William Macnee, Chronic Obstructive Lung Disease (2002)

Surgical Atlas
of
PEDIATRIC
OTOLARYNGOLOGY
Surgical Atlas
of
PEDIATRIC
OTOLARYNGOLOGY
with 900 illustrations
CHARLES D. BLUESTONE, MD
Eberly Professor of Pediatric Otolaryngology
University of Pittsburgh School of Medicine
Director, Department of Pediatric Otolaryngology
Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
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
2002
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© 2002 Charles D. Bluestone and Richard M. Rosenfeld
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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 ref-

erence 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 oto-
logic, 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 children’s hospitals, academic training
programs, and pediatric otolaryngology fellowship programs. Their com-
bined wisdom has been distilled and organized to promote optimal surgi-
cal results.
The Surgical Atlas builds upon a superb foundation established by Atlas
of Pediatric Otolaryngology, published in 1995 as a companion to the two-
volume classic text Pediatric Otolaryngology. This self-contained work con-
tains 15 new chapters on topics including ossiculoplasty, sphenoid sinus
surgery, nasal and septal deformities, surgery to correct drooling, velopha-
ryngeal insufficiency, soft tissue surgery, and maxillofacial trauma. More
than 40 additional procedures are illustrated with new artwork, and exist-
ing illustrations have been redrawn as needed for improved clarity. The text
is completely revised and updated, with extensive reorganization and refor-
matting for easy access.
vi 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” informa-
tion on the gamut of procedures they are likely to encounter in their resi-
dence 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 eso-
teric procedures, with literature citations for additional details. The beauti-
ful 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 consis-
tency and clarity to the text. We are also indebted to our excellent editori-
al assistants, Deborah Hepple and Billy Tang, for their secretarial support
and help in collating the manuscripts. Mr. Tang’s 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 pre-
cursor, 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 Margaretha L. Casselbrant, MD, PhD

Department of Otolaryngology Professor of Otolaryngology
New York University Medical Center University of Pittsburgh School of Medicine
New York, New York Department of Pediatric Otolaryngology
Chapter 9: Cochlear Implants Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Cuneyt M. Alper, MD
Chapter 26: Tracheotomy
Associate Professor of Otolaryngology
University of Pittsburgh School of Medicine Kenny H. Chan, MD
Department of Pediatric Otolaryngology Professor of Otolaryngology
Children’s Hospital of Pittsburgh University of Colorado School of Medicine
Pittsburgh, Pennsylvania Chairman, Department of Pediatric Otolaryngology
Chapter 26: Tracheotomy Children’s Hospital
Denver, Colorado
James S. Batti, MD
Chapter 25: Endoscopy of the Upper Aerodigestive Tract
Assistant Professor of Pediatric Otolaryngology
University of Connecticut Noel L. Cohen, MD
Department of Otolaryngology Professor of Otolaryngology
Connecticut Children’s Medical Center New York University School of Medicine
Hartford, Connecticut Chairman, Department of Otolaryngology
Chapter 4: Ossiculoplasty New York University Medical Center
New York, New York
Chapter 9: Cochlear Implants
Eberly Professor of Pediatric Otolaryngology
University of Pittsburgh School of Medicine William S. Crysdale, MD
Director, Department of Pediatric Otolaryngology Professor of Otolaryngology
Children’s Hospital of Pittsburgh University of Toronto
Pittsburgh, Pennsylvania Otolaryngologist-in-Chief
Chapter 1: Tympanostomy Tubes and Related Procedures Hospital for Sick Children
Chapter 2: Approaches to the Middle Ear and Mastoid Toronto, Ontario
Chapter 3: Myringoplasty and Tympanoplasty Chapter 11: Nasal and Septal Deformities
Chapter 4: Ossiculoplasty Chapter 19: Surgery for Drooling
Chapter 5: Mastoidectomy and Cholesteatoma
Chapter 6: Perilymphatic Fistula and Eustachian Tube Surgery
Chapter 31: Otoplasty for the Prominent Ear
viii Contributors
Michael J. Cunningham, MD Carlos Gonzalez, MD

Associate Professor of Otolaryngology Clinical Associate Professor of Otolaryngology
Harvard Medical School University of Puerto Rico School of Medicine
Department of Otolaryngology–Head and Neck Surgery Chief, Department of Surgery
Massachusetts Eye and Ear Infirmary San Jorge Children’s Hospital
Boston, Massachusetts San Juan, Puerto Rico
Chapter 20: Cervical Adenopathy Chapter 16: Surgery of the Tongue
Chapter 23: Salivary Gland Surgery
Chapter 24: Thyroidectomy Charles W. Gross, MD
Professor of Otolaryngology
Robin A. Dyleski, MD University of Virginia Health System
Assistant Professor of Pediatric Otolaryngology Department of Otolaryngology–Head and Neck Surgery
University of Arkansas for Medical Sciences University of Virginia Medical Center
Vice Chief, Department of Pediatric Otolaryngology Charlottesville, Virginia
Arkansas Children’s Hospital Chapter 29: Soft Tissue Surgery
Little Rock, Arkansas
Chapter 33: Cleft Lip and Cleft Palate Gady Har-El, MD
Roland D. Eavey, MD SUNY Downstate Medical Center
Associate Professor of Otolaryngology Vice Chairman, Department of Otolaryngology
Harvard Medical School Long Island College Hospital and University Hospital
Director of Pediatric Otolaryngology of Brooklyn
Department of Otolaryngology–Head and Neck Surgery Brooklyn, New York
Massachusetts Eye and Ear Infirmary Chapter 15: Sphenoid Sinus Surgery
Boston, Massachusetts
Chapter 30: Auricular Repair for Microtia Gerald B. Healy, MD
Professor of Otology and Laryngology
Jose N. Fayad, MD Harvard Medical School
Department of Otolaryngology Otolaryngologist-in-Chief, Department of
Manhattan Eye Ear and Throat Hospital Otolaryngology
Lenox Hill Hospital Children’s Hospital Boston
New York, New York Boston, Massachusetts
Chapter 8: Ear Canal Stenosis and Atresia Chapter 27: Surgery of the Larynx and Trachea
Norman Friedman, MD Raymond L. Hilsinger Jr, MD

Assistant Professor of Otolaryngology Chief, Department of Head and Neck Surgery
University of Colorado School of Medicine Kaiser Permanente Medical Center
Denver, Colorado Oakland, California
Chapter 25: Endoscopy of the Upper Aerodigestive Tract Chapter 7: Facial Nerve Exploration and Repair
Ari J. Goldsmith, MD Andrew J. Hotaling, MD

Associate Professor of Otolaryngology Professor of Otolaryngology and Pediatrics
SUNY Downstate Medical Center Chief, Pediatric Otolaryngology
Division of Pediatric Otolaryngology Department of Otolaryngology–Head and Neck Surgery
Department of Otolaryngology Loyola University Medical Center
Long Island College Hospital and University Hospital Chicago, Illinois
of Brooklyn Chapter 14: Inflammatory Sinonasal Disease
Brooklyn, New York
Chapter 17: Tonsillectomy, Adenoidectomy, and UPPP
Contributors ix
Kevin J. Hulett, MD Scott C. Manning, MD

Department of Otolaryngology–Head and Neck Surgery Associate Professor of Otolaryngology
Loyola University Medical Center University of Washington
Chicago, Illinois Chief, Pediatric Otolaryngology–Head and Neck Surgery
Chapter 14: Inflammatory Sinonasal Disease Department of Otolaryngology
Children’s Hospital & Medical Center
Glenn Isaacson, MD Seattle, Washington
Professor of Otolaryngology Chapter 10: Epistaxis
Chairman, Department of Otolaryngology–Head and
Neck Surgery Lawrence J. Marentette, MD
Temple University School of Medicine Associate Professor of Otolaryngology and Neurosurgery
Philadelphia, Pennsylvania Director, Cranial Base Program
Chapter 13: Endoscopic Ethmoidectomy and Antrostomy Department of Otolaryngology–Head and Neck Surgery
University of Michigan Health System
Robert M. Kellman, MD Ann Arbor, Michigan
Professor of Otolaryngology Chapter 34: Craniosynostosis
Chairman, Department of Otolaryngology and Com-
munication Sciences Khosrow Mojdehi, MD
SUNY Health Science Center at Syracuse Assistant Professor of Anesthesiology
Syracuse, New York SUNY Downstate Medical Center
Chapter 32: Maxillofacial Trauma Director, Division of Pediatric Anesthesiology
Department of Anesthesiology
Margaret A. Kenna, MD Long Island College Hospital and University Hospital
Associate Professor of Otology and Laryngology of Brooklyn
Harvard Medical School Brooklyn, New York
Department of Otolaryngology Chapter 36: Pediatric Anesthesia
Children’s Hospital Boston
Boston, Massachusetts Simon C. Parisier, MD
Chapter 12: Congenital Nasal Malformations Chairman Emeritus, Department of Otolaryngology
Manhattan Eye Ear and Throat Hospital
John Kim, MD Lenox Hill Hospital
Department of Otolaryngology–Head and Neck Surgery New York, New York
University of Michigan Health System Chapter 8: Ear Canal Stenosis and Atresia
Ann Arbor, Michigan
Chapter 34: Craniosynostosis Stephen S. Park, MD
Associate Professor of Otolaryngology
Charles F. Koopman Jr, MD University of Virginia Health System
Professor of Pediatric Otolaryngology Director, Division of Facial Plastic and Reconstructive
University of Michigan Medical Center Surgery
Chief, Division of Pediatric Otolaryngology Department of Otolaryngology–Head and Neck Surgery
Department of Otolaryngology–Head and Neck Surgery University of Virginia Medical Center
C.S. Mott Children’s Hospital Charlottesville, Virginia
Ann Arbor, Michigan Chapter 29: Soft Tissue Surgery
Chapter 21: Deep Neck Infections
David M. Polaner, MD
Greg R. Licameli, MD Associate Professor of Anesthesiology
Assistant Professor of Otology and Laryngology University of Colorado School of Medicine
Harvard Medical School Denver, Colorado
Department of Otolaryngology Chapter 25: Endoscopy of the Upper Aerodigestive Tract
Children’s Hospital Boston
Chapter 27: Surgery of the Larynx and Trachea
x Contributors
Reza Rahbar, DMD, MD Christopher E. Stevens, MD

Instructor in Otology and Laryngology Department of Otolaryngology–Head and Neck Surgery
Harvard Medical School University of Virginia Health System
Department of Otology and Laryngology Charlottesville, Virginia
Children’s Hospital Boston Chapter 29: Soft Tissue Surgery
Chapter 12: Congenital Nasal Malformations Sylvan E. Stool, MD
Emeritus Professor of Otolaryngology
Mark A. Richardson, MD University of Colorado School of Medicine
Professor and Chairman Denver, Colorado
Department of Otolaryngology–Head and Neck Surgery Chapter 25: Endoscopy of the Upper Aerodigestive Tract
Oregon Health and Science University
Portland, Oregon Sherard A. Tatum, MD
Chapter 22: Congenital Malformations of the Neck Associate Professor of Otolaryngology
Director, Division of Facial Plastic and Reconstructive
Keith H. Riding, MD Surgery
Clinical Professor Department of Otolaryngology and Communication
University of British Columbia Sciences
Staff Otolaryngologist SUNY Health Science Center at Syracuse
British Columbia Children’s Hospital Syracuse, New York
Vancouver, British Columbia Chapter 32: Maxillofacial Trauma
Chapter 25: Endoscopy of the Upper Aerodigestive Tract
Jon B. Turk, MD
J. Thomas Roland Jr, MD Assistant Professor of Otolaryngology
Department of Otolaryngology SUNY Downstate Medical Center
New York University Medical Center Director, Facial Plastic and Reconstructive Surgery
New York, New York Department of Otolaryngology
Chapter 9: Cochlear Implants Long Island College Hospital
Brooklyn, New York
Richard M. Rosenfeld, MD, MPH Chapter 11: Nasal and Septal Deformities
SUNY Downstate Medical Center Jay A. Werkhaven, MD
Director, Division of Pediatric Otolaryngology Associate Professor of Otolaryngology
Department of Otolaryngology Department of Otolaryngology
Long Island College Hospital and University Hospital Vanderbilt University Medical Center
of Brooklyn Nashville, Tennessee
Brooklyn, New York Chapter 28: Laryngotracheal Laser Surgery
Chapter 17: Tonsillectomy, Adenoidectomy, and UPPP
Chapter 22: Congenital Malformations of the Neck J. Paul Willging, MD
Chapter 35: Information for Parents and Caregivers Associate Professor of Otolaryngology
University of Cincinnati College of Medicine
Robert W. Seibert, MD Department of Otolaryngology
Professor of Pediatric Otolaryngology Children’s Hospital Medical Center
University of Arkansas for Medical Sciences Cincinnati, Ohio
Department of Pediatric Otolaryngology Chapter 18: Velopharyngeal Insufficiency
Arkansas Children’s Hospital
Little Rock, Arkansas
Chapter 33: Cleft Lip and Cleft Palate
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
xii Contents
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
Contents xiii
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
xiv Contents
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. Reinke’s edema and vocal cord polyps ..............................................................................660
Contents xv
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
In this chapter, I provide my indications and surgical techniques for the following proce-
dures: tympanocentesis, myringotomy, grommet-type tympanostomy tube placement, per-
manent 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 myringo-
tomy 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 symp-
toms
• 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 immunolog-
ically 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 anes-
thetic, is advisable.
• For older children and adolescents, a small amount of phenol can be
used on the tympanic membrane before the needle is inserted.
2 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 essen-
tial 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 col-
lection trap.
• The following method is recommended for tympanocentesis and aspira-
tion of a middle-ear effusion for microbiologic assessment:
♦ A culture of the external auditory canal can be obtained with a Cal-
giswab that is moistened with trypticase soy broth if an unusual mid-
dle-ear organism is suspected.
♦ The external canal is filled with 70% ethyl alcohol for 1 minute (Fig-
ure 1–1). The alcohol is removed from the ear canal by aspiration
when an unusual middle-ear organism is suspected.
Figure 1–1 Ethyl alcohol (70%)

is instilled in the external canal
for 1 minute.
Tympanostomy Tubes and Related Procedures 3
♦ Tympanocentesis is performed in the inferior portion of the tympan-

ic membrane with an Alden-Senturia trap with a needle attached
(Figure 1–2). 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 1–2 Alcohol is removed

from the ear canal by aspiration,
and tympanocentesis is per-
formed 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, tympa-
nocentesis 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 pro-
cedure,3 which awaits appropriate clinical trials comparing laser myringo-
tomy (with or without insertion of a tympanostomy tube) with the stan-
dard knife myringotomy.
• The anesthetic considerations and immobilization of the child are simi-
lar to those described for tympanocentesis.
Procedure
• A wide-field incision (Figure 1–3A) 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 1–3B) if a tympanostomy tube is to be inserted (an incision in
the anteroinferior quadrant is a reasonable alternative).
Figure 1–3 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 1–4A).
• When a wide-field inferiorly placed myringotomy is indicated, a larger
aspirator is used (Figure 1–4B).
• If, during myringotomy, the effusion is too viscid to be aspirated through
the anterosuperior radial myringotomy, a “counter incision” myringoto-
my 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 dis-
cussed in detail below (see Grommet-Type Tympanostomy Tube Insertion).
Figure 1–4 A, A small Baron or

Fraser aspirator is used for aspi-
ration of middle-ear effusion.
B, When a wide-field inferiorly
placed myringotomy is indicat-
ed, a larger aspirator is used.
GROMMET-TYPE TYMPANOSTOMY TUBE INSERTION

Of the many types of tubes currently available, the biflanged Armstrong-
type grommet tube is preferred for routine placement. Our studies have
shown that it remains functional for approximately 12-18 months (range
6-24 months). 5–7
Indications
The following are indications for the placement of a grommet-type tympa-
nostomy 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, dis-
equilibrium 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 dura-
tion 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 disequilibri-
um. 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).
♦ Eustachian tube function testing is usually not feasible prior to surgery
for cholesteatoma unless a tympanostomy tube is in place or a perfora-
tion 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.
• 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 2–1 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 anterosu-
perior 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 1–3A) 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 mid-
dle-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 1–5);
the Armstrong-type grommet tube is preferred.
Figure 1–5 An alligator forceps

is used to insert the tympanosto-
my tube into the previously per-
formed myringotomy in the
anterosuperior quadrant of the
pars tensa.
♦ Forceps with a serrated (not smooth) edge are recommended to per-

mit better control of tube position and angulation during insertion.
♦ The tube is placed in either the anterosuperior or anteroinferior
quadrant (Figure 1–6); there is no consensus regarding the safest and
most effective position for tube placement. Placement in the antero-
superior may be associated with a longer duration, however, if a
chronic perforation occurs following extrusion, repair of the tympan-
ic is somewhat more difficult than when the perforation develops in
the anteroinferior quadrant. Nevertheless, these perforations, irre-
spective of site, can be successfully repaired in most children (see
Chapter 3).
Figure 1–6 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 1–7). If a longer period of ventilation is desired, how-
ever, 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 instilla-
tion 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 func-
tioning, the child can be re-examined in 6-12 months and then every
Figure 1–7 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.
6 months until spontaneous extrusion occurs. Ideally, periodic examina-

tion 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 antimi-
crobial 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-inser-
tion, 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 oti-
tis media, with otorrhea, at the time of tube placement. To avoid this
complication, place the patient on prophylactic antibiotics (eg, amoxi-
cillin, 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.
♦ 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 prop-
erly repositioned or extracted and re-inserted.
♦ If the tympanostomy tube is found to be behind the tympanic mem-
brane during the postoperative period and the child requires re-inser-
tion of the tube, then the procedure described above can be per-
formed. 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
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 usu-
ally 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 fol-
lowing 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 inser-
tions 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) perfora-
tion is desirable. This author uses one of two types: the Per-Lee tube (Xomed-
Treace Inc, Jacksonville, FL)16 or the Richards T-Tube (Smith-Nephew Inc,
Bartlett, TN). 15
Indications
The following are indications for placement of a permanent tympanosto-
my tube:
• Otitis media or atelectasis of the middle ear is determined to be perma-
nent (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 potential-
ly life-long eustachian tube dysfunction.
• 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 pro-
cedures)
• When a Per-Lee tube is to be used, an incision is made with a myringoto-
my knife immediately anterior to the body of the malleus (Figure 1–8).
Figure 1–8 An incision is made

anterior to the body of the
malleus.
• A Per-Lee tube is preferred:

♦ 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 1–9).
♦ The tube is inserted using alligator forceps. Compression of flanges
with alligator or cup forceps aids in insertion of the tube (Figure 1–10).
♦ The tube is in place. Note the posterior flange behind the malleus
(Figure 1–11).
Figure 1–9 A Per-Lee tube is

shortened.
Figure 1–10 The tube is inserted using an alligator forceps. Figure 1–11 The tube in place.
• A Richards T-tube may also be used:

♦ The tube shaft is trimmed (Figure 1–12) 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 1–12 The Richards

T-tube is cut short (similar to
Figure 1–9) and grasped by the
tips of the alligator forceps so
that the two flanges are folded
backwards inside the forceps.
♦ Both flanges of the T-tube are pressed by the forceps (see Figure
1–12), inserted through the myringotomy incision (Figure 1–13A),
and allowed to spring out behind the tympanic membrane (Figure
1–13B). 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 1–13 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.
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 par-
tially 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 proce-
dure is painful and the rim of the perforation can be denuded of epithe-
lium. This also allows the defect to be closed (ie, myringoplasty) follow-
ing 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.5–7
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 infan-
cy and declines rapidly after about 6 years of age. In addition, the structure
and function of the eustachian tube as well as the child’s immunity are usu-
ally more mature after 6 years of age. Therefore, removal of tubes in chil-
dren 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 (appar-
ently 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
• 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 con-
trol 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 dura-
tion 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
• 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 (Fig-
ure 1–14).
• Epithelium from the rim of the perforation is removed using a right-
angled pick, or using a gently curved pick to split the layers of tympan-
ic membrane and a cup forceps to remove the tissue (Figure 1–15).
Figure 1–14 The myringotomy tube is gently removed using

an alligator forceps.
Figure 1–15 Epithelium from the rim of the perforation is

removed using a right-angled pick.
• A circular portion of Steri-Strip is cut and placed over the perforation

(Figure 1–16). 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 1–17).
Figure 1–16 A circular portion of Steri-Strip (Medical-Sur-

gical Division/3M, St. Paul, MN) is cut and placed over the
perforation.
Figure 1–17 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).
Postoperative Care
• The patient is re-examined after 4 to 6 weeks. At that time, the Steri-
Strip patch has usually come off the tympanic membrane and the per-
foration 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 otomi-
croscope and a Bruening otoscope with a nonmagnifying lens. A micro-
scopic defect, however, may still be present despite seemingly good tym-
panic mobility as observed during pneumatic otoscopy. Tympanometry
is the most sensitive method to confirm that the tympanic membrane is
intact.
REFERENCES
1. Bluestone CD, Klein JO. Otitis Media in Infants and Children. St. Louis, (MO): WB Saun-
ders; 2001. p. 162–3, 252–69.
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;87:466–73.
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;109:2009–14.
4. Bluestone CD. Efficacy of ofloxacin and other ototopical preparations for chronic suppurative oti-
tis media in children. Pediatr Infect Dis J 2001;20:111–5.
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 ran-
domized clinical trial. Pediatr Infect Dis J 1992;11:278–86.
6. Mandel EM, Rockette HE, Bluestone CD, et al. Myringotomy with and without tympanosto-
my tubes for chronic otitis media with effusion. Arch Otolaryngol Head Neck Surg
1989;115:1217–24.
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;11:270–7.
8. Bluestone CD, Klein JO, Gates GA. “Appropriateness” of tympanostomy tubes. Setting the
record straight. Arch Otolaryngol Head Neck Surg 1994; 120:1051–3.
9. Gross RD, Burgess LP, Holtel MR, et al. Saline irrigation in the prevention of otorrhea after
tympanostomy tube placement. Laryngoscope 2000; 110:246–51.
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;125:537–45.
11. Derkay CS, Carron JD, Wiatrak BJ, et al. Postsurgical follow-up of children with tympanosto-
my tubes: results of the American Academy of Otolaryngology-Head Neck Surgery Pediatric
Otolaryngology Committee National Survey. Otolaryngol Head Neck Surg 2000;
122:313–8.
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. 313–36.
13. Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect
Dis J 2000;19 Suppl:37–46.
14. Buckley WJ, Bowes AK, Marlowe JF. Complications following ventilation of the middle ear
with Goode T tubes. Arch Otolaryngol Head Neck Surg 1991;91:895–8.
15. Goode RL. Long-term middle-ear ventilation with T-tubes: the perforation problem. Oto-
laryngol Head Neck Surg 1996;115:500–1.
16. Per-Lee JH. Long-term middle ear ventilation. Laryngoscope 1981;91:1063–73.
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 postau-
ricular 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 trans-
canal approach to the middle ear. The tympanomeatal flap that is devel-
oped 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 postauricu-
lar 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 local-
ized 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 2–2B ).
• “Second look” tympanotomy: This procedure is usually performed approx-
imately 6 months after surgery for cholesteatoma, in which the tympan-
ic membrane is present and prevents adequate postoperative examina-
tion to determine if there is residual cholesteatoma. On occasion, a
“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 per-
formed and the external canal is large enough to provide adequate visu-
alization of the operative site
• Exploratory tympanotomy: When an examination of the middle ear is indi-
cated 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 per-
ilymphatic 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 tympa-
ni or stapedius muscles, which are rarely indicated in children.
• Local anesthetic (1% lidocaine with 1:100,000 epinephrine) is infiltrat-
ed into all four quadrants of the ear canal (6, 9, 12, and 3 o’clock) just
lateral to the bony-cartilaginous junction and the graft site, for hemo-
stasis and to enhance the anesthesia (Figure 2–1).
• 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 2–1 Injection sites (x)

for transcanal approach.
Approaches to the Middle Ear and Mastoid 23
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 surgeon’s hands are free to perform the procedure, a specu-
lum 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 2–2A). 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 epitympa-
num is desired, such as when disease involves the attic (ie, superior tym-
panomeatal flap) (Figure 2–2B). The incision is made more lateral and
anterior.
Figure 2–2 A, This incision

(dashed line) is used when the
mesotympanum and hypotym-
panum 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. B
• 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 2–3).
• The middle ear is entered by elevating the annulus with a curved pick
just below the chorda tympani nerve (Figure 2–4).
Figure 2–3 The tympanomeatal

flap is elevated to the annulus
with a moon elevator.
Figure 2–4 The middle ear is

entered by elevating the annulus.
• The superior portion of the tympanomeatal flap is completed using

microscissors (Figure 2–5).
• 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 2–6).
Figure 2–5 The superior por-

tion of the tympanomeatal flap
is completed using microscissors.
Figure 2–6 Curettage of the

scutum.
• 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 2–7).

flap is completed when the poste-
rior portion of the malleus is
exposed and the flap extends to
at least both 6 and 12 o’clock;
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 exam-
ple, if only a tympanoplasty was performed, the canal is filled with an
antibiotic ointment, as described in Chapter 1 (see Removal of Tympa-
nostomy Tube and Myringoplasty). In such cases, the child can be re-exam-
ined 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 meso-
tympanum; as well, a fascia graft can be easily obtained from the tempo-
ralis 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 enlarg-
ing, or when placement of a tympanostomy tube fails to reverse an
extensive pocket
• 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 tympa-
nomeatal flap (see Chapter 6)
• General anesthesia is almost always required, and local infiltrative anes-
thesia is also used. Injection sites are the same as those described for a
transcanal approach (see Figure 2–1), 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 orig-
inally 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
2–8). Injection sites are just lateral to the junction but directed toward the
bony canal and into the incisura of the pinna.
Figure 2–8 A Lempert speculum

exposes the bony-cartilaginous
junction for injection of a local
anesthetic agent.
x = injection sites
• 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 2–9).
• 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
2–10); the No 15C blade, which is smaller than the standard one, can
be used in infants to make the incision in the incisura.
Figure 2–9 A posterior canal

incision is made with the Rosen
flap knife.
Figure 2–10 The incision is

continued into the incisura of
the pinna but superficial to the
temporalis muscle.
• An anterior incision in the canal is connected to, and is a continuation

of, the posterior canal incision (Figure 2–11).
• The lateral posterior and anterior flaps are elevated with a periosteal ele-
vator to permit insertion of the self-retaining retractor (Figure 2–12).
• The tympanomeatal flap, tympanic membrane, and temporalis muscle are
exposed (Figure 2–13).
Figure 2–11 An anterior relaxing incision in the Figure 2–12 The lateral posterior and anterior flaps are elevated.
canal.
Figure 2–13 The tympa-

nomeatal flap, tympanic mem-
brane, and temporalis muscle are
exposed with the aid of a self-
retaining retractor.
• The tympanomeatal flap is elevated (Figure 2–14). When indicated, the

flap is dissected off the malleus (Figure 2–15).
Figure 2–14 The tympanomeatal flap is elevated.
Figure 2–15 Dissection of the flap off the malleus using a

curved pick.
• The flap is elevated, exposing the middle ear (Figure 2–16).

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.
POSTAURICULAR APPROACH
The postauricular approach is frequently used in children. Since it facili-
tates exposure of the middle ear, a fascia graft can be readily obtained from
the temporalis muscle, and it is the preferred approach when a mastoidec-
tomy is to be performed.
Indications
• The postauricular incisions and approach are indicated when there is dis-
ease 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).
• The anesthesia is the same as that described for the transcanal approach,
but additional injection sites are required in the postauricular area (Fig-
ure 2–17).
Figure 2–17 Injection sites (x)

in the postauricular area in addi-
tion to those in the canal.
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 2–18A). In children younger than 4 years of age, the inci-
sion is made away from the stylomastoid foramen and the facial nerve;
injection sites are altered accordingly (Figure 2–18B).
A B
Figure 2–18 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.
• The postauricular soft tissue is exposed (Figure 2–19).

• A transcanal incision is made from the 6 to 12 o’clock position about one-
third of the distance from the annulus to the meatus to create a Koerner
flap (the transcanal incision usually precedes the postauricular incision)
(Figure 2–20).
Figure 2–19 The postauricular

soft tissue is exposed.
Figure 2–20 A transcanal inci-

sion is made with a Rosen flap
knife to create a Koerner flap.
• Canal incisions are extended laterally (Figure 2–21).

• 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 2–22). 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 premature-
ly entering the middle ear.
Figure 2–21 Canal incisions are

extended laterally.
Figure 2–22 The Koerner flap is

elevated a few millimeters later-
ally in the canal.
• A “T” incision is made in postauricular soft tissue and the periosteum is

elevated (Figure 2–23). 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
2–24).
Figure 2–23 A “T” incision is

made in postauricular soft tissue
and is elevated with a periosteal
elevator.
Figure 2–24 The Koerner flap is

elevated.
• The tympanic membrane, tympanomeatal flap, and mastoid are exposed

(Figure 2–25).
• 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 (Fig-
ure 2–26).
Figure 2–25 The tympanic

membrane, tympanomeatal flap,
and mastoid are exposed.
Figure 2–26 A Penrose drain is

used to retract the Koerner flap
anteriorly to protect the flap
when the retractor is inserted.
• The tympanomeatal flap is elevated and reflected anteriorly to expose

the mesotympanum, similar to that described for the transcanal
approach (Figure 2–27).

flap is elevated and reflected
anteriorly to expose the meso-
tympanum.
Postoperative Care
• The postauricular incision is closed with an absorbable suture; a drain is
optional. Two strips of Adaptic gauze impregnated with antibiotic oint-
ment 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. Rosen S. Mobilization of the stapes to restore hearing in otosclerosis. NY J Med
1953;53:2650–3.
2. Rosenfeld RM, Moura RL, Bluestone CD. Predictors of residual-recurrent cholesteatoma in
children. Arch Otolaryngol Head Neck Surg 1992;118:384–91.
3. 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;27:555–87.
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 tech-
nique 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, where-
as 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 inferi-
or quadrants), a transcanal approach is used, employing a tympa-
nomeatal 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 tym-
panic 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.
Myringoplasty
Myringoplasty is a procedure used to repair a tympanic membrane perfo-
ration, 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 pre-
sent secondary to a previously extruded tympanostomy tube, as a compli-
cation 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 perfora-
tion 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 myringo-
plasty) 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 post-
operative otitis media. More recently, other surgeons4,5,6 have reported tym-
panoplasty 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 per-
formed 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 retrac-
tion pocket is present, or when an occult middle-ear cholesteatoma is sus-
pected. Additional indications would be when the perforation is large,
when its location makes it difficult to repair using a myringoplasty proce-
dure (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 oppor-
tunity 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 post-
operative 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 tympa-
nostomy 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 anterosupe-
rior 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 antero-
superior perforation is difficult owing to the constricted space. Perfora-
tions in this quadrant are repaired more effectively using the endaural
tympanoplastic technique described later (see Endaural Medial Fascia
Graft Tympanoplasty).
• 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 opera-
tion 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.
• 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 surgeon’s hands are free to perform the procedure, a specu-
lum 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 tempo-
ralis graft is to be used.
Procedure
• Sites of injection of the local anesthetic agent are just lateral to the bony-
cartilaginous junction at 3, 6, 9, and 12 o’clock (Figure 3–1). The anes-
thetic 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 3–2A), and the graft is excised (Figure
3–2B).
Figure 3–1 Sites of injection (x)

of the local anesthetic agent.
Figure 3–2 A, An incision for a

fascia graft is made superior to
the pinna just above the hairline.
B, The fascia graft is excised.
B
• 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 3–3A), and
the perichondrial graft is excised (Figure 3–3B).
Figure 3–3 A, An incision for a

perichondrial graft is made in
the tragus. B, The graft is
excised from the posterior sur-
face of the tragus.
B
• 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 3–4).
• A small central perforation is ideal for this procedure (Figure 3–5).
Figure 3–4 A fat graft is taken

from the lobule through an inci-
sion on the posterior surface.
Figure 3–5 A small central per-

foration is present.
• 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 3–6).
Figure 3–6 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 3–7) and the graft is
placed medial to the tympanic membrane (Figure 3–8).
Figure 3–7 The middle ear is filled with absorbable Figure 3–8 A tissue graft is placed medial to the tympanic
gelatin sponge (Gelfoam) (The Upjohn Company, membrane.
Kalamazoo, MI).
• A Steri-Strip is placed over the perforation and tissue graft (Figure 3–9).
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 3–10).
Figure 3–9 A Steri-Strip is

placed over the perforation and
tissue graft.
Figure 3–10 An antibiotic oint-

ment is instilled into the exter-
nal auditory canal using a
syringe and plastic needle tip.
When a fat-plug graft is used to repair the perforation:

• The graft is inserted tightly into the perforation (Figure 3–11A), with
half of the fat in the middle ear and half on the outer surface of the tym-
panic membrane (Figure 3–11B).
• 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 3–10.
Postoperative Care
• Postoperative care is similar to that described in Chapter 1 under
Removal of Tympanostomy Tube and Myringoplasty.
Figure 3–11 A, A fat-plug graft

is tightly inserted into the perfo-
ration. B, The plug should be
half in the middle ear and half
out on the lateral surface of the
tympanic membrane.
B
TRANSCANAL MEDIAL FASCIA OR FAT-PLUG GRAFT

TYMPANOPLASTY
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 tis-
sue 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 previ-
ously described in Chapter 2 (see Figures 2–1 to 2–7).
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 uti-
lizes 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 perfo-
ration is limited to the posterosuperior, posteroinferior, or both quadrants,
a medial graft can be utilized. The graft is placed over the superior, posteri-
or, 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 mem-
brane
• 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 3–1, and the post-
auricular anesthesia is shown in Chapter 2, Figure 2–17.
Procedure
• The epithelium is cleaned off the margin or rim of the perforation as
shown in Chapter 1, Figure 1–15. The canal and postauricular incisions
and approach are shown in Chapter 2, Figures 2–18 to 2–27.
• Following elevation of the tympanomeatal flap off the malleus (Figure

3–12A), the middle ear is filled with Gelfoam, and the fascia graft,
which has been harvested from the temporalis muscle, is placed anteri-
orly over the malleus, and onto the superior, posterior, and inferior
medial portions of the ear canal (Figure 3–12B).
Figure 3–12 A, The tympa-

nomeatal 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.
B
• The tympanomeatal flap is replaced to its original position (Figure

3–13A), and the Koerner flap is then replaced to its original position
(Figure 3–13B), 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 3–13 A, The tympa-

nomeatal flap is replaced.
B, The Koerner flap is replaced.
B
ENDAURAL MEDIAL FASCIA GRAFT TYMPANOPLASTY

Attempts to close perforations in the anterosuperior portion of the pars
tensa of the tympanic membrane using traditional transcanal myringoplas-
ty 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 com-
plete 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 expo-
sure provides an opportunity to visualize the mesotympanum as well as
place a medial graft on three areas of attachment: the anterior and superi-
or canal walls, and the malleus. In addition, the fascia graft from the tem-
poralis 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 tympa-
nostomy tube (see Cartilage Graft Tympanoplasty below). Also, this
approach is used for small congenital cholesteatomas that are in the antero-
superior 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.
Procedure
• Perforation occurs in the anterosuperior quadrant of the pars tensa (Fig-
ure 3–14).
• The epithelium at the rim of the perforation is removed with a pick, and
a cup forceps is also used (Figure 3–15).
Figure 3–14 Perforation in the

anterosuperior quadrant of the
pars tensa.
Figure 3–15 The epithelium at

the rim of the perforation is dis-
sected with a pick.
• 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 3–16).
• The fascia graft is harvested from the temporalis fascia (Figure 3–17).
Figure 3–16 An endaural inci-

sion and approach are completed.
Figure 3–17 A fascia graft is

harvested from the temporalis
fascia.
• 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 3–18).
• 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 dis-
sected 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 3–19).

flap is elevated from the canal walls.
Figure 3–19 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.
• 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 3–20).
• The tympanomeatal flap is replaced (Figure 3–21).

placed over the superior and
anterosuperior canal walls and
the malleus.

flap is replaced noting that the
perforation is completely covered
medially by the fascia graft.
• Adaptic packing is inserted into the external canal; a layer of Gelfoam is

placed over the tympanic membrane (Figure 3–22).
• The endaural incision is closed with an absorbable suture (Figure 3–23).
Postoperative Care
• The postoperative care is described earlier in Chapter 2 under Endaural
Approach.
Figure 3–22 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 3–23 The endaural inci-

sion is closed with absorbable
suture.
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 perfo-
rations. The reason why the lateral graft technique has a better long-term suc-
cess 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 nega-
tive middle-ear pressure, which is usually present in children who have mid-
dle-ear disease, is probably deleterious to a medial graft during the immedi-
ate postoperative period, whereas negative middle-ear pressure is an
advantage when a lateral graft is used. An additional application for the lat-
eral 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 epithe-
lial 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 canalo-
plasty 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
• 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 3–24).
Figure 3–24 This is the typical

size of a perforation to be
repaired.
• An incision for a “long” Koerner flap is made closer (approximately 2

mm) to the posterior annulus than the usual incision (Figure 3–25).
• The postauricular incision and approach are completed (see Chapter 2
under Postauricular Approach), and a fascia graft is taken from the tem-
poralis muscle (Figure 3–26).
Figure 3–25 An incision for a

“long” Koerner flap is made
closer to the posterior annulus.

incision and approach are com-
pleted, and a fascia graft excised.
• A “T” incision is made in the postauricular soft tissue (Figure 3–27).

• A Penrose drain is placed for retraction of the Koerner flap (Figure
3–28).
Figure 3–27 A “T” incision in

the postauricular soft tissue.
Figure 3–28 A Penrose drain is

placed for retraction of the
“long” Koerner flap.
• An anterior incision for the anterior flap is made approximately 2 mm

lateral to the anterior annulus and is connected to the Koerner flap inci-
sion (Figure 3–29). If the ear canal is too narrow to visualize the anteri-
or canal wall and annulus, a canaloplasty (primarily in the lateral por-
tion of the posterior canal wall), using an air drill, is helpful; the
canaloplasty is readily performed, since the two pedical flaps are retract-
ed out of the field and the bony canal is completely exposed.
• The anterior flap is elevated, rolled, and tucked laterally out of the medi-
al portion of the canal (Figure 3–30).
Figure 3–29 An anterior incision

is made approximately 2 mm
lateral to the anterior annulus.
Figure 3–30 The anterior flap is

elevated.
• 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 3–31).
• The canal wall is curetted to remove any remnants of canal skin; a
microdrill is another option. When indicated, a canaloplasty can be per-
formed at this stage (Figure 3–32).
Figure 3–31 The remaining

medial strip of canal skin and
the entire outer epithelial layer
of the tympanic membrane are
removed.
Figure 3–32 The canal wall is

curetted to remove any remnants
of canal skin.
• The annulus is elevated to examine the mesotympanum and the ossicles

(Figure 3–33).
• The middle ear is filled with Gelfoam (Figure 3–34).
Figure 3–33 The annulus is ele-

vated to examine the mesotym-
panum and the ossicles.

filled with Gelfoam.
• 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 3–35).
• The anterior pedicle flap is replaced and overlaps the lateral edge of the
anterior portion of the fascia graft (Figure 3–36).

