lore J. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988. Myer CM, Cotton RT. A practical approach to pediatric otolaryngology. Chicago: Year Book Medical Publishers; 1988. Richardson MA, Sie KCY. The neck: embryology and anatomy. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology. Vol 2. 3rd ed. Philadelphia: WB Saunders; 1996. p. 146479. Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995;112:37582. Wetmore RF, Mahboubi S, Soyupak SK. Computed tomography in the evaluation of pediatric neck infections. Otolaryngol Head Neck Surg 1998;119:6247. Yellon RF, Bluestone CD. Head and neck space infections in children. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric Otolaryngology. Vol 2. 3rd ed. Philadelphia: WB Saunders; 1996. p. 152545.
C H A P T E R 22
CONGENITAL MALFORMATIONS OF THE N ECK

Mark A. Richardson, MD Richard M. Rosenfeld, MD, MPH
THYROGLOSSAL DUCT CYST A thyroglossal cyst generally presents as a firm cystic mass near the midline, just below the level of the hyoid bone. The mass may be located superiorly, laterally, or inferiorly, and it may be draining if the patient had a previous infection or prior incision and drainage. Thyroglossal cysts are thought to be an abnormality of thyroid formation and can exist anywhere from the base of the tongue to the level of the thyroid gland. They may be above or below the hyoid bone. Indications Enlargement of the mass Infection Diagnosis of a mass present in the anterior of the neck Anesthetic Considerations General endotracheal anesthesia is used. The tube should be taped to the upper lip to allow the surgeon access to the mouth. Preparation A thyroid scan or high-resolution ultrasonography of the thyroid is performed to identify normal tissue and to rule out association of a lingual thyroid with the thyroglossal cyst. If a lingual thyroid is identified, and it is the only source of thyroid hormone production, thyroxin levels should be obtained preoperatively. Commonly, lingual thyroid tissue, if it is the only functional source of thyroxin, is associated with a hypothyroid status. Placing a roll underneath the shoulders extends the patients neck; the anterior part of the neck is prepared and draped to the level of the lower lip using sterile technique. Laryngeal scissors and loupe magnification should be available.
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Procedure An incision is created overlying the mass to permit approaching the hyoid bone (Figure 221). The incision is carried through the skin and subcutaneous tissue to anterior strap muscles, which are retracted laterally to expose the cystic lesion or inflammatory mass. The cyst is carefully dissected free from the surrounding soft tissue and pedicled to the middle third of the hyoid bone. Muscular attachments to the hyoid bone are divided with electrosurgery so that the hyoid bone can be visualized at its junction between the middle and lateral thirds (Figure 222). The laryngeal scissors are then used to resect the middle third of the hyoid bone and the cyst (Sistrunk procedure). An Allis clamp is used to put traction on the cyst and hyoid (Figure 223). At this point, using the nondominant hand after double gloving, the surgeon places a finger into the oral cavity and palpates the vallecula and the base of the tongue.
Figure 221 Incision site for removing a thyroglossal cyst. (Redrawn with permission from Peters GE. Excision of thyroglossal duct. In: John ME, Price JC, Mattox DE editors. Atlas of head and neck surgery. Vol 1. St. Louis: Mosby Year Book; 1990. p. 365.)
Congenital Malformations of the Neck
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Figure 222 An incision is made along the superior border of the hyoid bone. (Redrawn with permission from Lor JM. Atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988. p. 675.)
Figure 223 The hyoid bone is sectioned at each side with laryngeal scissors. (Redrawn with permission from Lor JM. Atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988. p. 677.)
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With an assistant holding the cyst and the hyoid bone, a core of muscular tissue, with its apex at the base of the tongue, is carefully excised without penetrating the mucosa (Figure 224).
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The surgeons hand in the vallecula guides the depth of excision. The hypoglossal and superior laryngeal nerve are avoided. The fistula itself is not dissected free from the surrounding tissue; instead, a core of tissue along with the middle third of the hyoid bone should be excised.
Bleeding is controlled using the electrosurgery unit. Prior to removing the surgeons finger from the oral cavity, a suture of 3-0 chromic is used to close the muscles in the deep space. Further closure of dead space is accomplished using interrupted sutures of 3-0 chromic after adequate hemostasis has been obtained. The strap muscles are replaced in their anatomic position, and a drain (generally a 14" Penrose) is placed into the wound prior to skin closure. The skin is closed using 4-0 Vicryl sutures in the subcutaneous and subcuticular layers. A compression dressing is applied, and the patient is awakened in the usual fashion. Special Considerations for Recurrent Lesions The Sistrunk procedure should reduce the recurrence rate to 3-5%, but the tract has a variable pathway, and re-operation may be necessary if traces remain. Recurrent lesions are best managed with wide resection of the affected area and a generous cuff of surrounding tissue. Careful examination with magnification can sometimes identify mucoid material exuding from the operative site, indicating the need to create a wider field in order to encompass the residual secreting epithelium. Postoperative Care The drain is normally removed after 24 hours, but longer drainage may be needed if the cyst was infected prior to surgery. Oral intake is not restricted, but discomfort is common and may prevent the patient from eating a normal diet for 24 to 48 hours.
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Figure 224 A finger placed in the vallecula elevates a core of muscular tissue. (Redrawn with permission from Rankow RM. An atlas of surgery of face, mouth and neck. Philadelphia: WB Saunders; 1968. p. 207.)
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CYSTIC HYGROMA (LYMPHANGIOMA) A soft doughy mass presents at birth 50% of the time and is present by 3 years of age 80% of the time. There is an equal incidence among males and females. Cystic hygroma and lymphangioma represent a spectrum of lymphatic malformations and are thought to arise from a common congenital blockage or arrest of normal development of the primordial lymph channels. They are often accompanied by ectatic veins or other varied vascular components. Both lesions are characterized by a heterogeneous collection of endothelially lined thin-walled lymphatic cysts and channels that can vary in size from a few millimeters to more than 20 cm. A widely accepted classification by Landing and Farber categorizes these lesions according to the size of their vascular spaces: Lymphangioma simplex consists of a capillary-like lymphatic vasculature. Cavernous lymphangiomas consist of dilated lymphatic channels with one or several endothelial layers (with or without an adventitial layer). Cystic hygromas or cystic lymphangiomas have large multilocular cysts. Although not generally referred to as microcystic or macrocystic, microcystic lesions are best suited for open surgical excision as described below. In contrast, macrocystic lesions may regress after intracystic injection of the sclerosing agent Picibanil (OK-432). This avoids the morbidity of open surgery, and has been particularly successful for macrocystic hygromas of the cervical area and infratemporal fossa. Regardless of the histopathology, cystic hygromas may increase rapidly in size due to infection or trauma and, if in a suprahyoid location, may cause respiratory distress or feeding difficulties. Indications Failure to resolve over a period of observation Enlargement of the mass Pain Infection Airway or respiratory distress Anesthetic Considerations Special instrumentation includes a nerve stimulator. The anesthesiologist should not use paralyzing agents. Preparation Multiple site involvement in suprahyoid locations worsens the prognosis for one-stage uncomplicated removal. Timing for surgery should be based on the appearance of complications, or an elective excision should be performed when appropriate for the surgeon and the patient. A preoperative evaluation should include a computed tomography (CT) or magnetic resonance imaging (MRI) scan. The addition of contrast to the CT examination is helpful to determine the vascular nature of the tumor. A preoperative workup should also include a complete blood count (CBC), blood typing, and cross-match.
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Perioperative antibiotics are given. The patients neck is extended and the head is rotated to permit maximum exposure. Procedure An attempt is made to remove the entire tumor and to preserve all normal and vital structures in a one-stage operation. Removing a large cervical cystic hygroma may require parotidectomy, submandibular gland excision, modified (functional) neck dissection, and facial nerve exploration, which are described thoroughly in Chapters 7, 20, and 23. This section outlines special considerations for cystic hygroma, but does not reproduce illustrations from other relevant chapters. An incision is planned to protect, identify, and access nerves that run within the area to be dissected and to allow complete access to the tumor. An extended parotidectomy incision (see Chapter 23) is often used. The incision is created through the skin and subcutaneous tissues through the level of the platysma. A skin flap is elevated over the parotid gland and sternocleidomastoid muscle using the Shaw knife (a Teflon-coated blade that uses heat but not electrical stimulation). The facial nerve is identified and dissected from the stylomastoid foramen in the usual fashion (see Chapter 7), with separation of the parotid gland from the cartilage of the ear and use of a neural stimulator to identify the facial nerve trunk. If a superficial parotidectomy (see Chapter 23) is done, all branches of the facial nerve are identified and dissected free. Lesions which only involve the submandibular area may only require that the marginal branch and buccal branches be identified and dissected because of the extension of the tumor in this area. In a plane directed anterior to the sternomastoid muscle, the dissection is carried deep to the level of the vascular sheath, where the digastric muscle is identified directly lateral to the vascular sheath. The cystic hygroma often extends below the level of the digastric muscle; however, at this point, branches of the external carotid artery and the hypoglossal nerve are encountered and must be preserved. Once these structures have been identified, dissection proceeds from a lateral to a medial direction as for a modified (functional) neck dissection (see Chapter 20). The inferior limit of the tumor can be elevated superiorly to the residual specimen now based in the submandibular triangle. The facial artery, where it enters the specimen, is carefully identified, clamped, and suture-ligated. As the specimen is elevated along with the involved portion of submandibular gland (see Chapter 23), the glossopharyngeal nerve can be seen, and the hygroma is excised from the submandibular space. The dissection then proceeds anteriorly, with the marginal branch of the facial nerve elevated safely out of the way. The facial vein is ligated, and the gland and tumor are retracted inferiorly. The lesions extension
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through the mylohyoid is carefully dissected free, again using the Shaw knife to eliminate any excessive bleeding. The submandibular duct is ligated using a right-angle clamp and a 3-0 chromic suture, and the specimen is removed. Adjunctive treatments include the following:
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The carbon dioxide laser may be applied to the intraoral involvement of the palate, tonsil, and mucosal surfaces. A partial glossectomy may be performed if the tongue is involved and is causing dentofacial abnormalities, airway distress, or difficulty with feeding.
Stimulation of any facial nerve branches is undertaken to make sure normal function is present. The wound is copiously irrigated with saline and skin flaps are replaced in their anatomic position over a 14" Penrose drain. A compression dressing is applied after closure is obtained using subcuticular and subcutaneous stitches of 4-0 Vicryl. Postoperative Care Facial nerve function is evaluated in the recovery room. Prolonged drainage is sometimes needed with a compression dressing. If surgical extirpation has been done at a site where it is difficult to perform dressing changes, preoperative fitting of a Jobst dressing may be helpful to maintain pressure on clean dressings postoperatively. Prolonged edema in superior or nearby structures (eg, at the tongue, cheek, or lips) may occur, because of interrupted lymphatics from a congenital disorder. Antibiotics should be continued postoperatively, and during any swelling or bleeding that may occur.

FIRST BRANCHIAL CLEFT FISTULA
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First branchial cleft fistulae are thought to represent a duplication of the external ear canal, and are divided into types I and II by Work: Type I lesions are limited to the first branchial groove, and contain no cartilage or adnexal tissue. If infected, they drain inferiorly, medially, or posteriorly to the pinna. They are superior to the facial nerve, usually parallel to the membranous ear canal, and end lateral to the tympanic annulus. Type II lesions are closely associated with the parotid gland, and contain skin and adnexal structures. If infected, they drain near the angle of the mandible. They can be medial or lateral to the facial nerve, in close proximity to the main trunk. The cyst and fistula generally drain intermittently; however, a first branchial cleft cyst may also present as a simple mass without fistula formation or discharge. In some cases, abnormalities may be visualized in the external ear canal of the affected side. Rarely, a cystic lesion of the tympanic membrane or middle ear may also be present. Prior to surgery, a CT scan is performed, and the risk of potential facial nerve injury is discussed with the patient and family. Indications Surgical removal is indicated if there is drainage, swelling, or infection. Anesthetic Considerations and Preparation No paralysis can be induced because of the potential need for stimulation and identification of the facial nerve at the time of surgery. A nerve integrity monitor can be placed for greater ease in identifying the facial nerve and its branches. Loupe magnification is useful to identify and preserve the facial nerve. The patients neck is extended and the head is rotated to the side opposite the fistula or first branchial cyst. The face and neck areas are draped in order to permit visualization of the eye and the corner of the mouth. Additional sterile drapes are applied to permit continued visualization of the face with a sterile field. Procedure There are two basic approaches to first branchial cleft lesions: 1. Wide-field excision with facial nerve identification. This is the traditional approach, outlined in detail below, for initial or recurrent type I and type II lesions. 2. Narrow-field excision without facial nerve identification. This approach is best suited for initial excision of uninfected type I lesions in and near the ear canal. A nerve integrity monitor is used for electrophysiological localization of the facial nerve trunk. This type of local excision is not described further.
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A pre-auricular incision, extending behind the ear and incorporating the fistulous tract in the neck, is created (Figure 225A). The flap is elevated in order to expose the parotid, and the fistulous tract is identified and dissected free from the surrounding tissue. As the dissection proceeds superiorly, identifying the facial nerve is mandatory, using the normal landmarks found in adults (Figure 225B). In younger children, the nerve is located further laterally, and because the mastoid tip is not as well defined, the nerve can be approached anatomically sooner than might be expected (see Chapter 7). After the facial nerve trunk has been identified and the lower or marginal branch is dissected free from the surrounding tissue, dissection along the fistulous area can be continued. The fistula may lead below the facial nerve to a cartilaginous tube containing dermal elements, which must all be excised. The fistula usually passes medial to the facial nerve trunk and its branches (see Figure 225B), ending either directly in the external ear canal or within a duplicated cartilaginous structure next to the ear canal, which must be dissected free and excised. This excision, in some cases, leaves a small defect in the external canal that should be closed primarily. In some cases, it may be necessary to do a superficial parotidectomy (see Chapter 23) to identify and preserve all branches of the facial nerve if there is confusion with regard to their location. As the dissection proceeds deep to the facial nerve, superficial temporal vascular branches may be encountered and should be ligated. Copious irrigation of the wound is performed. A drain is placed, and the skin flaps are sutured using interrupted sutures of 4-0 Vicryl for the subcutaneous tissue and a fast-dissolving plain suture for the skin of the parotid incision. If a superficial parotidectomy was performed, the use of an acellular tissue implant, such as AlloDerm, may prevent Freys syndrome postoperatively. A compression dressing is applied. Postoperative Care Postoperatively, routine wound care is performed. The drain, placed through the face-lift type of incision, is generally left in place for 1 to 3 days, depending on the amount of drainage.
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B Figure 225 A, Incision site. B, Intraoperative view clearly showing the location of the facial nerve. SCM = sternocleidomastoid muscle. (Redrawn with permission from Orobello PW. Excision of first branchial cleft. In: Johns ME, Price JC, Mattox DE. Atlas of head and neck surgery. Vol 1. St. Louis: Mosby Year Book; 1990. p. 345.)
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PRE-AURICULAR PIT OR FISTULA These are easily distinguished from true branchial anomalies by their position above the level of the tragus. They probably represent abnormal fusion of the Hillocks of Hiss, which form the external ear. Exceedingly common in some ethnic groups (ie, Chinese, African-American), they can be associated with hearing loss, especially when bilateral. Indications Recurrent infection Persistent drainage Preoperative Evaluation An audiogram is suggested to rule out associated hearing loss. Inquiring about possible familial inheritance is also suggested. Preparation Loupe magnification is useful. A nerve integrity monitor is used to monitor the facial nerve when excising deep, recurrent, extensive, or highly infected lesions. Procedure A pre-auricular incision is created to minimize any cosmetic alteration of esthetic units of the face. The incision should encompass any previously infected skin (Figure 226). The fistula tract is variable, and is often associated with a dermal sac or collection. The tract may be associated with abnormal folds of the helix and may penetrate cartilage. All dissection is performed superficial to the facial nerve. The incision may be extended posteriorly in the supra-auricular crease to facilitate excision of recurrent lesions or when extensive scarring exists. When using this approach, the temporalis fascia is identified and traced anteriorly, extending deep to the infected or scarred tissue, to provide a safe medial limit for the dissection. Once the tract is excised, skin flaps are advanced and the wound is closed with subcutaneous Vicryl sutures. Larger skin defects are closed by anterior rotation of the pinna after mobilizing the conchal cartilage. Fine fast-absorbing sutures complete the skin closure. Drain placement is generally unnecessary. Postoperative Care Standard wound care is provided.
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Figure 226 Incision for preauricular pit (dashed line) encompassing the fistula opening. Atrophic or previously infected skin (dotted line) is included, when necessary.
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SECOND AND THIRD BRANCHIAL CLEFT FISTULA Anomalies of the second and third branchial clefts include sinuses, fistulae, and cysts: Sinuses are blind pouches connected to either the skin (branchial cleft sinus) or the pharynx (branchial pouch sinus). Fistulae are complete connections between the skin and pharynx; a pseudo-fistula may also develop after rupture of a cervical abscess caused by a branchial pouch sinus. Cysts may occur independently, or in association with a branchial pouch sinus or fistula. The second cleft fistula traverses between the external and internal branches of the carotid artery and over the ninth cranial nerve (Figure 227A). Conversely, the third branchial fistula loops over the hypoglossal nerve, and runs down and medial to the carotid arteries, piercing the thyrohyoid membrane near the piriform sinus (Figure 227B). Draining sinuses or fistulae are best excised at an early age, when the procedure may be performed through a single incision. Stepladder incisions are necessary in older children, because the neck elongates with normal growth and development. The hypoglossal and superior laryngeal nerves may be encountered in the dissection. Indications A draining pit or fistula in the anterior triangle of the neck Infection within the fistulous tract A mass in the anterior cervical triangle Anesthesia and Preparation Children with bilateral lesions, or a family history of similar anomalies, have preoperative audiometry and renal ultrasonography to detect branchial-oto-renal syndrome. The endotracheal tube must be well secured, especially for bilateral fistulae requiring head rotation. No paralysis is induced in case neurostimulators are required. The patients neck is extended and draped from clavicle to chin. A 0-Prolene suture or a Fogarty embolization catheter (3-5 Fr) can be used to cannulate the tract for easier surgical identification. Lacrimal probes should also be available. Perioperative antibiotics are given for previously infected lesions. Procedure A lacrimal probe (or one of the previously mentioned flexible items) is placed within the fistulous tract as far as it will pass, taking care to not create a channel. When a Fogarty catheter is used, threading the catheter is facilitated by intermittent balloon dilatation. An elliptical incision is made along skin tension lines surrounding the fistula opening.
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Figure 227 Anatomical relations of the second (A) and third (B) branchial cleft fistula. An infected sinus from the third pouch may rupture and form a pseudo-fistula, which would reach the skin directly without looping around the carotid artery. SCM = sternocleidomastoid muscle; IX = ninth cranial nerve (glossopharyngeal); XII = twelth cranial nerve (hypoglossal).
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The tract is pulled away from the surrounding tissue with sharp dissection, and is dissected free from the attaching muscle fibers. Ragnell retractors permit exposure of the deepest part of the lesion, unless the patient has an excessively long tract that would require a second or stepladder incision (Figure 228). To create a second, more cranially placed incision 1. A hemostat is passed along the dissected fistulous tract to its most distal point; a small skin incision is made, and the fistula is brought out through the skin incision. 2. Dissection is continued further by sharp dissection, and a right-angle clamp is placed at the fistulas entrance to the mucosa. 3. It is generally not necessary to perform a tonsillectomy or penetrate the pharynx. A suture, generally a 3-0 chromic, is placed around the stump of the fistula and is tied when the fistula has been excised. The incisions are closed using subcutaneous and subcuticular Vicryl sutures. External drainage is generally unnecessary because the dissection is limited. Postoperative Care The patient can usually be discharged on the same day, unless an extensive dissection has been performed. Postoperative care consists of a compression dressing.
Figure 228 A stepladder incision is created by passing a hemostat along the dissected fistula tract. (Redrawn with permission from Lor JM. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988. p. 693.)

FOURTH BRANCHIAL POUCH SINUS
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The fourth branchial pouch sinus is an uncommon congenital anomaly with two characteristic clinical presentations: 1. Neonatal neck mass. A neonate presents with a lateral neck cyst or abscess associated with actual or impending airway compromise. The mass mimics a cystic hygroma, and may contain air or increase in size during crying or Valsalva. 2. Recurrent deep neck infection. A child, adolescent, or occasionally an adult, presents with recurrent deep neck abscess or suppurative thyroiditis, despite several attempts at drainage or neck exploration. The fourth branchial pouch sinus is not a complete fistula, but rather a brief, internal tract originating in the piriform sinus. After exiting the pyriform apex, caudal to the superior laryngeal nerve (Figure 229), the tract descends translaryngeally under the thyroid ala to emerge beneath the inferior constrictor muscle, and exit the larynx near the cricothyroid joint. Nearly all reported sinuses have been left sided. Indications Fourth branchial pouch sinus diagnosed by barium swallow, sinogram (when an external fistula exists), or hypopharyngoscopy Suspected fourth branchial pouch sinus based on clinical history, particularly unexplained recurrent deep neck infection or suppurative thyroiditis
Figure 229 Fourth branchial pouch sinus originating in the piriform apex (dashed lines), caudal to the superior laryngeal nerve (SLN), and terminating as a small cyst in the superior pole of the thyroid gland. The sinus tract is near the recurrent laryngeal nerve (RLN) at the cricothyroid joint.
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Preparation Acutely infected sinuses are treated with antibiotics, and incision and drainage if necessary; definitive excision is delayed several weeks until inflammation has resolved. Perioperative antibiotics are given routinely. Equipment is available for direct microlaryngoscopy to examine the ipsilateral piriform apex for a sinus tract. Anesthesia and Preparation General anesthesia with orotracheal intubation is required. The patients neck is extended and draped from the clavicle to the chin. Procedure Direct laryngoscopy is performed and the ipsilateral piriform apex is inspected for a sinus tract opening. If a distinct opening is found, two options exist: 1. Endoscopic cauterization. The sinus tract is obliterated by endoscopic cauterization using an insulated needlepoint electrocautery, and the procedure is concluded. Preliminary results with limited follow-up have been favorable. Cauterization is at low power and limited to the superficial mucosal layer, which leads to scarring and closure of the sinus tract with low risk of perforation. 2. Open surgical excision. The sinus tract is excised retrograde, beginning with complete exposure of the piriform fossa. Recurrence has not been reported with this approach, but morbidity is higher than with cauterization. In contrast, excising only the extralaryngeal portion of the tract almost guarantees recurrence. External excision begins by exposing the thyroid ala and carotid sheath, which allows the operation to begin in a region relatively free of postinflammatory fibrosis. 1. An incision is made along the anterior border of the sternocleidomastoid muscle, from superior aspect of the thyroid cartilage to the level of the cricoid cartilage (Figure 2210). 2. The sternocleidomastoid muscle is retracted, exposing the posterior edge of the lateral thyroid cartilage, with the attached inferior constrictor muscle. 3. If a tract is discovered exiting from the thyrohyoid membrane, rostral to the superior laryngeal nerve, the diagnosis of a third pouch sinus is confirmed and exposure of the piriform fossa is not required. The tract is ligated and dissected retrograde. 4. If a tract or fibrosis is not apparent near the thyrohyoid membrane, a fourth pouch sinus is likely, and the piriform fossa is exposed as described below. To expose the piriform fossa, a vertical incision is made along the posterior edge of the lateral thyroid cartilage and inferior cornu down to and through the perichondrium. The inferior constrictor is separated poste-
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Figure 2210 Skin incision for fourth branchial pouch sinus.
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riorly, hugging the cartilage closely and elevating the perichondrium around the posterior edge and on the medial side sufficiently to detach the inferior constrictor muscle. A tracheal hook distracts the posterior edge of the thyroid ala anteriorly (Figure 2211), and the facet-like joint between the inferior cornu and the cricoid cartilage is separated. To avoid recurrent laryngeal nerve injury, the joint is divided as close to the inferior cornu as possible. The thyroid perichondrium is elevated anteriorly to expose the posterior thyroid cartilage. A 1-cm strip of posterior thyroid ala is excised, exposing the underlying piriform sinus. The fourth pouch sinus tract is ligated from its origin at the piriform apex and any pharyngeal defect is repaired with pursestring closure. Recurrence is likely if the pharyngeal connection is incompletely ligated. The sinus tract is then excised retrograde, ending with a surrounding ellipse of skin if a fistula was present.
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Part of the superior pole of the thyroid gland may be included if necessary (see Figure 2211), but the superior parathyroid gland should be preserved. If the tract descends paratracheally, exposure of the recurrent laryngeal nerve is necessary to prevent injury. When the nerve cannot be identified because of inflammation or scarring, the excision should end at the cricothyroid region to prevent nerve injury.
A Penrose rubber drain is inserted and the incision is closed in layers. Postoperative Care Perioperative antibiotics are continued for 24 hours. The drain is removed on the first postoperative day unless drainage is excessive.
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Figure 2211 Translaryngeal course of a fourth branchial pouch sinus. The inferior constrictor attachment has been divided, and a hook retracts the posterior edge of the thyroid ala anteriorly. For clarity, the piriform fossa has been removed except for a portion of the apex. Note relationships to the superior (SLN) and recurrent (RLN) laryngeal nerves.
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FIBROMATOSIS COLLI Fibromatosis colli (sternomastoid tumor of infancy) is thought to represent an injury to the sternomastoid muscle, incurred either in utero or during delivery. The deformity is usually noted at birth or within the first 10 days of life, and may be associated with congenital hip dislocation. A firm mass becomes palpable in the muscle and progresses to a maximal size (1-3 cm), generally within 1 month. The head is usually tilted toward the side of the shortened muscle, and the chin rotates toward the opposite (normal) side. Fine needle aspiration aids in diagnosis. If left untreated, the condition may cause developmental asymmetry of the face and ocular imbalance. Conservative management, which consists of range of motion exercises, is generally successful in resolving the problem; however, surgery may be necessary in rare cases. Other evidence of injury should be looked for, such as a fracture of the clavicle or cervical spine injury or abnormality. Indications A mass within the body of the sternomastoid muscle that does not resolve with aggressive physical therapy, consisting of passive range of motion exercises performed by the parent three to four times daily Long standing torticollis in older children may benefit from tenotomy or release of the shortened sternomastoid muscle. Evaluation of the underlying cervical spine should be performed to detect any abnormalities. Anesthesia and Preparation General endotracheal anesthesia is necessary. The patients neck is extended, and the head is rotated away from the side of the torticollis to make the mass as prominent as possible. The neck is prepped from the clavicle to the chin. Procedure A horizontal incision is created over the mass and carried through the subcutaneous tissue (Figure 2212). The greater auricular nerve is preserved if possible. The mass can generally be separated from normal muscle fiber with preservation of the portion of the sternomastoid muscle that is not involved with the fibrosis. The accessory branch to the sternomastoid muscle should also be preserved. The incision is closed immediately in the standard fashion. Postoperative Care Postoperatively, the patient performs range of motion exercises to maintain the release that has been surgically created.
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Figure 2212 Skin incision for fibromatosis colli unresponsive to physical therapy. A spindleshaped mass is imbedded in the sternocleidomastoid muscle fibers.
BIBLIOGRAPHY
Bill AH, Sumner DS. A unified concept of lymphangioma and cystic hygroma. Surg Gynecol Obstet 1965;120:7986. Farrior JB, Santini H. Facial nerve identification in children. Otolaryngol Head Neck Surg 1985;93:1736. Feldman JI, Kearns DB, Pransky SM, Seid AB. Catheterization of branchial sinus tracts: a new method. Int J Pediatr Otorhinolaryngol 1990;20:15. Gonzales J, Ljung BM, Guerry T, Schoenrock L. Congenital torticollis: Evaluation by fine-needle aspiration biopsy. Laryngoscope 1989;99:6514. Greinwald JH Jr, Burke DK, Sato Y, et al. Treatment of lymphangiomas in children: an update of Picibanil (OK-432) sclerotherapy. Otolaryngol Head Neck Surg 1999;121:3817. Hoffman MA, Schuster SR. Thyroglossal duct remnants in infants and children: Reevaluation of histopathology and methods for resection. Ann Otol Rhinol Laryngol 1968;97:4836. Isaacson G, Martin WH. First branchial cleft cyst excision with electrophysiological facial nerve localization. Arch Otolaryngol Head Neck Surg 2000;126:5136. Jordan JA, Graves JE, Manning SC, et al. Endoscopic cauterization for treatment of fourth branchial cleft sinuses. Arch Otolaryngol Head Neck Surg 1998;124:10214.
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Kennedy TL. Cystic hygroma-lymphangioma: a rare and still unclear entity. Laryngoscope 1989;99 Suppl:110. Landing BH, Farber S. Function of the cardiovascular system. In: Atlas of tumor pathology, Washington (DC): Armed Forces Institute of Pathology; 1956. p. May J, DAngelo AJ Jr. The facial nerve and the branchial cleft surgical challenge. Laryngoscope 1989;99:5645. Mickel RA, Calcaterra TC. Management of recurrent thyroglossal duct cysts. Arch Otolaryngol Head Neck Surg 1983;109:346. Prasad S, Grundfast G, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope 1990;100:3201. Ricciardelli EJ, Richardson MA. Cervicofacial cystic hygroma: patterns of recurrence and management of the difficult case. Arch Otolaryngol Head Neck Surg 1991;117:54653. Riechelmann H, Muehlfay G, Keck T, et al. Total, subtotal, and partial surgical removal of cervicofacial lymphangiomas. Arch Otolaryngol Head Neck Surg 1999;125:6438. Rosenfeld RM, Biller HF. Fourth branchial pouch sinus: diagnosis and treatment. Otolaryngol Head Neck Surg 1991;105:4450. Sedwick CE, Walsh JF. Branchial cysts and fistulas: a study of seventy-five cases relative to clinical aspects and treatment. Am J Surg 1952;83:38. Simpson RA. Lateral cervical cysts and fistulas. Laryngoscope 1969;79:3058. Sistrunk WE. The surgical treatment of cysts of the thyroglossal tract. Ann Surg 1920;71:1214. Tom LW, Handler DS, Wetmore RF, Potsic WP. The sternocleidomastoid tumor of infancy. Int J Pediatr Otorhinolaryngol 1987;13:24555. Tom LW, Rossiter JL, Sutton LN, et al. Torticollis in children. Otolaryngol Head Neck Surg 1991;105:15. Woodman D. A modification of the extralaryngeal approach to arytenoidectomy for bilateral abductor paralysis. Arch Otolaryngol 1946;43:635. Work WP. Newer concepts of first branchial cleft defects. Laryngoscope 1972;82:158193.
C H A P T E R 23
S ALIVARY G LAND S URGERY

PAROTIDECTOMY During childhood, the parotid glands and paraparotid lymph nodes are subject to infection, inflammation, and neoplasia. Vasoformative and congenital cystic lesions often are clinically apparent. Conversely, chronic inflammation may present as an indolent firm mass indistinguishable from a benign or malignant neoplasm. Serology, skin tests, and radiologic imaging (contrast sialography, ultrasonography, computed tomography, or magnetic resonance imaging) may suggest, but typically cannot confirm, the specific underlying disease process. Fine-needle aspiration (FNA) biopsy has a limited role in diagnosing solid parotid masses. If the child needs general anesthesia for needle biopsy, then excisional biopsy will yield greater histopathologic information. More importantly the definitive treatment of many inflammatory and neoplastic causes of solid parotid masses in children is surgical excision. Excisional biopsy, or superficial parotidectomy, is therapeutic and diagnostic in such circumstances. As in adults, neither incisional biopsy nor the isolated enucleation of solitary parotid lesions is recommended. Total parotidectomy is rarely necessary in children. Indications Solid parotid mass of unknown or uncertain etiology Chronic recurrent parotitis First and second branchial system anomalies Vasoformative lesions Anesthetic Considerations and Preparation The procedure is performed under general anesthesia. Paralytic agents are avoided to allow for intraoperative facial nerve stimulation. Informed consent regarding the risk of facial nerve injury is an absolute necessity.
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The child is positioned supine with the head turned toward the uninvolved side. The operative field is draped with sterile transparent plastic sheeting to provide exposure of the entire face on the involved side, including the corners of the eye and mouth (Figure 231). This allows for the intraoperative assessment of facial nerve function. Procedure The planned incision is infiltrated with 1% lidocaine and 1:100,000 epinephrine solution for local hemostasis.
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In older children and adolescents, an S-shaped face lifttype incision is used (Figure 232A). This incision begins in the preauricular crease, runs under the lobule, continues up and over the mastoid process, and extends in a curvilinear fashion down into the neck approximately two finger breadths below the angle of the jaw. A Y-shaped incision with a retroauricular extension is an alternative approach (Figure 232B). In infants and very young children, a single curved incision, beginning 1.5 to 2 cm below the mandible and extending posterior and superior over the mastoid prominence, reportedly protects the superficially located facial nerve (Figure 232C).
Figure 231 The patient is positioned so that facial nerve function can be assessed.
Salivary Gland Surgery
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Figure 232 A, An S-shaped face lifttype incision used for older children and adolescents. B, A Y-shaped incision with a retroauricular extension. C, A single curved incision of potential use in infants or small children.
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The skin flaps are elevated in a plane of dissection deep to the subcutaneous tissues and superficial to the investing fascia of the parotid gland. The anterior margin of elevation is the parotid glands anterior border to avoid inadvertent transection of small facial nerve branches emerging from the gland over the masseter muscle (Figure 233). Posteroinferior flap dissection is performed in the subplatysmal plane until the anterior border of the sternocleidomastoid muscle is clearly identified.
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Care is particularly necessary in infants and young children because limited posterior development of the parotid gland may expose a large portion of the facial nerve (Figure 234). In older children, the tail of the parotid gland often needs to be separated from the sternocleidomastoid muscle. Both the greater auricular nerve and the posterior facial (retromandibular) vein are typically encountered and need to be sacrificed for gland retraction and exposure.
Using both superior traction on the earlobe and anterior traction on the parotid gland, blunt dissection along the tragal cartilage and adjacent mastoid bone allows separation of the small fibrous bands that attach the posterior border of the parotid gland to these structures (Figure 235).
Figure 233 Elevation of the anterior and posteroinferior flaps.
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Figure 234 A large portion of the facial nerve may be exposed in younger children due to limited parotid gland development. (Adapted from Welch KJ, Randolph JC, editors. Pediatric surgery. Vol. I. Chicago: Year Book Medical Publishers; 1986. p. 500.)
Figure 235 Blunt separation of small fibrous bands along the tragal cartilage and mastoid bone allows the main trunk of the facial nerve to be identified. (Adapted from Welch KJ, Randolph JC, editors. Pediatric surgery. Vol. I. Chicago: Year Book Medical Publishers; 1986. p. 500.)
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The goal of progressive medial dissection in this fashion is to identify the main trunk of the facial nerve as it emerges from the stylomastoid foramen. In older children and adolescents, the location of the facial nerve can be anticipated approximately halfway between the tip of the mastoid process and a triangular extension of the cartilaginous external ear canal, the so-called pointer. 1. Immediately before encountering the facial nerve, the temporoparotid fascia often arises from the tympanomastoid fissure as a firm band extending into the parotid gland. 2. Conservative use of the nerve stimulator during this portion of the procedure helps to distinguish fascia from nerve. 3. Hemostasis is crucial for visualization purposes; bipolar cauterization in a moist field is advocated to decrease the likelihood of cautery-induced neural damage.
In infants and young children, limited mastoid development results in less well-defined bony landmarks for facial nerve identification (Figures 236 A and B). In addition, some of the inflammatory conditions necessitating parotidectomy in children pathologically involve the external auditory canal, creating scarring in this region and placing the main trunk of the facial nerve in further jeopardy. 1. An alternative method of finding the facial nerve in such circumstances is to follow the anterior border of the sternocleidomastoid muscle superiorly to its temporal bone insertion and to locate the posterior belly of the digastric muscle just deep to this insertion site. 2. Using blunt dissection and working anteriorly, the facial nerve trunk typically can be found within the triangle formed by these two muscles and the cartilaginous ear canal (Figure 237).
In revision surgical procedures with extensive cervical scarring, an alternative approach is to use the retroauricular extension of a Y-shaped skin incision (see Figure 232B ). A limited mastoidectomy is then performed to provide access to the facial nerve in the descending portion of the fallopian canal prior to its skull base exit. Once the main trunk of the facial nerve is clearly identified, it is followed anteriorly to the pes anserinus.
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In adolescents and older children, this requires dissection into the parotid gland. In infants, the pes may actually be in the retromandibular region outside of the parotid gland proper (see Figure 234).
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Figure 236 A, Newborn temporal bone. B, Adult temporal bone. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. Figure 311.)
Figure 237 The triangle formed by the sternocleidomastoid muscle, the digastric muscle, and the cartilaginous ear canal. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 254.)
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A plane of cleavage through the parotid gland is developed as proximal to distal dissection of both the upper zygomaticotemporal and lower cervicofacial divisions of the facial nerve is performed (Figure 238). ! Branches of the posterior facial (retromandibular) vein require ligation during this portion of the procedure, as does the parotid duct if identified and transected. ! Once the temporal, zygomatic, buccal, and mandibular branches of the facial nerve have been followed completely to the point of turning deeply toward the facial musculature, the remaining portions of the parotid gland can be separated from the investing fascia (Figure 239). ! This separation completely mobilizes the superficial lobe of the parotid gland. The so-called deep lobe of the parotid gland is the salivary tissue that remains undisturbed under the preserved facial nerve. A superficial parotidectomy is adequate treatment for virtually all superficially located parotid masses; it allows the complete operative dissection of first and second congenital branchial anomalies. A total parotidectomy may prove necessary if the mass in question is located within the deep lobe, or if the pathology involves the entire gland, as is the case in some vasoformative lesions and chronic inflammatory processes. ! In such circumstances, the main trunk and individual branches of the facial nerve can be retracted gently with rubber vascular loops to allow access to the underlying parotid tissue (Figure 2310).
Figure 23-8: Dissection along the facial nerve develops a plane of cleavage through the parotid gland. (Adapted from Welch KJ, Randolph JC, editors. Pediatric surgery. Vol. I. Chicago: Year Book Medical Publishers; 1986. p. 500.)
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Figure 23-9: The remaining portions of the parotid gland are separated from the investing fascia, completely mobilizing the superficial lobe of the parotid gland. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 256.)
Figure 23-10: Retraction of the facial nerve with vascular loops allows access to the deep parotid tissue. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 255, 258; and from Lor JM. An atlas of head and neck surgery. Philadelphia: WB Saunders; 1988. p 717.)
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The deep parotid tissue is separated from the underlying facial musculature, temporomandibular joint, and mandible. Ligation of the medially adjacent maxillary and superficial temporal arteries may be necessary. Deep parotid lobe dissection exposes the parotid duct.
Neoplastic invasion of the facial nerve is extremely infrequent in pediatric parotid malignancies.
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In the rare case of a resectable undifferentiated or sarcomatous malignancy, total parotidectomy with facial nerve resection is performed in conjunction with a modified neck dissection and perhaps a partial mandibulectomy. The proximal aspect of the facial nerve typically is identified within the vertical segment of the fallopian canal; the peripheral facial nerve branches are likewise identified and tagged (Figure 2311). Frozen section histopathology is used to determine healthy neural margins. Immediate reconstruction by free autogenous nerve grafting is advocated using either the sural nerve or the greater auricular nerve from the opposite side of the neck; the harvesting of the former allows a two-team approach. Microanastomotic technique increases the likelihood of graft success.
When the facial nerve has been preserved in parotid surgery, the main trunk, divisions, and individual branches of the nerve should be stimulated prior to wound closure to determine neural integrity. If the facial muscles do not twitch briskly with stimulation, the nerve must be inspected along its entire course for possible disruption. A transected nerve should be repaired immediately. Stretching or compression may have injured an anatomically intact nerve. Following hemostasis and irrigation, suction drainage is recommended. The drain typically leaves the skin through a separate stab incision (Figure 2312).
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A Jackson-Pratt drain is appropriate in older children and adolescents. In infants and young children, a Brent butterfly drain using a large test tube for vacuum purposes works well.
Closure is performed in two layers using interrupted absorbable sutures subcutaneously, and either nylon or absorbable sutures in an interrupted or running fashion in the skin. A pressure dressing completes the procedure. Complications Facial paresis may be observed on the side of the operation for days or even weeks postoperatively, depending on the extent of nerve mobilization. If gentle retraction was performed and no significant branches of the facial nerve have been severed, complete recovery is the rule.
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Figure 2311 Facial nerve anastomosis.
Figure 2312 Drain placement through a stab incision separate from the parotidectomy closure.
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Gustatory sweating (Freys syndrome) occurs secondary to the regrowth of parasympathetic motor fibers from the auriculotemporal nerve, which preoperatively innervated the parotid gland, into the skin. Efferent impulses that had induced salivation now stimulate the cutaneous sweat glands. Hypoesthesia of the earlobe is commonly present for up to several months. Permanent hypoesthesia can occur if the greater auricular nerve has been sacrificed. Hemorrhage with secondary hematoma or seroma formation reflects inadequate hemostasis or drainage. Salivary fistula formation may occur if the parotid duct has not been identified and ligated prior to transection. SUBMANDIBULAR GLAND EXCISION Submandibular gland neoplasms are extremely rare in children. Vasoformative lesions, especially lymphatic vascular malformations, can arise within the submandibular space. The inflammatory processes that afflict the paraparotid lymph nodes can likewise involve the submandibular lymph nodes. The submandibular gland itself is also susceptible to a higher rate of stone formation (sialolithiasis) and secondary inflammation (sialoadenitis). Excision of the submandibular gland in children is infrequently necessary. Indications Chronic sialoadenitis with or without sialolithiasis A persistent firm submandibular mass of unknown or uncertain etiology Elective removal in an attempt to decrease salivary secretions in children with excessive drooling secondary to cerebral palsy and other neuromuscular disorders Anesthetic Considerations and Preparation The procedure is performed under general anesthesia. Paralytic agents are avoided to allow for intraoperative marginal mandibular nerve stimulation. Informed consent regarding the risk of marginal mandibular nerve injury is necessary. The child is positioned supine with the head turned toward the uninvolved side. The operative field is draped with sterile transparent plastic sheeting to provide exposure of the corner of the mouth on the involved side (Figure 2313). This allows for the intraoperative assessment of marginal mandibular nerve function. Procedure A horizontal skin incision is made in a neck crease two finger breadths inferior and parallel to the angle and body of the mandible (Figure 2314). The incision is infiltrated with 1% lidocaine and 1:100,000 epinephrine solution for hemostasis.
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Figure 2313 Plastic sheeting is positioned to expose the corner of the mouth on the involved side.
Figure 2314 An incision is made in a neck crease.
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The skin, subcutaneous tissues, and platysma muscle are divided down to the investing fascia of the submandibular gland. The mylohyoid muscle anteriorly, the sternocleidomastoid muscle posteriorly, and the digastric muscle inferiorly are exposed (Figure 2315). The fascia over the submandibular gland is divided at its inferior aspect and elevated toward the mandible. The anterior facial vein is sought because the marginal mandibular branch of the facial nerve usually crosses this vein; ligation and elevation of this vessel with the fascia helps to shield the marginal mandibular nerve from injury (Figures 2316A and B). Direct identification of the marginal mandibular nerve with the use of a nerve stimulator is the best way to protect and preserve the nerve during elevation of the fascia. Mobilization of the submandibular gland is begun along its inferior aspect. The plane between the intermediate tendon of the digastric muscle and the submandibular gland is opened (Figure 2317).
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The hypoglossal nerve will be encountered deeply in the digastric triangle. The external maxillary (facial) artery enters the posterior aspect of the submandibular gland; this vessel is double-ligated before transection. Branches of the posterior facial (retromandibular) vein also require careful ligation.
Figure 2315 Exposure of the mylohyoid, sternocleidomastoid, and digastric muscles. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 263.)
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Figure 2316 Ligation (A) and elevation (B) of the anterior facial vein, shielding the marginal mandibular nerve. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 264.)
Figure 2317 Exposure of the hypoglossal nerve. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 269.)
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Anterior retraction of the mylohyoid muscle and gentle downward traction on the submandibular gland allow identification of the lingual nerve, its attached submandibular ganglion, and the submandibular (Whartons) duct (Figure 2318).
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The duct is ligated and divided. The efferent fibers arising from the ganglion to the submandibular gland also are divided, freeing the lingual nerve from the gland. The submandibular gland is now completely mobilized by blunt dissection. The superior end of the external maxillary (facial) artery, if not previously ligated, should be identified and secured.
After removal of the specimen, the submandibular space is explored carefully (Figure 2319). The marginal mandibular nerve, if previously identified, should be stimulated to determine neural integrity. Following hemostasis and irrigation, a Penrose drain is placed through the operative incision (Figure 2320). Closure is performed in two layers using interrupted absorbable sutures for platysma muscle and subcutaneous tissue approximation, and either interrupted or a single subcuticular nylon suture in the skin. A pressure dressing completes the procedure. Complications Paresis or paralysis of the lower lip may occur secondary to injury to the marginal mandibular branch of the facial nerve. If the anatomic integrity of the nerve is operatively preserved, complete recovery is the rule. Because the platysma muscle aids in depressing the lower lip, there may be transient unilateral lip weakness secondary to its intraoperative division.
Figure 2318 Complete mobilization of the submandibular gland.
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Hemorrhage with secondary hematoma or seroma formation reflects inadequate hemostasis or drainage. Hypoglossal or lingual nerve injury is infrequent if these structures are properly identified intraoperatively.
Figure 2319 The submandibular space after gland removal. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 269.)
Figure 2320 Insertion of a Penrose drain and closure. (Adapted from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 269.)
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RANULA EXCISION Ranulas are cystic lesions of sublingual gland origin. Simple ranulas are true retention cysts appearing as transparent thin-walled cysts, typically unilateral, within the floor of the mouth. The cervical or plunging ranula is a mucous extravasation pseudocyst that arises as mucus escapes through a ruptured sublingual duct. Plunging ranulas may extend through the gap between the posterior edge of the mylohyoid muscle and the anterior edge of the hyoglossus muscle into the superior cervical neck. The presence of a cystic floor-of-mouth swelling on the same side as a cystic swelling in the submental and/or submandibular space is suggestive of the diagnosis. Computed tomography or magnetic resonance imaging can distinguish a ranula from a lymphatic vascular malformation, the clinical entity with which it is most commonly confused. Ranulas localized to the floor of the mouth are managed with intraoral marsupialization or complete excision. Plunging ranulas require complete excision, typically via a transcervical approach. PLUNGING RANULA EXCISION Indications Plunging ranula associated with
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Dysphagia, speech impediment, or respiratory distress manifestations Recurrent infection Progressive enlargement
Diagnostic confirmation of a cervical lesion Anesthetic Considerations and Preparation The procedure is performed under general anesthesia. Paralytic agents are avoided to allow for intraoperative marginal mandibular nerve stimulation. Nasotracheal intubation is preferable to allow intraoral access if necessary. Informed consent regarding the risk of marginal mandibular nerve injury is necessary. Procedure The transcervical approach described for submandibular gland resection is also used for surgical access to this lesion. The submandibular duct passes through the same muscle cleft through which the ranula typically extends. The submandibular duct empties into the floor of the mouth medial to the sublingual gland; it provides a direct pathway to the site of ranula origin (Figure 2321). The anatomic proximity of these glandular structures often dictates the removal of the submandibular gland with ligation of its duct to allow complete removal of the plunging ranula cyst. The cervical approach provides greater exposure and protection of the lingual nerve than is possible transorally (Figure 2322).
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Figure 2321 Relationship of the sublingual and submandibular glands.
Figure 2322 Common pathway of the plunging ranula cyst and the submandibular duct. Note the well-exposed lingual nerve in the cervical approach.
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Gloved intraoral palpation on the ipsilateral floor of the mouth can help to deflect the sublingual gland into the operative field (Figure 2323). Complete removal of the sublingual gland, ideally in continuity with the ranula cyst, is necessary. Cervical wound closure is performed as described abovesee Submandibular Gland Excision. ! If the floor-of-mouth mucosa has been disrupted, closure by interrupted absorbable sutures is recommended. ! If the submandibular gland is not removed and the submandibular duct is transected, the proximal end of the duct must be brought out through the mucosa of the floor of the mouth for salivary drainage (Figure 2324). Complications The same postoperative sequelae described for submandibular gland excision can occur following the transcervical excision of a ranula. A ranula may recur if the sublingual gland is not operatively removed. Submandibular sialoadenitis may occur if the submandibular gland is left in place and the submandibular duct is injured intraoperatively.
Figure 2323 Gloved intraoral palpation displaces the ranula and attached sublingual gland into the cervical operative field.
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Figure 2324 The proximal end of Whartons duct is brought out through the floor of the mouth if the submandibular gland is preserved.
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INTRAORAL RANULA EXCISION Indications Intraoral ranula associated with Dysphagia, speech impediment, or respiratory distress manifestations ! Recurrent infection ! Progressive enlargement Anesthetic Considerations and Preparation The procedure is performed under general anesthesia.
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Nasotracheal intubation is preferable to facilitate intraoral access. The patient is positioned supine with the neck extended. Procedure A mouth retractor without a tongue blade is placed. A silk suture placed in the midline of the tongue facilitates tongue retraction. The orifice of the ipsilateral submandibular gland duct should be cannulated with a Teflon catheter or metal lacrimal probe; this procedure identifies the location of the submandibular duct so that it can be protected from injury during dissection of the ranula cyst (Figure 2325). A wide elliptical incision is outlined over the dome of the cyst (see Figure 2325). Lidocaine 1% with 1:100,000 epinephrine is infiltrated submucosally for hemostasis. Care must be taken not to puncture the cyst. If solely marsupialization or exteriorization of the ranula is planned, the entire dome of the cyst is removed, leaving an exposed bed to heal by secondary intention; however, the rate of recurrence is high. The more definitive procedure is complete excision of the ranula and the ipsilateral sublingual gland from which it arises. When complete ranula excision is anticipated, no attempt is made to separate the overlying adherent mucosa from the underlying cyst: they are removed together to facilitate ranula dissection ideally without disruption. Using primarily blunt and limited sharp dissection, the ranula cyst is separated from the mucosal margins and deeper floor-of-mouth structures (Figure 2326). Care is taken not to injure the lingual nerve or the cannulated submandibular duct, both of which should be identifiable on the surface of the floor-of-mouth musculature (Figure 2327). ! The sublingual gland ideally is removed in continuity with the ranula cyst. Hemostasis is achieved by bipolar cauterization of numerous small lingual veins. Drains typically are not used.
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The mucosal edges are closed using interrupted absorbable sutures (Figure 2328).
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Ranula cyst
Sublingual gland
Figure 2325 The submandibular duct is cannulated on the same side as the ranula, and a wide elliptical incision is outlined over the dome of the cyst.
Figure 2326 The ranula cyst, attached floor-of-mouth mucosa, and contiguous sublingual gland are separated carefully from the deeper floor-of-mouth structures.
Submandibular duct
Lingual nerve
Figure 2327 Following removal, the submandibular duct and lingual nerve should be clearly identifiable.
Figure 2328 Mucosal closure.
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Complications Postoperative edema of the floor of the mouth can potentiate airway obstruction. Intravenous dexamethasone during surgery may decrease this risk. Monitored postoperative observation is recommended; overnight nasotracheal intubation is a consideration in selected cases. Postoperative hematoma of the floor of the mouth can likewise potentiate airway obstruction; this can be prevented by meticulous intraoperative hemostasis. Ranula recurrence is a possibility if the sublingual gland is not removed.
BIBLIOGRAPHY
Batsakis JG, Sneige N, El-Naggar AK. Fine needle aspiration of salivary glands; its utility and tissue effects. Ann Otol Rhinol Laryngol 1992;101:1858. Camacho AE, Goodman ML, Eavey RD. Pathologic correlation of the unknown solid parotid mass in children. Otolaryngol Head Neck Surg 1989;101:56671. Crysdale WS, Mendelsohn JD, Conley S. Ranulasmucoceles of the oral cavity: experience in 26 children. Laryngoscope 1988;98:2968. Farrior JB, Santini H. Facial nerve identification in children. Otolaryngol Head Neck Surg 1985;93:1736. Lor JM Jr. Excision of ranula. In: Lor JM. An atlas of head and neck surgery. Philadelphia: WB Saunders; 1988. p. 6289. Lor JM Jr. The parotid salivary glands. In: Lor JM. An atlas of head and neck surgery. Philadelphia: WB Saunders; 1988. p. 70825. Lor JM Jr. Resection of the submandibular salivary gland for benign disease. In: Lor JM. An atlas of head and neck surgery. Philadelphia: WB Saunders; 1988. p. 67881. Luna MA, Batsakis JG, El-Naggar AK. Salivary gland tumors in children. Ann Otol Rhinol Laryngol 1991;100:86971. Matt BH, Crockett DM. Plunging ranula in an infant. Otolaryngol Head Neck Surg 1988;99:3303. May M, DAngelo AJ Jr. The facial nerve and the branchial cleft: surgical challenge. Laryngoscope 1988;99:5645. Montgomery WW. Surgery of the salivary glands. In: Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 22569. Seligman I, Lusk R. Excision of a ranula in a child. In Bailey BJ. Surgery of the oral cavity. Chicago: Year Book Medical Publishers; 1989. p. 20914. Welch KJ. The salivary glands. In: Welch KJ, Randolph JC. Pediatric surgery. Chicago: Year Book Medical Publishers; 1986. p. 487502.
C H A P T E R 24
T HYROIDECTOMY
Thyroidectomy is an infrequent procedure in children, performed most often for a potentially malignant thyroid mass. The differential diagnosis of a thyroid mass in a child or adolescent includes congenital anomalies (thyroglossal duct cyst, ectopic thyroid, unilateral thyroid lobe agenesis), thyroid abscess, colloid nodule, Hashimotos thyroiditis, benign adenomas, and malignant neoplasms. Clinical factors suspicious for malignancy include large size or rapid growth of the mass, fixation of the mass to surrounding structures, associated vocal fold paralysis or ipsilateral cervical lymphadenopathy, bring exposure to radiation therapy, or a familial predisposition to thyroid tumors.
PREOPERATIVE EVALUATION Blood tests [serum thyroxine (T4), triiodothyronine (T3), thyroid-stimulating hormone (TSH), antithyroglobulin antibodies, and antimicrosomal antibodies] may be necessary for complete evaluation, but rarely prove diagnostic for solitary thyroid masses. The exception is an elevated serum calcitonin level for medullary thyroid cancer. Ultrasonography is useful in evaluating the size, position, and multiplicity of thyroid lesions, as well as determining their cystic or solid character. Thyroid scanning compliments ultrasonography, particularly in the evaluation of solid thyroid masses. Thyroid malignancies frequently appear cold on thyroid scanning; nonsuppressible warm and hot masses can also prove to be malignant. Radiologic evaluation of children and adolescents with suspected thyroid neoplasms should also assess the remainder of the neck and chest. Thyroid cancer in this age group often presents in an advanced stage with regional lymph node metastases and distant extrathyroidal disease, particularly to the lungs. Documenting regional or systemic metastases significantly influences initial surgical management, but does not necessarily imply a poor prognosis.
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Fine-needle aspiration (FNA) biopsy with cytopathologic examination is a valuable tool in the diagnostic work-up of thyroid masses, given the high specificity and ease and safety of this technique in experienced hands. Positive FNA results can help further select the appropriate thyroid surgical procedure. Open surgical biopsy is indicated for a solitary thyroid mass, which despite extensive preoperative evaluation, cannot be definitively determined to be benign or malignant. A total thyroid lobectomy (hemithyroidectomy) is performed initially, with more extensive surgery, if needed, dictated by intraoperative frozen section histopathologic tissue diagnosis. THYROIDECTOMY Indications A solitary thyroid mass, especially a solid mass for which a definitive benign diagnosis cannot be made on the basis of preoperative evaluation Anesthetic Considerations The procedure is performed under general anesthesia. Paralytic agents are avoided to allow for intraoperative recurrent laryngeal nerve (RLN) stimulation and monitoring. Preparation Preoperative evaluation of vocal fold function is mandatory. From a diagnostic standpoint, documentation of impaired vocal fold mobility at presentation is a clinical criterion suggestive of an underlying malignant etiology. The presence of overt vocal fold paralysis may be important in dictating the surgical course. When there is normal vocal fold function, informed consent regarding the risk of RLN injury is necessary. Consideration should be given to intraoperative RLN monitoring.
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In older children and adolescents, the Xomed NIM II EMG endotracheal tube can be used for this purpose (Figure 241). This endotracheal tube has exposed electrodes which come in contact with the luminal surface of the true vocal folds, allowing passive and evoked electromyogram (EMG) monitoring of the thyroarytenoid muscle during thyroid surgery. Unfortunately, the smallest EMG endotracheal tube (outer diameter 8.8 mm, inner diameter 6.0 mm) is too large for most children, but is applicable in adolescents. A surface electrode which monitors posterior cricoarytenoid muscle activity can alternatively be used in younger children; this electrode requires placement against the posterior cricoid lamina by intraoperative laryngoscopy before the child is positioned for the definitive thyroid procedure (Figure 242).
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Figure 241 Xomed NIM II EMG endotracheal tube in position with exposed electrodes contacting the luminal surface of the true vocal folds.
Figure 242 The surface electrode in the desired position against the posterior cricoid lamina following endoscopic placement.
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The child is placed in the thyroid position, supine with the neck in full extension (Figure 243). Procedure A transverse collar incision is outlined in the lower neck. 1. The exact position of the incision must take into account the relationship between the palpable portions of the laryngeal skeleton, the sternum, and the thyroid gland. 2. The thyroid isthmus is situated immediately inferior to the cricoid cartilage. A natural skin crease is chosen within 1-2 cm of this level (Figure 244). 3. In young children, the laryngeal structures may not be obviously palpable, and may be considerably more cephalad relative to the sternal notch than anticipated (Figure 245). The planned incision is infiltrated with 1% lidocaine with 1:100,000 epinephrine solution to provide hemostasis.
Figure 243 Thyroidectomy operative position.
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Figure 244 Standard incision site.
Figure 245 Incision site for younger patients.
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The skin, subcutaneous tissues, and platysma muscle are transected. The anterior borders of the sternocleidomastoid muscle serve as the lateral margins (Figure 246). The incision should be wide enough to allow adequate vertical exposure. A superior flap is elevated in the subplatysmal plane to the level of hyoid bone, and an inferior flap is elevated to the level of the sternal notch (Figure 247). The midline raphe between the strap muscles is incised, and the sternohyoid and sternothyroid muscles are separated from one another and from the underlying thyroid gland (Figure 248).
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Dividing the strap muscles is infrequently necessary in the pediatric population. When required for operative exposure, the muscles should be divided high in the neck, above the cricoid cartilage to preserve ansa cervicalis innervation.
Figure 246 Transection of the skin, subcutaneous tissues, and platysma muscle. (Adapted from the Lor JM. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988. p.759.)
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Figure 247 Elevation of the superior and inferior flaps. (Adapted from Silver CE. Atlas of head and neck surgery. New York: Churchill Livingstone; 1986. p. 263.)
Figure 248 Retraction of the strap muscles.
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Identifying the recurrent laryngeal nerves Once the strap musculature is separated or divided, the sternocleidomastoid muscle on the side of the lesion is retracted to identify the carotid sheath structures (Figure 249). The thyroid lobe is retracted medially, and blunt dissection is carefully performed in the superior thoracic inlet just caudal to the inferior thyroid pole to identify the recurrent laryngeal nerve (RLN). When searching for the RLN, it is preferable to identify the inferior thyroid artery. The nerve typically passes under this vessel, but may be superficial (Figure 2410). The right RLN normally recurs beneath the right subclavian artery; the left RLN recurs beneath the aortic arch (Figure 2411A). Both recurrent nerves ascend toward the larynx in the tracheoesophageal groove.
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The left nerve ascends in a straight longitudinal direction parallel to the lateral border of the trachea. The right nerve follows a shorter course, approaching the larynx at a right angle, coursing medially as it ascends. Both nerves pass posterior to the thyroid lobes as they approach the cricoid cartilage. A nonrecurrent right RLN can arise from the vagus nerve as a direct medial branch in the neck in approximately 0.5 to 1% of individuals (Figure 2411B). A nonrecurrent left RLN is rare, typically occurring only with transposition of the great vessels.
Figure 249 Retraction of the sternocleidomastoid muscle for carotid sheath exposure.
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Figure 2410 Possible positional relationships of the inferior thyroid artery and the recurrent laryngeal nerve. (Adapted from Silver CE. Atlas of head and neck surgery. New York: Churchill Livingstone; 1986. p. 261.)
Figure 2411 A, Normal right and left recurrent laryngeal nerves. B, Anomalous (nonrecurrent) right recurrent laryngeal nerve. (Adapted from Silver CE. Atlas of head and neck surgery. New York: Churchill Livingstone; 1986. p. 260261.)
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Thyroid mobilization Once the RLN is identified inferiorly, dissection proceeds cephalad. The inferior and middle thyroid veins on the side of the lesion will need to be ligated and divided for adequate gland mobilization (Figure 2412). Ligating the main trunk of the inferior thyroid artery should be avoided to preserve the blood supply to the parathyroid glands; smaller medial branches of this artery may be ligated close to the capsule of the thyroid. The superior pole of the thyroid lobe is mobilized next by transecting the superior vascular pedicle (Figure 2413). 1. Care must be taken during this portion of the procedure to avoid damage to the external branch of the superior laryngeal nerve. This nerve can sometimes be identified between the superior pole vessels and the laryngeal structures. 2. If the plane of the superior pole dissection continues bluntly along the presenting portion of the cricothyroid muscle, the likelihood of superior laryngeal nerve (SLN) injury is small. 3. Ligation without clamping of the superior pole vessels further decreases the likelihood of SLN injury.
Figure 2412 Ligation and division of the inferior and middle thyroid veins. (Adapted from Silver CE. Atlas of head and neck surgery. New York: Churchill Livingstone; 1986. p. 265.)
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Figure 2413 Transection of the superior vascular pedicle.
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Following transection of the superior vascular pedicle, the superior pole of the thyroid lobe is reflected inferiorly. The thyroid lobe now remains firmly attached by the lateral or posterior (Berrys) suspensory ligament (Figure 2414), which extends bilaterally from the cricoid cartilage and first tracheal ring to the posteromedial aspect of each thyroid lobe. 1. The suspensory ligament is an extremely important structure because the RLN typically passes immediately deep (see Figure 2414). Variations, however, exist and must be anticipated. 2. Once the RLN has been clearly identified, the suspensory ligament is transected. A portion of thyroid tissue may also extend deep to this ligament and must be carefully removed. 3. After transecting the ligament, the remaining thyroid separates easily from the surface of the trachea. Thyroid Excision Dissection proceeds medially until the entire isthmus has been elevated. The isthmus is transected at its junction with the contralateral lobe (Figure 2415). This completes a total thyroid lobectomy (hemithyroidectomy). If the indication for surgical intervention is a thyroid mass of unknown etiology, or if confirmation of needle biopsy findings is sought, a frozen section histopathologic examination of the hemithyroidectomy specimen is performed.
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Histopathologic findings may dictate the further performance of a total or near-total (subtotal) thyroidectomy. If the diagnosis of thyroid carcinoma (typically papillary or papillary-follicular) is histopathologically established, the decision needs to be made as to whether to consider the hemithyroidectomy as the definitive procedure, taking a chance of recurrence in the contralateral lobe, or to immediately perform a total or subtotal thyroidectomy. These procedures necessitate life-long thyroid hormone replacement, but allow for postoperative radionuclide scanning for future detection of both local recurrence and metastases, and enhance the efficacy of 131I therapy if needed.
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Figure 2414 Lateral (posterior) suspensory ligament before transection. (Adapted from Lor JM. Atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988. p. 775.)
Figure 2415 Transection of the thyroid isthmus.
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When removing the contralateral lobe, the identical technique, previously described for the ipsilateral lobe with exposure of the RLN, is used. Identifying and preserving parathyroid tissue is crucial. 1. Performing a subtotal thyroidectomy lessens the risk of permanent hypoparathyroidism. 2. With this technique, a small portion of the contralateral thyroid lobe is left in situ with its adjacent parathyroid gland(s). 3. The inferior thyroid artery is also not ligated in order to preserve the blood supply to these glands (Figure 2416). Subtotal thyroidectomy is controversial, because of the possible future need, if disease recurs, to remove the small wedge of remaining thyroid tissue. There is a much greater risk to the RLN and residual parathyroid glands under such circumstances. There also appears to be little correlation between thyroid function and the amount of residual thyroid tissue. These problems have led many surgeons to consider the procedure of choice to be total thyroidectomy with identification and, if need be, re-implantation of the parathyroid glands. When there is advanced thyroid cancer, as evidenced by infiltration of surrounding tissues or cervical and systemic metastases, total thyroidectomy with paratracheal lymph node removal is advocated. The accompanying performance of a more formal modified neck dissection depends on the specific thyroid malignancy. Wound Closure Following hemithyroidectomy, subtotal, or total thyroidectomy, the operative site is carefully re-inspected for the presence of parathyroid glands and the integrity of both the RLN and SLN. If intraoperative RLN monitoring has been utilized, positive electrical stimulation of RLN function confirms visual documentation of its integrity. Following hemostasis and irrigation, a Penrose drain is placed and the strap muscles are loosely approximated in the midline. Closure is performed in two layers, using interrupted absorbable sutures to approximate platysma muscle and subcutaneous tissues, and either interrupted or a single subcuticular nylon suture for the skin (Figure 2417). A compression dressing is applied to complete the procedure. Postoperative Care Injury to either the RLN or the external branch of the SLN may occur.
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RLN injury typically results in an immobile vocal fold in a midline or paramedian position, and may predispose to aspiration or airway obstruction. SLN injury results in a bowed vocal fold. Both neural injuries adversely affect the voice.
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Figure 2416 Remaining contralateral thyroid lobe and parathyroid glands after near-total thyroidectomy. (Adapted from Silver CE. Atlas of head and neck surgery. New York: Churchill Livingstone; 1986. p. 271.)
Figure 2417 Penrose drain position after closure.
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Hemorrhage with hematoma or seroma formation results from inadequate hemostasis or drainage. Airway obstruction immediately following thyroid surgery may result from hematoma formation with tracheal compression or bilateral RLN injury during total thyroidectomy. In the event of acute postoperative airway obstruction 1. The dressing is removed immediately to inspect the neck. 2. If no hematoma is found and airway intervention is not immediately necessary, a flexible laryngoscopic examination of the true vocal folds is indicated. 3. Documenting true vocal fold paralysis not anticipated from the intraoperative procedure dictates re-exploration of the neck to assess RLN integrity. Hypoparathyroidism with hypocalcemia may result from direct injury or resection of the parathyroid glands, or from devascularization by ligation of the inferior thyroid artery(s). Hypothyroidism is an expected result following total thyroidectomy and also frequently occurs following subtotal thyroidectomy. Life-long thyroid hormone replacement is anticipated under such circumstances.
BIBLIOGRAPHY
Bryarly RC, Schockley WW, Stucker FJ. The method and management of thyroid surgery in the pediatric patient. Laryngoscope 1985;95:10258. Camacho AE, Goodman ML, Eavey RD. Pathologic correlation of the unknown solid parotid mass in children. Otolaryngol Head Neck Surg 1989;101:56671. DeKeyser LFM, VanHerle AJ. Differentiated thyroid cancer in children. Head Neck Surg 1985;8:10014. LaQuagli MP, Black T, Holcolmb GW, et al. Differentiated thyroid cancer: clinical characteristics, treatment, and outcome in patients under 21 years of age who present with distant metastases. A report from the Surgical Discipline Committee of the Childrens Cancer Group. J Pediatr Surg 2000;35:95560. Lor JM. Endocrine surgery. In: Lor JM, editor. Atlas of head and neck surgery. Philadelphia: WB Saunders; 1988. p. 72683. Millman B, Pellitteri PK. Thyroid carcinoma in children and adolescents. Arch Otolaryngol Head Neck Surg 1995;121:12614. Randolph GW. Management and monitoring of the recurrent laryngeal nerve during thyroid and parathyroid surgery. Syllabus. Surgery of the Thyroid and Parathyroid Glands. Massachusetts Eye and Ear Infirmary and Harvard Medical School [In Press]. Reyes HN, Wright JK, Rosenfield RL. Prevention of hypocalcemia in children due to parathyroid infarction after thyroidectomy. Surg Gynecol Obstetr 1979;148:768. Segal K, Arad-Cohen A, Mechlis S, et al. Cancer of the thyroid in children and adolescents. Clin Otolaryngol 1997;22:5258.
C H A P T E R 25
E NDOSCOPY OF THE U PPER A ERODIGESTIVE T RACT

