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
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
Right vocal fold polyp.
Endoscopic view after the polyp excised.
The specimen measuring about 3 mm x 4 mm in dimension.
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
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.
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.
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.
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.
Inspira AIR™ Balloon Dilatation System by Acclarent Inc.
Pre-inflated (top) and post-inflated (below) balloon.
The full set of the balloon dilatation system.
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
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.
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.
Microdebrider with skimmer tip being used for removal
of this suprastomal granulations in a tracheotomized patient.
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.
(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.
Arrow- papillomas, skimmer blade tip facing papilloma under endoscopic view.
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.
Trans-tracheal jet ventilation.
Endoscopic panoramic view of larynx showing the inserted transtracheal jet cannula (arrow).
The close-up view at subcordal level showing the cannula in place (arrow). This patient had CO2 laser excision of his right false cord tumour with an excellent view achieved and ample room made available for instruments manipulation.