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 3–36 The anterior pedi-

cle flap is replaced and overlaps
the outer anterior edge of the
graft.
• The Penrose drain is removed, and the Koerner flap, which overlaps the
lateral edge of the posterior portion of the fascia graft, is replaced (Fig-
ure 3–37).
• A layer of Gelfoam is placed over the tympanic membrane remnant and
graft, and two strips of Adaptic gauze impregnated with antibiotic oint-
ment are inserted into the external canal (Figure 3–38).
Figure 3–37 The Penrose drain

is removed, and the Koerner flap
is replaced.
Figure 3–38 A layer of Gelfoam

is placed over the graft and
medial portions of the two flaps,
and two strips of Adaptic are
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,
between the graft and the remnant of the tympanic membrane or in the
canal wall, is not an uncommon postoperative sequela; occurrence is fre-
quently related to the inexperience of the surgeon.
• When lateralization of the graft is a postoperative complication, it usu-
ally 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 tym-
panic membrane or canal wall requires a stronger support than just a soft-
tissue (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, per-
sistent 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 tym-
panostomy tube placement, they usually occur in the posterosuperior
quadrant of the pars tensa or in the pars flaccida. When a retraction pock-
et 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 devel-
opment of the retraction pocket. Retraction pockets develop in middle ears
that become atelectatic, and are classified based on location, extent (local-
ized vs. generalized), duration (acute vs. chronic), and severity (mild, mod-
erate, 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: anato-
my 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 postero-
superior quadrant, which is the most compliant17 because of the long dis-
tance between the attachment of the tympanic membrane to the anterior
edge of the malleus and the posterosuperior portion of the annulus. Persis-
tent 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.
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 eustachi-
an 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 otomicro-
scope
• 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
• 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.
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 3–39).
• Using a postauricular approach (see Chapter 2), incisions for the Koern-
er flap are made (Figure 3–40).
Figure 3–39 Retraction pocket

defect in the posterosuperior
quadrant of the pars tensa; the
degree of posterior extension is
unknown (?).
Figure 3–40 Incisions for the

Koerner flap.
• The postauricular approach is completed, and the Koerner flap is

retracted anteriorly (Figure 3–41).
• The tympanomeatal flap and retraction pocket are elevated (Figure
3–42).

approach is completed, and the
Koerner flap is retracted anteriorly.

flap is elevated.
• 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 3–43).
• A 2.7-mm 70˚ Hopkins rod-lens telescope (Hopkins-Karl Storz,
Endoscopy-America Inc, Culver City, CA) is placed in the hypotympa-
num to visualize the facial recess and the sinus tympani for residual
epithelium (Figure 3–44).
• A Buckingham mirror is used as an alternative to the telescope (Figure
3–45).
Figure 3–43 A portion of the scutum of the posterosuperior

canal wall is removed with a curette to adequately visualize
the posterior mesotympanum.
Figure 3–44 A 70˚ rod-lens telescope is placed in the middle Figure 3–45 A Buckingham mirror can be used as an alter-
ear to visualize the facial recess and the sinus tympani. native to the telescope.
• A cartilage-perichondrial graft is taken from the conchal cartilage (Fig-

ure 3–46).
• 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 3–47).
Figure 3–46 A portion of con-

chal cartilage is exposed and a
cartilage-perichondrial graft is
harvested.
Figure 3–47 The conchal carti-

lage-perichondrial graft is placed
over the long process of the
malleus, and onto the superior
and posterior canal walls.
• 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 tympan-
ic membrane from retracting (Figure 3–48).
• A layer of Gelfoam is placed over the tympanic membrane and graft.
Two strips of Adaptic gauze impregnated with antibiotic ointment are
Figure 3–48 A tympanostomy

tube is inserted into the tympan-
ic membrane.
Postoperative Care
• The postoperative care is the same as that described in Chapter 2 under
Postauricular Approach.
REFERENCES
1. Saito H, Kazama Y, Yazawa Y. Simple maneuver for closing traumatic eardrum perforation by
micropore strip tape patching. Am J Otol 1990;11:427–30.
2. Paparella MM. Otologic surgery in children. Otolaryngol Clin North Am 1977;10:145–51.
3. Sheehy JL, Anderson RG. Myringoplasty: a review of 472 cases. Ann Otol Rhinol Laryngol
1980;89:331–4.
4. Koch WM, Friedman EM, McGill TJI, et al. Tympanoplasty in children. The Boston Children’s
Hospital Experience. Arch Otolaryngol Head Neck Surg 1990;116:35–40.
5. Smyth GD. Tympanic reconstruction. Otolaryngol Clin North Am 1972;5:111–25.
6. Shih L, de Tar T, Crabtree JA. Myringoplasty in children. Otolaryngol Head Neck Surg
1991;105:74–7.
7. Tos M, Orntoft S, Stangerup SE. Results of tympanoplasty in children after 15 to 27 years. Ann
Otol Rhinol Laryngol 2000;109:17–23.
8. Vrabec JT, Deskin RW, Grady JJ. Meta-analysis of pediatric tympanoplasty. Arch Otolaryngol
Head Neck Surg 1999;125:530–4.
9. Bluestone CD, Klein JO. Otitis media in infants and children. WB Saunders; 2001. p. 313–7.
10. Potsic WP, Winawer MR, Marsh RR. Tympanoplasty for the anterior-superior perforation in
children. Amer J Otol 1996;17:115–8.
11. 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;27:555–87.
12. Blaney SPA, Tierney P, Bowder DA. The surgical management of the pars tensa retraction pock-
et in the child—results following simple excision and ventilation tube insertion. Int J Pediatr
Otorhinolaryngol 1999;50:133–7.
13. Palva T, Johnsson L-G, Ramsey H. Attic aeration in temporal bones from children with recur-
ring otitis media: tympanostomy tubes did not cure disease in Prussak’s Space. Am J Otol
2000;21:485–93.
14. 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;53:17–24.
15. Gerber MJ, Mason JC, Lambert PR. Hearing results after primary cartilage tympanoplasty.
Laryngoscope 2000;110:1994–9.
16. Bluestone CD. Definitions, terminology, and classification. In: Bluestone CD, Rosenfeld RM,
editors. Evidence-based otitis media. Hamilton, Ontario: B C Decker Inc; 1999. p. 94–6.
17. Khanna SM, Tonndorf J. Tympanic membrane vibration in cats studied by time-averaged
holography. J Acoust Soc Am 1972;51:1904–20.
18. 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. 485–7.
CHAPTER 4
O SSICULOPLASTY
James S. Batti, MD
This chapter reviews methods for reconstructing the ossicular chain from tympanic mem-
brane to oval window, with emphasis on specific techniques for children with ossicular fix-
ation or discontinuity. Information is also provided regarding outcomes and prognostic fac-
tors, 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 super-
structure 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 anky-
losed to the attic wall or when tympanosclerosis of the attic is present.
Kartush3 modified Austin’s 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 sit-
uations requiring ossiculoplasty that are not easily included in the other
categories. These include lateralized tympanic membrane and some con-
genital abnormalities.
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 patient’s 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, ceram-
ic, and hydroxyapatite.5
Recommended methods of ossicular chain reconstruction are listed in
Tables 4–1 to 4–3. Many of the preferred methods attempt to utilize the
patient’s 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.
Ossiculoplasty 77
Table 4–1 Reconstructive options for ossicular chain discontinuity

with ossicles present
Site of discontinuity Recommended reconstructive options
Tympanic membrane / malleus Advancement flap

Malleus / incus Incus interposition
Incus / stapes Incus interposition
Stapes superstructure / footplate Cartilage autograft
Stapes footplate / oval window Mobilization
Stapedectomy, tissue graft, and prosthesis
Table 4–2 Reconstructive options for ossicular chain discontinuity

with ossicles absent
Absent ossicle(s) Recommended reconstructive options
Malleus Autograft incus

Type II tympanoplasty*
Incus Autograft cartilage
Incus prosthesis
Type III tympanoplasty*
Stapes superstructure Autograft incus
Incus-stapes prosthesis
Malleus and incus Autograft cartilage
Type III tympanoplasty*
PORP
Incus and stapes superstructure Autograft cartilage
Incus-stapes prosthesis
Malleus, incus, and stapes superstructure Autograft cartilage
TORP
PORP = partial ossicular replacement prosthesis; TORP = total ossicular replacement prosthesis
* See Chapter 3
Table 4–3 Reconstructive options for ossicular chain fixation

Site of fixation Recommended reconstructive options
Malleus / incus Incus interposition

Mobilization
Incus / stapes Incus interposition
Mobilization
Stapes superstructure / footplate Mobilization
Stapedectomy with prosthesis
Stapes footplate / oval window Mobilization
Stapedectomy with prosthesis
ADVANCEMENT FLAP
Indications
• Lateralized tympanic membrane following any method of tympanoplas-
ty, but more often following the lateral graft technique (see Chapter 3
under Tympanoplasty)
• Local anesthetic (1% lidocaine with 1:100,000 epinephrine) is infiltrat-
ed into all four quadrants of the ear canal (6, 9, 12, and 3 o’clock) just
lateral to the bony-cartilaginous junction for hemostasis and to enhance
the anesthesia.
Procedure
• Coronal view demonstrating the lateralized tympanic membrane (Figure
4–1).
• A transcanal incision is made just medial to the bony-cartilaginous junc-
tion (Figure 4–2A).
• The wide tympanomeatal flap is elevated (Figure 4–2B).
• The middle ear is entered by elevating the annulus (Figure 4–3A).
• The tympanomeatal flap and lateralized tympanic membrane are elevat-
ed to expose the entire middle ear space; the flap is attached only to the
anterior canal wall (Figure 4–3B).
Figure 4–1 Advancement flap

for lateralized tympanic mem-
brane. Coronal view showing that
the grafted tympanic membrane
does not connect to the malleus,
which usually results in mild to
moderate conductive hearing loss.
Ossiculoplasty 79
A B
Figure 4–2 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.
A B
Figure 4–3 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.
• The tympanomeatal flap is advanced medially against the malleus, leav-

ing bare bone in the ear canal medial to the bony-cartilaginous junction
(Figure 4–4).
• 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 4–5).
• An addition to the method described above is to incise part of the tympa-
nomeatal flap and insert the handle of the malleus through the incision.
This holds the flap against the malleus, but the incision is generally unnec-
essary 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 4–4 Tympanomeatal flap

is advanced medially against the
malleus, which leaves exposed
bone in the canal wall medial to
the bony-cartilaginous junction.
Figure 4–5 Coronal view show-

ing 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 81
INCUS INTERPOSITION
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 incudomal-
leal or incudostapedial joint.
• The anesthesia is the same as that described for the advancement flap.
Procedure
tion (see Figure 4–2A).
• The wide tympanomeatal flap is elevated (see Figure 4–2B).
• The middle ear is entered by elevating the annulus (see Figure 4–3A).
• 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 4–6A). 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 4–6B).
• 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 B
Figure 4–6 Incus interposition. A, The incus is removed and sculpted. B, The sculpted incus is inserted between the malleus
and head of the stapes.
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
Procedure
• The PORP is inserted on the stapes (Figure 4–7). 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 preven-
tion of extrusion of the prosthesis.
Postoperative Care
• A postoperative audiogram is obtained in 2-3 months.
A B
Figure 4–7 Placement of a partial ossicular replacement prosthesis (PORP). A, Surgeon’s view of PORP in place. B, Lateral
view of the PORP positioned on the stapes head.
Ossiculoplasty 83
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
Procedure
• The TORP is inserted on the stapes footplate (Figure 4–8).
Figure 4–8 Placement of a total

ossicular replacement prosthesis
(TORP). A, Surgeon’s view of
TORP in place. B, Lateral view
of the TORP positioned on the
stapes footplate.
B
• A cartilage graft is placed between the TORP and tympanic membrane

to reduce the chance of extrusion (Figure 4–9).
Postoperative Care
• A postoperative audiogram is obtained in 2-3 months.
Figure 4–9 Cartilage graft

between the TORP and
tympanic membrane.
Ossiculoplasty 85
OUTCOMES AND PROGNOSTIC FACTORS

Table 4–4 presents a summary of the published data on hearing level and
extrusion rate outcomes for various methods of ossicular reconstruc-
tion.2,5–21 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, com-
bined 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 availabil-
ity of the malleus handle and stapes superstructure. Black23 proposed a
combined system using the acronym SPITE for preoperative predictive fac-
tors 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 air-
bone 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 dysfunction–eustachian tube dysfunction / middle-
ear effusion present; severely collapsed tympanic membrane
Factors that failed to show statistically significant adverse effects in audio-
logic 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-attenua-
tion 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 fail-
ure include: (1) improperly sized prosthesis (too short), (2) sliding of the pros-
thesis, (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
Table 4–4 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 Nikolaou6 74 — 13
Jackson7 68 — —
PORP
Incus replacement, Grote8 — 83 —
hydroxyapatite Wehrs9 85 — —
Incudostapedial joint Schwetschenau10 — 91 0
Plasti-Pore Colletti11 77 48 0
Bayazit12 63 — 4
Goldenberg13 — 73 6
Jackson7 49 — 10
Brackmann14 73 — 7
Smyth15 — 43 11
Polyethylene Slater16 81 75 1
Nikolaou6 40 — 50
Daniels17 78 89 0
Ceramic Nikolaou6 89 — 5
Cartilage Chole5 — 65 0
18
Hydroxyapatite and Macias — 48 4
Plasti-Pore Chole5 43 — 4
Black19 71 — 7
TORP
Incus / stapes, hydroxy- Chole5 50 0 4
apatite and Plasti-Pore
Incus / stapes, Grote8 — 76 0
hydroxyapatite
Plasti-Pore Colletti11 68 46 23
Brackmann20 84 — —
Goldenberg13 — 55 8
Bayazit12 43 — 4
Polyethylene Nikolaou6 61 — 14
Slater16 68 54 1
Ceramic Nikolaou6 65 — 9
5
Cartilage Chole — 65 —
5
Hydroxyapatite and Chole 30 — 4
Plasti-Pore Macias18 — 21 0
Malleus / footplate, Colletti21 73 71 0
hydroxyapatite
TM / footplate, Colletti21 75 60 0
hydroxyapatite
Hydroxyapatite and Daniels17 61 55 2
fluoroplastic
PORP = partial ossicular replacement prosthesis; TM = tympanic membrane; TORP = total ossicular replacement prosthesis
Ossiculoplasty 87
Middle-ear disease may also cause ossiculoplasty failure. There are many
uncertainties in the hostile biological environment associated with surgery
for chronic ear disease—mucosal disease, middle-ear adhesions, and
eustachian tube dysfunction—that contribute to failure of the surgery.
These abnormalities promote middle-ear effusion, retraction of the tym-
panic membrane, atelectasis of the middle ear, and extrusion of the graft or
prosthesis. Perforation of the tympanic membrane, with or without extru-
sion of the prosthesis, may also occur.
Eustachian tube dysfunction is also a common cause of tympanic mem-
brane 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 mem-
brane, 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. Sil-
verstein et al28 reported 18 cases using Plasti-Pore PORPs and TORPs, but
obtained poor results with a 44% failure rate and 17% extrusion rate. Con-
versely, Sheehy29 and Kessler et al30 reported using PORPs and TORPs in
children with success rates similar to those in adults. In Kessler’s study, for
example, the mean patient age was 9.8 years and hearing results of an air-
bone 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 chil-
dren, 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 place-
ment 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 post-
poned.10 The principles of successful tympanoplasty, however, are similar for
adults and children. Once the child’s ear is made safe and stable, ossicular
reconstruction is the next goal and completes the restoration of normal mid-
dle-ear function. Some claim that children differ only in that they may be
more likely to require postsurgical tympanostomy tube insertion to main-
tain 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 guide-
lines for procedure timing. A useful rule of thumb is that eustachian tube
function may be considered adequate for ossiculoplasty when there has
been no otitis media (in an ear with an intact tympanic membrane) for at
least four consecutive seasons (12 months). This should minimize the inci-
dence 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 “sec-
ond 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. Hough J. Incudostapedial joint separation: etiology, treatment and significances. Laryngoscope
1959;69:644–53.
2. Austin DF. Ossicular reconstruction. Otolaryngol Clin North Am 1972;5:145–60.
3. Kartush JM. Ossicular chain reconstruction: capitulum to malleus. Otolaryngol Clin North Am
1994;27:689–715.
4. Moretz WH Jr. Ossiculoplasty with an intact stapes: superstructure versus footplate prosthesis
placement. Laryngoscope 1998;108:1–12.
5. Chole RA, Skarada DJ. Middle ear reconstructive techniques. Otolaryngol Clin North Am
1999;32:489–503.
6. Nikolaou A, Bourikas Z, Maltas V, Aidonis A. Ossiculoplasty with the use of autografts and syn-
thetic prosthetic materials : a comparison of results in 165 cases. J Laryngol Otol 1992;106:
692–4.
7. Jackson CG, Glasscock ME III, Nissen AJ, et al. Ossicular chain reconstruction: the TORP and
PORP in chronic ear disease. Laryngoscope 1983;93:981–8.
8. Grote J. Reconstruction of the middle ear with hydroxyapatite implants: long-term results. Ann
Otol Rhinol Laryngol 1990;144 Suppl:12–6.
9. Wehrs RE. Incus interposition and ossiculoplasty with hydroxyapatite prostheses. Otolaryngol
Clin NA 1994;27:677–88.
10. Schwetschenau EL, Isaacson G. Ossiculoplasty in young children with the Applebaum incud-
ostapedial joint prosthesis. Laryngoscope 1999;109:1621–5.
11. Colletti V, Fiorino FG, Sittoni, V. Minisculptured ossicle grafts versus implants: long-term
results. Am J Otol 1987;8:553–9.
12. Bayazit Y, Goksu N, Beder L. Functional results of Plasti-Pore prostheses for middle-ear ossicu-
lar chain reconstruction. Laryngoscope 1999;109:709–11.
13. Goldenberg RA. Hydroxylapatite ossicular replacement prostheses: preliminary results. Laryn-
goscope 1990;100:693–700.
14. Brackmann DE, Sheehy JL, Luxford WM. TORPs and PORPs in tympanoplasty: a review of
1042 operations. Otolaryngol Head Neck Surg 1984;92:32–7.
15. Smyth GD. Five year report on partial ossicular replacement prostheses and total ossicular
replacement prostheses. Otolaryngol Head Neck Surg 1982;90:343–6.
16. Slater PW, Rizer FM, Schuring AG, Lippy WH. Practical use of total and partial ossicular
replacement prostheses in ossiculoplasty. Laryngoscope 1997;107:1193–8.
Ossiculoplasty 89
17. Daniels RL, Rizer FM, Schuring AG, Lippy WL. Partial ossicular reconstruction in children: a
review of 62 operations. Laryngoscope 1998;108:1674–81.
18. Macias JD, Glasscock ME III, Widick MH, et al. Ossiculoplasty using the Black hydroxyap-
atite hybrid ossicular replacement prostheses. Am J Otol 1995;16:718–21.
19. Black B. Design and development of a contoured ossicular replacement prosthesis: clinical trials
of 125 cases. Am J Otol 1990;11:85–9.
20. Brackmann DE, Sheehy JL. Tympanoplasty with TORPs and PORPs. Laryngoscope
1979;89:108–14.
21. Colletti V, Fiorino FG. Malleus to footplate prosthetic interposition: experience with 265 patients.
Otolaryngology Head Neck Surg 1999;120:437–44.
22. Bellucci RJ. Dual classification of tympanoplasty. Laryngoscope 1973;83:1754–8.
23. Black B. Ossiculoplasty prognosis: the SPITE method of assessment. Am J Otol
1992;13:544–51.
24. Mills RP. The influence of pathological and technical variables on hearing results in ossiculo-
plasty. Clin Otolaryngol Allied Sciences 1993;18:202–5.
25. Smyth GD, Patterson CG. Results of middle ear reconstruction: do patients and surgeons agree?
Am J Otol 1985;6:276–9.
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 fail-
ure. Am J Otol 1987;8:551–2.
28. Silverstein H, McDaniel AB, Lichtenstein R. A comparison of PORP, TORP, and incus homo-
graft for ossicular reconstruction in chronic ear surgery. Laryngoscope 1986;96:159–65.
29. Sheehy JL. Cholesteatoma surgery in children. Am J Otol 1985;6:170–2.
30. Kessler A, Potsic WP, Marsh RR. Total and partial ossicular replacement prostheses in children.
Otolaryngol Head Neck Surg 1994;110:302–3.
31. Tos M, Lau T. Stability of tympanoplasty in children. Otolaryngol Clin N Am 1989;22:15–28.
32. Bluestone CD, Stool SE, Kenna M. Pediatric Otolaryngology. 3rd ed. Philadelphia: WB Saun-
ders; 1996.
33. Chandrasekhar SS, House JW, Devgan U. Pediatric tympanoplasty. A 10 year experience. Arch
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 indica-
tions 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 mas-
toidectomy with a middle-ear procedure, maintaining the posterior and
superior canal walls.
The basic steps in performing the three standard mastoidectomy proce-
dures 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 impor-
tant 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
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 proce-
dure becomes a “canal wall–up” tympanomastoidectomy (see Tympanomas-
toidectomy 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 pro-
cedure (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
• 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 5–1).
• The mastoid antrum is identified (Figure 5–2).
Mastoidectomy and Cholesteatoma 93
Figure 5–1 A postauricular

approach and drill are used to
uncover the mastoid antrum.
Figure 5–2 The mastoid antrum

is identified.
• A curette removes the thinned bone over the incus (Figure 5–3); drilling
at this stage could injure the incus and result in conductive, sen-
sorineural (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 5–4),
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 5–5).
• The postauricular wound is closed with an absorbable suture. The need
for drainage, if any, relates to the primary indication for surgery:
♦ For acute mastoid osteitis, a plastic drain with holes cut into the por-
tion that lies within the mastoid cavity, is placed in the mastoid cav-
ity (Figure 5–6).
♦ 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.
Figure 5–3 A curette removes the thinned bone over the Figure 5–4 Dissection is complete when the epitympa-
incus. num, zygomatic cells, and heads of the incus and malleus
are identified.
Figure 5–5 Tympanostomy tube and wide-field myringotomy. Figure 5–6 The postauricular wound is closed with an
absorbable suture and drain is inserted.
MODIFIED RADICAL MASTOIDECTOMY

A modified radical mastoidectomy is most commonly performed for con-
genital or acquired cholesteatoma, chronic suppurative otitis media with
mastoiditis, or both. The mastoid cavity, the epitympanum, and the exter-
nal canal are exteriorized into a common cavity, but the tympanic mem-
brane 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 mas-
toidectomy 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 wall–up 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 usu-
ally 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 mas-
toidectomy 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 wall–up 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
• 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.
Procedure
• A simple mastoidectomy is usually performed first (Figure 5–7).
• The posterior canal wall is taken down to the facial ridge (Figure 5–8).
• The tympanic membrane is replaced (Figure 5–9); the epitympanum
and the mastoid cavity are exteriorized.
Figure 5–7 A complete “simple” mastoidectomy is usually Figure 5–8 The posterior canal wall is taken down to the
performed first. facial ridge.
Figure 5–9 The tympanic mem-

brane is replaced.
• 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 mas-
toid (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 mastoidi-
tis, perioperative and postoperative intravenous antimicrobial therapy is
usually administered.
• Cavity care is more difficult in the infant and young child, and the pro-
cedure may have to be performed in the operating room with the patient
under general anesthesia, especially when residual cholesteatoma is pre-
sent. 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 mid-
dle ear, epitympanum, mastoid cavity, and external canal. The operation is
not performed as frequently today as it was in the preantibiotic era; how-
ever, it is performed when extensive cholesteatoma, which cannot be con-
trolled with a less radical procedure, is present. In children, an extensive
rapidly growing cholesteatoma is not uncommon, and radical mastoidec-
tomy is still performed in selected cases. In our series of 244 surgical pro-
cedures 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 wall–up 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 insert-
ed or a perforation is present in the reconstructed tympanic membrane.
Indications
• Extensive congenital or acquired cholesteatoma, when a less radical pro-
cedure is not possible.
• For suppurative intracranial complications of cholesteatoma, on an indi-
vidualized basis, or for selected children who have chronic suppurative oti-
tis media (and mastoiditis), when a less radical procedure (eg, canal wall–up
tympanomastoidectomy) is not likely to control the disease process.
• When suppurative disease is present within the middle-ear cleft, intra-
venous 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 5–10).
• The tympanic is removed. Removal of the malleus and incus is includ-
ed in the classic operation, but depends upon the extent of the disease
(Figure 5–11).
• 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 5–10 The posterior ear canal is taken down, and a Figure 5–11 The tympanic membrane, malleus, and incus
facial ridge is created. are removed.
TYMPANOMASTOIDECTOMY
A tympanomastoidectomy combines a simple mastoidectomy with a mid-
dle-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 intra-
venous 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 appar-
ently not a sequela of otitis media or eustachian tube dysfunction; howev-
er, 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 mesotympa-
num. Disease frequently extends into the anterior attic, or into the pos-
terosuperior portion of the mesotympanum, and can also invade the facial
recess, sinus tympani, and the attic. Also, the site can be in the posterosu-
perior portion of the mesotympanum. More advanced congenital middle-
ear 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, iatro-
genic) of the middle ear (including the tympanic membrane), ear canal, or
mastoid. Acquired cholesteatoma can be present anywhere in the middle-
ear 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 Children’s 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
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 lim-
ited 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 proce-
dures to treat and prevent residual cholesteatoma (disease remaining after
surgical attempts to eradicate it) and recurrent cholesteatoma (development
of new disease).
Canal Wall–Up vs. Canal Wall–Down Mastoidectomy
Controversy exists over whether to perform a canal wall–up or canal
wall–down procedure when the extent of cholesteatoma requires mas-
toidectomy. In infants and children, every effort should be made to avoid
a canal wall–down mastoidectomy because it is especially desirable to main-
tain or reconstruct the anatomy in this age group. Among the many disad-
vantages 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 postop-
eratively for children than in adults because children are frequently appre-
hensive 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 wall–up tympanomastoidec-
tomy and additional tympanoplasty, if needed. Since the middle ear and mas-
toid are not directly visible following these procedures, a “second look” oper-
ation 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
Residual or recurrent disease was significantly associated with ossicular ero-

sion 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 tym-
panotomy this author uses the 70˚ Hopkins rod-lens telescope to inspect
the middle ear for residual and recurrent disease.
Currently, a canal wall–down 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” tympan-
otomy) 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 wall–down procedure.
Otologic Telescope
The most significant factor in the preservation of the posterior and superi-
or canal walls in most children is the relatively recent availability of an opti-
cal telescope, which enhances visualization of the middle-ear cleft. I use the
2.7-mm 70˚ Hopkins rod-lens telescope (Hopkins-Karl Storz, Endoscopy-
America Inc, Culver City, CA). With this instrument, the surgeon can
directly visualize the facial recess and the attic; whereas in the past, the supe-
rior 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 infe-
riorly to determine whether or not there is persistent disease.
Although not related to performing a canal wall–up versus a canal
wall–down 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 eustachi-
an 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-
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 middle-
ear 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-exam-
ined periodically for at least 5 years. There are two major concerns:
1. Residual cholesteatoma that remains following the initial surgical proce-
dure
2. Recurrent cholesteatoma (new disease) because of persistent eustachian
tube dysfunction, and a new retraction pocket in an anatomic site simi-
lar to the original one, or in another area of the tympanic membrane4,9–12
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 diag-
nosed. 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 per-
formed in the 1970s and 1980s (excluding intratympanic disease), 56%
were limited to the middle ear (with or without atticotomy), 13% were
canal wall–up tympanomastoidectomies, 9% were modified radical mas-
toidectomies, 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.
Indications
• Intratympanic membrane congenital cholesteatoma.
• Congenital cholesteatoma medial to the intact tympanic membrane in
the anterosuperior quadrant of the middle ear
• 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 mem-
brane (Figure 5–12).
• The cholesteatoma is removed with a pick; a cup forceps is also used
(Figure 5–13).
• A Steri-Strip patch is placed over the defect if a small perforation is
present (Figure 5–14).
• If the perforation is large, a tissue graft myringoplasty is performed,
as shown in Chapter 3.
Figure 5–12 Congenital

cholesteatoma within the intact
tympanic membrane.
Figure 5–13 Cholesteatoma is

removed with a curved pick.
Figure 5–14 A Steri-Strip patch

is placed over the defect.
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 (Fig-
ure 5–15).
• The choice of approach (see Chapter 2) depends on the extent of
cholesteatoma and the size of the child’s ear canal:
♦ An endaural approach (Figure 5–16A) 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 5–16B) is used for disease localized
to the anterosuperior mesotympanum, with a large enough ear
canal to permit adequate visualization and access to the anterosu-
perior canal wall.
♦ A postauricular approach is used for disease extending into the pos-
terior 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
5–17), and the cholesteatoma is removed (for more extensive disease,
see Acquired Cholesteatoma below).
Figure 5–15 A congenital

cholesteatoma is visualized in
the middle ear, medial to antero-
superior quadrant of the intact
tympanic membrane.
Figure 5–16 A, Endaural incisions and approach when the

cholesteatoma is localized to the anterior mesotympanum and
the anterior epitympanum. B, Transcanal approach is used, if
A feasible.
Figure 5–17 An anterior attico-

tomy is done with a microdrill,
and cholesteatomas are removed.
• The tympanomeatal flap is replaced (Figure 5–18). A defect, if pre-

sent, 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 epi-
tympanic 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 5–18 A tympanomeatal

flap is replaced.
ACQUIRED CHOLESTEATOMA
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 chil-
dren 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 perfo-
ration, 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 pos-
terosuperior 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 fre-
quently 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 child’s final procedure should be individualized based on several fac-
tors. One surgical procedure is not advocated for all cholesteatomas. The
following factors are important in the preoperative planning and the intra-
operative 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 anato-
my 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,
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 Children’s Hospital of Pittsburgh
from 1973 to 1990, 28% involved only a middle-ear procedure, 20% were
canal wall–up tympanomastoidectomies, 25% were modified mastoidec-
tomies, and 28% were radical mastoidectomies.4 The current trend, how-
ever, 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 mesoepi-
tympanum), 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 ero-
sion 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 acces-
sible to surgical removal (eg, medial to labyrinth), with one or more ossi-
cles involved; fistula of the labyrinth may or may not be present
• Stage 6. Same as Stage 5, but cholesteatoma extends beyond the tempo-
ral 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 com-
mon sites of extension of the cholesteatoma and the final procedure select-
ed, depending on the extent of the disease. There is a logical progression of
the operation, and the reader can follow the decision-making process. Pre-
operative evaluation of the CT scans can be helpful in planning the proce-
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 accu-
rately 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 tym-
pani
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 5–19)
Figure 5–19 Posterosuperior

quadrant cholesteatoma of
uncertain extension into one or
more of four possible areas,
numbered one through four as
referenced above.

• 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 5–20) 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 con-
fined to the posterior mesotympanum, facial recess, and sinus tym-
pani (Figure 5–21).
• The posterosuperior portion of the canal wall scutum is removed with
a curette to further visualize the cholesteatoma (Figure 5–22). Alter-
natively, 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 3–44).
• 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 5–23). 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 tym-
panic membrane (Figure 5–24) to prevent cholesteatoma recurrence.18
Figure 5–21 The tympanomeatal flap is elevated to reveal a

Figure 5–20 Incisions for a Koerner flap are made approxi- cholesteatoma confined to the posterior mesotympanum,
mately one third of the distance from annulus to meatus. facial recess, and sinus tympani.
Figure 5–22 The posterosuperior portion

of the canal wall scutum is removed with
a curette.
Figure 5–23 A cartilage-perichondrial graft is

placed over the defect.
Figure 5–24 A tympanostomy tube is inserted into

the anterior portion of the tympanic membrane.
No 2. Cholesteatoma extending into the epitympanum

• The tympanomeatal flap is elevated to reveal cholesteatoma extend-
ing into the epitympanum (Figure 5–25).
• An atticotomy is performed with a microdrill and the incus is
removed (Figure 5–26).
• Incus interposition is one reconstructive option (see Chapter 4), but
removal of the entire malleus and a myringostapediapexy is an alter-
native.
• A cartilage-perichondrial graft and a fascia graft are placed medial to
the tympanic membrane remnant (Figure 5–27).
Figure 5–25 The cholesteatoma

extends into the epitympanum.
Figure 5–26 Atticotomy is performed. Figure 5–27 A cartilage-perichondrial graft and a fascia
graft are placed medial to the tympanic membrane remnant.
No 3. Cholesteatoma extending into the mastoid gas cells

• Atticotomy reveals cholesteatoma extending superiorly and posterior-
ly into the attic and the aditus ad antrum (Figure 5–28).
• The mastoid cortex is entered (Figure 5–29) and, if a cholesteatoma
can be removed without taking the canal wall down, a simple mas-
toidectomy is performed as described earlier.
• A cartilage-perichondrial graft and a fascia graft are placed medial to
the tympanic membrane remnant (see Figure 5–27).
• Thus, a canal wall–up mastoidectomy with tympanoplasty is per-
formed.
Figure 5–28 The cholesteatoma

extends posterosuperiorly.
Figure 5–29 “Simple” mas-

toidectomy is completed.
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 5–30).
• 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 dis-
ease is extensive, and may obviate the need for a canal wall–down
procedure. A canal wall–up tympanomastoidectomy (see Figure
5–29) is safe and effective in many children even when the disease is
extensive.
• A radical mastoidectomy (Figure 5–31) is reserved for only those
cholesteatomas that are so extensive that a canal wall–up 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 5–30 Mastoidectomy and middle-ear examination Figure 5–31 A radical mastoidectomy is performed when
reveal extensive cholesteatoma in the mastoid and entire disease is too extensive to perform a less radical procedure.
middle ear.
PARS FLACCIDA ATTIC CHOLESTEATOMA

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 eti-
ology and pathogenesis are most likely similar to cholesteatoma that devel-
ops in the posterosuperior quadrant of the pars tensa, and as described ear-
lier, 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 endau-
ral 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 classi-
cal Bondy modified radical mastoidectomy is performed in selected
cases; however, if there is extensive disease in the mastoid, the postau-
ricular approach is more feasible.
Also, as stated before, a canal wall–up 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 mas-
toid air cells and middle ear (Figure 5–32)
Figure 5–32 Cholesteatoma in

the pars flaccida with three
possible extensions, numbered
one through three as referenced
above.

• 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 5–33).
• An anterior atticotomy is completed (Figure 5–34).
• An incision is made in the tragus (the incision is made slightly medi-
al to the outside edge of the targus) to harvest a cartilage-perichondr-
ial graft (Figure 5–35) and the graft is excised leaving the outer por-
tion of the targus intact to prevent cosmetic deformity (Figure 5–36).
• The cartilage graft is positioned (Figure 5–37) to batten the tympan-
ic 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 5–38) if persistent eustachian tube dysfunc-
tion, otitis media, or both, are anticipated in the postoperative period.
Figure 5–33 Endaural incisions and approach are completed when Figure 5–34 An anterior atticotomy is completed.
the cholesteatoma is confined to the anterior epitympanum.
Figure 5–35 An incision is made in the tragus to harvest Figure 5–36 The tragal cartilage-perichondrial graft is
a cartilage-perichondrial graft. excised.
Figure 5–37 Defect is repaired using tragal cartilage- Figure 5–38 A tympanostomy tube is inserted into the
perichondrial and fascia grafts. tympanic membrane.
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 5–39).
• For mastoid disease, however, an initial postauricular approach is
more feasible. The preoperative CT scan is usually helpful in deter-
mining 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 5–40). However, a canal wall–up tympanomas-
toidectomy with a cartilage graft (from the conchal cartilage, placed
over the attic defect) tympanoplasty, similar to that described in Fig-
ure 5–27, is more desirable.
Figure 5–39 An endaural approach and atticotomy reveal Figure 5–40 A modified radical mastoidectomy is one
that cholesteatoma extends posterior toward the mastoid option, but a canal wall–up tympanomastoidectomy
air cells. with a cartilage graft tympanoplasty is preferred.
No 3. Extensive attic cholesteatoma

• Extensive cholesteatoma is anticipated from the CT scan (Figure
5–41).
• A postauricular approach is indicated, and the final procedure is
dependent on the extent of the cholesteatoma. A canal wall–up tym-
panomastoidectomy and cartilage graft tympanoplasty are preferred
(see Figures 5–27 and 5–29), reserving a canal wall–down 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 5–41 Extensive

cholesteatoma is anticipated
from the CT scans.
REFERENCES
1. Noss RS, Lalwani AK, Yingling CD. Facial nerve monitoring in middle ear and mastoid
surgery. Laryngoscope 2001;111:831–6.
2. Bluestone CD, Klein JO. Otitis media in infants and children. Philadelphia: WB Saunders;
2001. p. 329–40.
3. 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;9:12–26.
4. Rosenfeld RM, Moura RL, Bluestone CD. Predictors of residual-recurrent cholesteatoma in
5. Kenna MA, Rosane BA, Bluestone CD. Medical management of chronic suppurative otitis
media without cholesteatoma in children-update 1992. Am J Otol 1993;14:469–73.
6. Tos M. A new pathogenesis of mesotympanic (congenital) cholesteatoma. Laryngoscope 2000;
110:1890–7.
7. Soldati D, Mudry A. Cholesteatoma in children: techniques and results. Int J Pediatr Otorhi-
nolaryngol 2000;52:269–76.
8. Mishiro Y, Sakagama M, Okumura S, et al. Postoperative results for cholesteatoma in children.
Auris Nasus Larynx 2000;27:223–6.
9. Sivola J, Palva T. Long-term results of pediatric primary one stage cholesteatoma surgery. Int J
Pediatr Otorhinolaryngol 1999;48:101–7.
10. Stangerup SE, Drozdziewicz D, Tos M, Tabalzini E. Surgery for acquired cholesteatoma in chil-
dren: long-term results and recurrence of cholesteatoma. J Laryngol Otol 1998;112:724–49.
11. Stangerup SE, Drozdziewicz D, Tos M. Cholesteatoma in children: predictors and recurrence
rates. Int J Pediatr Otorhinolaryngol 1999;49:69–73.
12. Sivola J, Palva T. One stage surgery for pediatric cholesteatoma: long-term results and compar-
ison with primary surgery. Int J Pediatr Otorhinolaryngol 2000;56:135–9.
13. Golz A, Goldenberg D, Netzer A, et al. Cholesteatomas associated with ventilation tube inser-
tion. Arch Otolaryngol Head Neck Surg 1999;125:754–7.
14. Sheehy JL, Brachman DE, Graham MD. Complications of cholesteatoma: a report on 1024
cases. In: McCabe BF, Sadé J, Abramson M, editors. Cholesteatoma: First International Con-
ference, 1977; Iowa City, Iowa; New York: Aesculapius; 1977. p. 420–9.
15. Bluestone CD. Definitions, terminology, and classification. In: Rosenfeld RM, Bluestone CD,
editors. Evidence-based otitis media. Hamilton, Ontario: BC Decker Inc; 1999. p. 85–103.
16. Bluestone CD. Invited comments: Clinical forum—routine preoperative imaging in chronic ear
surgery. Am J Otol 1998;19:536–7.
17. Bluestone CD, Klein JO. Intratemporal Complications and Sequelae of Otitis Media. In: Blue-
stone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngology. Philadelphia: WB Saun-
ders; 1996. p. 604–14.
18. 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;56:41–4.
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 mid-
dle 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. Con-
genital PLF is present at birth, and commonly associated with middle-ear malformations.
PLF is diagnosed more often in adults than children.1–3
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 subse-
quently 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 win-
dow, or both.
Otitis media can be associated with a congenital PLF, producing nystag-
mus 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 fis-
tula at the Children’s 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
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 mid-
dle ear.12
♦ Even though the test results are only available postoperatively, a pos-
itive test will confirm the presence of a CSF leak, which can be help-
ful if the contralateral ear is suspected to have a similar defect.13
Indications
Congenital perilymphatic fistula is suspected preoperatively from the his-
tory, 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 fluctuat-
ing, progressive, or both, is the most common indication for explo-
ration; although a relatively uncommon presenting symptom in chil-
dren, 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 sen-
sorineural component is fluctuating, progressive, or both; the conduc-
tive 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.
• 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 125
• 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 6–1).
• Three types of malformed stapes are frequently encountered: posterior-
ly positioned anterior crus, no anterior crus, or a monopod stapes (Fig-
ure 6–2).
♦ A malformed round window is also frequently found, which is usual-
ly laterally faced with an abnormal niche.
♦ Also, the long process of the incus can be malformed with an anteri-
or facing concavity.

flap is elevated for an explorato-
ry tympanotomy.
Figure 6–2 Three types of stapes

malformations are frequently
encountered as described above.
• Because the anatomy of the stapes superstructure is difficult to visualize,

a 90˚ pick is used to palpate the crura and obturator foramen to deter-
mine if an abnormality is present (Figure 6–3). 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 beta-
2 transferrin testing (Figure 6–4).
♦ 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 6–3 A 90˚ pick is used

to palpate the crura and
obturator foramen.
Figure 6–4 Small pledgets of

Gelfoam are placed over the
stapes footplate and the round
window.
• An incision is made slightly above the hairline to remove a small piece

of temporalis muscle for a graft (Figure 6–5). The donor site is closed
with absorbable suture.
• Mucosa around the stapes footplate and the round window niche is
denuded for the graft (Figure 6–6). Small pieces of muscle are laid over the
stapes footplate and in and around the round window niche (Figure 6–7).
• A layer of Gelfoam is placed over the muscle grafts, and the tympa-
nomeatal flap is replaced; muscle grafts are placed even if a leak is not
visualized.