Kenny H. Chan, MD Norman Friedman, MD David M. Polaner, MD Keith H. Riding, MD Sylvan E. Stool, MD
Endoscopy of the upper aerodigestive tract is an important component of pediatric otolaryngology. Historically endoscopic procedures were limited by the instrumentation and anesthetics available to the pioneers in the early part of the 1900s. However, technologic advances during the last 30 years have made endoscopic surgery useful and safe.
AIRWAY PHYSIOLOGY Airflow is governed by the interplay of flow, pressure, and resistance. Under laminar flow conditions, resistance is proportional to the fourth power of the airway radius and is inversely related to airway length and viscosity. Under turbulent flow conditions, resistance is proportional to the fifth power of the radius, and, thus, decreased lumen size (from a pathologic process or a bronchoscope) is more critical. A greater flow rate is required to maintain a normal driving pressure in the presence of turbulent flow. The smaller airways of infants require higher driving pressures to achieve gas flow, especially when flow is turbulent. Infants desaturate more quickly because of their significantly higher metabolic rate and oxygen consumption and their modestly lower functional residual capacity. The incidence of abnormal control of breathing and apnea are increased in infants following general anesthesia. Older children with chronic upper airway obstruction (eg, adenotonsillar hypertrophy, subglottic stenosis, Down syndrome) also can have abnormal ventilatory drive and can be at increased risk of pulmonary hypertension, cor pulmonale, pulmonary edema, and postoperative respiratory obstruction.
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PRINCIPLES OF ENDOSCOPIC SURGERY Detailed history and physical examination are important for the surgeon and anesthesiologist. Specific discussion relating to the severity, type, and presumed location of the airway abnormality should occur well in advance of induction of anesthesia. All equipment that might possibly be needed should be available and be in proper working order. The principles of endoscopic surgery are
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Introduce instruments gently to avoid mucosal bleeding and edema. Advance the endoscope only when a lumen is visible to avoid perforating a viscus. Communicate with the anesthetist to accurately assess the depth and the duration of anesthesia. This coordinated effort is essential to minimize potential complications and bring about a safe and successful outcome.
Anesthetic Considerations Inhaled anesthetics Inhaled anesthetics can provide analgesia and amnesia and allow relatively accurate assessment and control of anesthetic depth. Dose-dependent respiratory depression is a feature common to almost all anesthetics. Anesthetic induction using inhalation anesthetics is usually faster in infants because of their higher minute ventilation, lower functional residual capacity, reduced blood-gas solubility, and greater percentage of cardiac output delivered to the brain. Most inhalation anesthetics are bronchodilators. Halothane is the prototypic inhalation agent for airway surgery. Halothane has the advantages of having little pungency and being minimally irritating to the airways. Halothane sensitizes the myocardium to the arrhythmogenic effects of catecholamines. Although halothane produces significant myocardial depression at high concentrations, this effect usually is mitigated by adequate volume replacement. Sevoflurane provides rapid induction and emergence, minimal airway irritation, and minimal myocardial sensitization to catecholamines. It is the least pungent of all of the inhalation agents, and it causes fewer effects than does halothane on myocardial function. Its principal disadvantages are (1) greater adverse effects on respiratory muscle function and respiratory drive than occur with halothane, and (2) higher incidence of emergence delirium than occurs with halothane. Desflurane may cause the least respiratory depression, but it is not recommended for inhalation induction or for airway surgery. It is highly pungent, causes a high incidence of severe laryngospasm, and is an airway irritant. These properties may be a problem during emergence as well as during induction. This agent produces significant tachycardia at higher concentrations.
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Isoflurane, while less pungent than desflurane, is considerably more pungent than are sevoflurane or halothane. Adjunctive agents OPIODS Opioids (narcotics) have been used as adjuncts to inhaled anesthetics to increase analgesia and as a part of a nitrous oxidenarcotic relaxant technique. All opioids reduce respiratory rate (apnea occurs with sufficient doses). When used alone, opioids do not control airway reflexes and do not provide reliable amnesia. All opioids can produce chest wall rigidity, an effect that can be minimized or avoided by slowly titrating small doses. Morphine may cause hypotension and the release of histamine. Fentanyl and sufentanil are more potent than is morphine, do not cause the release of histamine, and (when used in judicious doses) can be relatively short acting. Alfentanil, a congener of fentanyl with very short duration, has been supplanted by remifentanil, a new synthetic opioid of extremely short duration of action and rapid onset. Remifentanil can provide intense intraoperative analgesia with virtually no residual narcosis or respiratory depression at the end of the case. Because of a high incidence of apnea and bradycardia if bolus doses are given, this drug should be given by continuous infusion. Remifentanil has been used with great success in combination with propofol to provide balanced total intravenous anesthesia (TIVA); it is the authors preferred technique for laser and suspension laryngoscopy procedures. The authors use a mixture of 20 g of remifentanil per mL (10 mg) of propofol, and begin the infusion at 75 g/kg/min of propofol (0.150 g/kg/min of remifentanil). PROPOFOL The intravenous hypnotic propofol has become a mainstay in the anesthetic approach to laryngeal laser surgery. This agent provides complete amnesia, good control of hemodynamic responses, the ability to use O2/air for jet ventilation, and rapid smooth emergence. Propofol has antiemetic properties as well. Propofol has limited anesthetic properties, but the addition of remifentanil (see above) produces a balanced TIVA. The rapidity of action and offset of these agents allows rapid and precise control of anesthetic depth. LIDOCAINE Topical lidocaine, applied as a 1 to 4% spray to the vocal cords or instilled into the trachea after induction of anesthesia, can be an important adjunct to diagnostic airway procedures; it reduces the tendency toward laryngospasm or bronchospasm, and it reduces anesthetic requirements. Intravenous lidocaine (1 mg/kg) acts as a general anesthetic and can reduce airway reflex responses to laryngoscopy and intubation, but it is less effective than topical application. A maximum of 5 mg/kg can be administered by either route. ANTICHOLINERGICS Vagolysis is sometimes employed prior to airway procedures to reduce secretions and to minimize bradycardia associated with airway instrumentation. Routine use of an anticholinergic often is not necessary. If
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used, anticholinergics (with the possible exception of scopolamine) should be given prior to the procedure for best effect. These drugs may be administered orally as well as parenterally. The antisialogogue effects may take 15 minutes to occur. Their disadvantages are the loss of heart rate response as a sign of anesthetic depth, and the possibility of increased viscidity of secretions, which may produce inspissation in the respiratory tract. Atropine has been used most often, has a relatively short duration of action, and may cause delirium because it can cross the blood-brain barrier. Glycopyrrolate causes less tachycardia than does atropine. This drug may be more effective as an antisialagogue, lasts longer, does not enter the central nervous system, and is the best choice of anticholinergic. Scopolamine effectively reduces secretions, and it has a long duration and a minimal effect on heart rate, but it has sedative properties that can be profound, which may be undesirable postoperatively. HELIOX In cases of large airway obstruction, the inhalation of helium-oxygen mixtures (heliox) may reduce stridor and the work of breathing. Helium has a lower density than do oxygen, nitrogen, or nitrous oxide, and may convert turbulent gas flow to laminar flow. Concentrations of greater than 40% helium are required for clinical effect. Helium is compatible with all inhalation anesthetics, but specially calibrated heliox rotameters are required to be on the anesthesia workstation. In addition to decreasing stridor, heliox breathing speeds inhalation induction, and may improve oxygenation, even with lower inspired oxygen concentrations, by improving gas flow. MUSCLE RELAXATION There are a number of muscle relaxants available to the anesthesiologist, so the choice can now be tailored based on desired duration, mode of elimination, and side effects (eg, tachycardia and histamine release). For the patient undergoing airway endoscopy, a more fundamental consideration is whether to use relaxants at all and, if so, when? Spontaneous ventilation has several advantages, including (1) maintained gas exchange, (2) the ability to assess vocal cord and airway motion, and (3) the ability to obtain step-by-step control of the airway and avoid bridge burning (eg, a muscle-relaxed patient who cannot be intubated or ventilated). We usually avoid use of neuromuscular blockade except in suspension laryngoscopy and laser surgery (see below).

PHOTOGRAPHIC DOCUMENTATION
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Photographic documentation is an increasingly important aspect of medical care. Documentation is the key to effective communication, and occasionally it has legal ramifications. A picture or video of a complicated airway disorder is better than any description. The advantages of the video system are diverse and include Accommodation of multiple viewers Increased safety, especially at teaching institutions Enhanced education including via teleconferencing Facilitated documentation Hardware Blueprint To maximize the use of the video system, one should be aware of the system blueprint, as well as its special features (Figure 251). Light travels from the light source through a fiberoptic cable to the telescope, which illuminates the subject, and the reflected light is transmitted through a rod/lens system in the telescope center to the camera. The charged couple device (CCD) in the camera converts the reflected image into an electronic signal, which is then sent to the camera processor. Within the processing unit, the analog signal is converted into a digital signal and back to an analog signal, with adjustment and enhancement of the image occurring before it is transferred to the output cable.
Figure 251 Hardware blueprint of the typical video system.
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The various peripheral devices that can be attached include a monitor, a printer, a video recorder, or a digital capture device. The final resolution of the image generated is determined by the component with the least resolution. The take-home message is that one can buy an expensive camera and monitor, but if the telescope or light cable has many broken fibers, the image will be suboptimal. Each system component contributes to the final image quality. Video System Features When selecting a video system, the cost must be balanced against the systems performance and special features. Adequate illumination is a priority for any camera system. The best light source is xenon. A xenon light source provides a strong color-stable light. When selecting a video camera, the major decision is whether to select a camera that has three CCDs or a single CCD in its head. The threechip camera (which is more expensive) separates incoming light into the three primary colors and provides better resolution than does a one-chip camera. The processing unit has a variety of important features:
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Automatic exposure adjusts the amount of time that light is allowed to register on the chip, so that the image is not overexposed. Gain control compensates brightness when the available light is insufficient. A higher gain introduces more noise into the system, with the end result being a brighter image of lower quality. Gain should only be turned on when the light conditions are poor. Enhancement adjusts the brightness, contrast, and phase of the signal to optimize the image, which effectively reduces the noise level of the image. White-balance adjusts the camera to the light source. Different sources of light emit different colors; this affects the tone of a scene.
Connecting the System Output cables connect the processor to a variety of peripheral devices. One needs to match the output cable carrying the electronic signal to the resolution capacity of the peripheral device. All cables do not have the same ability to transfer information. If a high-resolution peripheral device is connected to a processor with a low-resolution cable, information will be lost. There are three types of video output cables: The composite cable (AKA BNC) is an all-in-one video signal format that sends all the information from the camera (ie, light, image, and color) down a single wire; it has a resolution of ! 230 lines. The Y/C cable (S video) has two separate channels in one large cable: they separate the video signal into two componentscolor and light. The Y/C cable has a resolution of ! 400 lines. The RGB cable has a separate cable for each color, and a resolution of ! 700 lines.
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A special cable is necessary to transfer a digital signal. For the transfer of digital information, resolution is measured in digital data size per frame; a better quality image has more bits per frame. Image Viewing and Storage The monitor displays the live image. In the operating room a high-resolution monitor (800 horizontal lines) is essential for the surgeon. In the office a lower resolution monitor may suffice. A printer reproduces a moment in time as a static picture. The best printer has 500 lines of horizontal resolution. Printers may be set up so that 1, 2, 4, 8, or 16 images may be printed on a single page. The major drawback of conventional printers is that, although a sequence of images may be stored, one cannot easily delete an unsatisfactory image during an operative procedure. A digital capture device stores multiple still images on a disk. At the procedures conclusion, one can download the best images to the printer and print a hard copy, or transfer these electronic images to a computer. To capture a dynamic view of the procedure, a video cassette recorder (VCR) is necessary. A standard VCR only has 240 lines of resolution. A still print generated from a VCR tape is of poor quality. A composite cable is sufficient to connect the VCR to the processor. An alternative to use of the standard VCR is attachment of a video camcorder to the system with a firewire cable. Although the signal is an analog signal, the camcorder can produce a high-quality reproduction. Since the higher-quality digital camcorders may record up to 60 blurfree frames per second, one may download a frame to a computer and then print a hard copy. This may be a less expensive option than use of a digital capture device; however, the disadvantage of this technique is that selection of the perfect image can be time consuming.
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PHARYNGOSCOPY Indications To examine the oral cavity and pharynx in uncooperative children under anesthesia To assess the extent of trauma (blunt or sharp) or burns (caustic or electrical) Procedure Adequate illumination with a headlight is generally sufficient. Exposure is enhanced with the Jennings or McIvor mouth gag. A Denhardt mouth gag helps when the lateral tongue or alveolar ridge is being examined. Hypopharyngoscopy is part of the laryngeal examination (see Laryngoscopy, below). Alternatively the nasopharynx can be examined with a 70 telescope from the oropharynx with the soft palate retracted (Figure 252).
Figure 252 Examination of the nasopharynx using a 70 telescope.

LARYNGOSCOPY Indications Diagnostic laryngoscopy is used to Assess alterations of anatomy ! Determine physiology of the larynx Therapeutic laryngoscopy is used to
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Ablate lesions ! Remove foreign bodies ! Dilate stenoses Anesthetic Considerations The use of anesthesia may be influenced by the age and overall medical condition of the patient.
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Awake diagnostic laryngoscopy is sometimes used in premature infants and infants younger than 3 months of age. The procedure is carried out while the patient is physically restrained with a sheet. Preparation Pediatric laryngoscopes and forceps currently in use at our institution are shown in Figures 253 and 254.
Figure 253 Sample of pediatric laryngoscopes.
Figure 254 Sample of the tips of forceps used in conjunction with laryngoscopy and bronchoscopy.
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Fiberoptic laryngoscopy using a fiberoptic nasopharyngoscope is an alternative to rigid laryngoscopy; however, because of the floppy epiglottis and the anteriorly placed larynx, this procedure is sometimes difficult to perform in young infants. Evaluation of an infant with a compromised airway should be performed in the operating room. An excellent alternative to the use of standard rigid laryngoscopes is the use of a telescope with the aid of an anesthesia laryngoscope. The ability to attach a video camera (see above) to the telescope enhances resolution and facilitates teaching. Because of potential synchronous airway lesions, laryngoscopy generally should be accompanied by bronchoscopy (see below). Procedure No 1. Introducing the laryngoscope The laryngoscope is held in the left hand, and the right index finger retracts the upper lip. In infants, moistened gauze is used to protect the alveolar ridge. However, for older children, it may be desirable to insert a tooth guard. The head (face forward) should be in the midline in a sniffing position. The laryngoscope is inserted on the right side of the tongue. The blade is rotated about 90 in most infants and children; the tip is inserted into the vallecula, and the epiglottis is identified (Figure 255). Exposure of the larynx is accomplished by pulling the epiglottis forward, not by prying on the teeth (Figure 256). The endoscopic view at this level is illustrated in Figure 257.
Figure 255 Laryngoscopy sequence I. The blade is rotated about 90 in most infants and children.
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Figure 256 Laryngoscopy sequence II. Arrows demonstrate correct and incorrect directions for lifting the laryngoscope.
Figure 257 Endoscopic view during laryngoscopy sequence I.
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The glottis can usually be visualized when the laryngoscope is advanced below the epiglottis. The endoscopic view at this level is shown in Figure 258. For an enhanced view, the rod-lens telescope can be used (Figure 259), and if a camera is attached, the vocal cord movement in infants can be recorded. If the glottis cannot be seen, it may be necessary to advance the tip of the laryngoscope down the laryngeal surface in the epiglottis. No 2. Diagnostic laryngoscopy Flexible laryngoscopy using a nasopharyngoscope is best facilitated by topical anesthesia2 to 4% lidocaine. Gentle sedation (if not contraindicated by airway status) can be achieved with nitrous oxide (by mask or nasal cannula) or midazolam. Larynx and vocal cord mobility can be assessed in anesthetized spontaneously breathing infants and children. One method is to perform a mask induction using inhalation agents. Nitrous oxide should be discontinued once consciousness is lost. When sufficient depth is obtained, the vocal cords and larynx are sprayed with 3 to 4 mg/kg of 2 to 4% lidocaine. The mask is then reapplied to re-establish appropriate anesthetic depth with spontaneous ventilation, and the table is turned to permit direct inspection of the larynx by the endoscopist. Close communication is required between the surgeon and the anesthesiologist because anesthetic depth continually decreases during the period of inspection.
Figure 258 Endoscopic view during laryngoscopy sequence II.
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No 3. Therapeutic laryngoscopy Foreign body removal. Once the larynx is exposed, foreign bodies can be removed by choosing the appropriate grasping forceps (see Figure 254). Laryngeal dilatation generally is performed in tracheostomized patients. Lubricated Jackson laryngeal dilators are inserted, which conform to the shape of the glottic opening in a serial fashion (Figure 2510).
Figure 259 Alternative method to examine the larynx using a rod-lens telescope.
Figure 2510 Laryngeal dilatation.
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No 4. Laser laryngoscopy Possible techniques include spontaneous ventilation with or without an endotracheal tube, use of laser-resistant endotracheal tubes, or suspension laryngoscopy with Venturi ventilation (see also Chapter 28). Regardless of the technique chosen, it is essential to confirm the ability to ventilate the patient using a mask before proceeding with muscle relaxation. No endotracheal tube (except metal ones), regardless of design or coating, is completely immune to ignition and combustion. Both oxygen and nitrous oxide support combustion, and, thus, the inspired oxygen concentration should be diluted as close to 21% as can be tolerated with either air or nitrogen. Metal laser endotracheal tubes are considerably larger in external diameter than are conventional tubes of the same size (internal diameter). We prefer suspension laryngoscopy with Venturi jet ventilation for the majority of laryngeal laser surgery procedures:
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Following successful induction and controlled mask ventilation, a muscle relaxant (usually atracurium, rocuronium, or vecuronium) is given. Muscle relaxation is essential to maximize chest wall compliance and ensure vocal cord immobility. This technique is potentially dangerous in the small child with upper airway obstruction; there must be adequate ability for exhalation; otherwise, gas trapping will occur, resulting in decreased cardiac output and airway barotrauma. Patients with significant obstruction in the region of the glottic opening may require debulking around an endotracheal tube to provide a sufficient opening for subsequent Venturi ventilation. Total intravenous anesthesia is achieved by using a propofol and remifentanil infusion.
Once adequate ventilation and muscle relaxation are established, the table is turned, and the suspension laryngoscope is placed.
!
A catheter, connected via a length of flexible tubing to the highpressure gas source/variable pressure-reducing valve, is aimed at the glottic opening. Both the surgeon and the anesthesiologist must confirm that this catheter is aimed appropriately, and its position must be constantly monitored. Insufflation pressure is best titrated to chest excursion. Driving pressures between 6 and 8 pounds per square inch (psi) for infants, 10 and 12 psi for children, and 12 and 16 psi for teenagers are usually adequate. The pressure limit setting on the Venturi injector should be adjusted before use to ensure that safe driving pressures are not exceeded.
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Nonetheless, continuous clinical inspection of catheter position/ aim, chest movement, and breath sounds is required.
!
When performed correctly, gas exchange has been shown to be acceptable in infants and children ventilated in this manner.
There are two options to manage the airway during emergence from anesthesia:
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After neuromuscular blockade is reversed, the patient may be allowed to emerge breathing spontaneously on a mask. This technique avoids the patient coughing on the endotracheal tube and the possibility of bronchospasm and iatrogenic trauma to the freshly operated airway. The risk of this technique is that the patient has an unprotected airway, which potentially is exposed to secretions and blood. This can produce laryngospasm as well as aspiration. Alternatively the airway may be protected by intubating at the end of the procedure. The patient is then extubated after emergence is completed, with airway reflexes intact. If a propofol-remifentanil infusion is used, this procedure usually can be accomplished smoothly with a minimum of coughing, if timed properly.
Cool mist, intravenous dexamethasone, or nebulized racemic epinephrine may be useful to treat postoperative stridor. BRONCHOSCOPY Indications Diagnostic bronchoscopy is used to
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Assess the anatomy of the tracheobronchial tree Perform a biopsy of lesions Culture or perform histologic examination of the secretion Remove tracheal and bronchial lesions and foreign bodies Dilate stenoses
Therapeutic bronchoscopy is used to

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Anesthetic Considerations General anesthesia is used in most rigid bronchoscopies. Topical anesthesia is used occasionally in extremely premature or unstable patients. Smaller bronchoscopes (especially those < 4 mm) with the telescope in place may significantly increase airway resistance. Increased resistance may be tolerated for relatively brief periods by spontaneously breathing infants. Spontaneous ventilation may be optimal to diagnose dynamic lesions such as tracheomalacia or bronchomalacia. It also may be a crucial method to maintain adequate gas exchange in cases of severe obstruction (eg, with a foreign body).
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In paralyzed subjects the passive recoil properties of the lung and chest wall are the only forces producing expiratory gas flow. A slow gentle pattern of manual ventilation is probably best, using larger-than-normal tidal volumes at reduced rates. Regardless of the mode of ventilation, frequent removal of the telescope (at least every 5 minutes, or more often if the patients condition so indicates) allows restoration of normocarbia and normoxia. Similarly, prolonged endobronchial intubation must be avoided. Suctioning can rapidly deplete lung oxygen content and accelerate the development of hypoxia. Suctioning should be brief and at reduced flow rates. Adequate ventilation may be impossible if the size of the patient (or that of the airway) requires the use of very small bronchoscopes (< 3 mm).
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The patient should be hyperventilated with 100% oxygen prior to telescope insertion, followed by apneic oxygenation during telescopic examination. The adjustable pressure relief (pop-off ) valve should be kept open. Higher than usual fresh gas flow rates may be helpful, but one must be careful to avoid pulmonary overdistention and air trapping if exhalation is restricted.
Preparation Two main types of bronchoscopes are available: open bronchoscopes and rod-lens bronchoscopes (Figures 2511A and B). Illumination during bronchoscopy can be accomplished by proximal or rod-lens lighting. Rod-lens telescopes offer the advantages of magnification, angled views (Figure 2512), if necessary, and video documentation. A variety of forceps (see Figure 254) and optical forceps (Figure 2513) are available.
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Figure 2511 A and B, Parts of a rod-lens bronchoscope.
Figure 2512 Angled views of rod-lens telescopes.
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Figure 2513 A variety of optical forceps for bronchoscopy and esophagoscopy.
Procedure No 1. Introducing the bronchoscope A defogging solution or warm saline is used to prevent condensation on the lens. The neck generally is extended with a shoulder roll unless extension is contraindicated for clinical reasons. The larynx is exposed as described above (see No 1. Introducing the laryngoscope). The gums and teeth are protected with a tooth guard and by suspending the bronchoscope with the thumb and forefinger (Figure 2514). The bronchoscope is inserted alongside the laryngoscope (Figure 2515); it is then turned 90 to align the leading edge of the bronchoscope with the vocal cords (Figures 2516A to D). As the left hand guides the bronchoscope into the trachea, the laryngoscope is removed. The index finger and thumb grasp the instrument, and the other fingers are inserted into the mouth to help stabilize the patients head (see Figure 2514). The bronchoscope has a male connector for the anesthesia tubing, which should be supported by the anesthesiologist throughout the procedure.
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Figure 2514 Gum and teeth protection using a tooth guard and suspension of the instrument.
Figure 2515 Insertion of a bronchoscope.
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Figure 2516 A to D. Sequence of passing the bronchoscope through the larynx. The asterisk indicates the orientation of the bronchoscope, and the arrows indicate the rotation and direction of the bronchoscope.
No 2. Diagnostic bronchoscopy The carina is identified as a sharp vertical spur (Figure 2517), but it may be blunt in the very young patient. To expose the right mainstem bronchus, the tip of the bronchoscope is turned to the right, slight lateral pressure is applied, and the childs face is rotated to the left. The endoscopic view is shown in Figure 2518. To expose the left mainstem bronchus, the tip of the bronchoscope is rotated to the left, and the childs face is turned to the right. Secretions can be removed using a metal-tipped suction that is inserted proximally. A blunt-tipped suction is preferred to avoid mucosal trauma. Secretions also can be removed with polyethylene tubing (internal diameter, 2 mm) that is inserted from the side channel. It is possible to direct the tubing into segmental bronchi for selective suctioning. Pneumothorax is a potential occurrence.
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Figure 2517 Endoscopic view of the carina.
Figure 2518 Endoscopic view of the right mainstem bronchus when the head is rotated to the left.
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No 3. Foreign body removal The preferred anesthetic technique for airway foreign bodies is bronchoscopy under spontaneous ventilation. Following a careful inhalation induction (the duration of which may be prolonged if obstruction is severe), spontaneous ventilation is maintained with deep inhalation anesthesia. ! Some clinicians prefer to use muscle relaxation during bronchoscopy and foreign body removal, but this has some additional risks. The use of positive pressure ventilation may pose a risk of propelling the foreign body deeper into the tracheobronchial tree. ! Muscle relaxation should not be attempted until a careful sequence of assisted to controlled ventilation has demonstrated adequate gas exchange in the absence of spontaneous ventilation. The first objective of airway foreign body removal is the assessment of the airway itself. When the airway is reasonably secured, the feasibility of foreign body removal is entertained. More than one procedure is sometimes necessary to remove the entire foreign body and associated granulation tissue. On a rare occasion an open procedure performed by the thoracic surgeon may be necessary.
!
The choice of forceps depends on the type of object aspirated: The most frequently aspirated vegetable matter is a peanut, which is removed with an optical double-action peanut forceps. ! Round objects are removed with the forward-grasping forceps. ! Sharp objects are removed with a grasping forceps, which sheaths the point inside the bronchoscope during retrieval. Once an appropriate forceps has been selected, the following sequence can be performed:
!
The bronchoscope is positioned proximal to the foreign body, and the secretions are suctioned using the flexible catheter. ! The telescope is removed, and the optical forceps is inserted. The jaws of the forceps are opened once it is beyond the bronchoscope. ! The foreign body is engaged, and the forceps is withdrawn through the bronchoscope. A fragile foreign body or sharp object is removed by sheathing it in the bronchoscope, and the bronchoscope and forceps are removed together. ! Cessation of ventilation at the time of removal is important. The airway distal to the foreign body is examined to rule out the presence of additional foreign bodies and to remove secretions.
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Most foreign bodies incite surrounding inflammation and granulation tissue formation. The goal is to minimize bleeding during foreign body removal. Instillation of vasoconstrictive agents (eg, NeoSynephrine) via a flexible suction catheter is sometimes useful. The remaining granulation tissue following foreign body removal may be removed using a cup forceps.
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No 4. Therapeutic bronchoscopy Laser bronchoscopy. Various laser bronchoscopy delivery systems are available. In the past we have used primarily the CO2 laser [Coherent (Santa Clara, CA)] coupled with a laser bronchoscope system. Currently, we prefer the KTP laser [Laserscope (San Jose, CA)]. Ambient oxygen concentration should be at the lowest level before the laser is used. Limitations exist in using CO2 in infants and small children owing to their size relative to the instrument. Electrocautery. The Bugbee electrocautery unit [Karl Storz (Culver City, CA)] can be used in conjunction with the rod-lens system. Lesions are cauterized by inserting the Bugbee electrode down the side port until it extends beyond the bronchoscope. Controlled cauterization can be obtained by manipulating the bronchoscope. Ambient oxygen concentration should be at the lowest level before the laser is used. Tracheobronchial dilatation. Tracheobronchial stenoses can sometimes be treated by successive dilatation with bronchoscopes, laser resection, angioplastic balloon, and open surgical correction. Postoperative Care A postoperative chest radiograph is often helpful when ruling out complications. Postobstructive pulmonary edema may occur and should be treated aggressively.
578

ESOPHAGOSCOPY Indications Diagnostic esophagoscopy is used to Assess the anatomy of the esophagus ! Evaluate the degree of pathologic changes Therapeutic esophagoscopy is used to
!
Remove foreign bodies ! Dilate stenoses Anesthetic Considerations and Preparation In children this procedure is performed under general anesthesia (usually after endotracheal intubation).
!
Similar to the bronchoscopes, esophagoscopes are classified as open or telescopic (Figure 2519). The rod-lens type of esophagoscope has several advantages over the distal lighting esophagoscope: it provides better image resolution, it can be a teaching tool, and it can be adapted to use with a video camera. The use of a shoulder roll during esophagoscopy is optional. Procedure No 1. Introducing the esophagoscope The esophagoscope is advanced using one of two methods: Without guidance, by identifying the cricopharyngeus muscle (Figure 2520) ! By placing a nasogastric tube as a lumen finder The hypopharynx is exposed using a laryngoscope as described above for direct laryngoscopy, but the instrument is passed posteriorly so the arytenoids can be visualized.
!
The cricopharyngeus is identified by its oval appearance and may be opened by forward traction to the larynx. If it is difficult to visualize the cricopharyngeus, and there is no foreign body beneath it, it may be identified by passing a catheter through the nose into the hypopharynx and upper esophagus. When the cervical esophagus is entered, secretions may obscure visualization and should thus be removed with suction. The rod-lens esophagoscope may be pulled back from the end of the esophagoscope so that it will not become clouded by secretions. The left hand guides the esophagoscope and protects the teeth with the thumb and index finger (identical to the technique described above for insertion of the bronchoscope). As the instrument passes from the cervical to the thoracic esophagus, the patients shoulders are elevated so the thoracic esophagus can be visualized. In the region of the heart, there is prominent cardiac pulsation. The esophagoscope is advanced slowly, while the lumen is visualized.
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Figure 2519 Rod-lens esophagoscopes.
Figure 2520 An endoscopic view of the cricopharyngeus muscle.
No 2. Foreign body removal Similar instruments are used for removal of esophageal foreign bodies as for airway foreign bodies. The timing for foreign body removal depends on the degree of distress. Removal in patients who are comfortable and who do not have potential airway compromise may be delayed for optimal timing. Because the endotracheal tube can be dislodged easily during the passage of the foreign body and esophagoscope through the pharynx, the surgeon-anesthetist team approach is important. The technique and forceps employed depend on the type of object to be removed:
580
Coins generally can be removed safely with an optical forceps through a rod-lens esophagoscope or with a grasping forceps through an esophageal speculum. ! Round objects generally are removed easily with the bead-grasping forceps through a Jackson esophagoscope. ! Sharp objects are sheathed into the esophagoscope by using a grasping forceps through a rod-lens esophagoscope. ! Jackstones are difficult to remove because of their size and sharp points. Figure 2521 illustrates how the sharp point is rotated into a Jackson esophagoscope and the jackstone is removed using a grasping forceps. Mucosal tears are common and may result in pneumomediastinitis and esophageal perforation. ! Safety pins have rarely been seen at our institution during the past two decades. The original techniques described by Jackson are presented (Figures 2522 A to F). The distal esophagus must be examined after foreign body removal to rule out the presence of additional objects or lesions. Not all esophageal foreign bodies are radiopaque.
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No 3. Caustic ingestion Oral cavity and pharyngeal examination are not sufficient to determine the extent of esophageal injury. Life-threatening caustic burns may require immediate surgical intervention. Generally, caustic ingestion is evaluated within 24 hours after the event to assess the depth of the burn. The esophagus is examined, and the sites and depth of caustic burns are noted. When concentric third-degree burns are identified, the esophagoscope is not advanced. Current management of a severe burn is as follows: Insert a small plastic tube through the side arm of the esophagoscope into the stomach. ! Perform a gastrotomy and retrieve the tube from the stomach. Either a string (monofilament suture) or a Silastic feeding tube can be pulled through the nose, esophagus, and gastrostomy to maintain a lumen. ! Use parenteral hyperalimentation for initial nutrition. ! Commence feeding through the gastrotomy tube when satisfactory healing has occurred. Retrograde dilatation is required when a repeat esophagoscopy reveals stenosis, but it can be started only following maturation of the gastrostomy.
! !
Before the dilatation procedure, Tucker bougies are attached to each other with sutures in the order of increasing calibers. The strength of each knot is tested individually.
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Figure 2521 Removal of a jackstone.
Figure 2522 Safety pin removal sequence (Jacksons classic technique). A, The rotation forceps is shown before the pin is seized by the ring of the spring end. (Forceps jaws are shown opening in the wrong diameter.) B, The pin is seized in the ring by the points of the forceps. C, The pin is carried into the stomach and is about to be rotated by withdrawal. D, The withdrawal of the pin into the esophagoscope closes the pin. If the pin is withdrawn by flat-jawed forceps (E), the esophageal wall will be fatally lacerated (F). (Adapted from Jackson C. Bronchoesophagoscopy. Philadelphia: WB Saunders; 1950. p. 251.)
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The loop of suture between the nostril and the gastrotomy stoma placed during the gastrotomy procedure is divided. The gastrotomy tube is then removed. Two sutures of the same length are pulled from the stoma through the nostril. One suture becomes the loop suture at the end of dilatation. The other suture is secured to the string of bougies. The suture that is attached to the bougies is pulled through the oral cavity. The Tucker bougies, which are coated with a lubricant, are then pulled through the stoma individually (Figure 2523). Dilatation is completed when moderate resistance is encountered. The bougies are separated by dividing the connecting suture and withdrawing it through the oral cavity. The remaining suture through the nostril is attached to the other end to form a loop. The gastrotomy tube is replaced. Erosion of the suture through the ala can be prevented by proper taping. Leakage of gastric content around the gastrotomy tube is seen commonly following dilatation.
Prograde dilatation is used for isolated strictures or webs. It is also useful for strictures that have been dilatated adequately using the retrograde method.
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Esophagoscopes may be used as esophageal dilators through serial dilatations. Dilatation can be performed through an anesthesia laryngoscope for a high stricture or through an esophagoscope for a low stricture. Hurst and Maloney bougies are available for this type of dilatation.
BIBLIOGRAPHY
Berci G. Endoscopy. New York: Appleton-Century-Crofts; 1976. Fleming MD, Weigelt JA, Brewer V, McIntire D. Effect of helium and oxygen on airflow in a narrowed airway. Arch Surg 1992;127:95660. Grundmann U, Uth M, Eichner A, et al. Total intravenous anaesthesia with propofol and remifentanil in paediatric patients: a comparison with a desflurane-nitrous oxide inhalation anaesthesia. Acta Anaesthesiol Scand 1998;42:84550. Jackson C, Jackson CL. Bronchoesophagology. Philadelphia: WB Saunders; 1950. Linder TE, Simmen D, Stool SE. Revolutionary interventions in the 20th century. Arch Otolaryngol Head Neck Surg 1987;123:11613. McCombie CW, Smith JC. Harold Horace Hopkins. Biog Mems Fell R Soc Lond 1998;44:23752. Motoyama EK. Sevoflurane in pediatric ENT procedures. Int Anesthesiol Clin 1997;35:937. Scamman FL, McCabe BF. Supraglottic jet ventilation for laser surgery of the larynx in children. Ann Otol Rhinol Laryngol 1986;95:1425. Szekely E, Farkas E. Pediatric bronchology. Baltimore: University Park Press; 1978.
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Figure 2523 A to G, Retrograde esophageal dilatation. (Reproduced with permission from Riding KH, Bluestone CD. Burns and acquired strictures of the esophagus. In: Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saunders; 1990. p. 1004.)
C H A P T E R 26
T RACHEOTOMY
Margaretha L. Casselbrant, MD, PhD Cuneyt M. Alper, MD
TRACHEOTOMY Tracheotomy is the act of cutting a hole in the trachea, whereas tracheostomy is the actual opening in the trachea. Indications Upper airway obstruction Prolonged mechanical ventilation Pulmonary toilet Anesthetic Considerations Use of general anesthesia is preferred, with an endotracheal tube or a bronchoscope in place to establish a safe airway and ventilation of the patient during the surgical procedure. If the airway cannot be secured because of an anatomic abnormality or a cervical spine fracture, a laryngeal mask airway or local anesthesia are used. Preparation To obtain maximal exposure of the trachea, a roll is placed under the shoulders to extend the neck and bring the trachea more anterior. The chin is held in position by the anesthesiologist, or by tape placed around the chin and secured to the operating table (Figure 261). Any esophageal tubing (eg, nasogastric tube or esophageal stethoscope) should be removed to ensure correct identification of the trachea. The patients neck is prepared and draped in such a way that the face is not covered. The neck is palpated, and the thyroid and cricoid cartilages are identified. 1. The infant larynx is high in the neck with the cricoid cartilage as the most prominent structure. 2. The thyroid cartilage has a broader angle in infants and is partially shielded by the hyoid superiorly. The trachea is soft and has more lateral mobility. 3. The cartilages, suprasternal notch, and skin incision should therefore be marked to avoid disorientation (Figure 262).
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Figure 261 Positioning of the patient.
Figure 262 Anatomy of the neck and suggested skin incisions.
Local anesthetic (1.0% lidocaine with 1:100,000 epinephrine, or, in infants, 0.5% lidocaine with 1:200,000 epinephrine) is injected into the planned skin incision for hemostasis. Prior to the procedure, an age-appropriate size tracheostomy tube should be selected (Table 261) with one size larger and one size smaller tracheotomy tube immediately available. Tubes are available in different sizes (width and length), shapes (neonatal and pediatric), materials (silicone and plastic), and may be cuffed or uncuffed (Figure 263). Pediatric tracheostomy tube sizes correspond to those of endotracheal tubes based on inner diameter. The tracheostomy tube in a child may be half a size (in mm) larger than the appropriate endotracheal tube. If needed, a tracheostomy tube can be custom ordered.
Tracheotomy
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Table 261 Suggested tracheostomy tube sizes

Childs Age Inner Diameter (mm)
Premature, <1000 g Premature, 1000-2500 g Neonate 6 months 6 months 1 year 1 2 years > 2 years
2.5 3.0 3.0 3.5 3.5 4.0 4.0 5.0 (Age in years +16) / 4
Figure 263 A, Tracheostomy tubes: Shiley Neonatal (upper left), Shiley Pediatric (upper right), Bivona Neonatal cuffed tube (lower left), and Bivona Pediatric cuffed tube (lower right). B, Bivona tracheostomy tubes (left to right): Hyperflex Pediatric, Adjustable Neck Flange Hyperflex Pediatric, Flex Tend Pediatric, Hyperflex Cuffed Pediatric.
588
Procedure The skin is incised horizontally midline between the cricoid and the sternal notch, and the incision is carried through the subcutaneous tissue. Excessive subcutaneous fat is removed with electrocautery. The trachea is palpated repeatedly during dissection, which is carried out in the vertical direction to ensure an accurate approach to the trachea in the midline and to avoid injuring the recurrent laryngeal nerve or vascular structures. The fascia is grasped on each side of the midline with a hemostat or forceps, elevated, and divided with scissors (Figure 264). The edges are undermined. The anterior jugular veins and the strap muscles are identified (Figure 265). Senn retractors are used to retract the muscles laterally, and to stabilize the trachea in the midline. Excessive lateral dissection is avoided to prevent subcutaneous air dissection or injury to the cupula of pleura, which would result in complications. The thyroid isthmus may need to be undermined, freed, and retracted superiorly if it overlies the trachea. When retraction is not possible, the isthmus is double-clamped, divided, and suture-ligated. Dissection is continued until the pretracheal fascia is identified. Stay sutures (4-0 nonabsorbable) are placed bilaterally, approximately 2 mm from the midline, around at least two tracheal rings (Figure 266).
Figure 264 Dissection of the fascia in the midline.
Tracheotomy
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Figure 265 Identification of the strap muscles and the anterior jugular vein.
Figure 266 Placement of stay suture at the second and third tracheal rings.
590
After hemostasis is obtained, a vertical incision is made with a scalpel in the midline of the second and third (or third and fourth) tracheal rings (Figure 267). ! No cartilage is removed when performing tracheotomy in children. ! When using electrocautery near the tracheostomy, ignition is prevented by reducing the FiO2 and by avoiding the endotracheal tube. Some authors recommend suturing the skin edges to the tracheal stoma with 4-0 chromic sutures to create a secure stoma; however, there is not enough evidence that this decreases complications and does not increase the fistula rate. The tracheostomy tube is inserted while applying slight traction on the stay sutures to open the stoma (Figure 268). Prior to inserting the tube, the endotracheal tube or bronchoscope is pulled back above the stoma but not out of the trachea. When satisfactory ventilation has been established through the tracheotomy tube, the endotracheal tube is removed. Ties are placed around the neck to secure the tube with the head in neutral position. One finger should be able to barely pass under the ties with the neck flexed to prevent accidental decannulation. The stay sutures, which are labeled right and left, are taped to the chest without tension (Figure 269). Labeling the sutures prevents acci-
Figure 267 Midline tracheal incision.
Tracheotomy
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Figure 268 Tracheal incision is stented open by traction on the stay sutures.
Figure 269 Position of the tracheal tube and adjustment of tracheostomy tapes. Stay sutures are secured and labeled.
592
dental crossing or twisting. The sutures facilitate safe re-insertion of the tube if it is dislodged or obstructed. The position of the tracheostomy tube can be assessed with a flexible laryngoscope through the tracheostomy tube. Postoperative Care A routine chest X-ray is obtained to assess the position of the tip of the tracheostomy tube and to rule out any intrathoracic complications such as pneumothorax, pneumomediastinum, or atelectasis. The patient is observed in the intensive care unit, or in a similar supervised setting, during the first 5-7 days. A same-sized tracheostomy tube and a tube that is one size smaller are kept at the bedside in case of emergency. Humidified air is provided by way of a tracheotomy collar or ventilator. Suctioning is performed following instillation of normal saline. The first tracheostomy tube change is performed on postoperative day 5-7, after which the stay sutures are removed if the tracheostomy tract is mature. If there are no stay sutures or the tract is not mature, a suction catheter inserted through the old tracheostomy tube can be used as a guide over which the new tracheostomy tube is inserted Complications Hemorrhage Subcutaneous emphysema Pneumothorax/pneumomediastinum Cricoid cartilage injury Esophageal puncture Recurrent laryngeal nerve injury
Tracheotomy
TRACHEOCUTANEOUS FISTULA CLOSURE
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After decannulation of a child, a tracheocutaneous fistula may persist. The fistula will allow mucus to exit during coughing but prevents swimming and bathing due to risk of aspiration. Indication Persistent tracheocutaneous fistula one year after decannulation Anesthesia Considerations The procedure should be performed under general anesthesia administered through an endotracheal tube or a bronchoscope. When using electrocautery near the tracheostomy, care should be taken to prevent ignition by reducing the FiO2. Preparation Prior to closure of the tracheocutaneous fistula, bronchoscopy is performed to evaluate the patency of the airway. In a patient with a borderline patent airway, closure of the fistula could cause respiratory distress requiring re-insertion of the tracheostomy tube. The patient is positioned as for a tracheostomy with the neck extended and the shoulder resting on a roll (see Figure 261). Local anesthetic (1% lidocaine with 1:100, 000 epinephrine) is injected in the area of the planned skin incision. Procedure An elliptical skin incision is marked around the opening of the tracheocutaneous fistula. The skin is incised and small flaps are elevated above and below the incision (Figure 2610).
Figure 2610 Elliptical skin incision and dissection of the tracheocutaneous tract.
594
The skin with the tract is dissected with scissors from the surrounding tissue down to the opening in the trachea. The tract is separated from the trachea with a knife (Figure 2611). Cartilage removal is generally unnecessary. If cartilage is removed, the amount should be minimal. There are different techniques for closure of the fistula. Regardless of technique, subcutaneous emphysema must be prevented.
!
A small tracheal opening can be left to close spontaneously. A larger tracheal opening can be closed primarily with 4-0 Vicryl sutures.
Strap muscles, subcutaneous tissues, and skin are closed loosely in layers with a drain beneath the strap muscles to prevent subcutaneous emphysema (Figure 2612). Alternatively, the incision may be left open and allowed to heal by secondary intention. This minimizes the risk of subcutaneous emphysema with an acceptable cosmetic result. Postoperative Care The patient is observed overnight in an intensive care unit, or a similarly supervised setting, for early detection and management of respiratory distress or subcutaneous emphysema. The drain is removed after 24 hours. Complications Subcutaneous emphysema Pneumothorax Respiratory distress
Tracheotomy
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Figure 2611 The tract is excised close to the opening in the trachea.
Figure 2612 Placement of drain under the strap muscles to prevent subcutaneous emphysema.
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BIBLIOGRAPHY
Myers EN, Stool SE, Johnson JT. Tracheotomy. New York: Churchill Livingstone; 1985. Rothfield RE, Petruzzeli GJ, Stool SE. Neonatal tracheotomy tube modification. Otolaryngol Head Neck Surg 1990;103:133134. Wetmore R. Tracheotomy. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology. 3rd ed. Philadelphia (PA): WB Saunders; 1996. p.142540.
C H A P T E R 27
S URGERY
OF THE L ARYNX AND T RACHEA

Greg R. Licameli, MD Gerald B. Healy, MD
Surgical conditions of the pediatric airway may be classified as supraglottic, glottic, subglottic, or tracheal. Although these disorders are infrequent, surgery can be lifesaving or improve the quality of life. The most commonly performed procedures in children are illustrated in this chapter and include the following: Supraglottic proceduresendoscopic arytenoidectomy, open (external) arytenoidectomy, and supraglottoplasty Glottic proceduresglottic web excision, posterior glottic stenosis repair, and laryngeal separation Subglottic procedureslaryngeal decompression (cricoid split) with hyoid interposition, augmentation laryngoplasty with cartilage graft, and augmentation laryngoplasty with cartilage stent Tracheal proceduressegmental tracheal resection, and cricotracheal resection ARYTENOIDECTOMY Bilateral vocal cord paralysis is a difficult and challenging problem (Figure 271A). Arytenoidectomy offers an opportunity for decannulation in selected cases. Either an endoscopic or an open (or external) approach may be used. Airway enlargement at the glottic level often comes at the price of voice degradation, which must be appreciated fully by the patient and family prior to surgery. First described by Jackson in 1922, the procedure today is facilitated by the laser. Advantages over cold techniques include improved hemostasis and decreased tissue manipulation. Indications Bilateral vocal cord paralysis in patients in whom spontaneous resolution has not taken place within 18 months of onset Chronic arytenoid dislocation with obstruction of the glottis Inability to decannulate because of glottic obstruction
598
Anesthetic Considerations The procedure is performed under general anesthesia.

