OtoRhinoLaryngology Portal

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CO2-Laser Surgical Instruments

    

         Laryngoscope of various sizes:           Triangular tissue holding forceps:

                  matte-finished                                         right and left 

 

      

      Suction-protector and distractor               Suction-protector to prevent

either from right or left side of the blade          laser from striking inferiorly

Transoral CO2-Laser Surgery: Achieving Homeostasis

Insulated diathermy forceps

                   Liga clip forceps                   Liga clip forceps with the secured clip  

 

These figures shows the instruments avaible for securing homeostasis in

transoral laser surgery especially for tumour removal.  Alternatively, monopolar suction diathermy or bipolar diathermy be use as they are more readily available.  Lesser bleeding can be controlled with topical pressure by using cotton pledget/cottonoid soaked in adrenaline 1:1000

 CO2 Laser Excision of Benign Vocal Fold Polyp

 

Right vocal fold polyp.

 

Endoscopic view after the polyp excised.

 

The specimen measuring about 3 mm x 4 mm in dimension.

CO2 Laser Excision of Benign Laryngeal Tumour

Cricotracheal Stenosis: Radial CO2- Ablation, Bougie Dilatation & Mitomycin-C Application

                            Before                                 Suction protector sizes

           Suction protector insertion             The flat surface shouldering the edge

                                                                 of stenosis from below and laser

                                                               strikes the stenotic tissue above it.

 

 

          Dilatation by using largest                  Topical Mitomycin-C application

   size bougie which can accomodate                           for 5 minutes

             the stenotic segment                    

       At completion of surgery                          At 1 month after surgery

 

Suggestes reference:

Perepelitsyn I, Shapshay AM. Endoscopic treatment of laryngeal and tracheal stenosis- has mitomycin C improved the outcome? Otolaryngol Head Neck Surg. 2004 Jul;131(1):16-20.

Tracheal Stenosis: Radial CO2- Ablation & Dilatation

      

     Radial incisions flushed with the           Dilatation with bougies till largest

medial edge of normal tracheal lumen.        size that accomodate the lumen.

 

Mitomycin-C modulates fibroblast activity and minimize the recurrence; apply topically.  T-tube or endoluminal stent placement is recommended

and later removed.

 

Another example of radial CO2-laser ablation of fibromembranous stenosis.

 Before radial CO2-laser excision.

After radial CO2-laser excision.  This will be followed by targeted dilatation using bougies or balloon to achieve the desired final diameter.

Evidence-Based Surgical Treatment for Tracheal Stenosis

Flexible Biopsy Forceps

Video shows flexible biopsy forceps which can be passed through the instrument port of flexible scope channel.  It can also be use to remove small foreign body. 

Optical Bronchoscope with Manouverable Tip

This video shows an example of optical bronchoscope with channels

for rigid endoscope and instrumentation.  Flexible tip allows

change of direction towards target area of interest.

Nd-YAG Laser Application for Tracheal Tumour Ablation

Balloon Dilatation for Subglottic & Tracheal Stenosis Management

Inspira AIR™ Balloon Dilatation System by Acclarent Inc.

Pre-inflated (top) and post-inflated (below) balloon.

The full set of the balloon dilatation system.

Montgomery T-tube in Tracheal Stenosis Management

This image shows a well-postion T-tube in the management of tracheal stenosis.  It upper limit should not touch the vocal folds upon phonation.

The external appearance of the horizontal limb of T-tube in the neck. 

Patient can close the opening with the stopper provided in the package

of by using his finger to enable phonation.

 

  T-Tube with it horizontal end capped       T-tube in-situ as seen on a CT-scan

 with a stopper provided in the package

Hardened Crusts From a Blocked T-Tube

This figures showed a hardened crusts involving the horizontal segment of T-tube. It was removed as an office procedure. Nursing aspect in the early period after its insertion is very important to avoid such occurence. Patient need to be informed to come back for review if they experienced difficulty in breathing or when they are capable to phonate even without closing the tube end as these may

indicate tube obstruction. 

Before removal.

After removal.

Infected T-Tube in Long-Term Usage

 

Figure shows discoloured and dirty-looking outer diameter of the T-tube after it remained in-situ for 2 years for the management of stenosis.  Peri-stomal granulations, discoloured and malodourous tracheal secretions, and discomfort/pain around the stomal area are strong pointers of on-going inflammation/infection.  Biofilm formation is a potential hazard of this type of prosthesis which need to be change whenever indicated.

 

 Similar appearance on luminal aspect of T-tube in another patient.

Cricotracheal Resection and Reanastomosis: Endoscopic Assessment

Laryngotracheal Reconstruction

Powered-Instruments Surgery

Microdebrider with skimmer tip being used for removal

of this suprastomal granulations in a tracheotomized patient.

RRP: Removal by Using Laryngeal Microdebrider

 

                          Figure 1                                             Figure 2

                            Figure 3                                            Figure 4

 

                         Figure 5                                             Figure 6

 

These figures show the technique used for removal

of laryngeal papillomatosis by using a microdebrider. 

 

A skimmer tip (Figure 1) was used instead of tricut to reduce risk of injuring the uninvolved normal vocal fold mucosa.  The speed can be controlled by the amount of pressure applied on the foot paddle (the maximum speed of 500 rpm).  The device has dual function: sucking & cutting.  At low speed it suck better.  Figure 2 shows the sucking effect without pressing the foot paddle.  Bleeding is to be expected and the amount varies on how florid and vascular the lesions were (Figure 3).  This can be controlled with topical ribbon gauze or cotton pledgets soaked in 1:1000 epinephrine (Figure 4).  Ensure removal of hidden papillomas posteriorly by lifting the endotracheal tube forward using the laryngoscope tip (Figure 5).  Figure 6 shows the laryngeal view at completion of the procedure.

Close-up view of the skimmer blade ( the sharp rotating inner blade) used for this procedure)

 

Watch video clip on The Use of Microdebrider for Laryngeal Papillomatosis Removal @ YouTube

 

Good view is essential and can be provided by rigid endoscope

projected to high definition display monitor as potrayed by these figures.

 

Few tips:

(i) Minimize anterior commissure injury. Consider topical Cidofocir injection.

(ii) Be sure the view and direction of the cutting tip to avoid unnecessary injury.

 

NB:The microdebrider device and accessories used are products of Medronic.

Tracheal Papillomas Removal by Using Tracheal Microdebrider: Skimmer Blade

Arrow- papillomas, skimmer blade tip facing papilloma under endoscopic view.

Endoscopic Removal of Bronchial Rhinosporidiosis

Jet Ventilation

Hunsaker Mon- Jet Ventilation Tube.

 

 

 

Endoscopic view of larynx and trachea without endotracheal tube (ETT) in-situ in supraglottic jet ventilation technique.  Excellent space with good access of instrumentation - particularly useful when dealing lesions involving posterior segment of both larynx and tracheal regions.

 

More Info

Cricothyrotomy

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