slightly above the hairline to
remove a small piece of tempo-
ralis muscle for a graft.
Figure 6–6 The mucosa around the stapes footplate and Figure 6–7 Small pieces of muscle are laid over the stapes
the round window niche is denuded for the graft site. footplate and in and around the round window niche.
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 ele-
vate 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 post-
operatively 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

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 dysfunction—failure 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
dysfunction—tympanostomy 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 otor-
rhea 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 mas-
toidectomy. The discharge can usually be controlled medically or by repair-
ing the tympanic membrane, which provides a closed middle-ear space (see
Chapter 3). In the absence of contamination from water entering the exter-
nal canal, the ear discharge is caused by unwanted nasopharyngeal secre-
tions 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 signifi-
cant 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 rea-
sonable alternative, as long as the patient and parents are fully informed of
the benefits (ie, prevention of otorrhea) and costs (eg, inability to recon-
struct a functioning gas-filled middle ear with an intact eardrum) of the
surgery. The most likely candidates are those who have no serviceable hear-
ing in the affected ear, and for them, obliteration of the entire middle-ear
cleft should be considered.16
Indications
• Presence of postoperative recurrent or chronic otorrhea following radi-
cal 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.
• 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 pâté is harvested with a drill from an uninvolved area of the cor-
tex and is collected in a Luki Disposable Aspirator trap (Sherwood Davis
and Geck, St. Louis, MO) (Figure 6–8).
Figure 6–8 Bone pâté is harvest-

ed and aspirated into a trap.
• A small piece of temporalis muscle, bone pâté, and a temporalis fascia

graft are used to obliterate the protympanic (ie, osseous or middle-ear)
portion of the eustachian tube (Figure 6–9). 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 oint-
ment are placed in the ear canal.
Postoperative Care
• Ear canal packing is removed after 1 week.
Figure 6–9 A small piece of

temporalis muscle, bone pâté,
and temporalis fascia are used to
obliterate the middle-ear end
(osseous, protympanic) of the
eustachian tube.
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 recent-
ly, we reported on nine patients who had the procedure and whose fol-
low-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 origi-
nally 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 non-
surgical measures and despite placement of a tympanostomy tube.19,20
• As described in Chapter 2 for the transcanal or endaural approach.
Procedure
• An incision is made for an anterior tympanomeatal flap (Figure 6–10).
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 6–11).
Figure 6–10 An incision is

made approximately 8 mm later-
al to the anterior annulus for an
anterior tympanomeatal flap,
which is similar to the standard
flap made on the posterior canal
wall.
Figure 6–11 The anterior tympa-

nomeatal flap is elevated, and the
orifice of the middle-ear end of
the eustachian tube is identified.
• A small-bore polyethylene tube (eg, No 90) is introduced into the ori-

fice of the eustachian tube to determine the site, direction, and approx-
imate length of the Medicut angiocatheter to be inserted (Figure 6–12).
• A small length of Medicut catheter is cut; a portion of the flared tip of
the catheter is maintained (Figure 6–13).
• Bone wax is inserted into the lumen of the catheter (Figure 6–14).
Figure 6–12 A small-bore polyethylene tube is intro-

duced into the orifice of the eustachian tube to con-
firm the location and direction in which the catheter
is to be inserted.
Figure 6–13 A small length of Medi-

cut angiocatheter (Argyle Medicut,
Sherwood Medical Industries, St.
Louis, MO) is cut.
Figure 6–14 Bone wax is inserted into the lumen of

the catheter.
• 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 6–15).
♦ An intraoperative test of eustachian tube function with a manometer
attached to a tympanometer ear canal earpiece is helpful in deter-
mining 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 6–16).
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 tympanos-
tomy tube if their middle ear remains aerated and they are without mid-
dle-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 6–15 A Medicut catheter is inserted into the orifice Figure 6–16 A tympanostomy tube is inserted into the tym-
of the eustachian tube. A pressure manometer tests whether panic membrane.
the eustachian tube is obstructed at this stage.
REFERENCES
1. Healy GB, Friedman JM, Strong MS. Vestibular and auditory findings of perilymphatic fistu-
la: a review of 40 cases. Trans Am Acad Ophthalmol Otolaryngol 1976;82:44–9.
2. Shelton C, Simmons FB. Perilymphatic fistula: the Stanford experience. Ann Otol Rhinol
Laryngol 1988;97:105–8.
3. Goto F, Ogawa K, Kunihiro T, et al. Perilymphatic fistula–45 case analysis. Auris Nasus Larynx
2001;28:29–33.
4. Grundfast KM, Bluestone CD. Sudden or fluctuating hearing loss or vertigo in children due to
perilymph fistula. Ann Otol Rhinol Laryngol 1978;87:761–71.
5. Supance JS, Bluestone CD. Perilymph fistula in infants and children. Otolaryngol Head Neck
Surg 1983;91:663–71.
6. Weber PC, Perez BA, Bluestone CD. Congenital perilymphatic fistula and associated middle
ear abnormalities. Laryngoscope 1993;103:160–4.
7. Bluestone CD. Otitis media and congenital perilymphatic fistula as a cause of sensorineural
hearing loss in children. Pediatr Infect Dis J 1988;7 Suppl:S141–5.
8. Weissman JL, Weber PC, Bluestone CD. Congenital perilymphatic fistula: computed tomog-
raphy appearance of middle ear and inner ear anomalies. Otolaryngol Head Neck Surg
1994;111:243–9.
9. Weber PC, Kelly RH, Bluestone CD, Bassiouny M. Beta-2 transferrin confirms perilymph fis-
tula in children. Otolaryngol Head Neck Surg 1994;110:381–6.
10. 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;16:277–82.
11. Buchman CA, Luxford WM, Hirsch BE, et al. Beta-2 transferrin assay in the identification of
perilymph. Am J Otol 1999;20:174–8.
12. Bluestone CD. Implications of beta-2 transferrin assay as a marker for perilymphatic versus
cerebrospinal fluid labyrinthine fistula. Am J Otol 1999;20:174–8.
13. Bluestone CD. Perilymphatic fistula in children. In: Gates GA, editor. Current therapy in otolaryn-
gology-head and neck surgery. 6th ed. Hamilton, Ontario: BC Decker Inc; 1998. p. 67–71.
14. Weber PC, Bluestone CD, Perez B. Outcome of hearing and vertigo following surgery for con-
genital perilymphatic fistula in children (Abstract). Annual meeting of the American Society
of Pediatric Otolaryngology; April 21, 1993; Los Angeles, CA; 1993.
15. Bluestone CD. Eustachian tube function and dysfunction. In: Rosenfeld RM, Bluestone CD,
editors. Evidence-based otitis media. Hamilton, Ontario: BC Decker Inc; 1999. p. 137–56.
16. Supance JS, Bluestone CD. “How I do it” — Medical management of the chronic draining ear.
17. Bluestone CD, Cantekin EI. Management of the patulous eustachian tube. Laryngoscope
1981;91:149–52.
18. Magit AE, Bluestone CD. Catheter occlusion of the patulous eustachian tube (Abstract). Pro-
ceedings of the American Otological, Rhinological, and Laryngological Society, Western Sec-
tion Meeting; January 13, 1992; Los Angeles, CA; 1992.
19. Bluestone CD, Magit AE. The abnormally patulous Eustachian tube. In: Brackmann DE, Shel-
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20. Bluestone CD. Management of the abnormally patulous eustachian tube. In: Myers EN, Blue-
stone CD, Brackmann DE, Krause CJ, editors. Advances in otolaryngology-head and neck
surgery. St. Louis (MO): Mosby, Inc; 1998. p. 205–34.
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 otolaryngology—head and neck surgery. To be successful, the head
and neck surgeon must have a precise knowledge of anatomy; the ability to handle trau-
matic, neoplastic, infectious, idiopathic, and congenital diseases; the skills to manage emer-
gent, 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, Mastoidecto-
my 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 7–1).
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 cere-
bellar peduncle and medial to the vestibulocochlear nerve and the nervus
intermedius (intermediate nerve).1–3 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 (hori-
zontal), 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.
♦ 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.
Figure 7–1 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.1–3
• 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.1–3
• 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.
♦ 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 semi-
circular canal.1–3
Facial Nerve Exploration and Repair 139
• 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 later-
al 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 lat-
erally 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 pos-
terior to the styloid process.1–3
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 cervi-
cofacial 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 intercon-
necting 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 cra-
nial 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 proce-
dure (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
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 decompres-
sion, 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 per-
sisting 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
• 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, infu-
sion pump, or similar device.
• Neonates and some young infants require a fluid warmer and either a
warming blanket, warming lights, or both. Appropriately sized breath-
ing circuits, blood pressure cuffs, masks, laryngoscopes, and endotra-
cheal tubes also are necessary.
• The anesthesiologist is stationed across the table from the surgeon and
inferior to the patient’s shoulder, to facilitate coordination and com-
munication among the surgical team. The endotracheal tube is taped
to the patient’s mouth on the side closest to the anesthesiologist (Fig-
ure 7–2). 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.
Figure 7–2 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 surgeon’s legs.
• The patient is placed in the supine position as close as possible to the
surgeon. The patient’s head can be placed in a foam-sponge head hold-
er so that the top of the patient’s head is positioned flush with the end
of the operating table and the patient’s 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 patient’s 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 micro-
scope. 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.
• 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 fenes-
tration 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 assistant’s ease of viewing and retraction.
The video camera attachment is positioned on the opposite side toward
the patient’s feet.
• Draped with a sterile cover, the microscope is positioned at the level of
the patient’s head; for stability, the long extension of the microscope’s
base is pointed toward the surgeon. Video camera attachments are con-
nected 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, fac-
ing the surgeon (see Figure 7–2).
Procedure
Figure 7–3 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.
Figure 7–3 Intratemporal explo-

ration and decompression of the
facial nerve.
No 1. Mastoidectomy
• The mastoid tip is palpated, and an incision is made 1 to 2 cm pos-
terior 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 7–4).
• 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 (Fig-
ure 7–5). 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 superopos-
terior aspect of the lateral bony canal wall (Figure 7-6). Further ele-
vation can be done anterosuperior to the canal to expose the zygo-
matic 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 7–7). Dur-
ing 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 7–4 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).
Figure 7–5 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 7–6 Postauricular eleva-

tion done to expose the spine of
Henle, zygomatic root, temporal
line, and mastoid process.
Figure 7–7 T-shaped opening

made to begin mastoidectomy.
• The tegmen is located posterosuperior to the external canal at the

temporal line. The dissection is continued medially along the tegmen
to identify Körner’s 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 posterior-
ly and superiorly, the mastoid tip and digastric ridge are drilled infe-
riorly, the zygomatic root is drilled anteriorly, and the sigmoid (later-
al) sinus is delineated posteriorly (Figure 7–8).
• 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 mas-
toid cavity.
• Superiorly the facial nerve can be identified just inferior to the fossa
incudis as well as anterior (and, usually, medial) to the lateral semicir-
cular 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 7–9).
• 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 sub-
segment of the facial nerve (Figure 7–10).
• Enlarging the facial recess and the epitympanum and working
through the tympanotomy incision facilitates exposure of the tym-
panic subsegment of the facial nerve. This approach can help deter-
mine 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 sur-
geon 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
Figure 7–8 Exposure of the lateral

semicircular canal, short process of
incus, sinodural angle, lateral sinus,
and digastric ridge.
Figure 7–9 Facial recess approach

to locate the facial nerve.
Figure 7–10 Facial recess approach to the chorda

tympani nerve and the facial nerve canal.
• 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 cov-
ering is left to protect the nontraumatized nerve in the facial canal.
♦ 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 7–11).
♦ 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 expand-
able ear wick, or gauze strips. A mastoid compressive dressing is
applied. Mittens can be placed on the hands of young children to pre-
vent 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 eye-
lid 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:
♦ If no denervation has occurred, recovery may be expected within 3 to
6 weeks.
♦ If compression has caused minimal or moderate denervation, recov-

ery should take 4 to 12 weeks.
♦ If denervation is severe, recovery will take at least 8 to 12 weeks.
Figure 7–11 Bone fragments lifted to expose facial nerve (n).

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-sec-
tional avulsion of the nerve exceeds 50%, intratemporal interposition nerve
grafting or rerouting of the facial nerve with primary anastomosis is prob-
ably indicated, depending on the surgeon’s clinical judgment. Possible
nerve graft donor sites include the ipsilateral or contralateral great auricu-
lar 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 neur-
al 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 paral-
ysis, 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 con-
dition, 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 articulate—and
make sure that patients and their families understand the following:
♦ 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 micro-
scope, a sharp blade (razor blade or 6500 Beaver Mini-Blade [R Beaver
Inc, Waltham, MA]) for nerve transection, and the fewest nonreactive 9-
0 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 pre-
clude suture line tension, and it should be placed in position with no
delay. Possibly because it is less traumatic to the nerve, epineural sutur-
ing 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.
• 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 nonessen-
tial 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, par-
ticularly 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 cross-
anastomosis or masseter neurotization. Advocates of both these theories
clip specific branches and/or tie the clipped ends by using a nonab-
sorbable suture.9–11
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 lac-
eration, with or without separation of the nerve endings. If no separa-
tion exists, the nerve endings will not remain in an unsupported approx-
imated 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. More-
over, 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.
♦ 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 nerve’s 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 pos-
terior bony canal wall.
♦ In children, the disadvantages of rerouting seem to outweigh the
advantages because the mastoid segment of the facial nerve in chil-
dren 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,
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 disadvan-
tage 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.
• General endotracheal anesthesia is used as described above —Intratem-
poral 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 Explo-
ration 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 7–12 overviews intratemporal repair, rerouting, and grafting of the
facial nerve.
• Simple mastoidectomy is always done (see Figures 7–5 to 7–8), with or
without exploratory tympanotomy. If necessary (ie, to locate facial
nerve, extent of neuroma, or trauma), a facial recess approach (see Fig-
ure 7–9 and 7–10) 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 millime-
ters proximal and distal to the site of trauma. All bone fragments are
carefully lifted from the nerve (see Figure 7–11).
• 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 7–13). If the nerve edges will not lie in an approx-
imated position, they are sutured with enough 9-0 or 10-0 monofilament
nylon sutures in the epineurium to maintain coaptation.
Figure 7–12 Intratemporal

repair, rerouting, and grafting of
facial nerve.
Figure 7–13 Facial canal exploration and exposure

of facial nerve proximal and distal to laceration of
facial nerve.
• For rerouting, the entire facial nerve must be exposed from the genicu-
late 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 7–14).12
• A neofacial nerve canal can be drilled for nerve stability but only if addi-
tional 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 dia-
mond burs for several millimeters proximal and distal to the avulsed or
lacerated section. Drilling must expose half to two-thirds of the circum-
ference of the nerve. Once the bony lining is thinned, it can be removed
with picks and elevators (see Figure 7–11). 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 neu-
roma, 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 success-
ful 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:
♦ The great auricular nerve (C2, C3) is the sensory branch of the cer-
vical plexus and courses from medial to lateral around the posterior
border of the sternocleidomastoid muscle (Erb’s point).
♦ The nerve ascends toward the inferior auricle and mastoid tip, pro-
ceeds along the lateral surface of the sternocleidomastoid muscle, and
usually terminates in three branches (Figure 7–15A).
♦ The great auricular nerve bisects an imaginary straight line extending
between the mastoid tip and the angle of the mandible (Figure
7–15B).
Figure 7–14 Facial nerve rerouted and sutured with fewest sutures needed to achieve coapta-
tion. (Adapted from Hilsinger RL Jr. The facial nerve. In: Bluestone CD, Stool SE, editors.
Atlas of pediatric otolaryngology. Philadelphia: WB Saunders; 1995. p. 145.)
A B
Figure 7–15 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.
• 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 7–16).
• 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 7–16 Nerve graft sutured in position in the facial canal.

EXTRATEMPORAL EXPLORATION AND REPAIR FOR

LESIONS
In children, neoplastic disease in the parotid area is uncommon, and heman-
gioma is more common than lymphangioma; pleomorphic adenoma is the
most common benign solid tumor. Of the malignant tumors, mucoepider-
moid 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 infre-
quently. Congenital anomalies of the first branchial cleft are rare.7,13–16
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 aspi-
ration 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 diagnosis—in children or in
adults—excisional 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.7,14–17
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
• General endotracheal anesthesia is used as described above—see
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 facil-
itate 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 patient’s contralateral shoulder
so that the surgeon and surgical assistants have easy access to the
patient’s entire head and each side of the patient’s neck (Figure 7–17).
Figure 7–17 Operating room

(OR) arrangement for extratem-
poral bone facial nerve proce-
dure 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 patient’s 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 patient’s shoulders to accentuate
the operative field. The patient’s 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 approx-
imate 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.
• 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 7–18 overviews extratemporal exploration and repair for lesions.
Figure 7–18 Extratemporal

exploration and repair for
parotid and nonparotid lesions.
No 1. Incision and exposure

• The proposed preauricular incision (Figure 7–19) is marked with a
surgical marker.
♦ 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 mas-
toid process and is then curved inferiorly and anteriorly about 2
cm inferior to the mandible rim, preferably within a skin crease
(see Figure 7–19A). 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 7–19B).4
Figure 7–19 A, Incision line for A

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;93:174–6.)
B
• 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 7–20).
• 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 7–20 Elevation of parotidectomy skin flaps to expose zygoma, buccal fat pad, masseter muscle, and
sternocleidomastoid muscle.
• The anterior border of the sternocleidomastoid muscle is dissected

medially until the posterior belly of the digastric muscle is located
(Figure 7–21). 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 ante-
rior (Figure 7–22).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 “point-
er” is identified at the bony cartilaginous junction of the external
auditory canal (Figure 7–23).
• This dissection plane is continued superiorly to the level of the zygo-
matic 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 7–21 Retraction of

inferior parotid gland and stern-
ocleidomastoid muscle to locate
posterior belly of digastric muscle.
Figure 7–22 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;93:174–6.)
Figure 7–23 Posterior border of

parotid gland retracted anterior-
ly to dissect external canal medi-
ally toward cartilaginous “point-
er.” (Adapted from Hilsinger RL
Jr. The facial nerve. In: Blue-
stone CD, Stool SE. editors.
Atlas of pediatric otolaryngology.
Philadelphia: WB Saunders;
1995. p. 151.)
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
canal–bony cartilaginous junction, just anterior to the stylomastoid
foramen (Figure 7–24).
♦ This area is separated with blunt dissection parallel to the expect-
ed 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 7–24 Exposure of main

trunk of facial nerve and its tem-
porofacial and cervicofacial divi-
sions.
• Proper surgical technique is essential when working near the facial

nerve:
♦ The surgeon should minimize any contact with the facial nerve
and its branches.
♦ Visualization obscured by blood can be improved by lightly touch-
ing 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 zygomat-
ic branch.
• The mandibular branch, or ramus mandibulae, is located in the neck
lateral to the facial vessels and just superior to the submandibular gland.
♦ 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 anterosu-
perior 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 circum-
stance 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 contin-
ued anteriorly along the trunk until its bifurcation is located; the
facial nerve is then identified conclusively, and the parotid tissue lat-
eral to the nerve can be incised with a Shaw scalpel or with a No 11,
12, or 15 blade.
• 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 7–25).
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 com-
pleted, 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 7–26).
• 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 poste-
rior 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.
♦ 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 auriculotempo-
ral 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 suffi-
ciently facilitate removal of tumor or parotid tissue.
Figure 7–25 Exposure of the

zygomatic branch of facial nerve
with a curved hemostat before
severing parotid tissue lateral to
the facial nerve.
Figure 7–26 Main trunk and

cervicofacial branch of facial
nerve retracted to expose under-
lying parotid gland tissue.
• Once the pathology specimen has been removed, the nerve is inspect-
ed to ensure that it is intact:
♦ 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 coap-
tation (Figure 7–27).
♦ 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 interposi-
tion nerve graft can be sutured in place (Figure 7–28).
♦ 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 branches—for
example, the buccal to the temporal or zygomatic branch, or the
buccal or cervical to the mandibular branch (Figure 7–29).18
Figure 7–27 Sutured laceration

of main trunk of facial nerve.
Figure 7–28 Interposition nerve

grafts sutured into zygomatic
and marginal branch defects.
Figure 7–29 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;88:348–54.)
• The wound is irrigated with saline solution, and the facial nerve is re-
examined 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 approximat-
ed 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 dress-
ing. 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.
♦ 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 com-
plication.
• 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 sta-
ples 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.
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 patient’s airway and car-
diovascular status is important. Neurologic evaluation should be done after
the patient’s condition has stabilized and should include assessment of the
facial nerve. Computed tomography scans are appropriate when the tem-
poral 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. Differ-
entiating 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.8–10 Wound exploration within 72 hours can thus be facil-
itated 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.8–10 Nerve
grafts should be done before 18 months, by which time fibrosis of the neur-
al 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 mas-
seter muscle (repair is unnecessary for branches severed anterior to the
masseter muscle).
• Facial paralysis immediately after blunt trauma to the head and neck.
• General nasotracheal anesthesia is used as described above—see
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 Decompres-
sion 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
Figure 7–30 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:
♦ 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 7–30 Extratemporal explo-

ration and repair after trauma.
• 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 located—and if the
ends can be approximated without causing tension—the 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 7–31A and B).18
• When the laceration is situated at the stylomastoid foramen or at a pos-
terior 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 7–31 A, Avulsed parotid tissue and facial nerve. B, Superficial and underlying parotid tissue is removed to enable approxi-
mation 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;88:348–54.)
• 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 7–32A 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 cont-
amination 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 Bar-
ton 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.
Figure 7–32 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 recipi-
ent nerve. C, Two nerve grafts of
smaller diameter are sutured to a
larger-diameter nerve trunk.
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 with-
out 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 accessory–facial (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.9–11,18
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 indicat-
ed in three circumstances:
1. Extratemporal facial nerve laceration in which primary approxima-
tion 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 approximat-
ed 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, func-
tioning distal nerve and neuromuscular junction, and no viable proxi-
mal 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.
General nasotracheal anesthesia is used as described above—see Extratem-
poral 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 Decompres-
sion 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 Ringer’s 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 par-
allel to (or, preferably, in) a skin crease about 2 cm inferior to the
mandibular margin and centered on the posterior border of the ster-
nocleidomastoid 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 cuta-
neous nerve in the middle of the leg.
♦ The sural nerve is usually located just medial to the small saphe-
nous vein; it then continues inferiorly and curves anteriorly, infe-
rior 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 7–33).
• 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 7–34A).
• 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 7–34B).
• Lateral traction on the vein and the sural nerve reveals the nerve’s
superior and inferior course and thus allows easier dissection. Hori-
zontal 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.
Figure 7–33 The sural nerve,

located adjacent to the saphenous
vein in the lower part of leg.
Figure 7–34 The sural nerve can

be identified through
(A) a vertical incision bisecting
the distance between lateral
malleolus and the Achilles ten-
don and curving inferiorly to
A
gain additional length or
branches, or (B) a horizontal
incision made just posterior to
the lateral malleolus with stair-
step 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 posi-
tion to determine the length needed. Slightly more graft than is need-
ed 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.
• An appropriate number of 9-0 or 10-0 monofilament nylon sutures

is used to approximate the perineurium of the graft to the epineuri-
um of the nerve (Figure 7–35). Depending on the width of the prox-
imal 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 bifur-
cation, 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 with-
out 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 7–36).
• Sacrifice of the hypoglossal nerve results in paralysis of the ipsilateral
side of the tongue and ipsilateral facial contraction during degluti-
tion. 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 postop-
eratively and may be expected to continue for at least 12 months post-
operatively.
Figure 7–35 Two grafts or fasci-

cles sutured to a facial nerve
trunk larger in diameter than are
available donor grafts.
Figure 7–36 Hypoglossal nerve

transected and sutured onto pre-
viously prepared distal facial
nerve.
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 com-
plete facial nerve paralysis. In addition, nerve action potentials remain near-
ly 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) subjective-
ly compares movement of each side of the face after the facial nerve is stim-
ulated with the minimal amount of current necessary to elicit muscle con-
traction. A difference of at least 3.5 mA in stimulation intensity at the facial
nerve trunk or over its branches indicates progressive or impending degen-
eration.22 As a clinical test, NET has largely been replaced by either maxi-
mal stimulation testing (MST) or electroneurography (ENOG).
Maximal stimulation testing. Maximal stimulation testing is a subjec-
tive 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 periph-
eral 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
Electromyography. When administered at least 2 to 3 weeks after nerve

injury, electromyography (EMG) can be useful for assessing facial re-inner-
vation. 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 oth-
erwise disproved.
Magnetic stimulation. Magnetic stimulation is a technique in which
stimulation generated by a magnetic coil is applied at the stylomastoid fora-
men and is recorded retrograde at the vertex. Results of this test can indi-
cate 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 depart-
ment 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 Freder-
ick 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 pro-
vided editorial assistance.
REFERENCES
1. Proctor B. The anatomy of the facial nerve. Otolaryngol Clin North Am 1991;24:479–504.
2. Clemente CD, editor. Gray’s 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;93:173–6.
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. 249–70.
8. Adkins WY, Osguthorpe JD. Management of trauma of the facial nerve. Otolaryngol Clin
North Am 1991;24:587–611.
9. Johns ME, Crumley RL. Facial nerve injury, repair, and rehabilitation [Otorhinolaryngology
self-instructional packages, 79200]. Washington (DC): American Academy of Otolaryngolo-
gy; 1979.
10. Papel ID. Rehabilitation of the paralyzed face. Otolaryngol Clin North Am 1991;24:727–38.
11. Fisch U, Lanser MJ. Facial nerve grafting. Otolaryngol Clin North Am 1991;24:691–708.
12. Hilsinger RL Jr. The facial nerve. In: Bluestone CD, Stool SE, editors. Atlas of pediatric oto-
laryngology. Philadelphia: WB Saunders; 1995. p. 129–66.
13. Batsakis JG. Tumors of the head and neck: clinical and pathological considerations. 2nd ed. Bal-
timore: Williams & Wilkins; 1979. p. 9–14, 64–6.
14. Gates GA. Diseases of the salivary glands. In: Bluestone CD, Stool SE, Arjona SK, editors. Pedi-
atric otolaryngology. Philadelphia: WB Saunders; 1983. p. 1023–36.
15. McRae RG, Lee KJ, Goertzen E. First branchial cleft anomalies and the facial nerve. Otolaryn-
gol Head Neck Surg 1983;91:197–202.
16. Schuller DE, McCabe BF. Salivary gland neoplasms in children. Otolaryngol Clin North Am
1977;10:399–412.
17. Harris JP, Davidson TM, May M, Fria T. Evaluation and treatment of congenital facial paraly-
sis. Arch Otolaryngol 1983;109:145–51.
18. Tucker HM. The management of facial paralysis due to extracranial injuries. Laryngoscope
1978;88:348–54.
19. Olsson JE, Shagets FW. Blunt trauma of the temporal bone [Otorhinolaryngology self-instruc-
tional package, 80386]. 2nd ed. Washington (DC): American Academy of Otolaryngolo-
gy–Head and Neck Surgery; 1986.
20. Adour KK. Facial nerve electrical testing. In: Jackeler RK, Brackmann DE, editors. Neurotol-
ogy. St. Louis (MO): Mosby; 1994. p. 1283–9.
21. Dobie RP. Tests of facial nerve function. In: Cummings CW, Frederickson JM, Harker LA, et
al, editors. Otolaryngology—Head & Neck Surgery. 3rd ed. St. Louis (MO): Mosby; 1998.
p. 2757–66.
22. Laumans EP, Jongkees LB. On the prognosis of peripheral paralysis of endotemporal origin.
Part II: Electrical tests. Ann Otol Rhinol Laryngol 1963;72:621–36.
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 tympa-
nomastoid 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 par-
tial postoperative stenosis. A narrow meatal opening defeats the self-cleaning mechanism of
the external ear canal, leading to the “problem ear.” Following a canal wall–down mas-
toidectomy, 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 prob-
lem 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 pro-
cedure using an operating microscope and appropriate delicate instru-
ments. 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 sili-
cone plugs or petroleum-impregnated lamb’s wool.
• Parents and patients are admonished not to use cotton-tipped applica-

tors, which can impact debris in the canal and irritate the skin.
• Occasionally, when a patient is unable to comply with the recommend-
ed instructions or is refractory to the treatment, hospitalization is rec-
ommended 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 inflam-
matory 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 accompa-
nied 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 carti-
lage 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-thick-
ness skin graft to provide a stable epidermal canal lining.
Surgical Anatomy
• In the tympanic part of the temporal bone, two prominent sutures—the
anterior tympanosquamous suture and the posterior tympanomastoid
suture—may protrude and encroach on the canal lumen (Figure 8–1).
The resulting overhangs can prevent the eardrum margin and related
pathologic changes from being visualized.
• The suprameatal spine (see Figure 8–1), when prominent and anteriorly
oriented, can further narrow the canal at the bony-cartilaginous junction.
Ear Canal Stenosis and Atresia 187
Figure 8–1 Tympanic portion of the temporal bone showing the anterior tympanosquamous suture (a), posterior tympa-
nomastoid 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.
• 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.
Procedure
The described approach is applicable to a wide variety of otologic proce-
dures, including tympanoplasty, mastoidectomy (wall–up or wall–down),
and repair of ear canal stenosis (acquired or congenital). The ear canal sur-
gical methods described include endaural and postauricular approaches
(Figures 8–2 and 8–3). Table 8–1 lists the advantages and limitations of
each approach.
Figure 8–2 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 8–3 A postauricular

approach. (Reproduced with
CV Mosby; 1991.)
Table 8–1 Endaural vs. postauricular approach for ear canal

reconstruction
Approach Advantages Disadvantages
Endaural ✓ Precise incision placement × Inadequate exposure to eradicate

✓ Facilitates development of a disease in a large pneumatized
rectangularly shaped, laterally mastoid cavity
based conchal-meatal skin flap × Cartilage resection,
✓ Pedicled flap promotes healing, especially from the canal floor,
reduces granulations, and is technically difficult while
eliminates stenosis formation preserving canal wall–meatal
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
wall–down 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. Injec-
tion 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 o’clock into the
loosely attached superior canal skin where the spread of the solu-
tion is limited by the skin’s fibrous attachments to the tympa-
nosquamous and tympanomastoid sutures. The second injection is
made into the skin inferiorly at 6 o’clock, the spread of the solu-
tion being confined to the tightly adherent skin overlying the tym-
panic bone.
• 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 8–4). The incision extends from above the lateral process of
the malleus (12 o’clock) to the floor of the external canal.
• The meatal opening is widely dilated using a Lempert endaural
speculum (Figure 8–5). Two vertical incisions are made using an elec-
trosurgical unit with a needlepoint tip to minimize bleeding and
enhance visibility:
1. The first incision is made superiorly in the notch between the tra-
gus and the anterior root of the helix (12 o’clock) (Figure 8–6).
• 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 ele-
vate the superior and posterior canal wall skin off the underly-
ing bone (Figure 8–7).
Figure 8–4 A horizontal inci-

sion is made using a stapes knife
through an ear speculum.
(Reproduced with permission
from Johnson JT, editor. Ameri-
can Academy of Otolaryngolo-
gy-Instruction Courses. Vol 4.
St. Louis (MO): CV Mosby;
1991.)
Figure 8–5 Dilation of the meatal opening with a Lem-

pert endaural speculum. (Reproduced with permission
from Johnson JT, editor. American Academy of Oto-
laryngology-Instruction Courses. Vol 4. St. Louis (MO):
CV Mosby; 1991.)
Figure 8–6 The first incision is made using an

electrosurgical unit with a needle point tip at the
12 o’clock position. (Reproduced with permission
from Johnson JT, editor. American Academy of
Otolarygology-Instruction Courses. Vol. 4. St.
Louis (MO): CV Mosby; 1991.)
Figure 8–7 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-Instruc-
tion Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
• This exposes the tympanosquamous suture anteriorly (Figure

8–8), 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 o’clock position beginning at the horizontal incision and extend-
ing laterally to the conchal opening (Figure 8–9).
• Using a duckbill elevator, the inferior posterior canal wall skin is dis-
sected from the underlying bony canal (Figure 8–10).
• The bridge of the skin that was initially preserved superiorly is now
cut using a Bellucci scissors, completing the mobilization of the rec-
tangular-shaped meatal canal skin flap (Figure 8–11).
Figure 8–8 Undermining reveals

a tympanosquamous suture
(arrow). (Reproduced with per-
mission from Johnson JT, editor.
American Academy of Otolaryn-
gology-Instruction Courses. Vol
4. St. Louis (MO): CV Mosby;
1991.)
Figure 8–9 A second incision is

made at the 6 o’clock position.
1991.)
Figure 8–10 The skin of the inferior posterior canal wall is Figure 8–11 Preserved skin is cut with a Bellucci scissors to
elevated. (Reproduced with permission from Johnson JT, form the meatal canal skin flap. (Reproduced with permis-
editor. American Academy of Otolaryngology-Instruction sion from Johnson JT, editor. American Academy of
Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.) 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 8–12A 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.
A B
Figure 8–12 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.)
No 2. Postauricular approach
• The skin is incised just posterior to the skin crease using an electro-
surgical unit with a needlepoint tip (Figure 8–13). The dissection sep-
arating 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 (Fig-
ure 8–14).
• The ear is retracted forward (see Figure 8–14) and grafts are harvest-
ed 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 8–14, inset). The areolar tissue is grasped, dissect-
ed from the underlying muscle with a Freer elevator (Figure 8–15),
and excised with a scissors (Figure 8–16). The graft is spread out
and allowed to dry on a Teflon block for later use in resurfacing the
bone when performing a canal wall–down mastoidectomy.
Figure 8–13 Using a postauricu-

lar approach, an incision is made
using electrocautery. (Repro-
duced with permission from
Johnson JT, editor. American
Academy of Otolaryngology-
Instruction Courses. Vol 4. St.
Figure 8–14 The ear is retracted

forward, and an incision is made
through the areolar tissue
(inset). (Reproduced with per-
1991.)
Figure 8–15 The incised tissue is lifted and dissected with a Figure 8–16 Areolar tissue is excised. (Reproduced with
Freer elevator. (Reproduced with permission from Johnson JT, permission from Johnson JT, editor. American Academy
editor. American Academy of Otolaryngology-Instruction of Otolaryngology-Instruction Courses. Vol 4. St. Louis
Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.) (MO): CV Mosby; 1991.)
♦ The temporalis fascia graft is obtained by making a circular incision

through the fascial layer (Figure 8–17). 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 wall–down 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 pick-
up and is bluntly freed off the temporalis muscle (Figure 8–18).
• The mastoid periosteum is incised in a T-like fashion (Figure 8–19).
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 car-
ried 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 retrac-
tors are inserted to enhance operative exposure.
Figure 8–17 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 Otolaryngology-
Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.)
Figure 8–18 The graft is

removed from the temporalis
muscle. (Reproduced with per-
1991.)
Figure 8–19 A T-shaped inci-

sion is made in the mastoid
periosteum. The first incision
(1) is made parallel to the supe-
rior temporal line and is fol-
lowed by another incision
(2), which is made at a right
angle to the mastoid tip. (Repro-
• The cartilage of the canal floor in the tympanomastoid sulcus area is

identified and dissected using a Stevens scissors (Figure 8–20A). 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 o’clock incision.
• The block of cartilage, freed from its adjacent connective tissue, is
amputated from its remaining anterior attachment, which is contin-
uous with the tragal cartilage (Figure 8–20B, 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 recon-
struction or to repair a defect in the lateral attic wall.
• To complete the meatoplasty, a crescent-shaped segment of the anteri-
or edge of the conchal cartilage is excised (Figure 8–21). The auricle is
held with the surgeon’s 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 8–22).
A B
Figure 8–20 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 Otolaryngolo-
gy-Instruction Courses. Vol 4. St. Louis (MO): CV Mosby; 1991.) B, Space created from its removal (arrow) enables enlarge-
ment of the inferior portion of the cartilaginous canal.
Figure 8–21 The conchal carti-

lage segment is excised. (Repro-
Figure 8–22 The tissue plane

between the cartilage and the
meatal skin is established.
1991.)
• The mobilized, rectangular, conchal-based posterior meatal canal wall

skin is debulked. The skin is grasped with a forceps and supported on
the surgeon’s finger (Figure 8–23), 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 surgeon’s index finger. If the meatus is
too small, the vertical 12 and 6 o’clock incisions may be extended lat-
erally into the concha, and additional soft tissue and cartilage resect-
ed (see the discussion on Figures 8–19 and 8–20).
Figure 8–23 The conchal-based

skin of the posterior meatal
canal wall is debulked. (Repro-
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 (Fig-
ure 8–24A).
• The skin is raised in a retrograde fashion until the tympanic bony-
cartilaginous junction (arrow) is reached (Figure 8–24B).
• The skin is usually firmly attached at the tympanic bony-cartilagi-
nous junction. The cartilage is separated from the rough bony surface
using a duckbill elevator, thus mobilizing the skin and gaining ade-
quate exposure of the entire tympanic ring (Figure 8–25).
Figure 8–24 A, An incision is

made through the anterior canal
skin and is elevated, B, until the
tympanic bone cartilage junction
(solid arrow) is reached. (Repro-
Figure 8–25 A duckbill elevator separates the cartilage from

the rough bony surface. (Reproduced with permission from
Johnson JT, editor. American Academy of Otolaryngology-
Instruction Courses. Vol 4. St. Louis (MO): CV Mosby;
1991.)
• The bony overhangs are removed with constant suction irrigation and
appropriate burs (Figure 8–26A). 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 8–26B). 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 com-
pleted when the tympanic annulus and pars flaccida are clearly visi-
ble and permit adequate exposure for removal of pathology and to
perform the necessary surgery.
• Upon completing the ear surgery, the anterior sulcus skin is reposi-
tioned and the area stented with Gelfoam (Figure 8–27). The angle
formed by the eardrum and canal wall skin must be preserved to pre-
vent 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 wall–up or a canal wall–down procedure.
Figure 8–26 A, Bony overhangs

are removed using suction and a
drill while the distal skin is ele-
vated and protected by sponges,
B. (Reproduced with permission
1991.)
Figure 8–27 The anterior sulcus

skin is repositioned, and the area
is stented with Gelfoam. (Repro-
No 4. Canal wall–down 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 8–28A).
This enlarges and stabilizes the meatal opening (Figure 8–28B).
• 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 8–28 A, A suture is used

to approximate connective tis-
sue, resulting in enlargement
and stabilization of the meatal
openings, B. (Reproduced with
CV Mosby; 1991.)
B
• 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 cavi-
ty and the ear canal, which is packed with additional Gelfoam. Bis-
muth-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 8–29A). A large
meatus reduces the area to the sinodural angle, and consequently the
mastoid cavity is smaller (Figure 8–29B).
Figure 8–29 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
CV Mosby; 1991.)
B
No 5. Canal wall–up 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 perios-
teum enlarging and stabilizing the meatal opening.
• Working endaurally, the posterior canal wall–meatal 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 suspen-
sion 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 dis-
solved or been removed and the ear canal and mastoid skin lining has
healed.
SKIN GRAFTING OF THE EXTERNAL AUDITORY CANAL

The purpose of skin grafting is to restore an epithelial lining to the exter-
nal 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 meatal–canal 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 eti-
ologies 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 8–30).
Figure 8–30 The lower

abdomen skin graft site.
• 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 pre-
vent curling (Figure 8–31A).
2. Benzoin adhesive is applied to the thin silicone sheeting, which is
allowed to dry and become sticky (Figure 8–31B).
3. The epidermal side of the skin graft is glued to the adhesive on the
silicone sheeting to form a composite graft (Figure 8–31C).
4. The composite graft is trimmed to the necessary size (Figure 8–32).
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 fas-
cia, which has been used to construct the tympanic membrane (see
Figure 8–32).
• The graft is positioned into the ear canal with the slit end medially (Fig-
ure 8–33A), and then placed over the reconstructed tympanic mem-
brane (Figure 8–33B). The lateral end may be sutured into the concha.
A C
Figure 8–31 Silicone sheeting is unfurled (A) and treated with benzoin adhesive (B) before a skin
graft is applied to it (C).
Figure 8–32 The skin-silicone

graft is trimmed (A), and slits
are cut (B and C) in order to
overlap the temporalis fascia.
A B
Figure 8–33 A, The graft is positioned into the canal. B, The graft is placed over the reconstructed tympanic membrane.
• Gelfoam is carefully inserted into the composite graft and packed snug-
ly. 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 8–34).
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 8–34 Artificial sponges

are used to suction Gelfoam and
ensure that grafts become
apposed to bony surfaces.
CONGENITAL AURAL ATRESIA