!
If a tracheostomy is present, anesthesia is delivered through this port. If an endoscopic laser technique is employed, a noncombustible tracheostomy tube must be used.
Maximal muscle relaxation facilitates the procedure. An intravenous line and pulse oximeter are placed. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. If an open procedure is used, the neck is prepared with Betadine solution and is then draped. The incision area is infiltrated with 1:200,000 epinephrine (1 to 2 mL). The eyes and face are protected if the laser is to be used. 1:200,000 epinephrine solution (1 mL) is injected into the arytenoid area for hemostasis. Procedure No 1. Endoscopic arytenoidectomy Arytenoidectomy may be performed endoscopically using a suspension binocular laryngoscope and operating microscope. The CO2 or KTP laser is extremely useful for the procedure. A horizontal incision is made over the arytenoid cartilage with a laser or sickle knife (Figure 271B). The arytenoid is grasped with alligator forceps, and the perichondrial attachments are separated with a laser or scissors (Figure 271C). The arytenoid cartilage is removed. The posterior one-third of the true vocal cord is resected to improve the glottic aperture (Figure 271D). The mucosal incision is sutured with 5-0 polyglactin 910.
Surgery of the Larynx and Trachea
599
D1
D2
Figure 271 Arytenoidectomyendoscopic approach. A, Bilateral abductor paralysis with vocal cords in the paramedian position. B, The incision over the arytenoid may be made with a laser or a sickle knife in the endoscopic approach. C, The arytenoid is grasped with alligator forceps, and attachments are separated with a laser or scissors. D, The posterior one-third of the true cord is resected to improve the glottic airway.
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No 2. Open-technique arytenoidectomy If an open approach is employed, an external horizontal skin incision is made at the midlevel of the thyroid cartilage and is carried to the margins of the sternomastoid muscle (Figure 272A). The dissection is carried subcutaneously through the platysma, exposing the external hyoid muscles. The strap muscles are separated in the midline to expose the thyrohyoid membrane, the anterior aspect of the thyroid cartilage, and the cricothyroid membrane. A vertical incision is made through the cricothyroid membrane and is carried up through the anterior thyroid cartilage in the midline. The thyroid laminae are retracted laterally (Figure 272B). A vertical incision is made through the epithelium anterior to the vocal process of the arytenoid. The vocal process is dissected free, and then the posterior cricoarytenoid, the lateral cricoarytenoid, and the thyroarytenoid muscles are cut. The cricoarytenoid joint is transected, and the arytenoid is removed. The incision is closed with a 4-0 polyglactin 910 suture (Figure 272C and D). A mattress suture is placed above and below the vocal cord with a 20 polyglactin 910 suture, then pulled through the thyroid lamina, and tied laterally. This lateralizes the vocal cord. The thyroid cartilage is closed with a 2-0 polyglactin 910 suture. The wound is closed in layers over a drain. Postoperative Care Wound care is undertaken twice a day. Systemic antibiotics are employed for 7 to 10 days. Meticulous tracheotomy care is encouraged.
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Figure 272 Arytenoidectomyexternal approach. A, A horizontal skin incision is made at the midlevel of the thyroid cartilage, and the thyroid cartilage is visualized. A vertical incision is made in the thyroid cartilage in the midline. B, A vertical incision is made through the epithelium anterior to the vocal process. C, The cricoarytenoid joint is transected, and the arytenoid is removed. D, The incision is closed with a 4-0 polyglactin 910 suture (PDS).
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SUPRAGLOTTOPLASTY Congenital laryngeal stridor (laryngomalacia) is usually self-limited; however, some patients have respiratory distress with associated symptoms severe enough to require surgery to improve ventilation. Indication Severe laryngomalacia (Figure 273A) causing obstructive apnea, cyanosis, cor pulmonale, or failure to thrive Anesthetic Considerations General anesthesia is employed in all cases. Combustion precautions are taken with the endotracheal tube if the laser is to be used. An intravenous line and a pulse oximeter are placed. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. The eyes and face are protected if the laser is used. Dexamethasone 1.5 mg/kg up to 20 mg is given in a single intravenous dose. Antireflux therapy is begun prior to surgery. Procedure Suspension microlaryngoscopy is employed with the CO2 or KTP laser. Excess mucosa over the cuneiform cartilages and arytenoids is vaporized (see Figures 273A and B). In severe obstruction (see Figure 273A), division of the aryepiglottic folds is completed with the laser to release the epiglottis. The mucosa may be trimmed from the lateral edges of the epiglottis, the aryepiglottic folds, and the arytenoids and corniculate cartilages (epiglottoplasty). Unilateral surgery can be performed in selected patients. The risk of supraglottic stenosis may be less due to fewer demucosalized surfaces. The risk of postoperative aspiration also may be decreased. Postoperative Care The patient is kept in a humidified atmosphere. Systemic antibiotics are administered for 7 to 10 days. Aggressive antireflux therapy helps to avoid healing difficulties.
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Figure 273 Supraglottoplasty. A, Supraglottic structures demonstrating significant obstruction. B, Laryngeal appearance after excision of redundant mucosa and division of aryepiglottic folds.
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GLOTTIC WEB EXCISION Congenital webs are commonly located in the anterior one-half to twothirds of the glottis. The lesion may be thick or thin and may extend into the subglottic space. Patients usually present with aphonia and demonstrate varying degrees of respiratory distress, depending on the amount of obstruction present. Webs occupying more than 50% of the glottis (Figure 274A) usually require treatment because of potential of airway compromise with a concurrent upper respiratory tract infection. Thin webs may be lysed with a laser or microsurgical instruments, but thicker webs with subglottic extension may require a tracheostomy. Indications Glottic web occupying 50% or more of the glottic inlet Glottic web causing respiratory distress or significant aphonia Anesthetic Considerations General anesthesia is always required. An intravenous line and a pulse oximeter are placed. If possible a small-bore fire-retardant endotracheal tube is inserted and a short-acting paralytic agent is given to stop vocal cord activity. Dexamethasone 1.5 mg/kg up to 20 mg is given in a single intravenous dose. If a tracheostomy is present, a fire-retardant tube should be inserted. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. The eyes and face are protected if the laser is used. Antireflux therapy is begun prior to surgery. Procedure A microsurgical technique with or without the laser is employed. Microscissors or a laser is used to divide the web along the free edge of one vocal cord (Figure 274B). Thin webs are easily lysed. Thick webs with subglottic extension require stenting with a keel or endotracheal tube to keep the opposing raw surfaces separated. A keel (Boston Medical Products, Westborough, MA) is placed endoscopically (Figure 274C), but a tracheostomy is required to maintain the airway. ! Alternatively the patient is intubated nasally, and the tube is left in place to stent the glottis for several days after surgery. Postoperative Care If a keel or endotracheal tube has been used, prophylactic antibiotics are given until the foreign object is removed.
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Antireflux therapy is continued. A keel is removed endoscopically after 5 to 7 days. An endotracheal tube is removed after 3 days.
Figure 274 Glottic web excision. A, A horizontal skin incision at upper level of the thyroid cartilage. B, A cut (vertical) is made through the thyroid lamina, mucosa, and web. C, A keel (or endotracheal tube) is inserted for 5 to 7 days.
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POSTERIOR GLOTTIC STENOSIS REPAIR The severity of posterior glottic stenosis varies from a thin web to a thick scar band. Management depends on the extent of the stenosis present. Thin webs may be divided with the CO2 laser (described below), but severe scarring and arytenoid fixation require division of the scar and the posterior cricoid with cartilage augmentation (not described). Indication Mild to moderate stenosis of the posterior glottis (Figure 275A) Anesthesia Considerations General anesthesia is always required. An intravenous line and a pulse oximeter are placed. If possible a small-bore fire-retardant endotracheal tube is inserted and a short-acting paralytic agent is given to stop vocal cord activity. Dexamethasone 1.5 mg/kg up to 20 mg is given in a single intravenous dose. If a tracheostomy is present, a fire-retardant tube should be inserted. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. The eyes and face are protected if the laser is used. Procedure Suspension microlaryngoscopy is employed with the CO2 or KTP laser. An inferiorly based posterior mucosal flap is created by carefully elevating the laryngeal mucosa (see Figure 275A). Scar tissue is ablated, and the mucosal flap is replaced (Figure 275B). Postoperative Care Humidification is critical. Antireflux therapy helps to avoid healing difficulties. Avoidance of an endotracheal tube, if possible, helps to ensure flap survival.
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Figure 275 Posterior glottic stenosis repair. A, Endoscopic view of stenosis and inferiorly based posterior mucosal flap. Stippled area indicates site of scar excision. B, Appearance after ablation of the scar tissue and replacement of the mucosal flap.
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LARYNGEAL SEPARATION Indications Life-threatening aspiration in patients with impaired laryngeal or pharyngeal function A potential for reversal of the procedure exists if function improves. Anesthetic Considerations General anesthesia is delivered via an endotracheal tube placed orally or through an existing tracheostomy site. After the trachea is divided, flexible endotracheal RAE tube may be used to ventilate through the distal trachea. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. Care must be taken to palpate and mark the landmarks, including the thyroid cartilage, cricoid cartilage, and sternal notch. A 0.5% lidocaine solution with 1:200,000 epinephrine is injected into the incision area for hemostasis. Procedure A horizontal incision is made halfway between the cricoid and the suprasternal notch in the anterior neck. If a tracheostomy already exists, the incision is placed superior to the stoma. The stoma is excised separately from the trachea. Superior and inferior subplatysmal flaps are created, and the strap muscles are separated and retracted in the midline (Figure 276A). The trachea is exposed anteriorly, and the recurrent laryngeal nerves are identified and protected. The trachea is transected at the third to fourth tracheal ring by beveling the incision superiorly (Figure 276B). If a tracheostomy already exists, the incision starts at its inferior aspect.
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Figure 276 Laryngeal separation: A, Exposure of the larynx and trachea. B, Anterior and lateral views of proposed tracheal incision.
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The posterior trachea is separated from the anterior esophagus (Figure 276C). The anterior edge of the trachea is secured to the inferior aspect of the skin incision with nonabsorbable suture (Figure 276D). The proximal trachea is closed with nonabsorbable suture to create a blind pouch (Figure 276E). A nasogastric tube is placed to avoid traumatizing the pouch. A superiorly based flap of sternohyoid muscle may be used to re-inforce the proximal tracheal incision line. A Penrose drain is placed, and the subcutaneous tissues and skin are closed with absorbable suture (Figure 276F). The endotracheal tube is removed and replaced with an appropriately sized tracheostomy tube. Postoperative Care The patient is admitted to the intensive care unit. The drain is left in place for 2 to 3 days. Feedings via the nasogastric tube can be instituted on postoperative day 1. Oral intake is avoided for 7 to 10 days after surgery. Local tracheostomy care is performed.
Figure 276 C, Posterior trachea is separated from the anterior esophagus.
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Figure 276 D, Anterior trachea is sutured to the inferior skin incision. E, Proximal trachea is sutured to create a blind pouch. F, Skin closure and drain.
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LARYNGEAL DECOMPRESSION (CRICOID SPLIT) WITH HYOID INTERPOSITION Prior to 1980, a tracheostomy was the only way to overcome complications secondary to endotracheal intubation. In 1980, the cricoid split procedure was introduced to decompress edematous mucosa in the subglottic space (Figure 277A). More recently, however, it has been used to treat mild forms of congenital and acquired stenosis. This procedure may be performed with cartilage interposition from the rib, ear, or hyoid; however, the morbidity from the donor site is less when hyoid cartilage is harvested. Compared with the traditional cricoid split procedure, cartilage interposition has a higher success rate and comparable morbidity and mortality. Indications Failure of extubation on at least two occasions caused by subglottic edema Mild acquired or congenital anterior subglottic stenosis in infants or children Child is in optimal condition for the procedure as evidenced by ! Weight greater than 1,500 g ! Oxygen requirement of less than 35% ! No assisted ventilation for 10 days prior to the procedure ! No congestive heart failure in the preceding 30 days ! No evidence of upper or lower respiratory infection ! No antihypertensive medication requirement ! No untreated active gastroesophageal reflux Anesthetic Considerations General anesthesia is administered through an indwelling endotracheal tube. A paralytic agent is used during the procedure. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. Care must be taken to palpate and mark the landmarks, including the thyroid cartilage, cricoid cartilage, and sternal notch. A 0.5% lidocaine solution with 1:200,000 epinephrine is injected into the incision area for hemostasis. Procedure A horizontal incision is made in the skin overlying the cricoid cartilage (Figure 277B). The soft tissue is separated, and the hyoid, cricoid, trachea, and lower border of the thyroid cartilage are identified. The suprahyoid musculature is dissected off the hyoid between the lesser and greater cornua. An incision is made through the cricoid cartilage (and mucosa), the first two tracheal rings, and the lower one-third of the thyroid cartilage (Figure 277C).
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Figure 277 Laryngeal decompression with hyoid interposition. A, Subglottic edema preventing decannulation. B, Skin incision for decompression. C, Laryngotracheal incision and cricoid stay sutures.
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Stay sutures are placed on both sides of the cricoid for emergency purposes (see Figure 277C). An endotracheal tube, 0.5 mm larger than might be expected for the age and weight of the patient, is inserted. This should be left in place for 7 days. The central portion of the hyoid is removed with Mayo scissors. The graft is sculpted using standard laryngoplasty techniques (Figure 277D). The graft is interposed in the cricoid split defect with the perichondrium facing the lumen (Figure 277E). Extramucosal nonabsorbable sutures are used to secure the graft. The wound is closed loosely and drained. Postoperative Care Admission to the intensive care unit postoperatively is mandatory for appropriate monitoring. Sedation and humidity are necessary while the endotracheal tube is in place. Meticulous endotracheal tube care as well as wound care is given while awaiting extubation. Dexamethasone 1 mg/kg is given approximately 6 hours before extubation. Extubation is performed in the operating suite, and rigid bronchoscopy is performed to evaluate the airway. One or two treatments of racemic epinephrine may be useful after extubation. Systemic antibiotics are administered for 7 to 10 days.
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Figure 277 D, Harvesting and preparation of hyoid interposition graft. E, Graft sutured in position.
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AUGMENTATION LARYNGOPLASTY WITH CARTILAGE GRAFT Subglottic stenosis is a rare and troublesome problem that affects the soft tissue and cartilaginous structures of the subglottic space. This condition may be congenital or acquired, but, in either case, management presents a perplexing clinical challenge. More than 90% of the cases in children occur secondary to intubation injuries. In the milder cases, endoscopic management may be undertaken (see Chapter 28). In patients with more severe stenosis, one-stage laryngotracheoplasty is recommended. However, in patients with significant stenosisgreater than 90% narrowing of the subglottic spacecartilaginous augmentation of the cricoid with stenting should be considered. Patients who fail laryngeal decompression, or who have severe stenosis with extreme congenital or acquired (chondritis-induced) deformity of the cricoid cartilage, usually require augmentation laryngoplasty or laryngotracheoplasty for successful decannulation. Autologous costal cartilage augmentation of the cricoid achieves the best and most consistent results. Indications Severe (> 70%) congenital subglottic stenosis Anterior acquired subglottic stenosis with tracheotomy dependence Significant respiratory distress in congenital or acquired stenosis of < 70% Anesthetic Considerations General anesthesia is administered through an endotracheal tube or existing tracheostomy, if present. An intravenous line and a pulse oximeter are placed. The patient is paralyzed for the duration of the procedure. Preparation Endoscopy is undertaken first to update airway status and to ascertain whether the operation is necessary. The patient is positioned with the shoulders elevated and the neck hyperextended. A 0.5% lidocaine solution with 1:200,000 epinephrine is injected into the incision sites. The cartilage graft site is prepared on the anterior chest. Procedure The autologous rib graft is removed with external perichondrium left attached (Figure 278A). The interior (posterior) perichondrium is left in situ. The chest wound is closed with a 4-0 polyglactin 910 suture. A horizontal neck incision is made (Figure 278B). If a tracheostomy is in place, the stomal area should be included in this incision.
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Figure 278 Augmentation laryngoplasty with rib graft. A, Rib graft donorresected cartilage graft with external perichondrium attached is shown. B, Skin incision to include the tracheostomy site (if present).
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The cricoid cartilage, thyroid cartilage, and upper trachea are identified. A midline vertical incision is made through the cricoid, the lower end of the thyroid cartilage, and the upper two tracheal cartilages (Figure 278C). The area of stenosis is then measured, and the cartilage graft is shaped appropriately (see Figure 278C). The superior and inferior ends of the cartilage overlap the trachea to prevent the graft from being displaced into the tracheal lumen. The costal cartilage with the perichondrium facing internally is fixed into position using a 4-0 polyglactin 910 suture (see Figure 278C). The wound is then closed in layers over a drain. Postoperative Care If the patient is left intubated, a nasotracheal tube is left in place for 7 to 10 days, and appropriate sedation is used. Meticulous endotracheal tube care is employed, and the patient is placed on broad-spectrum antibiotics for 7 days; wound care is performed twice daily. If an endotracheal tube is not placed, the patients tracheostomy tube is replaced at the end of the operation; approximately 6 weeks later the patient undergoes re-endoscopy for a possible decannulation. Antibiotics are administered in prophylactic doses until the endoscopy is performed. Meticulous tracheostomy care is employed.
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C2 Figure 278 C, A laryngotracheal incision with upper and lower extension, depending on the extent of stenosis. A cartilage graft is shown with the perichondrium internalized. A graft is sutured in position with a 4-0 polyglactin 910 suture.
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AUGMENTATION LARYNGOPLASTY WITH CARTILAGE STENT Indications Significant subglottic stenosis with > 90% narrowing, either congenital or acquired (Figure 279A) Significant tracheomalacia at the tracheotomy site Concomitant glottic and subglottic stenosis; in some cases, supraglottic stenosis may be present as well Anesthetic Considerations Inhalational agents should be administered through the tracheostomy tube. An intravenous line and a pulse oximeter are placed. A paralytic agent is used during the procedure. Preparation Endoscopy is undertaken first to update airway status and to ascertain whether the operation is necessary. The patient is positioned with the shoulders elevated and the neck hyperextended. The costal cartilage graft site is prepared, and the graft is obtained. The wound is closed with a 4-0 polyglactin 910 suture. A horizontal incision is made to include the old tracheotomy stoma. The incision is carried laterally to the level of the sternomastoid muscles (Figure 279B).
Figure 279 Augmentation laryngoplasty with cartilage stent. A, Severe congenital or acquired stenosis. B, Skin incision to include the tracheotomy site.
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The thyroid and cricoid cartilages are visualized, as is the upper trachea. Care must be taken not to denude the perichondrium over these structures because this may disrupt the blood supply for the future cartilage graft. A vertical incision is made through the cricoid and is carried as far superiorly and inferiorly as is necessary to expose the stenosis that may be present. This may include the supraglottic, glottic, and subglottic structures as well as the trachea (Figure 279C).
Figure 279 C, A laryngotracheal incision extended superiorly and inferiorly as necessary.
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The posterior cricoid lamina may need to be split to relieve the stenosis in severe cases (Figure 279D). This is done carefully to avoid entering the esophagus. A Teflon or c-flex stent is measured to the appropriate size and length.
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Superiorly the stent should extend approximately to the level of the false cords if significant supraglottic stenosis is not present. Inferiorly the stent should reside approximately 1.5 cm above the carina (Figure 279E).
The costal cartilage graft is shaped and measured to the appropriate length. The stent, with the attached tracheostomy tube, is inserted into the airway, and an endotracheal tube is inserted through the metal tracheostomy tube (the inner cannula is temporarily removed) as a temporary access for anesthesia. The costal cartilage graft, with the perichondrium facing the lumen, is inserted over the stent and is sutured into position in the subglottic areas (and to the thyroid cartilage and tracheal area, if necessary) (Figure 279F). A 4-0 polyglactin 910 suture is used. Before total closure is completed, the stent is viewed endoscopically to ascertain that it is appropriately positioned in the larynx. The tracheostomy tube is wired to the stent, and the wound is closed in layers over a drain. The HMS stent (Boston Medical Products, Westborough, MA) is packaged as a single unit and does not require this step. Postoperative Care Humidification and meticulous tracheostomy care are essential, as is cleaning or changing of the inner cannula. Wound care is conducted twice daily for 5 days, and the peristomal area is covered with antibiotic ointment. Postoperative antibiotics are used in therapeutic doses for 7 days and then in prophylactic dosages until the stent is removed. The stent is removed in the operating room after a variable length of time, usually weeks to months after placement. Factors affecting timing include a history of prior reconstructive surgery, unstable cartilage grafts, and the addition of a posterior cricoid split without cartilage grafting.
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E3 Figure 279 D, The posterior cricoid lamina is incised in severe cases. E, A method of preparation of a Teflon stent together with a Healy-Cotton modification of Holinger tracheostomy tube (Pilling). F, A stent is positioned in the laryngotracheal complex under the cartilage graft.
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SEGMENTAL TRACHEAL RESECTION Tracheal stenosis may be congenital or acquired. The trachea also may be affected by primary or secondary tracheomalacia. Complete assessment of the entire upper airway must be undertaken. Tracheal surgery in children may be performed under cardiopulmonary bypass or using conventional endotracheal anesthesia. Young infants are better served by cardiopulmonary bypass. Indications Congenital or acquired segmental stenosis of the trachea, occluding > 50% of the airway lumen Frequent episodes of respiratory distress or recurrent pneumonitis caused by inability to clear secretions past a narrowed or stenotic area Segmental tracheomalaciaprimary or secondary Anesthetic Considerations Communication with the anesthesiologist is critical. In patients with a complete ring, intubation is undertaken to place the endotracheal tube at a level just above the narrowing; then induction of anesthesia is continued. If the patient is to undergo surgery using cardiopulmonary bypass, the bypass is undertaken at this time. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. The skin is prepared from the chin to the umbilicus. The incision area is infiltrated with 1:200,000 epinephrine (1 to 2 mL). Procedure If cervical stenosis is present, a transverse incision is made just above the sternal notch to include the tracheostomy site (Figure 2710A). The trachea is mobilized, with care taken not to disrupt the recurrent laryngeal nerves. The thyroid is dissected free from the trachea. The area of narrowing or malacia is identified, and the trachea is opened to include this area. If a standard anesthetic technique is used, the endotracheal tube is advanced into the distal portion of the trachea (Figure 2710B). The diseased segment is resected, and the trachea is tested for adequate motility of the remaining segments by simulation of reapproximation (see Figure 2710B). The shoulders are returned to the normal position, and the neck is flexed to facilitate anastomosis. If adequate length is not achieved, a suprahyoid laryngeal release is done. The trachea is anastomosed with a 3-0 or 4-0 polyglactin 910 suture, depending on patients age (Figure 2710C). When placing the posterior sutures, the endotracheal tube is displaced laterally to facilitate access.
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C Figure 2710 Segmental tracheal resection. A, Cervical exposure to the trachea in cases of high tracheal stenosis. B, The area of stenosis is exposed and resected. C, Reanastomosis is accomplished with a 3-0 polyglactin 910 suture. m = muscle.
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The wound is copiously irrigated and is closed in layers over a drain. Drainage should be kept in place for a minimum of 5 days because of the potential for air leakage around the wound. A nasotracheal tube is left in place for 5 days, and the patient is sedated but is allowed to breathe spontaneously. For lower stenoses it is advisable to undertake a median sternotomy, and, with the assistance of the cardiothoracic surgeon, the patient is placed on bypass. Resection is undertaken in the method described earlier. Postoperative Care A posterior cervical collar is fitted to the patient for 1 week to prevent hyperextension of the neck. Antibiotics are administered in therapeutic doses for 7 days, and meticulous twice-daily wound care is employed. The endotracheal tube is removed in the operating room after 5 days, and direct bronchoscopic visualization of the anastomotic site is undertaken to confirm the integrity of the repair. CRICOTRACHEAL RESECTION Indications Severe subglottic stenosis (grade III or IV) with at least 1 mm of space between the undersurface of the true vocal cords and the stenosis Anesthetic Considerations In patients who have a tentative diagnosis of severe subglottic stenosis, communication between the surgeon and the anesthesiologist is of paramount importance. The patient should be breathing spontaneously under mask ventilation general anesthesia to allow the otolaryngologist the opportunity to evaluate the degree of stenosis endoscopically. If the patient already has a tracheostomy tube, ventilation can be performed through this site. Preparation The patient is positioned with the shoulders elevated and the neck hyperextended. The skin is prepared from the chin to the umbilicus. The incision area is infiltrated with 1:200,000 epinephrine (1 to 2 mL).
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Procedure Endoscopic evaluation of the airway is performed under general anesthesia to determine the location and degree of stenosis, and the amount of residual space between the true vocal cords and the stenosis. A skin incision is made over the cricoid cartilage (Figure 2711A). If a tracheostomy site is present, the incision can be fashioned to include the tracheostomy. The strap muscles are divided in the midline and retracted laterally with stay sutures to expose the airway (Figure 2711B).
Figure 2711 Cricotracheal resection. A, Skin incision. B, Stay sutures retract the strap muscles to expose the airway.
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A vertical incision is made through the cricoid and the tracheal stenosis (Figure 2711C). A subpericondrial plane is developed in the cricoid cartilage extending laterally to the anterior border of the cricoarytenoid joints. This protects the recurrent laryngeal nerves, which lie superficial to the perichondrium and posterior to the cricoarytenoid joints. After resecting the anterior cricoid, scar tissue from the inner aspect of the posterior cricoid is removed. The stenotic tracheal section is dissected free of surrounding attachments. Dissection posteriorly along the party wall between the trachea and esophagus is aided with placement of an esophageal bougie. Prior to removal of this segment, a posteriorly based mucosal flap is created to cover the exposed posterior cricoid surface (see Figure 2711C). The distal trachea is mobilized by freeing the attachment to the party wall for several rings (Figure 2711D). A suprahyoid release is performed to mobilize the larynx.
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Figure 2711 C, Cricotracheal incision (solid line) and extent of lateral resection (dashed lines); note the posteriorly based mucosal flap. D, Mobilization of distal trachea.
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The posterior mucosal anastomosis is reapproximated using 4-0 polyglactin (Vicryl) sutures in an interrupted fashion. A T tube, HMS tube, or endotracheal tube is placed at this point for ventilation. Subsequently 4-0 polypropylene (Prolene) sutures are placed between the thyroid cartilage and the posterior cricoid plate to the upper tracheal ring (Figure 2711E). Additional Prolene sutures are placed between the thyroid ala and the second or third tracheal ring to further support the anastomosis (see Figure 2711E). Postoperative Care The neck must be maintained in a flexed position after surgery for 5 to 7 days, using a chin-to-chest suture or a plaster cast encompassing the midback to the occiput. Antireflux medications and antibiotics are used. If the patient had his or her tracheostomy site resected, systemic steroids are given prior to extubation in the operating room. If a T tube or HMS tube was placed, it is replaced with a tracheostomy tube in 2 to 6 weeks. Surveillance endoscopies are performed every 3 months to assess for airway patency.
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E1 Figure 2711 E, Cricotracheal anastomosis.
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BIBLIOGRAPHY
Cotton RT, Seid AB. Management of the extubation problem in the premature child: anterior cricoid split as an alternative to tracheotomy. Ann Otol Rhinol Laryngol 1980;89:50811. Dedo H. Endoscopic Teflon keel for anterior glottic web. Ann Otol Rhinol Laryngol 1979;88:46773. Healy GB, Schuster SR, Jonas RA, McGill TJ. The correction of segmental tracheal stenosis in children. Ann Otol Rhinol Laryngol 1988;97:4447. Holinger LD, Konior RJ. Surgical management of severe laryngomalacia. Laryngoscope 1989;99:13642. Lawless ST, Cook S, Luft J, et al. The use of a laryngotracheal separation procedure in pediatric patients. Laryngoscope 1995;105:198202. McGuirt WF, Little JP, Healy GB. Anterior cricoid split: use of hyoid as autologous grafting material. Arch Otolaryngol Head Neck Surg 1997;123:127780. Montgomery WH. Surgery of the upper respiratory system. Vol. 2. Philadelphia: Lea & Febiger; 1973. Ossoff RH, Dunkavage JA, Shapshay SM, et al. Endoscopic laser arytenoidectomy revisited. Ann Otol Rhinol Laryngol 1990;99:76471. Seid AB, Park SM, Kearns MJ, et al. Laser division of the aryepiglottic folds for severe laryngomalacia. Int J Pediatr Otorhinolaryngol 1985;10:1538.
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Stern Y, Gerber ME, Walner DL, Cotton RT. Partial cricotracheal resection with primary anastomosis in the pediatric age group. Ann Otol Rhinol Laryngol 1997;106:8916. Thornell WC. Intralaryngeal approach of arytenoidectomy in bilateral abductor vocal cord paralysis. Arch Otolaryngol 1948;47:50512. Woodman DG, Pennington CL. Bilateral abductor paralysis: 30 years experience with arytenoidectomy. Ann Otol Rhinol Laryngol 1976;85:4379. Zalzal GH. Use of stents in laryngotracheal reconstruction in children: indications, technical considerations and complications. Laryngoscope 1988;98:84954. Zalzal GH, Anon JB, Cotton RT. Epiglottoplasty for the treatment of laryngomalacia. Ann Otol Rhinol Laryngol 1987;96:726.
C H A P T E R 28
L ARYNGOTRACHEAL L ASER S URGERY

Jay A. Werkhaven, MD
The use of lasers for pediatric laryngotracheal disorders is expanding as improved technology delivers the beam into smaller spaces. Experience gained with lasers in the adult airway has naturally led to pediatric applications. However, the unique nature of some pediatric airway disorders has necessitated unique approaches to their treatment. Although this chapter discusses laser surgery, in many cases nonlaser techniques also work well. In certain instances, the laser provides unique advantages, whereas in other cases (eg, laryngeal papilloma and subglottic hemangioma) the laser is the most appropriate instrument.
CARBON DIOXIDE LASER The carbon dioxide (CO2) laser is the most common laser used in otolaryngologyhead and neck surgery. Since the first endolaryngeal application by Jako in 1972, the applications for this laser have grown significantly. Newer advances in technology and instrumentation have kept the CO2 laser the instrument of choice for many laryngeal and tracheal procedures. The CO2 laser operates at a wavelength of 10,600 nm and is absorbed well by water. Because tissue is between 70 and 80% water, the CO2 laser is very effective for tissue vaporization. The laser parameters for normal use include 5 to 10 watts of power with pulse durations of 0.01 to 0.05 seconds. The optical penetration depth is approximately 50 m, and the thermal effect (coagulation lateral to the zone of vaporization) is usually between 120 and 240 m. Vessels up to slightly less than 0.5 mm may be coagulated, but larger vessels require another modality. The thermal effect from the CO2 laser depends on tissue water content and vascularity and the characteristics of the beam itself. Thermal coagulation decreases with increasing water content or vascularity, and coagulation also decreases with shorter pulse durations if the tissue is allowed to cool between pulses.
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Another important caveat with the CO2 laser is removing the carbonaceous char from the operative field. This char may function as a heat sink and produce local temperatures of approximately 2000F. The CO2 beam is delivered to tissue via an articulated arm from the laser to a delivery device. This delivery device may be a micromanipulator attached to the microscope or a bronchoscopic coupler for tracheobronchial applications. The standard for microscopic applications is now the microspot micromanipulator, which yields spot sizes of 250 m coincident with the optical path. Older micromanipulators often had a parallax error wherein the laser beam was offset below the optical path, such that the laser beam might contact the rim of the laryngoscope or the lip of the patient. The newer microspot micromanipulators eliminate this parallax problem and allow access to much smaller areas (Figure 281). For example, the CO2 laser may now be used through the neonatal subglottiscope with the smallest 3-mm blade. The bronchoscopic applications of the CO2 laser require attaching the articulated arm assembly to a bronchoscopic coupler. Within this coupler is a vapor barrier window to prevent secretions and saliva from being deposited on the internal optical components. Humidity within the system may condense on the barrier window, limiting target visualization, especially with small bronchoscopes in the pediatric and neonatal trachea. Two methods may be used to overcome condensation:
Figure 281 Microspot micromanipulator for the CO2 laser. This manipulator places the laser beam coincident with the visual path and allows spot sizes as small as 250 m.
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1. Heating the vapor barrier window in very hot water immediately prior to laser use 2. Coating the vapor barrier window with an antifog agent, which may contain an alcohol solvent base that is potentially flammable if not allowed to completely evaporate Additional helpful hints when using the CO2 laser bronchoscope include: 1. Focusing the coupler to the appropriate length of bronchoscope before inserting the scope 2. Centering the CO2 beam directly down the bore of the bronchoscope 3. Pointing the bronchoscope at the target rather than moving the joystick micromanipulator on the coupler 4. Disconnecting the humidifier circuit on the anesthesia machine to minimize condensation on the vapor window when ventilating through the bronchoscope side arm Endotracheal Tube Fire Potentially the worst complication when using the carbon dioxide laser in a patients airway is fire. Although uncommon, fire still occurs despite surgeons and anesthesiologists awareness of the potential risk. Fire can only occur if flammable materials are present, which include tubes for securing airway ventilation and cottonoid pledgets placed in the airway by the surgeon for hemostasis. Without any potential flammable materials, there is no risk of airway fire; human combustion may exist in the movies, but has not been proven in actuality. Desiccated tissue and the organic vaporization products from using the CO2 laser may ignite, but fire cannot be sustained. The concentration of oxygen for ventilating the patient should be as low as possible for any CO2 laser case. If there are no flammable materials, 100% oxygen may be used with jet ventilation. The use of helium as a diluent gas allows safe oxygen concentrations up to 60%, but without helium concentrations, no greater than 40% should be used. If a fire should occur, the four Es mnemonic may help in the management: Extract, Eliminate, Extinguish, and Evaluate: 1. Immediately remove (Extract) the combustible material, including the endotracheal tube and surgical pledgets. 2. Shut off (Eliminate) oxygen delivery if the endotracheal tube is flammable because continued oxygen can cause further damage by a blowtorch effect through the burning tube. 3. Extinguish by saline flush any fire that may still be present due to residual material in the airway. 4. Evaluate fire damage, including the operative field and remaining tracheal-bronchial tree for direct heat effects and for ash deposition from combustible material.
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Anesthesia for CO2 Laser Surgery The surgeon and anesthesiologist must cooperate during laryngoscopy to maximize surgical exposure while allowing adequate ventilation. The surgeon may need access to the hypopharynx, supraglottis, larynx, or subglottis, and this will dictate the type of airway available for the anesthesiologist to provide ventilation to the patient. A complicating factor is the simultaneous use of the CO2 laser in the airway. Delivery of the CO2 laser to the target tissue will allow the surgeon to perform the operation, but requires modifying the airway exposure for the anesthesiologist. Many different methods of securing an airway and delivering ventilation to the patient have been employed. These range from jet ventilation with no material within the airway, to use of various styles of endotracheal tubes, to intermittent use of an endotracheal tube with removal during active laser use. Each style of airway exposure and ventilation has both its proponents and appropriate use depending upon the surgical field. In addition, patient size may dictate modifications to each of the airways and may make certain options inappropriate. No 1. Subglottic jet ventilation Subglottic jet is not true Venturi ventilation, because outside air is not entrained through the laryngoscope into the airway while the jet is employed. Only the oxygen delivered through the tube actually makes it to the pulmonary parenchyma. The delivery system may obstruct part of the surgical field. In addition, whatever delivery method is used may also present a combustion source. There is significant risk of pneumothorax because insufflated air must be allowed to completely exhaust before another inhalation is given to the patient. Inadequate exhalation time may cause pneumothorax, pneumomediastinum, or subcutaneous emphysema. The small pediatric airway does not usually allow adequate exhalation for effective subglottic jet ventilation; however, certain surgical situations exist in which this is the only method available to oxygenate the patient (eg, subglottic submucosal cysts or a large subglottic hemangioma). In such cases, supraglottic jet would not deliver adequate oxygenation and endotracheal tubes would completely obstruct the airway. Subglottic jetting requires the very controlled insufflation of oxygen with scrupulous monitoring of exhalation. The progression of surgery generally results in the increase of the airway size such that the onset of the surgery is the riskiest period. No 2. Supraglottic jet ventilation Supraglottic jet ventilation is true Venturi ventilation, entraining outside air through the laryngoscope and resulting in a better ventilation of the patient. Generally, 100% oxygen is used, delivered via a cannula within the lumen of the laryngoscope. The initial onset of jet ventilation should be done with the delivery system in a completely closed position to avoid a massive uncontrolled onrush of air. The amount of air insufflated is then gradually increased until appropriate levels of ventilation are obtained.
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The rate of ventilation depends on the patients age and size. Although long slow ventilation can be performed, the surgeon often requests a shorter duration of jet to assist in clearing the laser smoke plume. Some surgeons request that ventilation be suspended while the laser is in active mode. Other surgeons may be capable of using the laser in the active mode while jet ventilation is ongoing, the caveat being that the rate of jet ventilation is held consistent so that the use of the laser can be timed to occur between insufflations. There is no risk of airway fire with supraglottic jet ventilation because there is no flammable material in the airway. A theoretical risk exists when removing recurrent respiratory papilloma: the jet may force papilloma fragments deeper into the airway, or may deliver the laser plume deeper into the airway. Neither situation has occurred in clinical practice. No 3. Intermittent endotracheal intubation Another mechanism of airway exposure for ventilation is the intermittent use of an endotracheal tube. The patient is ventilated to full oxygenation, the endotracheal tube is removed from the airway, and the surgical procedure occurs under apneic status. As the patients oxygen concentration falls, as measured on pulse oximetry, the laser is turned to standby safe mode, the endotracheal tube is inserted through the laryngoscope, and the patient may be actively ventilated. Depending upon the potential period of apnea before the patient undergoes oxygen desaturation, this technique may only allow a short duration of work for the surgeon. The advantage, however, is having no object obstructing the operative field. A potential surgical complication is that repeated passage of the endotracheal tube may disrupt aspects of the surgical field, such as a mucosal microflap. Fire may occur if the laser is not properly placed in standby safe mode while the patient is intubated. At our institution, the laser once fired spontaneously in standby mode because of an electrical short in the foot pedal and standby mode circuit. While the combination of these two events may seem exceedingly small, it has occurred. No 4. Continuous endotracheal intubation Endotracheal tubes ventilate the patient but can obstruct the surgical field. Sometimes they may not be used if the operative work involves the phonating edge of the true cord or the subglottis, but they may be required when work is being performed on the supraglottis or the hypopharynx. Endotracheal tubes are selected based on size and fire resistance. Metal tubes The first tubes used for CO2 laser laryngoscopy were malleable metal, which were completely fire resistant but also very cumbersome and inflexible.
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The next development was the flexible metal endotracheal tube, combining an increased flexibility with fire resistance, but the corrugation of the metal could abrade the vocal cord when passed through the glottis. Further modifications of the metal endotracheal tubes placed a balloon at the distal tip. By nature, the balloon material is potentially flammable, and therefore these tubes are not without risk for fire. Foil-wrapped tubes Red rubber endotracheal tubes can be wrapped with foil to increase their resistance to potential fires. The foil used originally was a copper burglar alarm sensing foil, but aluminum sensing foil has been used more recently. A polyvinyl chloride (PVC) tube should never be wrapped, because thermal transmission through the fire-safe material may still ignite PVC. Although foil-wrapped tubes are still used, especially when an extremely small tube (2.5 or 3.0) is required, this technique is less than ideal. The quality of the wrap depends on operator experience and there is a learning curve involved. To prepare a foil-wrapped red rubber endotracheal tube 1. Wrap from the distal end and proceed more proximally, with an overlap of one-half the width of the foil to prevent gaps in the foil coverage. 2. Leave the red rubber tube cuff exposed, but fill the cuff with saline to minimize ignition from stray laser impact (which may nonetheless occur). 3. Realize that when using a foil-wrapped tube the surgeon and anesthesiologist become manufacturers of a medical device, and as such, assume all responsibility for potential product failures. This makes them liable both as physicians and manufacturers. None of the foil manufacturers have given approval for use in laser surgery. A commercial foil system is available, using silver foil with a Merocel covering which is wrapped around the endotracheal tube and then soaked. The Merocel remains hydrated and serves as an initial barrier to errant laser impacts, absorbing some of the energy from the laser impact. The remaining beam is potentially dispersed or deflected from the silver foil. Laser-safe tubes Other commercially available approaches to laser-safe endotracheal tubes include wire-impregnated and wire-protected silicon endotracheal tubes. Silicon is relatively resistant to laser ignition, depending upon the thickness of the silicon wall. Silicon tubes still use a cuff, which must be filled with saline for protection. The wire wrapping on the outside of the tube, however, may abrade the phonating surface of the true vocal cords. Furthermore, the wall thickness will require using a smaller size tube.
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One commercial tube attempting to address this problem is a silicon tube wrapped first with a foil and then with a Teflon tape. The Teflon tape holds the foil in close approximation to the endotracheal tube thereby eliminating any gaps. Unfortunately, only two sizes are available, of which the smaller is too large for many younger children. POTASSIUM-TITANYL-PHOSPHATE (KTP) AND ARGON LASERS The KTP and argon lasers operate in the green and blue/green wavelength range of the spectrum. They are well absorbed by pigmented tissue, especially hemoglobin. Hence, they have found widespread application for certain lesions, such as hemangiomas and granulation tissue. The optical penetration depth and thermal coagulation for these lasers is deeper than that of the CO2 laser, with coagulation as deep as 1.5 mm. Because of this deep coagulation, care must be taken when using these lasers around sensitive structures, such as the vocalis muscle or the vocal process. Undesired scarring with permanent alteration of vocal vibratory function may result. The KTP laser has a micromanipulator for laryngeal (and otologic) applications. Because of the absorption of this beam by hemoglobin, this laser is well absorbed by the vasculature but is not as readily absorbed by the white surface of the vocal cords until protein denaturization or charring occurs. At this point, laser beam absorption proceeds quickly, and the surgeon must be aware of this increase in absorption during laser application. The argon laser does not as yet have a micromanipulator. Both of these lasers may be transmitted through fibers, permitting direct application through the operating bronchoscope side port. The argon laser has fibers available as small as 200 m, suitable for even the smallest bronchoscope. These lasers may also be used through some of the smaller flexible pediatric bronchoscopes, but limitations include the lack of concurrent ventilation and the caution that the fiber must extend far enough from the bronchoscope to prevent reflected energy from melting the tip of the bronchoscope. NEODYMIUM-YTTRIUM-ALUMINUM-GARNET LASER The neodymium-yttrium-aluminum-garnet (Nd:YAG) laser operates at a wavelength of 1064 nm in the near-infrared. Its depth of optical penetration and thermal coagulation is deeper than the preceding lasers, and may be as deep as 3 to 4 mm. The wavelength of the Nd:YAG laser is absorbed generally by tissue and does not have a specific chromophore. The Nd:YAG laser does not have a micromanipulator but does have a wide range of contact tips and flexible fibers for delivery. These fibers may be directed down the laryngoscope or the side suction port on a ventilating bronchoscope. Laryngeal applications of the Nd:YAG laser are limited because of the deep thermal effect, but tracheobronchial applications exist where this effect is a benefit. The ablation of granulation tissue, mixed capillary/cavernous hemangioma, or obstructing vascular tumors may be accomplished successfully with the Nd:YAG laser. Preparation and Intraoperative Precautions The operating room set-up is illustrated in Figure 282. The anesthesiologist is positioned to the surgeons left hand as most surgeons are right-hand-
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ed and most of the endoscopic instruments are designed for right-hand application. Some of the specialty laryngoscopes are specifically designed so the Venturi ventilation needle fits along the left side of the laryngoscope. This unilateral design minimizes the width of the distal tip. The scrub nurse is positioned to the surgeons right hand with all of the endoscopic equipment available within arms reach of the surgeon. The video console provides visualization for the personnel in the operating room and may be attached to the telescopes and/or the side position on the operating microscope. The CO2 laser usually has a limited length on the articulating arm and cannot be positioned at the foot of the bed, but may set alongside the operating table at the patients legs, as illustrated in the diagram. The safety precautions for each laser are unique for that particular wavelength. The surgeon should not attempt to use a new wavelength until he or she has obtained hands-on training, and is familiar with all safety considerations and expected tissue response from the laser. Appropriate eye protection should be provided for both the patient and the operating room personnel. ! With the CO2 laser, the patients eyes should be taped closed and then protected with wet saline gauze pads taped over the eyes. Taping the eyes first prevents accidental opening if anesthesia becomes too light, with subsequent possible corneal abrasion. Operating room personnel who use the CO2 laser should wear clear glasses with side shields. The surgeon is protected behind the eyepieces of the microscope and the bronchoscope coupler but should be aware of potential damage due to stray beams if the laser is accidentally left in the on position when not in use. ! The visible wavelength laser beams (argon and KTP) can be transmitted through clear glass and water. The patients eyes should be protected as with a CO2 laser, with added aluminum foil or other opaque nonflammable material on top of the eye pads. Operating room personnel should wear appropriate laser-specific goggles for the wavelength in operation. In addition, because these wavelengths may be transmitted through glass, the windows of the operating room must be covered with an opaque material to prevent a stray beam from causing damage outside the operating room itself. ! The Nd:YAG laser operates in the near-infrared and is therefore an invisible beam. The patients eyes should be protected as with the argon and KTP lasers, and all operating room personnel should wear appropriate wavelength-specific protective goggles. In addition, all operating room windows should be covered with opaque material. In general, manipulation of structures within the airway should be kept to a minimum to avoid undue trauma. Intraoperative steroids are a useful adjunct in most procedures. Dexamethasone (Decadron), 0.5 kg, is usually given intravenously. Giving dexamethasone at an early stage allows distribution within the tissue and has been shown to decrease edema after the impact of the laser. Occasionally, epinephrine on a neurosurgical pledget may be applied topically to control any excessive bleeding. This technique is generally
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not used when the patient is under Venturi jet ventilation, which may obstruct the airway. The homeostatic properties of the laser generally obviate the need for topical epinephrine. General Principles of Postoperative Care The guidelines in this section are for general care of the patient undergoing an upper airway procedure, and specific recommendations will be made under each procedure. Close attention is directed to evaluating the airway for any signs of edema and respiratory distress. Racemic epinephrine may be required in the recovery room. In addition, humidification and supplemental oxygen may be beneficial in selected cases. Postoperative edema is usually greatest within the first several hours, so postoperative evaluations should extend for several hours. Pain following most of these procedures is usually minimal. Acetaminophen (Tylenol), or rarely acetaminophen with codeine, may be given as needed for relief of pain. In procedures involving the true cords or the conus elasticus and subglottic region, postoperative voice rest is desirable. Realistically, however, it is difficult to achieve voice rest in children.
Figure 282 Typical operating room arrangement for laser procedures.
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EPIGLOTTIC CYSTS Indications Epiglottic cysts may be found along the laryngeal surface of the epiglottis or occasionally along the aryepiglottic fold (Figure 283A). The cysts vary in size. Anesthetic Considerations Suspension microlaryngoscopy with endotracheal intubation using a laser-resistant tube is most often used. Because of cyst location, it is difficult to employ Venturi jet or apneic ventilation. Procedure Traction may be applied to the cyst with a grasping forceps or a cup forceps (Figure 283B). Gentle dissection is performed using a low-power CO2 laser (3 to 6 watts, 0.01- to 0.05-second pulse duration, 250-m spot size) to dissect the cyst from the underlying stroma (Figure 283C). Large cysts may be marsupialized using the CO2 laser. The cyst is grasped with a cup forceps, and gentle traction is applied as the major portion of the cyst wall is resected with the CO2 laser (Figure 283D). Once the top of the cyst has been resected, the CO2 laser may be used on slightly higher powers (8 to 12 watts) in a defocused mode to ablate the lining of the cyst. Postoperative Care See General Principles of Postoperative Care.
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Figure 283 A, An epiglottic cyst. B, Traction is applied to the cyst with cup forceps. C, A low-power CO2 laser dissects the cyst from the underlying stroma. D, Resection of a large cyst with the CO2 laser.
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VALLECULAR CYSTS Indications Vallecular cysts may be found along the vallecula, depressing the epiglottis over the larynx (Figure 284A). These cysts usually present with a laryngomalacia-type fluttering stridor as the epiglottis is displaced inferiorly. The cysts vary in size. Anesthetic Considerations Suspension microlaryngoscopy with endotracheal intubation using a laser-resistant tube is required. Exposure is not adequate for Venturi jet or apneic ventilation. Procedure Traction may be applied to the epiglottis to place the cyst on stretch (Figure 284B). The cyst wall is ablated using the CO2 laser, 5 to 7 watts, 0.2 seconds to continuous, slightly defocused spot size, to aid in hemostasis. Small cysts may be removed in their entirety while large cysts frequently are marsupialized. The major portion of the cyst wall is resected with the CO2 laser, attempting to remove greater than 50%. Once the top of the cyst has been resected, the CO2 laser may be used on slightly higher powers (8 to12 watts) in a defocused mode to ablate the lining of the cyst (Figure 284C). Postoperative Care See General Principles of Postoperative Care.
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Figure 284 A, Direct laryngoscopic view of a cyst in the vallecula. B, Carbon dioxide laser used to vaporize the cyst wall. C, Carbon dioxide laser used to ablate lining wall of the cyst.
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VENTRICULAR CYSTS Indications Ventricular cysts are often mucous cysts and may be seen protruding from the ventricle (Figure 285A). Anesthetic Considerations Suspension microlaryngoscopy with Venturi jet ventilation, apneic ventilation, or endotracheal intubation with a laser-resistant tube may be used. Procedure The cyst is grasped with a cup forceps and is retracted medially, exposing the base of the cyst and the ventricle (Figure 285B). The CO2 laser is used on low-power setting (3 to 6 watts of power, 0.01to 0.05-second pulse duration, and 250-m spot size) to cut across the base of the cyst. The CO2 laser is very effective for this type of excision because it provides a bloodless field for dissection (Figure 285C). Postoperative Care See General Principles of Postoperative Care.
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C Figure 285 A, A ventricular cyst. B, The cyst is grasped and retracted medially. C, Excision using the CO2 laser on low power.
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INTRACORDAL CYSTS Indications Cysts of the true vocal fold are often mucous cysts, more rarely epidermoid cysts. They are most often located submucosally in the membranous portion of the vocal fold. Anesthetic Considerations Suspension microlaryngoscopy under general anesthesia, using Venturi jet ventilation, apneic ventilation, or a laser-resistant endotracheal tube may be used. If tracheal intubation is employed, a small-diameter endotracheal tube should be used. Procedure An incision is made over the supralateral aspect of the vocal fold and is carried down through mucosa (Figure 286A). This incision may be made with the CO2 laser to minimize hemorrhage and improve visualization but may also be made with a pair of scissors or a laryngeal knife. The mucosa is gently elevated using a blunt probe, with the medial mucosa carefully preserved. Gentle dissection with this probe may deliver the entire cyst. Sometimes, however, the cyst is bound down with tight scar tissue, and the enveloping fibrotic tissue must be ablated with the CO2 laser. The cyst is grasped with a cup forceps (Figure 286B), and traction is applied medially while the CO2 laser is used on low power (3 to 6 watts, 0.01to 0.05-second pulse duration, 250-m spot size) for gentle dissection. Once the cyst has been removed, the mucosa is redraped over the superior aspect of the vocal fold, and any excess mucosa is trimmed with the laser or scissors. The edges of the mucosa may be welded together using a milliwatt CO2 laser. Postoperative Care Vocal strain is minimized. Quiet talking is generally acceptable, but strained whispering, loud talking, shouting, and screaming are avoided. Independent of the surgical approach to the cordal cyst (CO2 laser, scissors, or laryngeal knife), removing the cyst has significant risk of scarring the overlying mucosa to the underlying vocalis ligament. On video laryngoscopy, this is seen as loss of a progressive mucosal wave and may manifest as a slight alteration in the fundamental quality of the voice. To minimize the loss of the mucosal wave, surgery is completed as far away from the phonating edge of the true cord as possible. The incision is placed as far laterally over the vocal fold as possible, and the dissection proceeds from lateral to medial.
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Figure 286 A, An intracordal cyst. B, The cyst is grasped with a cup forceps, and traction is applied medially while the CO2 laser is used on low power to dissect the cyst.
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VOCAL PROCESS GRANULOMAS Indications In children, vocal process granulomas are usually a sequela of trauma or prolonged intubation. Very rarely, a granuloma may be the result of chronic gastroesophageal reflux. Anesthetic Considerations Suspension microlaryngoscopy with Venturi jet ventilation, apneic ventilation, or endotracheal intubation is employed. If an endotracheal intubation anesthetic technique is to be used, a posterior commissure laryngoscope must be available in order to give adequate exposure. Procedure Because granulomas often consist of small capillary vessels, the CO2 laser is usually adequate for removal. The CO2 laser is used in a coagulation/vaporization mode (5 to 8 watts, 0.05- to 0.2-second pulse duration, 250-m spot size or slightly defocused). The granulation tissue is ablated to re-establish the contour of the vocal process, but care is taken to minimize the thermal damage to the cartilage. Great effort must be made not to expose the cartilage itself because this may predispose to recurrence (Figure 287). Triamcinolone (Kenalog) may be injected into the field of the granuloma. Bilateral granulomas may be removed concurrently if the vocal cords are mobile and adequate intact mucosa is preserved in the interarytenoid region. If the patient, however, has a vocal cord paresis with the cords in a paramedian position, simultaneous removal may lead to synechia formation. Postoperative Care Coughing should be minimized. If cartilage is exposed accidentally during excision of the granuloma, postoperative antibiotics may help prevent perichondritis or chondritis. If the vocal process granuloma is a sequela of trauma, resolution is generally good. However, if the vocal process is a result of gastroesophageal reflux, appropriate antireflux therapy should be instituted.
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Figure 287 Removal of a vocal process granuloma using the CO2 laser in coagulation/vaporization mode. Care is taken not to expose the cartilage, which could lead to reformation of the granuloma.
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LARYNGEAL PAPILLOMATOSIS Indications The CO2 laser is the instrument of choice for palliation of laryngeal papillomatosis. The goal of papilloma surgery is control of the papilloma without glottic scarring. Anesthetic Considerations Suspension microlaryngoscopy under general anesthesia, using Venturi jet ventilation, apneic ventilation, or a laser-resistant endotracheal tube is used. The Venturi and apneic techniques offer better exposure. Despite a theoretical concern for distal spreading of papillomatosis from jet ventilation, this has not been observed clinically. Another theoretical concern is the potential spread of viral particles in the laser plume. While this has not been proven clinically either, appropriate safety precautions of laser filter masks for operating room personnel are appropriate. Smoke evacuation is prudent whenever using the laser or electrocautery. Procedure No 1. Laser technique High magnification with the microscope is often required to accurately identify the borders of papilloma involvement. The papilloma is vaporized or ablated to the level of the mucosa or submucosa (Figure 288A). Vaporization deeper than these layers may result in unwanted scarring. When operating in the anterior or posterior commissure, a commissure retractor should be used to protect the opposite side (Figure 288B). At no time should both sides of the anterior and posterior commissures be vaporized at the same surgical setting, because this frequently results in web formation. Laser power settings used initially are 5 to 8 watts of continuous power to debulk the majority of the papilloma. However, once the bulk of papilloma has been vaporized, the parameters should be returned to 0.01- to 0.05-second pulse duration to limit the thermal damage. No 2. Non-laser technique Laryngeal papilloma can be removed with a laryngeal version of the endoscopic microdebrider used for sinus procedures. The device employs a rotating blade in a suction tube long enough for use through a laryngoscope. No controlled trials have been published (October, 2001) regarding the safety and efficacy of microdebrider excision of laryngeal papilloma. A purported advantage is the lack of thermal effect from the CO2 laser, but judicious control of the CO2 laser parameters can minimize the thermal effect to as little as 50-80 m. Potential disadvantages of the microdebrider technology include controlling a rotating and vibrating instrument at a 400-mm focal length distance. In addition, the design only allows a side-cutting action, which creates difficulties in removing papillomas on horizontal surfaces such as the superior surface of the true vocal cord or the ventricles.
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Use of the CO2 laser to remove papillomas on the infraglottic aspect of the true vocal cords can be accomplished by rolling the true vocal cord for exposure. While this is possible with a microdebrider, this requires the simultaneous use of two extremely long instruments within the airway. The potential for the CO2 laser to also affect hemostasis may be advantageous for visualization of the operative field. Postoperative Care See General Principles of Postoperative Care.
Figure 288 A, Vaporization of a laryngeal papilloma. B, Vaporization with a commissure retractor to protect the opposite side.
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LARYNGEAL WEBS Indications The anatomic location and type of laryngeal webs are variable. Laryngeal webs can occur at the supraglottic, glottic, or subglottic level, may be thick or thin, and may be anterior or posterior. In addition, the webs may be congenital or acquired; the latter is often a result of intubation trauma. Anesthetic Considerations Suspension microlaryngoscopy under general anesthesia is used. Venturi jet ventilation, apneic ventilation, or intubation with a laser-resistant endotracheal tube may be used. Because an endotracheal tube may obstruct the operative field, Venturi jet and apneic techniques may be the better approaches for treating laryngeal webs. Procedure Thin laryngeal webs may be divided by CO2 laser or scissors and generally have a good response, regardless of the technique employed (Figure 289A ). Thick anterior webs are treated with a modified microtrapdoor flap approach. The CO2 laser is used on a minimum thermal coagulation setting with 5 to 8 watts of power, 0.01- to 0.05-second pulse duration. With the smallest spot size possible (250 m), a cut is made along the line of one vocal fold up to the anterior commissure (Figure 289B ). The web is then reflected toward the surgeon, and the mucosa and substance of the web itself are vaporized, preserving the superficial superior mucosa intact (Figures 289C and D ). The mucosa is then replaced to cover the raw surface of the vocal fold. Generally, the mucosa heals in place with minimal reformation of a web (Figures 289E and F ). Treatment of a posterior glottic web is slightly more involved but also uses a microtrapdoor flap. Posterior glottic webs are often thick and overlie the posterior lamina of the cricoid. A microtrapdoor flap is elevated, preserving the mucosa over the lumen (Figures 289G through J ). Once the flap has been elevated, the substance of the scar in the web is ablated using the CO2 laser (Figures 289K and L ). Finally, the edges of the mucosa are incised and allowed to redrape over the raw surface that has been created (Figures 289M and N ). Postoperative Care See General Principles of Postoperative Care.
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Figure 289 A, Division of thin laryngeal webs. B, Thick anterior webs require a modified version of the microtrapdoor flap approach. C and D, The mucosa and web are vaporized, preserving the superficial superior mucosa intact. E and F, The mucosa is then replaced to cover the raw area of the vocal fold. Healing occurs with minimal web reformation.
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Figure 289 G through J, Use of a microtrapdoor flap to remove a posterior glottic web. The flap is elevated, preserving the mucosa over the lumen.
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Figure 289 K and L, Ablation of the web using the CO2 laser. M and N, The mucosa is repositioned over the raw surface.
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VOCAL CORD NODULES Indications Vocal cord nodules rarely require surgical intervention in children. Most nodules resolve as the vocal abuse patterns are eliminated. If vocal nodules are to be surgically removed, cold steel excision techniques or excision with a microspot micromanipulator should be used. Anesthetic Considerations Suspension microlaryngoscopy under general anesthesia is required. Venturi jet ventilation or apneic ventilation gives good exposure without obstruction of the target by an endotracheal tube. Procedure No 1. Laser technique The CO2 laser is used at the smallest spot size. Five to 8 watts of power with pulse duration of 0.01 to 0.05 seconds are employed. The beam is not directed to have an impact over the center of the nodule; rather, the edge of the beam is used to shave away the nodule (Figures 2810A and B). An operative platform is used as a backstop to prevent beam spread distal to the vocal cord. Large spot sizes with the micromanipulator should be avoided because lateral thermal damage may cause scarring to the underlying vocalis muscle. No 2. Nonlaser technique The nodule is grasped on the free edge using microsurgical forceps. Care should be taken not to include the underlying lamina. Tension is applied to stretch the nodule medially, and microscissors are used to remove only the nodule (Figure 2810C). This should result in a smooth free edge of the vocal cord without damage to underlying structures and without a depression in the cord. Direct removal with scissors is preferred to the older technique of cup forceps stripping because the scissors affords a more precise removal with conservation of normal mucosa. Postoperative Care Voice rest is encouraged. Speech therapy is continued to prevent a recurrence of the vocal abuse patterns, which usually cause the nodules.
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Figure 2810 A and B, Removal of a vocal cord nodule with the CO2 laser. C, Direct scissors removal of a vocal cord nodule.
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REINKES EDEMA AND VOCAL CORD POLYPS Indications Reinkes edema and vocal cord polyps are uncommon in children, but when they occur and cause distortion in the voice it is often of concern to the parents. Early or soft polyps may resolve spontaneously. Surgery is indicated for polyps of documented chronicity or for polyps that are pedunculated, hemorrhagic, or fusiform. Anesthetic Considerations Suspension microlaryngoscopy under general anesthesia should be used. Venturi jet ventilation or apneic ventilation gives good exposure without obstruction of the target by an endotracheal tube. Procedure A series of spots outlining the proposed incision on the superior lateral surface of the true vocal fold is made with the CO2 laser (Figure 2811A). These proposed incision marks are then connected, ablating the mucosa down to the level of the edema (Figure 2811B ). The laser is often helpful in this part of the procedure because the true vocal fold is often inflamed, and the laser provides good hemostasis and improved visualization. This incision may also be made with a microsurgical knife or scissors, but the resultant bleeding often obscures the proper tissue planes. A blunt probe is then used to elevate the medial surface of the mucosa, identifying the edema or the organized fibrous exudates (Figure 2811C ). The edema is suctioned away with a microsuction or may be ablated using the CO2 laser (Figure 2811D ). Once the edema has been removed, the excess mucosa is trimmed using the laser or scissors, and the mucosa is allowed to fall back into position superiorly (Figures 2811E and F ). The CO2 laser on milliwatt power settings may then be used to weld or anneal the mucosa. Pedunculated polyps are removed by grasping the polyp with a cup forceps and retracting medially.
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The CO2 laser is then used to vaporize along the base (Figure 2811G and H ). Care should be taken to apply the beam such that the majority of the beam diameter is directed to the polyp, and the edge of the beam is used to shave the polyp in line with the remainder of the vocal cord. Creating a depression on the vocal cord should be avoided whenever possible. Occasionally, pedunculated polyps are accompanied by a large feeding vessel, which should be carefully coagulated along its length with the laser before transecting it at the base of the polyp.
Hemorrhagic polyps are most often capillary and rarely have large vessels within them.
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Hemorrhagic polyps are best dealt with by complete vaporization or ablation with the CO2 laser. This laser affords generally good hemostasis for capillary-sized vessels.
Figure 2811 Incision marks are outlined (A), then connected (B) with the CO2 laser, ablating the mucosa down to the level of the edema. A blunt probe elevates the medial surface of the mucosa (C), so that the edema can be removed (D) by microsuction or use of the CO2 laser.
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In order to effect coagulation with the CO2 laser, powers of 5 to 8 watts are used with 0.2- to 0.5-second pulse duration to allow time for heat diffusion into the tissue to coagulate the vessels. Char should be removed as it is encountered to avoid unwanted deeper thermal coagulation.
Postoperative Care See General Principles of Postoperative Care.
Figure 2811 E and F, Excess mucosa is trimmed and repositioned. A pedunculated vocal polyp (G) is removed using the cup forceps and the CO2 laser (H).

