Surgical approaches and procedures Flashcards
Subtotal resection of nasal septum
Curved incision through skin & periosteum
19 mm trephine placed just rostral to frontal sinuses where nasal bones diverge
Nasal septum easily ID’d Doyen forceps placed vertically on nasal septum down to floor of nasal cavity (act as stop for guarded chisel when severing nasal septum & as guide for making caudal incision)
Rostral division in nasal septum performed by making curved incision w scalpel starting @ ventral aspect of septum extending in dorsocaudal direction leaving at least 5 cm of rostral septum to support alar cartilages & external nares
Guarded chisel used to incise dorsal & ventral attachments of septum caudal to forceps Caudal incision made w narrow osteotome immediately rostral to Doyens
Septum grasped & removed
Differences btw near total nasal septum resection & subtotal?
Caudal incision made @ 60 degree angle to nasal bones in dorsocaudal direction
Entire ventral septal attachment incised up to rostral incision & dorsal & ventral incisions created by OB wire; achieved by passing wire thru ventral nasal meatus into nasopharynx & retrieving wire thru opposite side; for dorsal incision OB wire threaded thru trephine opening on either side; caudal incision made @ 60 degree angle to nasal bones using long narrow osteotome or OB wire using chambers catheter to guide wire around vomer bone as far caudad as possible
Site for trephination of conchofrontal sinus?
60% distance from midline to medial canthus & 0.5 cm caudal to medial canthus
Site for trephination of caudal maxillary sinus?
2 cm rostral & 2 cm ventral to medial canthus
Site for trephination of rostral maxillary sinus?
40% distance from rostral end facial crest to level of medial canthus & 1 cm ventral to line joining infraorbital foramen & medial canthus
Describe approach for trephination of conchofrontal sinus via the “modified frontonasal flap technique”?
centered 5 cm axial to nasolacrimal duct, 4 cm lateral to the nasal midline, & 2 cm below horizontal line btw medial canthi; 5 cm skull trephine used to make opening into conchofrontal sinus
Describe margins for maxillary sinus flap?
Rostral margin is line drawn from rostral end of facial crest to infraorbital foramen; dorsal margin line from infraorbital foramen to medial canthus; caudal margin is line from medial canthus to caudal aspect of facial crest
Describe margins for frontonasal bone flap?
Caudal margin is perpendicular line from dorsal midline to point midway btw supraorbital foramen & medial canthus of eye; lateral margin begins @ caudal margin 2-2.5 cm medial to medial canthus & extends to pt approx. 2/3rds distance from medial canthus to infraorbital foramen; rostral margin perpendicular line from dorsal midline to rostral extension of lateral margin
Describe pharyngotomy approach?
Dorsal recumbency; ventral aspect basihyoid bone & thyroid cartilage palpated on ventral midline; skin incision extended from rostral aspect thyroid cartilage forward toward basihyoid bone; sternohyoideus mm separated bluntly on ventral midline & incision extended to loose fascia btw thyroid cartilage & basihyoid bone; hyoepiglotticus mm enclosed in elastic fascia (hyoepiglotticus ligament) deep to loose fascia; L & R hyoepiglotticus mm separated on midline & incision extended thru layers of loose fascia until oropharyngeal mucosa reached which is opened w curved scissors; further exposure obtained by splitting basihyoid longitudinally w osteotome; malleable or langenbeck retractors needed to retract each side of incision lateral & root of tongue rostrad
Technique for tension palatoplasty
Oral approach; elliptical incision made in oral mucosa starting immediately caudal to caudal edge of hard palate; elliptical section of approx 2/3rds of rostral SP mucosa & submucosa excised; mucosal & submucosal edges reapposed; can be repeated in 4 wks (maximum tension palatoplasty)
Describe staphylectomy
Via laryngotomy (10-12 cm incision along midline centered over cricothyroid space) Sternohyoideus mm divided bluntly; retractor placed btw separated mm exposing cricothyroid memb which is sharply incised along midline from cricoid cartilage to jxn of thyroid cartilages; self-retaining retractor in cricothyroid space; caudal free margin of SP rostral to incision ID’d; caudal free margin of SP containing mass/cyst resected using curved Satinsky thoracic scissors; crescent-shaped 3-4 cm long piece of mucosa less than 1 cm wide on midline & tapered toward both ends should be resected; laryngotomy left to heal by 2nd intention or preferably cricothyroid memb reapposed
Describe standard myectomy procedure for DDSP
10 cm ventral midline incision @ junction of proximal & middle third of neck; paired sternohyoideus mm identified; using curved forceps sternohyoideus & sternothyroideus mm are undermined; sternothyroideus positioned caudolateral to sternohyoideus mm; muscles elevated & clamped w Rochester-Carmalt forceps @ proximal & distal extents of incision; muscle bellies transected removing ~ 6-8 cm long section of mm; significant dead space is created if omohyoideus removed which leads to higher rate of incisional complications so no longer recommended; success rate 58-71%
Describe minimally invasive myectomy
Under GA; 5-7 cm ventral midline incision centered on cricoid cartilage; sternohyoideus mm divided bluntly with curved scissors; blunt dissection continued dorsal to sternohyoideus mm exposing caudolateral border of thyroid cartilage; tendon of insertion of sternothyroideus @ thyroid cartilage undermined & elevated & transected 1 cm caudal to attachment to avoid laryngeal artery & being careful not to damage cricothyroid mm (damage to this muscle causes vocal fold collapse); using one index finger sternothyroideus mm freed from surrounding fascia & transected more proximally removing a 3 cm section of mm; same procedure performed on contralateral sternothyroideus tendon
Describe laryngeal tie-forward procedure
Ventral skin incision made starting 1 cm caudal to cricoid cartilage extending 2 cm rostral to caudal aspect basihyoid bone; sternohyoideus mm separated on midline & bluntly dissected free of dorsolateral aspect of larynx lateral to thyrohyoideus mm; sutures first passed thru thyroid cartilage (No 5 USP polyblend suture – Fiberwire); suture passed twice into right lamina of thyroid cartilage ventral to insertion of sternothyroid tendon; junction of basihyoid & lingual process ID’d w Crile forceps after limited blunt dissection & wire passer placed under hyoid bone immediately lateral to lingual process; wire passer courses over dorsal aspect of basihyoid bone & exits on midline @ caudal aspect of basihyoid bone; after needle has been cut, the dorsal (leader) suture & ventral (trailer) suture of contralateral side passed into wire passer & retrieved; procedure repeated on other side such that dorsal & ventral sutures of each side tied over ventral aspect of basihyoid; bilateral partial sternothyroidectomy performed & sutures on each side tied so rostral aspect of thyroid cartilage located immediately dorsal & 0.1 to 1.5 cm rostral to caudal border of basihyoid bone; when closing loose fascia overlying larynx incorporated into closure to prevent post-op seromas