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 syn-
chronously 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:
♦ 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 nor-
mal appearance.
• In newborns, auditory brainstem-evoked potential testing can be per-
formed 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.
• 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 pre-
cedes the atresia surgery to prevent scar tissue and compromised vas-
cularity from jeopardizing the cosmetic results. The microtia repair
must be delayed until about age 6 years, to allow adequate develop-
ment of the costochondral cartilage for sculpting the auricular carti-
laginous scaffold.
• The risks and realistic expected benefits of this complicated surgery
must be discussed with the family relative to the individual surgeon’s
operative results.
Contraindications
• A significant neurosensory hearing loss or inner ear malformation.
• Limited middle ear–mastoid pneumatization or a significantly hypoplas-
tic 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 recom-
mended. 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 reconstruct-
ed auricle (Figure 8–35). 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 8–14 to 8–18).
• The periosteum is incised in a T-like fashion as described earlier (Figure
8–36).
• The mastoid cortex is exposed, and the glenoid fossa is identified (Fig-
ure 8–37). 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 mid-
dle cranial fossa (cranium) roughly corresponds to the superior tempo-
ral line (dashed).
Figure 8–35 A skin incision is made posterior

to the reconstructed auricle.
Figure 8–36 A T-shaped incision

is made on the periosteum.
Figure 8–37 The mastoid cortex

is exposed. The superior tempo-
ral line (dashed line) approxi-
mates the level of the tegmen.
Drilling is begun in the rudi-
mentary tympanic bone (circle).
TMJ = temporomandibular joint
• Drilling between the glenoid fossa and the tegmen plate (see Figure
8–37) creates the ear canal. In some cases, a core of dense bone repre-
sents the obliterated external canal. The surgeon should attempt to drill
a circular canal-like opening toward the middle-ear cleft (Figure 8–38).
It is important to avoid entering the mastoid air cells; however, the atre-
sia plate itself is occasionally pneumatized.
• Frequently, a dense periosteal membrane is identified at the medial end
of the atresia plate (Figure 8–39). 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 8–40). An opening that is similar in dimension to a normal tym-
panic 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 8–41). Occasion-
ally, a forward-lying facial nerve prevents this.
Figure 8–38 A circular canal-

like opening is made with a drill.
TMJ = temporomandibular joint
Figure 8–39 Dense periosteal

membrane.
Figure 8–40 The middle

ear is entered after an inci-
sion of the periosteal
membrane has been made.
Figure 8–41 Round window

niche.
• If air cells have been entered, they can be plugged using bone dust pâté
(Figure 8–42A) collected in the Sheehy bone pâté collector (Figure 8–42B).
• An ossicular reconstruction is performed when the chain is not contin-
uous; observing a round window reflex may help decide if the chain is
intact (Figure 8–43). 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 8–44).
• 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 8–45A). The flap is debulked,
removing cartilage and connective tissue (Figure 8–45B), thereby creat-
ing a rectangular full-thickness flap.
Figure 8–42 A, Bone dust pâté

is used to plug air cells.
B, Sheehy bone pâté collector.
B
Figure 8–43 Silastic sheeting prevents bony

fixation of the reconstructed ossicles.
Figure 8–44 A temporalis fascia

graft is inserted medial to the
endosteal flap (arrow).
Figure 8–45 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. B
• The flap is rotated into the canal and is sutured anteriorly (arrows) to
the soft tissue in the area of the glenoid fossa (Figure 8–46). This pro-
vides 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 8–30 to 8–32). 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 8–47).
• 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 8–46 The lateral half of the anterior canal is resurfaced with a skin graft.
Figure 8–47 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;13:236–40.
Beck DL, Benecke JE. Intraoperative facial nerve monitoring-technical aspects. Otolaryngol Head
Neck Surg 1990;102:270–2.
Bellucci RJ. Tympanoplasty, the malleus, stapes wire and total defect skin graft. Laryngoscope
1996;76:1439–58.
Bellucci RJ. Congenital malformations of the ear. Otolaryngol Clin North Am 1981;14:95–124.
Bellucci RJ, Converse JM. The problem of congenital auricular malformation. Trans Am Acad Oph-
thalmol Otolaryngol 1960;64:840.
Curtin HD. Congenital malformations of the ear. Otolaryngol Clin North Am 1988;21:317–36.
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
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;97:641–9.
Leonetti JP, Matz GJ, Smith PG, Beck DL. Facial nerve monitoring in otologic surgery: clinical indi-
cations and intraoperative technique. Ann Otol Rhinol Laryngol 1990;99:911–8.
Molony TR, De La Cruz A. Surgical approaches to congenital atresia of the external auditory canal.
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 deaf-
ness. Outcomes, in general, are much better for the former group. Conversely, most pedi-
atric implantees have congenital hearing impairment. Consequently, there is more experi-
ence 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 los-
ing 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 environ-
ment. As the child matures, uses the implant, and participates in rehabilitation and educa-
tion, 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
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 ampli-
fication
• 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, includ-
ing both computed tomography (CT) and magnetic resonance imag-
ing (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 contraindica-
tion; 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 envi-
ronment.
• 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.
Cochlear Implants 223
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 chil-
dren well below the age of 24 months, the small airway and lesser toler-
ation 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 9–1).
♦ The device should be slightly behind the edge of the auricle, allow-
ing 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 9–2). Unless there is a pre-
existing scar, the incision takes the shape of a “lazy” S or inverted J.
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 fash-
ion, 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 Fig-
ures 9–2B 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: self-
retaining retractors are rarely needed.
Incisions
• The skin is prepared with an organic iodine solution and thoroughly
draped.
♦ 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 9–2A).
♦ If the entire device is to be placed in the well (Clarion and Combi-
40+), the shave, draping, and incision are somewhat more exten-
sive (see Figure 9–2B and Figure 9–2C).
Figure 9–1 The implant is posi-

tioned 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+.
B C

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, Nucle-
us and Contour. B, Clarion and
CII. C, Med-El Combi-40+.
B C
• 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 clo-
sure 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 9–3A and B). Nontraumatic fish-
hooks 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 9–4).
A B
Figure 9–3 The scalp and Palva flaps are elevated and retracted with barbless fishhooks. A, Nucleus. B, Clarion and Med-El
Combi-40+.
Figure 9–4 Two pericranial

pockets (dashed lines) are elevat-
ed for the Nucleus devices: pos-
terosuperiorly for the body of
the device, and anterosuperiorly
for the ground electrode.
Creating the well

• A well is created for the electronics package. Drilling is begun with
cutting burs (Figure 9–5A) and is then finished with diamond burs
(Figure 9–5B).
• The well should be large enough to accommodate the electronics of the
Nucleus device or the entire Med-El or Advance Bionics implant (Fig-
ures 9–5C 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 cre-
ate an island of bone by thinning the floor of the well and cutting
around the periphery with a small diamond bur (see Figure 9–5B).
Figure 9–5 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).
C D
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 dia-
mond bur, leaving a bridge of bone intact (Figures 9–6A 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 “whirly-
bird” to facilitate easy passage of the tie-down suture (Figure 9–6C).
• 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 (Fig-
ure 9–7A) with the dura protected by a Freer elevator or similar tool.
2. Sutures are then passed through the holes (Figure 9–7B), forming
loops around the implant.
3. When the loops are tightened, the implant is recessed flush with
the surface of the skull (Figures 9–7C and D).
Figure 9–6 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).
Figure 9–7 A-D, Vertical holes

are drilled for the “sling suture”
of the Clarion, CII, and Med-El
Combi-40+ implants.
D
4. We advise two tie-downs for these devices since they require a larg-
er well (Figures 9–8A and B).
Mastoidectomy
• The goal of mastoidectomy is to approach the facial recess and accom-
modate 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 9–9).
• For infants, it is often necessary to drill into marrow to create a suffi-
ciently 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 9–10).
A B
Figure 9–8 Two sets of holes are drilled above and below the well for the ceramic devices. A, Clarion and CII. B, Med-El
Combi-40+.
Figure 9–9 The mastoidectomy

is performed, and a channel is
drilled connecting it to the well.
Figure 9–10 Mastoidectomy

and facial recess with: (A) ghost B
outline of facial nerve and chor-
da tympani nerve, as well as (B)
overhang of superior wall
(Adapted from Cochlear Corpo-
ration. Surgical Procedure
Manual. Englewood (CO):
Cochlear Corporation; 1987).
A
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 9–10). This space must be opened adequately to visualize the
round window area and the electrode placement (Figure 9–11A).
• Drilling begins by exenterating mastoid cells and thinning the poste-
rior canal wall. This is important to allow visualization from the lat-
eral 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.
♦ 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 pre-
sent, 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 rotat-
ing 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 win-
dow can usually be identified. The facial recess is then gradually
opened inferiorly in order to visualize the round window niche (see
Figure 9–11A).
♦ 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 9–11B).
♦ 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 under-
stood since this influences the cochleostomy location and direction of
electrode insertion (Figure 9–11C).
Figure 9–11 A, The facial recess

is opened, showing, from superi-
or 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 win-
dow membrane, niche, and a
hypotympanic cell. C, The
cochlea is viewed through the
promontory (Adapted from
Cochlear Limited. Surgeon’s
Guide for the CI24R(CS)
Cochlear Implant. Sydney,
Australia: Cochlear Limited;
2000).
C
• 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 9–12A 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 9–12C).
2. Direct cochleostomy approach. Cochleostomy is performed immedi-
ately anterior to the round window niche using a 1.5-mm dia-
mond bur (Figure 9–12D). It should be remembered that the scala
tympani is aligned in a lateral to medial position, more or less par-
allel with the thinned posterior canal wall.
A B
Figure 9–12 A, Opening of the

scala tympani using the round
window membrane approach.
B, Anteroinferior fenestration
(transpromontory cochleosto-
my). C, “Hook” is drilled.
D, Cochleostomy is completed.
(Adapted from Cochlear Limit-
ed. Surgeon’s Guide for the
C
CI24R(CS) Cochlear Implant.
Sydney, Australia: Cochlear Lim-
ited; 2000).
D
♦ When the bone over the scala tympani is thinned, the white
endosteum is visualized. This should be removed with right-
angled picks or stapes footplate instruments to avoid drilling
directly into the scala tympani with resultant trauma and depo-
sition of bone dust (Figure 9–13A).
♦ The cochleostomy should be more than adequate for introduc-
ing 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 dia-
mond bur (Figure 9–13B); fibrous tissue or osteoid may be removed
with picks.
• 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.
♦ 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 place-
ment. 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.
♦ 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 pericrani-
um 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).
Figure 9–13 A, Removal of

bone debris; smoothing sharp
edges of the cochleostomy.
B, Drilling through bony
obstruction (Adapted from
Cochlear Limited.Surgeon’s
Guide for the CI24R (CS)
Cochlear Implant. Sydney, Aus-
tralia: Cochlear Limited; 2000).
B
• The electrode is inserted into the scala tympani using the specially
designed insertion tool, claw, or other atraumatic instrument such as
fine jeweler’s forceps (Figures 9–14 and 9–15):
1. The receiver-stimulator, if not previously placed in the well or
pocket, is grasped in the surgeon’s 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 9–14A and 9–15A). 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 9–14B).
Figure 9–14 A straight electrode is inserted (A) and rotated

(B) inside the scala tympani (Adapted from Cochlear Limited.
Surgeon’s Guide for the CI24R(CS) Cochlear Implant. Sydney,
Australia: Cochlear Limited; 2000).
B
Figure 9–15 A, Insertion of

Nucleus Contour (or Med-El
Combi-40+) electrode with jew-
eler’s forceps. The special claw
may also be used. B, Insertion
of Clarion High Focus I or CII
HFII electrode using special
insertion tool.
B
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 9–15B) which places the electrode in the
scala tympani. The perimodiolar electrodes may also require a sec-
ond maneuver, such as removing a stylet for the Contour device to
allow the electrode to flex closer to the modiolus (Figure 9–16), or
adding a mechanical “positioner” for the Clarion device to active-
ly 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 manufacturer’s
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 9–17A, B, and C).
• The ground electrode of the Nucleus and Med-El devices is placed
under the temporalis muscle (see Figures 9–17A and C).
Figure 9–16 Removing the

Nucleus Contour stylet.
Figure 9–17 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.
B C
• Soft tissue is packed between the electrode and the walls of the
cochleostomy to prevent perilymph leakage, taking care not to dam-
age the electrode lead wire (Figure 9–18).
• 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 thorough-
ly irrigated to remove blood and bone dust.
Closure
• The anteriorly based Palva pericranial flap is sutured over the proxi-
mal 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 9–19A and B). Staples are
used for the older child.
Figure 9–18 Soft tissue packed

between the electrode and edge
of the cochleostomy.
Figure 9–19 A, Younger child

subcuticular suture. B, Older
child suture or staples.
B
• An intraoperative portable X-ray is strongly advised to verify elec-

trode placement while the patient is still asleep. The patient’s head is
straightened on the table, preferably prior to application of the dress-
ing. A single anteroposterior transorbital view (slightly over-penetrat-
ed) is taken (Figure 9–20). An incorrectly placed or compressed elec-
trode 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 9–20 An intraoperative

transorbital X-ray is taken to
verify electrode position.
A, Straight electrode. B, Peri-
modiolar electrode.
B
Postoperative Care
• The dressing is removed the morning following surgery. Staples are gen-
erally 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. Chil-
dren 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 hard-
ware 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 9–1). Complications for children are less than for
adults (Table 9–2).
Table 9–1 Cochlear implant complications over time (for both

adults and children)
Type of 1991 1993 1995 1998 2000
complication (N=459) (N=2,751) (N=4,969) (N=9,221) (N=12,300)
(%) (%) (%) (%) (%)
Flap 5.4 3.0 2.7 2.1 0.9

Electrode 1.7 1.5 1.2 1.0 0.9
Facial nerve 1.7 0.7 0.6 0.4 0.1
Table 9–2 Cochlear implant complications in adults vs. children

Type of complication Adults (%) Children (%)
Flap 2.70 1.40

Electrode 1.20 0.76
Facial nerve 0.43 0.39
Extrusion, receiver-stimulator 1.47 0.37
Extrusion, electrode 0.17 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 Eise-
le DW, editor. Complications in Head and Neck Surgery. St. Louis: Mosby-Year; 1993. p. 722–9
and Hoffman RA, Cohen NL. Complications of cochlear implant surgery. Ann Otol Rhinol Laryn-
gol 1995;166 Suppl 420–2.
• Major complications include facial palsy and others requiring re-hospi-

talization 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 sig-
nificant increase in morbidity occurs.
• Finally, there has not been an increased incidence of otitis media in chil-
dren 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 ossi-
fied cochlea. Otolaryngol Head Neck Surg. 1996 Jan;114(1):4–11.
Bielamowicz SA, Coker MJ, Jenkins HA, Igarashi M. Surgical dimensions of the facial recess in
adults and children. Arch Otolaryngol Head Neck Surg 1988;114:534–7.
Cochlear Corporation. Surgical procedure manual. Englewood (CO): Cochlear Corporation; 1987.
Cochlear Limited. Surgeon’s 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 4:15S–24S.
Cohen NL, Hoffman RA. Complications of cochlear implant surgery. In: Eisele DW, editor. Com-
plications in head and neck surgery. St Louis: Mosby-Year Book; 1993. p. 722–9.
Cohen NL. Surgical techniques to avoid complications of cochlear implants in children. Adv Oto-
Rhino-Laryngol 1997;52:161–3.
Cohen NL. Surgical techniques for cochlear implants. In: Waltzman SB, Cohen NL, editors.
Cochlear implants. New York: Thieme; 2000. p. 151–6.
Fishman AJ, Holliday RA. Principles of cochlear implant imaging. In: Waltzman SB, Cohen NL,
editors. Cochlear implants. New York: Thieme; 2000. p. 79–107.
Hoffman RA, Downey LL, Waltzman SB, Cohen NL. Cochlear implantation in children with
cochlear malformations. Am J Otol 1997;18:184–7.
Hoffman RA, Cohen NL. Complications of cochlear implant surgery. Ann Otol Rhinol Laryngol
1995;166 Suppl:420–2.
Kveton J, Balkany TJ. Status of cochlear implantation in children. American Academy of Otolaryn-
gology – Head and Neck Surgery Subcommittee on Cochlear Implants. J Pediatr
1991;118:1–7.
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. 163–5.
Roland JT Jr, Fishman AJ, Alexiades G, Cohen NL. Electrode to modiolus proximity: a fluoroscop-
ic and histologic analysis. Am J Otol 2000;21:218–25.
Roland JT Jr, Fishman AJ, Waltzman SB, et al. Stability of the cochlear implant in children, Laryn-
goscope 1998;108:1119–23.
Shpizner BA, Holliday RA, Cohen NL, et al. Postoperative imaging of the multichannel cochlear
implant. Am J Neuroradiol 1995;16:1517–24.
Waltzman SB, Cohen NL. Cochlear implantation in children younger than 2 years old. Am J Otol-
ogy 1998;19:158–62.
Webb RL, Lehnhardt E, Clark GM, et al. Surgical complications with the cochlear multiple-chan-
nel intracochlear implant: experience at Hannover and Melbourne. Ann Otol Rhinol Laryn-
gol 1991;100:131–6.
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 rhab-
domyosarcomas in young children or angiofibromas in adolescent boys, are a rare cause of
dramatic difficult-to-control epistaxis. Appropriate radiographic evaluation, such as com-
puted 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 com-
plication 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 sep-
tum, where several terminal branches of both the internal and external
carotid systems come together under a thin delicate mucosa. Kiessel-
bach’s or Little’s area is also the part of the nose that is most likely to be
adversely affected by trauma and dry air (Figure 10–1).
• Superior epistaxis usually involves terminal branches of the anterior or
posterior ethmoidal arteries (Figures 10–1 and 10–2), which are branch-
es of the ophthalmic arteries from the internal carotid system. The ante-
rior 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.
Figure 10–1 Arteries supplying

the nasal septum. (Modified from
Culbertson MC, Manning SC.
Epistaxis. In: Bluestone CD, Stool
SE, editors. Pediatric otolaryngol-
ogy. 2nd ed. Philadelphia: WB
Saunders; 1990. p. 673.)
Figure 10–2 Arteries supplying

the lateral nasal wall. (Modified
from Culbertson MC, Manning
SC. Epistaxis. In: Bluestone CD,
Stool SE, editors. Pediatric
otolaryngology. 2nd ed.
1990. p. 673.)
• Posterior epistaxis usually involves terminal branches of the sphenopala-

tine 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 10–1), and a lat-
eral branch supplies the inferior and middle turbinates (see Figure
10–2). The medial branch may be injured during endoscopic sinus
surgery as it crosses the anterior inferior face of the sphenoid sinus.
Epistaxis 253
LOCAL CAUTERY
Indications
• Identified focal bleeding site on the anterior septum
• 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
• Topical anesthesia and vasoconstriction are achieved with cotton pled-
gets 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
As described above—see 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.
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 reduc-
ing mucosal inflammation.
ENDOSCOPIC-GUIDED CAUTERY
Indications
• Failure of anterior packing
• Cooperative patient
Procedure
• The bleeding site is visualized with an endoscope in a cooperative
patient (Figure 10–3) —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” bipo-
lar cautery or suction cautery.
• Antibiotic-coated absorbable gelatin sponge or oxidized cellulose is
applied to the cautery site.
Figure 10–3 Demonstration of

the rigid endoscope used to visu-
alize the posterior nasal cavity.
Epistaxis 255
POSTERIOR PACKING
Indications
• Epistaxis caused by an identified posterior (sphenopalatine area) bleed
• Posterior epistaxis caused by facial fractures, severe coagulopathies, or
sinus surgery
Procedure
• Manufactured nasal balloons may be placed in the nasal cavity and
inflated as per instructions below (Figure 10–4).
• 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 10–4 Demonstration of

a manufactured epistaxis bal-
loon. The posterior balloon in
the nasopharynx provides an
anchor for the anterior balloon
to apply pressure to the posterior
nasal cavity.
• Gauze packs also can be used for posterior packing (Figure 10–5):
♦ 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 uncoop-
erative 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, par-
ticularly 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.
A B
Figure 10–5 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 257
ARTERIAL LIGATION
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
• General anesthesia with a hypotensive technique is used if possible.
• Local injection of the greater palatine foramen can allow for better visu-
alization by temporarily reducing the bleeding.
• Anterior and posterior packs are removed, and the nasal cavities are suc-
tioned 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 branch-
es 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 epis-
taxis. Ann Otol Rhinol 1998;107:1033–7.
Fairbanks DNF. Complication of nasal packing. Otolaryngol Head Neck Surg 1986;94:412–5.
Lund VJ, Howard DJ. A treatment algorithm for the management of epistaxis in hereditary hemor-
rhagic telangiectasia. Am J Rhinol 1999;13:319–22.
Moreau S, DeRugy MG, Babin E, et al. Supraselective embolization in intractable epistaxis: review
of 45 cases. Laryngoscope 1999;108:887–8.
Murthy P, Nilssen EL, Rao S, McClymont LG. A randomized clinical trial of antiseptic basal carri-
er cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis. Clin Oto-
laryngol 1999;24:228–31.
Murray AB, Milner RA. Allergic rhinitis and recurrent epistaxis in children. Ann Allergy Asthma
Immunol 1995;74:30–3.
Wormald PJ, Weed TH, van Hasselt CA. Endoscopic ligation of the sphenopalatine artery for refrac-
tory posterior epistaxis. Am J Rhinol 2000;14:261–4.
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 pro-
long 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 tis-
sues. The periosteum overlying the nasal bones should always be pre-
served to prevent collapse of the nasal bones with resultant pyriform
aperture and internal nasal valve stenosis.
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 main-
tain 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 visu-
alization. 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 frac-
ture, 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 11–1), usually under general anesthesia.
A septal quilting stitch is placed (Figures 11–2A and B) and nasal packs are
inserted bilaterally. This may prevent more serious sequelae such as septal
abscess and saddle nose deformity.
Figure 11–1 The mucoperi-

chondrium is incised with a No
11 scalpel blade.
Nasal and Septal Deformities 261
A B
Figure 11–2 A, A short Keith needle on a 4-0 plain gut suture is passed back and forth through the septum. B, Final appear-
ance 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 car-
tilage and bone, is complicated or comminuted, or if treatment must be
deferred beyond 2 weeks.
• 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 anes-
thesiologist, and the surgeon (if right-handed) stands to the patient’s right.
• A pediatric closed reduction tray and a small Frazier tip suction are pre-
pared as the anesthesiologist begins induction.
Procedure
• Well wrung-out pledgets sprayed with oxymetazoline are gently inserted
into the patient’s 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 11–3A).
• The surgeon’s contralateral hand is placed on the skin overlying the out-
wardly 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 patient’s nose.
• With both the displacer and the contralateral thumb or fingers moving in
unison, the surgeon performs a fluid two-part movement (Figure 11–3B):
1. A downward movement (towards the patient’s 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 dis-
placer, 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.
A B
Figure 11–3 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.
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 suit-
able only for pathology limited to the posterior inferior aspect of the nasal
septum. The external approach has higher morbidity, but facilitates prima-
ry or revision surgery for all types of septal pathology, including large car-
tilaginous 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 11–4A and B).
• To facilitate access to the nasal cavity when completing other nasal
surgery (ie, polypectomy, endoscopic sinus surgery).
A B
Figure 11–4 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
Contraindications
• Mucosal disease such as allergic rhinitis.
• Systemic disease that places the patient at significant risk from general
anesthesia.
• General anesthesia with a cuffed oral endotracheal tube stabilized on the
chin of the supine patient. The anesthetic machine is on the patient’s left
side to permit the surgeon (may be opposite if surgeon left handed) to
stand on the patient’s 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 11–5).
Figure 11–5 Completing the

right hemi-transfixion incision.
• On the concave side of the nasal septum, the mucoperichondrium is dis-

sected back 4-5 mm from the edge of the QC using Converse scissors
(Figure 11–6). 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 11–7)
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 sep-
tum is not problematic as this will now serve as the “drainage” site).
• The Freer elevator is inserted from the concave side into the subperi-
chondrial 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 11–8) 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 quilt-
ing has been completed.
• Occasionally, there will be persistent bleeding. A small amount of Vase-
line 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.
Figure 11–6 Dissecting the perichondrium

back in a posterior direction.
Figure 11–7 Using the Freer elevator to

carry the dissection below the perichondrium
more posteriorly.
Figure 11–8 The view after removing

adequate amounts of cartilage and bone.
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 chal-
lenging 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 11–9 and 11–10).
• 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 anes-
thesia.
• Lack of parental insight as to degree of septal pathology requiring this
type of operative approach.
• General anesthesia is required with a cuffed oral endotracheal tube sta-
bilized 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 patient’s left side to permit the surgeon
(if right-handed) to stand on the patient’s right side.
• The patient’s 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 11–9 Gentle thumb

pressure readily reveals anterior
nasal septal pathology.
Figure 11–10 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
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 mem-
branous 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
11–11). 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 11–12).
• 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 11–13):
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 inferi-
orly beyond the transcolumellar incision.
Figure 11–11 The location and

form of the transcolumellar
incision.
Figure 11–12 Completing the

right rim incision.
Figure 11–13 Using the Con-

verse scissors to dissect across the
columella external to the medial
crura into the left rim incision.
• The transcolumellar incision is completed using a No 11 blade held at

right angles to the skin (Figure 11–14) using a sawing motion. Only 2
mm of the blade tip are inserted to minimize any damage to the under-
lying medial crura.
• The rim incisions are then advanced on each side along the caudal bor-
der 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 11–15).
• Once the rim incisions are of adequate length, dissection is carried “over
the domes” until the upper lateral cartilages (ULCs) are encountered. Dis-
section 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 11–16). 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 11–14 The No 11 blade

is utilized to complete the
transcolumellar incision.
Figure 11–15 The lower lateral

cartilages are exposed with
advancing rim incisions.
Figure 11–16 The caudal strut

of the quadrilateral cartilage is
exposed after dividing tissue
between the medial crura.
• Dissection will be limited because of the attachment of the ULCs to the

QC. This attachment is divided under direct vision in a progressive fash-
ion with a Beaver blade until the nasal bones are encountered. Dissection
can now be carried posteriorly until the vomer is encountered; superior-
ly 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. Ideal-
ly, 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 usu-
ally be dislocated from the nasal crest of the maxilla towards the concave
side of the nose to permit adequate access. Again, the mucoperichondri-
um 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. Par-
ticular 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 11–17). 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 sig-
nificant 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 11–18):
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 11–19). This distance has varied from 19-
33 mm in 85 patients (aged 4 to 16 years) for whom data are available.
Figure 11–17 The entire quadrilateral carti-

lage removed intact; the instrument points to
a fracture line in the anterior aspect.
Figure 11–18 A nonabsorbable suture is

placed through the anterior nasal spine.
Figure 11–19 Surgical calipers measure

distance from the anterior nasal spine to
the nasal bones.
• 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 approxi-
mate position where the QC articulates with anterior nasal spine. The
other end then determines where the free graft will meet the nasal
bones (Figure 11–20).
3. A notch is drawn into the template (Figure 11–21), 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 11–22).
• 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 11–23).
Figure 11–20 The distance

determined by the surgical
calipers is transferred to the
paper template.
Figure 11–21 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 11–22 The cut out paper

template lying on the posterior
aspect of the excised quadrilater-
al cartilage.
Figure 11–23 The finished car-

tilage free graft.
• The free graft is placed between the mucous membrane flaps with the
notch under the nasal bones. Two interrupted sutures of the 4-0 Mersi-
lene are placed through the ULCs and the edge of the free graft 1 and 3
mm from the nasal bones (Figure 11–24). 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 for-
ward 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 11–25). 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 11–26).
• 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 com-
pleted 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 11–24 The free graft

being sewn to the upper end of
the upper lateral cartilages.
Figure 11–25 The inferior

aspect of the graft being fixed to
the anterior nasal spine follow-
ing the sagittal plane swing
maneuver.
Figure 11–26 A transfixion

suture further stabilizes the free
graft position.
• 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 inferi-
or 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 post-
operatively 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 fol-
lowing 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 follow-
ing 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
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 transcol-
umellar incision (external or open approach), each method offering specif-
ic advantages and disadvantages (Table 11–1). When functional and cos-
metic deformities coexist, techniques that simultaneously address the
septum and external nasal framework may be combined to offer a single-
stage return to form and function. Finally, because of its central location on
the face, an aesthetically displeasing nose can be the source of much emo-
tional 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-pos-
terior 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 congen-
itally deformed nose (see also External Approach for Septoplasty-Indications).
• Alteration of an aesthetically displeasing nose.
Table 11–1 Endonasal vs. external approach for rhinoplasty

Approach Advantages Disadvantages
Endonasal ✓ Allows better intraoperative × More difficult to judge symmetry

visualization of final result during tip maneuvers
✓ Preferred for simple tip × Cannot address or reconstruct
maneuvers or if no tip surgery dorsal septum, if affected
is necessary
✓ No visible scar
External ✓ Allows more precise tip surgery × Potentially visible external scar
✓ Affords excellent access to the × Difficult to judge or visualize
dorsal septum, if affected final result
✓ Less destructive to existing nasal × Slightly more time consuming
support mechanisms
• All pediatric rhinoplasty surgery is performed under general endotra-
cheal 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 require-
ments 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 pre-
vent 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 11–27). 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 mid-
line, 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 (Fig-
ure 11–28). 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 11–29). By utilizing the
contralateral hand to pull up the nasal superficial musculoaponeurot-
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 intercartilagi-
nous 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 cau-
dal aspect of the septum without impedance.
Figure 11–27 A transfixion inci-

sion is made between the medial
crura of lower lateral cartilages
and the caudal edge of septum.
Figure 11–28 An intercartilaginous incision is

made between the caudal margin of the upper lat-
eral cartilage and the cephalic border of the lateral
crus of the lower lateral cartilage.
Figure 11–29 Skeletonizing the dorsum is facilitated by pinching up

the nasal skin and SMAS with the contralateral hand.
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 immedi-
ately visible from the anterior septal angle back to the rhinion. If a car-
tilaginous dorsal hump exists, it can now be trimmed with a No 11 or
No 15 blade (Figure 11–30). The trimming should be incremental, con-
stantly 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 11–31). 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 electro-
cautery 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 insert-
ing 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 (Fig-
ure 11–32).
• Curved guarded osteotomes are then inserted through the pyriform
incisions and “locked” into place on the pyriform rim; proper place-
ment 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 11–32).
• 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 rhinoplas-
ty, there is generally less bleeding encountered.
Figure 11–30 The cartilaginous

hump is reduced incrementally
with a No 11 scalpel blade.
Figure 11–31 The bony hump

is reduced with a fine rasp.
Figure 11–32 Path of medial

(dotted line) and lateral (dashed
line) osteotomies.
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 inci-
sion) to allow the nasal tip to slightly rotate up.
2. If the tip is slightly bulbous, but the domes of the lower lateral car-
tilages are close together, a retrograde cephalic trim may be per-
formed via the intercartilaginous incision with aid of an assistant:
• A fine blunt scissors is used to dissect on both sides of the lat-
eral crus of the lower lateral cartilage (Figure 11–33A). The car-
tilage 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
11–33B). This should be performed evenly on both sides, gen-
erally 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 11–34). A blunt fine scissors is used
to dissect directly over the top of the lateral crus and exits at the
intercartilaginous incision.
A B
Figure 11–33 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 11–34 An infracartilagi-

nous (marginal) incision is made
with a No 15 scalpel blade and
a sharp double hook at the cau-
dal margin of the lower lateral
cartilage.
• The resulting bipedicled flap of lower lateral cartilage and

vestibular skin is “delivered” through the marginal incision in
anatomic configuration (Figure 11–35).
• 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 11–36).
• The domes are bound together with 5-0 Prolene suture, there-
by narrowing the nasal tip and creating a small degree of pro-
jection and rotation (Figure 11–37):
♦ 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 symmetrical-
ly. 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 11–35 The lower lateral

cartilage is delivered as a bipedi-
cled chondrocutaneous flap.
Figure 11–36 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 11–37 A horizontal mat-

tress suture of 5-0 clear Prolene
is used to narrow the interdomal
distance.
Incision closure
• A dorsal augmentation graft (Figure 11–38), 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. Fix-
ation 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
11–39).
• 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 11–40).
Figure 11–38 Correct position

of dorsal onlay graft.
Figure 11–39 Folded Telfa nasal

packs are inserted bilaterally.
Figure 11–40 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.
• 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 11–41).
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 lac-
erate 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 11–42) and
laterally up over the lateral crura (Figure 11–43).
• From this point on, the dorsal dissection is identical to that for the
endonasal approach (see Figures 11–29 to 11–32). The sub-SMAS
plane is entered at the anterior septal angle, and with the contralater-
al 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 easi-
ly 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 11–41 Bilateral infracar-

tilaginous incisions (1) are made
with the No 15 blade. A fine
scissors (2) is used to connect the
medial portions of both infracar-
tilaginous incisions in the pre-
crural plane. The transcolumellar
incision (3) is then completed
with a No 11 blade.
Figure 11–42 A fine scissors is

used to dissect over the medial
crura and domes in the subperi-
chondrial plane.
Figure 11–43 The dissection

continues laterally over the later-
al 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.
• 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 11–44). The domes are aligned in exact sym-
metric 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 11–45) 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 11–46) 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 11–44 A cartilaginous

strut is sutured between the
medial crura.
Figure 11–45 The interdomal

distance is narrowed with a 5-0
clear Prolene horizontal mattress
suture.
Figure 11–46 The supratip area

is narrowed with a 5-0 clear Pro-
lene horizontal mattress suture.
Note the placement of the
suture behind the domes.
3. The tip complex may now be set to the proper “height” with sever-
al millimeters of projection or deprojection achievable utilizing the
recession projection control suture (Figure 11–47). 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 com-
plex is now fixed at the appropriate level of projection or recession.
4. Finally, if further tip rotation is desired, a tip rotation suture (Fig-
ure 11–48) 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 11–38), 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. Fix-
ation 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 11–49); if a septoplasty was
performed, a quilting suture is placed.
Figure 11–47 A recession pro-

jection control suture is placed
between the caudal edge of the
septum and posterior edges of
the medial crura.
Figure 11–48 A rotation control

suture is placed between the dor-
sal edge of the anterior septum
(anterior septal angle) and the
superior posterior edges of the
medial crura.
Figure 11–49 The transcolumel-

lar incision is meticulously
closed using a 6-0 Prolene suture
on a fine needle.
• Two folded Telfa packs are coated with antibiotic ointment and insert-
ed into each nasal passage with a bayonet forceps (see Figure 11–39).
• Paper tape is cut to size and placed over the entire nasal dorsum; addi-
tional tape should not be placed around the nasal tip as this may com-
promise 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 togeth-
er 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 under-
correction of deformities.
• Many such deformities are minor and can be corrected with a small revi-
sion procedure after an appropriate healing time (usually a minimum of
one year following primary rhinoplasty).
BIBLIOGRAPHY
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Crysdale WS. Clinical challenges in otolaryngology (commentary): septoplasty in children—yes, but
do the right thing. Arch Otolaryngol Head Neck Surg 1999;125:701.
Crysdale WS. External septoplasty in children. J Otolaryngol 1996;25:257–60.
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;1:1–22.
Walker P, Crysdale WS. External septorhinoplasty in children—patient selection and surgical tech-
nique. J Otolaryngol 1994; 23:28–31.
Walker P, Farkas L, Crysdale WS. External septoplasty in children: outcome and effects on growth.
Arch Otolaryngol Head Neck Surg 1993;119:984–9.
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 physi-

cal 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 anom-
alies, 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 air-
way is secure and the initial workup for evaluation of possible associat-
ed 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 sinus-
es and nasopharynx.
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 abnor-
malities, 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 embryol-
ogy.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 actu-
al 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 MRI’s 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 short-
ly 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 suit-
ed 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.
• This procedure should be performed under general anesthesia using
either an oral endotracheal or tracheotomy tube.
Congenital Nasal Malformations 301
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 cav-
ity 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 12–1) 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 atre-
sia 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 12–1 The posterior

choanal atresia mucosa is
exposed with a nasal speculum.
• The position of the instrument in the nasopharynx is confirmed:

1. In unilateral cases, the position is confirmed using a 0˚ or 30˚ endo-
scope 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
12–2). The authors prefer this method.
3. In revision cases, and in some primary cases, it is often difficult to ele-
vate 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 microdebrid-
er 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 12–2 The anterior

mucosa is incised vertically, and
flaps are elevated medially and
laterally.
A B
Figure 12–3 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 posi-
tion 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 selec-
tively 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 chemother-
apeutic agent, double gloves are used and drug is diposed of in a spe-
cial 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 place-
ment, 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.
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 12–4).
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 12–5)
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 12–6), 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 suc-
tion catheter can be passed through the stent into the nasopharynx, as it
is difficult to correct this once the child is awake.
Figure 12–4 A flexible endotra-

cheal tube is fashioned into a
stent for the posterior choanae.
Figure 12–5 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 poste-
rior into the nasopharynx.
Figure 12–6 The anterior ends

of the stent protrude from the
nares and are sutured in position.
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 inspect-
ed 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 visualiza-
tion. A deviated septum, large turbinates, other anatomical abnormali-
ties, 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 per-
formed as early as the first few days of life.
• 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 epi-
nephrine, 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.
• 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 12–7), 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 pos-
terior choanal size. The other incisions in Figure 12–7 are not recom-
mended, 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 12–7 Incisions used in

the transpalatal approach:
(1) Steinzeug, (2) Owens,
(3) Wilson, (4) Brunk, and
(5) Ruddy. The stippled area
represents the atresia plate.
• The mucoperiosteal flaps are elevated posteriorly to the edge of the hard
palate (Figure 12–8A). Care must be taken to preserve the neurovascu-
lar bundle coming out of the greater palatine foramen (Figure 12–8B).
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 12–9) 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 12–10), the nasal mucosa must be pre-
served and elevated from the nasal surface of the hard palate. The pos-
terior edge of the hard palate is then removed using a cutting bur (Fig-
ure 12–11) 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.
A B
Figure 12–8 The mucoperiosteal flap is elevated (A) while preserving the greater palatine vessels, (B).
Figure 12–9 The mucope-

riosteal flap has been elevated.
Dashed lines indicate the inci-
sion between the hard and soft
palates.
Figure 12–10 Dashed lines indicate areas of bone removal Figure 12–11 The posterior edge of the hard palate is
for bilateral atresia. removed with a cutting bur.
• 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, max-
illary sinus, and pterygopalatine fossa can be considered for increased
choanal size. The CT scan should be examined first, however, to deter-
mine 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 open-
ing (Figure 12–12).
• 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 mito-
mycin 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 pre-
fer the use of an endotracheal tube in the “U” shape as described earlier
(see Figure 12–4).
• The stent is placed, and proper position confirmed by direct visualiza-
tion through the palatal incision (Figures 12–13A and B).
• Palatal closure is done with an absorbable suture in an interrupted fash-
ion and the stent is secured to the nasal septum (Figure 12–13C).
Figure 12–12 Technique for

obtaining a mucoperiosteal flap
from the membranous atresia.
Figure 12–13 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 dis-
placement of the tubes; the
palatal incision has been closed.
B C
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 inspect-
ed 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.
• 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 solu-
tion) 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 12–14). Hatch marks are
placed along the nasal incision and the alar rim to allow exact skin clo-
sure; a broken line at the level of the medial canthus may be used to pre-
vent postoperative webbing.
• The incision begins just below the medial aspect of the eyebrow, extend-
ing inferiorly in a plane approximately one-half the distance between the
medial canthus and the nasion. The incision should be carried anterior-
ly to the nasomaxillary sulcus, then continue to the alar sulcus and nasal
vestibule.
• The incision is performed in layers, using the bipolar electrosurgical for-

ceps for meticulous hemostasis.
• The alar incision is carried through all layers of tissue until the bony
edge of the maxillary process is reached (Figure 12–15). 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 12–16).
Figure 12–14 Nasal incision for

lateral rhinotomy.
Figure 12–15 An alar incision is carried through all layers Figure 12–16 A lesion is visible on the septum and anterior
of tissue. nasal floor.
• Additional procedures may be performed to improve exposure:

1. The periosteum of the nasal bone and ascending process of the max-
illa 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 steno-
sis, 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.
Preparation
• Use of magnification (operating microscope with 300-mm lens, or sur-
gical endoscope) is highly recommended.
• The procedure should be performed under general anesthesia with air-
way secured by endotracheal or tracheotomy tube.
• The sublabial area is infiltrated with 0.5% lidocaine with 1:200,000 epi-
nephrine, taking care not to exceed the maximum dose for age and
weight.
• Neuropledgets with topical vasoconstrictor (0.5% oxymetazoline solu-
tion) are placed intranasally.
Procedure
• A standard sublabial incision is made, bridging the right and left canine
fossae (Figure 12–17A).
• The mucosa and mucoperiosteum are elevated to expose the pyriform
aperture (Figure 12–17B), 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 pyri-
form aperture. Dissection continues until the lesion is adequately
exposed, or the area of pyriform stenosis is passed.
A B
Figure 12–17 A, Incision for sublabial approach. B, The anterior nasal spine is left attached to septal cartilage.
• A diamond cutting bur or mastoid curettes may be used to remove the

lateral bony aspect of the pyriform (Figure 12–18). Bone removal from
the nasal floor, when necessary, is performed judiciously to avoid injur-
ing 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 con-
troversial, 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 inter-
rupted fashion (Figure 12–19).
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 12–18 Bone is removed from the pyriform aperture Figure 12–19 The sublabial incision is closed. Placement
laterally and anteriorly. of a small drain (as shown) is rarely necessary.
REFERENCES
1. Hengerer AS, Newburg JA. Congenital malformations of the nose and paranasal sinuses. In:
Bluestone CD, Stool SE, editors. Pediatric otolaryngology. 2nd ed. Philadelphia: WB Saun-
ders; 1990. p. 718–28.
2. Hengerer AS, Strome A. Choanal atresia: a new embryologic theory and its influence on surgi-
cal management. Laryngoscope 1982;92:913–21.
3. Bergstrom L, Owens O. Posterior choanal atresia: a syndromal disorder. Laryngoscope
1984;94:1273–6.
4. Lowe LH, Booth TN, Joglar JM, Rollins NK. Midface anomalies in children. Radiographics
2000;20:907–22.
5. Brown OE, Myer CM, Manning SC. Congenital nasal pyriform aperture stenosis. Laryngo-
scope 1989;99:86–91.
6. Godil MA, Galvin-Parton P, Monte D, et al. Congenital nasal pyriform aperture stenosis asso-
ciated with central diabetes insipidus. J Pediatr 2000;137:260–2.
7. Lo FS, Lee YJ, Lin SP, et al. Solitary maxillary central incisor and congenital nasal pyriform
aperture stenosis. Eur J Pediatr 1998;157:39–44.
8. 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;22:393–7.
9. Hughes GB, Sharpino G, Hunt W, Tucker HM. Management of the midline nasal mass: a
review. Otolaryngol Head Neck Surg 1980;2:222–33.
10. Pensler JM, Bauer BS, Naidich TP. Craniofacial dermoids. Plast Recon Surg 1988;82:953–8.
11. Stahl RS, Jurkiewicz MJ. Congenital posterior choanal atresia. Pediatrics 1985;76:429–36.
12. Stankiewicz JA. The endoscopic repair of choanal atresia. Otolaryngol Head Neck Surg
1990;103:931–7.
13. Osguthorpe JD, Singleton GT, Adkins WY. The surgical approach to bilateral choanal atresia.
14. Lantz HJ, Birch HG. Surgical correction of choanal atresia in the neonate. Laryngoscope
1981;91:1629–34.
15. Muntz H. Pitfalls to laser correction of choanal atresia. Ann Otol Rhinol Laryngol
1987;96:43–6.
16. Healy GB, McGill TJ, Jako GJ, et al. Management of choanal atresia with the carbon dioxide
laser. Ann Otol Rhinol Laryngol 1987;87:658–62.
17. 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;14:282–6.
18. Rahbar R, Shapshay SM, Healy GB. Mitomycin: effects on laryngeal and tracheal stenosis, ben-
efits and complications. Ann Otol Rhinol Laryngol 2001;110:1–6.
19. Grundfast KM, Thomsen JR, Barber CS. An improved stent method for choanal atresia repair.
20. Gleeson MJ, Hibbert J. A stent for the corrective management of bilateral choanal atresia.
21. 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;12:267–72.
22. Krespi YP, Husain S, Levine TM, Reede DL. Sublabial transeptal repair of choanal atresia or
stenosis. Laryngoscope 1987;97:1402–6.
23. Resouly A, Barnard JDW, Purnell AN. Access by Lefort I osteotomy for correction of unilater-
al choanal atresia. Clin Otolaryngol 1990;15:281–2.
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 sur-
gical technique, nor are there published studies comparing endoscopic surgery to classical
techniques in comparable situations. Over a decade of experience with endoscopic tech-
niques, however, has shown that well-trained otolaryngologists can perform this surgery safe-
ly, 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 sys-
temic 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 bac-
terial 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
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 cil-
iary 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 out-
grow their disease within a short period of time. Lastly, endoscopic eth-
moidectomy is rarely appropriate for a child with chronic headaches and
normal computed tomography (CT) of the sinuses.
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 decision-
making and establish appropriate surgical expectations. Additional preop-
erative considerations include
• Anterior rhinoscopy and nasal endoscopy (rigid or flexible) to assess sep-
tal 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 diag-
nosis of sinusitis and to serve as a surgical road map. Some centers incor-
porate intraoperative computerized image guidance, especially for revi-
sion cases.
• Consultation with appropriate specialists for any pre-existing pul-
monary, cardiac, renal, or hematologic disorders.
• One month of appropriate oral antibiotics and one week of systemic oral
corticosteroids just prior to surgery.
• 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 321
• Local anesthesia with sedation may be feasible for unusually mature

teenagers. Older patients with cystic fibrosis and poor pulmonary func-
tion 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 pseu-
doephedrine.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
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 emul-
sion (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 surgeon’s eye shares the
view with a video camera also supported by the nondominant hand
(Figure 13–1).
Procedure
• A young child’s nose is much narrower than that of a teen or adult (Fig-
ure 13–2).
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 13–1 The patient is

supine with head slightly elevat-
ed. The surgeon sits with instru-
ments in the dominant hand,
and the telescope (with camera
and beam splitter) in the non-
dominant hand.
4. The anterior border of the maxillary natural ostium is only a few mil-
limeters 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 child’s 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 impreg-
nated with 0.5% oxymetazoline, which are advanced into the middle
meatus with the spatulated end of a Cottle elevator (Figure 13–3).
Figure 13–2 Comparison of four-year-old sinuses (A) A B

and adult sinuses (B). In the child, the orbit is rela-
tively large and the maxillary sinus small and sur-
rounded by thick bone. An unerupted tooth presents
in the maxillary floor. There is little frontal sinus
development.
Figure 13–3 A pledget, impregnated with oxymetazoline, is

introduced into the middle meatus with the spatulated end
of a Cottle elevator.
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 13–4). 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 typ-
ically 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 epi-
nephrine.
2. The posterior edge of the uncinate is identified and mobilized with a
Lusk double-balled seeker (Figure 13–5).
3. An inferior incision is made in the uncinate with a small backbiting
forceps (Figure 13–6), and an anterior incision at the “break point”
with a 1-mm Kerrison forceps (Figure 13–7). Alternatively, the “pull”
side of a Parsons push-pull knife can make both incisions. These tech-
niques 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 demucosal-
ized with a straight microdebrider and the denuded bone is removed.
Figure 13–4 A dimple in the soft tissue overlies the greater Figure 13–5 A Lusk double-balled seeker is placed behind
palatine foramen, which is located 1 cm anterior to the the posterior edge of the uncinate process to rotate it medi-
junction of hard and soft palate, halfway between the medially and to identify the “break point”.
an raphe of the hard palate and the alveolus.
Figure 13–6 A small backbiting forceps makes an inferior Figure 13–7 A 1-mm Kerrison forceps makes an anterior
incision in the uncinate. incision along the “break point” to the insertion of the
middle turbinate.
• Once the uncinate is removed, the natural ostium of the maxillary sinus
is easily found near the floor of the middle meatus (Figure 13–8). 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.
♦ 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 impor-
tant 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 13–9 and 13–10). 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 13–8 Paramedial sagittal

section through an infant skull.
AN= agger nasi cells, AE = ante-
rior ethmoid cells, PE= posterior PE AE
ethmoid cells, MT= middle AN
}
turbinate, EB= ethmoid bulla,

GL= ground lamella of middle
turbinate, MO= maxillary
ostium.
MT
GL EB
MO
Figure 13–9 A J-curette opens

the ethmoid bulla inferiorly and
medially (intranasal view).
Figure 13–10 A J-curette opens

the ethmoid bulla inferiorly and
medially (sagittal view).
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 13–8). The lower row of anterior eth-
moid 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 J-
curette (Figure 13–11).
5. The dangling mucosa of the ethmoid cells is removed with a straight
microdebrider tip (Figures 13–12 and 13–13) to avoid stripping the
lining of the ethmoid cavity. Residual bone fragments are removed
with Blakesley forceps (Figure 13–14).
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 13–11 The right angle

end of the J-curette sweeps gen-
tly along the roof of the eth-
moids from posterior to anterior
(sagittal view).
Figure 13–12 Dangling mucosa

is removed using the straight
microdebrider to avoid stripping
(sagittal view).
Figure 13–13 Dangling mucosa is removed using the Figure 13–14 Remaining bony fragments are removed
straight microdebrider to avoid stripping (intranasal view). with Blakesley forceps (intranasal view).
• 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 lat-
eral nasal wall (Figure 13–15).
2. Hyaluronic acid. A MeroGel sinus stent (Medtronic Xomed, Jack-
sonville, FL) is rolled up and placed in the ethmoid cavity. The stent
is hydrated by injection with saline solution, which gradually trans-
forms 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 anes-
thesia. 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 sep-
arate 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.
Figure 13–15 Rolled gelatin

sheeting is placed in the ethmoid
cavity. A flap separates the mid-
dle turbinate from the lateral
nasal wall.
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 13–16) 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 13–17).
• Selected cases of orbital subperiosteal abscess may be treated with antibi-
otics 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 sinusitis—orbital cellulitis and
orbital abscess—require 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 neuro-
surgeons request surgical drainage of the sinuses, which can be accom-
plished endoscopically.
• When acute frontal sinusitis leads to contiguous epidural, subdural, or
parenchymal brain abscesses, open surgical drainage at the time of cran-
iotomy 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 frontoeth-
moidectomy.
Figure 13–16 Orbital preseptal

cellulitis.
Figure 13–17 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 anteri-
orly, producing proptosis.
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 sympto-
matic 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 13–18). 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 microde-
brider (Figure 13–19). 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 13–20).
Figure 13–18 Polyps arise from

the ethmoid air cells and maxil-
lary antrum, and protrude into
the nose.
Figure 13–19 Bulky ethmoid

polyps are removed with the
microdebrider.
Figure 13–20 The fontanelle is

enlarged with the curved
microdebrider.
• The contents of the maxillary sinus are tenacious and cannot be suc-
tioned out. To clean the sinus, the curve of the microdebrider tip must
be increased to about 70˚ (Figure 13–21). A small aluminum pipe ben-
der (available at most plumbing supply stores) is used to avoid kinking
(Figure 13–22).
• Thick secretions and hyperplastic mucosa are removed from the antrum
using the 30˚ and 70˚ endoscopes for visualization (Figure 13–23).
Oxymetazoline-impregnated pledgets are placed into the antrum to con-
trol 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 pre-
viously for chronic sinusitis. Of note, ethmoid partitions are often very
thick secondary to chronic osteitis and must be removed with through-
biting forceps instead of the J-curette to avoid injuring the ethmoid roof.
Figure 13–21 Microdebrider tips. (A ) Straight. (B ) Curved. (C ) Curved reversed and augmented.
Figure 13–22 The curve of a

microdebrider tip is reversed and
augmented with a small alu-
minum pipe bender.
Figure 13–23 The augmented

curve allows removal of polyps
and tenacious debris.
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. Parsons DS, Phillips SE. Functional endoscopic surgery in children: a retrospective analysis of
results. Laryngoscope 1993;103:899–903.
2. Clement PA, Bluestone CD, Gordts F, et al. Management of rhinosinusitis in children. Int J
Pediatr Otorhinolaryngol 1999;49 Suppl 1:S95–100.
3. Gentile VG, Isaacson G. Patterns of sinusitis in cystic fibrosis. Laryngoscope 1996;106:1005–9.
4. Alvarez RJ, Liu NJ, Isaacson G. Pediatric ethmoid mucoceles in cystic fibrosis: long-term fol-
low-up of reported cases. Ear Nose Throat J 1997;76:538–9 and 543–6.
5. Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal orbital abscess forma-
tion: diagnosis and treatment. Otolaryngol Head Neck Surg 1993;109:886–94.
6. 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;113:440–5.
7. Madonna D, Isaacson G, Rosenfeld RM, Panitch H. Effect of sinus surgery on pulmonary func-
tion in patients with cystic fibrosis. Laryngoscope 1997;107:328–31.
8. Lusk RP, Polmar SH, Muntz HR. Endoscopic ethmoidectomy and maxillary antrostomy in
immunodeficient patients. Arch Otolaryngol Head Neck Surg 1991;117:60–3.
9. Parsons DS, Greene BA. A treatment for primary ciliary dyskinesia: efficacy of functional endo-
scopic sinus surgery. Laryngoscope 1993;103:1269–72.
10. Blackwell KE, Ross DA, Kapur P, Calcaterra TC. Propofol for maintenance of general anesthe-
sia: a technique to limit blood loss during endoscopic sinus surgery. Am J Otolaryngol
1993;4:262–6.
11. Riegle EV, Gunter JB, Lusk RP, et al. Comparison of vasoconstrictors for functional endoscop-
ic sinus surgery in children. Laryngoscope 1992;102:820–3.
12. Lusk RP, Muntz HR. Endoscopic sinus surgery in children with chronic sinusitis: a pilot study.
13. Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and
results of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247:63–76.
14. 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;118:1179–84.
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 surgeon’s training and expe-
rience. 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 subpe-
riosteal 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.
• The procedure usually is performed under general anesthesia.
• Neuropledgets moistened with 0.05% oxymetazoline solution are placed
intranasally for topical decongestion.
Procedure
• An incision is made over the abscess or hematoma, usually in the depen-
dent portion to assist drainage. If pus is encountered, a culture may be
taken (Figure 14–1).
• 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 satis-
factory.
• 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 14–1 Drainage of a septal abscess.

Inflammatory Sinonasal Disease 341
ANTRAL ASPIRATION AND LAVAGE

Indications
• Acute maxillary sinusitis unresponsive to medical management
• Aspiration of culture specimen in immunocompromised patient with
maxillary sinusitis
• The procedure is performed under general anesthesia or topical anesthe-
sia with intravenous sedation.
Procedure
• After induction of anesthesia, the nose is decongested. Two small cot-
tonoids soaked in oxymetazoline are placed along and under the inferi-
or 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 14–2). If the tro-
car 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 14–2 Aspiration of the maxillary sinus with a trocar. The trocar is aimed toward the ipsilateral lateral canthus.
♦ Middle meatal approach. The middle meatus is identified with the 0°

endoscope, and the natural ostium of the maxillary sinus in the pos-
terior 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 mea-
tus 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 aspi-
rated, instillation of nonbacteriostatic saline into the sinus and subse-
quent aspiration may be helpful. Aspirated material is sent for culture
and sensitivity testing.
• Antral irrigation is performed next, using a syringe attached to the tro-
car 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
CALDWELL-LUC PROCEDURE
Indications
• Presence of a mass within the sinus, such as a cyst or a suspected neo-
plasm
• Recurrent antrochoanal polyp, refractory to endoscopic management
• The operation is not recommended for chronic sinusitis; maxillary
sinusitis usually improves following adequate medical or surgical treat-
ment of ethmoid disease.
• A 0.05% lidocaine solution with 1:200,000 epinephrine is injected into
the gingivobuccal sulcus.
Procedure
• The incision is placed above the secondary dentition. A plain sinus radi-
ograph can be helpful in determining this level.
• The periosteum is elevated until the infraorbital nerve is seen (Figure
14–3A).
• 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 pal-
pation, 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 14–3B).
• 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.
A B
Figure 14–3 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.
Postoperative Care
• The packing or Foley catheter is removed after 1 or 2 days.
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 tech-
nique, an external approach is recommended.
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 14–4A).
• 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 14–4B).
• 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 sub-
periosteal 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 dehis-
cent. 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.
• 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 inter-
nally (Figure 14–4C).
• An eye pad is an excellent dressing for the external incision.
A C
Figure 14–4 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.
B
FRONTAL SINUS TREPHINATION

Indications
• Acute frontal sinusitis unresponsive to medical management
• Intracranial complication of frontal sinusitis
• 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 14–5A). 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
• 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 14–5B).
• A culture is taken through the opening, after which a lacrimal probe is
used to palpate gently all the walls of the sinus (Figure 14–5C).
• The opening is made large enough to accept a small endotracheal tube,
through which a smaller red rubber catheter is placed (Figure 14–5D).
• The catheter extends beyond the end of the endotracheal tube.
• The proximal end of the red rubber catheter is fitted with a blunt nee-
dle 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.
A B
C D
Figure 14–5 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.
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
• Dacryocystorhinostomy (DCR) usually is performed under general
anesthesia.
• 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 14–6A). A similar injection is
performed intranasally on the lateral nasal wall, anterior to the mid-
dle 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 chis-
el. The entire bony fossa is then removed using back-biting rongeurs.
• Local anesthetic with epinephrine should be injected into the under-
lying 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 14–6B).
• 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 inter-
rupted 4-0 chromic sutures (Figure 14–6C).
• The skin and subcutaneous tissue are closed in two layers.
• The Silastic stent is removed after 7 to 10 days.
Figure 14–6 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.
C
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 (Figure14–7). 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 medi-
al 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.
• Antibiotic ophthalmic drops used three times daily will help if purulent
conjunctivitis is present.
• The silicone stents are removed after 4 to 6 weeks.
Figure 14–7 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 Oto-
Sprekelsen MB, Barberan MT. Endoscopic dacryocystorhinostomy: surgical technique and results.
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.1–4
Indications
The most common indication for sphenoidotomy in children is an acute or
chronic inflammatory process, with or without orbital, visual, or intracra-
nial 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. Where-
as all approaches are discussed briefly below, only the transnasal are
described in detail. The approaches are
• Transorbital transethmoidal—external
• Transantral transethmoidal
♦ 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.5–7 It is especially helpful when both eth-
moid and sphenoid sinus disease coexist. This approach provides excel-
lent 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 use-
ful for isolated sphenoid sinus disease, because it requires ethmoidecto-
my 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 max-
illary 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 sphe-
noid 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 fac-
tor in limiting the exposure, most transnasal transseptal approaches
include an additional incision line (most often sublabial) for wider expo-
sure. 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 suit-

able for infections. It does not provide the sphenoid sinus with a per-
manent 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 pitu-
itary 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 simul-
taneous exploration (ie, ethmoid and sphenoid sinusitis). If the sphenoid
sinus is the only sinus that requires exploration,8–10 violating the ethmoid
complex can be avoided by using the direct transnasal approach.
• Intranasal ethmoidectomy, although a common procedure, is not with-
out complications and sequelae. Possible immediate serious complica-
tions 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.11–20 The technique of ethmoidecto-
my 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 intra-
operative C-arm image intensifier or with more sophisticated intraoper-
ative navigation systems. For routine nonrevision cases, however, imag-
ing is usually not required.
• 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 15–1A).
• The safest location to enter the sphenoid sinus will be as medially as pos-
sible, 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 frac-
ture 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 flu-
oroscopy 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 15–1B).
• 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 15–2).
• 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 actual-
ly done. The 70˚ telescope can be also used to positively identify the
structures on the lateral wall (carotid artery and optic nerve).
A B
Figure 15–1 Transnasal transethmoidal sphenoidotomy. A, Sagittal view. B, Surgeon’s view. Note complete anterior and poste-
rior ethmoidectomy has been done.
Figure 15–2 Palpation within

the sinus before proceeding with
lateral bone removal.
DIRECT TRANSNASAL SPHENOIDOTOMY

The direct transnasal approach is preferred for isolated sphenoid sinus disease
to avoid the potential complications and sequelae of ethmoidectomy.22–26
• 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 eth-
moid complex is not entered.
♦ The procedure is done with endoscopic scissors after appropriate infil-
tration with a vasoconstricting solution. Bipolar cautery may be used
before transecting the turbinate to reduce bleeding (Figure 15–3).
• After displacement or partial resection of the middle turbinate is com-
pleted, the superior meatus is now exposed and the superior turbinate is
seen. Additional vasoconstriction may be achieved by inserting neuro-
surgical 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 self-
retaining nasal speculum or the Hardy transsphenoidal pituitary specu-
lum). 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 15–4). Alternatively,
the newer endoscopic coaxial bipolar instruments can be also used for
this purpose.
A B
Figure 15–3 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 15–4 Bipolar cauteriza-

tion of the superior turbinate
close to the skull base.
• Next, endoscopic scissors are used to transect the superior turbinate

superiorly, close to its skull base attachment, through the cauterized area
(Figure 15–5).
• The tip of the turbinate is pulled down gently, and with the combina-
tion 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 15–6).
• A 90˚ bipolar forceps may be used to control bleeding from the tran-
sected attachments of the superior turbinate to the anterior sphenoid
wall and to the skull base (Figure 15–7).
• If the sphenoid sinus ostium has not been identified before it is usually
apparent now.
♦ Sphenoidotomy is performed with fine Kerrison rongeurs or a sphe-
noid punch. It is safer to start from the natural ostium moving later-
ally, superiorly, and inferiorly (Figure 15–8).
♦ 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 ante-
rior sphenoid wall.
• The posterior division of the sphenopalatine artery (the nasoseptal divi-
sion) 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 inferi-
or 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.
Figure 15–5 The superior turbinate is transected close to the Figure 15–6 The superior turbinate is removed.
skull base through the cauterized area.
Figure 15–7 The posterior attachment of the superior Figure 15–8 Transnasal sphenoidotomy.
turbinate to the anterior sphenoid wall is cauterized.
• Lateral extension of the sphenoidotomy

1. Lateral exposure is achieved by performing limited posterior eth-
moidectomy through the superior meatus. This is followed by additional
removal of anterior sphenoid wall in a lateral direction (Figure 15–9).
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 safe-
ly 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-to-
anterior direction.
2. Alternatively, (this is especially helpful when the intrasphenoidal sep-
tum is thick and does not allow the surgeon to use the backbiting for-
ceps), 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 15–10). Heavy
straight forceps are then used to remove the remaining strut of nasal
septum, and proceed into the sphenoid sinus by removing the sphe-
noid rostrum and the intrasphenoidal septum (Figure 15–11).
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 pro-
cedure was done to treat an infectious process. They may be changed
according to the results of intraoperative cultures.
Figure 15–9 Lateral enlargement of the sphenoidotomy Figure 15–10 The posterior attachment of the nasal septum
through the superior meatus. to the sphenoid rostrum is penetrated.
Figure 15–11 After the posteri-

or septal strut has been removed,
both sphenoid sinuses are
exposed and the surgeon now
removes the intrasphenoid
septum (if needed).
REFERENCES
1. Anon JB, Rontal M, Zinreich SJ. Anatomy of the paranasal sinuses. New York: Thieme; 1996.
p. 3–11, 25–8.
2. 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.
3. Rice DH. Embryology. In: Donald PJ, Gluckman JL, Rice DH, editors. The Sinuses. New
York: Raven Press; 1995. p. 15–23.
4. Tom LWC. Structure and function of the nose, paranasal sinuses, and nasopharynx. In: Wet-
more RF, Muntz HR, McGill TJ, editors. Pediatric Otolaryngology-principles and practice
pathways. New York: Thieme; 2000. p. 409–21.
5. Donald PJ. Conventional surgery for ethmoid and sphenoid sinusitis. In: Donald PJ, Gluck-
man JL, Rice DH, editors. The sinuses. New York: Raven Press; 1995. p. 233–46.
6. Portmann G. Trephination of the sphenoid sinus. In: Portmann G, editor. A treatise on the sur-
gical technique of otorhinolaryngology. Baltimore: Williams & Wilkins; 1939. p. 370–89.
7. Weiss, RL, Bailey BJ. Approaches to the sphenoid. In: Bailey BJ, editor. Head and neck surgery-
otolaryngology. Vol. 1. Philadelphia: JB Lippincott; 1993. p. 402–12.
8. Cakmak O, Shohet MR, Kern EB. Isolated sphenoid sinus lesions. Am J Rhinol 2000;
14:13–19.
9. Ruoppi P, Seppa J, Pukkila M, Nuutinen J. Isolated sphenoid sinus disease. Arch Otolaryngol
Head Neck Surg 2000;126:777–81.
10. Sethi DS. Isolated sphenoid lesions: diagnosis and management. Otolaryngol Head Neck Surg
1999;120:730–6.
11. 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;120:308–13.
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sinus surgery. St. Louis (MO): Mosby; 1995. p. 95–102.
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tors. Endoscopic sinus surgery. New York: Thieme; 1993. p. 105–75.
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McGill TJ, editors. Pediatric otolaryngology-principles and practice pathways. New York:
Thieme; 2000. p. 475–85.
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surgery. St. Louis (MO): Mosby; 1995. p. 25–31.
18. Stankiewicz JA. The endoscopic approach to the sphenoid sinus. Laryngoscope
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27. Har-El G. The anterior wall of the sphenoid sinus. Ear Nose Throat J 1994;73:446–8.
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 malignan-
cies 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
• 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 intu-
bation 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.
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 nee-
dle-tip monopolar cautery, or a laser. When using the laser vaporization
technique, laser energy can be applied using a hand piece or the operat-
ing microscope.
• For excisional biopsy, an elliptical incision is made around the lesion
(Figure 16–1A). 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 tol-
erated.
• Oral hygiene with normal saline solution increases the patient’s comfort
postoperatively.
A B
Figure 16–1 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 Loré).1
Surgery of the Tongue 369
MACROGLOSSIA
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, lymphan-
gioma, 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 enlarge-
ment causing airway distress.2
Indications
• Chronic airway obstruction
• Maxillofacial deformity and malocclusion
• Recurrent hemorrhage from drying effects of chronic tongue protrusion
• Cosmetic deformity
• 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
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
block, is placed.
• Wedge resection of the tongue (Figure 16–2) can be fashioned in sever-

al forms, depending on the amount of tongue that needs to be excised.
One advantage of wedge resection is that more lateral tongue can be pre-
served, thus preserving taste and sensation.
♦ Simple wedge excision is shown in Figure 16–2A.
♦ Extended wedge excision is shown in Figure 16–2B.
♦ Keyhole wedge excision is shown in Figure 16–2C.
• 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 16–2D).
• Incision of the tongue surface and musculature is carried out using a sur-
gical 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-approxi-
mate tongue musculature and mucosal surfaces (see Figures 16–2E and F).
Postoperative Care
• Postoperative edema of the tongue during the first 24 to 48 hours may
cause significant airway distress. Overnight nasotracheal intubation ver-
sus tracheotomy must be considered.
• Patients and parents should be counseled for recurrent macroglossia,
especially in cases of lymphangioma.
A B
Figure 16–2 A, Simple wedge incision. B, Extended wedge incision.

C D
E F
Figure 16–2 C, Keyhole wedge incision. D, Tip reduction. E and F, Closing technique (adapted from Loré).1
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 usu-
ally 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
• 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
position.
Procedure
No 1. Intraoral approach
• A mouth retractor, without tongue blade, such as the Jennings or a
bite block, is placed.
• The dome of the cyst is incised, and contents of the cyst are aspirat-
ed (Figure 16–3A).
• The entire dome of the cyst is removed (marsupialized), leaving a
granulation bed exposed to heal by second intention (Figure 16–3B).
• Primary closure can also be performed if the lesion can be complete-
ly excised.
A B
Figure 16–3 A and B, Intraoral marsupialization of a base of the tongue lesion.

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 (vallec-
ula) would be poorly visualized from an oral approach. Large thyroglos-
sal duct cysts and mucoceles, as well as lingual thyroids, can be ade-
quately 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
16–4B).
♦ In cases of lingual thyroglossal duct cyst or lingual thyroid, the
midportion of the hyoid bone can be freed of infrahyoid muscula-
ture 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 16–4C). The tongue base lesion is identi-
fied 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 tracheoto-
my) 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 tol-
erated.
• 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.
Figure 16–4 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.
C
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
• Bleeding due to trauma against teeth
• 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 bleed-
ing 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 tech-
nique 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
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 16–5A).
• The restrictive lingual frenulum is incised using cold dissection or a nee-
dle-tip monopolar cautery (Figure 16–5B).
• Dissection is carried down to the tongue musculature with care to pre-
vent injury to the submandibular salivary ducts or papilla.
• This releases the tongue and leaves a defect on the tongue’s ventral sur-
face extending to the floor of the mouth (Figure 16–5C).
• 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.
Figure 16–5 Release of restric-

tive lingual frenulum. A, Tongue
retractor in position, tethering
the lingual frenulum. B, Electro-
cautery is used to release the lin-
gual frenulum. C, Surgical defect
on the ventral surface of tongue.
Tongue musculature is exposed;
salivary ducts and papilla are
protected and preserved.
B C
REFERENCES
1. Loré J. An Atlas of head and neck surgery. Philadelphia: WB Saunders; 1988.
2. Gupta OP. Congenital macroglossia. Arch Otolaryngol Head Neck Surg 1971;93:378–83.
3. Sistrunk WE. Technique for removal of cysts and sinuses of the thyroglossal duct. Surg Gynecol
Obstet 1928;46:109–12.
C H A P T E R 17
TONSILLECTOMY,
A DENOIDECTOMY, AND UPPP
Ari J. Goldsmith, MD
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 dis-
tinct 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
• 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 nec-
essary for children with known or suspected obstructive sleep apnea syn-
drome (OSAS).
• Coagulation tests remain controversial. There is no consensus on the ben-
efit 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 manage-
ment after surgery.3
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.
• 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 patient’s head, while the anesthesiologist has access to the intra-
venous 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 Rose’s position by lowering the head, unless
there is Down syndrome or other conditions affecting the cervical spine.
Tonsillectomy, Adenoidectomy, and UPPP 381
• 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 cavi-
ty 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 per-
sisting 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.
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 17–1).
• A laryngeal mirror (dipped in soapy water to prevent fogging) is used to
inspect the nasopharynx (Figures 17–2 A and B). Pulsations may indi-
cate 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:
♦ 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 ade-
noid size.
♦ Secondary (revision) adenoidectomy can also be performed using
curette, suction coagulator, or microdebrider; however, greater preci-
sion 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 suit-
ed for this procedure.7
Figure 17–1 The palate is

inspected and palpated for evi-
dence of a submucous cleft: bifid
uvula (a), zona pellucida (b),
and/or notching of the posterior
hard palate (c).
Figure 17–2 A and B. A laryn-

geal mirror is used to visualize
the adenoid, assess the degree of
obstruction, and select the
appropriate instrument for ade-
noidectomy.
B
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 supe-
riorly up to the septal vomer (Figure 17–3A).
• The curette is swept inferiorly with a side-to-side rocking motion to
completely remove all adenoid tissue (Figure 17–3B). 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 17–4A).
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 with-
drawn 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 17–4B).9
• Adenoid tissue is removed, taking care not to injure adjacent struc-
tures, particularly the torus tubarius and lateral nasopharynx.
A B
Figure 17–3 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.
Figure 17–4 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.
• 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 17–5). 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 nasophar-
ynx 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 col-
onization 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 hyper-
nasality 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 (Grisel’s syndrome), which presents with persis-
tent torticollis 1-2 weeks after surgery. Neurological or orthopedic con-
sultation 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 laryn-
goscopy and bronchoscopy must be performed for any newly discovered
missing teeth.
• Nasopharyngeal stenosis, caused by excessive tissue removal. Repair is dif-
ficult and may include dilation, steroid injection, or a tissue flap (rota-
tional, advancement, or free flap).11
• Eustachian tube injury, if the torus tubarius is cauterized or denuded.
• 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 17–5 Patients at risk for

velopharyngeal insufficiency
undergo a partial adenoidecto-
my, whereby an inferior adenoid
remnant is left to aid in velopha-
ryngeal closure.
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 syn-
drome (OSAS); poor feeding and failure to thrive; muffled speech
caused by enlarged tonsils
• Miscellaneous reasons: asymmetric enlargement with suspicion of neo-
plasm; recurrent hemorrhagic tonsillitis; velopharyngeal insufficiency
caused by enlarged tonsils
• 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 orienta-
tion (Figure 17–6). 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.
♦ Once the incision is made, the cautery is used to identify the avascu-
lar 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 17–7).
♦ After the plane is identified, the Allis clamp can then regrasp the ton-
sil capsule and mucosal fold for the rest of the procedure.
Figure 17–6 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 17–7 A small scissors or

clamp can be used to identify
the appropriate avascular dissec-
tion plane in scarred or fibrotic
tonsils.
• Dissection between the tonsillar capsule and fossa proceeds from superi-
or 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 17–8).
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 post-
operative 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 17–9). The plane between the
inferior palatine and lingual tonsil must be established to prevent over-
aggressive 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 17–8 The tonsil is

stretched medially and the
cautery is used to gently divide
the fibers between the tonsillar
capsule and the tonsillar fossa.
Figure 17–9 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 medi-
al 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
17–10A).
2. The superior pole of the tonsil can be visualized with a laryngeal mir-
ror to allow hemostasis in this region (Figure 17–10B).
A B
Figure 17–10 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.
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 (Fig-
ure 17–10C). Hemostatic sutures must be placed superficially to pre-
vent deeper vascular injury (Figure 17–11).
4. Other hemostatic techniques include prolonged packing, ties, bis-
muth, 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 17–11 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).
the lip area, to prevent premature extubation (Figure 17–12).
• 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 17–12 To prevent accidental extubation, the endotracheal tube is held down at the lip while removing the mouth gag.
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 rec-
ommended for16
♦ 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 care-
giver 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 col-
onization of the tonsil and adenoid beds.
• There is no consensus on activity resumption after T&A, though gener-
al 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 respirato-
ry 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 17–10).
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 tam-
ponade the bleeding.
• Dehydration, requiring re-admission for hydration with isotonic solu-

tions (to prevent hyponatremia) while monitoring electrolytes.
• Airway obstruction, requiring observation in an intensive setting, parenter-
al steroids, racemic epinephrine, careful insertion of a nasopharyngeal air-
way 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 (Grisel’s syndrome), presenting with persistent
torticollis 1-2 weeks after surgery. Neurological or orthopedic consulta-
tion may be required.
• Depression, which must be considered in children with persistent post-
operative 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 laryn-
goscopy 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 dif-
ficult 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 17–11).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

Indications
• Post-tonsillectomy hemorrhage, persisting despite the measures listed
above, including embolization of the external carotid artery (if available).
• General anesthesia with endotracheal intubation is mandatory.
• The pharynx is packed with gauze pads or sponges, as needed, to tam-
ponade hemorrhage from the tonsil fossae; an assistant applies direct
manual pressure.
Procedure
• A skin incision is made along the anterior border of the sternocleido-
mastoid muscle (Figure 17–13). The anterior muscle border is identified
and cleaned of fascial attachments.
Figure 17–13 A skin incision is made along the anterior border of the sternocleidomastoid muscle.
• The carotid sheath is exposed by dissection between the sternocleido-

mastoid muscle posteriorly, and the strap muscles anteriorly (Figure
17–14A).
• A large blunt clamp is spread in the direction of the sheath until the con-
tents are identified (Figure 17–14B).
• The internal jugular vein, ansa hypoglossi, and vagus nerve are retracted
posteriorly, while a vessel loop retracts the common carotid anteriorly
(Figure 17–15). The common carotid artery is followed superiorly above
the bifurcation, avoiding injury to the hypoglossal nerve as it crosses
superficially.
Figure 17–14 A, The carotid sheath is exposed between the sternocleidomastoid muscle posteriorly, and the strap muscles ante-
riorly. B, A large blunt clamp is used to open the sheath by spreading in the same direction.
Figure 17–15 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.
• 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 17–16).
• Persistent bleeding is probably due to collateral flow and will require
selective ligation of the ascending pharyngeal, lingual, and facial branch-
es, 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 17–17).
Figure 17–16 The external

carotid artery (a) is ligated with a
2-0 silk tie placed above the first
superior thyroid division (b).
Figure 17–17 The wound is closed in layers over a small Penrose drain.
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
• As described earlier under General Considerations
• Preoperative nasopharyngoscopy or video fluoroscopy should demon-
strate 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 pre-
operative cardiac evaluation and postoperative observation in the ICU.
• Parents must be advised that if UPPP fails to alleviate OSAS, tracheoto-
my 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:
♦ Pulling the uvula superiorly and anteriorly will help identify the junc-
tion 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 17–18).
♦ 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 17–19 A and B).
♦ Only the uvula is removed; remaining palatal musculature is pre-
served.
• After removing the redundant anterior and posterior palatal mucosa with
the attached uvula, hemostasis is achieved using the suction cautery.
Figure 17–18 The uvula is

tensed and pulled inferiorly and
anteriorly, while an incision is
made into the palatal mucosa.
This incision is carried down lat-
erally towards the anterior ton-
sillar pillars.
A B
Figure 17–19 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).
• 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 17–20 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 later-
al 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 lip area, to prevent premature extubation (see Figure 17–12).
• 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.
A B
Figure 17–20 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).
Postoperative Care
• Diet, medications, and activity are the same as described above for ton-
sillectomy.
• The patient must be admitted overnight to the ICU and observed close-
ly 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 postopera-
tive 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 post-
operative 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 return-
ing 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. Hartnick CJ, Ruben RJ. Preoperative coagulation studies prior to tonsillectomy. Arch Oto-
2. Wei JL, Beatty CW, Gustafson RO. Evaluation of posttonsillectomy hemorrhage and risk fac-
tors. Otolaryngol Head Neck Surg 2000;123:229–35.
3. Allen GC, Armfield DR, Bontempo FA, et al. Adenotonsillectomy in children with von Wille-
brand disease. Arch Otolaryngol Head Neck Surg 1999;125:547–51.
4. Halvorson DJ, McKie V, McKie K, et al. Sickle cell disease and tonsillectomy. Arch Otolaryn-
5. Goldman AC, Govindaraj S, Rosenfeld RM. A meta-analysis of dexamethasone use with ton-
sillectomy. Otolaryngol Head Neck Surg 2000;123:682–6.
6. Keller C, Elliott W, Hubbell RN. Endotracheal tube safety during electrodissection tonsillecto-
my. Arch Otolaryngol Head Neck Surg 1992;118:643–5.
7. Kakani RS, Callan ND, April MM. Superior adenoidectomy in children with palatal abnor-
malities. Ear Nose Throat J 2000;79:300–5.
8. Jones J, Greenberg L, Groudine S, et al. Phenylephrine advisory panel report. Int J Pediatr
Otorhinolaryngol. 1998;45:97–99.
9. Stanislaw P, Koltai PJ, Feustel PJ. Comparison of power-assisted adenoidectomy vs. adenoid
curette adenoidectomy. Arch Otolaryngol Head Neck Surg 2000;126:845–9.
10. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol
11. Giannoni C, Sulek M, Friedman EM, Duncan NO. Acquired nasopharyngeal stenosis. Arch
12. Zinder DJ, Parker GS. Electrocautery burns and operator ignorance. Otolaryngol Head Neck
Surg 1996;115:145–9.
13. Nunez DA, Provan J, Crawfoird M. Postoperative tonsillectomy pain in pediatric patients. Elec-
trocautery vs. cold dissection and snare tonsillectomy–a randomized trial. Arch Otolaryngol
Head Neck Surg 2000;126:837–41.
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;121:1410–2.
15. Steward DL, Chung SJ. The role of adjuvant therapies and techniques in tonsillectomy. Cur
Opin Otolaryngol Head Neck Surg 2000;8:186–92.
16. Gabalski EC, Mattucci KF, Setzen M, Moleski P. Ambulatory tonsillectomy and adenoidecto-
my. Laryngoscope 1996;106:77–80.
17. Moir MS, Bair E, Shinnick P, Messner A. Acetaminophen versus acetaminophen with codeine
after pediatric tonsillectomy. Laryngoscope 2000;110:1824–7.
18. Ozcan M, Altuntas A, Unal A, et al. Sucralfate for posttonsillectomy analgesia. Otolaryngol
19. Klausner RD, Tom LWC, Schindler PD, Potsic WP. Depression in children after tonsillectomy.
20. Ghorayeb BY. Cicatricial velopharyngeal stenosis. Arch Otolaryngol Head Neck Surg
1988;114:192–4.
21. Krespi Y, Kacker A. Management of nasopharyngeal stenosis after uvulopalatoplasty. Otolaryn-
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 res-
onance; 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 limit-
ed 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 deter-
mines the level and pattern of velopharyngeal closure. Additional informa-
tion is obtained concerning the size and location of the area of velopharyn-
geal 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 velopha-
ryngeal 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. Passa-
vant’s 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 medial-
izing 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. Phoneme-
specific 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.
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.
• 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 Car-
diac status should be investigated.
• Antibiotic prophylaxis is often necessary to prevent subacute bacterial
endocarditis.
Preparation
• Adenotonsillar hyperplasia may require tonsillectomy and adenoidecto-
my 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 18–1).
Velopharyngeal Insufficiency 409
♦ 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 18–1 Incisions for a

superiorly based pharyngeal flap.
• 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.
♦ 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 nasopha-
ryngeal stenosis.
• An incision is made on the nasal surface of the posterior soft palate.
♦ Traction sutures placed on the nasal surface of the free edge of the soft
palate can improve visualization for this incision (Figure 18–2).
♦ Care is taken to incise the mucosa with an adequate area of separa-
tion 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.
• 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 lat-
eral 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 18–3).
• 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.

horizontally on the nasopharyn-
geal surface of the soft palate to
create a pocket to inset the trans-
posed pharyngeal flap.
Figure 18–3 The pharyngeal

mucosa of the pharyngeal flap is
sewn to the anterior nasopharyn-
geal mucosa of the soft palate,
anchoring the flap into position.
• 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 18–4). 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 vis-
ible in the oropharynx; it must be high in the nasopharynx (Figure 18–5).
• If the palate was divided for improved exposure, it is closed in three lay-
ers. Meticulous technique is necessary to minimize fistula formation.
• The nasal stents are positioned with their distal end in the midorophar-
ynx, 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 hyper-
nasality or nasal emission is detected.
Figure 18–4 Horizontal mat-

tress 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 18–5 Superiorly based

pharyngeal flap in final position
Complications
• Adenotonsillar hyperplasia must be addressed prior to performing a pha-
ryngeal 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 ther-
apy to learn how to use their flap. Failure to improve by 3 months sug-
gests that further surgery will be necessary.
• Narrowing of the flap may cause inadequate obturation of the velopha-
ryngeal 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 deter-
mined to be necessary preoperatively, an additional step of lining the
flap with mucosal flaps, based on the free margin of the soft palate, min-
imizes the raw surface of the flap left to granulate, and can more pre-
dictably maintain the width of the flap (Figure 18–6). This requires
splitting the palate to elevate the soft palate nasal flaps.4
Figure 18–6 Elevating the

mucosa off the nasopharyngeal
surface of the posterior soft
palate allows lining of the pha-
ryngeal flap to minimize flap
narrowing.
ROLLED PHARYNGEAL FLAP

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
• There is a high prevalence of velo-cardio-facial syndrome.3 Cardiac sta-
tus 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.
of the neck.
Procedure
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 18–1). 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 sur-
rounding 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.
• The inferior edge of the flap is sewn to the prevertebral fascia at the base
of the flap (Figure 18–7).
• 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.
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 velopharyn-
geal closure.
Figure 18–7 A pharyngeal flap

can be rolled onto itself and
used to augment the posterior
pharyngeal wall.
POSTERIOR PHARYNGEAL WALL AUGMENTATION

Biocompatible or homologous tissues are used to augment irregularities or
deficiencies in the posterior pharyngeal wall that create areas of velopha-
ryngeal 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
• Antibiotic prophylaxis is often necessary for subacute bacterial endo-
carditis.
Preparation
• The material to be injected must be available.
♦ Medical grade Teflon carries the risk of infection, granuloma forma-
tion, inferior displacement over time,6 or theoretically, embolization.7
♦ Commercially available collagen products are available from manu-
facturers, but little experience exists concerning their use in the pos-
terior 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.
of the neck.
Procedure
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 nasopharyn-
geal 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
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 18–8). This creates a
broad barrier to displacement of the injected material in an inferior
direction.
• The augmentation material is slowly injected onto the prevertebral fas-
cia. Generally 1 to 2 cc of material are injected at each site. Over-cor-
rection 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
• Postoperative neck pain is expected because the prevertebral fascia has
been irritated.
Complications
• VPI may persist if the injection is not positioned at the level of velopha-
ryngeal closure.
• VPI may re-develop if resorption of the injected material re-opens an
area for nasal escape.
Figure 18–8 Implanted material

should be placed on the prever-
tebral 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 superi-
or pedicle. The major benefit of this procedure results from the static nar-
rowing produced by transposing the flaps. Additional benefit is realized
from the added bulk of the flaps to the posterior pharyngeal wall, aug-
menting 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 Rosenmüller
• Antibiotic prophylaxis is often necessary for subacute bacterial endo-
carditis.
Preparation
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 sig-
nificant vessels in the operative field.
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 rectan-
gular 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 18–9).
• 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 dis-
section is limited in the area of the tonsil.
• After making the transverse incision at the level of velopharyngeal clo-
sure, 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 effec-
tively 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 later-
al limit of the recipient horizontal incision of the opposite side (Figure
18–10). One flap will reside above the other.
• If the palate was divided for improved exposure, it is closed in three lay-
ers. Meticulous technique is necessary to minimize fistula formation.
Postoperative Care
• Postoperative neck pain is expected as the prevertebral fascia has been
irritated.