LARYNGEAL AND SUBGLOTTIC HEMANGIOMAS
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Indications Pediatric hemangiomas are typically subglottic, whereas adult hemangiomas are usually glottic or supraglottic. Pediatric hemangiomas are generally capillary hemangiomas, whereas adult hemangiomas are often missed capillary or cavernous hemangiomas. Capillary hemangiomas can typically be treated with the CO2 laser, whereas cavernous hemangiomas may require a laser capable of deeper thermal coagulation (eg, the argon, KTP, or Nd:YAG laser). Both types of hemangiomas are treated with suspension microlaryngoscopy with high magnification. Once the type of hemangioma has been determined, the appropriate laser may be brought into the field. Anesthetic Considerations For most laryngeal and subglottic hemangiomas, Venturi jet ventilation or apneic ventilation must be employed to give adequate exposure. An endotracheal tube would obstruct visualization of the subglottic region. As most of these patients have had a prior tracheostomy to establish an airway, the tracheostomy tube is changed to a metal tracheostomy tube to remove any flammable material from the airway. In addition, the presence of an established airway allows the surgeon to proceed in a cautious serially progressive manner. Procedure Typical power levels for the CO2 laser for ablation of a capillary hemangioma are 5 to 8 watts of power and 0.2- to 0.5-second pulse duration. The microspot micromanipulator is used to reach the subglottis because of the lack of parallax. The spot size is slightly defocused to give a spot larger than 250 m in order to obtain wider thermal coagulation.
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Because the depth and the extent of the hemangioma are generally not able to be determined from an endoscopic evaluation, endoscopic removal of hemangiomas is limited to removing 2 to 3 mm of tissue at a time (Figure 2812). This can be compared with chopping off the top of an iceberg and waiting for the iceberg to float back to the top to chop again. Several procedures may be required, but by minimizing the aggressiveness of the approach potential complications (eg, scar or damage to supporting cartilage) are also minimized. Mixed cavernous and capillary hemangiomas are best treated with a laser with a slightly deeper thermal effect. In this case, the argon, KTP, or Nd:YAG laser is used to coagulate the hemangioma. Care is taken to avoid deep thermal effect, because, as previously mentioned, the depth and extent of the hemangioma are not known. Coagulation is established to the depth of the optical penetration depth for the appropriate laser. Six to 10 weeks are then allowed to elapse to permit slough of the necrotic tissue and fibrosis and contracture to enlarge the airway. Adjunctive measures in the treatment of subglottic hemangiomas include use of systemic steroids or triamcinolone (Kenalog) injection into the bed of the hemangioma. Postoperative Care See General Principles of Postoperative Care.
Figure 2812 Removal of a subglottic hemangioma with a CO2 laser.

SUBGLOTTIC STENOSIS
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Indications The characterization of the scar in subglottic stenosis determines the type of approach used. Subglottic stenosis may be either thin or thick, and may be circumferential or involve only a segmented part of the subglottis. Anesthetic Considerations Suspension microsubglottoscopy with the appropriate subglottiscope is employed. In general, Venturi jet ventilation or apneic ventilation is used to provide exposure unless the patient has an indwelling tracheostomy tube to establish an airway. In this case, the tracheostomy tube must be changed to a metal tracheostomy tube to ensure that there is no flammable material in the airway. Procedure The CO2 laser is generally used in an ablation mode with 5 to 8 watts of power, 0.01- to 0.05-second pulse duration, and 250-m spot size to minimize thermal coagulation. Thin subglottic webs may be incised radially. In this technique, incisions are made in the web in each of three or four quadrants, preserving bridges of mucosa between the laser incisions. The area is allowed to heal and contract, and procedures may be repeated at 6- to 8-week intervals. Dilatation after radial incision may be of some benefit because it may compress and break the scar adhesions. However, dilatation is being performed against a fixed obstruction (ie, the cricoid ring). Thick subglottic stenosis (Figures 2813A1 and A2 ) is difficult to treat by almost any method but is occasionally amenable to serial radial incision or to serial microtrapdoor flap excision of scar. Serial radial incision is carried out in a manner similar to the previous technique. Serial microtrapdoor flap excision is performed by excising scar in a microtrapdoor fashion in quadrant sections over a period of time. The microtrapdoor flaps are elevated in small segments (ie, from 12 oclock to 3 or 4 oclock). 1. The mucosa is incised (Figure 2813B ). 2. The mucosa is elevated and maintained, while the deep scar tissue is ablated using the CO2 laser. Care must be taken not to expose cartilage (Figure 2813C ). 3. The mucosa is then incised along the edge, leaving the mucosa attached to the inferior side as a flap (Figure 2813D ). 4. The mucosa is allowed to adhere to the area of scar ablation and provides mucosal coverage for approximately one-half of the surface area due to shrinkage of the mucosa flap. Although this procedure is technically difficult, the free edge of the flap may be welded into position with the defocused laser (Figure 2813E ).
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5. The scar tissue is excised, and serial procedures are repeated over 6- to 8-week intervals (Figure 2813F ). Even in cases in which serial microtrapdoor flaps are unable to provide an adequate airway, it generally results in a much larger mucosa-covered lumen that improves the success of subsequent laryngotracheoplasty. Postoperative Care See General Principles of Postoperative Care.
Figure 2813 A1 and A2, Thick subglottic stenosis. B through E, A serial microtrapdoor flap excision of the subglottic stenosis. The mucosa is incised (B ), then elevated while deep scar tissue is ablated with the CO2 laser (C ). The mucosa is then incised along the edge (D) and allowed to adhere to the area of scar ablation. The free edge of the flap may be welded into position with the defocused laser (E ).
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A2
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Figure 2813 F, Scar tissue is excised, and serial procedures are repeated at 6- to 8-week intervals.
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TRACHEAL STENOSIS Indications When tracheal stenosis is distal to the subglottis, a bronchoscope must be used to obtain exposure. If the lumen is large enough (7.5 mm absolute diameter or larger), a CO2 laser ventilating bronchoscope may be used. For lumens that are smaller, a smaller bronchoscope may be used with a laser that may be transmitted through an optical fiber. Anesthetic Considerations General anesthesia through the side port of the bronchoscope is employed. The humidifier circuit is not connected in the anesthesia machine to minimize vapor buildup on the internal optics. Procedure For both thick and thin tracheal scars, the CO2 laser may be used in a fashion similar to that employed in the laser excision of subglottic stenosis (see earlier). The spot size with a 250-mm bronchoscope is approximately 300 m and is appropriate for use in this area. With larger bronchoscopes, the spot size is appropriately larger due to the defocusing effect caused by the length of the bronchoscope. Stenosis in a small lumen that would not allow the admission of a CO2 laser ventilating bronchoscope may be treated with a standard ventilating bronchoscope and the KTP, argon, or Nd:YAG laser.
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The surgeons eyes are protected with appropriate filters or glasses. The laser may be directed down an optical fiber in the bronchoscope side port. In general, depending on which laser is available (eg, argon, KTP, or Nd:YAG), the laser with the shallower thermal effect is preferred. In addition, the smallest fiber available is used. The guideline for the general technique of excision of scar with these lasers is to use power densities that are high enough and pulse durations that are short enough to effect vaporization with minimal thermal coagulation. The scar tissue is generally treated in a radial incision and dilatation manner because it is exceedingly difficult to attempt to raise a microtrapdoor flap with these fibers. The success of treatment of tracheal stenosis with these other lasers has been only fair to date.
Postoperative Care See General Principles of Postoperative Care.

BIBLIOGRAPHY
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Benjamin B, Croxson G. Vocal cord granulomas. Ann Otol Rhinol Laryngol 1985; 94:53841. Booth JB, Birck HG. Operative treatment and postoperative management of saccular cyst and laryngocele. Arch Otolaryngol Head Neck Surg 1981;107:5002. Boulnois JL. Photophysical processes in recent medical laser developments: a review. Lasers Med Sci 1986;1:4766. DeSanto LW. Laryngocele, laryngeal mucocele, large saccules, and laryngeal saccular cysts: a developmental spectrum. Laryngoscope 1974;84:12916. Harris DM, Werkhaven JA. Biophysics and applications of medical lasers. In: Myers EN, Bluestone CD, editors. Advances in otolaryngologyhead and neck surgery. Vol 3. Chicago: Year Book Medical Publishers; 1989. p. 91123. Holinger LD, Barnes DR, Smid LJ, et al. Laryngocele and saccular cysts. Ann Otol Rhinol Laryngol 1978;87:67585. Hunsaker DH. Anesthesia for microlaryngeal surgery: the case for subglottic jet ventilation. Laryngoscope 1994;104 Suppl 65:130. Jako GJ. Laser surgery of the vocal cords. Laryngoscope 1972;82:220416. McKenzie AL, Karruth JAS. Lasers in surgery and medicine. Phys Med Biol 1984;29:61941. Mizono G, Dedo HH. Subglottic hemangiomas in infants: treatment with CO2 laser. Laryngoscope 1984;94:63841. Monday LA, Cornut G, Bouchayer M, et al. Epidermoid cysts of the vocal cords. Ann Otol Rhinol Laryngol 1983;92:1247. Ossoff RH, Aly A, Gonzales D, et al. A new endotracheal tube for carbon dioxide and KTP laser surgery of the aerodigestive tract. Otolaryngol Head Neck Surg 1993;108:969. Ossoff RH, Toriumi DM, Duncavage JA. The use of the laser in head and neck surgery. In: Myers EN, Bluestone CD, Brackman DE, Krause FJ, editors. Advances in otolaryngologyhead and neck surgery. Vol 1. Chicago: Year Book Medical Publishers; 1987. p. 21740. Ossoff RH, Werkhaven JA, Raif J, Abraham M. Advanced microspot microslad for the CO2 laser. Otolaryngol Head Neck Surg 1991;105:4114. Sheppard L, Werkhaven J, Mickelson S, et al. The effect of steroids or tissue precooling on edema and tissue thermal coagulation after CO2 laser impact. Lasers Surg Med 1992;12:13741. Strong MS, Vaughn CW. Vocal cord nodules and polypsthe role of surgical treatment. Laryngoscope 1971;91123. Strong MS, Vaughn CW, Healy GB, et al. Recurrent respiratory papillomatosis: management with the CO2 laser. Ann Otol Rhinol Laryngol 1976;85:50816. Vaughn CW. Use of the carbon dioxide laser in the endoscopic management of organic laryngeal disease. Otolaryngol Clin North Am 1983;16:84964. Werkhaven J. Laser applications in pediatric laryngeal surgery. Otolaryngol Clin North Am 1996;100510. Weisberger EC, Emhardt JD. Apneic anesthesia with intermittent ventilation for microsurgery of the upper airway. Laryngoscope 1996;106:1099102.
C H A P T E R 29
S OFT T ISSUE S URGERY

Christopher E. Stevens, MD Stephen S. Park, MD Charles W. Gross, MD
This chapter discusses principles for evaluating and managing acute soft tissue wounds of the face in children and highlights special concerns for complex injuries to facial units. The material also applies to similar wounds from neoplasms or congenital problems.
GENERAL PRINCIPLES Facial plastic and reconstructive surgery in children is similar to adults, but with some important distinctions: Trauma remains the most common reason for facial plastic surgery, especially falls, motor vehicle accidents, bites, and projectile injuries from objects such as balls or bats. While the child has a remarkable ability to heal marginal wounds and maintain viability of tenuous flaps, their skin is also characterized by a smooth texture with little laxity. The latter is cause for more conspicuous scars than one might find in the senescent adult. Additional considerations include the psychosocial impact a disfiguring scar might have and the important growth centers of the childs face that must be preserved. Initial Patient Encounter Depending upon the nature of the trauma, it is often necessary to assess for associated injuries. The facial trauma consultant should confirm that a thorough physical examination has been performed and that all potential injuries have been evaluated, particularly intracranial, cervical spine, ophthalmologic, and dental injuries. The appropriate investigations and consultations should be obtained. The initial encounter with the patient and parents is paramount in setting the tone for optimal cooperation. A calm and nonthreatening approach can help bring order to what is often a stressful and chaotic situation. Gaining the confidence of the parents and putting them at ease will often trans-
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fer to the child. The initial cursory examination should be quick and serve to cover the areas often overlooked when a soft tissue injury is evident Cranial nerve examination is performed with particular attention to the facial nerve, where early diagnosis and documentation is imperative for appropriate initial management and for treating delayed onset deficits. Visual acuity or visual field deficits, diplopia, ophthalmoplegia, enophthalmos, exophthalmos, or extensive lid lacerations should prompt ophthalmologic consultation. Bony maxillofacial trauma as evidenced by palpable bony step-offs, facial instability, malocclusion, trismus, gingival tears, and facial hypesthesias should prompt radiographic evaluation. The parotid duct may be at risk with cheek lacerations. Clear saliva from Stensens duct strongly suggests an intact duct system. Often there is only a single opportunity to massage the gland, which is avoided until maximal visualization of the duct orifice is achieved. Tympanic membranes should be visualized to evaluate for hemotympanum, potential cerebrospinal fluid leak, or drum rupture. Dentition should be visualized and palpated to identify any teeth that are avulsed, chipped, cracked, or loose. Preparation Selecting the appropriate arena Any child whose nonfacial injuries will require surgical intervention in the operating room (within an appropriate time frame) should undergo facial repair during the same general anesthetic. Because the face has an excellent vascular supply, most facial wounds can even be closed several days following trauma. Minor repairs with a cooperative patient can often be done without the need for intravenous medications or special facilities. For short procedures, a papoose restraint system can be considered, recognizing that the tight restraint of the infant can be more disturbing than the repair itself. Most pediatric emergency facilities have capabilities and protocols for conscious sedation with agents such as midazolam or ketamine, and one can work with a cooperative child when sedation is administered appropriately. Ideally, a separate physician or specifically trained nurse should monitor the sedation. When extensive reconstruction or debridement is needed, it is often best achieved under general anesthesia in the more controlled environment of the operating room. Photo documentation Preoperative photographs are essential in elective facial plastic procedures, and can be quite beneficial in many traumatic cases as well. It is occasionally beneficial to show the patient or family the extent of the original injury, not to mention the medical, legal, and personal educational uses.
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Instruments and sutures Most emergency centers are reasonably well equipped with the soft tissue instruments needed for simple repairs. For more extensive procedures, however, they are often ill prepared; it remains prudent to be familiar with what they maintain in stock and what will need to be obtained from the operating room. Similarly, standard sutures are often available, but one may need to bring any specialty sutures. In general, deep layer suture should be absorbable, undyed, and maintain strength for at least three weeks. Skin sutures should be monofilament, noninflammatory, and either rapidly absorbing (such as plain gut suture) or removed after 3-5 days. Tissue adhesives, such as 2-octyl cyanoacrylate (Dermabond, Ethicon, NJ), may be useful for the cutaneous layer in children. Anesthesia Prior to the application of any anesthetic agent, be it general, systemic sedation, or local infiltration, it is imperative to assess and document a complete cranial nerve exam. This is particularly important when a laceration may be in proximity to a branch of the facial nerve. This is equally important with more significant head trauma where a skull base fracture may be revealed later, and the need for urgent surgical intervention is dependent on the facial nerve status at presentation. Topical anesthetic agents There are several commercially available topical anesthetic combinations that can be used to obtain anesthesia of the superficial tissues in the immediate vicinity. They generally consist of a combination of anesthetics such as lidocaine, tetracaine, cocaine, or prilocaine, and often a vasoconstrictor such as epinephrine. EMLA Cream (AstraZeneca, Wilmington, DE) is a topical anesthetic with active ingredients of 2.5% lidocaine and 2.5% prilocaine. Advantages include painless application with effective cutaneous anesthesia and avoidance of threatening needles. The disadvantages are prolonged contact (45 minutes) and only superficial anesthesia. One of the distinct uses of these topical agents is with superficial lacerations where the cutaneous anesthesia is adequate for suture repair. Tissue infiltration Lidocaine (1%) is one of the most common local anesthetics used due to its rapid action, relative safety, and adequate duration. Bupivacaine (0.25%) is an alternative with longer duration (up to 12 hours when used with a vasoconstrictor), but is associated with a more delayed onset and increased pain with injection. These agents tend not to work as well in acutely inflamed and infected areas due to the degree of acidity in those regions. When using these agents to anesthetize large wounds, care must be taken to not produce systemic toxicity. The maximum recommended safe dose of infiltrated lidocaine is 3-4 mg/kg for children. The risk of
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seizure and cardiotoxicity using bupivacaine is considerably higher; thus, it should be used sparingly. Adding 1:100,000 epinephrine improves hemostasis and duration of action. In the face and neck, it can be used without much concern for permanent ischemic injury, unlike the previous dogma of avoiding it at the nasal tip and ear lobe. Traumatic soft tissue flaps with marginal perfusion at the periphery may not tolerate the vasoconstriction as well, but fortunately, these rarely need significant amounts of local anesthesia. Adding sodium bicarbonate solution (8.4%) neutralizes the acidity of the local anesthetic solution and can significantly decrease the burning with infiltration. A 9:1 mixture of local anesthetic to sodium bicarbonate is appropriate. Method of infiltration can influence the degree of discomfort. Using the smallest needle (30 gauge), injecting at a very slow rate through the wound margin rather than piercing the skin, and gently rubbing adjacent skin areas can work together to distract the patient and minimize pain and anxiety. Only a small volume of anesthetic is needed as long as adequate time is given for full effect. Excessive infiltrate in a single area distorts the tissues and complicates alignment and repair. Large or complex injuries may require regional blocks of the face.1 Wound Preparation Exploration of the wound depth must be accomplished to remove foreign bodies, identify possible soft tissue flaps, and recognize injury to associated vital structures such as the parotid duct or facial nerve. Debridement is essential to prevent infection, future extrusion, or pigment problems with a tattoo phenomenon, especially from road grime. It is performed most thoroughly after complete anesthesia has been achieved. Larger particulate materials are individually removed, occasionally requiring magnification and gentle scrubbing or small instrumentation. Vigorous irrigation of the wound with a large amount of sterile saline (23 liters) should be performed. There is evidence that powered pulsatile irrigation may be more effective and should be used for large or contaminated wounds.2 Conservation of tissue is an important concept in the initial repair of acute injuries; however, clearly nonviable tissue should be sharply debrided with primary closure of viable skin edges. Some areas that eventually heal by secondary intention may result in wound contraction and facial distortion that is more problematic to repair at a future time. Contractures along the eyelid, alar rim, or lip are examples where debridement and resurfacing may be prudent at an earlier stage rather than excessive conservatism and observation of a full thickness wound contraction later on.
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Beveled lacerations may require modification for optimum results. The more obtuse angled side can be trimmed to allow for better alignment and eversion of the skin closure. Judicious undermining allows for a true layered closure and can be used to reduce tension on skin edges when partial avulsion has occurred. Undermining should be performed sharply in the subcutaneous plane at a uniform depth. Facial lines and aesthetic units have a significant role in managing cutaneous malignancies and during scar revision but are rarely utilized in the acute traumatic wound. Even though a laceration may violate existing relaxed skin tension lines or aesthetic units of the face, one usually closes the wound primarily and entertains scar re-orientation or resurfacing methods as a future consideration. Wound Closure A layered wound closure obliterates dead space, allows more primary healing, supports the overlying cutaneous closure, reduces wound tension, and minimizes the risk of hematomas. Functional tissues, such as underlying orbicularis muscle or a tarsal plate, must be re-approximated meticulously in order to preserve normal anatomic relationships. The internal layer of full thickness lacerations, such as intraoral mucosa, nasal mucosa, conjunctiva, etc, should be closed first. Dermal sutures are essential to remove tension from the skin edge closure and assist in eversion. Because a childs skin and soft tissue are characterized by such elasticity and lack of extensibility, the buried sutures should maintain their tensile strength longer than those needed for more senescent adults. Deep sutures are usually an undyed 4-0 polydioxanone (PDS II, Ethicon, NJ) or polyglactin 910 (Vicryl, Ethicon, NJ). The cutaneous layer, in contrast, heals rapidly and allows earlier removal of sutures. Cutaneous sutures are either a fine monofilament, eg, 6-0 nylon, or rapidly dissolving gut material. The advantage of not needing to remove sutures from a child can be significant; with proper wound care, the gut sutures dissolve within 6 days. Tissue adhesive products have a similar advantage in this patient group. Running sutures permit rapid closure of wounds that are resting in good apposition. A running locked suture tends to equalize wound tension better across skin edges. Unfortunately, a single break in the suture can destabilize the entire wound. Interrupted horizontal and vertical mattress sutures optimize eversion and prevent complete wound separation in the event of one broken suture. Running subcuticular sutures can yield excellent results as they minimize skin perforation but require more experience and precision for optimal alignment and eversion.
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Tissue adhesives such as 2-octyl cyanoacrylate (Dermabond, Ethicon, NJ) are commercially available and should be utilized only when skin edges can be approximated free of tension. Skin edges are held in eversion while the adhesive is applied and allowed to dry. ! Care should be taken to prevent adhesive from falling between the wound margins.3 On occasion, wound edges that are being re-approximated are of unequal length. The halving technique can be used in these circumstances where wound margins are repeatedly halved by placing sutures in the middle of the remaining free edges (Figure 291A). This distributes the length discrepancy evenly throughout the wound.
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For larger discrepancies, a Burrows triangle can be excised from the longer side to prevent a standing cutaneous deformity (Figure 291B). Passive drains using a sterile rubber band may be needed and are often removed the following day. An interrupted suture can be placed and left untied at the drain site. After removal of the drain this sleeper stitch can be painlessly tied to close the drain site. Wound Care Wound care is often an under appreciated aspect of soft tissue injuries, yet it can greatly influence the cosmetic outcome. Because both patient and family are often distracted at this point, repetition and written instructions are often needed. Two essential measures are keeping the wound moist with an ointment and clean from crusts and scabs. 1. Small amounts of blood that dry on the incision and around the suture material appear to lead to a wider and less favorable final scar. Cleaning with dilute hydrogen peroxide can easily remove these scabs and should be performed the first few days. 2. During the first 24-36 hours, patients are instructed to keep the suture lines covered in an antibiotic ointment, re-applied 3-4 times per day as needed. After this, they can wash the wound gently with soap and water, using diluted hydrogen peroxide on a cotton tip applicator to remove any dried crusts or scabs. This practice continues while at school. 3. An exception to this rule is when an abrasion exists and re-epithelialization is part of the wound healing. Under these circumstances, the hydrogen peroxide is too toxic to cells and impedes the rate of healing. Only a mild soap and warm water are used for cleaning purposes. Avoidance of sun exposure is critical during the first several weeks and remains important for a year. Traumatized tissues are particularly photosensitive and small degrees of actinic exposure can result in skin burns, easy tanning, and occasionally, a permanent dyschromia that distinguishes it from the surrounding skin. Beginning around the third week, patients are instructed to apply a small amount of sunscreen each morning and use a barrier, such as a hat or Band-Aid, when outdoors for longer periods of time.
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Figure 291 Management of unequal wound margins. A, Halving technique. B, Excision of Burrows triangle.
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Complications Dehiscence of facial wounds in the absence of infection is uncommon and is most often caused by minor blunt trauma with an inadequate layered closure. If recognized early, these wounds can be reclosed in a more secure fashion. Infection is rare due to the tremendous blood supply. Cellulitis often responds to a course of antibiotics. In the case of delayed wound separation with discharge, part or all of the wound should be opened, debrided, and packed with moist gauze to allow healing by second intention. As always, abscesses must be drained. Keloids and hypertrophic scars are two distinct processes with different clinical, histologic, and biochemical characteristics. Hypertrophic scars are raised, widened, and have altered pigmentation but are generally confined to the location and boundaries of the initial wound. They eventually stabilize in size and often regress. ! Keloids, which are much more common in darker skinned races, continue to deposit collagen until the scar grows beyond the original wound boundaries, and have even been reported on areas of skin with no history of trauma. Keloids and hypertrophic scars can usually be treated in a similar manner based upon the size of the lesion:4
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1. Small lesions may respond to serial triamcinolone injections (10 mg/mL) in 2-4 week intervals if recognized early. 2. Occlusive dressings such as silicone based ointments or even silastic sheeting have been shown to decrease excess collagen deposition. 3. Larger keloids may require simple or serial excision as described above with initiation of steroid injections at the time of the surgery. 4. Individuals with known predisposition for hypertrophic scars or keloids can be treated prophylactically with steroid injections and occlusive dressings at the time of any surgical procedure or repair. LIP REPAIR Lacerations of the lip may transect the skin, orbicularis oris muscle, and mucosa. The keystones of lip repair are (Figure 292) 1. Perfect alignment of the vermilion border Even subtle irregularities at the border of the vermilion may be conspicuous. The vermilion border is marked before infiltration of anesthetic with vasoconstrictor because the blanching may obscure the precise location. The first suture is placed at the vermilion margin for precise alignment. This is done at the outset for complex lacerations, prior to tissue edema and possible distortion. The alignment suture may need to be placed but left untied to work on the intraoral and muscular layers.
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D Figure 292 Layered repair of lip laceration. Example of through and through lip laceration (A ). Schematic of three-layer closure (B ). Layered closure illustrating importance of vermilion border alignment and adequate muscle apposition (C ). Optional Z-Plasty to prevent contracture notching of lip margin (D ).
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2. Precise re-anastomosis of the muscular layer The orbicularis oris muscle serves to provide bulk and function to the lip. The muscle must be secured as a separate layer with a longer-lasting absorbable material, eg, polyglactin 910 (Vicryl, Ethicon, NJ), to prevent diastasis leading to contour depression and notching. 3. Closure of intraoral mucosa The mucosa must also be closed as a separate layer. This layer heals quickly and a short-acting material will usually suffice. Avulsions and resections usually occur on the lower lips from traumatic bites. Most are small, associated with lacerations and irregular edges, and can be closed at the initial encounter. Small deficits adjacent to the lip border are best closed primarily in a perpendicular fashion in order to avoid traction on the free lip margin.5 Larger avulsions may require temporary closure with a more definitive reconstruction performed later. The method of repair is based largely on the size and location of the defect. Lower Lip Defects Defects less than 1/3 the lip length can be converted to a wedge excision and closed primarily. Lateral defects of 1/3-2/3 of the lip involving the commissure are repaired using the Estlander flap (Figure 293).6 Lateral defects of 1/3-2/3 of the lip not involving the commissure are repaired using the Abbe flap (Figure 294).7 Midline defects of 1/3-2/3 of the lip are closed with bilateral advancement flaps of the lower lip. The incisions to create the advancement flaps are made in the sulcus that forms the boundary between the chin unit and lower lip. Defects greater than 2/3 of the lip are closed with more complicated flaps, as described by Karapandzic et al.810 Upper Lip Defects Lateral defects of up to 1/3 of the lip can be repaired by conversion to a wedge followed by primary closure. Larger or central defects that involve the philtrum require more extensive reconstruction.11
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Figure 293 Repair of lip defect involving the commissure with Estlander type flap. Lip defect, in this case due to neoplasm resection. Note flap design (A ). Result after flap transposition and mucosal advancement (B ). (Reprinted with permission from Renner GJ. Reconstruction of the lip. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 34596.)
Figure 294 Repair of lip defect not involving the commissure using the Abbe flap. Lip defect, showing flap design (A ). Result after flap transposition and mucosal advancement with pedicle intact (B ). Final result following pedicle division, which is delayed (C ). (Reprinted with permission from Renner GJ. Reconstruction of the lip. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 34596.)
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AURICULAR REPAIR The pinna is particularly susceptible to injury and avulsion. The auricular contour has little role in terms of hearing, so reconstruction is aimed at creating an inconspicuous unit. Fortunately, both ears are rarely seen simultaneously. Consequently, exact symmetry of the ears has a lesser priority than preserving general contour and definition. Auricular cartilage is elastic and covered by a thin layer of skin that allows the irregular contours to be apparent. This unique relationship is difficult to recreate and every effort is made to preserve as much native tissue as possible. Chondritis of the ear can destroy a meticulous repair and cause significant deformity. Consequently, all open injuries to the ear require systemic antibiotics with adequate cartilage penetration. Quinolones are used frequently in adults, but are inappropriate for pediatric use because of the potential for damage to structural cartilages. Auricular Hematomas Auricular hematomas should be incised and drained. The hematoma usually exists between the perichondrium and cartilage, along the anterior and posterior surfaces, and must be fully expressed. Residual blood can devitalize the cartilage and result in a characteristic auricular deformity, ie, the cauliflower ear. Incisions are placed along anatomic boundaries when possible. A bolster dressing secured with through-and-through mattress sutures applies pressure to the site to prevent re-accumulation. Lacerations Ear lacerations are closed in layers. Cartilage is repaired with permanent or slowly absorbing monofilament suture. Skin closure is performed with emphasis on everting the helical rim to prevent contracture. A small Z-plasty can be created along the helical rim to minimize the notching, but is rarely performed at the acute setting. Cartilage edges that cannot be covered because of skin deficiencies are trimmed to allow primary skin closure. Even if the conservative trimming of cartilage creates a slightly smaller ear, it is rarely conspicuous and less important than risking chondritis. Cutaneous Defects Isolated cutaneous defects of the auricle are unusual and more often arise from resection of skin lesions. Best results are generally achieved with a full thickness skin graft, which preserves auricular height, definition, and orientation. Helical rim defects are an exception, because of greater fibrofatty tissue producing a cookie bite deformity after skin grafting.
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The skin graft is readily harvested from the periauricular, supraclavicular, or upper eyelid areas. Perichondrium or the contralateral skin must be intact as the recipient bed. When bare cartilage is exposed, it is often resected to create a vascularized wound bed. A bolster dressing may be sewn in position to assure graft stability. While these dressings are often unnecessary in the face, the additional security is welcome in children. Through-and-through tacking sutures of rapidly absorbing gut are helpful to maintain close apposition between the graft and wound bed. Helical Rim Defects Isolated helical rim defects are managed according to their size.4,11
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< 20% of defects can be closed using helical rim advancement flaps (Figure 295). > 20% of defects may require a combination of wedge resection and helical advancement. Alternatively, one may create a tubed preauric-
Figure 295 Repair of small helical rim defect using advancement flaps. Scar to be excised and incision planning (A ). Advancement flaps raised (B ). Advancing and securing the flaps (C ). Final closure (D ). Note: Larger rim defects may require small wedge excision of scaphoid fossa to allow closure of flaps. (Reprinted with permission from Quatela VC, Cheney ML. Reconstruction of the auricle. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 44380.
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ular or postauricular pedicled flap with staged take down, delayed by 3-6 weeks (Figure 296). Composite Defects Larger composite defects, such as those involving the helical rim with the antihelix and scaphoid fossa, are also treated based on their size.4,11 ! < 20% of defects can be closed primarily after simple wedge or star excisions. ! > 20% of defects require a cartilage graft interposition with postauricular flap coverage and delayed pedicle division. Composite grafts from the opposite ear can be utilized, but have questionable reliability and leave a significant donor site scar. Auricular Avulsions Partial avulsion Partial avulsions are re-anastomosed primarily (Figure 297). Tremendous vascular reserve allows many near complete avulsions to survive. If only partial viability occurs, the result may still be better than what can be achieved secondarily. The adjacent peri-auricular skin must not be interrupted, because nonhair bearing skin may be essential in a future definitive auricular reconstruction. Complete avulsion Complete avulsion of the auricle is a perplexing problem with no clear method of repair that maintains consistent results. There are several options: Primary anastomosis, with or without microvascular repair, has been successful. In general, the successful outcomes are found as individual case reports and the number of failed primary re-anastomoses is difficult to find.12 The amputated auricle can be de-epithelized and banked in abdominal fat for future use as a structural framework. Unfortunately, the cartilage loses much of its form and is unable to support a vascularized cutaneous flap. More often, the banked cartilage is used only as small onlay grafts to a definitive framework from costal cartilage. The pocket principle can be utilized. The avulsed ear is dermabraded to the dermal layer, re-attached primarily to the auricular stump, then buried under a postauricular skin flap. The buried period is only transient and serves to maintain nutrients to the amputated cartilage until vascular flow can be re-established through the primary anastomosis. Once the ear is delivered from the pocket, auricular skin is regenerated from the residual dermal elements and the postauricular skin is replaced in toto.13 The auricular stump can be closed primarily and the avulsed tissue discarded with a delayed complete reconstruction using conventional microtia repair techniques.14 If there is significant trauma to the periauricular tissues, use of the temporoparietal fascia flap with costal cartilage and a full thickness skin graft may be warranted.15
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Figure 296 Pre-auricular tubed flap for staged repair of larger defects of the helical rim. A bipedicled flap is raised and allowed to roll itself into a tube. As much as possible of the underlying defect is closed (A ). After a three week delay, one end of the preauricular flap is divided and anastomosed to the corresponding end of the helical defect (B ). After a second three week delay the entire flap is transposed and used to reconstruct the helical rim (C ). (Reprinted with permission from Quatela VC, Cheney ML. Reconstruction of the auricle. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 44380.
Figure 297 Acute auricular repair following trauma. Example of partial avulsion of the auricle, which would be expected to survive based on intact helical bridge of skin (A ). Re-approximation of tissues allowing complete coverage of all cartilage with vascularized tissue (B ).
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NASAL REPAIR The pediatric nose is rarely injured due to its relative small size with respect to the forehead and cheeks. The mostly cartilage and soft tissue framework further contributes to decreased damage during trauma by imparting greater elasticity. When they occur, however, nasal injuries present some unique challenges: Cosmetically, the nose has a central position where small scars and subtle asymmetries are readily detected. The juvenile nose assumes the adult proportion and shape during puberty and disruption of the growth centers can significantly impact this development. Successful repair is predicated on a functional result with preservation of normal nasal physiology and patency. Nasal injuries must be viewed as a potential three-layered problem with diligent assessment of the cutaneous tissue, cartilaginous framework, and mucosal lining. Each layer requires meticulous and independent repair. Cutaneous Defects Lacerated skin edges are closed primarily in a separate layer. Avulsion of nasal skin is managed initially with conservative measures, but a definitive repair often requires a small transposition flap. When electing to treat conservatively with second intention healing, one must anticipate some degree of wound contracture and be wary of distortion to the alar rim. Cartilaginous Framework Injuries The nasal septum must be evaluated for a hematoma, even if sedation or topical anesthesia with vasoconstriction is necessary. 1. Septal hematomas are typically bilateral, occurring in the potential space between the perichondrium and cartilage. 2. Untreated hematomas can devascularize the cartilage, leading to cartilage absorption or septal perforation. In addition to the physiologic disturbance this causes, it may impact nasal growth and dorsal projection. The result is a persistent juvenile nose with a saddle deformity and nasal obstruction. 3. All hematomas must be drained and the mucoperichondrial flaps reapposed with absorbable sutures, packing, or splints. In the child, this requires general anesthesia. Cartilage lacerations should be meticulously re-approximated with permanent or slowly absorbing monofilament suture. Cartilage deficits are replaced using existing avulsed cartilage or conchal cartilage grafts. Avulsed cartilage may be a precious source of autologous material. Injuries to the alar lobule and nasal sidewall may occur without cartilage violation, but repair with soft tissue alone will result in nasal obstruc-
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tion. A cartilage graft may need to be placed in a nonanatomic location to protect against future collapse. Mucosal Injuries Lacerations of the intranasal mucosa must be specifically repaired. Left alone, they will heal through second intention but not before some degree of wound contracture with possible notching along the alar rim or vestibular stenosis. Once this has occurred, the surgical repair is significantly more challenging. Tissue loss intranasally is a challenging problem that requires a second epithelial flap for repair. While this is usually done at a later stage, one must not delay too long lest permanent contracture, distortion, and stenosis occur. There are many options for reconstituting the internal lining, and the surgeon should be facile with several options.16 Nasal Avulsion Nasal avulsions are fortunately rare but less resilient than those of the ear. Nevertheless, the amputated segments are generally replaced and closed primarily. Graft enhancement with hyperbaric oxygen17 or medicinal leeches may be helpful.
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PERIORBITAL REPAIR Injuries to this region should prompt a consultation with the ophthalmologist, particularly when there is hyphema, diplopia, enophthalmos, exophthalmos, hypophthalmos, globe injury, diminished acuity, or penetration of the orbital septum as evidenced by prolapsing orbital fat. The rudimentary examination should include visual acuity, pupillary function, range of motion, and a fluorescein stain for corneal abrasions. Eyelid Injuries Eyelid anatomy The eyelid is uniquely devoid of subcutaneous fat and the orbicularis oculi is a thin layer of muscle fibers intimately applied to the deep surface of the thin dermis (Figure 298).18 Layered relations are important when exploring lid lacerations: 1. At the level of the upper lid margin, the sequential layers are skin, muscle, levator aponeurosis, tarsal plate, and conjunctiva. 2. More superiorly, above the crease, the sequential layers are skin, muscle, orbital septum, orbital fat, levator aponeurosis, and conjunctiva. The lower lid is retracted via a layer of fascia, which is acted on by the inferior rectus muscle. This fascia is roughly analogous to the levator aponeurosis, but does not require repair when injured. The gray line is the transition from conjunctiva to squamous epithelium and analogous to the vermilion border of the lip. The Meibomian glands are more internal and distinct from the gray line. Eyelid lacerations Repair of lid lacerations should focus on meticulous layered closure and exact re-alignment of the gray line (Figure 299).19 Tarsal plate injuries are repaired with 2-3 interrupted 6-0 polyglactin sutures through the anterior 2/3 of the plate. The sutures should not penetrate the posterior surface of the tarsus. The conjunctiva is not repaired, but is held in apposition by the tarsal repair. This prevents abrasion of the cornea by the suture. Levator aponeurosis can be evaluated by observing for appropriate lid retraction when the patient looks upward. When clearly injured, the levator aponeurosis should be repaired separately with interrupted 60 polyglactin sutures. The sutures are placed precisely at the cut margin of the levator to avoid bunching of the aponeurosis, which may result in lid retraction or lagophthalmos. Orbicularis oculi fibers are repaired using interrupted 6-0 polyglactin sutures. Skin margins are traditionally closed with interrupted 6-0 silk suture, however, rapidly absorbing gut can be used.
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The first suture is placed at the gray line and is left long for retraction. Sutures are placed on either side of the lash line, progressing away from the lid margin.
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Figure 298 Cross-sectional anatomy of the upper eyelid. (Reprinted with permission from Patel BC, Flaharty PM, Anderson RL. Reconstruction of the eyelids. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 273304).
Figure 299 Primary repair of a lower lid defect. The same basic technique is used for repair of traumatic lacerations. Lower lid defect with edges sharply incised, showing lateral cantholysis incision (A ). Detail of suture planning for lid closure (B ). Following closure (C ). Detail of lid margin suture tails secured under knot of distal suture (D ). (Reprinted with permission from Patel BC, Flaharty PM, Anderson RL. Reconstruction of the eyelids. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 273304).
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The tails of the sutures nearest the lid margin are left long and secured under the knot of the more distal skin sutures. This technique secures the ends away from the globe while leaving them long enough for easy subsequent removal.
Eyelid defects Lid defects are repaired with the same layered technique (see Figure 299). Small defects of the lids that do not involve the tarsal plate or lid margin can be closed in a vertical fashion to prevent lid retraction. Small defects of the lid margin and tarsal plate can be closed primarily. Lateral cantholysis is performed if there is excessive tension. More extensive lid reconstruction techniques are discussed by Putterman.20 Medial Periorbital Injuries The medial periorbital region contains the medial canthal tendons and lacrimal system. Injuries to this area must be explored with attention to the relative anatomy and possible disruption. Canthal anatomy Canthal tendons are fibrous bands from each end of the tarsal plate and orbicularis muscle that attach to the bone of the medial and lateral orbital walls (Figure 2910). Medial and lateral canthal tendons separate into anterior and posterior limbs. The limbs of the medial canthal tendon (MCT) straddle the lacrimal sac and attach respectively to the anterior and posterior lacrimal crest of the medial orbital wall. The anterior limb of the MCT is most prominent. The posterior limb of the lateral canthal tendon (LCT) is most prominent and attaches at Whitnalls tubercle, which lies 3-4 mm posterior to the orbital rim. The anterior limb fibers interdigitate with the orbicularis muscle and attach at the orbital rim. Canthal tendon injury Repair of the canthal tendons is imperative to prevent ectropion, scleral show, canthal dystopia, and to maintain a normal intercanthal distance.19 Sharply cut tendons can be primarily repaired with 6-0 nylon sutures. Avulsed tendons must be re-attached to the periosteum or underlying bone with permanent suture or wire. The keystone principle of reattaching canthal tendons is over-correction. Securing the lateral tendon a few millimeters posterior and superior to their anatomic attachment sites provides for a good outcome after gravity and tension exert their effects.
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Figure 2910 Canthal tendon system. The medial and lateral tendons each divide into anterior and posterior limbs before attaching to their respective orbital walls. The lacrimal sac sits between the anterior and posterior limbs of the medial canthal tendon.
Canalicular anatomy Superior and inferior canaliculi arise from the puncta at the medial end of their respective lids (see Figure 2910). The canaliculi continue posteriorly and medially, wrapping around the anterior limb of the medial canthal tendon to empty into the lacrimal sac, which is straddled by the limbs of the medial canthal tendon. Therefore, an injury that exposes the anterior limb of the MCT, by anatomic definition, must have disrupted the canaliculus because the latter is superficial. The lacrimal sac extends inferiorly where it becomes the nasolacrimal duct, which empties into the inferior meatus of the nasal cavity. If injury is suspected, the puncta can be irrigated to check for leakage and to help identify the level of injury.
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Canalicular repair Lacrimal system injuries should be suspected in any trauma to the area of the medial canthus. Repair can be delayed 1-2 days and is often easier at that point.19 The puncta are dilated with lacrimal probes and cannulated with the ends of a single piece of 0.94 mm silicone tubing (Figure 2911). The ends are then identified in the wound and passed into the respective proximal canalicular stumps after dilation. The ends of the tubing are passed into the lacrimal sac and directed inferiorly through the nasolacrimal duct and into the nose. The ends are retrieved from the inferior meatus and tied in a knot with tails long enough for later retrieval. The tubing is removed after 3-4 months. Eyebrow Injuries Brow injuries are often discounted, but there are a few points that assist with repair. The brow should never be shaved. Any incisions should be made oblique and parallel to the direction of the hair shafts and follicles. Brow continuity is essential in order to be inconspicuous; it may be necessary to excise incomplete avulsions and re-align edges of the brow. Brow defects can often be repaired using opposing advancement flaps of the remaining brow (Figure 2912).
Figure 2911 Stent of the superior lacrimal canaliculus into the nasal cavity.
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Figure 2912 Repair of brow defect using bilateral advancement flaps. Defect in brow and incision planning for repair. Inset: all incisions within the brow are beveled with follicles (A ). Following repair (B ). (Reprinted with permission from Siegle RJ. Reconstruction of the Forehead. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 42142).
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PAROTID DUCT REPAIR Posterior cheek lacerations require exploring the parotid duct. Duct injury is suspected when firm massage of the gland fails to produce clear saliva from Stensens duct, and is confirmed when saliva, or an orally placed duct probe, is visible in the cheek wound. More often, duct continuity is assured when clear saliva is expressed intraorally following massage. Prior to milking, the gland visualization should be optimized, because there is usually a single opportunity to obtain salivary flow even when the duct is intact. Anatomy The duct tracts anteriorly on the lateral surface of the masseter muscle approximately 1 cm inferior to the zygomatic arch. At the anterior border of the masseter, the duct dives medially to pierce the buccinator muscle and exits the oral mucosa adjacent to the second maxillary molar. Duct Laceration The intraoral papilla is dilated with lacrimal probes and a 16-20 gauge silastic catheter is inserted to cannulate the distal duct segment. Alternatively, No 9 polyethylene tubing or a large nylon suture may be used as a stent. The proximal segment is identified by salivary flow in the wound bed and cannulated with the stent emerging from the distal segment. The duct is repaired over the stent with 9-0 or 10-0 monofilament suture. Surrounding tissues should also be re-approximated to relieve tension. The stent is secured to the buccal mucosa and removed in 2-3 weeks. Duct Avulsion When large segments of the duct are missing and primary repair is not possible, the proximal stump can be tunneled through the buccinator and marsupialized into the oral cavity. FACIAL NERVE REPAIR Injury to the facial nerve is suspected in any laceration of the lateral face, and nerve integrity must be documented before sedating the child or infiltrating local anesthetics. Management of facial paresis is conservative and significant recovery can be anticipated. Complete paralysis, however, should be specifically documented and ideally photographed. Nerve injuries in the central face are not explored, because of small neural fibers and significant arborization. Injuries located posterior or lateral to a vertical line from the lateral canthus warrant consideration for exploration. Although not a true surgical emergency, the wound is cleaner during the acute stage and the distal segments can be identified via neural stimulation for up to 72 hours following injury.
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Anatomy The facial nerve arises from the stylomastoid foramen deep to the lobule of the ear and courses anteriorly and then superiorly to enter the substance of the parotid gland at the base of the tragal cartilage. Arborization occurs in a variable manner within the parotid. The branches emerge from the anterior border of the gland, continue forward into the midface immediately deep to the superficial muscular aponeurotic system (SMAS), and innervate the muscles of facial expression from the undersurface. Nerve Transection Distal nerve segments can be identified within the wound bed by a nerve stimulator. If the proximal stump is not readily identifiable, a superficial parotidectomy is performed to identify the nerve at the stylomastoid foramen and dissect to the severed end. Crushed nerve ends should be freshened with a sharp razor blade or scalpel. Trimming the ends at a 45 angle improves regrowth of axons of the proximal end into the neural tubule of the distal segment. The identified ends are anastomosed under magnification with 3 or 4 simple sutures (9-0 or 10-0 nylon) through the epineurium. A few sutures must be placed through the surrounding tissues to relieve tension from the neural anastomosis. If the proximal stump cannot be identified and the surgeon is not prepared to perform a superficial parotidectomy, the distal stump should be tagged with a colored permanent suture in the adjacent soft tissue for future identification. SCAR REVISION Most unacceptable scars can be revised to yield a more inconspicuous result. Pediatric scar revisions are unique in that they significantly involve the parents, whose desires and expectations may be unrealistic and differ from the patients. Discussions of scar revisions should always be put in terms of scar improvement and not scar removal, and several requirements must be met prior to surgical intervention: 1. The scar must be allowed time to mature. 2. The patient and parents should be over the initial emotional reaction of the trauma and have had the opportunity to adjust and accept the facial disfigurement. This allows for a more realistic outlook on potential outcomes and expectations. 3. Cooperation and motivation of the child is imperative for diligent wound care, sun protection, and avoidance of even minor trauma during the healing phase. 4. As with any cosmetic procedure, if the anticipation is indirect improvement in social life, school performance, etc, the surgeon is destined to have an unhappy patient.
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Indications and Timing Linear scars greater than 2 cm long and 2 mm wide can often be improved. A straight and lengthy scar is often noticeable because similar facial lines do not normally exist. Breaking the scar into shorter segments of different orientations is beneficial. Scars that are of excessive width will improve with a simple excision. Revision is often warranted for scars that are poorly oriented to facial lines, distort normal anatomic landmarks, or have contracted and formed webs.21 Simple Excision Some scars may improve with just a direct excision and primary closure, especially when they are relatively short, ie, less than 2 cm, and are aligned well with facial lines, but are either wide or have an irregular contour. Tension free closure and good soft tissue techniques are paramount for optimal results. Incisions are made in the margin of normal tissue immediately peripheral to the scar. Slight beveling away from the scar will facilitate skin edge eversion during closure. The deep layer of scar is left in place, which often serves to support the new scar and prevent depression and contraction. The skin margins are undermined and closed in a layered fashion. Serial Excision Very broad scars, or benign lesions in which complete excision would be difficult to close primarily, can be excised serially. The scar is removed with serial excisions in multiple stages. Each stage is delayed by 2-3 months to allow for maturation and adjacent tissue expansion. In the initial stages, all incisions are made within the scar to prevent damage to healthy skin. The final stage is a complete excision and can be closed with broken line closure if indicated. Z-Plasty A Z-plasty is a double triangle interposition flap that can be used to lengthen or re-orient scars. It is perhaps most useful to elongate existing scars that have contracted and become a small web or caused distortion of adjacent structures.22 The central limb is oriented in the axis of excessive tension. This is usually the pre-existing scar, which can be excised concurrently (Figure 2913). The lateral limbs are of identical length to the central limb and extend from the ends of the central limb at angles of ! 60 or less. This should result in parallel arms.
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Angles between the central and lateral limbs determine the amount of elongation in the vector of the central limb.
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60 angles achieve 75% elongation and rotate the central limb 90. 45 angles achieve 50% elongation and less rotation. 30 angles result in 25% elongation.
Arms are created parallel to the relaxed skin tension lines when possible. The resulting triangle flaps are elevated, transposed, and secured with a layered closure. The major disadvantages of Z-plasty are that it increases total incision length by 200% and increases wound tension in the direction perpendicular to the vector of elongation.
Figure 2913 Z-plasty scar revision. Scar from previous injury has caused contracture distortion of vermilion edge (A ). Result following excision of scar and Z-plasty used to elongate scar and release contracture (B ). (Adapted with permission from Frodel JL, Wang TD. Z-plasty. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 13150).
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Broken Line Closures Long straight or curvilinear scars are very noticeable because the course is predictable and easily followed. Therefore, scar excision with broken line closure can create an irregular pattern with better camouflage. A W-plasty is a rapid and effective means of converting a straight line to a jagged one with small limbs that can be better oriented along facial lines (Figure 2914). The scar is excised. Skin margins are evenly undermined. Interlocking mini-flaps are created using a No 11 scalpel perpendicular to the skin surface.
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Each limb of the pattern should be at least 2-3 mm to avoid a wide scar appearance.23 Individual flaps should not exceed 4-5 mm in any surface dimension. A geometric broken line closure (Figure 2915) is preferable for very long scars, because a long W-plasty creates a recognizable repeating pattern. Although more challenging and time consuming, a geometric broken line closure creates an irregular pattern and can provide maximal camouflage.
The broken line closure is closed in layered fashion. Dermabrasion Scars with subtle surface irregularities may have conspicuous shadowing from small step-offs, which may often be improved by dermabrasion. Abrading skin and scar to the level of the papillary dermis allows the epithelium to regenerate from the deeper adnexal structures in the reticular dermis. The desired result is a more subtle transition of color and surface from the surrounding skin to the scar. Individuals with darker skin, hormonal changes due to pregnancy or exogenous replacement, or a history of oral herpes are prone to excessive pigmentary changes and scarring during healing.24 Local anesthesia, either topical or infiltration, is used. Young children usually require a general anesthesia. A powered hand piece with a 5-10 mm wide diamond abrasive fraise is used to create a controlled superficial injury. Injury is limited to the papillary dermis, because injury to the reticular dermis damages adnexal structures and increases scarring. Multiple delayed sessions and prolonged maturation may be required for optimum results. Dermabrasion can be an important adjunct to other techniques such as broken line closures. Diligent wound care is imperative during the postoperative period, being sure to maintain cleanliness and moisture. Hydrogen peroxide is avoided due to cellular toxicity and delayed healing.
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Figure 2914 Scar excision with W-plasty closure. (Reprinted with permission from Thomas JR, Frost TW. Scar revision and camouflage. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 58795).
Figure 2915 Scar excision with geometric broken line closure. (Reprinted with permission from Thomas JR, Frost TW. Scar revision and camouflage. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 58795).
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. Zide BM, Swift R. How to block and tackle the face [published erratum appears in Plast Reconstr Surg 1998;101:2018]. Plast Reconstr Surg 1998;101:84051. Brown LL, Shelton HT, Bornside GH, Cohn I Jr. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg 1978;187:1703. Toriumi DM, OGrady K, Desai D, Bagal A. Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery. Plast Reconstr Surg 1998;102:220919. Larrabee WF, Sherris DA, Murakami CS. Principles of facial reconstruction. New York: Raven Press; 1995. Estlander JA. Eine Methode aus der einen Lippe Substanzverluste der anderen zu ersetzen. Arch Klin Chir 1872;14:6228. Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg 1968;42:4813. Bernard C. Cancer de la levre inferieure opere par un procede nouveau. Bull Soc Chir Paris 1853;3:35765. Gillies HD, Millard DR. The principles and art of plastic surgery. 1st ed. Boston: Little, Brown; 1957.
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9. 10. 11. 12. 13. 14. 15.
Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:937. Renner GJ. Reconstruction of the lip. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 34596. Quatela VC, Cheney ML. Reconstruction of the auricle. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 44380. McDowell F. Successful replantation of a severed half ear. Plast Reconstr Surg 1971;48:2813. Mladick RA, Horton CE, Adamson JE, Cohen BI. The pocket principle: a new technique for the reattachment of a severed ear part. Plast Reconstr Surg 1971;48:21923. Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg 1999;104:31934. Park SS, Wang TD. Temporoparietal fascial flap in auricular reconstruction. Facial Plast Surg 1995;11:3307.
16. Park SS, Cook TA. Reconstructive rhinoplasty. Facial Plast Surg 1997;13:30916. 17. McClane S, Renner G, Bell PL, et al. Pilot study to evaluate the efficacy of hyperbaric oxygen therapy in improving the survival of reattached auricular composite grafts in the New Zealand white rabbit. Otolaryngol Head Neck Surg 2000;123:53942. 18. Ellis E, Zide MF. Surgical approaches to the facial skeleton. Baltimore: Williams & Wilkins; 1995. 19. Leone CR Jr. Periorbital trauma. Int Ophthalmol Clin 1995;35:124. 20. Putterman AM. Cosmetic oculoplastic surgery: eyelid, forehead, and facial techniques. 3rd ed. Philadelphia: WB Saunders; 1999. 21. Koopman CF. Wound healing and scar revisions in the pediatric patient. In: Smith JD, Bumsted RM, editors. Pediatric facial plastic and reconstructive surgery. New York: Raven Press; 1993. p. 31735. 22. Frodel JL, Wang TD. Z-plasty. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 13150. 23. Park SS. Scar revision through W-plasty. Facial Plastic Surgery Clinics of North America 1998;6:15761. 24. Thomas JR, Frost TW. Scar revision and camouflage. In: Baker SR, Swanson NA, editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995. p. 58795.
C H A P T E R 30
A URICULAR R EPAIR FOR M ICROTIA

Roland D. Eavey, MD
Anxious parents of a newborn with microtia should be counseled that successful surgical correction of a severely malformed auricle is possible.17 Conventional repair using rib cartilage to augment the auricle is generally postponed until age 6-7 years. Hearing assessment, however, is necessary soon after birth to determine if a normal-appearing contralateral ear hears adequately. When microtia is bilateral, a standard bone conduction hearing aid should be placed as soon as possible.
The goal of microtia surgery is to provide the patient with an auricular appearance that is sufficiently close to normal in order that no attention will be attracted to the ear. Options include Auricular repair with rib augmentation. The results of rib augmentation are consistent and reliable, such that children need no longer be deprived of the surgical option of auricular correction. The trade-off for an improved auricular appearance by rib reconstruction is a linear scar over the contralateral lower chest and a donor skin graft site. Bone-anchored titanium implant with prosthetic auricle.8 Advantages include fewer surgeries with less morbidity and a realistic pinna appearance at arms length. Disadvantages include artificial feel of the ear, the need for strict hygiene in a child, a lifetime of replacement protheses, unsightly appearance of the anchoring site with the prosthesis removed, and generally, older age requirement for initial placement. Transfer of contralateral conchal bowl cartilage and postauricular skin.9 Advantages include fewer surgeries with less morbidity and a normal feeling pinna. Disadvantages include a result that is somewhat smaller than the normal ear, and that mastering this technique is a formidable task for the surgeon. Nonsurgical options. The patient may elect to simply cover the ear with long hair. Potential option. In the future, tissue engineering might evolve sufficiently for actual patient use.10,11
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AURICULAR REPAIR OF MICROTIA Indications and Timing Microtia repair is indicated for severe auricular congenital malformation. Surgery is postponed until age 6-7 years to ensure a sufficient volume of cartilaginous rib, and to allow a symmetric reconstruction when the contralateral ear is nearly normal adult size. Auricular reconstruction for microtia should always precede repair of ear canal atresia (see Chapter 8) so that the regional skin coverage is not violated. Anesthetic Considerations General anesthesia is given for all surgical stages. Preparation Measure the normal contralateral ear (Figure 301), including vertical height, and distances from the lateral canthus of the eye to the anterior insertion helix and to the lobule. Note the axis of the auricle (nearly parallel with the nasal dorsum). Measurements from the normal ear are used in reconstructing the microtic ear (Figure 302). Note the position of each lobule viewed en face (Figure 303); the microtic lobule lies more superiorly.
Figure 301 Preoperative measurements of a normal contralateral ear. Relationship of the superior auricle to the brow (A). Distance from the lateral canthus to the auricle (B). Distance from the lateral canthus to the lobule (C). Axis of the auricle relative to the nasal dorsum (D). Vertical height of the auricle (E).
Auricular Repair for Microtia
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Figure 302 Measurements for the malformed ear are taken from the normal ear.
Figure 303 An en face view reveals a difference in vertical height and relationships of the superior and inferior aspects of the auricle.
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Create a template from the normal ear using an X-ray film and a marker (Figure 304). For bilateral microtia, an ear design template for rib reconstruction can be created from the ear of a family member. Examine for other potential facial asymmetry and facial nerve malfunction. Evaluate the childs overall size (the child should be at least 6 years of age and preferably older). Evaluate the size of the contralateral cartilaginous ribs by palpation. Check for possible trauma to the ribs or a congenital malformation that could require use of ipsilateral ribs. Procedure Overview The repair involves at least three stages: (1) rib harvest, (2) lobule transposition, and (3) creation of a functional postauricular sulcus. A fourth stage, to add a tragus or to perform a contralateral otoplasty of the normal auricle, is needed occasionally. Repair of bilateral microtia is staged efficiently. The initial ear receives a rib graft at the first operation. At the next operation, the second ear receives the rib graft and the previously grafted ear undergoes the lobule rotation simultaneously, and so on. Microtia repair is surprisingly well tolerated. The first stage (rib harvest) is the most painful; usually 2 nights of hospitalization are required because of discomfort and drainage requirements. All other hospital stays are shorter.
Figure 304 An X-ray film template is created from the normal ear.