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 18–9 The posterior tonsillar pillars are incorporated Figure 18–10 The transposed flaps should be high in the
into the musculocutaneous flaps for the sphincteroplasty. nasopharynx, at the level of velopharyngeal closure.
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
• Preoperative nasopharyngoscopic evaluation during connected speech
has identified the lateral ports that require revision.
of the neck.
Procedure
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 18–11). The advancement is on the
posterior lateral pharyngeal wall, extending into the nasopharynx, adja-
cent to the pedicle of the flap.
• Bilateral port procedures may be necessary.
Figure 18–11 Y-V advancement

flap to close a lateral port that is
excessively wide.
Postoperative Care
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.
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
• Preoperative nasopharyngoscopic evaluation during connected speech
has identified the lateral ports that require revision.
of the neck.
Procedure
• 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 18–12). 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
• Perioperative oral antibiotics are not generally required.
Figure 18–12 Enlargement of a

stenotic lateral port.
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 rea-
sons for the previous surgical failure so precautions can be taken to mini-
mize their recurrence. Pharyngeal flaps can be raised a second time if 6-12
months are permitted to elapse. Unilateral sphincteroplasties may be per-
formed in patients who fail to develop adequate lateral wall motion fol-
lowing pharyngeal flap placement.
Patients must have an objective evaluation 3-6 months following recon-
structive procedures to assess their nasal resonance. Precise terminology is
necessary to judge outcome; “normal” is not the same as “acceptable.” A
family’s satisfaction with the results of surgery does not equate to normal or
acceptable resonance. Without objective scrutiny of postoperative out-
comes, 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. Collab-
oration 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;29:152–6.
2. 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;91:265–71.
3. 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;15:56–62.
4. 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;10:331–45.
5. Gray SD, Pinborough-Zimmerman J, Catten M. Posterior wall augmentation for treatment of
velopharyngeal insufficiency. Otolaryngol Head Neck Surg 1999;121:107–12.
6. Smith J, McCabe B. Teflon injection in the nasopharynx to improve velopharyngeal closure.
Ann Otol Rhinol Laryngol 1977;86:559–63.
7. Borgatti R, Tettamanti A, Piccinelli P. Brain injury in a healthy child one year after periureter-
al injection of Teflon. Pediatrics 1996;98:290–1.
8. Jackson I, Silverton J. The sphincter pharyngoplasty as a secondary procedure in cleft palates.
Plast Reconst Surg 1977;59:518–24.
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 par-
ticularly high prevalence (10-20%) among children with cerebral palsy. Management deci-
sions 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 19–1.
SUBMANDIBULAR DUCT RELOCATION WITH

SUBLINGUAL GLAND EXCISION
Indications
• Operation of choice1 for chronic significant drooling in the neurologi-
cally 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
• General anesthesia is maintained through a nasotracheal tube that is sta-
bilized on the patient’s 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
patient’s head.
Preparation
• The patient is placed in a slight reverse Trendelenburg position. A head-
light 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.
Table 19–1 Comparison of surgical procedures for drooling

Procedure Advantages Disadvantages
Submandibular duct ✓ Result is usually maintained ✕ Significant morbidity

relocation with ✓ Oral cavity remains moist ✕ Hospital stay of 3-4 days
sublingual gland ✓ Dentition remains healthy ✕ About 2% require a secondary procedure
excision ✓ Complications requiring surgery for persistent drooling
(ie ranula) have not occurred ✕ Long-term result may not be better than
submandibular duct relocation alone
Submandibular duct ✓ Result is usually maintained ✕ Significant morbidity
relocation ✓ Oral cavity remains moist ✕ Hospital stay of 3-4 days
✓ Dentition remains healthy ✕ Ranula incidence of 8% within 6 months
✓ Short procedure ✕ About 2% require a secondary procedure
✓ Sublingual glands are not removed for persistent drooling
✕ About 1% of ducts obstruct, forming a retention cyst
requiring external excision of the ipsilateral
submandibular gland
Parotid duct ligation ✓ Short procedure ✕ Xerostomia may occur when used as a secondary
✓ Low morbidity procedure
✓ Hospital stay of 1-2 days
Tympanic neurectomy ✓ Short hospital stay ✕ Sialorrhea frequently returns to preoperative
✓ Low morbidity levels within 6 months
Submandibular duct ✓ Minimally invasive procedure ✕ Xerostomia may be problematic when combined with
ligation parotid duct ligation
✕ Ranula formation secondary to disruption of
sublingual gland tissue
Procedure
• Exposure of the floor of the mouth is facilitated by inserting a two-
pronged 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
• An island of mucosa 2 cm wide and 1 cm deep, encompassing the sub-
mandibular papillae, is created (Figure 19–1A).
1. For the right-handed surgeon it is easiest to identify the left sub-
mandibular 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 tis-
sue towards the lower dentition. With a sharp scissors, the dissection
proceeds laterally from the midline, just underneath the edge of the
mucosal island (Figure 19–1B).
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 posi-
tion of the already displayed contralateral duct.
Surgery for Drooling 429
A B
Figure 19–1 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).
♦ 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 19–2A).
• 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 19–2B).
• 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 anteri-
or incision and continuing posteriorly for 3-4 cm.
• The anterior aspect of the sublingual gland is mobilized off the inner
aspect of the mandible with blunt scissors dissection (Figure 19–3A).
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 19–3B).
• 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 19–4A).
• 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 19–4B).
♦ 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 submen-
tal 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.
A B
Figure 19–2 A, Both submandibular ducts are dissected free. B, The island of mucosa temporarily sutured to the tongue.
A B
Figure 19–3 A, The anterior aspect of the sublingual gland is mobilized. B, Sublingual gland is mobilized posteriorly.
A B
Figure 19–4 A, Division of the mucous membrane close to the tongue. B, Mobilization of the sublingual gland off the lingual nerve.
• 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 19–5A).
3. Leaving the self-retaining retractor in place, the tongue is pulled for-
ward and a Negus clamp is passed forward from the tonsillar fossa
into the operative area, staying in the submucous space (Figure
19–5B).
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 re-
inserted; the floor of mouth is examined closely to ensure complete
hemostasis.
• The anterior incision is closed with five or six simple interrupted stitch-
es 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 man-
ageable 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.
• 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.
A B
Figure 19–5 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
• General anesthesia is maintained through a nasotracheal tube that is sta-
bilized on the patient’s 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 at the foot of the operating table and to the
left of the patient so that the surgical team has ample access to the
patient’s head.
Preparation
• The patient is placed in a slight reverse Trendelenburg position. A head-
light 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
pronged self-retaining retractor between the upper and lower dentition,
and by suturing the tip of the tongue to the soft palate.
• An island of mucosa 2 cm wide and 1 cm deep, encompassing the sub-
mandibular papillae, is created (see Figure 19–1A).
1. For the right-handed surgeon it is easiest to identify the left sub-
mandibular 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 tis-
sue 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 19–1B).
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 19–2A).
• 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 19–2B).
• 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-
mandibular gland to the tonsillar fossa by pushing a Kelly clamp

through from the anterior incisional area (Figure 19–6A).
• 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 19–6B),
and then pulled through the submucosal tunnels into the tonsillar fos-
sae. 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 stitch-
es of absorbable suture material (4-0 chromic catgut).
Postoperative Care
• Same as described above for Submandibular Duct Relocation with Sub-
lingual Gland Excision.
• 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.
A B
Figure 19–6 A, Pulling a catheter into the anterior incisional

area. B, Threading of the suture through the catheter.
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 techni-
cally 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
• An oral endotracheal tube is adequate and permits access to both parotid
ducts.
Preparation
• The patient’s head is in a neutral position with a slight reverse Trende-
lenburg 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
• 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 19–7A). 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 19–7B). 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.
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 inad-
vertently divided
Figure 19–7 A, Location of the

incision anterior to the parotid
duct orifice. B, Instrument
around the parotid duct to grasp
the nonabsorbable ligature.
B
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 patient’s 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 secre-
tomotor 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 cov-
ered 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.
• 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 lig-
ation.3
Contraindications
• Severe retrognathia, making access to this area problematic
• A nasotracheal tube facilitates completing the procedure.
Preparation
• The surgeon wears a headlight to improve visualization.
Procedure
pronged self-retaining retractor between the upper and lower dentition,
and by suturing the tip of the tongue to the soft palate.
• A 2.5 cm mucosal incision is made approximately 1 cm posterior to the
orifices of the submandibular papillae (Figure 19–8A).
• The left submandibular duct is found first (see Figure 19–1B) by grasp-
ing 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 19–8B).
• The incision in the floor of mouth is closed with interrupted absorbable
sutures.
A B
Figure 19–8 A, Location of incision posterior to the submandibular papillae. B, Instrument around the submandibular duct to
grasp the nonabsorbable ligature.
Postoperative Care
• Morbidity is minimal, and discharge from hospital may be possible the
same day.
• This procedure may become the operation of choice, because the mor-
bidity is significantly less than submandibular duct relocation with sub-
lingual gland excision.
REFERENCES
1. Crysdale WS, Greenberg J, Koheil R, Moran R. The drooling patient: team evaluation and
management. Int J Pediatr Otorhinolaryngol 1985;9:241–8.
2. Klem C, Mair EA. Four-duct ligation: a simple and effective treatment for chronic aspiration
from sialorrhea. Arch Otolaryngol Head Neck Surg 1999;125:796–800.
3. 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):379–83.
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 pedi-

atric 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 can-

cer, (2) previous primary neoplasm, (3) known predisposition to sys-
temic 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 diam-
eter in children over 1 year of age.
In the absence of the above findings, observation with serial measure-
ments over several weeks is a reasonable method of discriminating less wor-
risome 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 progres-
sively 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 reso-
nance imaging (MRI) are the radiologic studies of choice; in specific clini-
cal circumstances, radioisotope scans and angiographic procedures may
supply additional information.
Although, with few exceptions, the physical examination and laborato-

ry evaluation may suggest a diagnosis, biopsy is required for diagnostic con-
firmation. 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 child-
hood cervicofacial masses. A close working relationship between the sur-
geon and pathologist is essential for success. The principal role of percuta-
neous 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 nee-
dle biopsy should never be considered definitive when there is clinical sus-
picion of malignancy. A subsequent open surgical biopsy is necessary.
Indications
• A preliminary histopathologic diagnosis is desired to better select, mod-
ify, or eliminate definitive operative intervention.
• Clinically unresectable cervicofacial mass
• 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 cutting–nee-
dle 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 20–1A) or the disposable
TRU-Cut (14-gauge) needle (Figure 20–1B) may be used.
2. The FNA technique uses much smaller 22- to 25-gauge needles from
1 1⁄2 to 3 1⁄2 inches in length, depending on the lesion depth (Figure
20–1C). An 18- to 20-gauge needle may be needed to aspirate cystic
lesions containing thick mucoid material.
Cervical Adenopathy 443
Figure 20–1 A, Vim-Silverman A

(12-gauge) needle. B, TRU-Cut
biopsy needle. C, 22-gauge 3 1⁄2”
needle.
C
Procedure
• The child is positioned and draped with the proposed biopsy site readi-
ly available to the surgeon, and the surrounding anatomic landmarks
easily visualized (Figure 20–2).
• 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:
♦ For superficial lesions, the mass is stabilized with the thumb and the
index finger of the opposite hand (Figure 20–3).
♦ 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 cutting–needle biopsy
• A 1-2 mm skin incision is made with a No 11 scalpel blade prior to
needle insertion (Figure 20–4).
• 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 20–2 The patient is posi-

tioned so that the biopsy site is
easily accessible to the surgeon.
Figure 20–3 Superficial lesions

can be stabilized with the thumb
and index finger.
Figure 20–4 A large-bore needle

biopsy requires that a 1- to
2-mm skin incision be made
prior to needle insertion.
• 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 differ-
ent angles, into the mass (Figure 20–5).
• 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 reat-
tached. 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 plas-
tic adhesive bandage.
Complications
• The potential dissemination of malignancy from mechanical trauma is a
major concern in large bore cutting–needle biopsy. This implantation
problem has theoretically been eliminated by the FNA technique.
• Bleeding with hematoma formation is a potential complication, partic-
ularly 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.
Figure 20–5 Fine-needle aspiration technique is shown.

CERVICAL LYMPH NODE BIOPSY

In adults, open surgical excisional or incisional biopsy is typically con-
traindicated 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 child’s 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 diagno-
sis (for example, suspected lymphoma).
• There is a clinical suspicion of malignancy despite a negative percuta-
neous biopsy.
• Excision is likely the definitive treatment of the cervical mass in ques-
tion.
• 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 recom-
mended to make a definitive intraoperative diagnosis.
• Preoperative pathology consultation is also important in suspected lym-
phoma cases so that fresh tissue preparations can be made for cell cul-
ture and lymphoma marker studies.
• Specific clinical situations may dictate preoperative oncology consulta-
tion 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 20–6). 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 (Fig-
ure 20–7). Detailed knowledge of the regional anatomy is necessary to
avoid neurovascular injury.
Figure 20–6 The incision is out-

lined in a cervical skin crease.
Figure 20–7 The mass beneath

the superficial layer of the deep
cervical fascia.
• The mass is carefully delineated before removal (Figure 20–8). If feasi-

ble, 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
20–9).
• 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. Par-
ticular care is necessary near the tail of the parotid or submandibular tri-
angle, and in the posterior triangle of the neck, to avoid potential injury
to the facial nerve and spinal accessory nerve, respectively.
Figure 20–8 Removal of the

cervical nodal mass.

closed after placement of a small
Penrose drain.
FUNCTIONAL (MODIFIED) NECK DISSECTION

The lymph nodes of the neck are anatomically localized into six levels (Fig-
ure 20–10):
• 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 rad-
ical 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, respec-
tively (Figures 20–11 and 20–12).
Limiting the procedure to specific node levels can further modify a func-
tional neck dissection. For example, a supraomohyoid neck dissection selec-
tively removes the lymphatic tissue from levels 1 through 3, a posterolateral
Figure 20–10 Cervical lymph

node groups by anatomic levels.
1
2
3 6
5
4
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
A Anterior digastric muscle
Facial vein
Hyoid bone
Submaxillary gland
Parotid gland
Facial artery
Internal carotid artery
Internal jugular vein
Figure 20–11 Structures removed
Sternocleidomastoid muscle
(stippled area) at the level of the
hyoid in a radical neck dissection Vagus nerve
(A) compared to a functional neck Posterior digastric muscle
dissection (B).
Levator scapulae muscle
B
Thyroid cartilage Thyroid cartilage
Omohyoid muscle Omohyoid muscle
Sternocleidomastoid muscle Sternocleidomastoid muscle
Internal carotid artery Internal carotid artery
Internal jugular vein Internal jugular vein
Scalenus medius muscle Scalenus medius muscle
Levator scapulae muscle Levator scapulae muscle
A B
Figure 20–12 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; 2001:616–24.)
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 cer-
vical metastases due to the location of the primary lesion
• An adolescent or young adult has undifferentiated nasopharyngeal car-
cinoma 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 malig-
nancy 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 inflammato-
ry process such as atypical mycobacterial infection unresponsive to med-
ical management
• A child, adolescent, or young adult has a non-neoplastic lymphoprolif-
erative disorder with symptomatic airway and/or great vessel compro-
mise, or when there is suspicion of an increased risk of neoplastic trans-
formation

• The patient is positioned with an inflatable thyroid bag under the shoul-
ders 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 modi-
fied 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 20–13). The S-shape of the vertical
component of the modified Conley incision also heals well with mini-
mal contracture and comparatively good cosmesis.
• The incision is infiltrated with 1% lidocaine with 1:100,000 epineph-
rine for hemostasis.
Figure 20–13 Child draped in

surgical position with modified
Conley incision outlined.
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 20–14):
♦ superiorly to the lower border of the mandible, extending to the mas-
toid 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 communi-
cate 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 struc-
tures:
♦ 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 20–15).
♦ Structures additionally preserved during all functional neck dissec-
tions include the sternocleidomastoid muscle, internal jugular vein,
and spinal accessory nerve (Figure 20–16).
Figure 20–14 Elevation of cervical flaps with identification of important superficial anatomical structures.
Figure 20–15 Completed radical neck dissection with identification of important deep anatomical structures.
Figure 20–16 Completed functional neck dissection with identification of the principal anatomical structures to be preserved.
• 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 mid-
dle layers surround the strap muscles and the viscera, and (3) the deep
layer covers the deep neck musculature (Figure 20–17).
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 20–18).
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. Spe-
cific 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 postero-
lateral 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 Erb’s point, where the
greater auricular nerve turns over the posterior border of the sternoclei-
domastoid 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 superi-
or portion of this dissection.
• Dissection of the level 1 lymph nodes within the submental and sub-
mandibular 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.
Figure 20–17 Fascial layers of

the neck.
Figure 20–18 Triangles of the

neck.
Submandibular triangle
Submental triangle
Anterior
Occipital triangle Superior carotid triangle triangle
Posterior
Inferior carotid or
triangle Omoclavicular triangle muscular triangle
(Greater supraclavicular fossa)
• During removal of the level 5 lymph nodes within the posterolateral cer-
vical 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 intra-
aponeurotic 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 infe-
rior one-third and superior two-thirds, and is elevated superiorly to
enhance clearance of the lymphatic tissues from levels 2 through 5
(Figure 20–19).
♦ Once the neck dissection is complete, the sternocleidomastoid mus-
cle 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
flap’s blood supply (Figure 20–20).
Postoperative Care and Complications
• 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 sternocleido-
mastoid muscle.
• Injury of the phrenic nerve during posterolateral neck dissection results
in ipsilateral paralysis of the diaphragm. Visual identification and stim-
ulation of the nerve will intraoperatively verify its anatomical integrity.
For medicolegal reasons, preoperative documentation of diaphragmatic
function is valuable.
Figure 20–19 Division of the

sternocleidomastoid muscle in a
Bocca functional neck dissection.
Figure 20–20 Cervical incision

closure and suction drain
placement.
• 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 fortu-
nately 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. Con-
versely, 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 mandibu-
lar nerve injury; this condition resolves with progressive compensation
by adjacent facial musculature.
• Unilateral hypoglossal nerve injury may cause moderate speech and mas-
ticatory difficulties secondary to unilateral tongue paralysis. Visual iden-
tification 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 dis-
section. The resulting Horner’s 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 intraopera-
tively 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 anesthesi-
ologist may notice an intraoperative change in the respiratory pattern or
signs of circulatory failure. Alternatively, immediate postoperative (post-
extubation) 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 dissec-
tion in a nonirradiated field. Careful attention to appropriate flap design
and meticulous surgical technique decrease the risk of carotid injury.
BIBLIOGRAPHY
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in paediatric neck masses. Eur Radiol 2000;10:512–5.
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JB Lippincott Company; 1994. Chapter 44:1–13.
Cunningham MJ. Neoplastic disorders: benign and malignant. In: Cotton RT, Myer CM III, edi-
tors. Practical pediatric otolaryngology. Philadelphia: Lippincott-Raven Publishers; 1999. p.
681–91.
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. 597–627.
Knight PJ, Mulney AF, Vassey LE. When is a lymph node biopsy indicated in children with enlarged
peripheral nodes? Pediatrics 1982;69:391–6.
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147–53.
Montgomery WW. Surgery of the neck. In: Montgomery WW, editor. Surgery of the upper respi-
ratory system. Vol II. 2nd ed. Philadelphia: Lea & Febiger; 1989. p. 83–124.
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and neck masses. Laryngoscope 1991;101:469–72.
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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, infrahy-
oid space, or spaces involving the entire neck. This chapter describes the surgical approach-
es 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 air-
way 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 con-
nected to the vertebral spinous processes and ligamentum nuchae. It com-
pletely encircles the neck and divides to surround the trapezius muscle (Fig-
ure 21–1). 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
(suprahyoid) and below (infrahyoid). The superior part of this fascia enclos-
es the submandibular and parotid glands and forms the stylomandibular lig-
ament, which runs from the styloid process to the hyoid bone. The infrahy-
oid 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 pre-
tracheal layer encloses the strap muscles (omohyoid, thyrohyoid, sternohy-
oid, and sternothyroid). This layer also passes in front of the trachea,
esophagus, and thyroid gland, and as it courses inferiorly along the infrahy-
oid 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 pretra-
cheal layer, and the prevertebral layer (see Figure 21–1). The lateral portion
of the pretracheal fascia fuses with the outer superficial fascia layer. The vis-
ceral 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 buc-
copharyngeal 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 ante-
rior to the vertebral column (Figure 21–2). Both the anterior and posteri-
or 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.
Deep Neck Infections 467
Figure 21–1 Cross section of

the neck illustrating visceral
structures and fascial planes.
(Adapted from Barrett G, Koop-
man CF, Coulthard SW.
Retropharyngeal abscess—a ten
year experience. Laryngoscope
1984;94:455–63.)
Figure 21–2 Lateral neck

emphasizing retropharyngeal,
prevertebral, and “danger”
spaces. (Adapted from Barrett G,
Koopman CF, Coulthard SW.
Retropharyngeal abscess—a ten
year experience. Laryngoscope
1984;94:455–63.)
SUBMANDIBULAR SPACE DRAINAGE

The submandibular space (Figure 21–3) 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 odonto-
genic infections.
Indications
• Ludwig’s 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 ini-
tially 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.
• General anesthesia is needed to control the airway and avoid aspiration.
• Nasotracheal or oral endotracheal anesthesia is preferred, but may be dif-
ficult 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 gener-
al anesthesia, when necessary, if nasotracheal or oral endotracheal intu-
bation is not possible.
• The skin is prepared with an antiseptic scrub of the surgeon’s choice if
an external approach is needed.
• The throat is packed with gauze.
Figure 21–3 Submandibular and masticator space fascial planes. (Adapted from Hollinshead
WH. Anatomy for surgeons. Vol 1. 2nd ed. New York: Hoeber; 1968.)
Procedure
• An abscess in the sublingual space may respond adequately to intraoral
drainage.
• For bilateral submandibular space infections, especially Ludwig’s angina,
a submental incision is necessary (Figure 21–4A):
♦ 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 dis-
section is used, as necessary, to identify, enter, and drain the abscess
cavity (Figure 21–4B).
♦ 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 21–4C). The suction drains may also be used for wound irri-
gation 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.
Figure 21–4 Incision and

drainage of a submental space
abscess or Ludwig’s angina infec-
tion. 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 Loré J. An atlas
of head and neck surgery. 3rd ed.
1988.)
C
PHARYNGOMAXILLARY (LATERAL PHARYNGEAL)

SPACE DRAINAGE
This space is bounded by the petrous portion of the temporal bone superi-
orly; the superior constrictor muscle medially; the pterygoid muscles,
mandible, and parotid gland laterally; the pterygomandibular raphe anteri-
orly; the buccopharyngeal and prevertebral fascia posteriorly; and the hyoid
bone inferiorly.
Infection may originate from the teeth, tonsils, peritonsillar space, pen-
etrating 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 poste-
rior 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 rup-
ture of the internal carotid artery
• 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 surgeon’s 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 21–5A).
• 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 21–5B).
• The anterior border of the sternocleidomastoid muscle is retracted pos-
teriorly and the carotid sheath structures are identified opposite the tip
of the hyoid bone greater cornu.
A B
Figure 21–5 Drainage of the pharyngomaxillary (lateral pharyngeal) space (A) Illustration depicting planned exter-
nal incision (B) Dissection illustrating important, relavant structures (C) Illustration depicting approach used to
retract structures prior to drainage of abcess. (Adapted from Loré J. An atlas of head and neck surgery. 3rd ed.
Philadelphia: WB Saunders; 1988.)
• The pharyngomaxillary space includes two compartments, separated by

the styloid process, which must both be adequately drained (Figure 21–6):
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 eleva-
tor beneath the angle of the mandible facilitates exposure (Figure
21–5C). 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 Jackson-
Pratt 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 antibi-
otics for 2-3 weeks.
• The drains are advanced slowly over 5-7 days.
Figure 21–6 Axial section of the

nasopharynx showing major fas-
cial layers and anatomic struc-
tures. The styloid process divides
the lateral pharyngeal space into
prestyloid and poststyloid por-
tions, 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 chil-
dren. In: Bluestone CD, Stool SE,
Kenna MA, editors. Pediatric oto-
laryngology. Vol 2. 3rd ed.
1996. p. 1532.)
MASTICATOR SPACE DRAINAGE

The deep cervical fascia forms the masticator space as it covers the masseter
muscle laterally and the pterygoid muscles medially (see Figure 21–3).
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 infe-
rior 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
• Impending airway obstruction or asphyxia
• 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 surgeon’s 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 infec-
tion 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 antibiot-
ic solution, and a Penrose drain or suction drain is inserted and
advanced slowly.
• 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 ascend-
ing 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 lat-
eral 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. Alterna-
tively, Betadine-impregnated packing may be placed and advanced
over several days.
Postoperative Care
• 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.
PAROTID SPACE DRAINAGE

The superficial layer of the deep cervical fascia forms the parotid space (Figure
21–7) 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
• The procedure is usually performed under general oral endotracheal
anesthesia.
Figure 21–7 Parotid space.

(Adapted from Hollinshead
WH. Anatomy for surgeons.
Vol 1. 2nd ed. New York:
Hoeber; 1968.)
Procedure
• An incision is made in the standard fashion used for a parotidectomy, with
curved pre-auricular and infra-auricular portions (Figure 21–8A). 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 car-
tilage 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 21–8B). Multiple open-
ings 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
21–8A) 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
• The drains are advanced over 4-5 days.
Figure 21–8 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
Loré J. An atlas of head and
neck surgery. 3rd ed. Philadel-
phia: WB Saunders; 1988.)
B
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 con-
strictor into the lateral pharyngeal space. The signs and symptoms of infec-
tion include dysphagia; trismus; swelling of the tonsillar pillars, the soft
palate, and often the uvula, with displacement of the uvula to the con-
tralateral side; displacement of the tonsil (also to the contralateral side); and
a “hot potato” voice.
Indications
• Peritonsillar abscess
• Airway compromise
• 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 usual-
ly 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 21–9). 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 dan-
gerous for aspiration). If there is pointing in another area, or if the ini-
tial 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 fluc-
tuant area or at the site of a purulent needle aspirate. When general anes-
thesia 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.
Figure 21–9 Aspiration, inci-

sion, and drainage of a periton-
sillar abscess. (Adapted from
Myer CM, Cotton RT. A practi-
cal approach to pediatric oto-
laryngology. Chicago: Year Book
Medical Publishers; 1988.)
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 com-
munication with the posterior visceral space.
Visceral space infection may be caused by purulent thyroiditis, progres-
sion of pharyngitis, foreign body in the cervical esophagus, or esophageal
perforation from a foreign body. Signs and symptoms include odynopha-
gia, 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
• General anesthesia is usually used via the oral endotracheal route.
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
• The drains are slowly advanced daily to allow the wound to close medi-
ally to laterally.
RETROPHARYNGEAL SPACE DRAINAGE

The retropharyngeal space (see Figures 21–1 and 21–2) is bounded poste-
riorly by the alar fascia, anteriorly by the posterior pharyngeal wall, and
superiorly by the base of the skull. The space extends inferiorly to the supe-
rior mediastinum at the level of T1, where the middle and deep cervical fas-
cia layers fuse.
Retropharyngeal space infection may be caused by regional purulent dis-
ease (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,
malaise), nuchal rigidity, occasionally a hoarse or soft voice, and potential-

ly 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 com-
pression
• Progressive airway obstruction
Some practitioners treat cellulitis and abscesses (as diagnosed by con-
trast-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 nontox-
ic patient. However, surgical drainage is strongly recommended for toxici-
ty, 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 medi-
astinum are much more serious than a well-planned drainage procedure.
• This procedure must be performed under general anesthesia with pro-
tection 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 occa-
sions, 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 complica-
tions 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 surgeon’s choice.
• The patient is placed in Rose’s position to prevent aspiration of the
abscess contents.
Procedure
• If there is a question concerning the presence of purulence, aspiration
with an 18-gauge needle into the upper retropharyngeal space is indi-
cated (Figure 21–10A).
• Intraoral aspiration and drainage are recommended if the abscess is lim-
ited 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 (Fig-
ure 21–10B).
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
21–10C) with a horizontal limb at the midportion of the abscess cav-
ity (judged on a lateral X-ray and CT scan), and the vertical portion
is carried along the anterior border of the sternocleidomastoid mus-
cle 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 oint-
ment) 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.
A B
Figure 21–10 Intraoral aspiration (A) and incision (B) of a retropharyngeal abscess. C, Incision (dashed line) for external approach to
the retropharyngeal space. (Adapted from Loré J. An atlas of head and neck surgery. 3rd ed. Philadelphia: WB Saunders; 1988.)
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.
otics 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 21–2) is found between the prevertebral
layer of the deep cervical fascia and the osseous bodies of the cervical verte-
brae extending from the base of skull to the coccyx. Infections are most com-
monly 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 cervi-
cal spine).
Indications
• Abscess or infection of the prevertebral space
• 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.
Procedure
• The treatment is directed at cervical drainage via a lateral approach in a
fashion similar to that for the external method of treating retropharyn-
geal 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

The vascular space is a potential space within the carotid sheath (Figure
21–11) 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 lat-
eral 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 pit-
ting edema. A purplish discoloration may indicate hemorrhage. Spiking
fevers and severe chills may indicate thrombosis of the internal jugular vein
with septic emboli. Horner’s syndrome is occasionally seen.
Figure 21–11 Vascular (carotid

sheath) space. (Adapted from
Everts EC, Echevarria J. The
pharynx and deep neck infec-
tions. In: Paparella MM, Shum-
rick DA, editors. Otolaryngolo-
gy. Vol. 3. 2nd ed. Philadelphia:
WB Saunders; 1980. 2313.)
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 Horner’s syndrome
• 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 surgeon’s 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 21–10C).
• 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 21–2) 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
• Risk airway obstruction, spread to the mediastinum or diaphragm, or
involvement of the vertebrae or neural structures including an epidural
abscess

• The procedure is performed under general oral endotracheal anesthesia,
if possible. If airway obstruction is impending, a tracheostomy must be
performed.
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 inac-
cessible orally or for infections that extend to the lower cervical verte-
brae. 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 abscess—a ten year experience. Laryn-
goscope 1984;94:455–63.
Cunnington P, Mongia S. Pharyngeal abscess in a small infant presenting as upper airway obstruc-
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1996. p. 1525–45.
C H A P T E R 22
CONGENITAL MALFORMATIONS
OF THE N ECK
Mark A. Richardson, MD
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 superior-
ly, laterally, or inferiorly, and it may be draining if the patient had a previ-
ous 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
• 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 per-
formed 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 hor-
mone 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 patient’s 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.
Procedure
• An incision is created overlying the mass to permit approaching the
hyoid bone (Figure 22–1).
• The incision is carried through the skin and subcutaneous tissue to ante-
rior 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 mid-
dle and lateral thirds (Figure 22–2).
• 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 22–3).
• 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 22–1 Incision site for

removing a thyroglossal cyst.
(Redrawn with permission from
Peters GE. Excision of thyroglos-
sal 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 493
Figure 22–2 An incision is made along the

superior border of the hyoid bone. (Redrawn
with permission from Loré JM. Atlas of head
and neck surgery. 3rd ed. Philadelphia: WB
Saunders; 1988. p. 675.)
Figure 22–3 The hyoid bone is sectioned at each

side with laryngeal scissors. (Redrawn with per-
mission from Loré JM. Atlas of head and neck
surgery. 3rd ed. Philadelphia: WB Saunders;
1988. p. 677.)
• With an assistant holding the cyst and the hyoid bone, a core of mus-
cular tissue, with its apex at the base of the tongue, is carefully excised
without penetrating the mucosa (Figure 22–4).
♦ The surgeon’s 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 surgeon’s 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 1⁄4" Penrose) is placed into the wound prior to skin closure.
• The skin is closed using 4-0 Vicryl sutures in the subcutaneous and sub-
cuticular 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 pre-
vent the patient from eating a normal diet for 24 to 48 hours.
Figure 22–4 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.)
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 lym-
phatic malformations and are thought to arise from a common congenital
blockage or arrest of normal development of the primordial lymph chan-
nels. 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, micro-
cystic lesions are best suited for open surgical excision as described below. In
contrast, macrocystic lesions may regress after intracystic injection of the scle-
rosing agent Picibanil (OK-432). This avoids the morbidity of open surgery,
and has been particularly successful for macrocystic hygromas of the cervi-
cal 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
• Special instrumentation includes a nerve stimulator.
• The anesthesiologist should not use paralyzing agents.
Preparation
• Multiple site involvement in suprahyoid locations worsens the progno-
sis 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.
• Perioperative antibiotics are given.

• The patient’s neck is extended and the head is rotated to permit maxi-
mum exposure.
Procedure
• An attempt is made to remove the entire tumor and to preserve all nor-
mal and vital structures in a one-stage operation.
• Removing a large cervical cystic hygroma may require parotidectomy, sub-
mandibular 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 hygro-
ma, 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 mus-
cle; 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 superi-
orly 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 glos-
sopharyngeal 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 lesion’s extension
through the mylohyoid is carefully dissected free, again using the Shaw
knife to eliminate any excessive bleeding. The submandibular duct is lig-
ated using a right-angle clamp and a 3-0 chromic suture, and the speci-
men is removed.
• Adjunctive treatments include the following:
♦ 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 nor-
mal function is present.
• The wound is copiously irrigated with saline and skin flaps are replaced
in their anatomic position over a 1⁄4" Penrose drain. A compression dress-
ing is applied after closure is obtained using subcuticular and subcuta-
neous 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 per-
form 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 con-
genital disorder.
• Antibiotics should be continued postoperatively, and during any
swelling or bleeding that may occur.
FIRST BRANCHIAL CLEFT FISTULA

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 car-
tilage or adnexal tissue. If infected, they drain inferiorly, medially, or pos-
teriorly to the pinna. They are superior to the facial nerve, usually paral-
lel 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 prox-
imity 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 for-
mation 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.
• No paralysis can be induced because of the potential need for stimula-
tion 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 iden-
tify and preserve the facial nerve.
• The patient’s neck is extended and the head is rotated to the side oppo-
site 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 tradi-
tional 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 electrophys-
iological localization of the facial nerve trunk. This type of “local exci-
sion” is not described further.
• A pre-auricular incision, extending behind the ear and incorporating the

fistulous tract in the neck, is created (Figure 22–5A). The flap is elevat-
ed 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 22–5B).
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 mar-
ginal 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 branch-
es (see Figure 22–5B), 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 pro-
ceeds 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 sub-
cutaneous 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 Frey’s 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.
Figure 22–5 A, Incision site. B, Intraoperative view clearly showing the location of the facial nerve. SCM = sternocleidomas-
toid 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.)
PRE-AURICULAR PIT OR FISTULA

These are easily distinguished from true branchial anomalies by their posi-
tion 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 associ-
ated with hearing loss, especially when bilateral.
Indications
• Recurrent infection
• Persistent drainage
• 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 excis-
ing 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 previ-
ously infected skin (Figure 22–6).
• 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 pro-
vide 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.
Figure 22–6 Incision for pre-

auricular pit (dashed line)
encompassing the fistula open-
ing. Atrophic or previously
infected skin (dotted line) is
included, when necessary.
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 pseu-
do-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
22–7A). Conversely, the third branchial fistula loops over the hypoglossal
nerve, and runs down and medial to the carotid arteries, piercing the thy-
rohyoid membrane near the piriform sinus (Figure 22–7B).
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 fis-
tulae requiring head rotation. No paralysis is induced in case neu-
rostimulators are required.
• The patient’s 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.
Figure 22–7 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).
• The tract is pulled away from the surrounding tissue with sharp dissec-
tion, 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 sec-
ond or stepladder incision (Figure 22–8). To create a second, more cra-
nially placed incision
1. A hemostat is passed along the dissected fistulous tract to its most dis-
tal 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 fistula’s 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 fis-
tula 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 exten-
sive dissection has been performed.
• Postoperative care consists of a compression dressing.
Figure 22–8 A stepladder inci-

sion is created by passing a
hemostat along the dissected fis-
tula tract. (Redrawn with per-
mission from Loré JM. An atlas
of head and neck surgery. 3rd
ed. Philadelphia: WB Saunders;
1988. p. 693.)
FOURTH BRANCHIAL POUCH SINUS

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 thy-
roiditis, 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 pyri-
form apex, caudal to the superior laryngeal nerve (Figure 22–9), the tract
descends translaryngeally under the thyroid ala to emerge beneath the infe-
rior 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, particu-
larly unexplained recurrent deep neck infection or suppurative thyroiditis
Figure 22–9 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 laryn-
geal nerve (RLN) at the
cricothyroid joint.
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 ipsi-
lateral piriform apex for a sinus tract.
• General anesthesia with orotracheal intubation is required.
• The patient’s 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 postin-
flammatory fibrosis.
1. An incision is made along the anterior border of the sternocleido-
mastoid muscle, from superior aspect of the thyroid cartilage to the
level of the cricoid cartilage (Figure 22–10).
2. The sternocleidomastoid muscle is retracted, exposing the posterior
edge of the lateral thyroid cartilage, with the attached inferior con-
strictor 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 poste-
rior edge of the lateral thyroid cartilage and inferior cornu down to and
through the perichondrium. The inferior constrictor is separated poste-
Figure 22–10 Skin incision for fourth branchial pouch sinus.

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 22–11), 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 posteri-
or 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. Recur-
rence 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.
♦ Part of the superior pole of the thyroid gland may be included if nec-
essary (see Figure 22–11), but the superior parathyroid gland should
be preserved.
♦ If the tract descends paratracheally, exposure of the recurrent laryn-
geal 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.
Figure 22–11 Translaryngeal

course of a fourth branchial
pouch sinus. The inferior con-
strictor attachment has been
divided, and a hook retracts the
posterior edge of the thyroid ala
anteriorly. For clarity, the piri-
form fossa has been removed
except for a portion of the apex.
Note relationships to the superi-
or (SLN) and recurrent (RLN)
laryngeal nerves.
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 prob-
lem; 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 abnormal-
ities.
• General endotracheal anesthesia is necessary.
• The patient’s 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 22–12).
• 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 main-
tain the release that has been surgically created.
Figure 22–12 Skin incision for

fibromatosis colli unresponsive
to physical therapy. A spindle-
shaped mass is imbedded in the
sternocleidomastoid muscle
fibers.
BIBLIOGRAPHY
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1965;120:79–86.
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1985;93:173–6.
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method. Int J Pediatr Otorhinolaryngol 1990;20:1–5.
Gonzales J, Ljung BM, Guerry T, Schoenrock L. Congenital torticollis: Evaluation by fine-needle
aspiration biopsy. Laryngoscope 1989;99:651–4.
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;121:381–7.
Hoffman MA, Schuster SR. Thyroglossal duct remnants in infants and children: Reevaluation of
histopathology and methods for resection. Ann Otol Rhinol Laryngol 1968;97:483–6.
Isaacson G, Martin WH. First branchial cleft cyst excision with electrophysiological facial nerve
localization. Arch Otolaryngol Head Neck Surg 2000;126:513–6.
Jordan JA, Graves JE, Manning SC, et al. Endoscopic cauterization for treatment of fourth branchial
cleft sinuses. Arch Otolaryngol Head Neck Surg 1998;124:1021–4.
Kennedy TL. Cystic hygroma-lymphangioma: a rare and still unclear entity. Laryngoscope 1989;99
Suppl:1–10.
Landing BH, Farber S. Function of the cardiovascular system. In: Atlas of tumor pathology, Wash-
ington (DC): Armed Forces Institute of Pathology; 1956. p.
May J, D’Angelo AJ Jr. The facial nerve and the branchial cleft surgical challenge. Laryngoscope
1989;99:564–5.
Mickel RA, Calcaterra TC. Management of recurrent thyroglossal duct cysts. Arch Otolaryngol
Prasad S, Grundfast G, Milmoe G. Management of congenital preauricular pit and sinus tract in
children. Laryngoscope 1990;100:320–1.
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ment of the difficult case. Arch Otolaryngol Head Neck Surg 1991;117:546–53.
Riechelmann H, Muehlfay G, Keck T, et al. Total, subtotal, and partial surgical removal of cervico-
facial lymphangiomas. Arch Otolaryngol Head Neck Surg 1999;125:643–8.
Rosenfeld RM, Biller HF. Fourth branchial pouch sinus: diagnosis and treatment. Otolaryngol Head
Neck Surg 1991;105:44–50.
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aspects and treatment. Am J Surg 1952;83:3–8.
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Sistrunk WE. The surgical treatment of cysts of the thyroglossal tract. Ann Surg 1920;71:121–4.
Tom LW, Handler DS, Wetmore RF, Potsic WP. The sternocleidomastoid tumor of infancy. Int J
Pediatr Otorhinolaryngol 1987;13:245–55.
Tom LW, Rossiter JL, Sutton LN, et al. Torticollis in children. Otolaryngol Head Neck Surg
1991;105:1–5.
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Work WP. Newer concepts of first branchial cleft defects. Laryngoscope 1972;82:1581–93.
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 con-
genital 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 imag-
ing (contrast sialography, ultrasonography, computed tomography, or mag-
netic 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 biop-
sy, then excisional biopsy will yield greater histopathologic information.
More importantly the definitive treatment of many inflammatory and neo-
plastic causes of solid parotid masses in children is surgical excision. Exci-
sional 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 parotidecto-
my 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
• Paralytic agents are avoided to allow for intraoperative facial nerve stim-
ulation.
• Informed consent regarding the risk of facial nerve injury is an absolute
necessity.
• The child is positioned supine with the head turned toward the unin-
volved 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 23–1). 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.
♦ In older children and adolescents, an S-shaped face lift–type incision is
used (Figure 23–2A). 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 approxi-
mately two finger breadths below the angle of the jaw. A Y-shaped
incision with a retroauricular extension is an alternative approach
(Figure 23–2B).
♦ In infants and very young children, a single curved incision, beginning
1.5 to 2 cm below the mandible and extending posterior and superi-
or over the mastoid prominence, reportedly protects the superficially
located facial nerve (Figure 23–2C).
Figure 23–1 The patient is posi-

tioned so that facial nerve func-
tion can be assessed.
Salivary Gland Surgery 517
Figure 23–2 A, An S-shaped

face lift–type 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.
C
• The skin flaps are elevated in a plane of dissection deep to the subcuta-
neous tissues and superficial to the investing fascia of the parotid gland.
The anterior margin of elevation is the parotid gland’s anterior border to
avoid inadvertent transection of small facial nerve branches emerging
from the gland over the masseter muscle (Figure 23–3).
• Posteroinferior flap dissection is performed in the subplatysmal plane
until the anterior border of the sternocleidomastoid muscle is clearly
identified.
♦ 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 23–4).
♦ In older children, the tail of the parotid gland often needs to be separat-
ed 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 23–5).
Figure 23–3 Elevation of the anterior and posteroinferior flaps.

Figure 23–4 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 23–5 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 Med-
ical Publishers; 1986. p. 500.)
♦ The goal of progressive medial dissection in this fashion is to identi-

fy the main trunk of the facial nerve as it emerges from the stylomas-
toid 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 tem-
poroparotid 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 cauteriza-
tion 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 (Fig-
ures 23–6 A and B). In addition, some of the inflammatory condi-
tions necessitating parotidectomy in children pathologically involve
the external auditory canal, creating scarring in this region and plac-
ing the main trunk of the facial nerve in further jeopardy.
1. An alternative method of finding the facial nerve in such circum-
stances 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 23–7).
• In revision surgical procedures with extensive cervical scarring, an alter-
native approach is to use the retroauricular extension of a Y-shaped skin
incision (see Figure 23–2B). A limited mastoidectomy is then per-
formed 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 fol-
lowed anteriorly to the pes anserinus.
♦ In adolescents and older children, this requires dissection into the
parotid gland.
♦ In infants, the pes may actually be in the retromandibular region out-
side of the parotid gland proper (see Figure 23–4).
Figure 23–6 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 3–11.)
Figure 23–7 The triangle formed by the sternocleidomastoid muscle, the digastric muscle, and the cartilaginous ear canal. (Adapt-
ed from Montgomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 254.)
• A plane of cleavage through the parotid gland is developed as proximal

to distal dissection of both the upper zygomaticotemporal and lower cer-
vicofacial divisions of the facial nerve is performed (Figure 23–8).
♦ Branches of the posterior facial (retromandibular) vein require liga-
tion 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 23–9).
♦ This separation completely mobilizes the superficial lobe of the
parotid gland. The so-called deep lobe of the parotid gland is the sali-
vary tissue that remains undisturbed under the preserved facial nerve.
• A superficial parotidectomy is adequate treatment for virtually all super-
ficially located parotid masses; it allows the complete operative dissec-
tion 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 inflam-
matory 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 23–10).
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.)
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 Mont-
gomery WW. Surgery of the upper respiratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 255, 258; and from Loré
JM. An atlas of head and neck surgery. Philadelphia: WB Saunders; 1988. p 717.)
♦ The deep parotid tissue is separated from the underlying facial mus-
culature, 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 pedi-
atric parotid malignancies.
♦ In the rare case of a resectable undifferentiated or sarcomatous malig-
nancy, 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 23–11).
♦ Frozen section histopathology is used to determine healthy neural
margins.
♦ Immediate reconstruction by free autogenous nerve grafting is advo-
cated 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 stimu-
lated 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 (Fig-
ure 23–12).
♦ 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.
subcutaneously, and either nylon or absorbable sutures in an interrupt-
ed 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 mobiliza-
tion. If gentle retraction was performed and no significant branches of
the facial nerve have been severed, complete recovery is the rule.
Figure 23–11 Facial nerve anastomosis.
Figure 23–12 Drain placement

through a stab incision separate
from the parotidectomy closure.
• Gustatory sweating (Frey’s syndrome) occurs secondary to the regrowth of

parasympathetic motor fibers from the auriculotemporal nerve, which pre-
operatively 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.
• 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. Vasofor-
mative lesions, especially lymphatic vascular malformations, can arise with-
in 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 neuro-
muscular disorders
• 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 unin-
volved 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 23–13). 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
23–14).
• The incision is infiltrated with 1% lidocaine and 1:100,000 epinephrine
solution for hemostasis.
Figure 23–13 Plastic sheeting is

positioned to expose the corner of
the mouth on the involved side.
Figure 23–14 An incision is

made in a neck crease.
• The skin, subcutaneous tissues, and platysma muscle are divided down
to the investing fascia of the submandibular gland. The mylohyoid mus-
cle anteriorly, the sternocleidomastoid muscle posteriorly, and the digas-
tric muscle inferiorly are exposed (Figure 23–15).
• 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 23–16A
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 mus-
cle and the submandibular gland is opened (Figure 23–17).
♦ The hypoglossal nerve will be encountered deeply in the digastric tri-
angle.
♦ 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 23–15 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.)
Figure 23–16 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; B
1989. p. 264.)
Figure 23–17 Exposure of the

hypoglossal nerve. (Adapted
from Montgomery WW. Surgery
of the upper respiratory system.
Vol. II. Philadelphia: Lea &
Febiger; 1989. p. 269.)
• Anterior retraction of the mylohyoid muscle and gentle downward trac-

tion on the submandibular gland allow identification of the lingual
nerve, its attached submandibular ganglion, and the submandibular
(Wharton’s) duct (Figure 23–18).
♦ The duct is ligated and divided. The efferent fibers arising from the
ganglion to the submandibular gland also are divided, freeing the lin-
gual nerve from the gland.
♦ The submandibular gland is now completely mobilized by blunt dis-
section. 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 23–19). 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 23–20).
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 integri-
ty 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 23–18 Complete mobi-

lization of the submandibular
gland.

• Hypoglossal or lingual nerve injury is infrequent if these structures are
properly identified intraoperatively.
Figure 23–19 The submandibu-

lar space after gland removal.
(Adapted from Montgomery
WW. Surgery of the upper
respiratory system. Vol. II.
Philadelphia: Lea & Febiger;
1989. p. 269.)
Figure 23–20 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.)
RANULA EXCISION
Ranulas are cystic lesions of sublingual gland origin. Simple ranulas are true
retention cysts appearing as transparent thin-walled cysts, typically unilat-
eral, 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
♦ Dysphagia, speech impediment, or respiratory distress manifestations
♦ Recurrent infection
♦ Progressive enlargement
• Diagnostic confirmation of a cervical lesion
• 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 typical-
ly 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 23–21).
• 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 pos-
sible transorally (Figure 23–22).
Figure 23–21 Relationship of

the sublingual and submandibu-
lar glands.
Figure 23–22 Common path-

way of the plunging ranula cyst
and the submandibular duct.
Note the well-exposed lingual
nerve in the cervical approach.
• Gloved intraoral palpation on the ipsilateral floor of the mouth can help
to deflect the sublingual gland into the operative field (Figure 23–23).
Complete removal of the sublingual gland, ideally in continuity with the
ranula cyst, is necessary.
• Cervical wound closure is performed as described above–see Sub-
mandibular Gland Excision.
♦ If the floor-of-mouth mucosa has been disrupted, closure by inter-
rupted 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 23–24).
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 23–23 Gloved intraoral

palpation displaces the ranula
and attached sublingual gland
into the cervical operative field.
Figure 23–24 The proximal end

of Wharton’s duct is brought out
through the floor of the mouth
if the submandibular gland is
preserved.
INTRAORAL RANULA EXCISION

Indications
• Intraoral ranula associated with
♦ Dysphagia, speech impediment, or respiratory distress manifestations
♦ Recurrent infection
♦ Progressive enlargement
• 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 can-
nulated with a Teflon catheter or metal lacrimal probe; this procedure
identifies the location of the submandibular duct so that it can be pro-
tected from injury during dissection of the ranula cyst (Figure 23–25).
• A wide elliptical incision is outlined over the dome of the cyst (see Fig-
ure 23–25).
• 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 ipsilater-
al sublingual gland from which it arises.
• When complete ranula excision is anticipated, no attempt is made to sep-
arate 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 struc-
tures (Figure 23–26).
♦ Care is taken not to injure the lingual nerve or the cannulated sub-
mandibular duct, both of which should be identifiable on the surface
of the floor-of-mouth musculature (Figure 23–27).
♦ The sublingual gland ideally is removed in continuity with the ranu-
la cyst.
• Hemostasis is achieved by bipolar cauterization of numerous small lin-
gual veins. Drains typically are not used.
• The mucosal edges are closed using interrupted absorbable sutures (Fig-
ure 23–28).
Ranula
cyst
Sublingual
gland
Figure 23–25 The submandibular duct is cannulated on Figure 23–26 The ranula cyst, attached floor-of-mouth
the same side as the ranula, and a wide elliptical incision is mucosa, and contiguous sublingual gland are separated care-
outlined over the dome of the cyst. fully from the deeper floor-of-mouth structures.
Submandibular
duct
Lingual
nerve
Figure 23–27 Following removal, the submandibular Figure 23–28 Mucosal closure.
duct and lingual nerve should be clearly identifiable.
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 potenti-
ate airway obstruction; this can be prevented by meticulous intraopera-
tive 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;101:185–8.
Camacho AE, Goodman ML, Eavey RD. Pathologic correlation of the unknown solid parotid mass
in children. Otolaryngol Head Neck Surg 1989;101:566–71.
Crysdale WS, Mendelsohn JD, Conley S. Ranulas—mucoceles of the oral cavity: experience in 26
children. Laryngoscope 1988;98:296–8.
Farrior JB, Santini H. Facial nerve identification in children. Otolaryngol Head Neck Surg
1985;93:173–6.
Loré JM Jr. Excision of ranula. In: Loré JM. An atlas of head and neck surgery. Philadelphia: WB
Saunders; 1988. p. 628–9.
Loré JM Jr. The parotid salivary glands. In: Loré JM. An atlas of head and neck surgery. Philadel-
phia: WB Saunders; 1988. p. 708–25.
Loré JM Jr. Resection of the submandibular salivary gland for benign disease. In: Loré JM. An atlas
of head and neck surgery. Philadelphia: WB Saunders; 1988. p. 678–81.
Luna MA, Batsakis JG, El-Naggar AK. Salivary gland tumors in children. Ann Otol Rhinol Laryn-
gol 1991;100:869–71.
Matt BH, Crockett DM. Plunging ranula in an infant. Otolaryngol Head Neck Surg
1988;99:330–3.
May M, D’Angelo AJ Jr. The facial nerve and the branchial cleft: surgical challenge. Laryngoscope
1988;99:564–5.
Montgomery WW. Surgery of the salivary glands. In: Montgomery WW. Surgery of the upper res-
piratory system. Vol. II. Philadelphia: Lea & Febiger; 1989. p. 225–69.
Seligman I, Lusk R. Excision of a ranula in a child. In Bailey BJ. Surgery of the oral cavity. Chica-
go: Year Book Medical Publishers; 1989. p. 209–14.
Welch KJ. The salivary glands. In: Welch KJ, Randolph JC. Pediatric surgery. Chicago: Year Book
Medical Publishers; 1986. p. 487–502.
C H A P T E R 24
T HYROIDECTOMY
Thyroidectomy is an infrequent procedure in children, performed most often for a poten-

tially malignant thyroid mass. The differential diagnosis of a thyroid mass in a child or ado-
lescent includes congenital anomalies (thyroglossal duct cyst, ectopic thyroid, unilateral
thyroid lobe agenesis), thyroid abscess, colloid nodule, Hashimoto’s thyroiditis, benign ade-
nomas, 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-stim-
ulating hormone (TSH), antithyroglobulin antibodies, and antimicro-
somal antibodies] may be necessary for complete evaluation, but rarely
prove diagnostic for solitary thyroid masses. The exception is an elevat-
ed 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 eval-
uation 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. Thy-
roid cancer in this age group often presents in an advanced stage with
regional lymph node metastases and distant extrathyroidal disease, par-
ticularly to the lungs. Documenting regional or systemic metastases sig-
nificantly influences initial surgical management, but does not necessar-
ily imply a poor prognosis.
• 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 thy-
roid 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
• Paralytic agents are avoided to allow for intraoperative recurrent laryn-
geal 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.
♦ In older children and adolescents, the Xomed NIM II EMG endo-
tracheal tube can be used for this purpose (Figure 24–1). This endo-
tracheal 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 intraoper-
ative laryngoscopy before the child is positioned for the definitive
thyroid procedure (Figure 24–2).
Thyroidectomy 541
Figure 24–1 Xomed NIM II

EMG endotracheal tube in posi-
tion with exposed electrodes
contacting the luminal surface of
the true vocal folds.
Figure 24–2 The surface elec-

trode in the desired position
against the posterior cricoid lam-
ina following endoscopic place-
ment.
• The child is placed in the thyroid position, supine with the neck in full
extension (Figure 24–3).
Procedure
• A transverse collar incision is outlined in the lower neck.
1. The exact position of the incision must take into account the rela-
tionship 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 24–4).
3. In young children, the laryngeal structures may not be obviously pal-
pable, and may be considerably more cephalad relative to the sternal
notch than anticipated (Figure 24–5).
• The planned incision is infiltrated with 1% lidocaine with 1:100,000
epinephrine solution to provide hemostasis.
Figure 24–3 Thyroidectomy operative position.

Thyroidectomy 543
Figure 24–4 Standard incision

site.
Figure 24–5 Incision site for

younger patients.
• The skin, subcutaneous tissues, and platysma muscle are transected. The
anterior borders of the sternocleidomastoid muscle serve as the lateral
margins (Figure 24–6).
• 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 24–7).
• The midline raphe between the strap muscles is incised, and the ster-
nohyoid and sternothyroid muscles are separated from one another and
from the underlying thyroid gland (Figure 24–8).
♦ 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 24–6 Transection of the

skin, subcutaneous tissues, and
platysma muscle. (Adapted from
the Loré JM. An atlas of head
and neck surgery. 3rd ed.
1988. p.759.)
Thyroidectomy 545
Figure 24–7 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 24–8 Retraction of the

strap muscles.
Identifying the recurrent laryngeal nerves

• Once the strap musculature is separated or divided, the sternocleido-
mastoid muscle on the side of the lesion is retracted to identify the
carotid sheath structures (Figure 24–9).
• The thyroid lobe is retracted medially, and blunt dissection is care-
fully performed in the superior thoracic inlet just caudal to the infe-
rior 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 24–10).
• The right RLN normally recurs beneath the right subclavian artery;
the left RLN recurs beneath the aortic arch (Figure 24–11A). Both
recurrent nerves ascend toward the larynx in the tracheoesophageal
groove.
♦ The left nerve ascends in a straight longitudinal direction parallel
to the lateral border of the trachea. The right nerve follows a short-
er course, approaching the larynx at a right angle, coursing medi-
ally 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 24–11B). A nonrecurrent left RLN is rare, typ-
ically occurring only with transposition of the great vessels.
Figure 24–9 Retraction of the

sternocleidomastoid muscle for
carotid sheath exposure.
Thyroidectomy 547
Figure 24–10 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.)
A B
Figure 24–11 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. 260–261.)
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 24–12).
• Ligating the main trunk of the inferior thyroid artery should be
avoided to preserve the blood supply to the parathyroid glands; small-
er 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 24–13).
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 ves-
sels 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 24–12 Ligation and divi-

sion of the inferior and middle
thyroid veins. (Adapted from
Silver CE. Atlas of head and
neck surgery. New York:
Churchill Livingstone; 1986.
p. 265.)
Thyroidectomy 549

superior vascular pedicle.
• 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 (Berry’s) suspenso-
ry ligament (Figure 24–14), 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
24–14). 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 ele-
vated. The isthmus is transected at its junction with the contralateral
lobe (Figure 24–15).
• 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 hemithy-
roidectomy specimen is performed.
♦ Histopathologic findings may dictate the further performance of a
total or near-total (subtotal) thyroidectomy.
♦ If the diagnosis of thyroid carcinoma (typically papillary or papil-
lary-follicular) is histopathologically established, the decision
needs to be made as to whether to consider the hemithyroidecto-
my 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 replace-
ment, but allow for postoperative radionuclide scanning for future
detection of both local recurrence and metastases, and enhance the
efficacy of 131I therapy if needed.
Thyroidectomy 551
Figure 24–14 Lateral (posterior)

suspensory ligament before tran-
section. (Adapted from Loré JM.
Atlas of head and neck surgery.
3rd ed. Philadelphia: WB Saun-
ders; 1988. p. 775.)

thyroid isthmus.
• When removing the contralateral lobe, the identical technique, pre-

viously 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 24–16).
• 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 iden-
tification 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 thy-
roidectomy with paratracheal lymph node removal is advocated. The
accompanying performance of a more formal modified neck dissec-
tion 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 electri-
cal 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 24–17).
• 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.
♦ 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.
Thyroidectomy 553
Figure 24–16 Remaining con-

tralateral thyroid lobe and
parathyroid glands after near-total
thyroidectomy. (Adapted from
Silver CE. Atlas of head and neck
surgery. New York: Churchill Liv-
ingstone; 1986. p. 271.)
Figure 24–17 Penrose drain

position after closure.
• Hemorrhage with hematoma or seroma formation results from inade-

quate 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 intra-
operative 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;95:1025–8.
Camacho AE, Goodman ML, Eavey RD. Pathologic correlation of the unknown solid parotid mass
in children. Otolaryngol Head Neck Surg 1989;101:566–71.
DeKeyser LFM, VanHerle AJ. Differentiated thyroid cancer in children. Head Neck Surg
1985;8:100–14.
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 metas-
tases. A report from the Surgical Discipline Committee of the Children’s Cancer Group. J
Pediatr Surg 2000;35:955–60.
Loré JM. Endocrine surgery. In: Loré JM, editor. Atlas of head and neck surgery. Philadelphia: WB
Saunders; 1988. p. 726–83.
Millman B, Pellitteri PK. Thyroid carcinoma in children and adolescents. Arch Otolaryngol Head
Neck Surg 1995;121:1261–4.
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;148:76–8.
Segal K, Arad-Cohen A, Mechlis S, et al. Cancer of the thyroid in children and adolescents. Clin
Otolaryngol 1997;22:525–8.
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 oto-

laryngology. 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 tur-
bulent. 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, pul-
monary edema, and postoperative respiratory obstruction.
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
♦ Introduce instruments gently to avoid mucosal bleeding and edema.
♦ Advance the endoscope only when a lumen is visible to avoid perfo-
rating a viscus.
♦ Communicate with the anesthetist to accurately assess the depth and
the duration of anesthesia. This coordinated effort is essential to min-
imize potential complications and bring about a safe and successful
outcome.
Inhaled anesthetics
Inhaled anesthetics can provide analgesia and amnesia and allow rela-
tively accurate assessment and control of anesthetic depth. Dose-depen-
dent respiratory depression is a feature common to almost all anesthet-
ics. 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 vol-
ume 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 dis-
advantages are (1) greater adverse effects on respiratory muscle func-
tion 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 rec-
ommended for inhalation induction or for airway surgery. It is high-
ly 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 tachycar-
dia at higher concentrations.
Endoscopy of the Aerodigestive Tract 557
• 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 oxide–narcotic relaxant tech-
nique. 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. Fen-
tanyl and sufentanil are more potent than is morphine, do not cause
the release of histamine, and (when used in judicious doses) can be rel-
atively 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 laryn-
goscopy procedures. The authors use a mixture of 20 µg of remifen-
tanil per mL (10 mg) of propofol, and begin the infusion at 75
µg/kg/min of propofol (0.150 µg/kg/min of remifentanil).
PROPOFOL
The intravenous hypnotic propofol has become a mainstay in the anes-
thetic 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 impor-
tant 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 anes-
thetic and can reduce airway reflex responses to laryngoscopy and intu-
bation, 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 instru-
mentation. Routine use of an anticholinergic often is not necessary. If
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 decreas-
ing 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 anesthesiolo-
gist, 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? Spon-
taneous 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
Photographic documentation is an increasingly important aspect of med-
ical care. Documentation is the key to effective communication, and occa-
sionally it has legal ramifications. A picture or video of a complicated air-
way 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 sys-
tem “blueprint,” as well as its special features (Figure 25–1).
• Light travels from the light source through a fiberoptic cable to the tele-
scope, which illuminates the subject, and the reflected light is transmit-
ted 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 25–1 Hardware blueprint of the typical video system.

• 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 com-
ponent 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 sys-
tem component contributes to the final image quality.
Video System Features
When selecting a video system, the cost must be balanced against the sys-
tem’s 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 three-
chip 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:
♦ 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 insuf-
ficient. 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 reso-
lution capacity of the peripheral device. All cables do not have the same
ability to transfer information. If a high-resolution peripheral device is con-
nected 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 components—color 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.
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-res-
olution 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 pro-
cedure’s 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 cam-
corder to the system with a firewire cable. Although the signal is an ana-
log signal, the camcorder can produce a high-quality reproduction.
Since the higher-quality digital camcorders may record up to 60 blur-
free 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.
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 elec-
trical)
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 Laryn-
goscopy, below).
• Alternatively the nasopharynx can be examined with a 70° telescope
from the oropharynx with the soft palate retracted (Figure 25–2).
Figure 25–2 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
♦ Ablate lesions
♦ Remove foreign bodies
♦ Dilate stenoses
• The use of anesthesia may be influenced by the age and overall medical
condition of the patient.
• 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 25–3 and 25–4.
Figure 25–3 Sample of pediatric

laryngoscopes.
Figure 25–4 Sample of the tips

of forceps used in conjunction
with laryngoscopy and bron-
choscopy.
• Fiberoptic laryngoscopy using a fiberoptic nasopharyngoscope is an

alternative to rigid laryngoscopy; however, because of the floppy epiglot-
tis 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 per-
formed 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 abili-
ty to attach a video camera (see above) to the telescope enhances resolu-
tion 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 25–5).
• Exposure of the larynx is accomplished by pulling the epiglottis for-
ward, not by prying on the teeth (Figure 25–6). The endoscopic view
at this level is illustrated in Figure 25–7.
Figure 25–5 Laryngoscopy

sequence I. The blade is rotated
about 90° in most infants and
children.
Figure 25–6 Laryngoscopy

sequence II. Arrows demonstrate
correct and incorrect directions
for lifting the laryngoscope.
Figure 25–7 Endoscopic view

during laryngoscopy sequence I.
• The glottis can usually be visualized when the laryngoscope is

advanced below the epiglottis. The endoscopic view at this level is
shown in Figure 25–8.
• For an enhanced view, the rod-lens telescope can be used (Figure
25–9), 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 anesthesia—2 to 4% lidocaine. Gentle sedation (if not con-
traindicated 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 spon-
taneously 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 sponta-
neous 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 anes-
thesiologist because anesthetic depth continually decreases during the
period of inspection.

during laryngoscopy sequence II.
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
25–4).
• 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
25–10).
Figure 25–9 Alternative method

to examine the larynx using a
rod-lens telescope.
Figure 25–10 Laryngeal dilata-

tion.
No 4. Laser laryngoscopy
• Possible techniques include spontaneous ventilation with or without an
endotracheal tube, use of “laser-resistant” endotracheal tubes, or sus-
pension laryngoscopy with Venturi ventilation (see also Chapter 28).
• Regardless of the technique chosen, it is essential to confirm the abil-
ity to ventilate the patient using a mask before proceeding with mus-
cle 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 conven-
tional tubes of the same size (internal diameter).
• We prefer suspension laryngoscopy with Venturi jet ventilation for
the majority of laryngeal laser surgery procedures:
♦ 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 exha-
lation; 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 high-
pressure 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 constant-
ly 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 usu-
ally adequate.
♦ The pressure limit setting on the Venturi injector should be adjust-
ed before use to ensure that safe driving pressures are not exceeded.
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:
♦ After neuromuscular blockade is reversed, the patient may be
allowed to emerge breathing spontaneously on a mask. This tech-
nique 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 epi-
nephrine may be useful to treat postoperative stridor.
BRONCHOSCOPY
Indications
• Diagnostic bronchoscopy is used to
♦ Assess the anatomy of the tracheobronchial tree
♦ Perform a biopsy of lesions
♦ Culture or perform histologic examination of the secretion
• Therapeutic bronchoscopy is used to
♦ Remove tracheal and bronchial lesions and foreign bodies
♦ Dilate stenoses
• General anesthesia is used in most rigid bronchoscopies. Topical anes-
thesia 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).
• In paralyzed subjects the passive recoil properties of the lung and chest
wall are the only forces producing expiratory gas flow. A slow gentle pat-
tern 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 patient’s condition so indi-
cates) allows restoration of normocarbia and normoxia. Similarly, pro-
longed 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).
♦ The patient should be hyperventilated with 100% oxygen prior to
telescope insertion, followed by apneic oxygenation during telescop-
ic 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 exha-
lation is restricted.
Preparation
• Two main types of bronchoscopes are available: open bronchoscopes and
rod-lens bronchoscopes (Figures 25–11A 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 25–12), if necessary, and video documentation.
• A variety of forceps (see Figure 25–4) and optical forceps (Figure 25–13)
are available.
Figure 25–11 A and B, Parts of

a rod-lens bronchoscope.
Figure 25–12 Angled views of

rod-lens telescopes.
Figure 25–13 A variety of opti-

cal 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 25–14).
• The bronchoscope is inserted alongside the laryngoscope (Figure
25–15); it is then turned 90° to align the leading edge of the bron-
choscope with the vocal cords (Figures 25–16A to D).
• As the left hand guides the bronchoscope into the trachea, the laryn-
goscope is removed. The index finger and thumb grasp the instru-
ment, and the other fingers are inserted into the mouth to help sta-
bilize the patient’s head (see Figure 25–14).
• The bronchoscope has a male connector for the anesthesia tubing,
which should be supported by the anesthesiologist throughout the
procedure.
Figure 25–14 Gum and teeth

protection using a tooth guard
and suspension of the instru-
ment.
Figure 25–15 Insertion of a

bronchoscope.
Figure 25–16 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 direc-
tion of the bronchoscope.
A B
C D
No 2. Diagnostic bronchoscopy
• The carina is identified as a sharp vertical spur (Figure 25–17), 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 child’s face
is rotated to the left. The endoscopic view is shown in Figure 25–18.
• To expose the left mainstem bronchus, the tip of the bronchoscope is
rotated to the left, and the child’s 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.

of the carina.

of the right mainstem bronchus
when the head is rotated to the
left.
No 3. Foreign body removal

• The preferred anesthetic technique for airway foreign bodies is bron-
choscopy 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 bron-
choscopy 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 feasi-
bility of foreign body removal is entertained. More than one proce-
dure 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 broncho-
scope 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 pres-
ence of additional foreign bodies and to remove secretions.
• Most foreign bodies incite surrounding inflammation and granula-
tion tissue formation. The goal is to minimize bleeding during for-
eign body removal. Instillation of vasoconstrictive agents (eg, Neo-
Synephrine) via a flexible suction catheter is sometimes useful.
• The remaining granulation tissue following foreign body removal
may be removed using a cup forceps.
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. Cur-
rently, 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 cau-
terization can be obtained by manipulating the bronchoscope. Ambi-
ent 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 resec-
tion, angioplastic balloon, and open surgical correction.
Postoperative Care
• A postoperative chest radiograph is often helpful when ruling out com-
plications.
• Postobstructive pulmonary edema may occur and should be treated
aggressively.
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
• In children this procedure is performed under general anesthesia (usual-
ly after endotracheal intubation).
• Similar to the bronchoscopes, esophagoscopes are classified as open or
telescopic (Figure 25–19).
• The rod-lens type of esophagoscope has several advantages over the dis-
tal 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 25–20)
♦ 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 for-
eign 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 visu-
alization and should thus be removed with suction. The rod-lens
esophagoscope may be pulled back from the end of the esophago-
scope 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
patient’s shoulders are elevated so the thoracic esophagus can be visual-
ized. In the region of the heart, there is prominent cardiac pulsation.
• The esophagoscope is advanced slowly, while the lumen is visualized.
Figure 25–19 Rod-lens

esophagoscopes.
Figure 25–20 An endoscopic

view of the cricopharyngeus
muscle.
No 2. Foreign body removal

• Similar instruments are used for removal of esophageal foreign bod-
ies as for airway foreign bodies.
• The timing for foreign body removal depends on the degree of dis-
tress. 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 pas-
sage 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:
♦ 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 grasp-
ing forceps through a rod-lens esophagoscope.
♦ Jackstones are difficult to remove because of their size and sharp
points. Figure 25–21 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 pre-
sented (Figures 25–22 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.
No 3. Caustic ingestion
• Oral cavity and pharyngeal examination are not sufficient to deter-
mine the extent of esophageal injury.
• Life-threatening caustic burns may require immediate surgical inter-
vention. 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 esophago-
scope is not advanced. Current management of a severe burn is as fol-
lows:
♦ Insert a small plastic tube through the side arm of the esophago-
scope 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 main-
tain a lumen.
♦ Use parenteral hyperalimentation for initial nutrition.
♦ Commence feeding through the gastrotomy tube when satisfacto-
ry healing has occurred.
• Retrograde dilatation is required when a repeat esophagoscopy reveals
stenosis, but it can be started only following maturation of the gas-
trostomy.
♦ 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.
Figure 25–21 Removal of a

jackstone.
E F
A B C D
Figure 25–22 Safety pin removal sequence (Jackson’s 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.)
♦ The loop of suture between the nostril and the gastrotomy stoma
placed during the gastrotomy procedure is divided. The gastroto-
my 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 25–23).
♦ 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 use-
ful for strictures that have been dilatated adequately using the retro-
grade method.
♦ 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 stric-
ture. Hurst and Maloney bougies are available for this type of
dilatation.
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Szekely E, Farkas E. Pediatric bronchology. Baltimore: University Park Press; 1978.
Figure 25–23 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 tra-
cheostomy is the actual opening in the trachea.
Indications
• Upper airway obstruction
• Prolonged mechanical ventilation
• Pulmonary toilet
• 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 26–1).
• Any esophageal tubing (eg, nasogastric tube or esophageal stethoscope)
should be removed to ensure correct identification of the trachea.
• The patient’s 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 lat-
eral mobility.
3. The cartilages, suprasternal notch, and skin incision should therefore
be marked to avoid disorientation (Figure 26–2).
Figure 26–1 Positioning of the

patient.
Figure 26–2 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 26–1) with one size larger and one size small-
er tracheotomy tube immediately available. Tubes are available in differ-
ent sizes (width and length), shapes (neonatal and pediatric), materials
(silicone and plastic), and may be cuffed or uncuffed (Figure 26–3).
• 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 587
Table 26–1 Suggested tracheostomy tube sizes

Child’s Age Inner Diameter (mm)
Premature, <1000 g 2.5

Premature, 1000-2500 g 3.0
Neonate – 6 months 3.0 – 3.5
6 months – 1 year 3.5 – 4.0
1 – 2 years 4.0 – 5.0
> 2 years (Age in years +16) / 4
Figure 26–3 A, Tracheostomy

A
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.
B
Procedure
• The skin is incised horizontally midline between the cricoid and the
sternal notch, and the incision is carried through the subcutaneous tis-
sue. 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 vas-
cular structures.
• The fascia is grasped on each side of the midline with a hemostat or for-
ceps, elevated, and divided with scissors (Figure 26–4). The edges are
undermined.
• The anterior jugular veins and the strap muscles are identified (Figure
26–5).
• Senn retractors are used to retract the muscles laterally, and to stabilize
the trachea in the midline. Excessive lateral dissection is avoided to pre-
vent 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 26–6).
Figure 26–4 Dissection of the

fascia in the midline.
Tracheotomy 589
Figure 26–5 Identification of

the strap muscles and the anteri-
or jugular vein.
Figure 26–6 Placement of stay

suture at the second and third
tracheal rings.
• 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 26–7).
♦ No cartilage is removed when performing tracheotomy in children.
♦ When using electrocautery near the tracheostomy, ignition is pre-
vented 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 26–8). 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 estab-
lished through the tracheotomy tube, the endotracheal tube is removed.
• Ties are placed around the neck to secure the tube with the head in neu-
tral 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 26–9). Labeling the sutures prevents acci-
Figure 26–7 Midline tracheal

incision.
Tracheotomy 591
Figure 26–8 Tracheal incision is

stented open by traction on the
stay sutures.
Figure 26–9 Position of the tra-

cheal tube and adjustment of
tracheostomy tapes. Stay sutures
are secured and labeled.
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 593
TRACHEOCUTANEOUS FISTULA CLOSURE

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 adminis-
tered 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 per-
formed to evaluate the patency of the airway. In a patient with a bor-
derline patent airway, closure of the fistula could cause respiratory dis-
tress 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 26–1).
• 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 tracheo-
cutaneous fistula. The skin is incised and small flaps are elevated above
and below the incision (Figure 26–10).
Figure 26–10 Elliptical skin

incision and dissection of the
tracheocutaneous tract.
• 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 26–11).
• 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 emphy-
sema (Figure 26–12).
• Alternatively, the incision may be left open and allowed to heal by sec-
ondary 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 similar-
ly 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 595
Figure 26–11 The tract is

excised close to the opening in
the trachea.
Figure 26–12 Placement of drain

under the strap muscles to pre-
vent subcutaneous emphysema.
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;103:133–134.
Wetmore R. Tracheotomy. In: Bluestone CD, Stool SE, Kenna MA, editors. Pediatric otolaryngolo-
gy. 3rd ed. Philadelphia (PA): WB Saunders; 1996. p.1425–40.
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 com-
monly performed procedures in children are illustrated in this chapter and
include the following:
• Supraglottic procedures—endoscopic arytenoidectomy, open (external)
arytenoidectomy, and supraglottoplasty
• Glottic procedures—glottic web excision, posterior glottic stenosis repair,
and laryngeal separation
• Subglottic procedures—laryngeal decompression (cricoid split) with
hyoid interposition, augmentation laryngoplasty with cartilage graft,
and augmentation laryngoplasty with cartilage stent
• Tracheal procedures—segmental tracheal resection, and cricotracheal
resection
ARYTENOIDECTOMY
Bilateral vocal cord paralysis is a difficult and challenging problem (Figure
27–1A). 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 resolu-
tion has not taken place within 18 months of onset
• Chronic arytenoid dislocation with obstruction of the glottis
• Inability to decannulate because of glottic obstruction
♦ If a tracheostomy is present, anesthesia is delivered through this port.
♦ If an endoscopic laser technique is employed, a noncombustible tra-
cheostomy 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 solu-
tion 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 suspen-
sion 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 27–1B).
• The arytenoid is grasped with alligator forceps, and the perichondri-
al attachments are separated with a laser or scissors (Figure 27–1C).
The arytenoid cartilage is removed.
• The posterior one-third of the true vocal cord is resected to improve
the glottic aperture (Figure 27–1D).
• The mucosal incision is sutured with 5-0 polyglactin 910.
Surgery of the Larynx and Trachea 599
A B
D1 D2
Figure 27–1 Arytenoidectomy—endoscopic 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.
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 27–2A).
• 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 27–2B).
• 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
27–2C and D).
• A mattress suture is placed above and below the vocal cord with a 2-
0 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.
A B
C D
Figure 27–2 Arytenoidectomy—external approach. A, A horizontal skin incision is made at the midlevel of the thyroid carti-
lage, 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 ary-
tenoid is removed. D, The incision is closed with a 4-0 polyglactin 910 suture (PDS).
SUPRAGLOTTOPLASTY
Congenital laryngeal stridor (laryngomalacia) is usually self-limited; how-
ever, some patients have respiratory distress with associated symptoms
severe enough to require surgery to improve ventilation.
Indication
• Severe laryngomalacia (Figure 27–3A) causing obstructive apnea,
cyanosis, cor pulmonale, or failure to thrive
• 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
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 27–3A and B).
• In severe obstruction (see Figure 27–3A), 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.
Figure 27–3 Supraglottoplasty.