STAGE 1: RIB HARVEST
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Preparation The contralateral chest is prepared with an iodine solution; those ribs have a curvature that is favorable for reconstruction. Towels are placed with a square window sufficiently generous to harvest several cartilaginous ribs from the lower costal margin. Injection of local anesthesia and epinephrine is optional. Simultaneously, the ear site is prepped with an iodine solution. No local injection should be used. The area is shielded with three towels; a clear plastic drape permits a view of the face. Procedure Rib harvest Make a linear incision (approximately 5 cm) over the lower contralateral ribs (Figure 305). Identify and retract (do not divide) the rectus abdominus muscle.6 Isolate three lower cartilaginous ribs: 1. Use the film template, and place it over two ribs connected at the synchondrosis to select for the base of the framework. A third floating rib is to be used for the helix. 2. Cut the ribs cleanly at the costochondral junction. Remove with the perichondrium (see Figure 305). 3. A fourth rib (floating) can be harvested more caudad as needed.
Figure 305 Rib harvest procedure.
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Repair the pleura, if entered, with a pursestring suture, which is tightened as a suction tube is removed. Close the incision, without a drain, using absorbable subcutaneous suture. A long-acting local anesthesia block can be used. Place a sterile dressing. Obtain an intraoperative chest X-ray to check for a pneumothorax. Framework Creation Clean the adherent muscle attachments. Use a No 10 blade to shave perichondrium and cartilage off the floating rib on what will be the exterior surface of the helix. The rib will curl, which facilitates creating a helix (Figure 306). Preserve the perichondrium on the inner curve. Place the film template on the upper two ribs with the synchondrosis. Carve around the template with a scalpel to create the shape of the auricle (Figure 307). Suture the helix (lower free rib) to the base (upper two ribs of the synchondrosis) using a 4-0 clear nylon suture (Figure 308).
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The sutures must purchase the perichondrium for strength. Place the knot on the framework undersurface, not on the cartilage surface that will be adjacent to the skin.
Figure 306 Creation of a helix. Shaving the perichondrium and cartilage on one side of the rib allows the rib to curl.
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Figure 307 Shaping of the auricle. A solid block is carved as a base using the X-ray template.
Figure 308 A helix is attached to the base ribs.
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Draw the outline of the fossa triangularis and the scaphoid fossa. Use a scalpel and septal gouge to carve these areas to create realistic contours (Figure 309). Keep the cartilage moist. Skin pocket preparation Place the template over the malformed ear. Using preoperative measurements, locate and outline the correct position. Create a 2-3 cm vertical pre-auricular incision (Figure 310). Avoid the superficial temporal artery. A scalp incision can also be used as an alternative. Remove the malformed cartilage of the auricle. Do not remove the fatty tissue or the skin. Elevate the skin pocket. The plane should be an extension of the skin depth already existing over the malformed cartilage. During dissection, the scissors tips should be slightly visible, tenting the skin (Figure 3011). Apply pressure for hemostasis; the pocket dissection can be bloody. Insert the framework and check the measurements. Insert two suction drains and close the incision with a running Prolene suture (Figure 3012). Tiny skin fenestrations are closed with a 6-0 mild chromic suture. Apply a mastoid dressing.
Figure 309 Carving of the scapha, fossa triangularis, and antitragus features.
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Figure 3010 A template is placed over the malformed ear to outline the correct position for the incision.
Figure 3011 Elevation of the skin pocket.
Figure 3012 The framework is inserted and the incision is closed. Two suction drains are preferred.
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Postoperative Care Manage rib area pain as necessary with patient-controlled anesthesia. The suction drains require an hourly change of red-topped vacuum tubes that are displayed in a test tube rack to monitor drainage. The mastoid dressing is changed daily, or at the surgeons discretion, when the patient is discharged from the hospital. Discharge the patient on postoperative day 2 or 3, depending on the amount of drainage and pain. Suture removal is performed at 7-10 days. No new dressings are necessary. STAGE 2: LOBULE TRANSPOSITION Preparation The malformed ear is prepared with an iodine solution. An adherent transparent plastic drape is placed anteriorly in the towel window to permit a view of face. Procedure The microtic ear usually has a lobule-like appendage located anterior to the normal anatomic position (Figure 3013A). Mark the area of excision, as well as the area for transfer, over the lower area of the framework. Remove the skin over the framework. Preserve the subcutaneous connective tissue over the framework. Elevate the lobule-like remnant, retaining the inferior pedicle. Rotate the remnant posteriorly to the lower framework (Figure 3013B). Trim the skin and fat until a realistic lobule contour is achieved. Close the sites without drains, using Prolene sutures. The donor site may be closed with a small graft of skin obtained from the recipient site. A sterile mastoid dressing is applied. Postoperative Care Pain is managed with acetaminophen. This stage can be handled as ambulatory surgery at the surgeons discretion. The mastoid dressing and sutures are removed after 1 week.
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Figure 3013 A, The soft tissue remnant of the malformed ear is detached and rotated. The skin is removed, and subcutaneous connective tissue is preserved. B, The donor site is closed either primarily or with a skin graft.
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STAGE 3: SEPARATION FROM THE HEAD AND CREATION OF A FUNCTIONAL POSTAURICULAR SULCUS Procedure Obtain a skin graft.
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One technique is to use a dermatome to harvest skin (18/2000-inch thickness) from the ipsilateral buttock. Place a sterile dressing on the donor site. Alternatively, the author prefers an elliptical full thickness graft, approximately 10 x 5 cm, harvested from over the lumbar spine area, using primary closure to mimic spine surgery in a location that the patient cannot see. The graft is then thinned with a scalpel and scissors until translucent and flexible.
Incise the skin along the helical rim to the depth that preserves connective tissue over the cartilage (Figure 3014A). The incision placement depends on the zone of hair-bearing skin. The region of hair-bearing skin can be diminished if the patient undergoes preoperative laser hair removal. Elevate the framework and preserve the thin layer of subcutaneous connective tissue over the cartilage (Figure 3014B). Create a sulcus under approximately two-thirds of the framework. Retract the scalp skin away from the framework. Attach the skin graft to the superior edge of the skin (Figure 3014C). Pull the skin over the perimeter of the framework and tuck it medially under the framework to create a rounded helical contour. Trim excess skin graft. Apply remainder of the skin graft to the side of the head (see Figure 3014C). Apply a bolster and mastoid dressing. Postoperative Care Provide pain management with acetaminophen and perhaps a narcotic. A dressing is left on the donor site. The patient will be in the hospital overnight. A sterile mastoid dressing and the bolster are left in place for 1 week. After the bolster has been removed, instill antibiotic topical drops into the sulcus for 3 weeks.
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Figure 3014 A, An incision is made through the skin only. Placement is determined by the caudad margin of hair-bearing skin. B, The lined area represents the approximate region to undermine. C, The lined region represents one skin graft, and the unlined region represents the second skin graft on the side of the head between the intentionally retracted scalp and the sulcus.
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STAGE 4: OPTIONAL CREATION OF THE TRAGUS OR CONTRALATERAL OTOPLASTY Procedure (conventional) A crescent-shaped composite cartilage graft with postauricular skin is harvested from behind the contralateral ear. This provides a further opportunity to complete the symmetry by tailoring the normal ear. A J-shaped incision is created in the reconstructed ear. The cartilage is inserted under the preauricular skin. A small skin graft with a bolster is applied to the interior raw surface. Alternative procedures can be performed depending on anatomical circumstances. Given excess rib at the first stage, a neotragus can be created from rib spanning the helical root to lobule area. In other patients, the malformed cartilaginous remnant with overlying skin can be contoured into a tragus. Controlateral ear cartilage without attached skin can be used. These techniques are favoured by the author. Sequellae If an infection occurs despite perioperative antibiotics, incision and drainage are performed if the skin envelope is fluctuant. Antibiotics are continued until the soft tissue is normal. Skin breakdown, when it occurs, usually is located over the helix anterosuperiorly.
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Observe for skin breakdown, and allow to demarcate. The skin may re-epithelialize if the area is small. To promote reepithelialization, use antibacterial ointment for several weeks and debride the underlying cartilage to a fresh white substance if cartilage sloughs. If re-epithelialization does not occur, either a bilobed scalp flap or a temporalis fascia flap is needed to cover the cartilage and provide a skin graft bed. At times, hyperbaric oxygen can be considered if the skin appears dusky but has not broken down.
A hypertrophic scar may occur.
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Figure 3015 Postoperative appearance following removal of the suture.
REFERENCES
1. Brent B. The correction of microtia with autogenous cartilage graft. I: The classic deformity. Plast Reconstr Surg 1980;66:112. 2. Brent B. Total auricular construction with sculpted costal cartilage: Case No. 15. In: Brent B, editor. The artistry of reconstructive surgery. St. Louis: CV Mosby; 1987. p. 113127. 3. Eavey RD. Management strategies for congenital ear malformations. Pediatr Clin North Am 1989;36:152134. 4. Eavey RD, Cheney ML. Reconstruction of congenital auricular malformation. In: Nadol JB, Schuknecht HF, editors. Surgery of the ear and temporal bone. New York: Raven Press; 1992. p. 43547. 5. Eavey RD. Ear malformations: what a pediatrician can do to assist with auricular reconstruction. Pediatr Clin North Am 1996;43:123344. 6. Eavey RD, Ryan DP. Refinements in pediatric microtia reconstruction. Arch Otolaryngol Head Neck Surg 1996;122:61720. 7. Eavey RD. Microtia repair: creation of a functional postauricular sulcus. Otolaryngol Head Neck Surg 1999;120:78993. 8. Tjellstrom A. Five years experience with bone-anchored auricular prosthesis. Otolaryngol Head Neck Surg 1985;93:36672. 9. Davis J. Severe microtia and radical auriculoplasty. In: Davis J, editor. Otoplasty. Aesthetic and reconstruction techniques. New York: Thieme-Verlag; 1997. p. 66100. 10. Cao Y, Vacanti JP, Paige KT, et al. Transplantation of chondrocytes utilizing a polymer-cell construct to produce tissue engineered cartilage in the shape of a human ear. Plast Reconstr Surg 1997;100:297302. 11. Eavey RD. [Discussant for article reference #10]. Plast Reconstr Surg 1997;100:3034.
C H A P T E R 31
OTOPLASTY FOR THE P ROMINENT E AR

A prominent ear, or prominauris, is the abnormal protrusion of the auricle, which is most commonly caused by a poorly developed antihelix or an absent antihelical fold. The goal of otoplasty is to reconstruct a normally appearing antihelix in which the superior crus of the antihelix is rounded and smooth, not sharp. The procedure described below fulfills this goal, and is a modification of the otoplasty technique originally described by Becker.1,2
OTOPLASTY FOR THE PROMINENT EAR Surgical Anatomy Prior to undertaking surgery to correct a prominent ear, the surgeon should be fully familiar with the anatomy of the anterior and posterior auricular cartilage (Figures 311 and 312). The parts of the cartilage of the auricle that are prominent on the anterior surface will be depressions on the posterior surface, and vice versa. For example, the fossa triangularis on the anterior surface is the eminentia triangularis on the posterior surface. The angle between the scapha and concha is produced by the antihelix. Indications Otoplasty is indicated when both the child and the parents agree that a prominent ear deformity is causing psychologic disturbance to the child. The procedure is best performed when the auricle has reached maturation and the child is old enough to understand the problem, desires the operation, and can cooperate with the postoperative care, which is usually 4 to 5 years of age and older. Caution should be exercised when recommending otoplasty if the child is known to form keloids, or has a severe and extensive deformity of the auricle that involves more than just the antihelix.
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Figure 311 The anatomy of the anterior surface of auricular cartilage.
Figure 312 The anatomy of the posterior surface of auricular cartilage.
Otoplasty for the Prominent Ear
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When the child has a unilateral moderate-to-severe deformity and the contralateral ear appears normal, naturally, only the deformed ear should be operated on. However, when the contralateral ear has even a mild deformity, a bilateral otoplasty should be performed to ensure postoperative symmetry of the ears. Anesthetic Considerations The procedure in children is performed under general endotracheal anesthesia; however, in some adolescents, the operation can be carried out with only local infiltrative anesthesia with the aid of intravenous analgesia. The postauricular skin is infiltrated with 1% lidocaine containing 1:100,000 epinephrine for hemostasis. Preparation of the Patient and Ears Prior to surgery, photographs are obtained that show the full head and ears of the patient. Frontal, posterior, and both right and left sides should be included. These photographs can then be compared with postoperative ones usually obtained 6 months after the operation. Following the usual preoperative sterilization of the auricle, the ear is draped.
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When both ears are to be operated on, both can be prepared and draped; however, care should be taken not to fold the first auricle forward toward the face when the contralateral ear is being operated on. During bilateral surgery, the surgeon should not repeatedly turn the patients head from side to side, because movement of the endotracheal tube may traumatize the subglottis.
Cotton pledgets can be placed into the external auditory canal to prevent blood from entering and forming a clot, which, when present in the postoperative period, can be troublesome to both the surgeon and the patient.
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Procedure By folding the pinna back into the desired position, the amount of redundant postauricular skin to be excised is estimated (Figure 313). An elliptical portion of skin to be excised is outlined with methylene blue and injected with lidocaine and epinephrine (Figure 314). The excess skin is excised from the postauricular incisions and discarded (Figure 315). Undermining of postauricular skin and the perichondrium to the eminentia scaphae is done, exposing the cauda helicus and fissura antitragohelicina (Figure 316).
Figure 313 The pinna folded back into desired position to estimate the amount of redundant postauricular skin to be excised.
Figure 314 An elliptical portion of skin to be excised is outlined with methylene blue and injected with local anesthetic agent.
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Figure 315 Postauricular skin is excised and discarded.
Figure 316 Undermining of the postauricular skin and the perichondrium.
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The dashed line shown on the anterior surface of the auricle marks the position of the incisions to be made on the posterior surface of the auricle (Figure 317). 1. A Keith needle and methylene blue are used to mark the position for the incisions. 2. The needle is inserted through the anterior surface of the auricle at one or two points in the concha, just below the new antihelix, and at one or two points under the helix through to the eminentia scaphae. 3. The needle puncture sites on the posterior auricular surface are marked with methylene blue. 4. No incision is made in the outer edge of the new antihelix, since such an incision results in a sharp and unacceptable antihelix. The Keith needles are removed by pulling from anterior to posterior, to avoid tattooing the anterior skin with methylene blue. Cartilage incisions are then performed (Figure 318): 1. The outer edge of the eminentia scaphae, hidden anteriorly in the scapha under the helix, is incised to create the outer border of new antihelix. 2. The eminentia conchae, hidden anteriorly under new antihelix, is incised to create the inner border of the new antihelix. The incision is carried through the middle of the cauda helicus. 3. Incisions should go through cartilage, but should not penetrate the anterior auricular skin in order to avoid creating a button-hole. 4. The new antihelix is undermined partially on the outer and inner surfaces, leaving a new antihelix attached in the middle.
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Figure 317 Dashed line shown on the anterior surface of the auricle marks the position of the incisions to be made on the posterior surface of the auricle. The incisions to construct the new antihelix are hidden under the helix and scaphae, in the concha anterior, and below the new helix.
Figure 318 Incisions are made along the outer edge of the eminentia scaphae and the eminentia conchae.
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The outer and inner edges of the new antihelix are rolled to almost approximate each other and are sutured in place using a 4-0 white Mersilene suture (Figure 319). About three to five sutures are used and inverted to bury the knot in the depths of the new antihelix. Two small bolsters made of Adaptic are placed on the anterior surface of the auricle on each side of the new antihelix and sutured in place with 4-0 silk mattress sutures (Figure 3110). The postauricular wound is closed with an interrupted absorbable suture (Figure 3111); a drain is used only if bleeding has been a problem. Cotton, impregnated with glycerine, is inserted into the external meatus of the canal, concha, and scapha. A fluff dressing is placed over the anterior surface of the pinna, and a piece of Adaptic and one or two 4 x 4 gauze pads are placed between the posterior surface of the auricle and the temporal bone. Bilateral mastoid compression dressings are applied. Postoperative Care The mastoid dressings are changed after 24 hours. A hematoma, if present, must be evacuated promptly and a pressure dressing re-applied. The mastoid dressing is changed again 4 days following the surgery, and the bolsters and mattress sutures are removed. The mastoid dressing remains for a total of 2 weeks, after which the child wears a stockinette over the ears (or loose ski cap that fits over the ears) for an additional 3 months, but only during sleep. Complications and Long-Term Outcomes The most common complication is hematoma, which is best recognized by changing the dressing after 24 hours. A hematoma, if present, must be promptly evacuated and a pressure dressing applied. An undetected hematoma may cause permanent thickening of the pinna, which is a cosmetic problem that is difficult to remedy by revision surgery. Asymmetry may develop if the dressings are too loose during the first 2 weeks after surgery. If this occurs, the child should be properly redressed for another 1-2 weeks. Recently, we reported on the long-term outcomes of unilateral and bilateral otoplasty in 16 children (30 ears), aged 4-17 years (mean 8.2), with an average follow-up of 4.6 years:3
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All were either happy or very happy with the result, as determined by a satisfaction survey and objective assessment of the ear. All patients had preservation of the antihelix and good to excellent ear symmetry at follow-up. One child had an early postoperative hematoma from accidental blunt trauma, while playing softball, but had an excellent long-term result after the hematoma was evacuated. No child required revision surgery.
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Figure 319 The outer and inner edges of the new antihelix are rolled to almost approximate each other and are sutured. Sutures are inverted to bury the knot in the depths of the new antihelix.
Figure 3110 Two small bolsters made of Adaptic are placed on the anterior surface of the auricle on each side of the new antihelix.
Figure 3111 The postauricular wound is closed.
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REFERENCES
1. 2. 3. Becker OJ. Surgical correction of the abnormally protruding ear. Arch Otolaryngol 1949;50:54160. Becker OJ. Correction of the protruding deformed ear. Br J Plast Surg 1952;5:18796. Lee D, Bluestone CD. The Becker technique for otoplasty: modified and revisited with longterm outcomes. Laryngoscope 2000;100:94954.
C H A P T E R 32
M AXILLOFACIAL T RAUMA
Sherard A. Tatum, MD Robert M. Kellman, MD
The oft-cited phrase that children are not just scaled-down adults is particularly true with regard to craniomaxillofacial trauma. There are behavioral, anatomic, and physiologic differences other than scale that necessitate specific management strategies for children: The ratio of anterior cranial vault height to facial skeletal height changes with growth and development (Figure 321). Cranial height in infants accounts for about two-thirds of the craniofacial height. Cranial growth is initially faster than is facial growth; however, after age 5 to 6 years cranial growth is nearly complete, except for increasing bone thickness. As the child matures the cranial height accounts for about one-third of craniofacial height. Craniofacial skeleton growth is an additional consideration because trauma, and the management of trauma, may disturb normal development. Knowing skeletal growth centers and vectors can predict potential adverse affects. Management can be planned accordingly. Sinus pneumatization also must be considered. Infants sinuses are rudimentary with very small maxillary and ethmoid sinuses (see Figure 321). As the pneumatization expands, the facial skeleton becomes less dense. This process progresses through puberty as the sphenoid and frontal sinuses form. Tooth buds initially occupy much of the volume in the maxilla and mandible and are later replaced by bone or sinus. Pediatric bone is less mineralized than is adult bone, leading to a greater softness and plasticity. There is also a greater ratio of cancellous bone to cortical bone. Bone healing after fracture typically begins quickly and proceeds at an accelerated rate relative to adult healing. Children have more soft tissue around the craniofacial skeleton than do adults; this pads the skeleton in blunt trauma, providing some relative protection against fractures and altering fracture patterns.
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Because of the above factors, pediatric craniofacial injury patterns are different than are those in adults: Soft tissue injury is often greater. Cranial trauma is more common. Maxillofacial trauma is much more likely to be associated with head and brain injuries. Greenstick fractures are common. If active management of fractures is indicated, there is greater urgency to perform the indicated treatment because of the rapid healing and the tendency toward malunion. Mandible fractures, particularly those involving the condyle and subcondylar region, and nasal fractures, are most common. Fractures in early childhood are caused most often by motor vehicle accidents. In later life sporting injuries and altercations take on a more prominent role. Child abuse or neglect should be suspected in cases of unusual injuries or injuries in which the history is questionable.
Figure 321 Infant, child and adult skulls showing skeletal changes occurring with craniofacial growth and development. (Adapted from Kazanjian VS, Converse JM. Surgical treatment of facial injuries. Baltimore: Williams & Wilkins; 1974.)
Maxillofacial Trauma
EVALUATION AND MANAGEMENT
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Physical examination typically reveals soft tissue edema and ecchymosis, possible crepitous, and subcutaneous air where sinuses are involved. Hematomas may be present with focal tenderness over fracture sites and obvious step-offs or deformities. There may be trismus and decreased extraocular motions, mobility of fractured segments, malocclusion, decreased sensation of trigeminal nerve branches, hemotympanum, or external auditory canal lacerations including aural, oral, or nasal bleeding, and cerebrospinal fluid leaks. Initial Management Initial priorities are airway control, circulatory support, and immobilization to stabilize potential neurologic injury. Avulsed teeth are reimplanted and stabilized as soon as possible because delays will decrease the likelihood of successful outcomes. Brain and spine injuries are evaluated with appropriate radiographic studies. A chest radiograph is reviewed for tooth aspiration. All but the simplest injuries are imaged with computed tomography (CT) because cranial and brain injuries are often associated with maxillofacial fractures. Axial and coronal CT scans are performed to determine the nature and extent of injuries including the degree of soft tissue involvement, particularly of the orbital contents. The anterior cranial fossa, orbits, and ethmoid region as well as the mandibular condyles and rami typically are best visualized with coronal scanning. Axial scans best show the zygomatic arches, palate, pterygoid plates, mandibular body, and symphysis. Imaging is facilitated with new fast spiral CT scanners. Rarely, but perhaps in severe cases of panfacial fractures with major displacement and distortion or pre-existing deformity, three-dimensional CT scanning may be beneficial. Magnetic resonance imaging is occasionally used to visualize vascular injuries or the soft tissue of the temporomandibular joints in cases of meniscal trauma. Definitive Management Once appropriate imaging has been obtained, definitive management is planned. Conservative treatment is generally desirable when managing pediatric maxillofacial trauma: Many nondisplaced or minimally displaced fractures, particularly greenstick fractures, can be managed nonoperatively, with a soft diet and avoidance of contact sports or strenuous activity for 1 month. Other fractures may require simple closed reduction with external stabilization with a Barton dressing or mandibulomaxillary fixation. If open reduction and internal fixation are required, the minimal amount of fixation to achieve adequate stability is best. Absorbable sutures or absorbable plating systems, if available, are most desirable,
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particularly in a growing child. When titanium plates and screws are used, the smallest possible system providing adequate stability should be chosen, and consideration should be given to removal of the hardware within a few months of application because of potential growth disturbance by the plate. Periosteal stripping is minimized to just what is adequate for reduction and fixation. Screw holes are placed to avoid tooth buds. Because of the softer bone, sometimes slightly smaller drill bits need to be used so that the screws will hold well in the bone. Once reduction and rigid internal fixation have been achieved, critical soft tissue structures such as the mentalis, medial and lateral canthi, and infraorbital periosteum should be reattached to appropriate skeletal areas. The following sections provide step-by-step directions for exposure and repair of craniomaxillofacial fractures. Common steps for most procedures, such as positioning, skin preparation, draping, local infiltration with epinephrine, and irrigation, are not repeated. Pressure dressings are frequently used over dissected areas. Occasionally drains are used. Suction drains should be used carefully if located where they might pull sinus or oral secretions into the wound. The authors typically use perioperative antibiotics and steroids. Postreduction radiographs are recommended for all cases requiring fracture manipulation. Surgical Exposure General principles of exposure for maxillofacial trauma are described below. The italicized incisions or procedures are described in detail later in the chapter. Skull and upper orbits The bicoronal incision provides the widest available exposure to this area and additionally exposes the skull as a potential bone graft donor site. For extensive trauma to the skull, upper orbits, and nasoethmoid region, this is the approach of choice. If less exposure is needed, a lateral brow or superior lid crease incision can be used to expose the upper lateral orbital rim and orbital roof. The superior lid crease incision is preferred because it tends to be less visible than is the brow scar, which typically creates a defect in the brow. Medial orbital and nasoethmoid exposure can be obtained through a variety of approaches. The transcaruncular approach leaves no visible scar but affords limited exposure. Bilateral Lynch, butterfly, and open sky-type incisions all expose this area but have the consequence of visible external scars. Occasionally when a large laceration in this area accompanies frontonasoethmoid trauma, treatment can be effected through the laceration without additional scars. Lower orbits and midface Lower lid incisions include the lower lid blepharoplasty or subciliary incision, the lower lid crease incision, the infraorbital rim incision, and the transconjunctival incision with or without lateral canthotomy and cantholysis.
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Only the transconjunctival incision is described in detail below, because all others produce an external scar, which tends to be more visible in children than in adults. The lower lid crease incision, although providing more exposure, leaves a long and visible scar. The transconjunctival incision alone offers limited exposure, but wide exposure can be achieved by lateral canthotomy and inferior cantholysis. The canthotomy and inferior cantholysis extension reduce retraction tension on the palpebral ligament and extend exposure to the lateral rim and malar eminence with a minimal external scar. An upper lid crease incision may be unnecessary with the extended transconjunctival incision. The subciliary incision or the transconjunctival incision with lateral cantholysis affords the widest exposure because the infraorbital rim incision is limited to the medial side of the midpupillary line. The lower midface can be exposed through vestibular or canine fossa incision, which can be joined across the midline or through elevation with inferior lid incisions. Occasionally a transbuccal trocar is needed to place screws and plates low and lateral on the malar eminence. Mandible The decision whether to approach a mandible fracture intraorally or extraorally depends first and foremost on the surgeons experience and comfort with the approaches. In general, intraoral scars are more desirable than are extraoral scars. The entire mandible, except the condyles, can be exposed intraorally. Anterior fractures of the symphyseal or parasymphyseal region are best approached intraorally unless there is extensive soft tissue injury, comminution, or bone loss. The degree of difficulty for intraoral approaches increases as fractures progress posteriorly because of the limited tangential view and the need for transbuccal or right-angle instrumentation. High subcondylar fractures also are difficult to access intraorally.
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CORONAL INCISION Indications Necessary wide exposure of the skull and upper orbits for fracture repair Extensive trauma to the skull, upper orbits, and nasoethmoid region Necessary exposure of the skull for calvarial bone graft (see below) Procedure The skin is incised from ear-to-ear behind the hairline, far enough posterior to allow for an adequate pericranial flap, if needed (Figure 322). 1. A wavy line or saw-tooth incision results in a scar that is hard to find in the hair. 2. A scalpel incises the skin, but low-power electrosurgery is used for the subcutaneous tissue and galea. Anterior elevation of the flap can be subperiosteal or subgaleal. The temporalis muscle and fat pad are left undisturbed to limit postoperative pain and edema, and to avoid long-term soft tissue wasting in the temple region. Elevation is performed subgaleal laterally over the temporalis muscle (Figure 323) and anteriorly 1 to 2 cm above the orbits (see Figure 322). Periosteum may need to be incised along the superior temporalis line. The temporal branch of the facial nerve is protected by carefully elevating the temporoparietal fascia or by incising the superficial layer of deep temporal fascia below the temporal line of fusion (see Figure 323). If an osteoplastic flap is planned, adequate periosteal attachment to the frontal sinus should be maintained. A chisel is used to release the supraorbital nerve (V1) if it is encased in bone. Supraorbital and supratrochlear blood supplies are preserved for the pericranial flap, if used. When elevating the periorbita, the surgeon should avoid periosteal violation caused by unanticipated overhang of the superior orbital rim. Excess traction on the orbital apices is avoided, and the nasolacrimal duct is protected medially. Forward retraction of the flap may be increased by circumferential orbital elevation and by vertical incision of the midline musculature over the glabella and nasion. The dissection is extended inferiorly, when necessary, to the zygomatic arch and infraorbital rim, joining periorbital or intraoral exposure as necessary. The fracture is repaired. The canthi are resuspended and the galea is closed. Subcuticular skin closure is considered in very young children to avoid the stress associated with suture or staple removal. A pressure dressing is applied.
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Figure 322 Wavy coronal incision with pericranium incised just above orbits.
Figure 323 Detail of temporal dissection of coronal incision protecting temporal branch of facial nerve.
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Complications Overaggressive cautery, hemostatic clips, or hemostatic sutures can lead to alopecia around the wound margins. A straight incision tends to be more visible, especially when the patients hair is wet. The temporal branch of the facial nerve can be cut, stretched, or otherwise injured if care is not taken to elevate in the proper plane. Hypesthesia can occur if the nerve is not carefully freed from the bony canal. If the elevation is extended down into the midface and periorbitally, too much traction on the orbital apices can lead to neurovascular damage. When the flap is returned and closed, care must be taken to reanchor the medial and lateral canthi if they were elevated; otherwise, soft tissue ptosis may result. Similarly, failure to close the galea well can lead to brow ptosis. Hematoma and infection can occur. SUPERIOR LID CREASE INCISION Indications Necessary limited exposure of the upper orbits for fracture repair The superior lid crease incision is preferred over the lateral brow incision because it is less visible than the brow scar, which typically creates a visible defect. Procedure The lateral one-third of the superior lid crease between the brow and lateral canthus is incised with a No 15 blade (Figure 324). The incision is extended through the orbicularis muscle by bluntly spreading the fibers while retracting the lid laterally over the lateral orbital rim. Periosteum over the lateral orbital rim is incised to expose the fracture (Figure 325). The fracture is repaired. A layered closure of periosteum, muscle, and skin is performed. Complications If the lid crease is identified incorrectly, the scar may be more apparent since it is not aligned with the lid folds of the opened lid. Dissection into the orbit can result in damage to the lacrimal gland, the globe, or the levator or extraocular muscles. Bleeding, including orbital hematoma, and infection are concerns.
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Figure 324 Superior lid crease incision.
Figure 325 Lateral orbital rim exposure through superior lid crease incision.
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TRANSCONJUNCTIVAL INCISION Indications Necessary exposure of the central inferior orbital rim and orbital floor Necessary wide exposure of the lower orbit, lateral orbital rim, and malar eminence (wide exposure can be achieved when incision is combined with a lateral canthotomy and inferior cantholysis) Procedure Lateral canthotomy and inferior cantholysis, if planned, are performed first (Figure 326). The lower lid skin is retracted inferiorly, and the conjunctiva is incised with low-power electrosurgery just above the low point of anterior fornix. The incision is lateral to the canaliculus. Dissection is performed to expose the orbital rim. 1. Preseptal dissection (Figure 327) avoids orbital fat exposure, but it may increase the incidence of postoperative lid retraction. 2. Postseptal dissection exposes fat but affords better lid protection. The orbital rim periosteum is incised, and the fracture is exposed with subperiosteal dissection. Care is taken to avoid damaging the infraorbital nerve at the foramen and at the inferior orbital fissure level. The fracture is repaired. The orbital floor is explored and repaired, as needed. The periosteum is approximated. Conjunctival edges are aligned, but closure is optional. If the conjunctiva is closed, knots must be buried. The inferior cantholysis is repaired by suturing the inferior canthal tendon to the superior canthal tendon with slow resorbing (polydioxanone) or permanent suture. The canthotomy incision is closed in layers, including orbicularis fibers and skin. Complications Incorrectly performed periorbital incisions can lead to infraorbital nerve injury, damage to the lid or extraocular musculature, or lacrimal injury. Scar contracture can lead to lid retraction trichiasis, entropion, or ectropion. The globe may be damaged if sufficient care is not taken.
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Figure 326 Lateral canthotomy with inferior cantholysis. Transconjunctival incision (broken line).
Figure 327 Transconjunctival incision with preseptal dissection down to the orbital floor.
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VESTIBULAR OR CANINE FOSSA INCISION Indication Exposure of the lower midface Procedure A scalpel is used to incise the mucosa (Figure 328). 1. Posterior extension beyond first molar tooth may expose masticator fat. 2. Unilateral incision extends to the midline but does not enter the nasal cavity. 3. Bilateral circumvestibular incision exposes entire maxilla. The incision is extended through the submucosa and periosteum with electrosurgery, preserving a 3- to 4-mm cuff of vestibular mucosa above masticatory mucosa for closure. Less mucosa is hard to close; more is visually obstructing. Subperiosteal dissection is performed with care to avoid damaging the infraorbital nerve (V2). The mucoperiosteum around inside of pyriform crest is elevated to extend exposure slightly without having to enter nose (see Figure 328). The circumvestibular (nasal vestibule) incision allows midfacial degloving for nasoethmoid exposure. The nasal vestibular incision should be staggered to reduce stenosis and should not be done in the immature nose (ie, less than 10 to 12 years old). Complications Wound dehiscence with plate exposure and chronic infection may occur. Occasionally a fistula can form with the antral mucosa through small bony defects. The V2 nerve can be transected, compressed, or stretched. Nasal vestibular incisions can cause circumferential stenosis of the vestibule, particularly if the nose is small or the incisions are staggered to interrupt circumferential scarring. With extensive elevation or significant soft tissue injury, midfacial soft tissue ptosis is possible. Skeletal suspension sutures and/or compressive dressings should be considered.
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Figure 328 Circumvestibular incision exposing maxilla with pyriform crest elevation allowing greater superior retraction of soft tissue.
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EXTRAORAL MANDIBULAR EXPOSURE Indications High subcondylar mandible fractures Fractures of the posterior mandible or condyle, which cannot be accessed intraorally Anterior fractures not suitable for intraoral repair because of severe soft tissue trauma, comminution, or bone loss Procedures No 1. Submental incision An incision is made with a No 15 blade in the submental crease, curving, if necessary, to follow the inferior border of the mandible (Figure 329). The subcutaneous tissue is dissected using electrosurgery.
!
Lateral extension should not go beyond the lingual cortex of mandible. Posterior extension beyond the cuspid risks marginal mandibular nerve damage.
The periosteum along the inferior border of mandible is incised and elevated to expose the fracture site. The fracture is repaired. The periosteum, subcutaneous tissue, and skin are closed in separate layers. No 2. Submandibular incision The skin, subcutaneous tissue, and platysma muscle are incised with a No 15 blade at least 2 cm below the inferior mandibular border to protect marginal nerve (Figure 3210). Dissection is continued in the subplatysmal plane. Use of the HaysMartin maneuver helps to protect the marginal nerve, which is retracted superiorly (see Figure 3210). The periosteum along the inferior border of the mandible is incised and elevated to expose the fracture site. The fracture is repaired. The periosteum, platysma, subcutaneous tissue, and skin are closed in layers.
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Figure 329 Submental incision.
Figure 3210 Submandibular incision.
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No 3. Preauricular incision This approach is most useful for condylar and high subcondylar exposure. The skin over the apex of, or slightly behind, the tragus is incised with a No 15 blade and extended inferiorly following the anterior auricular contour closely (Figure 3211). An inferior limb can be used if needed, as in a parotidectomy incision. The plane of dissection is close to the tragal perichondrium. A subperichondrial plane is slightly more difficult to dissect but it bleeds less. The main trunk of the facial nerve may need to be identified, depending on level of fracture (see Chapter 7). The periosteum along the posterior border of the mandible is incised and elevated to expose the fracture site. Superior retraction is performed cautiously to avoid facial nerve trauma. A submandibular incision may be added, if necessary, for complete exposure. The fracture is repaired. The periosteum, platysma, subcutaneous tissue, and skin are closed in layers. No 4. Retromandibular incision The skin is incised with a No 15 blade along the anterior border of sternocleidomastoid muscle, just anterior and inferior to the tip of the mastoid (Figure 3212). Caution is needed in young children because the facial nerve can be very close to mastoid tip (see Chapter 7). The anterior border of sternocleidomastoid muscle is identified by deep dissection. Dissection proceeds superiorly, deep to the platysma muscle and the tail of the parotid gland. The posterior and inferior borders of the angle of the mandible are identified. The periosteum is incised and elevated to expose the fracture site. The fracture is repaired. The periosteum, subcutaneous tissue, and skin are closed in layers. Complications Facial nerve injury from transection, crush, or traction can occur. Submandibular gland injury may occur with the submandibular incision. Greater auricular nerve injury may occur with the postauricular incision or the preauricular incision with parotid extension. All extraoral approaches carry the risk of hematoma, infection, and hypertrophic scarring.
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Figure 3211 Preauricular incision.
Figure 3212 Approach to the ramus and condyle with cranial nerve VII anatomy. Retromandibular incision is posterior and inferior to the angle. The approach is similar to the submandibular approach. (Adapted from Kent JN, Neary JP, Silvia C, Zide MF. Open reduction of fractured mandibular condyles. Oral Maxillofac Surg Clin North Am 1990;2(1):76.)
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INTRAORAL MANDIBULAR EXPOSURE Indications Anterior fractures of the symphyseal or parasymphyseal region without extensive soft tissue injury, comminution, or bone loss Mandibular fractures excluding the condylar and subcondylar regions Procedures No 1. Anterior vestibular sulcus incision The anterior vestibular sulcus is incised with a No 15 blade or electrosurgery (Figure 3213). The incision is made 2 to 4 mm on the gingival side of the low point of the sulcus to leave adequate mucosa for closure and to avoid a suture line at the most dependent point. The dissection is angled gradually toward the menton, leaving a small amount of mentalis muscle attached beneath gingiva to assist with closure. The periosteum is incised and elevated inferiorly to the border of the mandible. The mental nerve (V3) is identified between the canine tooth and the second bicuspid. If more lateral exposure is required, the incision can be extended to join the posterior sulcus incision after the nerve is identified. The fracture is repaired. Watertight closure is performed with 3-0 chromic gut or Vicryl. This is a dependent incision, so a good closure is particularly important. No 2. Posterior vestibular sulcus incision The cheek is retracted laterally to stretch the buccal mucosa (Figure 3214). The mucosa is incised far enough lateral to the mandibular ramus so that the medial part of the incision does not retract medial to the teeth, making closure difficult when the patient is in maxillomandibular fixation. The periosteum is incised and elevated to the inferior border of the mandible exposing the fracture site. A transbuccal trocar is introduced, if needed. The fracture is repaired. Watertight closure is performed with 3-0 chromic gut or Vicryl. This is a dependent incision, so a good closure is particularly important. Complications Dehiscence and poor healing can occur, which can contaminate the fracture and hardware with possible osteomyelitis. The mental nerve can be damaged during the incision and dissection, and is at risk from stretch during retraction.
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The anterior vestibular incision can lead to chin ptosis if the mentalis muscle is not resuspended, either to residual mentalis attachments or to the mandibular cortex, with small drill holes used to anchor sutures. Hematoma may require wound exploration and evacuation for management. Prevention includes pressure dressings. Facial nerve damage rarely occurs from the transbuccal trocar.
Figure 3213 Anterior vestibular sulcus incision.
Figure 3214 Posterior vestibular sulcus incision.
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MAXILLOMANDIBULAR FIXATION The choice of method for maxillomandibular fixation is related to the age of the patient and the nature of the injury: Children less than age 2 to 2.5 years have inadequate dentition for circumdental wires, and therefore require an acrylic splint with circummandibular wires and maxillary or frontal skeletal suspension (see below). Children aged 2 to 5 years have adequate deciduous dentition to support circumdental wires. The roots are fully formed, and the majority of the deciduous teeth have erupted, so interdental fixation works well in this age range. In children between age 6 and 12 years, the succedaneous teeth are beginning to resorb the deciduous tooth roots, weakening the deciduous teeth and making them inadequate for interdental wiring. Occlusal splints and skeletal suspension wiring are required. In children beyond age 12 years, enough succedaneous teeth have erupted and have adequate root structure to again support interdental wiring for maxillomandibular fixation. Options for interdental fixation include Ivy loops, arch bars with circumdental wires, or adhesive arch bars. Maxillomandibular skeletal screw fixation is an alternative, but the screws may injure tooth buds. Unstable dentoalveolar segments may require splints for stabilization, regardless of the patients age or the type of fixation chosen. Indications Necessary maxillomandibular fixation in those with weak tooth roots Stabilization of many facial fractures Suspension wires can be used alone or with arch bars or splints. Procedure Skeletal suspension is performed using 24- or 26-gauge wire. Wires are passed through soft tissue and around skeletal structures with spinal needles or awls. The amount of soft tissue between the wire and skeleton should be minimized. Circum-mandibular wires are placed as shown in Figures 3215 and 3216.
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Figure 3215 Skeletal suspension wiring via pyriform crest wires and circum-mandibular wires.
Figure 3216 Lateral view of pyriform crest and circummandibular wires.
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Maxillary suspension wires (Figure 3217) may be placed circumzygomatic, superior orbital, or at the nasal spine or pyriform crest. Skeletal suspension wires are connected intraorally with a third wire (Figure 3218), which is typically of a lighter gauge. A lighter gauge is used so that if a wire were to break it would be the intraoral wire rather than one of the skeletal suspension wires, which are much harder to replace. Complications Tooth avulsion or fracture, damage to the gingival margin causing gingival recession, and loosening of wires (which have stretched or trapped soft tissue between the wire and the tooth causing the soft tissue to necrose) can occur.
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Temporomandibular joint ankylosis may occur after an extended period of fixation. Tooth decay may be caused by inadequate dental hygiene.
Figure 3217 Alternative maxillary suspension sites: the zygomatic arch, the nasal spine or pyriform crest, and the frontal bone with screw and pullout wire.
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In skeletal suspension fracture at the drill hole site for wire suspension, damage to tooth roots or neurovascular structures from the drilling, and soft tissue damage during the passing of the skeletal suspension wires also can occur.
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Soft tissue trapped between the wire and bone can necrose causing the wires to loosen. Infection can occur at the mucosal exit sites of the wires. Visible scarring can occur at the puncture sites for the percutaneous passage of the wires.
Figure 3218 Detail of connection between the skeletal suspension wires and an intraoral wire.
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RIGID INTERNAL FIXATION Rigid internal fixation promotes efficient bone healing by stabilizing the fracture site, while stress shielding the fracture to allow early mobilization of the fractured component. Early mobilization reduces functional morbidity, but restoration of premorbid occlusion is also critical to maintaining normal function. Basic concepts of occlusion include the following: The angle classification of occlusion (class I, II, or III) refers to the relationship of the first molars of the mandible and the maxilla to each other (Figure 3219). Normal occlusion (class I) is defined as the mesial buccal cusp of the maxillary first molar articulating with the buccal groove of the mandibular first molar. This definition was originally applied to adult occlusion; however, patients in full deciduous dentition have similar relationships of their molars in the absence of the premolars.
Figure 3219 Angle classification of occlusion based on the relationship of the maxillary and mandibular first molars.
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The maxillary arch is normally slightly wider than is the mandibular arch, so the buccal cusps of the molars rest buccally or laterally to the buccal cusps of the mandibular molars. In mixed dentition-aged children, identification of normal occlusion can be difficult because teeth are in various stages of exfoliation and eruption. In these situations, wear facets on the teeth, dental midlines, and close examination of the fracture edges all must be used to assist in accurate fracture reduction and re-establishment of the premorbid occlusion. Indication Fractures of the mandible or maxillofacial skeleton (Figure 3220)
Figure 3220 Recommended primary plating locations for craniomaxillofacial fractures.
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Procedure Adequate exposure for fracture reduction and stabilization is obtained by using the incisions described earlier in this chapter. Titanium or absorbable plates and screws are preferred; micro- and miniplates with monocortical screws generally are used. An appropriate size plate is chosen based on the location, the amount of stress from muscles, and the severity of fractures (see Figure 3220 and Table 321). Skeletal buttresses are plated first. Areas of thinner bone are repaired next. Bony defects are repaired with cranial bone grafts, as described below. The bone graft is applied under the plate after anatomic reduction and plate application to bridge the defect. Drilling is done slowly, with copious irrigation to prevent thermal bone injury (which may cause screws to loosen). Care is taken to avoid injury to tooth buds. The order of repair in multiple fracture cases is controversial. Most experts advocate repairing anterior skull and superior orbital fractures first, followed by mandible fractures, zygomaticomaxillary complex fractures, and nasoethmoid complex fractures. The orbital floor should always be explored after reducing significantly displaced zygomaticomaxillary complex fractures. Nonabsorbable plates and screws may need to be removed from the growing face after healing is complete. Complications Rigid internal fixation, when used properly, is an excellent technique for stabilizing reduced fractures and promoting rapid healing. However, if reduction is inadequate, the rigid internal fixation will hold that inadequate reduction, leading to malunion, deformity, and dysfunction. Application of plates, particularly stiffer thicker plates, requires some skill in contouring the plate to the reduced fracture surface; otherwise, the tightening of the screws will lead to fracture distraction and loss of reduction. Screws must fit snugly in the drill holes; irrigation and slow drilling speed are critical to maintaining the viability of the bone around the drill hole where the screw threads bite. Drilling too quickly, chattering away too much bone, or creating too much heat will lead to loose screws, which may become infected, extrude, or lead to a poor union. If plates selected are too large for the given application they will be palpable and may lead to cold intolerance and necessitate removal. Plates that are too small may bend too easily or fracture. Plates that are bent too many times in an effort to contour them to a fracture also may break easily.
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Drill holes can damage underlying structures such as nerves, tooth buds, and orbital or cranial contents. Poor wound closure can lead to plate exposure and infection. Absorbable plates tend to be thicker for a given strength level and are more palpable until they resorb. Occasionally, chronic inflammation can develop around absorbable plates during the resorption phase.
Table 321 Pediatric plate applications*

Location Recommended Size Range (mm)
Anterior skull and orbits Maxilla Buttresses Intervening bone Mandible
1.01.5 1.31.5 1.01.5 1.52.0
* Three-dimensional or lattice plates provide more strength and stability at a given size than do nonlattice plates. For a given strength range application, current absorbable plates must be thicker than their titanium counterparts. Plates used for the mandible are generally thicker (high profile) than are plates used elsewhere (low profile), even though they may have the same footprint.
NASOETHMOID, NASO-ORBITAL ETHMOID, AND SKULL BASE TRAUMA (INCLUDING SUBCRANIAL APPROACH) The subcranial approach is an extension inferior to the subfrontal and orbital bar approaches. By extending the osteotomies inferiorly to include the nasal bones, the angle of access to the floor of the anterior fossa is straight (0) or even from below, thereby negating the need for most (if not all) frontal lobe retraction. In the presence of frontal lobe trauma, this procedure allows for earlier surgical intervention with lower risks of aggravation of brain injury and swelling. Since the nature of traumatic injuries varies, the osteotomies are described as if the bones are intact. The surgeon must obviously make appropriate modifications when fractures pre-exist. Indications Fractures of the nasal root, nasoethmoid complex, and skull base The nasal root is severely traumatized and disarticulated from the frontal bone with detachment of the medial canthal ligamentstemporary removal of the disarticulated nasal bony structure may allow for better control of the repair
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Associated trauma to the anterior skull base, particularly with a communication between the sinonasal cavities and the anterior fossathe subcranial approach provides access for reconstruction of the anterior fossa floor while allowing excellent access for repair of the facial structures Preparation The patient is placed in the supine position on the operating table. If the frontal sinuses are present (ie, in teenagers), an osteoplastic design of the frontal osteotomies may be used, in which case a template is cut out of a 1.8-m anteroposterior radiograph (Caldwell view). A lumbar drain may be placed to decrease the flow when there is severe cerebrospinal fluid rhinorrhea, although it generally is changed or removed at the end of the procedure to avoid increasing the risk of development of tension pneumocephalus. Procedure A coronal incision is performed and the flap elevated as described above under Coronal Incision. With flap elevation completed, attention is turned to the bone cuts. The bone flap is outlined to include the central forehead, including the medial one-third to one-half (or more, if needed) of the supraorbital rims (Figure 3221). ! Plates are preapplied, prior to the osteotomies being performed. This assures that the ultimate repositioning of the bone flap will be in the precise preosteotomy position. ! The plates are then turned and hinged on a single screw. Screws may be placed in the other holes (not through the plates) for easy identification later. ! Small bur holes are placed in the corners, and a craniotome is used to make the horizontal and vertical bone cuts. A small- to medium-sized bur is used to cut the bone inside the orbit from the superior orbital bone cut following, but just posterior to, the orbital rim, taking care to avoid penetration of the dura (Figure 3222). The cut continues inferiorly in the superomedial orbit. It then extends behind the anterior lacrimal crest (the posterior lacrimal crest may be included in the flap, if desired) inferiorly toward the distal nasal bone. The bone cut may be taken to the inferior edge of the nasal bone, and an inferior scalpel incision may be used to separate the nasal bones from the upper lateral cartilages.
!
As an alternative, when possible, the authors prefer to leave 4 to 5 mm of distal nasal bone intact, completing the bone flap by cutting across the distal nasal bones with a micro sagittal saw. This preserves the support of the upper lateral cartilages and decreases the likelihood of later internal nasal valve collapse.
The flap is held posteriorly by the attachments of the frontal bone to the crista galli and of the nasal bones to the underlying bony nasal septum. These attachments may be separated from above under direct vision by first elevating the superior portion of the flap off the dura.
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Figure 3221 Osteotomies outlined and pre-plated.
Figure 3222 Retraction of periorbita, laterally exposing medial orbital wall cut.
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Alternatively an osteotome may be passed horizontally from one side to the other behind the glabella and the nasal bones (Figure 3223). Tapping on the osteotome will thereby release the bone flap from the remaining attachments to the crista galli and nasal septum.
Once the posterior cuts are completed, the bone flap should lift away, exposing the frontal dura, the anterior ethmoids, and the nasal mucosa, which is often intact (Figure 3224). This provides direct access to the floor of the anterior fossa, bilateral ethmoid sinuses and their roofs, nasal cavities, and cribriform plates. Exposure of the orbital roofs and sphenoid sinuses also can be obtained. If optic nerve decompression is needed, the medial orbit can be followed posteriorly directly to the optic canals. Significant fractures can facilitate elevating the bone flap because some of the exposure is immediately available. For severe nasal root fractures and telescoping fractures of the nasoethmoid complex, removing the nasal bones and nasal root gives access to the floor of the anterior fossa and allows for easier control of the medial canthal ligaments. The fracture repair is performed:
!
Dural defects are repaired using the surgeons preferred technique. Fractures of the frontal bone are repaired if possible, but if the bones are severely comminuted, replacement with bone grafts or bone cement should be considered. Calvarial bone grafts are easily accessible with this approach. Orbital wall defects are exposed for direct repair. The floor of the anterior fossa may be reconstructed if needed.
To isolate the cranial cavity from the sinonasal area, a pericranial flap may be elevated, taking care to maintain its integrity. Before positioning the flap, the medial canthal ligaments are positioned (Figure 3225):
!
Each ligament is grabbed independently with a 3-0 nonabsorbable suture (eg, polyester) and passed across the midline (through the nasal septum, if it is present) and positioned in the region of the contralateral medial superior orbital rim. The soft tissue flap is replaced, and the suture is tensed to assess the impact of pulling. The suture must capture the ligament securely or the medial canthus will lateralize during the postoperative period.
If a pericranial flap is used to repair the anterior fossa dura, a small midline incision must be made in the pericranium to allow passage of the nasal bones. Blood supply comes from the supratrochlear and supraorbital vessels, so a midline incision should not be a problem.
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The pericranial flap is fixed in place, and the bone flap is positioned and fixed with the plates in its original position.
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Figure 3223 Transverse osteotomy of anterior cranial fossa in region of crista galli.
Figure 3224 Exposure after removal of the subcranial bone flap.
Figure 3225 Centripetal suspension wiring of medial canthal tendons.
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The medial canthal sutures are then tensed with the skin flap replaced to allow proper positioning of the medial canthi. Note that, with this technique, excessive overcorrection of the medial canthus is possible and should be avoided. The sutures are fixed to the contralateral medial supraorbital rims through a hole in the bony overhang or around a screw or plate (see Figure 3225). Raveh designates this a centripetal suspension, which allows for significant control of medial canthal position.
The skin flap is replaced. Use of suction or Penrose drains is at the discretion of the surgeon. The galea is closed with absorbable sutures, and the skin generally is closed with staples. Some surgeons use fibrin glue or a manufactured equivalent in the roof of the nose. If nasal packing is desired, a few layers of gelatin film are first placed, so that when packs are removed, they do not pull against the repair. Complications Brain trauma, cribriform damage, cerebrospinal fluid leak, meningitis, and meningocele or encephalocele through anterior fossa defects over the nasal cavity may occur. The free bone flap can become infected or resorb; the medial canthal position can be over- or undercorrected. Inadequate medial wall reconstruction can lead to enophthalmos. The lacrimal system can be damaged and visual disturbances can occur from elevation of the trochlea during the subperiosteal dissection. BONE GRAFTING Intervening bone loss after fracture reduction, particularly in buttress areas, should be replaced acutely with a cranial or other bone graft. The manner of harvesting cranial bone graft is dependent on the age of the patient: Although calvarial splitting has been reported in children at 13 months of age, it is difficult to split the cranial bone into an inner and outer cortex in patients of less than 4 to 5 years of age. In children less than 1 year old, a full-thickness bone graft can be used, leaving a secondary cranial defect, which will heal spontaneously. In children between 2 and 5 years of age, cranial bone should be used sparingly (unless there is radiographic evidence of adequate thickness for splitting) because full-thickness cranial defects are less likely to heal. Therefore, alternative sites such as rib should be considered. In the 5- to 10-year old age range the skull can be split, but it is not recommended to harvest outer table calvarium in situ because of the relative thinness of the skull and higher risk of inner table penetration. Full-thickness cranial bone is harvested and split away from the patient. One table can then be replaced, and the other table can be used for bone graft. In children 10 to 12 years of age, skull thickness approaches adult thickness, and it becomes safer to consider in situ outer table harvesting.
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Indication Bone loss after fracture reduction, particularly in buttress areas, in children aged 5 years or older Procedure Adequate exposure of cranium is obtained for grafting.
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If a bicoronal incision was used for initial exposure of the fractures, the donor site is already in the operative site. Otherwise, depending on the amount of bone needed, parasagittal incisions can provide adequate exposure for bone grafting. A three-sided trap door incision increases exposure dramatically. Craniotomy is performed in the usual fashion with a cranial perforator and craniotome (Figure 3226). The craniotomy bone flap is removed and split away from the patient with chisels or saws into inner and outer tables (see Figure 3226). One of the tables is returned to the cranial defect and is fixated with sutures or plating.
To harvest the bone graft ex-situ

!
Figure 3226 Calvarial bone graft harvesting techniques. In situ harvest on skulls right; full-thickness with ex situ splitting on skulls left.
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To harvest the bone graft in situ

!
The size of the required bone graft is identified. A trench is developed around the outer table with a fluted bur, saucerizing peripherally to allow an adequate tangential angle for separating tables (see Figure 3226). The calvarium is split with chisels or a power saw, taking care to maintain a tangential angle to prevent inner table perforation. The outer table bone graft is removed. Because of skull curvature, grafts wider than 3 cm increase the risk of inner table violation.
The bone graft is used as needed for craniofacial reconstruction. Complications Dura or brain damage, intracranial hemorrhage, meningitis, creation of a nonhealing cranial defect, palpable edges from inadequate donor site contouring, and bone resorption from inadequate cooling of power instrumentation may occur. If the surgeon is not comfortable with the in situ harvest technique, the full-thickness harvest with the split away from the patient should be done, regardless of age.
BIBLIOGRAPHY
Kaban LB. Pediatric oral and maxillofacial surgery. Philadelphia: WB Saunders; 1990. Kellman R. Use of the subcranial approach in maxillofacial trauma. Facial Plast Surg Clin North Am 1998;6:50110. Kellman R, Marentette L. Atlas of craniomaxillofacial fixation. Unit III: surgical approaches. New York: Raven Press; 1995. Kelly KJ. Pediatric facial trauma. In: Achauer BM, Eriksson E, editors. Plastic surgery: indications, operations, and outcomes. St. Louis: Mosby; 2000:94169. Koltai PJ. Craniofacial skeletal trauma in childhood. In: Cotton RT, Myer CM, editors. Practical pediatric otolaryngology. Philadelphia: Lippincott-Raven; 1999:72958. Loder RT. Skull thickness and halo-pin placement in children: the effects of race, gender, and laterality. J Pediatr Orthop 1996;16:3403. Posnick JC. Facial fractures in the pediatric patient. In: Ferraro JW, editor. Fundamentals of maxillofacial surgery. New York: Springer; 1997:21523. Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofacial Surg 1993;51:83644. Raveh J, Laedrach K, Vuillemin T, Zingg M. Management of combined frontonaso-orbital/skull base fractures and telecanthus in 355 cases. Arch Otolaryngol Head Neck Surg 1992;118:60514. Raveh J, Redli M, Markwalder TM. Operative management of 194 cases of combined maxillofacialfrontobasal fractures: principles and surgical modifications. J Oral Maxillofacial Surg 1984;42:55564.
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Raveh J, Vuillemin T, Sutter F. Subcranial management of 395 combined frontobasal-midface fractures. Arch Otolaryngol Head Neck Surg 1988;114:111422. Senders CW. Pediatric facial trauma. In: Wetmore RF, Muntz HR, McGill TJ, editors. Pediatric otolaryngology. New York: Thieme Medical Publishers; 2000:497512. Shapiro AM. Injuries of the nose, facial bones, and paranasal sinuses. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology, Vol. 1. 3rd ed. Philadelphia: WB Saunders; 1996:88092.
C H A P T E R 33
C LEFT L IP AND C LEFT PALATE R EPAIR

Robin A. Dyleski, MD Robert W. Seibert, MD
Care of children with cleft lip and cleft palate is ongoing and complex. The process begins at birth with feeding, swallowing, and respiration, and continues into adulthood with dental occlusive issues and secondary maxillofacial anomalies. The complex problems faced by a child with cleft lip and cleft palate are dynamic, and best managed by a cleft palate or craniofacial team. This multidisciplinary team meets regularly, shares findings and treatment goals, and coordinates ongoing care.
A general timeline for surgical rehabilitation of a child with cleft lip and cleft palate who has demonstrated initial feeding success would begin with repair of the cleft lip: Cheiloplasty most often occurs at about 8-12 weeks of age, unless the cleft lip was particularly wide and required a preliminary lip adhesion. Cleft palate repair usually follows at about 9-12 months of age. Tympanostomy tubes are usually placed concurrently with cleft palate repair, because nearly every child with cleft palate has eustachian tube dysfunction and chronic otitis media. In the first few years after the palatoplasty, the major issues faced by the patient involve speech development and production, maintenance of satisfactory hearing, and control of chronic middle ear effusion. As the child grows, secondary procedures are considered, such as cleft nasal tip reconstruction and alveolar ridge bone grafting with orthodontic dental rehabilitation. The cleft palate team coordinator oversees treatment and services by team members, including reconstructive surgeons, otolaryngologists, audiologists, speech pathologists, dentists and orthodontists. This involves regular team appointments, in which the patient and parents are seen by all of the team specialists, and an individualized plan is formulated. In addition, the patient and family are aided by nursing specialists, social workers, and medical geneticists as part of the concept of comprehensive team care.
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CLEFT LIP REPAIR The most common procedures in the United States for correcting unilateral and bilateral cleft lip are described, including the occasionally needed preliminary lip adhesion. In general, the anesthetic needs and considerations, patient preparation and positioning, and general postoperative care are similar for cleft adhesion and repair. Specific information regarding the indications, landmarks for incisions, and method of closure is detailed for each procedure. Anesthetic Considerations and Preparation General inhalation anesthesia via oral endotracheal tube, preferably an oral RAE tube, is usually used. Because many children with cleft lip and cleft palate may be somewhat difficult to intubate due to their altered oropharyngeal anatomy, it is preferable that an experienced pediatric anesthesiologist administer the patients anesthetic. A small amount (usually less than 1cc) of local anesthetic with a vasoconstrictor (1% lidocaine with 1:100,000 epinephrine) may be infiltrated into the labial sulci and the areas of the intranasal incisions for hemostasis, if desired. The endotracheal tube is taped to the midline of the chin without distorting the lower lip. A small roll is placed under the infants shoulders to slightly extend the neck. The surgeon sits at the patients head; loupe magnification (2.5 to 3x) is usually used. A small, moistened gauze pack is usually placed in the oropharynx. Procedures Two procedures are described in the next sections of this chapter: 1. Cleft lip repair, unilateral and bilateral 2. Lip adhesion, unilateral and bilateral Lip adhesion is a preliminary, or first stage procedure, first described in the 1960s for wide or severe cleft lip deformities. The procedure facilitates definitive lip closure (cheiloplasty) by decreasing tension, improving nasal symmetry, and narrowing alveolar clefts. Patients with asymmetric bilateral cleft lip may benefit from lip adhesion, because symmetry is improved for the definitive cheiloplasty. Postoperative Care A 3-0 silk suture is placed in the tongue tip for airway control after extubation, and is usually removed in the recovery room once respiratory status is stable. Arm restraints are applied in the recovery room and are worn by the patient at all times for 10 days to prevent inadvertent suture disruption by the patients fingers.
Cleft Lip and Cleft Palate
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Feeding begins on the morning after the procedure, using a 20 cc syringe with rubber tubing attached at the tip, and is continued for 10 days. If the infant is breast-feeding, use of the syringe is not necessary and feeding can begin later on the operative day. Pressure or rubbing on the suture line from bottle nipples or pacifiers may result in increased scar formation. The sutures are cleaned with half-strength hydrogen peroxide once or twice daily if crusting occurs. Bacitracin ointment is applied three times a day. Sutures are removed in 7 days under sedation (meperidine, 1-2 mg/kg intramuscularly) or general inhalation anesthesia by mask to minimize trauma at the suture line. Complications Wound infections are very rare. Simple stitch abscesses may rarely occur if Vicryl sutures were used. Hypertrophic scars with contraction and elevation of Cupids bow peak occur occasionally, but will often improve with time as the scar matures. UNILATERAL CLEFT LIP REPAIR Since first described by Millard in the 1950s, the rotation-advancement cleft lip repair (also known as the Millard Repair), has gained acceptance as the repair of choice for unilateral cleft lip. The basic principles of this technique have remained unchanged, although numerous relatively minor refinements and modifications have been made. In contrast to other cleft lip repair techniques, such as the triangular flap repair that rely upon geometric measurements, this technique is more flexible and amenable to modifications made during the procedure in a cut as you go style. Adjustments are relatively easy to make with the Millard technique, because the surgeon assesses the symmetry and degree of release created as the procedure is performed. Precise positioning of the alar base and primary tip rhinoplasty are possible. Indications Any unilateral cleft lip, ranging from microform clefts to wide complete cleft lips, with or without a prior lip adhesion, and some very mild bilateral cleft lips (with sufficient orbicularis oris muscle crossing the philtrum). The operation is usually performed when the patient has demonstrated satisfactory weight gain. Using the rule of tens, most children have surgery after attaining 10 pounds of weight, 10 weeks of age, and 10 g/dL of hemoglobin. There is a trend toward slightly earlier lip repair (6-10 weeks of age); however, the child must be healthy, gaining weight, and an experienced pediatric anesthesiologist must be present. If a lip adhesion has been performed (such as in the case of a very wide cleft lip), the definitive lip repair follows in 3-4 months. Anesthetic Considerations and Preparation As described above under Cleft Lip Repair.
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Procedure The goal is to create a perfectly symmetrical lip and nasal contour by matching the abnormal cleft side to the normal noncleft side. The final appearance of the lip repair after healing and scar maturation will be what is achieved at the end of the operation. Scars will improve with time, but discrepancies in form will not change. Constant assessment and adjustment during the procedure are needed for best results. Surgical landmarks The following points (Figure 331A) are determined, measured with calipers, and marked with gentian violet: 1. Nasal alar base 2. Cupids bow peak (lateral) 3. Cupids bow peak (low point) 4. Cupids bow peak (medial)
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The distance from 2 to 3 equals the distance from 3 to 4.
Noncleft side (rotation flap) 5. The lateral limit of the rotation incision that lowers the Cupids bow into position, does not extend into the normal philtral column, but creates its mirror image. The rotation incision curves laterally at the junction of the columella and the lip. 6. The limit of the back-cut of the rotation incision, which is necessary in most cases to achieve enough downward rotation of the Cupids bow. Cleft side (advancement flap) 7. Cupids bow peak (lateral lip) on the advancement flap will be joined to medial lip at 4, usually located where the white roll above the vermilion-cutaneous junction (VCJ) disappears. 8. The distance from 4 to 6 determines the advancement flap length. 9. The distance along the alar crease (from 7 to 9) is equal to the distance from 1 to 2 on the noncleft side. This distance determines the vertical lip height. Incisions The labial sulci, nasal columella, and intercartilaginous regions are infiltrated with a small amount (usually less than 1cc) of 1% lidocaine with 1:100,000 epinephrine. All incisions (Figure 331B) are made with a 6300 Beaver blade or a No 15 Bard-Parker blade. The rotation incision (4 to 5, see Figure 331A) is made first, and carried superiorly until 4 lies at the same level as 2. The back-cut (5 to 6) is made as needed to allow the Cupids bow peaks (2 and 4) to
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Figure 331 Unilateral cleft lip repair. A, Landmarks for left unilateral cleft lip repair (see text for numbering); incisions are depicted with broken lines. B, Rotation incisions are made. The back-cut (5-6) is made if additional rotation is needed to level the Cupids bow.
lie horizontally. Lip muscle is included in the back-cut, and the lip is freed from the premaxilla to allow for sufficient rotation. The skin that is left attached to the columella, medial to the vermilion edge (the c flap), may be used to lengthen the columella by advancing the flap upon itself, and/or is used to augment the medial nasal sill. The lateral cleft edge and the circum-alar incisions are made (7 to 8 and 8 to 9) to create the advancement flap. The incision is extended in the gingivolabial sulcus and is freed from the underlying maxilla in a supraperiosteal plane. Dissection should be limited to the minimum necessary for sufficient advancement and a tension-free closure. Incision in the nasal vestibule of the intercartilaginous region allows medial advancement of the alar base, independent of the lip. This may be omitted if the nasal deformity is minimal. Mucosal flaps from the cleft edges (or tissue of the lip adhesion) may be used to bridge the superior aspect of the alveolar cleft or may be discarded. The white roll flap (just above the VCJ laterally) is not cut until after the lip segments are approximated and sutured (see later). The white roll flap is a triangular flap of skin that measures the same height as the normal white roll and is usually 1.5 to 2.5 mm in length.
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Suturing The first key suture (3-0 or 4-0 Vicryl) is placed deeply from the back-cut to the superior edge of the advancement flap at or lateral to 9. This advances the lateral lip flap and reduces tension on the orbicularis oris sutures (Figure 331C). It also produces more normal convexity to the lip. The orbicularis oris muscles are approximated with interrupted 4-0 or 5-0 Vicryl (Figure 331D). Assessment of lip length and symmetry is made after each suture is placed to ensure that the lip has not been shortened. This closure includes the muscle fibers present in the vermilion edge to avoid notching at the vermilion border (the whistle-tip deformity). The position of the alar base is determined, and it is sutured into position (Figure 331D). The tip of the alar base flap is sutured to the anterior nasal spine with 4-0 or 5-0 Vicryl to create symmetry with the noncleft side. There should be minimal, if any, trimming of the alar base to avoid narrowing or stenosis of the nostril (a secondary deformity that is very difficult to correct later). If needed, a small crescent of cheek skin may be excised to prevent excessive narrowing of the nostril. The skin edges are trimmed, if necessary, and slightly undermined to allow the edges to be everted. The c flap is advanced upon itself to lengthen the columella and/or is utilized for nasal sill reconstruction. The white roll flap is incised if needed. If additional rotation is required to horizontally align the Cupids bow, a small incision at the VCJ is made at 3. If the position of Cupids bow is adequate, a small triangular skin excision at 3 is made the same size of the white roll flap. Subcutaneous 6-0 chromic or Vicryl secures the flap into place. Using interrupted 7-0 nylon sutures, the skin edges are approximated and everted (Figure 331E). The vermilion-cutaneous junction is carefully approximated with 7-0 nylon at the vermilion border. The mucosa is approximated with 5-0 or 6-0 chromic suture. This incision may lend itself to a broken line closure, or a Z-plasty may be done to decrease the tendency of contracting with healing. Postoperative Care and Complications As described above under Cleft Lip Repair.
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Figure 331 C, The key stitch is placed, with interdigitation of the advancement flap into the apex of the rotation flap. D, After closing the orbicularis oris muscle, the alar flap is sutured into position for nasal base symmetry. E, The skin edges are sutured and the vermilion-cutaneous junction aligned.
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BILATERAL CLEFT LIP REPAIR The goal of the bilateral cleft lip repair is to create a symmetric lip and nose contour. Several methods are available, the most popular of which, in the United States, is the Millard technique (described below). This technique also provides tissue for future repair of the nasal columella. Careful preoperative assessment of the patients deformity allows the surgeon to modify and adjust the procedure to meet the specific needs in reconstructing the defect. Indications Any bilateral cleft lip (including any combination of complete or incomplete cleft lip, with or without a prior lip adhesion) is included. In general, the operation is performed when the child is 8-12 weeks of age, has 10 g/dL hemoglobin level, and is about 10 pounds in weight. A trend toward earlier lip repair is underway, however, only in healthy growing infants. If lip adhesion has been performed (either bilateral lip adhesion in the wide bilateral cleft lip or unilateral lip adhesion in the asymmetric bilateral cleft lip [one side wide and complete, the other incomplete, for example]), the definitive bilateral lip repair follows 3 to 4 months later. Anesthetic Considerations and Preparation As described above under Cleft Lip Repair. Procedure Surgical landmarks The following points (Figure 332A) are located and marked on the skin with gentian violet: Prolabium 1. Midpoint of the vermilion-cutaneous junction on the prolabium (the future low point, or midline, of the Cupids bow) 2. Right prolabium Cupids bow peak (measured 2.5 to 3 mm lateral to 1) 3. Left prolabium Cupids bow peak (measured 2.5 to 3 mm lateral to 1) 4. Right prolabium columella junction 5. Left prolabium columella junction
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The distance from 1 to 2 is equal to 1 to 3. The distance from 2 to 4 is equal to 3 to 5.
Lateral lip (right and left) 6. Right lateral lip vermilion-cutaneous junction (point of white line attenuation) 7. Superior extent of right lateral lip flap 8. Left lateral lip vermilion-cutaneous junction (point of white line attenuation)
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9. Superior extent of left lateral lip flap

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Vermilion flaps (represented by ! in Figures 332 A and B) are created on both lateral lip elements (measured to approximate the length of 1 to 2 and 1 to 3). The distances 6 to 7 and 8 to 9 are equal to and the same as 2 to 4 and 3 to 5.
Incisions The labial sulci, mucosal attachment of the prolabium to the premaxilla, and intercartilaginous regions of the nose are infiltrated with 1% lidocaine with 1:100,000 epinephrine (usually less than 1 cc total). All incisions are made with a 6300 Beaver blade. The prolabium is incised (Figure 332B) to create the central prolabium flap (the future philtrum) and the two lateral forked flaps (to be used later to reconstruct the columella). The three flaps are undermined with superiorly based pedicles. A small rectangle of vermilion (the e flap) is left attached at the inferior border of the philtrum flap by only subcutaneous tissue.
Figure 332 Bilateral cleft lip repair. A, Landmarks for symmetric bilateral cleft lip repair (see text for numbering); incisions are depicted with broken lines. B, The incisions on the prolabium are made first creating the philtrum, two forked flaps, and e flap. The e flap is a mucosal flap attached to the philtrum by subcutaneous tissue.
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The lateral lip incisions are then made (Figure 332C) and extended a variable distance along the alar crease. It is often necessary to modify the height of the lateral lip by excising a small triangular wedge of tissue from under the nares above points 6 and 8. The two small vermilion flaps, 6 to ! and 8 to !, are incised through and through on the lateral lip elements (Figure 332D). Lateral gingivobuccal sulci incisions are made to allow for adequate relaxation and advancement medially. Limited dissection around the piriform aperture and maxilla in the supraperiosteal plane is performed for additional release if needed. The remaining mucosa and vermilion of the prolabium and premaxilla are pedicled inferiorly and sutured to the superior attachment of the premaxilla at the nasal spine (see Figure 332D).
Figure 332 C, Remaining prolabium mucosa is advanced superiorly and sutured to line the anterior premaxilla; the lateral lip flaps are incised. D, Small lateral vermilion flaps are created on the lateral lip elements.
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Suturing Closure begins by approximating the inner lateral lip mucosa with interrupted 4-0 chromic sutures, beginning at the superior aspect and continuing inferiorly (Figure 332E). The orbicularis oris muscle from the lateral lip elements is advanced medially and closed with several interrupted sutures of 4-0 Vicryl (Figure 332F). The edges of the vermilion flaps are closed with 5-0 Vicryl (deep), 50 chromic (inner mucosa), and 7-0 nylon (outer mucosa). A small space posterior to the flaps is left open for inserting the e flap (Figure 332G).
Figure 332 E, The lateral lip buccal mucosa is sutured to create the inner lip lining. F, Approximation of the orbicularis oris muscles recreates the oral sphincter. G, The small vermilion flaps are sutured at the midline. A small pocket is present on the buccal surface of the lip for the e flap.
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The philtrum flap is fitted into position between the lateral lip flaps and sutured in place with 7-0 nylon (Figure 332H). The e flap is tucked behind the inferior vermilion flaps and sutured with 5-0 chromic. The e flap helps to create the central vermilion tubercle. The two lateral prolabium flaps (forked flaps) are sutured into position under the nostrils with 5-0 Vicryl for the deeper tissues and 7-0 nylon for the skin edges (Figure 332I). These two small flaps are considered banked for future use in reconstructing the columella. Postoperative Care and Complications As described above under Cleft Lip Repair
Figure 332 H, The e flap is tucked into its pocket and sutured into position. I, The philtrum and forked flaps are sutured into position.

LIP ADHESION UNILATERAL LIP ADHESION
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The procedure may be performed either low in the lip (near the vermilion), which minimizes soft tissue undermining from the maxilla, or high in the lip (superior lip-nasal sill), which is the technique described below. The procedure is described for both unilateral and bilateral clefts. Although it requires some dissection of the lip from the maxilla, this technique provides relief from excessive tension where the basic deficiency is greatesthigh in the lip. Indications A very wide complete unilateral cleft lip in which a definitive procedure could be performed only under excessive tension A very asymmetric bilateral cleft lip in which one side is complete and the other is incomplete; a unilateral lip adhesion may result in improved symmetry For unilateral lip adhesion, the infant should be at least 4 weeks of age, have satisfactory weight gain, and no other significant untreated medical problems. Anesthetic Considerations and Preparation As described above under Cleft Lip Repair Procedure Landmarks and incisions The landmarks for a definitive procedure are determined (see rotation-advancement method, Figure 331A) and marked with gentian violet. The cleft edge mucosa/vermilion flaps are placed well away from the definitive landmarks. The cleft mucosal edges are marked with gentian violet to create small mucosal flaps in an open book fashion (Figure 333A). Flap elevation and undermining A 6300 Beaver blade is used to incise and elevate the cleft edge mucosal flaps (Figure 333B). An incision is made along the pyramidal aperture of the nasal vestibule (dotted line in Figure 333B); this frees the alar sill for medial advancement. Undermining from the premaxilla should be minimal (if needed at all); on the lateral maxilla, supraperiosteal undermining should also be conservative and just enough to allow sufficient advancement for closure. Suturing The sutures are placed in the following order and kept untied: 1. A retention suture (3-0 nylon) is placed through the membranous septum, deep into the lateral lip/alar incision, and back through the septum (Figure 333C). 2. Mucosal sutures, usually three or four 4-0 or 5-0 chromic are placed to approximate the inner lip mucosa.
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3. The orbicularis oris and subcutaneous tissues are approximated with three or four sutures of 4-0 or 5-0 Vicryl. 4. All of the above sutures are tied in the sequence they were placed. The anterior cleft edges are closed with interrupted 6-0 chromic sutures (Figure 333D). Cleansing of the sutures with hydrogen peroxide is not necessary unless the sutures become crusted. It is expected that the sutures will be absorbed in approximately 7-10 days. Complications Breakdown of adhesion is usually caused by excessive tension and rarely by infection. The incidence of complete dehiscence is approximately 5%. Partial dehiscence (separation of the lower part of the adhesion) is more common and does not affect the overall goal of the procedure. Scarring may occur when landmarks are violated. When the landmarks are not violated, scarring from the adhesion is not a factor in the definitive repair. Maxillary growth disturbance is controversial with no definitive human subject data; however, not dissecting the maxillary periosteum will decrease any risk.
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Figure 333 Unilateral lip adhesion. A, The lip is marked as if for complete lip repair; adhesion incisions are made on the cleft vermilion edges only, away from the future Cupids bow peaks (see unilateral cleft lip text for surgical landmarks). B, The cleft vermilion edges are incised and small mucosal flaps created. C, A transcolumellar key suture is placed to bear the tension across the cleft. D, The buccal and external mucosal flaps are closed.
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BILATERAL LIP ADHESION Indications Bilateral lip adhesion should be considered for the very wide complete bilateral cleft lip, when there is considerable asymmetry between the two cleft sides, or when the prolabium is very small. For bilateral lip adhesion, the infant should be at least 4 weeks of age, have satisfactory weight gain, and no other significant untreated medical problems. Anesthetic Considerations and Preparation As described above under Cleft Lip Repair Procedure Landmarks and incisions Landmarks for a definitive (one stage) procedure are determined (see Bilateral Cleft Lip Repair, Figure 332A) and marked with gentian violet. The cleft edge mucosa/vermilion flaps are placed well away from the definitive landmarks (Figure 33-4A). Flap elevation and undermining A 6300 Beaver blade is used to incise and elevate the cleft edge mucosal flaps on the lateral lip elements and the vermilion/mucosal edge of the prolabium (Figure 334B). The prolabium should not be elevated from the premaxilla. Undermining of the lateral lip elements from the maxilla should be minimal, just enough to allow for adequate release, and in the supraperiosteal plane. Suturing All deep sutures (mucosal and muscular) are placed prior to tying. A retention suture (3-0 nylon) is placed as a horizontal mattress suture (Figure 334C). Starting at the lateral lip orbicularis oris muscle, the suture is then passed between the prolabium and premaxilla in the supraperiosteal plane, then into the lateral lip orbicularis oris muscle, and then back between the prolabium and premaxilla in the supraperiosteal plane completing the mattress loop. The inner lip mucosal sutures are placed, starting superiorly and continuing inferiorly, with 4-0 chromic. Additional support within the cleft edge muscle/subcutaneous tissue is provided with several interrupted 4-0 Vicryl sutures. The first suture tied is the retention suture, then the mucosal and deep subcutaneous sutures. The external lip mucosal closure is completed with 4-0 or 5-0 interrupted chromic sutures (Figure 334D). Complications As described above under Unilateral Lip Adhesion
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Figure 334 Bilateral lip adhesion. A, The lip is marked as if for complete lip repair; adhesion incisions are made on the prolabium vermilion mucosal edges and the lateral lip element cleft edges, away from the planned future lip repair landmarks (see bilateral cleft lip repair text for points and surgical landmark definitions). B, The vermilion edges are incised and small mucosal flaps created. C, A key suture is placed to secure the orbicularis oris muscles in the lateral lip elements (subcutaneous through the prolabium), to reduce tension across the cleft. D, The buccal and external mucosal flaps are closed.
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CLEFT PALATE REPAIR Palatoplasty creates an intact and physiologically adequate velopharyngeal mechanism for normal speech production. The primary goals are normal oronasal resonance, effortless production of non-nasal sounds in speech, and the absence of abnormal compensatory articulation patterns such as glottal stops and pharyngeal fricatives. Other goals include the anatomic separation of the nasal and oral cavities, elimination of nasal reflux of food and secretions, and possible improvement of eustachian tube function. Timing The optimal age for palatoplasty is controversial, with potential trade-off between speech production and possible inhibition of maxillofacial growth:
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Optimum maxillofacial growth occurs when palatoplasty is delayed until after age 18 months, but this may result in more secondary procedures to achieve velopharyngeal competency for speech production (pharyngeal flap and pharyngoplasty). Optimum speech production occurs when palatoplasty is performed at age 9-12 months.
Surgical timing also depends on sufficient palatal shelf width for the closure, and adequate body size (minimum 8 kg), which appears to decrease upper airway risks. In general, a rule of tens applies, in which the infant is about 10 months of age, 10 kilograms in weight, has at least 10 g/dL hemoglobin, and is a healthy thriving child. Anesthetic Considerations and Preparation General anesthesia via oral endotracheal intubation, preferably with an oral RAE tube, administered by an experienced pediatric anesthesiologist, is preferred. 1% lidocaine (maximum dose 5-7 mg/kg) with 1:100,000 epinephrine is injected into the incision areas of the palate for hemostasis. The endotracheal tube is taped at the midline of the lower lip and chin. A Dingman mouth gag is used with a slotted tongue blade that holds the endotracheal tube in the center of the tongue. The gag is opened only wide enough to allow for adequate exposure to work within the mouth. Care is taken to prevent compression of the endotracheal tube or excessive pressure on the tongue with the gag. The mouth gag is supported with a folded towel under the handle and usually not suspended from the Mayo stand. A roll is placed under the patients shoulders to slightly extend the neck into Roses position. The surgeon sits or stands at the head of the table. Headlight illumination is desirable. Procedures Many methods of palatoplasty have been described.
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Three single-stage procedures are described in the next sections of this chapter: 1. V to Y pushback palatoplasty for clefts of the secondary palate, involving part or all of the secondary palate. 2. Two-flap palatoplasty for complete cleft palates, involving the entire palate including the alveolus and the lip. 3. Double reversing Z-plasty (Furlow palatoplasty) for submucous clefts or narrow clefts of the soft palate. Postoperative Care The patient is given nothing by mouth (NPO) for the first postoperative night. With the child pretrained to drink by cup, feedings begin the first postoperative day. After adequate oral intake and pain control is achieved, the child may be discharged home. Bottle-feeding and pacifiers are not permitted for the first 3 weeks. Elbow restraints are used for the first 3 weeks, until the first postoperative check, whenever the child is unsupervised. Complications Airway obstruction is prevented by releasing the mouth gag periodically to prevent venous congestion; opening the gag only as much as needed for adequate exposure; and by suctioning the stomach, oropharynx, and nasal passages prior to extubation. A tongue tip suture (3-0 silk) placed prior to extubation, can be used to easily open the airway if the tongue causes pharyngeal obstruction. This suture is removed in the recovery room. Severe or prolonged upper airway obstruction is uncommon unless an underlying anomaly (eg, Robins Sequence, Treacher Collins Syndrome) is present. Management includes prolonged observation in the intensive care unit; maintaining tongue traction with a tongue tip suture; and positioning, intubation, or tracheotomy in rare cases. Bleeding is minimized by intraoperative injections of the incision sites with 1% lidocaine and 1:100,000 epinephrine, and by ensuring hemostasis with meticulous judicial electrocautery, microfibrillar collagen packing in the relaxation incisions, and gentle pressure applied with a moist sponge on the reconstructed hard palate. Blood loss rarely requires transfusion. Late bleeding (5-7 days) from the incision edges is rare, particularly if microfibrillar collagen has been used, unless there has been trauma to the flaps. Suture line breakdown or fistula occurs most often at the junction of the hard and soft palates, where the mucoperiosteum is thinnest. A large fistula is rare, unless the neurovascular bundle is divided. If the greater palatine artery is sacrificed, necrosis and loss of the distal mucoperiosteal flap are possible, particularly in older children and adults. If the alveolar cleft is not closed at primary cheiloplasty, a fistula will remain with the two-flap repair. This is expected and will be repaired at the time of the alveolar ridge bone graft.
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V TO Y PUSHBACK PALATOPLASTY Indications This technique is utilized most frequently for clefts involving only the secondary palate (clefts posterior to the incisive foramen). The cleft may extend into the hard palate a variable distance, and is usually bilateral if the hard palate is affected. Anesthetic Considerations and Preparation As described above under Cleft Palate Repair Procedure Landmarks and incisions Figure 335A shows a typical incomplete cleft of the secondary palate involving the hard palate. The shaded area represents the premaxilla, which, along with the lip, comprises the primary palate. The medial (cleft edge) incision is made about 2-3 mm lateral to the cleft margin. The lateral (relaxation) incisions extend from slightly anterior to the cleft apex posteriorly to just behind the maxillary tuberosity over the hamular process of the medial pterygoid plate (Figure 335B). The neurovascular bundle is located medial to this incision. The medial and lateral incisions are connected with an oblique incision with the apex oriented toward the location of the future canine (see Figure 335B). All incisions over the bone are made through the periosteum. An incision is made in the vomer midline if there is significant vomer exposed by the cleft. Right and left sided vomer flaps are raised.
Figure 335 V-Y pushback palatoplasty. A, Landmarks. B, Incisions. Note the position of the neurovascular bundles (VB), the vomer (V), and the posterior edge of the hard palate (P). VB = neurovascular bundle, P = posterior hard palate; V = vomer.
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Flap elevation and undermining Mucoperiosteal flaps are elevated by blunt dissection with a Freer elevator (Figure 335C). Blunt dissection within the plane between the superior constrictor muscle and the pterygoid muscle allows medial mobility of the palatal flaps. Infracture of the hamulus and stripping of the tendon of the tensor veli palatini muscle are often necessary in wide clefts for adequate relaxation and mobilization. The neurovascular bundle is preserved and may be lengthened by incising the periosteum on both sides of the bundles attachment to the flap (see inset in Figure 335C). If necessary, the bone medial to the bundle may be removed with a rongeur or drill for additional length. The mucoperiosteal flap is elevated from the vomer with dental periosteal elevators. All muscular fibers and soft tissue are completely freed from the medial and posterior edges of the hard palate; this includes the tissue around the suture just behind and lateral to the neurovascular bundle. Dissection should be minimized at the vomeropremaxillary suture (a facial growth center) in complete clefts.
Figure 335 C, The cleft edges are incised and flaps elevated. The neurovascular bundle is isolated and preserved (inset). D, The nasal floor and nasopharyngeal mucosa are sutured. The levator muscular sling is approximated with several horizontal mattress sutures.
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Flap suturing Closure begins by approximating the nasal mucoperiosteum, either side-to-side or to the vomer flaps, with interrupted sutures of 4-0 Vicryl (Figure 335D). Suturing begins at the anterior most aspect of the cleft and continues posteriorly to the mucosa of the soft palate and the uvula (closed with 5-0 or 6-0 Vicryl), with all knots placed into the nasal cavity. The palatal levator muscular sling is reconstructed using several horizontal mattress sutures of 3-0 Vicryl, to approximate the velar muscles (see Figure 335D). Using 4-0 Vicryl, the periosteum of the flaps is closed, proceeding anteriorly toward the flaps oblique incision. A tacking stitch of 4-0 Vicryl is used to approximate the sutured flaps to the nasal closure. This helps keep the flap in proper position during healing by obliterating dead space. The oral mucosa is approximated with interrupted simple 4-0 or 5-0 Vicryl or chromic, with 5-0 suture used on the uvula (Figure 335E). The exposed bone at the lateral relaxation incision sites and the dissection over the hamulus is backed with microfibrillar collagen (Avitene or Instat) for hemostasis and bony coverage (see Figure 335E). Postoperative Care and Complications As described above under Cleft Palate Repair
Figure 335 E, The oral mucosa is sutured and the tips of the flaps secured anteriorly. Microfibrillar collagen is packed into the lateral relaxation incisions.

TWO-FLAP PALATOPLASTY
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Indications The most commonly used technique for complete cleft palates involving the alveolus, hard and soft palate. This technique is modified for bilateral complete cleft palates by creating bilateral vomer flaps to close both sides of the nasal floor. Anesthetic Considerations and Preparation As described above under Cleft Palate Repair Procedure Incisions The incisions on the noncleft palatal shelf (the greater segment) begin about 2-3 mm away from the medial cleft edge and extend anteriorly from the uvula tip to the vomeropremaxillary suture (Figure 336A). The lateral relaxation incision is made as described in the V to Y pushback procedure, and is brought around to the tip of the medial cleft edge incision. On the cleft palatal side (the lesser segment), the medial incision is created in a similar fashion as on the noncleft side. The lateral incision is similar to that on the greater segment, except that the anterior aspect of the incision is brought forward to the alveolar ridge.
Figure 336 Two-flap palatoplasty. Landmarks and incisions. Note the position of the neurovascular bundles (VB).
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Flap elevation Mucoperiosteal flaps are elevated with a Freer elevator from the greater and lesser palatal segments, and from the vomer on the greater palatal segment (Figure 336B). The nasal floor mucoperiosteum is elevated on the lesser palatal segment. Dissection of the neurovascular bundles and lateral relaxation incisions over the hamulus are the same as described above in the section on V to Y pushback palatoplasty. The soft palate and uvula cleft edges are prepared in the same fashion as in the V to Y pushback. Suturing Closure begins by approximating the vomer and nasal palatal mucoperiosteal flaps using 4-0 or 5-0 Vicryl, beginning anteriorly and proceeding posteriorly to the nasal surface of the soft palate and uvula (Figure 336C). The knots are placed in the nasal cavity. The levator muscle sling and oral closure are as described in the V to Y pushback procedure. The anterior tips of the palatal mucoperiosteal flaps are sutured to the alveolar mucoperiosteum to decrease the size of the residual alveolar cleft (Figure 336D). Microfibrillar collagen is packed into the lateral relaxation incisions. Postoperative Care and Complications As described above under Cleft Palate Repair
Figure 336 B, Cleft edges are incised and flaps elevated, preserving the neurovascular bundles.
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Figure 336 C, The nasal floor and nasopharyngeal mucosa are sutured. Several horizontal mattress sutures approximate the levator muscular sling. D, The oral mucosa is sutured and the flap tips secured anteriorly. Microfibrillar collagen is packed into the lateral relaxation incisions.
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DOUBLE REVERSING Z-PLASTY (FURLOW PALATOPLASTY) Indications Submucous cleft palate or isolated soft palate cleft. The procedure consists of a soft palatal lengthening Z-plasty with overlap of the mucomuscular flaps to re-align the levator sling. Double reversing Z-plasty is increasingly being used with the previously described two-flap palatoplasty procedure for reconstructing the soft palate. Anesthetic Considerations and Preparation As described above under Cleft Palate Repair Procedure Incisions and flap elevation Incisions for a Z-plasty are marked on the oral mucosa of the soft palate with gentian violet (unbroken lines in Figure 337A) using the cleft as the central limb on the Z-plasty. Broken lines represent the incisions to be made on the nasopharyngeal aspect of the soft palate. The cleft margins are incised with a 6300 Beaver blade. In the case of a submucous cleft palate, a No 11 Bard-Parker blade is used to incise the central limb of the Z-plasty, thus creating a complete cleft. Using a No 15 Bard-Parker blade, the lateral limbs of the Z-plasty are incised through the mucosa and submucosa only. The left oral mucosal flap is then elevated with tenotomy scissors such that the levator muscles are elevated attached to the oral mucosa (Figure 337B). The plane of dissection is between the levator muscles and the nasopharyngeal submucosa. The right oral mucosal flap is sharply elevated with scissors in a plane between the submucosa and levator muscles. The levator muscles are dissected from the posterior aspect of the hard palate the right side and remain attached to the nasopharyngeal mucosa. Using angled scissors, the nasopharyngeal incision is made from the apex of the central limb toward the superior region of the posterior tonsillar pillar (Figure 337C). The final limb of the nasopharyngeal Z-plasty is made on the left side, extending from the uvula tip toward the junction of the lateral hard palate and pterygoid plate. A key aspect of the incisions is that after interdigitation of the nasopharyngeal and oral flaps, the levator muscles are positioned to overlap. Suturing Closure begins by interdigitating the nasopharyngeal flaps and closing the nasopharyngeal incisions with interrupted 4-0 and 5-0 Vicryl sutures (Figure 337D). The oral mucosal flaps are then interdigitated and the tips are placed into position with 4-0 Vicryl suture.
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Figure 337 Double reversing Z-plasty (Furlow palatoplasty). A, Solid lines indicate the oral mucosal incisions; broken lines indicate the incisions to be made on the nasopharyngeal mucosa. B, The cleft edges are incised; oral mucosal (patients right side) and oral mucomuscular (patients left side) flaps are elevated. C, Incising the nasopharyngeal flaps; the scissors depict incision of the nasopharyngeal mucomuscular flap. D, The nasopharyngeal flaps are interdigitated and sutured. Note the muscle containing nasopharyngeal and oral flaps overlap. E, The oral flaps are interdigitated and sutured.
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Although the muscles are overlapped in the inferior flaps, a 3-0 Vicryl suture placed in a horizontal mattress position through the muscle helps to tighten the levator sling. The limbs of the oral mucosal Z-plasty are then sutured together with alternating interrupted sutures of 4-0 Vicryl and 4-0 chromic gut (Figure 33-7E). The dead space between the superiorly located oral and nasopharyngeal mucosal flaps may be obliterated with a small amount of microfibrillar collagen if desired. Postoperative Care and Complications As described above under Cleft Palate Repair
BIBLIOGRAPHY
Bardach J, Morris H. Multidisciplinary management of cleft lip and palate. Philadelphia: WB Saunders; 1990. Furlow LT Jr. Cleft repair by double opposing z-plasty. Plast Reconstr Surg 1986;78:7246. Millard DR Jr. Cleft craft-the evolution of its surgery I: the unilateral deformity. Boston: Little Brown; 1976. Millard DR Jr. Cleft craft-the evolution of its surgery II: the bilateral and rare deformities. Boston: Little Brown; 1977. Millard DR Jr. Cleft craft-the evolution of its surgery III:alveolar and palatal deformities. Boston: Little Brown; 1980.
C H A P T E R 34
C RANIOSYNOSTOSIS
Lawrence J. Marentette, MD John Kim, MD
Craniosynostosis is the premature ossification (fusion) of one or more suture lines of the cranial vault, which narrows the skull in any one or several dimensions (craniostenosis). The head shapes resulting from craniosynostosis can often be readily recognized, leading to psychosocial issues that may plague the affected individuals. Craniosynostosis may or may not be associated with an underlying syndrome. Nonsyndromic craniosynostosis is more amenable to single-stage procedures for correction, whereas syndromic craniosynostosis is usually addressed with several stages spanning years. This chapter emphasizes surgery for nonsyndromic craniosynostosis. CLASSIFICATION AND ETIOLOGY Primary craniosynostosis refers to those processes that, among other issues, largely manifest with premature fusion of the cranial sutures, and the sequelae of such fusion. Depending on the suture(s) involved, craniosynostosis produces a characteristic head shape. Surgery is described below for correcting plagiocephaly (unilateral coronal synostosis), brachycephaly (bilateral coronal synostosis), trigonocephaly (metopic synostosis), scaphocephaly (sagittal synostosis), and posterior plagiocephaly (lambdoidal synostosis). Primary craniosynostosis can be syndromic or nonsyndromic. Cohen reported over 60 syndromes associated with craniosynostosis.1 Syndromic craniosynostosis can be further categorized into monogenic syndromes, chromosomal abnormalities, and environmentally induced syndromes.
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Monogenic syndromes are usually autosomal dominant including Aperts, Crouzons, and Pfeiffers. Recessively dominant syndromes include Antley-Bixler, Carpenters, and Gorlin-Chaudhry-Moss. Chromosomal abnormalities can occur in the long or short arms of chromosomes I, III, V, VI, VII, IX, XI, XII, XIII, and XV. Environmentally induced syndromes include retinoic acid and fetal hydantoin syndrome.
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Secondary craniosynostosis refers to craniosynostosis caused by an established disorder, including hematologic processes (sickle cell anemia, thalassemia, congenital hemolytic icterus, and polycythemia vera), metabolic disease (hyperthyroidism, rickets, and mucopolysaccharidosis), congenital malformations (microcephaly, encephalocele, and holoprosencephaly), and iatrogenic causes (decreased intracranial pressure secondary to ventricular peritoneal shunts). There are multiple factors involved in the etiology of craniosynostosis, with many theories proposed regarding the mechanism of premature fusion. Moss and Greenberg proposed that initial fusion of the skull base sutures produces dural tension, which prevents brain and dural growth causing suture separation to cease with resultant premature fusion.2 Park and Powers proposed that the abnormality was directly related to intrauterine injury of the sutural anlage.3 CRANIOSYNOSTOSIS SURGERY Given the complex nature of craniosynostosis, a complete evaluation by a craniofacial team is emphasized. A team approach helps ensure that all aspects of the patients care are considered. Members of the team typically come from several disciplines including anesthesiology, audiology, dentistry, genetics, neurology, neurosurgery, ophthalmology, oral surgery, otolaryngology, pediatrics, plastic surgery, psychiatry, psychology, radiology, speech pathology, and social work. Indications The treatment for craniosynostosis is controversial, and depends on the type of deformity and its etiology. Close communication between the anesthesiologist, neurosurgeon, and the craniofacial surgeon is paramount. Treatment options range from observation alone to early surgery before the age of 6 months. Some have advocated head molding with helmets for some forms of craniosynostosis.4 Since there is no universal consensus on treatment, it is advisable to review each individual case with a craniofacial team. In general, surgery should be considered when there is evidence of increased intracranial pressure, and when the forehead and orbital esthetic units are affected. If the craniosynostosis does not affect the frontal or orbital esthetic units, the malformation and potential surgical risks should be weighed against the consideration that these malformations may sometimes be camouflaged. The treatment plan should also take into consideration that plagiocephaly leads to facial deformities that can be diminished with surgery. The timing of surgical intervention is equally individualized. Proponents of early correction argue that early surgical intervention allows the normal rapid brain growth during early development to promote normal craniofacial development. Facial deformities may also be diminished with early intervention. Waiting for surgical correction may require a more complex procedure. Proponents of later surgical intervention (9 to 12 months of age) argue that waiting may help to more accurately determine the etiology of the
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synostosis thus leading to tailored treatment plans. Later surgical intervention also allows for better bone development and relies less on brain growth. Treatment becomes easier to determine if the etiology is known. Anesthetic Considerations Given the complexity of craniosynostosis surgery, close communication must exist between the surgeon and anesthesiologist. A preoperative anesthesia evaluation is advised, including a thorough history and physical examination. Cardiopulmonary history should be elucidated. Particularly important is a neurologic history, including any history of intracranial pressure elevation, seizures, or previous surgeries. Any associated syndromes should be recognized and treated accordingly to optimize the childs condition prior to surgery. Airway anomalies should be ascertained and precautions should be taken. Syndromes such as Pierre Robin, Treacher Collins, and BeckwithWiedemann are associated with micrognathia, retrognathia, or mandibular hypoplasia. To prevent injuries during intubation and positioning of the child during surgery, syndromes that present with spinal abnormalities should be analyzed, and the possibility of injury with flexion or extension should be determined. During the preoperative evaluation with anesthesia, questions that the parents may have regarding anesthesia and monitoring can be answered. Preparation Pre-existing acute or chronic sinusitis should be treated before surgery to minimize the possibility of intraoperative intracranial contamination. Positioning of the patient can be determined with close communication between the craniofacial surgeon, neurosurgeon, and anesthesiologist. A coronal incision (Chapter 32) is used in all procedures to access the upper craniofacial skeleton and the posterior part of the skull.
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Procedures No 1. Unilateral coronal craniosynostosis Plagiocephaly refers to the asymmetric morphology that results in unilateral retrusion of the forehead with contralateral protrusion, caused by premature fusion of a unilateral coronal suture (Figures 341A and B). Facial deformities may also arise secondary to plagiocephaly, with midline deviation away from the fused suture. Vertical dystopia occurs with elevation of the orbit on the side of fusion (teardrop orbit with an upper-outer slanting pattern or harlequin orbit) and inferior displacement of the contralateral eye. Correction involves opening the coronal suture with forehead advancement. Although this may be done in selected cases as a unilateral advancement, better results are often achieved with bilateral frontal orbital osteotomies and rotation advancement of the affected side. After exposing the upper craniofacial skeleton, including the upper half of the orbits and the nasal glabellar complex, a bifrontal craniotomy is performed. Osteotomies (Figure 342A) mobilize the supraorbital bar, which consists of the glabella and upper one-half of the orbits. In the temporal fossa, a tongue-and-groove osteotomy provides adequate bone contact following advancement and fixation (plate and screw). After the orbital bar has been mobilized, it is advanced forward into the correct position and secured in the temporal fossa with rigid fixation (Figure 342B). The bifrontal craniotomy bone flap is replaced and secured to the supraorbital bar anteriorly with rigid fixation. Correction of plagiocephaly caused by unilateral coronal craniosynostosis usually involves rotating the affected side forward to match the unaffected side. Rarely, a hemicraniotomy can be performed with only an osteotomy and advancement of the supraorbital bar on the affected side.
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Figure 341 Plagiocephaly caused by unilateral coronal craniosynostosis compared with normal skull position (dotted line). A, Ipsilateral frontal retrusion with contralateral expansion or bossing. B, Frontal view of associated nasal, orbital, and maxillary deformities.
Figure 342 Surgical correction of unilateral coronal craniosynostosis. A, Osteotomies. B, Bone advancement and rigid fixation.
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No 2. Bicoronal craniosynostosis Brachycephaly refers to the widening of the skull with a decrease in the anterior-posterior dimension caused by bilateral fusion of the coronal sutures (Figure 343). The basilar sutures may also be fused. Nonsyndromic cases have nasoethmoidal retrusion with normal intelligence. Syndromic cases (Aperts or Crouzons) may have mental retardation as an inherent consequence of the syndrome, or as a result of untreated hydrocephalus. Bilateral frontal orbital advancement is performed, with equal advancement on either side if the forehead is initially symmetric but retruded. After bifrontal craniotomy and removal of the bone flap, a supraorbital bar osteotomy is created bilaterally involving the upper halves of the orbits and the glabella with tongue-and-groove osteotomies in the temporal fossa (Figure 344A). The supraorbital bar is advanced forward into the new position bilaterally (Figure 344B) and secured in place in the temporal fossa with rigid fixation. The bifrontal craniotomy bone flap is secured to the supraorbital bar with rigid fixation. The gap left in the cranial vault corresponds to the amount of forehead advancement.
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Figure 343 Brachycephaly caused by bilateral coronal craniosynostosis compared with normal skull position (dotted line). Sagittal shortening involves primarily the lower forehead and cranial base; the skull has compensatory widening.
Figure 344 Surgical correction of bilateral coronal craniosynostosis. A, Osteotomies. B, Bone advancement.
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No 3. Metopic craniosynostosis Trigonocephaly refers to the triangular morphology of the forehead caused by fusion of the metopic suture (vertical midline suture of the frontal bone). A prominent midline is evident with recessed lateral supraorbital rims and forehead (Figure 345). Bitemporal narrowing and orbital hypotelorism are not uncommon. Mental retardation may be present because trigonocephaly is associated with holoprosencephaly and agenesis of the corpus callosum. Reconstruction requires a frontal orbital remodeling including reopening the midline frontal suture and flattening the supraorbital bar. The forehead is recontoured to match the bar and give a smoother mid-forehead flattening. Bifrontal craniotomy is performed with removal of the bone flap following mobilization of the supraorbital bar (Figure 346A). The supraorbital bar is removed and remodeled on a sterile table (Figure 346B). An osteotomy is created in the midline portion of the bar, through the area of the fused metopic suture.
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The mid portion of the supraorbital bar is then flattened and secured with rigid fixation. A bone graft may be used additionally on the inner portion of the supraorbital bar to further strengthen the fixation in this area.
Figure 345 Trigonocephaly caused by metopic craniosynostosis compared with normal skull position (dotted line). Note sharp angulation at the midforehead with keel-shaped frontal deformity.
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The bar is contoured as needed, just lateral to the supraorbital rims to prevent the tongue-and-groove osteotomy from protruding excessively. This is best accomplished with bone-bending forceps. If fractures do occur, which is common in this area, then the contour is maintained with rigid fixation.
After remodeling, the bar is placed into its new position and secured in the temporal fossa with rigid fixation (Figure 346C). An osteotomy is created in the midline of the bifrontal craniotomy bone flap and the bone flaps are rotated to match the contour of the newly recreated supraorbital bar. The flaps are secured with rigid fixation (see Figure 346C).
Figure 346 Surgical correction of metopic craniosynostosis. A, Osteotomies. B, Remodeling of the supraorbital bar with midline osteotomy and lateral contouring. C, Bone advancement and rigid fixation.
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No 4. Sagittal craniosynostosis Scaphocephaly refers to the broad boat-shaped morphology caused by fusion of the sagittal suture. Head width is decreased but sagittal length is increased (Figure 347). This is the most common form of isolated craniosynostosis, and is not usually associated with mental retardation. After coronal incision, the scalp is dissected anteriorly and posteriorly exposing the entire cranial vault, the occiput, and the upper half of the orbits anteriorly. Multiple craniotomy bone flaps are created (Figure 348A) and removed from the patient. The supraorbital bar is also removed and recontoured (as described above) if bitemporal narrowing is part of the deformity. After removing the bone flaps, the brain shape will often return to normal configuration creating a template for the recontouring of the cranial vault. The multiple bone flaps of the cranial vault are replaced and reshaped to a more normal head contour by decreasing the anterior-posterior dimension and increasing the transverse dimension (Figure 348B). The bone flaps are secured with rigid fixation.
Figure 347 Scaphocephaly caused by sagittal craniosynostosis compared with normal skull position (dotted line). The skull is lengthened and narrowed, creating a boat-shaped appearance.
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Figure 348 Surgical correction of sagittal craniosynostosis. A, Osteotomies. B, Bone repositioning and rigid fixation.
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No 5. Lambdoidal craniosynostosis Posterior plagiocephaly refers to the asymmetry of the occiput caused by unilateral fusion of a lambdoidal suture (Figure 349). The ipsilateral occipitomastoid region is flattened and the contralateral coronal suture is often fused, producing a twisted head. Fusion of the lambdoidal suture is the only synostosis that manifests without a palpable ridge; however, an internal ridge towards the dura may be evident on computed tomography (CT) scanning. Imaging may also help distinguish lambdoid synostosis from intrauterine molding, which is treated conservatively. After coronal incision, scalp dissection is carried in a posterior direction down to the posterior base of the skull exposing the entire occiput. The occipital craniotomy is performed, excising through, or anterior to, both lambdoidal sutures (Figure 3410A). The bone flap is removed and recontoured, if necessary, on a sterile table. The occipital bone flap is replaced, advancing the affected side to achieve posterior head symmetry (Figure 3410B). The bone flaps are secured with rigid fixation. Postoperative Care Postoperative management involves care in an appropriate intensive care unit. This may be a neurosurgical intensive care unit, or a pediatric intensive care unit depending on the institution.
Figure 349 Posterior plagiocephaly caused by lambdoidal craniosynostosis compared with normal skull position (dotted line). Note flattening of the ipsilateral occipitomastoid region.
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Patients usually require close observation for 24 to 48 hours after surgery. Neurologic status should be monitored closely for altered mental status since this may be the first sign of cerebral edema. Other conditions to be aware of include large fluid shifts, intracranial bleeding, hypoglycemia, and electrolyte imbalance. The care of the patient in the immediate postoperative period is provided by the neurosurgeon.
Figure 3410 Surgical correction of lambdoidal craniosynostosis. A, Osteotomies. B, Bone advancement and repositioning.
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Complications Mortality for craniofacial procedures is estimated between 1.5 and 2.0%.5 Mechanisms of mortality include massive hemorrhage, meningitis, respiratory obstruction, and hypovolemia. Death may also be caused by cerebral edema and respiratory infections. Careful preoperative planning, intraoperative management, and postoperative observation are paramount in minimizing mortality. Postoperative infection is fortunately infrequent, occurring in about 6.2% of intracranial procedures.6 Risk is reduced by preoperative control of sinusitis and routine administration of perioperative antibiotics, typically for 5 days. If the patient develops postoperative signs of central nervous system infection, cerebral spinal fluid should be sent for analysis and culture. Meningitis is treated with intravenous antibiotics, usually without neurologic sequelae. Subdural or epidural empyemas usually require surgical evacuation. Large bone flaps used for reconstruction can become devitalized and subsequently infected. Clues to infection include fever, persistent swelling to the operative site, collection of fluid under the galea, tenderness, exposed bone, and frank purulent drainage. Infection can also occur if implanted alloplasts become exposed or seeded with systemic infections. Nonporous alloplasts usually cannot be treated with conservative methods and will likely require removal. Porous alloplasts may be salvaged with irrigation, intravenous antibiotics, localized debridement, and coverage with vascularized tissue. Hemorrhage during surgery is particularly significant in children. The anesthesiologist and surgeons must be vigilant, and the need for blood transfusion should be determined in a timely fashion. Major bleeding during surgery for craniosynostosis can be encountered if the venous sinus is violated. In this case, the craniotomy flap must be quickly removed and the bleeding must be controlled. Occlusion of the sagittal venous sinus may be carried out without sequelae; however, the middle or posterior third should not be occluded. ! Epidural hematomas are not uncommon in the postoperative period. Observation is appropriate for asymptomatic patients without evidence of a mass effect or increased intracranial pressure. Otherwise, the hematoma should be evacuated surgically in a timely fashion. Subdural hematomas are fortunately less common and may be treated similarly. ! Intracerebral hemorrhage is an uncommon occurrence and should be monitored closely until resolution if the patient is asymptomatic. If the patient is symptomatic, the hematoma should be quickly evacuated with surgery. Seizures may arise from a number of causes including increase in intracranial pressure, cerebral trauma or laceration, hemorrhage, cerebral infarction, pneumocephalus, or electrolyte imbalances. Anticonvulsant therapy is usually successful. With recurrent seizures or status epilepticus, the source of the seizure should be identified to more effectively address the etiology.
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Cerebral spinal fluid (CSF) leakage can best be addressed preventively with meticulous closure of all dural defects created or encountered. Reinforcement of dural tears can be accomplished utilizing the paracranial flap.
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If CSF leaks occur after meticulous closure, conservative measures are attempted. Bed rest along with head positioning, such that the brain is used to tamponade the defect, may encourage closure. Use of acetazolamide with diuretics to diminish CSF production may be attempted as long as the electrolytes are carefully monitored. A lumbar drain may be inserted to divert CSF from the defect and encourage closure. If a lumbar drain is to be utilized, personnel caring for the drain should be trained to keep the drain at an appropriate level so that neither excessive nor inadequate drainage occurs. If CSF drainage persists despite the above measures, it may be necessary to re-explore the operative site.
Pneumocephaly is very common following most intracranial surgery, and may be serious if associated with increased intracranial pressure (tension pneumocephalus). A significant pneumocephalus can occur, especially if the paranasal sinuses communicate with the cranium. Patient counseling to avoid forceful nose blowing, sneezing, etc, may help to minimize this complication. If tension pneumocephalus is suspected, a CT scan is obtained to detect midline shift or increased intracranial pressure. Treatment involves aspiration via a previously placed bur hole. Preventive measures for high-risk patients include tracheotomy, nasal packing, nasal trumpet placement, and intubation. Alopecia at the site of incision may occur. This is often easily camouflaged with hair, but may require scar excision and re-approximation if extensive. Relapse of certain unusual head morphologies may occur after surgical correction. Although uncommon in nonsyndromic craniosynostosis, relapse may be caused by brain growth abnormalities and other inherent problems associated with underlying syndromes. Also, cardiopulmonary complications may arise if some syndromes go unrecognized. Therefore, it is important to carefully review the patient and patients history in the preoperative setting. A craniofacial team approach also helps to minimize misdiagnoses. Ophthalmologic complications are exceedingly rare. Care should be taken intraoperatively to avoid excess pressure to the globes. Postoperatively, abducens function can be extremely sensitive to intracranial pressure changes. Scalp necrosis may result from excessive intraoperative tension. Careful handling of the soft tissues during surgery may minimize this rare complication. Plate removal may be necessary if the plate or screws become prominent and bothersome for the patient. Controversy exists as to whether routine plate removal should be carried out. Proponents argue that intrusion of the plate intracranially will likely occur if the rigid fixation plates are not
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removed. However, there is no evidence at this time that such intrusion is actually detrimental. Venous air embolism can occur when venous structures that become exposed to the atmosphere come under lower pressures and allow air transfer to occur into the venous structures.
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The risk of air embolism increases if the patient is in a sitting position, if the venous sinuses are exposed to air, or if the patient becomes dehydrated, causing decreased central venous pressures. Air embolisms should be suspected if there is an unexplained drop in the end-tidal carbon dioxide concentration. This occurs because an air embolism can block pulmonary blood flow causing increased dead space; a water wheel murmur is heard on the precordial stethoscope. If an air embolism is suspected, the surgical field should be flooded with normal saline, nitrous oxide should be discontinued, and the patients head should be lowered. A pulmonary artery catheter, or a central venous catheter in the case of a large embolism, may be used to attempt aspiration of the embolism.
CONCLUSION Surgical correction of craniosynostosis requires a team approach with close cooperation among all team members. Underlying syndromes must be detected because they greatly affect preoperative counseling for the parents and family. With modern techniques, craniosynostosis surgery is safe and effective; however, only those surgeons with thorough training in the area of craniofacial surgery should undertake it. ACKNOWLEGEMENTS The authors thank Kenneth Anderson, MD for his illustration of this chapter.
REFERENCES
1. 2. 3. 4. 5. Cohen MM Jr. Syndromes with craniosynostosis. In: Cohen MM Jr, editor. Craniosynostosis: diagnosis, evaluation, and management. New York: Raven Press; 1986. p. 413590. Moss ML, Greenberg SV. Postnatal growth of the human skull base. Angle Orthod 1955;25:7784. Park EA, Powers GF. Acrocephaly and scaphocephaly with symmetrically disturbed malformation of the extremities. Am J Dis Child 1920;20:235315. Clarren SK, Smith DW, Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. J Pediatr 1979;94:436. Whitaker LA. Problems and complications in craniofacial surgery. In: Goldwyn RM, editor. The unfavorable result in plastic surgery Avoidance and Treatment. Boston: Little, Brown; 1984. p. 229. Carson BS, Dufresne CR. Surgical Complications. In: Dufresne CR, Carson BS, Zinreich SJ, editors. Complex craniofacial problems. New York: Churchill Livingstone Inc; 1992. p. 468.
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C H A P T E R 35
I NFORMATION
FOR PARENTS AND C AREGIVERS

Richard M. Rosenfeld, MD, MPH
Most families are too anxious during the baseline office visit or surgical encounter to efficiently process and recall verbal instructions regarding postoperative care. Visual aids, such as patient education sheets, are an effective means of rapidly informing parents about what to expect after their childs surgery.1
ANESTHESIA EDUCATION SHEET Although not a distinct procedure, enough parents have concerns about general anesthesia to merit a separate handout. A useful method to reassure parents of anesthetic safety is to describe risk in the context of other daily activities as shown in paragraph three of the education sheet (Figure 351).24 Assuming a 1:50,000 fatality rate from general anesthesia, an individual incurs the same risk of death by engaging in 40 hours (2,000 miles) of automobile driving 40 hours of bicycle riding 24 hours of commercial airline flying (the risk is 10-fold higher for private flights) 7 hours of downhill recreational skiing 1 hour of motorcycle driving 30 minutes of rock climbing 340 trips in a passenger elevator Therefore, the risk of anesthesia is no greater than for many typical activities engaged in on a regular basis without much attention to the concept of risk. Moreover, the true risk of anesthesia may be substantially less than 1:50,000, which is based on historical estimates. The current anesthesia fatality rate is estimated at approximately 1:250,000.5 Risk, however, is significantly higher for inpatient surgery, children under 12 months of age, or when the child has underlying systemic disease.
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Your Child and General Anesthesia

During general anesthesia, your child breathes a carefully prepared mixture of oxygen and anesthetic gas to eliminate any pain or awareness during surgery. In contrast, local anesthesia is injected directly into tissues or nerves to reduce sensation at a specific location. Most ear, nose, and throat surgery in children is performed under general anesthesia because infections are difficult to administer and do not relieve chil anxiety. Is All General Anesthesia the Same? All general anesthesia uses a gas mixture, but the mixture may be given through a mask placed over the nose and mouth or a flexible tube placed in the windpipe (trachea). Many brief surgeries (less than 20 to 30 minutes) in young children are performed with mask anesthesia, including ear tube insertion, repair of tongue-tie, and removal of small growths or lesions. Tube anesthesia (intubation) is required for most other surgeries to protect and control breathing. Temporary coughing and hoarseness may occur after tube anesthesia because the tube rests in the voice box (larynx) during surgery. Isnt Anesthesia Risky? General anesthesia is one of the safest experiences in your childs life because they are monitored very closely. The risk of anesthesia is about 1 in 50,000, meaning that for every 50,000 ambulatory surgeries in healthy children there is, on average, one death. Although most parents would prefer zero risk, nothing in life meets this goal. For example, consider the following activities that all have the same risk (1:50,000) as anesthesia: 40 hours (2,000 miles) of car driving, 40 hours of bicycling, 24 hours of airline flying, 7 hours of skiing, 1 hour of motorcycle driving, 30 minutes of rock climbing, or 340 elevator trips (Larry Laudan, Danger Ahead and The Book of Risks, published by John Wiley & Sons, NY, 1997 and 1994). The risk of anesthesia is higher than 1:50,000 for infants, children with other illness, or major surgery with a hospital admission. Other Issues and Concerns Colds and upper respiratory infections are very common in young children, but do not always require postponing surgery. Children having a mask anesthesia (eg, ear tubes) can usually have surgery if there is no fever, productive cough, or chest congestion. Most surgery requiring tube anesthesia, however, must be postponed if the child is ill. Loose teeth may be dislodged during anesthesia, and should be evaluated by your childs dentist for stability or possible removal. Please contact us if you have any concerns. Food and drink is limited before surgery to prevent excess stomach acid or liquids. Most children can have 4 ounces of clear liquids (water, apple juice, soda, or Jell-O) up to 2 hours before surgery, but cannot have any solid foods for 4 to 8 hours depending on age. Child fear or anxiety is common but manageable. Before entering the operating area, most children receive a sedative (midazolam) that will make them very sleepy and relaxed. Furthermore, there should be little memory of the time in the operating or recovery rooms. You may rejoin your child once they arrive in the recovery room.
Figure 351 Education sheet for general anesthesia.
Information for Parents and Caregivers

PROCEDURE EDUCATION SHEETS
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The educational sheets reproduced in this chapter are offered as practical examples that can be adapted to any practitioners specific circumstances. Sheets are included for the following commonly performed pediatric otolaryngology procedures: Tympanostomy tubes (Figure 352). Parent education for tubes is perhaps more important than with any other procedure. An expanded version of this sheet is distributed at the first postoperative visit (see below). Adenoidectomy (Figure 353). A routine follow-up visit is not scheduled for adenoidectomy (or tonsillectomy). Instead, the nurse contacts the patient 2-3 weeks after surgery and completes an outcome questionnaire that is signed by the physician and kept in the medical record.6 Only those patients who request a follow-up appointment (usually less than 5%) are seen after surgery.7 Tonsillectomy (Figure 354). Pain management and the importance of good hydration are emphasized. As with adenoidectomy (see above) less than 5% of patients generally request a postoperative visit. Endoscopic sinus surgery (Figure 355). Children are seen about 3 weeks after surgery to clean any crusts or debris from the nasal cavity; rigid endoscopy is rarely necessary or tolerated. A routine second look debridement under general anesthesia is not performed. Head and neck surgery (Figure 356). This very nonspecific sheet relates primarily to suture care and monitoring for signs of infection. Specific verbal instructions are provided depending on the procedure performed. Middle ear or mastoid surgery (Figure 357). The sheet is self-explanatory. Ear tube removal with paper-patch tympanoplasty (Figure 358). The sheet is self-explanatory. Laryngoscopy and bronchoscopy (Figure 359). This sheet is most applicable to diagnostic procedures, but may also be used for laser surgery or biopsies. Frenuloplasty (Figure 3510). The sheet is self-explanatory.
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What to Expect after Ear Tube Insertion

Congratulations! Now that your child has ear tubes you can finally relax. If you follow the suggestions below, your child should enjoy healthy ears and excellent hearing. While the Tubes are in Place Although the tubes are not painful, some children will touch their ears because they initially fell different. Please do not worry; your child cannot reach or dislodge the tube. Drainage from the ear canals may occur for several days after surgery, and represents a gradual return of the middle ear to a normal state. Do not be alarmed if the discharge is mixed with a small amount of blood. Routine water precautions following tube insertion are unnecessary for most children. If water seems to bother your child (or if your doctor recommends water precautions), we will gladly fit them with soft ear plugs. Tube Check-Ups Please schedule an office visit within 2 months after surgery to check your childs tubes and hearing. Additional check-ups are required every 6 months while the tubes remain in place (usually about 6 to 18 months). Regular check-ups are essential for proper tube function, and are required even if your child is having no problems. Your primary care doctor does not have the training or equipment necessary for proper tube surveillance. If You See Drainage from the Ears Drainage from the ears may occur during a cold, or if water manages to pass through the tube opening (very difficult!) into the middle ear. Do not panic if you see drainage, even if it is bloody; there is no danger to your childs ears or hearing. If you notice any discharge (1) place cotton in the ear canal to absorb the drainage, and change it often, (2) use an ear plug (or cotton with Vaseline) when bathing to deep out water, and (3) do not allow your child to swim until the ear has been dry for at least 48 hours. Drainage persisting despite these measures is treated as a routine ear infection with antibiotic-containing ear drops alone for 3 to 5 days (Floxin or Ciloxan). Oral antibiotics are needed only for persistent or severe infections. When to Call Us Please call our office if: (1) your childs regular doctor doesnt see the tube (dont worry it cant fall into the middle ear), (2) your child has hearing loss or continued ear infections (the tube may be blocked), (3) drainage from the ears persists beyond 7 days, (4) you see the tube lying in the ear canal (it does no harm while there), or (5) there is excessive sax build-up in the ear canal. I have received a copy of this information sheet. Parent or Guardian ____________________ Childs name _________________________ Relation to child _______________________ Date ________________________________
Figure 352 Education sheet for tympanostomy tubes.
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What to Expect after Adenoidectomy

Adenoidectomy is a safe and effective surgical procedure that will provide your child with lasting benefits. The suggestions below should help with a rapid recovery. Diet & Activity No special changes in diet are required after adenoidectomy. The adenoids are located where the back part of the nose joins the throat, an area protected from food and liquids by the palate. Let your child eat whatever they want after surgery; ice cream or other special foods are unnecessary. There are no strict rules for activity, other than to avoid contact sports, heavy exertion, or hanging upside down during the first 1-2 weeks after surgery. Encourage your child to get out of bed frequently, and to return to normal activity as soon as possible. Dealing with Pain Pain is generally not severe after adenoidectomy, but you can minimize your childs discomfort by (1) encouraging adequate food and liquid intake, (2) making sure they take all of the prescribed antibiotic, (3) distracting them with games and activities, and (4) reassuring them that within 2-3 days they should be getting back to normal. Acetaminophen (Tylenol) can be used liberally, but ibuprofen products (Motrin, Advil) are avoided because they can cause bleeding. Codeine and other narcotic pain relievers are generally unnecessary. Some Things Not to Worry About A hoarse or abnormal voice may occur for several days from the anesthesia tube. Vomiting may occur for up to 24 hours after anesthesia. Snoring may persist for 1-2 weeks because of temporary swelling of the tissues around the adenoids. Fever up to 101 degrees and bad breath may persist for up to several days after surgery. A small amount of bloody discharge from the nose is common, particularly during the first 24 hours. Mild neck stiffness may occur for up to 7 days. When to Call Us Call our office if (1) there is persistent or excessive bleeding, (2) your child has inadequate food or beverage intake, (3) fever is 102 degrees or higher despite acetaminophen (Tylenol), (4) your child develops a severe or progressive stiff neck, (5) foul breath is persisting (without signs of improvement) after 3-4 days, or (6) your child seems to be getting worse not better as the days go by. Unless requested by your doctor, a routine postoperative office appointment is not necessary after adenoidectomy. I have received a copy of this information sheet. Parent or Guardian __________________ Childs name _______________________ Relation to child _______________________ Date ________________________________
Figure 353 Education sheet for adenoidectomy.
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What to Expect after Tonsillectomy

Tonsillectomy is a safe and effective surgical procedure that will provide your child with lasting benefits. The suggestions below should help with a rapid recovery. Diet & Activity Encourage your child to drink at least 4 to 6 eight-ounce glasses of liquid daily (Gatorade, fruit punch and noncitrus juices) to prevent dehydration. Within 1-2 days, add cold and soothing foods (ices, ice-cream, frozen yogurt, Jell-O). As your child feels better, add soft bland items that are easy to chew and swallow (pasta, puddings, mashed potatoes, tuna or chicken salad, macaroni and cheese). Avoid foods that are hare, sharp, hot, or spicy; a good rule is to imagine what you would want to eat if you had a whopping sore throat. Lollipops and hard candies may be sucked, not chewed. There are no strict rules for activity after surgery, other than to avoid contact sports or heavy exertion for about 2 weeks. School can be resumed after one week for nearly all children. Your child should get out of bed frequently, and return to normal activity as soon as possible. Dealing with Pain Theres no doubt about it: tonsillectomy does not top the list of ways children like to have fun. You can, however, minimize your childs discomfort by (1) encouraging adequate food and liquid intake, (2) making sure they take all of the prescribed antibiotic, (3) letting them chew their favorite gum (it exercises the jaw muscles and lubricates the throat with saliva), (4) distracting them with games and activities (new toys are particularly effective!), and (5) reassuring them that within 7 days they should be getting back to normal. Acetaminophen (Tylenol) can be used liberally, but ibuprofen products (Motrin, Advil) should be avoided because they can increase the chance of bleeding. Some Things Not to Worry About A hoarse or abnormal voice may occur for several days from the anesthesia tube and from a temporary stiffness of the palate. Vomiting may occur for up to 24 hours. Snoring may persist for 1-2 weeks because of temporary swelling around the tonsils. Ear pain may occur (the ears and tonsil share common nerves), but is temporary and requires no treatment. Fever up to 101 degrees, and bad breath are common for several days. A scab or crust will form in the throat, and will absorb gradually within about 2 weeks. When to Call Us Call our office if (1) there is persistent or excessive bleeding (go right to the nearest emergency room if severe), (2) your child has inadequate food or beverage intake, (3) fever is 102 degrees or higher despite acetaminophen (Tylenol), (4) your child develops a severe stiff neck, (5) foul breath is persisting (without signs of improvement) after 3-4 days or (6) your child seems to be getting worse not better as the days go by. I have received a copy of this information sheet Parent or Guardian ________________________ Childs name _____________________________ Relation to child _________________ Date __________________________
Figure 354 Education sheet for tonsillectomy.
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What to Expect after Endoscopic Sinus Surgery

Endoscopic sinus surgery is a safe and effective procedure that will provide your child with lasting benefits. The suggestions below should help with a rapid recovery. Nasal Care A gauze pad will be taped under the nose after surgery to absorb any discharge or oozing. The pad should be changed as needed for the next 1-2 days (use a two-inch gauze pad and surgical tape from your local drugstore). Most children have a small piece of packing placed deep in the nose to promote healing. This material does not interfere with breathing and will gradually absorb; it does not need to be removed. While the packing absorbs (about 3 weeks) your child will receive an antibiotic to prevent infection. For several weeks after surgery, a nasal saline spray (Ayr, Nasal, Salinex, Ocean, etc) should be used to moisten the nostrils and promote healing (spray each nostril 2-3 times daily). Gentle nose-blowing is allowed, but forceful nose-blowing should be discourages. Activity & Pain There are no strict rules for activity after surgery, other than to avoid contact sports, heavy exertion, or hanging upside down for 1-2 weeks. During this period swimming is allowed, but a nose plug should be used when diving or jumping into the pool. Pain is generally mild and resolves within 2-3 days. Acetaminophen (Tylenol) can be used liberally, but ibuprofen products (Motrin, Advil) are avoided because they may cause bleeding. Codeine and other narcotic pain relievers are unnecessary after sinus surgery. Some Things Not to Worry About A small amount of bloody discharge from the nose is common, and should gradually resolve within several days. Nasal congestion may occur for several weeks from temporary swelling of the nasal membranes. A hoarse or abnormal voice may occur from the anesthesia tube, but should subside within 2 days. Vomiting may occur for up to 24 hours. Fever up to 101 degrees and bad breath may persist for up to several days. When to Call Us Call our office if (1) there is persistent or excessive bleeding, (2) fever is 102 degrees or higher despite acetaminophen (Tylenol), (3) your child is completely unable to breathe through the nose (there may be some crusts that need to be cleaned out), (4) headache persists or worsens despite acetaminophen (Tylenol) (5) your child has eye swelling or abnormal vision, (6) a large amount of clear or watery nasal discharge occurs and fails to subside in a few days, or (7) your child is getting worse not better as the days go by. I have received a copy of this information sheet. Parent or Guardian _________________________ Childs name ______________________________ Relation to child ________________ Date _________________________
Figure 355 Education sheet for endoscopic sinus surgery.
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What to Expect after Head & Neck Surgery

Head & neck surgery includes many diverse procedures that involve a skin incision and sutures. The suggestions below should help with a rapid recovery. Taking Care of Stitches Depending on the type of surgery your child has, the stitches may or may not need to be removed. Absorbable stitches do not require removal, and usually dissolve within 5 to 7 days. During this time keep the stitches dry and do not apply any ointment or creams. Nonabsorbable stitches are removed in the office within 5 to 10 days after surgery. You may get nonabsorbable wet 48 hours after surgery, and may apply antibiotic ointment (Bacitracin or neomycin) if the stitches itch or become uncomfortable. Dealing with Pain Pain is generally nonsevere after head and neck surgery, but you can minimize your childs discomfort by (1) encouraging adequate food and liquid intake, (2) distracting them with games and activities, and (3) reassuring them that within 2 to 3 days they should be getting back to normal. If the surgical area is initially sensitive, cover with several fluffed-up gauze pads for cushioning. Acetaminophen (Tylenol) can be used liberally, but ibuprofen products (Motrin, Advil) are avoided because they may cause bleeding. Codeine and other narcotic pain relievers are generally unnecessary. Some Things Not to Worry About A hoarse or abnormal voice may occur for several days from the anesthesia tube. Vomiting or nausea may occur for up to 24 hours. Discharge or oozing may occur from the suture line for several days after surgery, and may be blood-tinged or pink: use a clean gauze pad or bandage to absorb any initial discharge. Numbness or the skin around the surgical incision is very common, and should gradually subside within several days or weeks. Itching may occur during the first one or two weeks; if necessary prevent your child from scratching the area by keeping it covered or by trimming fingernails short. When to Call Us Call our office if (1) there is persistent or excessive bleeding from the surgical incision, (2) your child has inadequate food or beverage intake, (3) fever is 102 degrees or higher despite acetaminophen (Tylenol), (4) the skin around the sutures becomes swollen, red or very tender (some redness of the incision itself is normal for several weeks), (5) the stitches break or the incision begins to open up, or (6) your child seems to be getting worse not better as the days go by. Your doctor will arrange a postoperative visit to check the healing process and remove sutures (if necessary). I have received a copy of this information sheet. Parent or Guardian _______________________ Childs name ____________________________ Relation to child ________________ Date _________________________
Figure 356 Education sheet for head and neck surgery.
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What to Expect after Middle-Ear or Mastoid Surgery

Middle-ear and mastoid surgery are performed under microscopic vision for extreme precision. The suggestions below should help with a rapid recovery. Taking Care of the Ear Prevent water from entering the ear for about 2 months when washing your childs hair by placing cotton saturated with Vaseline in the outer ear opening; swimming is not allowed. Avoid excessive pressure in the ear by telling you child not to pop their ears or blow their nose forcefully, and to keep the mouth open if they must sneeze. Cotton in the outer ear opening may be changed as needed during the first few days to absorb drainage, but do not attempt to clean or remove any packing from inside the ear canal. Absorbable stitches, if present, do not require removal, and usually dissolve within 5 to 7 days (keep the stitches dry and do not apply any ointment). Nonabsorbable stitches are removed in the office within 10 days (you may get them wet or apply ointment after 48 hours). Dealing with Pain Mild intermittent pain may occur during the first 2 weeks, particularly above or in from of the ear, when chewing. If the skin around the surgical area is sensitive, it may be covered with several fluffed-up gauze pads for cushioning. Acetaminophen (Tylenol) can be used liberally, but ibuprofen products (Motrin, Advil) are avoided because they can increase the chance of bleeding. Codeine may be prescribed if mastoid surgery was performed. Some Things Not to Worry About A hoarse or abnormal voice may occur for several days from the anesthesia tube. Numbness of the skin around the surgical incision is common, and should gradually subside within several days or weeks. Popping or clicking sounds may be heard, along with a feeling of fullness or liquid in the ear; these will resolve gradually as the healing process continues. A mild degree of dizziness may be present on head motion, and is not of concern unless it increases. Hearing may be temporarily worse after surgery because of swelling of the ear tissues and packing in the ear canal; improvement occurs over several months. Taste disturbance and mouth dryness may occur for a few weeks. When to Call Us Call our office if (1) discharge from the ear lasts longer than 7 days, or shows signs of infection (yellow color, foul odor, or high fever), (2) packing or material from inside the ear canal falls out (dont panic), (3) the skin around the sutures becomes swollen, red, or very tender (please note that some redness of the incision itself is normal), (4) the stitches break or the incision begins to open up, or (5) your child seems to be getting worse not better as the days go by. Your doctor will arrange a postoperative visit to check the healing process and remove sutures (if necessary). I have received a copy of this information sheet. Parent or Guardian )_______________________ Childs name ____________________________ Relation to child ________________ Date _________________________
Figure 357 Education sheet for middle-ear and mastoid surgery.
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What to Expect after Ear Tube Removal

Ear tube removal is combined with a paper-patch tympanoplasty to promote optimal healing of the eardrum. The suggestions below should help with a rapid recovery. Taking Care of the Ear The goal of ear care is to maintain a clean and dry environment that offers the maximal chance for complete healing of the eardrum. Do not allow water to enter the ear canal until the first office visit, generally about 6 weeks after surgery. Cover the ear canal opening with a piece of cotton mixed with Vaseline to prevent water entry during bathing or hair washing. Cotton alone is insufficient, because water may still penetrate between the fibers. A soft earplug, available in your local pharmacy, may be used if you find it more convenient. There is no need to cover the ear or to use an earplug during the remainder of the day when your child is not exposed to water. Swimming is not permitted unless specifically approved by your doctor. The Office Visit After Surgery Please schedule an office visit for about 6 weeks after surgery to check for complete healing of the eardrum to check that the small hole at the site of the previous tube is completely closed. The small paper-patch (about the size of a hole-punch) will be removed if it has not already fallen out. Water precautions are not required after the small opening in the eardrum has closed. Some Things Not to Worry About A clogged or stuffed-up sensation may be present initially because of ointment placed in the ear canal to promote healing. Drainage may occur for several days after surgery, as the ointment softens at body temperature (do not be alarmed if the discharge is mixed with a small amount of blood). Nausea or upset stomach may occur for up to 24 hours after the brief anesthesia, and require no special treatment. Pain is usually minimal and subsides rapidly, but acetaminophen (Tylenol) may be used as needed during the first few days if your child complains of any discomfort. Antibiotics are unnecessary. When to Call Us Please call our office if (1) drainage from the ear persists longer than 7 days after surgery, (2) pain or discomfort is unrelieved by Tylenol, or (3) pain or discomfort is accompanied by a fever or upper respiratory infection (a middle-ear infection may be developing). I have received a copy of this information sheet. Parent or Guardian _________________________ Childs name ______________________________ Relation to child ________________ Date _________________________
Figure 358 Education sheet for ear tube removal with paper-patch tympanoplasty.
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What to Expect after Laryngoscopy & Bronchoscopy

Your child has just undergone an in-depth evaluation of the air and breathing passages, and may also have had something removed from the vocal cords (most likely with a laser). Your doctor will discuss the findings and may also show you a photograph. After Surgery Your child will most likely be crying or upset in the recovery room, and their voice may be weak and hoarse. You may also notice a barking croup-like cough, and even some noisy breathing; this is all to be expected and will not injure the voice box or windpipe. Disorientation is common after general anesthesia, and causes 90% of the crying you may notice in the recovery room (the other 10% may be due to discomfort). After a brief recovery period, your child will most likely go to the pediatric floor for several hours. Overnight observation may be required for some children. A hoarse or weak voice may persist for several days, but should gradually improve. Coughing and noisy breathing will also improve gradually over time. Older children may complain of muscle aches for several days, because of certain medications given during the procedure. Any discomfort can be relieved by acetaminophen (Tylenol). Diet & Activity Infants and younger children may resume bottle feeding and soft foods soon after surgery. Older children should be given soft foods for the first 24 hours following surgery, and can then usually resume a normal diet. If a laser was used, however, your childs throat will most likely be sore for several days, and a soft diet should be continued until there is no further discomfort. Older children may return to school or daycare within one or two days after surgery. While normal activity can typically be resumed by the morning after surgery, some voice rest is helpful if a laser was used during the operation. Older children should be encouraged to avoid yelling or whispering; regular talking is fine. When to Call Us Call our office if (1) your child is having any breathing difficulty following surgery, (2) breathing is noisy and getting worsenot betteras the days go by (3) there are persistent swallowing troubles that interfere with your childs ability to maintain an adequate diet, (4) your child develops a progressive or persistent cough following surgery, or (5) fever is 102 degrees or higher despite acetaminophen (Tylenol). I have received a copy of this information sheet. Parent or Guardian ___________________ Childs name ________________________ Relation to child ______________________ Date _______________________________
Figure 359 Education sheet for laryngoscopy and bronchoscopy.
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What to Expect after Tongue-Tie Repair

Tongue-tie repair (frenuloplasty) is a safe and effective procedure that will provide you child with lasting benefits. The suggestions below should help with a rapid recover. Pain & Diet Pain is generally mild and should subside rapidly over a few days. Acetaminophen (Tylenol) may be used as often as necessary, but products that contain ibuprofen (eg, Motrin, Advil) should be avoided because they may promote bleeding or oozing. Although pain is typically minimal, most children will be protective of their tongue because it feels different. If your child is reluctant to eat after surgery, limit the diet to liquids or to solid foods that are bland and require minimal chewing (pudding, yogurt, macaroni, etc). Most children return to a normal feeding routine within a few days. After Leaving the Hospital Schedule an office visit for about 4 to 6 weeks after surgery to check for complete healing. By this time any stitches placed by your doctor should have absorbed (please note that stitches are not always used), but do not be alarmed if part of a stitch remains. If an antibiotic was prescribed, please be sure to finish all of the medication. Some Things Not to Worry About Temporary swelling or indentation of the tongue is common for a few days. Limited tongue motion may occur because of initial discomfort. Nausea or vomiting may occur for up to 24 hours after anesthesia. Fever up to 101 degrees may persist for up to several days after surgery. A small amount of bloody discharge from the tongue tip or under surface is common, particularly during the first 24 hours. When to Call Us Call our office is (1) there is persistent or excessive bleeding, (2) your child has inadequate food or beverage intake, (3) fever is 102 degrees or higher despite acetaminophen (Tylenol), (4) swelling of the tongue begins to worsen, (5) pus or discharge develops under the tongue, or (6) your child seems to be getting worse not better as the days go by. I have received a copy of this information sheet. Parent or Guardian ___________________ Childs name ________________________ Relation to child _______________________ Date ________________________________
Figure 3510 Education sheet for frenuloplasty.
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Using the Sheets The following sequence is recommended for distributing patient education sheets: 1. The parent or caregiver is given the general anesthesia sheet (see Figure 351) and the relevant procedure sheet (see Figures 352 through 35-10) during the office visit when surgery is scheduled. Any other teaching materials from the hospital or anesthesia department are also distributed. 2. Two copies of the relevant procedure sheet are placed in the patients medical chart on, or before, the day of surgery. 3. In the holding area prior to surgery, the surgeon gives the parent or caregiver one copy of the relevant procedure sheet and has them sign the other copy, which stays in the medical record. 4. Before entering the operating room, the surgeon tells the parent or caregiver to read the educational sheet carefully during surgery and to note any questions or concerns. 5. After surgery, the surgeon verifies that the parent or caregiver read and understood the educational sheet, and answers any additional questions they may have. Especially important issues (eg, adequate hydration after tonsillectomy) are verbally reinforced. 6. The parents are then brought immediately to visit their child in the recovery room. Unnecessary delays in reuniting them with their child will significantly heighten parent anxiety and concern. 7. Before entering the room, parents are cautioned that their child may be crying, disoriented, and thrashing about wildly. This emergence delirium may occur when anesthesia wears off quickly, and usually lasts about 30 minutes. Parents are encouraged to hold, reassure, and re-orient their child until the delirium resolves. Tympanostomy Tubes The importance of patient education in achieving optimal tympanostomy tube outcomes cannot be overemphasized.8 Well-intentioned friends, relatives, and other physicians are an abundant source of misinformation regarding tube care and sequelae. A comprehensive information sheet for parents will provide not only parent peace of mind, but will also limit the number of panicked telephone calls received by the office staff. With these goals in minds, the education sheet in Figure 3511 was developed. This sheet is used as follows: 1. At the first postoperative visit after tube insertion, the parent or caregiver is given the instruction sheet, and a signed copy is kept in the medical record to confirm receipt. 2. The physician reinforces the importance of reading the sheet and saving it for future reference. The parent is told that the sheet is their instruction manual for the childs tubes. 3. The physician may wish to highlight or underline especially pertinent aspects of tube care. Parents are more likely to read materials that have been personalized and discussed with them by the physician (not just the office staff ).
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How to Care for Your Childs Ear Tubes (Page 1 of 2)

Your Insurance Policy Ear tubes are your childs insurance policy against infections, middle-ear fluid, and the temporary hearing problems that accompany them. Consider this sheet a policy holders manual, which will allow your child to benefit most while the tubes are in place. Most tubes last for 6-18 months, allowing children time to outgrow their ear problems. Nearly all tubes fall out as debris accumulates between the eardrum and outer lip of the tube. The chance of a tube falling in, instead of out, is negligible. Tubes that fail to come out after 3 or more years may need to be removed by your doctor. The eardrum normally heals rapidly and completely after a tube is removed or falls out. Tubes and Water Precautions Earplugs, headbands, or other special efforts to prevent water from entering your childs ears are unnecessary fro about 95% of children. In theory, the small opening in the tube (about 1/20th of an inch) may permit water to enter the normally dry middle-ear, leading to bacterial infection and ear discharge. In practice, the pressure needed to force water through the tube is very high and not reached unless swimming deeply under water. Special efforts to prevent water from entering your childs ear are necessary only when: Water entry in the ear canal causes pain or discomfort Active discharge or drainage is observed coming out of the ear canal Frequent or prolonged episodes of ear discharge occur Other situations in which routine water precautions should be considered are when: Swimming more than 6 feet under water Swimming in lakes or non-chlorinated pools Dunking head in the bathtub (soapy water has a lower surface tension) A variety of soft, fitted earplugs and neoprene bands are available for water precautions, if needed. Never use Playdoh or Silly Putty as an earplug. Once the tube becomes blocked or comes out. Water precautions may be stopped if the eardrum is intact. Tube Follow-Up and Aftercare While the tubes are in place, you should see the ear doctor every 6 months. Regular follow-up is required to detect the following conditions, which may not be apparent: Blockage or obstruction of the tube opening with relapse of middle-ear fluid Hearing loss caused relapse of fluid if the tube is blocked Displacement or extrusion of the tube from the eardrum Irritation of the eardrum by the edge of the tube, producing a small pimple (granuloma) Please note that an absence of symptoms does not mean the tube is functioning properly; all children need follow-up regardless of how well they are doing. After your childs tubes fall out, you should return for a final re-check after 6-12 months.
Figure 3511 Education sheet for tympanostomy tube care. A, side one.
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How to Care for Your Childs Ear Tubes (Page 2 of 2)

Tubes & Ear Infections Although uncommon, your child may still get an ear infection with a functioning tube. If this occurs, you may notice discharge, drainage, or a bad smell from the ear canal. If your child gets an ear infection with visible drainage or discharge from the ear canal 1. Do not worry: there is no danger to hearing. Ear drainage can be clear, cloudy, or even bloody. The drainage indicates that the tube is working to eliminate infection. 2. Use a cotton ball to prevent discharge from building up and irritating the skin of the ear canal and outer ear. Clean any crusts with a Q-tip dipped in hydrogen peroxide. 3. Prevent water entry into the ear canal during bathing by using cotton saturated with Vaseline to cover the opening; do not allow swimming until the drainage stops. 4. Most discharge results from a cold or viral illness; antibiotics are unnecessary unless drainage lasts more than a few days, your child is very ill, or has another illness. 5. Persistent drainage is treated with antibiotic drops alone (Floxin or Ciloxan), placed in the ear canal twice daily for 3-5 days. Clean any discharge before placing the drops, and pump the skin in front of the canal after placing the drops so they enter properly. 6. An oral antibiotic is sometimes also necessary, but drops should usually be tried first. If your child gets an ear infection without visible drainage from the ear canal 1. Ask your primary doctor if the tube is open; if it is, the infection should resolve without a need for oral antibiotics or antibiotic eardrops. 2. If your doctor gives you an antibiotic or ear drop prescription anyway, ask if you can wait a few days before filling it; chances are you will not need the medication. Use acetaminophen (Tylenol) or ibuprofen (Advil) to relieve pain during the first few days. 3. If the tube is not open, the ear infection is treated as if the tube was not there; the blocked tube does not do any harm, but it also does not do any good. Tubes & Scarring of the Eardrum Rest assured that tubes do not cause significant scarring. Some children develop a white mark on the eardrum caused by calcium deposits (called sclerosis), which does not affect your childs hearing or future chance of ear infections. Some children develop a small depression or pocket in the eardrum at the tube site after it falls out. Again, this does not affect hearing and rarely requires active treatment. Less than 1 in 100 children develop a persistent hole or perforation of the eardrum (about 1/10 of an inch wide) after a tube falls out. Often the hole will close over time, but if it does not, it can be patched. All of the above problemssclerosis, pockets, and perforationsalso occur in ears without tubes; they usually relate more to your childs underlying ear disease than to the tube itself. When to Call Us Please call our office if (1) your childs regular doctor doesnt see the tube, (2) your child has hearing loss or continued ear infections (the tube maybe blocked), (3) drainage from the ears persists beyond 7 days, (4) drainage from the ears occurs frequently, (5) you see the tube lying in the ear canal (it does not harm), or (6) there is excessive wax build-up.
Figure 3511 Education sheet for tympanostomy tube care. B, side two.
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4. The section on Tube Follow-up and Aftercare is emphasized, since many parents are remiss with routine follow-up visits when there are no active symptoms. We purposefully avoid giving this sheet at the time of surgery to avoid information overload. Instead, the abbreviated version noted above is used (see Figure 352). SATISFACTION VS EFFICIENCY Most pediatric otolaryngology surgery is brief and may be performed rapidly in an ambulatory setting. Efficiency may come at the expense of patient satisfaction if surgeons are insensitive to the parental expectations. Parents consider satisfaction with the surgeon, nurses, and anesthetic staff as three separate quality dimensions.9 Satisfaction is based not only on technical factors, but also on the availability, engagement, and care provided by the surgeon. In this context, patient education sheets provide a tangible starting point for informed discussion, which should promote optimal outcomes yet maximize efficiency.
REFERENCES
1. 2. 3. 4. 5. 6. Lashley M, Talley W, Lands LC, Keyerslingk EW. Informed proxy consent: communication between pediatric surgeons and surrogates about surgery. Pediatrics 2000;105:5917. Holzman RS. Morbidity and mortality in pediatric anesthesia. Pediatr Clin North Amer 1994;41:23956. Laudan L. The book of risks: fascinating facts about the chances we take every day. New York: John Wiley & Sons, Inc; 1994. Laudan L. Danger ahead: the risks you really face on lifes highway. New York: John Wiley & Sons, Inc; 1997. Cotrell JE, Golden S. Under the mask: a guide to feeling secure and comfortable during anesthesia and surgery. New Brunswick (NJ): Rutgers University Press; 2001. Rosbe KW, Jones D, Jalisi S, Bray MA. Efficacy of postoperative follow-up telephone calls for patients who underwent adenotonsillectomy. Arch Otolaryngol Head Neck Surg 2000;126:71821. Lesperance MM, Schneider B, Garetz SL, et al. Substituting a telephone call for pediatric adenotonsillecotmy postoperative visits. Arch Otolaryngol Head Neck Surg 2001;127:2278. Rosenfeld RM, Isaacson GC. Tympanostomy tube care and consequences. In: Rosenfeld RM, Bluestone CD, editors. Evidence-based otitis media. Hamilton: BC Decker, Inc; 1999. p. 31536. Moen MC, Kvner KJ, Haugeto O, Mair IWS. Quality of care in pediatric daycare surgery: a cross-sectional study. Int J Pediatr Otorhinolaryngol 2000;52:1723.
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C H A P T E R 36
P EDIATRIC A NESTHESIA
Khosrow Mojdehi, MD
This chapter overviews a generalized approach to pediatric anesthesia; anesthetic considerations for specific surgical procedures are not discussed. The intent is to describe the basic concepts and principles that produce optimal outcomes for infants and children. The reader should refer elsewhere in the text for specific information concerning the nuances of anesthesia management for specific types of surgery.
PREOPERATIVE EVALUATION AND MANAGEMENT A complete history is mandatory, including unanticipated reactions to previous anesthetics in the patient or family. Pertinent facts are documented on the preoperative anesthesia note and the nursing assessment is reviewed for vital signs, height, weight, temperature, medications, and potential drug allergies. The child is examined for general health status, paying special attention to the respiratory system. If the child is febrile, surgery should be postponed to allow time for further investigation of the cause of the temperature elevation. Healthy children undergoing minor procedures do not require routine preoperative laboratory testing; however, testing on an individualized basis is advised for children with chronic disease, a complex medical history, or surgery with anticipated significant blood loss. GENERAL ANESTHESIA Fasting Guidelines The guidelines for preoperative fluid restriction may vary at different institutions. In general, children at low risk of pulmonary aspiration undergoing outpatient procedures may have up to 4 ounces of clear liquids (water, apple juice, soda, or jello) until 2 hours before surgery.
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Solid foods (including milk products and pulp juices) are allowed up to 4 hours before surgery for infants aged 0-6 months, up to 6 hours for children aged 6-36 months, and up to 8 hours for older children. Children with diabetes, renal disease, delayed gastric emptying, or other high risk factors are excluded from the above guidelines and must adhere to strict nothing by mouth (NPO) after midnight. Premedication The main goals for premedication in children are to decrease anxiety, ease separation from the parents, and to facilitate smooth induction. Midazolam is the most commonly used premedication, administered orally to about 80% of patients. It is an acceptable practice to administer midazolam in the holding area. Additional benefits of midazolam include antegrade amnesia and an antiemetic effect, which contribute to a pleasant anesthetic experience. Anesthetic Induction Inhalation induction remains the most commonly used technique in children, providing an opportunity to start the intravenous line and apply noninvasive and invasive monitors after the child is asleep. In some instances, children with an unpleasant prior experience with mask induction may prefer intravenous induction. Anesthesia can commence with the pulse oximeter, with other monitors placed after the induction. Intramuscular induction using ketamine is preferred for extremely uncooperative and combative mentally challenged patients. Rectal induction may be suitable for younger children. Extubation and Recovery Criteria for extubation include, but are not limited to, the signs of awakening, rhythmic regular respiration, and recovery from neuromuscular blockade. Most children are extubated when fully awake. Early extubation during a plane of light anesthesia can be risky and life threatening. In some situations (eg, following middle ear surgery), deep extubation is preferred to prevent a reaction to the endotracheal tube. After terminating anesthesia, the patient should be able to maintain their airway and return to baseline mental status. Postanesthesia Care Unit (PACU) All children are monitored in the PACU immediately following surgery. Emergence delirium is common in children, and may manifest with crying, disorientation, or wild thrashing for up to 30 minutes after arriving in the PACU. Anesthesia- or surgery-related complications that can arise in the immediate postoperative period include pain, bleeding, and residual anesthetic effects of narcotics, inhalation agents, and drugs used for neuromuscular blockade.
Pediatric Anesthesia
825
Discharge from the PACU is based on assessment of mental status and cardiorespiratory stability, but ultimately depends on sound clinical judgment. Some recovery care units may use different scoring systems to assess discharge readiness. Nausea, vomiting, and surgical complications are the most frequent reasons for unanticipated hospital admission. CHALLENGES IN PEDIATRIC ANESTHESIA Airway Management Optimal airway management remains the most important factor in reducing anesthesia-related morbidity and mortality in infants and children. An in-depth knowledge of pediatric airway anatomy and physiology is essential. The skill of the anesthesiologist is also an extremely important outcome determinant. Most institutions have a chart and scale for evaluating and predicting difficult intubation, with an algorithm that explains step-by-step the management of a difficult airway. In general, when a difficult airway is anticipated, premedication is avoided and inhalation induction is performed while maintaining spontaneous respiration. Upper Respiratory Infection Upper respiratory infection (URI) is common in young children and may contribute to anesthesia morbidity. Although there are no recent studies indicating serious risk, the course of anesthesia can be complicated by coughing, laryngospasm, bronchospasm, and postoperative croup or atelectasis if a URI is present. If there are no signs of severe viremia, bacteremia, or lower respiratory tract infection, children can undergo elective procedures that do not require endotracheal intubation without a significant increase in adverse anesthetic outcomes. Conversely, endotracheal intubation should not be performed when a URI is present. Laryngospasm Laryngospasm is a challenging problem during pediatric anesthesia. The resulting complete or incomplete airway obstruction and can have deleterious complications including hypoxia, aspiration, bronchospasm, arrhythmia, pulmonary edema, and ultimately, cardiac arrest. Laryngospasm occurs three times more often in infants aged 1-3 months compared with older infants and children. A URI will also predispose to laryngospasm. Most laryngospasm is managed successfully with jaw thrust, chin lift, and positive pressure ventilation with 100% oxygen. The spasm will convert first to laryngeal stridor and then to an unobstructed airway. If complete airway obstruction persists, atropine 0.02 mg/kg followed by succinylcholine 0.5-1.0 mg/kg can be administered intravenously. When no intravenous access is available, administration of succinylcholine 3 mg/kg in the deltoid muscle can break laryngospasm.
826
Cardiac Arrest in Infants The incidence of anesthetic-related cardiac arrest in the first year of life is three times greater than the rate for all other ages. Overdose of inhalation anesthetics (high concentration) is most often the immediate cause of cardiac arrest. Keenan and coworkers reviewed over 4,300 cases of infant anesthesia and found that the risk of anesthetic-related cardiac arrest was significantly higher for nonpediatric anesthesiologists. The risk of cardiac arrest was significantly reduced when a pediatric anesthesiologist (pediatric fellowship training or the equivalent) supervised the case. Postoperative Nausea and Vomiting Unpleasant postoperative nausea and vomiting (PONV) is most common in children aged 5-10 years. The incidence is highest for otologic surgery and other procedures associated with pharyngeal bleeding (oral surgery, tonsillectomy) and accumulation of blood in the stomach. Routine suctioning of the stomach at the end of surgical procedures associated with potential blood in the stomach will significantly decrease the incidence of PONV. Midazolam (as a premedication) and dexamethasone (given intravenously during tonsillectomy) also have antiemetic effects. Droperidol 10-25 g/kg IV or metoclopramide 0.10-0.15 mg/kg IV can decrease the incidence and severity of PONV. Children aged 2-12 years weighing 40 kg or less can receive slow intravenous ondansetron 0.1 mg/kg. Children weighing more than 40 kg can receive ondansetron 4 mg IV immediately after induction of anesthesia, or postoperatively if the patient complains of nausea and vomiting. Apnea of Prematurity Preterm infants may suffer from underlying cardiac, pulmonary, or neurologic disease, and are therefore at risk for complications relating to any or all of these problems. Preterm infants have a higher incidence of apnea and bradycardia; anesthesia can further compromise their cardiac and respiratory function and place them at risk for 12-24 hours postoperatively. There is no universal protocol for general anesthesia, but discharging infants 44-60 weeks of postconceptual age is considered safe. Younger infants must be admitted overnight under close nursing observation, including an apnea monitor and pulse oximeter. When to Extubate Small infants and children can be extubated after recovery from inhalation anesthetics, narcotics, and neuromuscular blockade. If muscle relaxant was used, recovery from the neuromuscular blockade can be monitored using a peripheral nerve stimulator. Muscle relaxants can be reversed with intravenous glycopyrrolate (0.01 mg/kg) or atropine (0.02-0.03 mg/kg) followed by neostigmine (0.05-0.07 mg/kg).
Pediatric Anesthesia
827
A child is clinically ready for extubation if they can 1. maintain rhythmic and regular respiration, 2. sustain leg and knee flexion, 3. open their eyes (not necessarily to command), 4. cough forcefully, and 5. move their extremities purposefully. Children suspected of having a full stomach must be extubated fully awake with intact protective laryngeal reflexes. ANESTHESIA AND SEDATION OUTSIDE THE OPERATING ROOM Administering anesthesia and sedation in a location other than the operating room can be extremely challenging, requiring careful and extensive preparation. Sedation in the Pediatric Intensive Care Unit (ICU) Inhalation anesthetics offer rapid onset, controlled depth and level of sedation, and rapid emergence. Benzodiazepines (diazepam, midazolam, lorazepam) are the most frequently used agents for sedation in the pediatric ICU. Midazolam has a short half-life and is administered by continuous infusion in a dose ranging from 0.05 to 0.20 mg/kg/hr after an initial dose of 0.1 mg/kg. Ketamine may be a drug of choice for patients with a compromised respiratory and cardiovascular system. It can be administered by continuous infusion for sedation, with a bolus dose of 1 to 2 mg/kg followed by infusion of 1.0 mg/kg/hr. Propofol has a rapid induction and short recovery time, which makes it a frequently used drug for invasive procedures in hospitalized, ambulatory, and pediatric ICU patients. Propofol can be administered by intravenous bolus of 0.5-3.0 mg/kg or by intravenous infusion at 25-300 g/kg/min. Adverse effects include severe cardiovascular depression and pain at the injection site. Adding lidocaine to the propofol syringe can decrease or attenuate the pain. Management of Postoperative Pain A sound and appropriate anesthetic plan should effectively prevent and control postoperative pain. A variety of techniques are currently available. Narcotics may be administered IM, IV, transmucosally, transdermally, or orally. Intranasal sufentanil 1.5 g/kg, administered 10 to 15 minutes before terminating inhalation anesthesia, can provide good pain relief. Transdermal fentanyl provides a steady-state plasma concentration. Nonsteroidal anti-inflammatory drugs and acetaminophen are popular alternatives to narcotics for pain control. Local wound infiltration is a very effective and simple way to reduce or attenuate the need for additional postoperative pain medication. At the end of surgery, local wound infiltration can be accomplished by using 0.25% bupivacaine.
828
Regional blocks can be used as an isolated technique or in conjunction with general anesthesia, depending on inherent risks and benefits. Blocks provide effective pain control after hernia repair or circumcision, but are rarely applicable to most head and neck surgery. Pain management after major abdominal, thoracic, and orthopedic surgery can be accomplished with epidural anesthesia. Patient-controlled analgesia (PCA) is applicable to children as young as age 5-6 years. The amount of delivered narcotic and the time interval of delivery are preselected and can be administered with or without a low basal infusion. PCA is usually started in the PACU to prevent a decrease in the serum concentration of opioid.
BIBLIOGRAPHY
Deshpande JK, Tobias JD. The pediatric pain handbook. New York: Mosby; 1996. Gregory GA. Pediatric anesthesia. New York: Churchill Livingstone; 1994. Keenan RL, Shapiro JH, Dawson K. Frequency of anesthetic cardiac arrest in infants: effect of pediatric anesthesiologists. J Clin Anesth 1991;3:4337. Miller RD. Anesthesia. New York: Churchill Livingstone; 2000. Miller RD. Atlas of Anesthesia. Vol 7, Pediatric anesthesia (CD-ROM). Linguistic Software Product, 1996. Motoyama EK, Davis PJ. Smiths anesthesia for infants and children. St. Louis: Mosby; 1996.
I NDEX
In this index, page numbers in italics designate figures; page numbers followed by the letter t designate tables. See also cross-references designate related topics or more detailed subtopic listings.
Abb flap, 680, 681 Abscess deep neck, 465489. See also under Infections septal, drainage of, 339340, 340 Acquired cholesteatoma, 109116. See also under Cholesteatoma Acquired perilymphatic fistula, 123136. See also Perilymphatic fistula Acute coalescent mastoiditis, 9192, 94 Acute mastoid osteitis, 92, 94 Adenoidectomy, 379387. See also Tonsillectomy anesthetic considerations, 380 complications, 386387 indications, 381 parent/caregiver information, 811 partial superior, 382 postoperative care, 386 preoperative evaluation, 379380 preparation, 380381 primary, 382 procedure, 382, 382387, 383 procedures curette adenoidectomy, 384, 385 microdebrider (shaver) adenoidectomy, 384386, 385, 387 secondary (revision), 382 suction coagulator (liquefaction) adenoidectomy, 384 selection, 382
velopharyngeal examination, 381. See also Velopharyngeal insufficiency Adenopathy, cervical, 441463. See also Cervical adenopathy Adhesives, tissue, 676 Advancement flap ossiculoplasty, 7880, 7880 Air cells, plugging of, 216, 216 Air embolism, in craniofacial procedures, 806 Airway management, perioperative, 825 Airway obstruction after tonsillectomy, 396 after uvulopalatopharyngoplasty (UPPP), 405 Airway physiology, 555 Airway procedures. See also Endoscopy; Tracheostomy; Tracheotomy endoscopy, 555583 tracheotomy, 585596 Alfentanil, 557 Alopecia, postoperative, in craniofacial procedures, 805 Analgesia patient-controlled, 828 postoperative, 827828 Anatomy facial nerve, 137139, 138 fascial layers of neck, 465466, 467 Anesthesia, pediatric, 823828 challenges in, 825827 general, 823825 in pediatric ICU, 827
830
Index
postoperative pain management, 827828 preoperative evaluation and management, 823 Anesthetic considerations. See also Anesthesia; Anesthetics in adenoidectomy/tonsillectomy, 380 in cervical biopsy procedures, 442, 448, 455 in choanal atresia repair, 306 in cleft lip/cleft palate repair, 764, 780 in congenital neck malformations, 491, 496, 499, 504, 508, 512 in craniosynostosis correction, 793 in drooling correction, 427, 433434, 438 in ear canal reconstruction, 187, 189 in endaural approach, 27, 27 in endoscopic ethmoidectomy/antrostomy, 320321 in endoscopy, 556558, 563, 569570, 578 in facial nerve procedures, 140, 152, 157 in facial soft tissue surgery, 673674 in inflammatory sinonasal disease, 339, 341, 342, 344, 346, 348, 350 in laryngotracheal surgery, 598, 602, 604, 606, 608, 612, 616, 620, 624, 626 in laser surgery, 636639, 642, 644, 646, 648, 650, 652, 654, 658, 660, 663, 665 in myringoplasty, 41, 42, 43 in neck drainage procedures, 468, 472, 475, 477, 478, 482, 483, 486,488 in parotidectomy, 515516 in postauricular approach, 32, 32 in posterosuperior quadrant acquired cholesteatoma, 112 in rhinoplasty, 282 in septoplasty, 265, 268269 in thyroid surgery, 540 in tongue surgery, 367, 369, 372, 376 in tracheotomy, 585 in transcanal approach, 22, 22 in tympanostomy tube insertion, 7 in tympanostomy tube removal, 17 Anesthetics adjunctives to, 557558 inhaled, 556557 local, 673674 neuromuscular relaxants/blockade, 558 topical, 557, 673 sodium bicarbonate with, 674 Ankyloglossia, 376, 377 Anterior pedicle flap, 64, 64 Anterior vestibular sulcus incision, 744, 745 Anterosuperior middle-ear congenital cholesteatoma, 106, 106108, 107, 108
Anticholinergics, as anesthesia adjuncts, 557558 Antral aspiration and lavage, 341, 341342 Antrostomy, endoscopic. See Endoscopic ethmoidectomy/antrostomy Apnea obstructive sleep apnea syndrome. See Adenoidectomy; Tonsillectomy; Uvulopalatopharyngoplasty (UPPP) of prematurity, 826 Aspiration fine-needle, cervical, 442447, 443, 444, 445, 447 myringotomy, 45 needle of middle ear, 13. See also Tympanocentesis; Tympanostomy tube Aspiration and lavage, antral, 341, 341342 Atelectasis of middle ear, tympanostomy tube insertion and, 6 of pars tensa, 58 Atlantoaxial subluxation (Grisels syndrome), as complication of adenoidectomy/tonsillectomy, 386, 396 Atresia, congenital aural, 211219. See also Congenital aural atresia Atropine, 558 Attic cholesteatoma, 117121. See also Pars flaccida attic cholesteatoma Attic retraction pocket, surgical approach, 2627 Augmentation laryngoplasty with cartilage graft, 616618, 617, 619 with cartilage stent, 620, 620622, 621, 623 Auricular repair, 682685 avulsions, 684, 685 composite defects, 684 cutaneous defects, 682683 helical rim defects, 683, 683684 hematoma, 682 lacerations, 682 for microtia, 701715 anesthetic considerations, 702 general considerations, 701 indications and timing, 702 preparation, 702, 702704, 703, 704 procedure overview, 704 stage 1: rib harvest, 705, 705710, 706, 707, 708, 709 stage 2: lobule transposition, 710, 711 stage 3: separation from head and creation of functional postauricular sulcus, 712, 713 stage 4: optional creation of tragus or contralateral otoplasty, 714, 715 otoplasty for prominent (lop) ear, 717726
Index
831
anatomical considerations, 717, 718 anesthetic consideration, 719 complications and long-term outcomes, 724 indications, 717719 postoperative care, 724 preparation, 719 procedure, 720, 720724, 721, 723, 725 Avulsions auricular, 684, 685 lip, 680 nasal, 687 parotid duct, 694 Benzodiazepines, 827 Bicoronal deformity craniosynostosis, 796, 797 Biopsy cervical incisional, 448451, 449, 451 percutaneous needle, 442447, 443, 444, 445, 447 thyroid, 540 Bivona tracheostomy tubes, 587 Bleeding, post-tonsillectomy, 380, 395, 397401. See also Carotid artery ligation Bone flaps, devitalization of, 804 Bone grafts/grafting, maxillofacial, 758760, 759 Brachycephaly, 796, 797 Branchial cleft fistula, first, 499500, 501 Branchial cleft fistula, second and third, 504506, 505, 506 Branchial pouch sinus, fourth, 507, 507510, 509, 511 Broken line closures, 698, 699 Bronchoscopy, 569577 anesthetic considerations, 569570 indications, 569 instrumentation, 570, 571, 572 parent/caregiver information, 817 postoperative care, 577 procedures, 572577 diagnostic bronchoscopy, 574, 575 foreign body removal, 576 introducing bronchoscope, 572, 573, 574 therapeutic bronchoscopy, 577 Brunk incision, 307, 307 Buckingham mirror, 70, 70 Bupivacaine, 673674 Burrows triangle, 676,677 Caldwell-Luc procedure, 342344, 343 Canalicular anatomy, 691, 691 Canalicular repair, 692, 692
Canine fossa incision, 738, 739 Canthal anatomy, 691 Canthal tendon injury, 690, 691 Carbon dioxide (CO2) laser, 633639634 Cardiac arrest, anesthesia and, 826 Carotid artery injury, in tonsillectomy, 393, 396 Carotid artery ligation, in post-tonsillectomy hemorrhage, 397, 397401, 398, 399, 400, 401 Carotid space, drainage, 487, 487488 Cartilage graft, in augmentation laryngoplasty, 616618, 617, 619 Cartilage graft tympanoplasty, 6672 Cartilage-perichondrial graft, 71, 71 Cartilaginous framework injuries, nasal, 686687 Caustic ingestion, 580582, 583 Cautery. See Electrocautery Cerebrospinal fluid leakage, postoperative, in craniofacial procedures, 805 Cervical adenopathy, 441463 functional (modified) neck dissection, 452, 452462, 453, 454, 455, 459, 461 incisional biopsy, 448451, 449, 451 percutaneous needle biopsy, 442447, 443, 444, 445, 447 preliminary considerations, 441442 Cervical fascia, 465466, 467 CHARGE association, 299 Choanal atresia defined, 299 transnasal repair, 300306, 301, 302, 303.304, 305 transpalatal repair, 306312, 307, 308, 309, 310, 311 Cholesteatoma, 52, 98, 100121. See also Mastoidectomy acquired, 109116 posterosuperior quadrant, 111116 anesthetic considerations, 112 extending into epitympanum, 114, 114 extending into mastoid gas cells, 115, 115 extensive, 116, 116 indications, 111, 111 in posterior mesotympanum, facial recess, and sinus tympani, 112, 112, 113 postoperative care, 116 selection of procedure, 109110 staging, 110 surgical planning, 110111 canal wallup vs. canal walldown mastoidectomy, 101102 classification, 100101 congenital, 103108
832
Index
anterosuperior middle ear, 106, 106108, 107, 108 intratympanic membrane, 104, 104, 105 postoperative care, 108 facial nerve complications, 140 follow-up visits, 103 otologic telescope in, 102 pars flaccida attic, 117121 anesthetic considerations, 118 confined to anterior epitympanum, 118, 118, 119 extending into mastoid, 120, 120 extensive, 121, 121 indications, 117, 117 surgery in children vs. adults, 101 surgical approach, 21, 22, 27 timing of ossiculoplasty, 102103 Chronic suppurative otitis media, 140 Chronic suppurative otitis media, 92, 94, 96 Cleft lip/cleft palate, 763790 cleft lip repair, 764774 anesthetic considerations, 764 bilateral, 770774 indications, 770 procedure, 770773, 771, 772, 773, 774 complications, 765 postoperative care, 764765 unilateral, 765769 indications, 765 procedure, 766, 766768, 767, 769 cleft palate repair, 780790 anesthetic considerations and preparation, 780 complications, 780 palatoplasty double reversing Z-plasty (Furlow), 788790, 789 selection, 780781 two-flap, 785, 785786, 786, 787 V to Y pushback, 782, 782784, 783, 784 postoperative care, 781 timing, 780 general considerations, 763 lip adhesion, 775780 bilateral indications, 778 procedure, 778, 779 unilateral complications, 776 indications, 775 procedure, 775776, 777 Congenital nasal malformations, 299317 Coagulation tests, before adenoidectomy/tonsillectomy, 379380 Cochlear implantation, 221249
anesthetic considerations, 222 complications, 247t, 247248 indications, 222 preparation, 222 principles and devices, 221222 procedure, 223246 positioning implant, 223, 224 planning the flap, 223, 225 incisions, 223227, 225, 227 creating the well, 228, 229 tie-down holes, 230, 230232, 231 mastoidectomy, 232, 233 facial recess, 233, 234 cochleostomy, 234236, 235, 237, 239 device placement and electrode insertion, 238242, 240, 241, 242 securing implant, 242, 242244, 243, 244 closure, 244246, 245, 246 postoperative care, 247 Cochleostomy, 234236, 235, 237, 239 Complete (cortical, simple) mastoidectomy, 9195, 93, 95 Compound muscle action potential (CMAP), 182 Conchal-cartilage graft, 71, 71 Congenital aural atresia, 211219 contraindications, 212 indications, 211212 postoperative care, 218 preoperative evaluation, 211 procedure, 212219, 213, 214, 215, 216, 217, 218, 219 Congenital cholesteatoma, 103108. See also under Cholesteatoma Congenital malformations, 299317. See also under specific lesions nasal, 299317. See also under Nasal surgery and specific lesions of neck, 491514 cystic hygroma (lymphangioma), 496498 fibromatosis colli, 512, 513 first branchial cleft fistula, 498500, 501 fourth branchial pouch sinus, 507, 507510, 509, 511 pre-auricular pit or fistula, 502, 503 second and third branchial cleft fistula, 504506, 505, 506 thyroglossal duct cyst, 482, 491494, 493, 495 Congenital perilymphatic fistula, 123136. See also Perilymphatic fistula Coronal incision, 732734, 733. See also Craniosynostosis
Index
833
Cortical (simple, complete) mastoidectomy, 9195, 93, 95 Cranial nerve examination, 672 Craniofacial growth, 727728, 729 Craniofacial surgery. See Craniosynostosis Craniosynostosis, 791806 classification and etiology, 791792 primary, 791 secondary, 792 surgical correction, 792806 anesthetic considerations, 793 bicoronal deformity, 796, 797 complications, 804806 indications, 792793 lambdoidal deformity, 802, 802803, 803 metopic deformity, 798, 798, 799, 799 preparation, 793 sagittal deformity, 800, 801 unilateral coronal deformity, 794, 795 Cricoid split (laryngeal decompression) with hyoid interposition, 612614, 613, 615 Cricotracheal resection, 626630, 627, 629, 631 Curette adenoidectomy, 384, 385 Cutaneous defects auricular, 682683 nasal, 686 Cystic fibrosis, endoscopic sinus surgery in, 334, 334337, 335, 336 Cystic hygroma (lymphangioma), 496498 Cystic lesions epiglottic, 642, 643 intracordal, 648, 649 ranula, 532538 thyroglossal duct cysts, 482, 491494, 493, 495 of tongue, 367378. See also Tongue vallecular, 644, 645 ventricular, 646, 647 Dacryocystorhinostomy, 348350, 349, 351 endoscopic, 350, 351 external (open), 348, 349 Danger space of neck, drainage, 488489 Debridement, 673 Decompression, laryngeal (cricoid split) with hyoid interposition, 612614, 613, 615 Dehiscence, of soft tissue wounds, 678 Dehydration, post-tonsillectomy, 395 Dental examination, in facial trauma, 672 Dental injury in adenoidectomy, 386 in tonsillectomy, 396
Dermabrasion, in scar repair, 699 Dermoids, nasal, 300 Desflurane, 556 Devitalization of bone flaps, 804 Dexamethasone, in postoperative nausea and vomiting, 826 Direct transnasal sphenoidotomy, 358363, 359, 361, 363 Discontinuity, ossicular, 75, 77t Dorsal augmentation graft, nasal, 289, 289, 290 Double reversing Z-plasty (Furlow) palatoplasty, 788790, 789 Down syndrome, 9 preoperative evaluation in, 380 Drainage of deep neck infections, 465489. See also under Infections septal abscess or hematoma, 339340, 340 Drooling, 427440 parotid duct ligation, 436437, 437 selection of procedure, 428t submandibular duct ligation, 438440, 439 submandibular duct relocation, 433435, 435 with sublingual gland excision, 427432, 429, 430, 431, 433 tympanic neurectomy, 438 Droperidol, in postoperative nausea and vomiting, 826 Duct(s) parotid ligation, 428t, 436437, 437 repair, 694 trauma to, 672 submandibular. See also under Drooling ligation, 438440, 439 relocation, 427433, 428t, 448440 Ear canal, 185219 congenital aural atresia repair, 211219 contraindications, 212 indications, 211212 postoperative care, 218 preoperative evaluation, 211 procedure, 212219, 213, 214, 215, 216, 217, 218, 219 principles of surgery, 185186 reconstruction of external, 186206 anatomic considerations, 186187, 187 anesthetic considerations, 187188 indications, 186 procedure canal walldown procedure, 204, 204205, 205
834
Index
canal wallup procedure, 206 elimination of obstructions, 200203, 201, 202, 203 endaural approach, 188, 188, 189t, 189193, 190, 191, 192, 193 postauricular approach, 188, 189, 189t, 194, 194200, 195, 196, 197, 198, 199, 200 selection, 188, 188, 189t skin grafting of external auditory canal, 207210 indications, 207 postoperative care, 210 preparation, 207 procedure, 207, 207210, 208, 209, 210 Ear surgery. See Auricular repair; Otoplasty Education, of parents and caregivers, 807822. See also Parent/caregiver information Effusion, chronic middle-ear, 6, 7 Electrocautery in epistaxis endoscopic-guided, 254, 254 local, 253 in tonsillectomy, 389, 390, 390393, 391, 392, 393 versus laser dissection, 388 Electromyography (EMG), 183 Electroneurography, 182 Electrophysiologic testing, facial nerve, 182183 Embolism, air, in craniofacial procedures, 806 EMLA Cream, 673 Endaural approach anesthetic considerations, 27, 27 in external ear canal reconstruction, 188, 188, 189t, 189193, 190, 191, 192, 193 indications, 26 postsurgical care, 31 preparation, 27 procedure, 2731, 28, 29, 30, 31 Endaural medial fascia graft tympanoplasty, 5257, 5357. See also Endaural approach Endonasal approach to rhinoplasty, 281t, 282291, 283, 285, 287, 288291 to septoplasty, 264-267 Endoscopic arytenoidectomy, 598, 599 Endoscopic dacryocystorhinostomy, 350, 351 Endoscopic ethmoidectomy/antrostomy, 319338 anatomic considerations, 322323, 323 anesthetic considerations, 320321 complications, 332, 333 in cystic fibrosis, 334, 334337, 335, 336 indications, 319320 instrumentation, 321
parent/caregiver information, 813 postoperative care, 330 preoperative evaluation, 320 preparation, 322, 322 procedure, 322330, 325, 326, 327, 328, 329, 330 Endoscopic-guided cautery, in epistaxis, 254, 254 Endoscopic sinus surgery, parent/caregiver information, 813 Endoscopy bronchoscopy, 569577 anesthetic considerations, 569570 indications, 569 instrumentation, 570, 571, 572 postoperative care, 577 procedure, 572577 diagnostic bronchoscopy, 574, 575 foreign body removal, 576 introducing bronchoscope, 572, 573, 574 therapeutic bronchoscopy, 577 esophagoscopy, 578582 anesthetic considerations, 578 indications, 578 instrumentation, 578, 579 procedure caustic ingestion, 580582, 583 foreign body removal, 579580, 581 introducing bronchoscope, 578, 579 laryngoscopy, 564569 anesthetic considerations, 563 indications, 563 instrumentation, 563, 563564 procedure, 564569 diagnostic laryngoscopy, 566 introducing laryngoscope, 564, 564566, 565, 566 laser laryngoscopy, 568569 therapeutic laryngoscopy, 567, 567 pharyngoscopy, 562, 562 photographic documentation, 559, 559561 physiological considerations, 555 principles of endoscopic surgery, 556558. See also Anesthetics Endotracheal tube fire, in laser procedures, 635 Epiglottic cysts, 642, 643 Epistaxis, 251257 anatomical classification, 251252, 252 arterial ligation, 257 endoscopic-guided cautery, 254, 254 local cautery, 253 packing anterior, 253254
Index
835
posterior, 255, 255256, 256 Esophagoscopy, 578582 anesthetic considerations, 578 indications, 578 instrumentation, 578, 579 procedure caustic ingestion, 580582, 583 foreign body removal, 579580, 581 introducing bronchoscope, 578, 579 Estlander flap, 680, 681 Ethmoidectomy endoscopic. See Endoscopic ethmoidectomy/ antrostomy external, 344345, 345 Eustachian tube closure, surgical approach, 27 Eustachian tube dysfunction, 129135. See also Perilymphatic fistula classification, 129 fistulous tube: catheter obstruction, 132135, 133, 134 obliteration, 129131, 131 tympanostomy tube insertion and, 6 Eustachian tube injury, as complication of adenoidectomy, 386 Exploration, wound, 673 External approach to rhinoplasty, 291298, 292, 293, 294, 295, 296, 297 to septoplasty, 268280 anesthetic considerations, 268269 indications/contraindications, 268, 269 procedure, 270, 270280, 271, 272, 273, 275, 276, 277, 278, 279 External carotid artery ligation, 397401. See also Carotid artery ligation External ethmoidectomy, 344345, 345 Extratemporal segment, of facial nerve, 138, 139 Extubation, 826827 Eyebrow injuries, 692, 693 Eyelid injuries, 688690 Facial nerve anastomosis, 525 Facial nerve surgery, 138184 anatomy, 137139, 138 electrophysiologic testing, 182183 extratemporal exploration and repair: lesions, 157170 anesthetic considerations, 157 indications, 157 postoperative care, 170 preparation, 158, 158159
procedure, 159170159 identification of nerve, 164, 164166, 167 incision and exposure, 160, 160163, 161, 162, 164 superficial and deep parotidectomy, 166170, 167, 168, 169 extratemporal exploration and repair: trauma, 171183 indications, 171 postoperative care, 174 preparation, 171 procedure, 171, 171175, 172, 173, 175 extratemporal repair, rerouting, and grafting, 176182 indications, 176 postoperative care, 181 preparation, 177 procedure, 177182 great articular nerve graft, 177 hypoglossalfacial anastomosis, 180, 181 interposition grafting, 179180, 181 sural nerve graft, 177178, 178, 179 intratemporal exploration and decompression, 139150 anesthetic considerations, 140 indications, 140 preparation, 141, 141142 procedure, 142148, 143 exploration, 148, 149 mastoidectomy, 144, 144146, 145 nerve identification, 146148, 147 postoperative care, 148149 intratemporal repair, rerouting, and grafting, 150156, 694695 anesthetic considerations, 152 indications, 151152 postoperative care, 156 principles of repair, 150151 procedure, 152156, 153 exploration, 148, 149, 153 interposition grafting, 154156, 155, 156 mastoidectomy, 144, 145, 152 rerouting, 154, 155 Facial paralysis, 139149. See also Facial nerve procedures Facial recess, 233, 234 Facial trauma, 671700. See also Soft tissue surgery Fat-plug graft myringoplasty, 4148. See also under Myringoplasty Fentanyl, 557 Fibromatosis colli, 512, 513
836
Index
Fine-needle aspiration cervical, 442447, 443, 444, 445, 447 thyroid, 540 Fire, endotracheal tube, in laser procedures, 635 Fistula branchial cleft first, 498500, 501 second and third, 504506, 505, 506 perilymphatic, 123136. See also Perilymphatic fistula pre-auricular, 502, 503 tracheocutaneous, 593, 593594, 594, 595 Fistulous eustachian tube, catheter obstruction in, 132135, 133, 134 Fixation complications, 748749, 752753 maxillomandibular, 746751, 747, 748, 749 ossicular, 75, 77t rigid internal, 750, 750753, 751, 753t Flap(s). See also Palatoplasty Abbe, 680, 681 anterior pedicle, 64, 64 bone, devitalization of, 804 in ear canal reconstruction, 193, 193 Estlander, 680, 681 Koerner, 3538, 60, 6061, 61, 68, 69 mucoperiosteal, 308, 308, 309, 310 pharyngeal rolled, 415416, 416 superiorly based, 408414, 409, 410, 413, 414 tympanomeatal, 2931, 55, 55, 56 Foreign body removal bronchoscopic, 576 esophagoscopic, 579580, 581 Four Es mnemonic, 635 Fracture, nasal. See also Rhinoplasty closed reduction, 260, 260263, 261, 263 Frenuloplasty, 376, 377. See also Tongue surgery parent/caregiver information, 818 Frontal sinus trephination, 346, 347 Functional (modified) neck dissection, 452, 452462, 453, 454, 455, 459, 461 Furlow (double reversing Z-plasty) palatoplasty, 788790, 789 Gland(s) salivary, 515538. See also Salivary gland procedures sublingual, excision, 427, 431, 432. See also Drooling submandibular, excision, 526531, 527, 528, 529530, 531 Glasscock dressing, 31
Glioma, nasal, 300. See also Congenital nasal malformations Glottic hemangioma, 663664, 664 Glottic stenosis, posterior, 606, 607 Glottic web excision, 604605, 605 Glycopyrrolate, 558 Grafts/grafting bone, maxillofacial, 758760, 759 cartilage, in augmentation laryngoplasty, 616618, 617, 619 cartilage-perichondrial, 71, 71 conchal-cartilage, 71, 71 dorsal augmentation, 290, 290, 291 external auditory canal, 207, 207210, 208, 209, 210 facial nerve, 176182 indications, 176 postoperative care, 181 preparation, 177 procedure, 177182 great articular nerve graft, 177 hypoglossalfacial anastomosis, 180, 181 interposition grafting, 179180, 181 sural nerve graft, 177178, 178, 179 great articular nerve, 177 hyoid interposition, 614, 615 interposition, of facial nerve, 179180, 181 myringoplasty fat-plug graft, 45, 45, 46 perichondrial graft, 44, 44 in septoplasty, 276, 276280, 277, 278, 279 sural nerve, 177178, 178, 179 temporalis fascia, 54, 54 tissue selection for, 42 tympanoplasty cartilage graft, 6672 endaural medial fascia graft, 5257, 5357. See also Endaural approach fat-plug graft, 2226, 49 lateral fascia graft, 5865, 5866 postauricular medial cartilage-fascia, 6772, 6871 postauricular medial fascia graft, 4951, 50, 51 transcanal medial fascia or fat-plug graft, 2226, 49. See also Transcanal approach Granulomas, vocal process, 650, 651 Great articular nerve graft, 177 Grisels syndrome (atlantoaxial subluxation), as complication of adenoidectomy/tonsillectomy, 386, 396 Grommet-type tympanostomy tube insertion, 611, 7, 8, 9
Index
837
Halothane, 556 Halving technique, in wound closure, 676, 677 Head and neck surgery, parent/caregiver information, 814 Head trauma, 140. See also Facial nerve procedures; Maxillofacial surgery Helical rim defects, auricular, 683, 683684 Heliox administration, 558 Hemangioma glottic, 663664, 664 laryngeal, 663664, 664 Hematoma auricular, 682 septal, drainage, 339340, 340 Hemorrhage postoperative, in craniofacial procedures, 804 post-tonsillectomy, 380, 395, 397401. See also Carotid artery ligation Hopkins rod-lens telescope, 70, 70 Hygroma, cystic (lymphangioma), 496498 Hyoid interposition grafts, 614, 615 Hyperflex tracheostomy tubes, 587 Hypernasality after uvulopalatopharyngoplasty (UPPP), 405 as complication of adenoidectomy, 386 Hypertrophic scars, 678 Hypoglossalfacial nerve anastomosis, 180, 181 Iatrogenic complications of adenoidectomy, 386 facial nerve injury, 140. See also Facial nerve procedures of tonsillectomy, 396 Incisional biopsy, cervical, 448451, 449, 451 Incisions coronal, 732734, 733 laryngotracheal, 619 preauricular, 742, 743 for repair of choanal atresia, 307, 307 retromandibular, 742, 743 submandibular, 740, 741 submental, 740, 741 superior lid crease, 734, 735 transconjunctival, 736, 737 vestibular or canine fossa, 738, 739 vestibular sulcus anterior, 744, 745 posterior, 744, 745 Incus interposition, 81, 81 Incus prostheses, 76 Incus-stapes prostheses, 76
Infections deep neck danger space drainage, 488489 masticator space drainage, 475476 parotid space drainage, 477, 477478, 479 peritonsillar space drainage, 480, 481 pharyngomaxillary (lateral pharyngeal) space drainage, 472474, 473, 474 prevertebral space drainage, 486 retropharyngeal space drainage, 482486, 485 submandibular space drainage, 468470, 469, 471 vascular (carotid) space drainage, 487, 487488 visceral space drainage, 482 of facial soft tissue wounds, 678 mastoiditis, 9192, 96 postoperative, in craniofacial procedures, 804 upper respiratory, anesthesia and, 825 Infiltration anesthetics, 673674 Inflammatory disease, sinonasal, 339351 septal abscess or hematoma, 339340, 340 Internal approach, to septoplasty, 264267 anesthetic considerations, 265 indications/contraindications, 264, 264265 preparation, 265 procedure, 265, 265266, 267 Interposition grafting, facial nerve, 154156, 155, 156 Intracordal cysts, 648, 649 Intracranial segment, of facial nerve, 137, 138 Intraoral ranula excision, 536538, 537 Intratemporal segment, of facial nerve, 137138, 138 Intratympanic membrane congenital cholesteatoma, 104, 104, 105 Isoflurane, 557 Keloids, 678 Ketamine, 827 Ketorolac tromethamine, contraindications, 380 Koerner flap, 35, 35, 60, 6061, 61, 68, 69 Labyrinthine segment, of facial nerve, 138, 138 Lacerations auricular, 682 eyelid, 688690, 689 facial nerve, 171176 lip, 678680, 679, 681 parotid duct, 694 Lambdoidal craniosynostosis, 802, 802803, 803 Laryngeal decompression (cricoid split) with hyoid interposition, 612614, 613, 615 Laryngeal hemangioma, 663664, 664 Laryngeal mask, 380
838
Index
Laryngeal nerve, 552 injury to, 552553 recurrent anatomic localization, 546547, 547 anomalous (nonrecurrent), 547 monitoring, 540, 541 superior, 548, 552553 Laryngeal papillomatosis, 652, 653 Laryngeal separation, 608610, 609, 610, 611 Laryngeal webs, 654, 655657 Laryngoscopes, 563, 563564 Laryngoscopy, 564569 anesthetic considerations, 563 indications, 563 instrumentation, 563, 563564 parent/caregiver information, 817 procedure, 564569 diagnostic laryngoscopy, 566 introducing laryngoscope, 564, 564566, 565, 566 laser laryngoscopy, 568569 therapeutic laryngoscopy, 567, 567 Laryngospasm, anesthesia and, 825 Laryngotracheal surgery, 597669 arytenoidectomy, 597600 anesthetic considerations, 598 indications, 597 preparation, 598 procedure endoscopic arytenoidectomy, 598, 599 open technique, 600, 601 postoperative care, 600 augmentation laryngoplasty with cartilage graft, 616618, 617, 619 with cartilage stent, 620, 620622, 621, 623 cricotracheal resection, 626630, 627, 629, 631 glottic web excision, 604605, 605 laryngeal decompression (cricoid split) with hyoid interposition, 612614, 613, 615 laryngeal separation, 608610, 609, 610, 611 laser surgery, 633669 cysts epiglottic, 642, 643 intracordal, 648, 649 vallecular, 644, 645 ventricular, 646, 647 instrumentation carbon dioxide (CO2) laser, 633639634 neodymium-yttrium-aluminum-garnet (Nd:YAG) laser, 639641, 641 potassium-titanyl-phosphate (KTP) laser, 639 laryngeal and glottic hemangiomas, 663664, 664
laryngeal papillomatosis, 652, 653 laryngeal webs, 654, 655657 Reinkes edema and vocal cord polyps, 660662, 661, 662, 663 subglottic stenosis, 665, 665666, 666 tracheal stenosis, 668 vocal cord nodules, 658, 659 vocal process granulomas, 650, 651 posterior glottic stenosis repair, 606, 607 segmental tracheal resection, 624626, 625 supraglottoplasty, 602, 603 Laser laryngoscopy, 568569 Laser myringotomy, 4 Lasers carbon dioxide (CO2), 633639, 634 neodymium-yttrium-aluminum-garnet (Nd:YAG) laser, 639641, 641 potassium-titanyl-phosphate (KTP), 639 Laser surgery, laryngotracheal cysts epiglottic, 642, 643 intracordal, 648, 649 vallecular, 644, 645 ventricular, 646, 647 instrumentation carbon dioxide laser, 633639, 634 neodymium-yttrium-aluminum-garnet (Nd:YAG) laser, 639641, 641 potassium-titanyl-phosphate (KTP) laser, 639 laryngeal and glottic hemangiomas, 663664, 664 laryngeal webs, 654, 655657 Reinkes edema and vocal cord polyps, 660662, 661, 662, 663 subglottic stenosis, 665, 665666, 666 tracheal stenosis, 668 vocal cord nodules, 658, 659 vocal process granulomas, 650, 651 Laser tonsillectomy, versus electrocautery, 388 Lateral fascia graft tympanoplasty, 5865, 5866 Lateral rhinotomy, 312315, 313. See also Nasal surgery Lavage, antral, 341, 341342 Lempert procedures, modified, 2731. See also Endaural approach Lidocaine, 673674 intravenous, 557 topical, 557 Lingual nerve palsy, after tonsillectomy, 396 Liquefaction (suction coagulator) adenoidectomy, 384 Lymphangioma (cystic hygroma), 496498 Lymph node dissection. See Cervical adenopathy
Index
839
Magnetic stimulation testing, 183 Mandibular exposure, 731 extraoral complications, 742 preauricular incision, 742, 743 retromandibular incision, 742, 743 submandibular incision, 740, 741 submental incision, 740, 741 intraoral anterior vestibular sulcus incision, 744, 745 complications, 744745 posterior vestibular sulcus incision, 744, 745 Masses. See Cystic lesions; Neoplasia Masticator space, drainage, 475476 Mastoid, surgical approaches, 2138 endaural, 2631, 27, 28, 29, 30, 31 postauricular, 32, 3238, 33, 34, 35, 36, 37 transcanal, 2126, 22, 23, 24, 25, 26 Mastoidectomy, 91100. See also Cholesteatoma canal wallup vs. canal walldown, 101102 in cochlear implantation, 232, 233 in facial nerve procedures, 144, 144146, 145, 152 modified radical, 9698, 97 radical, 9899, 99 simple (cortical, complete), 9195, 93, 95 tympanomastoidectomy, 100 Mastoiditis, 91, 96 acute coalescent, 9192 Mastoid subsegment, of facial nerve, 138, 139 Maxillofacial trauma, 727761. See also Facial nerve repair; Facial trauma; Soft tissue repair anatomical considerations, 727728, 729 bone grafting, 758760, 759 coronal incision, 732734, 733 evaluation and management, 729732 definitive management, 729730 initial management, 729 surgical exposure, 730731 mandible, 731 skull and upper orbits, 730731 fixation complications, 748749, 752753 maxillomandibular, 746751, 747, 748, 749 rigid internal, 750, 750753, 751, 753t mandibular exposure extraoral complications, 742 preauricular incision, 742, 743 retromandibular incision, 742, 743 submandibular incision, 740, 741 submental incision, 740, 741
intraoral anterior vestibular sulcus incision, 744, 745 complications, 744745 posterior vestibular sulcus incision, 744, 745 nasoethmoid, naso-orbital ethmoid, and skull base trauma/subcranial approach, 753757, 755, 757 superior lid crease incision, 734, 735 transconjunctival incision, 736, 737 vestibular or canine fossa incision, 738, 739 Maximal stimulation testing (MST), 182 Medial fascia or fat-plug graft myringoplasty, 4148. See also under Myringoplasty Metopic craniosynostosis, 798, 798, 799, 799 Microdebrider (shaver) adenoidectomy, 384386, 385, 387 Microdebrider technology, versus laser surgery, 652 Microdebrider tips, 336 Microtia repair, 701715 anesthetic considerations, 702 general considerations, 701 indications and timing, 702 preparation, 702, 702704, 703, 704 procedure overview, 704 stage 1: rib harvest, 705, 705710, 706, 707, 708, 709 stage 2: lobule transposition, 710, 711 stage 3: separation from head and creation of functional postauricular sulcus, 712, 713 stage 4: optional creation of tragus or contralateral otoplasty, 714, 715 Midazolam, in postoperative nausea and vomiting, 826 Middle ear, surgical approaches, 2138 endaural, 2631, 27, 28, 29, 30, 31 postauricular, 32, 3238, 33, 34, 35, 36, 37 transcanal, 2126, 22, 23, 24, 25, 26 Middle-ear/mastoid surgery, parent/caregiver information, 815 Mitomycin C, topical use in nasal surgery, 303 Modified radical mastoidectomy, 9698, 97 Morphine, 557 Mortality in anesthesia, 807, 808 in craniofacial procedures, 804 Mucocele, 372375. See also Tongue surgery Mucoperiosteal flap, 308, 308, 309, 310 Mucosal injuries, nasal, 687 Muscle relaxants, 558 Myringoplasty approach and technique selection, 4041 fat-plug graft, 45, 45, 46, 48, 48
840
Index
with medial fascia or fat-plug graft, 4148 anesthetic considerations, 42 indications, 4142 preparation, 42 procedure, 4248, 4348 tissue selection for graft, 42 perichondrial graft, 44, 44 Myringotomy, 4, 45. See also Tympanostomy tubes laser, 4 Narcotic analgesics, 827 Nasal dermoids, 300. See also Congenital malformations Nasal fracture, closed reduction, 260, 260263, 261, 263 Nasal glioma, 300 Nasal malformations, congenital, 299317. See also under Nasal surgery and specific lesions Nasal splint, 291 Nasal surgery, 259298 congenital nasal malformations, 299317 choanal atresia transnasal repair, 300306, 301, 302, 303.304, 305 transpalatal repair, 306312, 307, 308, 309, 310, 311 lateral rhinotomy, 312315, 313 overview of lesions, 299300 sublabial approach, 315, 315316, 316 fracture: closed reduction, 260, 260263, 261, 263 in inflammatory sinonasal disease, 339351 antral aspiration and lavage, 341, 341342 Caldwell-Luc procedure, 342344, 343 dacryocystorhinostomy, 348350, 349, 351 external ethmoidectomy, 344345, 345 frontal sinus trephination, 346, 347 septal abscess or hematoma, 339340, 340 principles, 259260 rhinoplasty, 281298 anesthetic considerations, 282 approach selection, 281, 281t complications, 298 indications, 281 postoperative care, 298 procedure endonasal approach, 281t, 282291, 283, 285, 287, 288, 289, 290, 291 external approach, 291298, 292, 293, 294, 295, 296, 297 with septoplasty, 280 septoplasty, 264280
external approach, 268280 anesthetic considerations, 268269 indications/contraindications, 268, 269 procedure, 270, 270280, 271, 272, 273, 275, 276, 277, 278, 279 internal approach, 264267 anesthetic considerations, 265 indications/contraindications, 264, 264265 preparation, 265 procedure, 265, 265266, 267 postoperative care, 280 special considerations, 280 soft tissue repair, 686687 avulsion, 687 cartilaginous framework injuries, 686687 cutaneous defects, 686 mucosal injuries, 687 Nasal teratoma, 300. See also Congenital malformations Nasal tip deformity, 286289, 287, 288, 289, 293, 293296, 294, 295, 296. See also Rhinoplasty Nasoethmoid, naso-orbital ethmoid, and skull base trauma/subcranial approach, 753757, 755, 757 Nasopharyngeal stenosis, as complication of adenoidectomy, 386 Nasopharyngoscopy, in velopharyngeal insufficiency, 407. See also Velopharyngeal insufficiency Nausea and vomiting, postoperative, 826 Neck, fascial layers, 465466, 467 Neck dissection functional (modified), 452, 452462, 453, 454, 455, 457, 459, 461 radical, 453, 454, 457 Neck surgery in cervical adenopathy, 441463 cervical needle biopsy, 448451, 449, 451 functional (modified) neck dissection, 452, 452462, 453, 454, 455, 459, 461 percutaneous needle biopsy, 442447, 443, 444, 445, 447 preliminary considerations, 441442 in congenital malformations, 491514 cystic hygroma (lymphangioma), 496498 fibromatosis colli, 512, 513 first branchial cleft fistula, 498500, 501 fourth branchial pouch sinus, 507, 507510, 509, 511 pre-auricular pit or fistula, 502, 503 second and third branchial cleft fistula, 504506, 505, 506
Index
841
thyroglossal duct cyst, 482, 491494, 493, 495 in deep neck infections, 465489 anatomical considerations, 465466, 467 danger space drainage, 488489 masticator space drainage, 475476 parotid space drainage, 477, 477478, 479 peritonsillar space drainage, 480, 481 pharyngomaxillary (lateral pharyngeal) space drainage, 472474, 473, 474 prevertebral space drainage, 486 retropharyngeal space drainage, 482486, 485 submandibular space drainage, 468470, 469, 471 vascular (carotid) space drainage, 487, 487488 visceral space drainage, 482 thyroidectomy, 539554 anesthetic considerations, 540 postoperative care, 552554 preoperative evaluation, 539540 preparation, 540543, 541, 542 procedure, 540552, 543, 544, 545, 546, 547, 548, 549, 551, 553 Necrosis, scalp, in craniofacial procedures, 805 Needle aspiration, 13 of middle ear. See also Fine-needle aspiration; Tympanocentesis; Tympanostomy tube Neodymium-yttrium-aluminum-garnet (Nd:YAG) laser, 639641, 641 Neoplasia cervical, 441463. See also Cervical adenopathy and specific procedures of tongue, 367378. See also Tongue Nerve excitability testing (NET), 182 Neurectomy, tympanic, 438 Neuroma, facial nerve, 140 Neuromuscular blockade, 558 Neurovascular preservation, in cervical biopsy procedures, 442, 448, 455 Newborn vs. adult temporal bone, 521 Nodules, vocal cord, 658, 659 Obliteration, of eustachian tube, 129131, 131 Obstetric trauma, facial nerve, 140. See also Facial nerve procedures Obstructive sleep apnea syndrome. See Adenoidectomy; Tonsillectomy; Uvulopalato pharyngoplasty (UPPP) Ondansetron, in postoperative nausea and vomiting, 826 Ophthalmologic complications, in craniofacial procedures, 805 Opiate analgesics, 827
Opioids, as adjunctives to anesthesia, 557 Oropharyngeal stenosis, in tonsillectomy, 396 Ossicular discontinuity, 75, 77t Ossicular fixation, 75, 77t Ossiculoplasty, 7589 advancement flap, 7880, 7880 etiologic considerations, 75 incus interposition, 81, 81 outcomes and prognostic factors, 8587, 86t partial ossicular replacement prosthesis (PORP), 82, 82, 86t recommendations, 8788 reconstruction options, 76, 77t surgical approach, 22 timing of, 102103 total ossicular replacement prosthesis (TORP), 76, 8384, 8384, 86t Osteitis, acute mastoid, 92, 94 Otitis media chronic suppurative, 140 chronic suppurative, 92, 94, 96 facial nerve complications, 140 tympanostomy tube insertion and, 6 Otoplasty in microtia, 701715. See also under Auricular repair in prominent (lop) ear, 717726. See also under Auricular repair Otorrhea, postsurgical, 9, 17 Otosclerosis, surgical approach, 22 Owens incision, 307, 307 Pain, management of postoperative, 827828 Palatoplasty, 780790 anesthetic considerations and preparation, 780 complications, 780 postoperative care, 781 procedures double reversing Z-plasty (Furlow), 788790, 789 selection, 780781 two-flap, 785, 785786, 786, 787 V to Y pushback, 782, 782784, 783, 784 timing, 763, 780 Papillomatosis, laryngeal, 652, 653 Paralysis, facial, 139149. See also Facial nerve surgery Parent/caregiver information, 807822 anesthesia education sheet, 807, 808 procedure education sheets, 822 adenoidectomy, 811 ear tube insertion, 810 ear tube removal, 816 endoscopic sinus surgery, 813
842
Index
frenuloplasty, 818 head & neck surgery, 814 laryngoscopy and bronchoscopy, 817 middle-ear/mastoid surgery, 815 tonsillectomy, 812 satisfaction versus efficiency, 822 Parotid duct ligation, 428t, 436437, 437. See also Drooling repair, 694 anatomical considerations, 694 avulsion, 694 laceration, 694 trauma to, 672 Parotidectomy anatomic considerations, 521 facial nerve anastomosis, 525 postoperative care, 170, 524 preparation, 158, 158159 procedure, 159170, 159, 516, 516526, 517, 518, 519, 521, 522, 523, 525 anesthetic considerations, 515516 identification of facial nerve, 164, 164166, 167 incision and exposure, 160, 160163, 161, 162, 164, 517 indications, 515 preparation, 515516 superficial and deep parotidectomy, 166170, 167, 168, 169 total parotidectomy, 522-524 Parotid space, drainage, 477, 477478, 479 Pars flaccida attic cholesteatoma, 117121 anesthetic considerations, 118 confined to anterior epitympanum, 118, 118, 119 extending into mastoid, 120, 120 extensive, 121, 121 indications, 117, 117 Pars tensa atelectasis, 58 perforation, 58 Partial ossicular replacement prosthesis (PORP), 76, 82, 82, 86t Patient-controlled analgesia, 828 Pedicle flap, anterior, 64, 64 Percutaneous needle biopsy, cervical, 442447, 443, 444, 445, 447 Perichondrial graft myringoplasty, 44, 44 Perilymphatic fistula, 123136. See also Eustachian tube dysfunction acquired, 123 congenital, 123128 anesthetic considerations, 124125
indications, 124 postoperative care, 128 preoperative evaluation, 124 procedure, 125, 125128, 126, 127 Periorbital injuries, 688693 eyelid injuries, 688690 anatomical considerations, 688, 689 lacerations, 688690, 689 medial, 690693 canalicular anatomy, 691, 691 canalicular repair, 692, 692 canthal anatomy, 691 canthal tendon injury, 690, 691 eyebrow injuries, 692, 693 Peritonsillar space, drainage, 480, 481 Pharyngomaxillary (lateral pharyngeal) space, drainage, 472474, 473, 474 Pharyngoplasty, sphincter, 419421, 421 Pharyngoscopy, 562, 562 Photodocumentation of endoscopy, 559, 559561 of facial soft tissue surgery, 672 Plagiocephaly, 794, 795 posterior, 802, 802803, 803 Plunging ranula excision, 532534, 533, 534, 535 Pneumocephaly, postoperative, in craniofacial procedures, 805 Polyps, vocal cord, 660662, 661, 662, 663 Postauricular approach anesthesia, 32, 32 in external ear canal reconstruction, 188, 189, 189t, 194, 194200, 195, 196, 197, 198, 199, 200 indications, 32 preparation, 33 procedure, 33, 3338, 34, 35, 36, 37 Postauricular medial fascia graft tympanoplasty, 4951, 50, 51 Posterior glottic stenosis repair, 606, 607 Posterior pharyngeal wall augmentation, 417419, 418 Posterior vestibular sulcus incision, 744, 745 Posterosuperior quadrant acquired cholesteatoma extending into epitympanum, 114, 114 extending into mastoid gas cells, 115, 115 extensive, 116, 116 in posterior mesotympanum, facial recess, and sinus tympani, 112, 112, 113 postoperative care, 116 Postoperative nausea and vomiting, 826 Potassium-titanyl-phosphate (KTP) laser, 639 Preauricular incision, 742, 743
Index
843
Preauricular pit or fistula, 502, 503 Prematurity, apnea of, 826 Prevertebral space, drainage, 486 Prominent (lop) ear, 717726 anatomical considerations, 717, 718 anesthetic consideration, 719 complications and long-term outcomes, 724 indications, 717719 postoperative care, 724 preparation, 719 procedure, 720, 720724, 721, 723, 725 Propofol, 557, 827 Prostheses, ossicular replacement partial (PORP), 76, 82, 82, 86t, 87 total (TORP), 76, 8384, 8384, 86t, 87 types of, 76 Pulmonary edema, post-tonsillectomy, 396 Pyriform aperture stenosis, 300. See also Congenital malformations Quadrilateral cartilage (QC). See Septoplasty Radical mastoidectomy, 9899, 99 modified, 9698, 97 Radiologic evaluation, in thyroid surgery, 539 Radioscintigraphy, thyroid, 539 Ranula excision intraoral, 536538, 537 plunging, 532534, 533, 534, 535 formation, in drooling correction procedures, 435 Recurrent laryngeal nerve anatomic localization, 546547, 547 anomalous (nonrecurrent), 547 injury to, 552553 monitoring, 540, 541 Reinkes edema and vocal cord polyps, 660662, 661, 662, 663 Remifentanil, 557 Retraction pocket defect, 66, 68 Retromandibular incision, 742, 743 Retropharyngeal space, drainage, 482486, 485 Rhinoplasty, 281298 anesthetic considerations, 282 approach selection, 281, 281t complications, 298 indications, 281 postoperative care, 298 procedure endonasal approach, 281t, 282291, 283, 285, 287, 288, 289, 290, 291
external approach, 291298, 292, 293, 294, 295, 296, 297 with septoplasty, 280 Rhinotomy, lateral, 312315, 313. See also Nasal surgery Rolled pharyngeal flap, 415416, 416 Ruddy incision, 307, 307 Sagittal craniosynostosis, 800, 801 Salivary gland surgery, 515538. See also Parotid glands parotidectomy, 515526, 516, 517, 518, 519, 521, 522, 523, 525 ranula excision, 532538 intraoral, 536538, 537 plunging, 532534, 533, 534, 535 submandibular gland excision, 526531, 527, 528, 529530, 531 Scalp necrosis, in craniofacial procedures, 805 Scaphocephaly, 800, 801 Scar revision, 695699 broken line closures, 698, 699 dermabrasion, 699 indications and timing, 696 serial excision, 696 simple excision, 696 Z-plasty, 696697, 697 Scars, hypertrophic, 678 Scopolamine, 558 Second and third branchial cleft fistula, 504506, 505, 506 Sedation, 827. See also Anesthesia; Anesthetic considerations Segmental tracheal resection, 624626, 625 Seizures, postoperative, in craniofacial procedures, 804 Septal abscess, drainage, 339340, 340 Septal hematoma, drainage, 339340, 340 Septoplasty, 264280 external approach, 268280 anesthetic considerations, 268269 indications/contraindications, 268, 269 procedure, 270, 270280, 271, 272, 273, 275, 276, 277, 278, 279 internal approach, 264267 anesthetic considerations, 265 indications/contraindications, 264, 264265 preparation, 265 procedure, 265, 265266, 267 postoperative care, 280 special considerations, 280 Sevoflurane, 556
844
Index
Shaver (microdebrider) adenoidectomy, 384386, 385, 387 Shiley tracheostomy tubes, 587 Sialorrhea, See Drooling Sickle cell disease, preoperative evaluation in, 380 Simple (cortical, complete) mastoidectomy, 9195, 93, 95 Sinus surgery endoscopic ethmoidectomy/antrostomy, 319338 anatomic considerations, 322323, 323 anesthetic considerations, 320321 complications, 332, 333 in cystic fibrosis, 334, 334337, 335, 336 indications, 319320 instrumentation, 321 postoperative care, 330 preoperative evaluation, 320 preparation, 322, 322 procedure, 322330, 325, 326, 327, 328, 329, 330 in inflammatory sinonasal disease, 339351 antral aspiration and lavage, 341, 341342 Caldwell-Luc procedure, 342344, 343 dacryocystorhinostomy, 348350, 349, 351 external ethmoidectomy, 344345, 345 frontal sinus trephination, 346, 347 septal abscess or hematoma, 339340, 340 sphenoid sinus, 353365 direct transnasal sphenoidotomy, 358363, 359, 361, 363 surgical approaches, 353355 transnasal transethmoidal sphenoidotomy, 355356, 357 Sinus tract, fourth branchial cleft, 507, 507510, 509, 511 Skull and upper orbits, surgical exposure, 730731 Soft tissue surgery, 671700 auricular microtia repair, 701715. See also Microtia for prominent ear (prominauris), 717726. See also Otoplasty auricular repair, 682685 avulsions, 684, 685 composite defects, 684 cutaneous defects, 682683 helical rim defects, 683, 683684 hematoma, 682 lacerations, 682 facial nerve repair, 694695 general principles, 671678 complications, 678 initial patient encounter, 671672
preparation, 672673 anesthetic considerations, 673674 facility selection, 672 instruments and sutures, 673 photo documentation, 672 wound care, 676 wound closure, 675676, 677 wound preparation, 674675 lip repair, 678680, 679, 681 nasal repair, 686687 avulsion, 687 cartilaginous framework injuries, 686687 cutaneous defects, 686 mucosal injuries, 687 parotid duct repair, 694 anatomical considerations, 694 avulsion, 694 laceration, 694 periorbital injuries, 688693 eyelid injuries, 688690 anatomical considerations, 688, 689 lacerations, 688690, 689 medial, 690693 canalicular anatomy, 691, 691 canalicular repair, 692, 692 canthal anatomy, 691 canthal tendon injury, 690, 691 eyebrow injuries, 692, 693 scar revision, 695699 broken line closures, 698, 699 dermabrasion, 699 indications and timing, 696 serial excision, 696 simple excision, 696 Z-plasty, 696697, 697 Sphenoidotomy direct transnasal, 358363, 359, 361, 363 transnasal transethmoidal, 355356, 357 transorbital, 353, 354 transpalatal, 353, 354 transseptal, 353, 354355 Sphincter pharyngoplasty, 419421, 421 SPITE acronym, 85 Stapedial muscle reflex testing, 183 Steinzeug incision, 307, 307 Stenosis ear canal, 185210. See also under Ear canal nasopharyngeal, as complication of adenoidectomy, 386 oropharyngeal, in tonsillectomy, 396 posterior glottic, 606, 607
Index
845
pyriform aperture, 300. See also Congenital nasal malformations subglottic, 665, 665666, 666 tracheal, 668 velopharyngeal, after uvulopalatopharyngoplasty (UPPP), 405 Stents cartilage, in augmentation laryngoplasty, 620, 620622, 621, 623 in repair of choanal atresia, 304, 304, 305, 311 in sinus procedures, 330, 331 Subcranial approach, 753757, 755, 757 Subglottic stenosis, 665, 665666, 666 Sublabial approach, 315, 315316, 316 Sublingual gland, excision, 427, 431, 432. See also Drooling Subluxation, atlantoaxial (Grisels syndrome), as complication of adenoidectomy/tonsillectomy, 386, 387 Submandibular duct relocation, 428t, 433435, 435 with sublingual gland excision, 427432, 428t, 429, 430, 431, 433 Submandibular gland, excision, 526531, 527, 528, 529530, 531 Submandibular incision, 740, 741 Submandibular space, drainage, 468470, 469, 471 Submental incision, 740, 741 Suction coagulator (liquefaction) adenoidectomy, 384 Sufentanil, 557 Sun exposure, of soft tissue wounds, 676 Superior laryngeal nerve, 548, 552553 injury to, 552553 Superior lid crease incision, 734, 735 Superiorly based pharyngeal flap, 408414, 409, 410, 413, 414 Suppurative complications, tympanostomy tube insertion and, 6 Suppurative otitis media, 140 chronic, 92, 94, 96 Supraglottoplasty, 602, 603 Sural nerve graft, 177178, 178, 179 Surgical approaches. See also under specific procedures in antral aspiration and lavage, 342 to middle ear and mastoid, 2138 endaural, 2631, 27, 28, 29, 30, 31 postauricular, 32, 3238, 33, 34, 35, 36, 37 transcanal, 2126, 22, 23, 24, 25, 26 to sphenoid sinus, 353354 subcranial, 753757, 755, 757 sublabial, 315, 315316, 316
Sutures in facial surgery, 675676, 677 for soft tissue surgery, 673 Temporal bone, newborn vs. adult, 521 Temporalis fascia graft, 54, 54 Teratoma, nasal, 300. See also Congenital malformations Thromboembolic complications, in craniofacial procedures, 806 Thyroglossal duct cyst, 482, 491494, 493, 495 Thyroid biopsy, 540 Thyroidectomy, 539554 anesthetic considerations, 540 postoperative care, 552554 preoperative evaluation, 539540 preparation, 540543, 541, 542 procedure, 540552, 543, 544, 545, 546, 547, 548, 549, 551, 553 Thyroid scanning, 539 Thyroid tests, 539 Tissue adhesives, 676 Tissue conservation, in facial surgery, 673 Tongue surgery, 367378 anterior lesions, 367368, 368 base (mucocele), 372375 intraoral approach, 372, 373 transcervical approach, 374, 375 frenuloplasty, 376, 377 macroglossia, 369370, 370, 371 Tongue-tie. See Ankyloglossia Tonsillectomy, 380397. See also Adenoidectomy anesthetic considerations, 380 complications, 395396 parent/caregiver information, 812 postoperative care, 395 preoperative evaluation/coagulation studies, 379380 preparation, 380381 procedure, 383, 388393, 389, 390, 391, 392, 394 Total intravenous anesthesia (TIVA), 557 Total ossicular replacement prosthesis (TORP), 76, 8384, 8384, 86t Tracheal stenosis, 668 Tracheocutaneous fistula closure, 593, 593594, 594, 595 Tracheostomy, defined, 585 Tracheostomy tubes, 587, 587t. See also Laryngotracheal procedures Tracheotomy, 585596 anesthetic considerations, 585 complications, 592 indications, 585
846
Index
instrumentation, 586, 587, 587t postoperative care, 592 preparation, 585586, 586 procedure, 588, 588592, 589, 590, 591 tracheocutaneous fistula closure, 593, 593594, 594, 595 Transcanal approach, 2126 anesthetic considerations, 22, 22 indications, 2122 postsurgical care, 26 preparation, 23 procedure, 23, 2326, 24, 25, 26 Transcanal medial fascia or fat-plug graft tympanoplasty, 2226, 49. See also Transcanal approach Transconjunctival incision, 736, 737 Transnasal repair, in choanal atresia, 300306, 301, 302, 303.304, 305 Transnasal sphenoidotomy, direct, 358363, 359, 361, 363 Transnasal transethmoidal sphenoidotomy, 355356, 357 Transorbital sphenoidotomy, 353, 354 Transpalatal repair, in choanal atresia, 306312, 307, 308, 309, 310, 311 Transpalatal sphenoidotomy, 353, 354 Transseptal sphenoidotomy, 353, 354355 Trauma facial, 671700. See also Soft tissue surgery head, 140. See also Facial nerve surgery maxillofacial, 727761. See also Maxillofacial trauma Trephination, frontal sinus, 346, 347 Trigonocephaly, 798, 798, 799, 799 Tumors. See Neoplasia Two-flap palatoplasty, 785, 785786, 786, 787 Tympanic neurectomy, 438 Tympanic subsegment, of facial nerve, 138, 138 Tympanocentesis, 13 anesthetic considerations, 1 indications, 1 postoperative care, 3 procedure, 2, 23, 3 Tympanomastoidectomy, 91, 92, 100. See also Mastoidectomy Tympanomeatal flap, 2931, 55, 55, 56 Tympanoplasty, 50, 51 approach and technique selection, 4142 cartilage graft, 6672 endaural medial fascia graft, 5257, 5357. See also Endaural approach lateral fascia graft, 5865, 5866
postauricular medial cartilage-fascia approach, 6772, 6871 postauricular medial fascia graft, 4951, 50, 51. See also Postauricular approach surgical approach, 21 transcanal medial fascia or fat-plug graft, 2226, 49. See also Transcanal approach Tympanostomy tube insertion and, 6 Tympanoplasty, surgical approach, 26 Tympanostomy exploratory, 22 second-look, 2122 Tympanostomy tubes Armstrong, 16 extrusion of, 1011 insertion, 72 grommet-type, 611 anesthetic considerations, 7 complications and sequelae, 1011 indications, 6 postoperative care, 910 procedure, 7, 79, 8, 9 parental education, 810, 816, 819822, 820821 Per-Lee, 1213 permanent insertion, 1115 indications, 12 postoperative care, 15 procedure, 12, 1215, 13, 14, 15 removal, 1619 anesthetic considerations, 17 case selection, 16 indications, 1617 postoperative care, 19 procedure, 17, 1718, 18 T-tube, Richards, 1415 Ultrasonography, in thyroid evaluation, 539 Uncinectomy, 324326, 325 Unilateral coronal craniosynostosis, 794, 795 Upper respiratory infection, anesthesia and, 825 Uvulopalatopharyngoplasty (UPPP), 402405 complications, 405 indications, 402 postoperative care, 405 procedure, 402404, 403, 404 Vallecular cysts, 644, 645 Vascular (carotid) space, drainage, 487, 487488 Velopharyngeal examination, before adenoidectomy, 381 Velopharyngeal insufficiency, 407425
Index
847
general considerations, 407 lateral port revision enlarging, 424, 424425 narrowing, 422, 422423 posterior pharyngeal wall augmentation, 417419, 418 rolled pharyngeal flap, 415416, 416 sphincteroplasty, 419421, 421 superiorly based pharyngeal flap, 408414 flap positioning, 410, 413, 414 incisions, 409, 410 surgical outcomes, 425 Velopharyngeal stenosis, after uvulopalatopharyngoplasty (UPPP), 405 Ventricular cysts, 646, 647 Vermilion border, 678 Vestibular or canine fossa incision, 738, 739 Vestibular sulcus incision
anterior, 744, 745 posterior, 744, 745 Visceral space, of neck, drainage, 482 Visual acuity tests, 672 Vocal cord nodules, 658, 659 Vocal cord paralysis. See Arytenoidectomy Vocal process granulomas, 650, 651 V to Y pushback palatoplasty, 782, 782784, 783, 784 Webs, laryngeal, 654, 655657 Wilson incision, 307, 307 Wound care, in facial soft tissue surgery, 676 Wound closure, in facial surgery, 675676, 677 Xomed NIM II EMG endotracheal tube, 541 Z-plasty, 696697, 697 double reversing (Furlow) palatoplasty, 788790, 789

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Surgical Atlas

RICHARD M. ROSENFELD, MD, MPH

2002 BC Decker Inc Hamilton London

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T YMPANOSTOMY T UBES AND R ELATED P ROCEDURES

Surgical Atlas of Pediatric Otolaryngology

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

Figure 16 Tympanostomy tube in place.

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

Figure 18 An incision is made anterior to the body of the malleus.

Tympanostomy Tubes and Related Procedures

A Per-Lee tube is preferred:

Figure 19 A Per-Lee tube is shortened.

Figure 110 The tube is inserted using an alligator forceps.

Figure 111 The tube in place.

Surgical Atlas of Pediatric Otolaryngology

A Richards T-tube may also be used:

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

Tympanostomy Tubes and Related Procedures

Surgical Atlas of Pediatric Otolaryngology

A PPROACHES TO THE M IDDLE E AR AND M ASTOID

Surgical Atlas of Pediatric Otolaryngology

Figure 21 Injection sites (x) for transcanal approach.

Approaches to the Middle Ear and Mastoid

Surgical Atlas of Pediatric Otolaryngology

Figure 24 The middle ear is entered by elevating the annulus.

Approaches to the Middle Ear and Mastoid

Figure 26 Curettage of the scutum.

Surgical Atlas of Pediatric Otolaryngology

Approaches to the Middle Ear and Mastoid

Surgical Atlas of Pediatric Otolaryngology

Approaches to the Middle Ear and Mastoid

Figure 211 An anterior relaxing incision in the canal.

Surgical Atlas of Pediatric Otolaryngology

Figure 214 The tympanomeatal flap is elevated.

Approaches to the Middle Ear and Mastoid

The flap is elevated, exposing the middle ear (Figure 216).

Figure 216 The middle ear is exposed.

Surgical Atlas of Pediatric Otolaryngology

Approaches to the Middle Ear and Mastoid

Surgical Atlas of Pediatric Otolaryngology

Figure 219 The postauricular soft tissue is exposed.

Approaches to the Middle Ear and Mastoid

Figure 221 Canal incisions are extended laterally.

Surgical Atlas of Pediatric Otolaryngology

Figure 224 The Koerner flap is elevated.

Approaches to the Middle Ear and Mastoid

Surgical Atlas of Pediatric Otolaryngology

M YRINGOPLASTY AND T YMPANOPLASTY

Surgical Atlas of Pediatric Otolaryngology

Myringoplasty and Tympanoplasty

Surgical Atlas of Pediatric Otolaryngology