A, Supraglottic structures
demonstrating significant
obstruction. B, Laryngeal
appearance after excision of
redundant mucosa and division
of aryepiglottic folds.
B
GLOTTIC WEB EXCISION

Congenital webs are commonly located in the anterior one-half to two-
thirds 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 27–4A) usually
require treatment because of potential of airway compromise with a con-
current upper respiratory tract infection. Thin webs may be lysed with a
laser or microsurgical instruments, but thicker webs with subglottic exten-
sion may require a tracheostomy.
Indications
• Glottic web occupying 50% or more of the glottic inlet
• Glottic web causing respiratory distress or significant aphonia
• General anesthesia is always required.
• If possible a small-bore fire-retardant endotracheal tube is inserted and a
short-acting paralytic agent is given to stop vocal cord activity.
dose.
• If a tracheostomy is present, a fire-retardant tube should be inserted.
Preparation
hyperextended.
• 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 27–4B).
• 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 endo-
scopically (Figure 27–4C), 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.
• Antireflux therapy is continued.

• A keel is removed endoscopically after 5 to 7 days.
• An endotracheal tube is removed after 3 days.
A B
Figure 27–4 Glottic web exci-

sion. A, A horizontal skin inci-
sion at upper level of the thyroid
cartilage. B, A cut (vertical) is
made through the thyroid lami-
na, mucosa, and web. C, A keel
(or endotracheal tube) is inserted
for 5 to 7 days. C
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 scar-
ring 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 27–5A)
Anesthesia Considerations
• General anesthesia is always required.
• If possible a small-bore fire-retardant endotracheal tube is inserted and a
short-acting paralytic agent is given to stop vocal cord activity.
dose.
• If a tracheostomy is present, a fire-retardant tube should be inserted.
Preparation
hyperextended.
Procedure
• Suspension microlaryngoscopy is employed with the CO2 or KTP laser.
• An inferiorly based posterior mucosal flap is created by carefully elevat-
ing the laryngeal mucosa (see Figure 27–5A).
• Scar tissue is ablated, and the mucosal flap is replaced (Figure 27–5B).
Postoperative Care
• Humidification is critical.
• Antireflux therapy helps to avoid healing difficulties.
• Avoidance of an endotracheal tube, if possible, helps to ensure flap survival.
Figure 27–5 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.
B
LARYNGEAL SEPARATION
Indications
• Life-threatening aspiration in patients with impaired laryngeal or pha-
ryngeal function
• A potential for reversal of the procedure exists if function improves.
• 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
hyperextended.
• Care must be taken to palpate and mark the landmarks, including the
thyroid cartilage, cricoid cartilage, and sternal notch.
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 sepa-
rately from the trachea.
• Superior and inferior subplatysmal flaps are created, and the strap mus-
cles are separated and retracted in the midline (Figure 27–6A).
• 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 27–6B). If a tracheostomy already exists,
the incision starts at its inferior aspect.
Figure 27–6 Laryngeal separa-

tion: A, Exposure of the larynx
and trachea. B, Anterior and lat-
eral views of proposed tracheal
incision.
B1 B2
• The posterior trachea is separated from the anterior esophagus (Figure

27–6C).
• The anterior edge of the trachea is secured to the inferior aspect of the
skin incision with nonabsorbable suture (Figure 27–6D).
• The proximal trachea is closed with nonabsorbable suture to create a
blind pouch (Figure 27–6E).
• 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 27–6F).
• 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 27–6 C, Posterior tra-

chea is separated from the ante-
rior esophagus.
C
Figure 27–6 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.
F
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 27–7A). 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
• General anesthesia is administered through an indwelling endotracheal
tube.
• A paralytic agent is used during the procedure.
Preparation
hyperextended.
• Care must be taken to palpate and mark the landmarks, including the
thyroid cartilage, cricoid cartilage, and sternal notch.
the incision area for hemostasis.
Procedure
• A horizontal incision is made in the skin overlying the cricoid cartilage
(Figure 27–7B). The soft tissue is separated, and the hyoid, cricoid, tra-
chea, and lower border of the thyroid cartilage are identified.
• The suprahyoid musculature is dissected off the hyoid between the less-
er 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 (Fig-
ure 27–7C).
A B
C1 C2
Figure 27–7 Laryngeal decompression with hyoid interposition. A, Subglottic edema preventing decannulation. B, Skin inci-
sion for decompression. C, Laryngotracheal incision and cricoid stay sutures.
• Stay sutures are placed on both sides of the cricoid for emergency pur-
poses (see Figure 27–7C).
• 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 27–7D).
• The graft is interposed in the cricoid split defect with the perichondri-
um facing the lumen (Figure 27–7E). 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.
Figure 27–7 D, Harvesting and

preparation of hyoid interposi-
tion graft. E, Graft sutured in
position.
E
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 laryngo-
tracheoplasty is recommended. However, in patients with significant steno-
sis—greater than 90% narrowing of the subglottic space—cartilaginous
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 laryngotra-
cheoplasty for successful decannulation. Autologous costal cartilage aug-
mentation 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%
• General anesthesia is administered through an endotracheal tube or
existing tracheostomy, if present.
• 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.
hyperextended.
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 27–8A). 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 27–8B). If a tracheostomy is
in place, the stomal area should be included in this incision.
A2
A1 A3
A4 B
Figure 27–8 Augmentation laryngoplasty with rib graft. A, Rib graft donor—resected cartilage graft with external perichondri-
um attached is shown. B, Skin incision to include the tracheostomy site (if present).
• 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
27–8C).
• The area of stenosis is then measured, and the cartilage graft is shaped
appropriately (see Figure 27–8C). 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 27–8C).
• 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 per-
formed twice daily.
• If an endotracheal tube is not placed, the patient’s tracheostomy tube is
replaced at the end of the operation; approximately 6 weeks later the
patient undergoes re-endoscopy for a possible decannulation. Antibi-
otics are administered in prophylactic doses until the endoscopy is per-
formed. Meticulous tracheostomy care is employed.
C1
C2
Figure 27–8 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.
AUGMENTATION LARYNGOPLASTY WITH CARTILAGE

STENT
Indications
• Significant subglottic stenosis with > 90% narrowing, either congenital
or acquired (Figure 27–9A)
• Significant tracheomalacia at the tracheotomy site
• Concomitant glottic and subglottic stenosis; in some cases, supraglottic
stenosis may be present as well
• Inhalational agents should be administered through the tracheostomy tube.
• 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.
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 (Fig-
ure 27–9B).
Figure 27–9 Augmentation

laryngoplasty with cartilage stent.
A, Severe congenital or acquired
stenosis. B, Skin incision to
include the tracheotomy site.
A B
• 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 supe-
riorly and inferiorly as is necessary to expose the stenosis that may be
present. This may include the supraglottic, glottic, and subglottic struc-
tures as well as the trachea (Figure 27–9C).
Figure 27–9 C, A laryngotra-

cheal incision extended superior-
ly and inferiorly as necessary.
C
• The posterior cricoid lamina may need to be split to relieve the stenosis
in severe cases (Figure 27–9D). This is done carefully to avoid entering
the esophagus.
• A Teflon or c-flex stent is measured to the appropriate size and length.
♦ 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 27–9E).
• The costal cartilage graft is shaped and measured to the appropriate
length.
• The stent, with the attached tracheostomy tube, is inserted into the air-
way, 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
27–9F). 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, West-
borough, 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.
D E1 E2
E3 E4
Figure 27–9 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 tra-
cheostomy tube (Pilling).
F, A stent is positioned in the
laryngotracheal complex under
the cartilage graft.
F
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 cardiopul-
monary 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 tracheomalacia—primary or secondary
• 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
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 27–10A).
• 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 endo-
tracheal tube is advanced into the distal portion of the trachea (Figure
27–10B).
• The diseased segment is resected, and the trachea is tested for adequate
motility of the remaining segments by simulation of reapproximation
(see Figure 27–10B). 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 patient’s age (Figure 27–10C). When placing the posteri-
or sutures, the endotracheal tube is displaced laterally to facilitate access.
A B2
B2
Figure 27–10 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.
• 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 metic-
ulous 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 under-
taken 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
• In patients who have a tentative diagnosis of severe subglottic stenosis,
communication between the surgeon and the anesthesiologist is of para-
mount importance.
• The patient should be breathing spontaneously under mask ventilation
general anesthesia to allow the otolaryngologist the opportunity to eval-
uate the degree of stenosis endoscopically.
• If the patient already has a tracheostomy tube, ventilation can be per-
formed through this site.
Preparation
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
• Endoscopic evaluation of the airway is performed under general anes-
thesia 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 27–11A). 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 27–11B).
Figure 27–11 Cricotracheal

resection. A, Skin incision.
B, Stay sutures retract the strap
muscles to expose the airway.
B
• A vertical incision is made through the cricoid and the tracheal stenosis
(Figure 27–11C).
• 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 perichondri-
um 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 attach-
ments. 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 27–11C).
• The distal trachea is mobilized by freeing the attachment to the party
wall for several rings (Figure 27–11D).
• A suprahyoid release is performed to mobilize the larynx.
C1 C2
D1 D2
Figure 27–11 C, Cricotracheal incision (solid line) and extent of lateral resection (dashed lines); note the posteriorly based
mucosal flap. D, Mobilization of distal trachea.
• 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. Subse-
quently 4-0 polypropylene (Prolene) sutures are placed between the thy-
roid cartilage and the posterior cricoid plate to the upper tracheal ring
(Figure 27–11E).
• Additional Prolene sutures are placed between the thyroid ala and the
second or third tracheal ring to further support the anastomosis (see Fig-
ure 27–11E).
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 air-
way patency.
E1 E2
Figure 27–11 E, Cricotracheal anastomosis.
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;89:508–11.
Dedo H. Endoscopic Teflon keel for anterior glottic web. Ann Otol Rhinol Laryngol
1979;88:467–73.
Healy GB, Schuster SR, Jonas RA, McGill TJ. The correction of segmental tracheal stenosis in chil-
dren. Ann Otol Rhinol Laryngol 1988;97:444–7.
Holinger LD, Konior RJ. Surgical management of severe laryngomalacia. Laryngoscope
1989;99:136–42.
Lawless ST, Cook S, Luft J, et al. The use of a laryngotracheal separation procedure in pediatric
patients. Laryngoscope 1995;105:198–202.
McGuirt WF, Little JP, Healy GB. Anterior cricoid split: use of hyoid as autologous grafting mater-
ial. Arch Otolaryngol Head Neck Surg 1997;123:1277–80.
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;99:764–71.
Seid AB, Park SM, Kearns MJ, et al. Laser division of the aryepiglottic folds for severe laryngoma-
lacia. Int J Pediatr Otorhinolaryngol 1985;10:153–8.
Stern Y, Gerber ME, Walner DL, Cotton RT. Partial cricotracheal resection with primary anasto-
mosis in the pediatric age group. Ann Otol Rhinol Laryngol 1997;106:891–6.
Thornell WC. Intralaryngeal approach of arytenoidectomy in bilateral abductor vocal cord paraly-
sis. Arch Otolaryngol 1948;47:505–12.
Woodman DG, Pennington CL. Bilateral abductor paralysis: 30 years experience with arytenoidec-
tomy. Ann Otol Rhinol Laryngol 1976;85:437–9.
Zalzal GH. Use of stents in laryngotracheal reconstruction in children: indications, technical con-
siderations and complications. Laryngoscope 1988;98:849–54.
Zalzal GH, Anon JB, Cotton RT. Epiglottoplasty for the treatment of laryngomalacia. Ann Otol
Rhinol Laryngol 1987;96:72–6.
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 technol-
ogy 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 chap-
ter 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 papil-
loma 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 oto-
laryngology—head and neck surgery. Since the first endolaryngeal applica-
tion by Jako in 1972, the applications for this laser have grown significant-
ly. 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 µm, and the thermal
effect (coagulation lateral to the zone of vaporization) is usually between
120 and 240 µm. Vessels up to slightly less than 0.5 mm may be coag-
ulated, 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 coag-
ulation decreases with increasing water content or vascularity, and coag-
ulation also decreases with shorter pulse durations if the tissue is allowed
to cool between pulses.
• Another important caveat with the CO2 laser is removing the carbona-
ceous char from the operative field. This char may function as a heat
sink and produce local temperatures of approximately 2000°F.
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 tracheo-
bronchial applications. The standard for microscopic applications is now
the “microspot micromanipulator,” which yields spot sizes of 250 µm coin-
cident 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 28–1). For exam-
ple, 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, lim-
iting target visualization, especially with small bronchoscopes in the
pediatric and neonatal trachea. Two methods may be used to overcome
condensation:
Figure 28–1 Microspot micro-

manipulator for the CO2 laser.
This manipulator places the laser
beam coincident with the visual
path and allows spot sizes as
small as 250 µm.
Laryngotracheal Laser Surgery 635
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 joy-
stick 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 patient’s airway is fire. Although uncommon, fire still occurs despite sur-
geons’ 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 prod-
ucts 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 manage-
ment: 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 flam-
mable because continued oxygen can cause further damage by a blow-
torch 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 tra-
cheal-bronchial tree for direct heat effects and for ash deposition from
combustible material.
Anesthesia for CO2 Laser Surgery

The surgeon and anesthesiologist must cooperate during laryngoscopy to
maximize surgical exposure while allowing adequate ventilation. The sur-
geon may need access to the hypopharynx, supraglottis, larynx, or subglot-
tis, and this will dictate the type of airway available for the anesthesiologist
to provide ventilation to the patient. A complicating factor is the simulta-
neous 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 situa-
tions exist in which this is the only method available to oxygenate the
patient (eg, subglottic submucosal cysts or a large subglottic heman-
gioma). In such cases, supraglottic jet would not deliver adequate oxy-
genation 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 uncon-
trolled onrush of air. The amount of air insufflated is then gradually
increased until appropriate levels of ventilation are obtained.
• The rate of ventilation depends on the patient’s 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 clin-
ical practice.
No 3. Intermittent endotracheal intubation
Another mechanism of airway exposure for ventilation is the intermit-
tent 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 patient’s oxygen concentration falls, as measured
on pulse oximetry, the laser is turned to standby safe mode, the endo-
tracheal 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 endo-
tracheal 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.
• The next development was the flexible metal endotracheal tube, com-
bining 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 bal-
loon 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 cop-
per “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 nonethe-
less occur).
3. Realize that when using a foil-wrapped tube the surgeon and anes-
thesiologist 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 endotra-
cheal 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 pro-
tection. 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.
• 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 avail-
able, 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, espe-
cially hemoglobin. Hence, they have found widespread application for cer-
tain lesions, such as hemangiomas and granulation tissue. The optical pen-
etration 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 scar-
ring 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 sur-
geon 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 µm, suitable for even the smallest broncho-
scope. These lasers may also be used through some of the smaller flexible pedi-
atric 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 penetra-
tion 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 con-
tact 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/cav-
ernous 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 28–2. The anesthesiolo-
gist is positioned to the surgeon’s left hand as most surgeons are right-hand-
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 surgeon’s right hand with all of the
endoscopic equipment available within arm’s 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 patient’s legs, as illustrated
in the diagram.
• The safety precautions for each laser are unique for that particular wave-
length. 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 patient’s 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 sur-
geon is protected behind the eyepieces of the microscope and the bron-
choscope 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 trans-
mitted through clear glass and water. The patient’s 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 patient’s 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 use-
ful 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
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 undergo-
ing 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 oxy-
gen 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. Aceta-
minophen (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 sub-
glottic region, postoperative voice rest is desirable. Realistically, howev-
er, it is difficult to achieve voice rest in children.
Figure 28–2 Typical operating

room arrangement for laser pro-
cedures.
EPIGLOTTIC CYSTS
Indications
• Epiglottic cysts may be found along the laryngeal surface of the epiglot-
tis or occasionally along the aryepiglottic fold (Figure 28–3A). The cysts
vary in size.
• 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 for-
ceps (Figure 28–3B).
• Gentle dissection is performed using a low-power CO2 laser (3 to 6
watts, 0.01- to 0.05-second pulse duration, 250-µm spot size) to dissect
the cyst from the underlying stroma (Figure 28–3C).
• 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 28–3D).
• 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.
A B
C D
Figure 28–3 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.
VALLECULAR CYSTS
Indications
• Vallecular cysts may be found along the vallecula, depressing the epiglot-
tis over the larynx (Figure 28–4A). These cysts usually present with a
laryngomalacia-type fluttering stridor as the epiglottis is displaced infe-
riorly. The cysts vary in size.
• 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 28–4B).
• 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 frequent-
ly 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 28–4C).
Postoperative Care
Figure 28–4 A, Direct laryngoscopic view of a A

cyst in the vallecula. B, Carbon dioxide laser
used to vaporize the cyst wall. C, Carbon diox-
ide laser used to ablate lining wall of the cyst.
C
VENTRICULAR CYSTS
Indications
• Ventricular cysts are often mucous cysts and may be seen protruding
from the ventricle (Figure 28–5A).
• Suspension microlaryngoscopy with Venturi jet ventilation, apneic ven-
tilation, or endotracheal intubation with a laser-resistant tube may be
used.
Procedure
• The cyst is grasped with a cup forceps and is retracted medially, expos-
ing the base of the cyst and the ventricle (Figure 28–5B).
• The CO2 laser is used on low-power setting (3 to 6 watts of power, 0.01-
to 0.05-second pulse duration, and 250-µm spot size) to cut across the
base of the cyst.
• The CO2 laser is very effective for this type of excision because it pro-
vides a bloodless field for dissection (Figure 28–5C).
Postoperative Care
A B
Figure 28–5 A, A ventricular cyst. B, The cyst is grasped and retracted medially. C, Excision using the CO2 laser on low power.
INTRACORDAL CYSTS
Indications
• Cysts of the true vocal fold are often mucous cysts, more rarely epider-
moid cysts. They are most often located submucosally in the membra-
nous portion of the vocal fold.
• 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 28–6A). This incision may be
made with the CO2 laser to minimize hemorrhage and improve visual-
ization 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 deliv-
er 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 28–6B), and traction is applied
medially while the CO2 laser is used on low power (3 to 6 watts, 0.01-
to 0.05-second pulse duration, 250-µm spot size) for gentle dissection.
• Once the cyst has been removed, the mucosa is redraped over the supe-
rior 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, scis-
sors, 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.
A B
Figure 28–6 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.
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.
• Suspension microlaryngoscopy with Venturi jet ventilation, apneic ven-
tilation, or endotracheal intubation is employed.
• If an endotracheal intubation anesthetic technique is to be used, a pos-
terior commissure laryngoscope must be available in order to give ade-
quate 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 coagu-
lation/vaporization mode (5 to 8 watts, 0.05- to 0.2-second pulse dura-
tion, 250-µm 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 carti-
lage. Great effort must be made not to expose the cartilage itself because
this may predispose to recurrence (Figure 28–7).
• 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 parame-
dian 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 gen-
erally good. However, if the vocal process is a result of gastroesophageal
reflux, appropriate antireflux therapy should be instituted.
Figure 28–7 Removal of a vocal

process granuloma using the
CO2 laser in coagulation/vapor-
ization mode. Care is taken not
to expose the cartilage, which
could lead to reformation of the
granuloma.
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 papillo-
ma without glottic scarring.
• 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 accu-
rately identify the borders of papilloma involvement.
• The papilloma is vaporized or ablated to the level of the mucosa or
submucosa (Figure 28–8A). Vaporization deeper than these layers
may result in unwanted scarring.
• When operating in the anterior or posterior commissure, a commis-
sure retractor should be used to protect the opposite side (Figure
28–8B). 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 papillo-
ma. 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 µm.
• Potential disadvantages of the microdebrider technology include con-
trolling 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.
• 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 with-
in the airway. The potential for the CO2 laser to also affect hemosta-
sis may be advantageous for visualization of the operative field.
Postoperative Care
Figure 28–8 A, Vaporization of

a laryngeal papilloma. B, Vapor-
ization with a commissure retrac-
tor to protect the opposite side.
B
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.
• 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 gener-
ally have a good response, regardless of the technique employed (Figure
28–9A).
• Thick anterior webs are treated with a modified microtrapdoor flap
approach. The CO2 laser is used on a minimum thermal coagulation set-
ting with 5 to 8 watts of power, 0.01- to 0.05-second pulse duration.
With the smallest spot size possible (250 µm), a cut is made along the
line of one vocal fold up to the anterior commissure (Figure 28–9B).
• The web is then reflected toward the surgeon, and the mucosa and sub-
stance of the web itself are vaporized, preserving the superficial superior
mucosa intact (Figures 28–9C 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 28–9E 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 over-
lie the posterior lamina of the cricoid. A microtrapdoor flap is elevated,
preserving the mucosa over the lumen (Figures 28–9G through J).
• Once the flap has been elevated, the substance of the scar in the web is
ablated using the CO2 laser (Figures 28–9K and L).
• Finally, the edges of the mucosa are incised and allowed to redrape over
the raw surface that has been created (Figures 28–9M and N).
Postoperative Care
A B
C D
E F
Figure 28–9 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.
Figure 28–9 G through J, Use

of a microtrapdoor flap to
remove a posterior glottic web.
The flap is elevated, preserving
the mucosa over the lumen.
G H
I J
Figure 28–9 K and L, Ablation

of the web using the CO2 laser.
M and N, The mucosa is reposi-
tioned over the raw surface.
K L
M N
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 nod-
ules are to be surgically removed, cold steel excision techniques or exci-
sion with a microspot micromanipulator should be used.
• 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 28–10A 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 28–10C).
• 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.
Figure 28–10 A and B, Removal

of a vocal cord nodule with the
CO2 laser. C, Direct scissors
removal of a vocal cord nodule.
B C
REINKE’S EDEMA AND VOCAL CORD POLYPS

Indications
• Reinke’s 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.
• 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
28–11A). These proposed incision marks are then connected, ablating
the mucosa down to the level of the edema (Figure 28–11B).
• 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 micro-
surgical 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 28–11C).
• The edema is suctioned away with a microsuction or may be ablated
using the CO2 laser (Figure 28–11D).
• 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 28–11E 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 for-
ceps and retracting medially.
♦ The CO2 laser is then used to vaporize along the base (Figure 28–11G
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 feed-
ing 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.
♦ Hemorrhagic polyps are best dealt with by complete vaporization or

ablation with the CO2 laser. This laser affords generally good hemo-
stasis for capillary-sized vessels.
A B
C D
Figure 28–11 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 micro-
suction or use of the CO2 laser.
♦ 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 deep-
er thermal coagulation.
Postoperative Care
E F
G H
Figure 28–11 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

Indications
• Pediatric hemangiomas are typically subglottic, whereas adult heman-
giomas 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 microlaryn-
goscopy with high magnification. Once the type of hemangioma has
been determined, the appropriate laser may be brought into the field.
• 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 cau-
tious serially progressive manner.
Procedure
• Typical power levels for the CO2 laser for ablation of a capillary heman-
gioma 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 µm in order to obtain wider thermal coagulation.
• 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 28–12). 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 dam-
age 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 estab-
lished 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
Figure 28–12 Removal of a

subglottic hemangioma with a
CO2 laser.
SUBGLOTTIC STENOSIS
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 sub-
glottis.
• 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 mate-
rial 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-µm 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 per-
formed against a fixed obstruction (ie, the cricoid ring).
• Thick subglottic stenosis (Figures 28–13A1 and A2) is difficult to treat
by almost any method but is occasionally amenable to serial radial inci-
sion 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 o’clock
to 3 or 4 o’clock).
1. The mucosa is incised (Figure 28–13B).
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 carti-
lage (Figure 28–13C ).
3. The mucosa is then incised along the edge, leaving the mucosa
attached to the inferior side as a flap (Figure 28–13D).
4. The mucosa is allowed to adhere to the area of scar ablation and pro-
vides mucosal coverage for approximately one-half of the surface area
due to shrinkage of the mucosa flap. Although this procedure is tech-
nically difficult, the free edge of the flap may be welded into position
with the defocused laser (Figure 28–13E).
5. The scar tissue is excised, and serial procedures are repeated over 6- to
8-week intervals (Figure 28–13F ). Even in cases in which serial
microtrapdoor flaps are unable to provide an adequate airway, it gen-
erally results in a much larger mucosa-covered lumen that improves
the success of subsequent laryngotracheoplasty.
Postoperative Care
Figure 28–13 A1 and A2, Thick subglottic stenosis.

B through E, A serial microtrapdoor flap excision of the sub-
glottic 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 ).
A1 A2
B C D E
Figure 28–13 F, Scar tissue is

excised, and serial procedures are
repeated at 6- to 8-week intervals.
F
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.
• 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 steno-
sis (see earlier). The spot size with a 250-mm bronchoscope is approxi-
mately 300 µm and is appropriate for use in this area. With larger bron-
choscopes, 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 ventilat-
ing bronchoscope and the KTP, argon, or Nd:YAG laser.
♦ The surgeon’s 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 dura-
tions that are short enough to effect vaporization with minimal ther-
mal coagulation.
♦ The scar tissue is generally treated in a radial incision and dilatation
manner because it is exceedingly difficult to attempt to raise a micro-
trapdoor flap with these fibers. The success of treatment of tracheal
stenosis with these other lasers has been only fair to date.
Postoperative Care
BIBLIOGRAPHY
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Boulnois JL. Photophysical processes in recent medical laser developments: a review. Lasers Med Sci
1986;1:47–66.
DeSanto LW. Laryngocele, laryngeal mucocele, large saccules, and laryngeal saccular cysts: a devel-
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CD, editors. Advances in otolaryngology—head and neck surgery. Vol 3. Chicago: Year Book
Medical Publishers; 1989. p. 91–123.
Holinger LD, Barnes DR, Smid LJ, et al. Laryngocele and saccular cysts. Ann Otol Rhinol Laryn-
gol 1978;87:675–85.
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goscope 1994;104 Suppl 65:1–30.
Jako GJ. Laser surgery of the vocal cords. Laryngoscope 1972;82:2204–16.
McKenzie AL, Karruth JAS. Lasers in surgery and medicine. Phys Med Biol 1984;29:619–41.
Mizono G, Dedo HH. Subglottic hemangiomas in infants: treatment with CO2 laser. Laryngoscope
1984;94:638–41.
Monday LA, Cornut G, Bouchayer M, et al. Epidermoid cysts of the vocal cords. Ann Otol Rhinol
Laryngol 1983;92:124–7.
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;108:96–9.
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 otolaryngology—head
and neck surgery. Vol 1. Chicago: Year Book Medical Publishers; 1987. p. 217–40.
Ossoff RH, Werkhaven JA, Raif J, Abraham M. Advanced microspot microslad for the CO2 laser.
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;12:137–41.
Strong MS, Vaughn CW. Vocal cord nodules and polyps—the role of surgical treatment. Laryngo-
scope 1971;911–23.
Strong MS, Vaughn CW, Healy GB, et al. Recurrent respiratory papillomatosis: management with
the CO2 laser. Ann Otol Rhinol Laryngol 1976;85:508–16.
Vaughn CW. Use of the carbon dioxide laser in the endoscopic management of organic laryngeal dis-
ease. Otolaryngol Clin North Am 1983;16:849–64.
Werkhaven J. Laser applications in pediatric laryngeal surgery. Otolaryngol Clin North Am
1996;1005–10.
Weisberger EC, Emhardt JD. Apneic anesthesia with intermittent ventilation for microsurgery of
the upper airway. Laryngoscope 1996;106:1099–102.
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, espe-
cially 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 conspicu-
ous 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 child’s 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, oph-
thalmologic, and dental injuries. The appropriate investigations and con-
sultations should be obtained.
The initial encounter with the patient and parents is paramount in set-
ting the tone for optimal cooperation. A calm and nonthreatening approach
can help bring order to what is often a stressful and chaotic situation. Gain-
ing the confidence of the parents and putting them at ease will often trans-
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, enoph-
thalmos, exophthalmos, or extensive lid lacerations should prompt oph-
thalmologic 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
Stensen’s 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 hemotympa-
num, 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 envi-
ronment of the operating room.
Photo documentation
• Preoperative photographs are essential in elective facial plastic proce-
dures, 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.
Soft Tissue Surgery 673
Instruments and sutures

• Most emergency centers are reasonably well equipped with the soft
tissue instruments needed for simple repairs. For more extensive pro-
cedures, 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 seda-
tion, or local infiltration, it is imperative to assess and document a com-
plete cranial nerve exam. This is particularly important when a laceration
may be in proximity to a branch of the facial nerve. This is equally impor-
tant 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 combina-
tions 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 anesthet-
ic 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 lac-
erations 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 infect-
ed 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
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 burn-
ing 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 min-
imize 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 for-
eign 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 pig-
ment 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, occa-
sionally requiring magnification and gentle scrubbing or small instru-
mentation.
• Vigorous irrigation of the wound with a large amount of sterile saline (2-
3 liters) should be performed. There is evidence that powered pulsatile
irrigation may be more effective and should be used for large or conta-
minated 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 ear-
lier stage rather than excessive conservatism and observation of a full
thickness wound contraction later on.
• 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 cuta-
neous 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 clos-
es 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 heal-
ing, 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 child’s 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.
• 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 circum-
stances where wound margins are repeatedly “halved” by placing sutures
in the middle of the remaining free edges (Figure 29–1A). This distrib-
utes the length discrepancy evenly throughout the wound.
• For larger discrepancies, a Burrow’s triangle can be excised from the
longer side to prevent a standing cutaneous deformity (Figure 29–1B).
• 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-epithelial-
ization 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 pho-
tosensitive and small degrees of actinic exposure can result in skin burns,
easy tanning, and occasionally, a permanent dyschromia that distin-
guishes it from the surrounding skin. Beginning around the third week,
patients are instructed to apply a small amount of sunscreen each morn-
ing and use a barrier, such as a hat or Band-Aid, when outdoors for
longer periods of time.
A B
Figure 29–1 Management of unequal wound margins. A, Halving technique. B, Excision of Burrow’s triangle.
Complications
• Dehiscence of facial wounds in the absence of infection is uncommon
and is most often caused by minor blunt trauma with an inadequate lay-
ered 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 sepa-
ration with discharge, part or all of the wound should be opened,
debrided, and packed with moist gauze to allow healing by second inten-
tion. 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 pigmenta-
tion 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, con-
tinue 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 man-
ner based upon the size of the lesion:4
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 29–2)
1. Perfect alignment of the vermilion border
• Even subtle irregularities at the border of the vermilion may be con-
spicuous.
• 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 align-
ment. This is done at the outset for complex lacerations, prior to tis-
sue edema and possible distortion.
• The alignment suture may need to be placed but left untied to work
on the intraoral and muscular layers.
A B
Figure 29–2 Layered repair of lip laceration. Example of through and through lip laceration (A ). Schematic of three-layer clo-
sure (B ). Layered closure illustrating importance of vermilion border alignment and adequate muscle apposition (C ). Option-
al Z-Plasty to prevent contracture notching of lip margin (D ).
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 pre-
vent 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 bor-
der 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 29–3).6
• Lateral defects of 1/3-2/3 of the lip not involving the commissure are
repaired using the Abbe flap (Figure 29–4).7
• Midline defects of 1/3-2/3 of the lip are closed with bilateral advance-
ment 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.8–10
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 exten-
sive reconstruction.11
Figure 29–3 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. 345–96.)
A B
Figure 29–4 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 pedi-
cle intact (B ). Final result follow-
ing 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 reconstruc-
tion. St. Louis: Mosby; 1995.
p. 345–96.)
A B
C
AURICULAR REPAIR
• The pinna is particularly susceptible to injury and avulsion. The auric-
ular 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 signifi-
cant deformity. Consequently, all open injuries to the ear require sys-
temic 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 set-
ting.
• Cartilage edges that cannot be covered because of skin deficiencies are
trimmed to allow primary skin closure. Even if the conservative trim-
ming 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 ori-
entation. Helical rim defects are an exception, because of greater fibrofatty
tissue producing a “cookie bite” deformity after skin grafting.
• The skin graft is readily harvested from the periauricular, supraclavicu-

lar, 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 vas-
cularized 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 rapid-
ly 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
♦ < 20% of defects can be closed using helical rim advancement flaps
(Figure 29–5).
♦ > 20% of defects may require a combination of wedge resection and
helical advancement. Alternatively, one may create a tubed preauric-
Figure 29–5 Repair of small heli-

cal rim defect using advancement
flaps. Scar to be excised and inci-
sion planning (A). Advancement
flaps raised (B). Advancing and
securing the flaps (C). Final clo-
sure (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. 443–80.
A B
C D
ular or postauricular pedicled flap with staged take down, delayed by

3-6 weeks (Figure 29–6).
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 postau-
ricular flap coverage and delayed pedicle division.
• Composite grafts from the opposite ear can be utilized, but have ques-
tionable reliability and leave a significant donor site scar.
Auricular Avulsions
Partial avulsion
• Partial avulsions are re-anastomosed primarily (Figure 29–7).
• 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
non–hair bearing skin may be essential in a future definitive auricu-
lar 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 individ-
ual 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 carti-
lage 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 tran-
sient 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 regenerat-
ed 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 peri-
auricular tissues, use of the temporoparietal fascia flap with costal car-
tilage and a full thickness skin graft may be warranted.15
Figure 29–6 Pre-auricular tubed A B

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 under-
lying defect is closed (A). After a
three week delay, one end of the
preauricular flap is divided and
anastomosed to the correspond-
ing 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 permis-
sion from Quatela VC, Cheney
ML. Reconstruction of the auri-
cle. In: Baker SR, Swanson NA,
editors. Local flaps in facial C D
reconstruction. St. Louis: Mosby;
1995. p. 443–80.
Figure 29–7 Acute auricular A B

repair following trauma. Exam-
ple of partial avulsion of the
auricle, which would be expected
to survive based on intact helical
bridge of skin (A ). Re-approxi-
mation of tissues allowing com-
plete coverage of all cartilage
with vascularized tissue (B ).
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 sub-
tle asymmetries are readily detected.
• The juvenile nose assumes the adult proportion and shape during puber-
ty 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 dis-
tortion 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 car-
tilage absorption or septal perforation. In addition to the physiologic
disturbance this causes, it may impact nasal growth and dorsal pro-
jection. The result is a persistent juvenile nose with a saddle deformi-
ty and nasal obstruction.
3. All hematomas must be drained and the mucoperichondrial flaps re-
apposed with absorbable sutures, packing, or splints. In the child, this
requires general anesthesia.
• Cartilage lacerations should be meticulously re-approximated with per-
manent 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-
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 sig-
nificantly 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.
PERIORBITAL REPAIR
Injuries to this region should prompt a consultation with the ophthalmol-
ogist, particularly when there is hyphema, diplopia, enophthalmos, exoph-
thalmos, 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 29–8).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 con-
junctiva.
• 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 epithe-
lium and analogous to the vermilion border of the lip. The Meibo-
mian 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 29–9).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 6-
0 polyglactin sutures. The sutures are placed precisely at the cut mar-
gin 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.
♦ The first suture is placed at the gray line and is left long for retrac-
tion. Sutures are placed on either side of the lash line, progressing
away from the lid margin.
Figure 29–8 Cross-sectional

anatomy of the upper eyelid.
Patel BC, Flaharty PM, Ander-
son RL. Reconstruction of the
eyelids. In: Baker SR, Swanson
reconstruction. St. Louis:
Mosby; 1995. p. 273–304).
Figure 29–9 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 canthol-
ysis incision (A ). Detail of
suture planning for lid closure
(B ). Following closure (C ).
Detail of lid margin suture tails
secured under knot of distal A C
suture (D ). (Reprinted with per-
mission from Patel BC, Flaharty
PM, Anderson RL. Reconstruc-
tion of the eyelids. In: Baker SR,
Swanson NA, editors. Local flaps
in facial reconstruction.
St. Louis: Mosby; 1995.
p. 273–304).
B D
♦ The tails of the sutures nearest the lid margin are left long and
secured under the knot of the more distal skin sutures. This tech-
nique 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
29–9).
• Small defects of the lids that do not involve the tarsal plate or lid mar-
gin can be closed in a vertical fashion to prevent lid retraction.
• Small defects of the lid margin and tarsal plate can be closed primar-
ily. Lateral cantholysis is performed if there is excessive tension.
• More extensive lid reconstruction techniques are discussed by Putter-
man.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 lat-
eral orbital walls (Figure 29–10).
• Medial and lateral canthal tendons separate into anterior and posteri-
or 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 Whitnall’s 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-correc-
tion. Securing the lateral tendon a few millimeters posterior and
superior to their anatomic attachment sites provides for a good out-
come after gravity and tension exert their effects.
Figure 29–10 Canthal tendon

system. The medial and lateral
tendons each divide into anteri-
or 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 29–10).
• 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.
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 29–11).
• The ends are then identified in the wound and passed into the respec-
tive 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 nec-
essary 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 29–12).
Figure 29–11 Stent of the supe-

rior lacrimal canaliculus into the
nasal cavity.
Figure 29–12 Repair of brow

defect using bilateral advance-
ment flaps. Defect in brow and
incision planning for repair.
Inset: all incisions within the
brow are beveled with follicles
(A ). Following repair (B ).
Siegle RJ. Reconstruction of the
Forehead. In: Baker SR, Swan-
son NA, editors. Local flaps in
facial reconstruction. St. Louis:
Mosby; 1995. p. 421–42).
B
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 Stensen’s 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 milk-
ing, 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. Alter-
natively, 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 infil-
trating local anesthetics.
• Management of facial paresis is conservative and significant recovery can
be anticipated. Complete paralysis, however, should be specifically doc-
umented and ideally photographed.
• Nerve injuries in the central face are not explored, because of small neur-
al 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 stimula-
tion for up to 72 hours following injury.
Anatomy
• The facial nerve arises from the stylomastoid foramen deep to the lob-
ule of the ear and courses anteriorly and then superiorly to enter the sub-
stance 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 expres-
sion 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 parotidec-
tomy 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 pre-
pared 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 patient’s. 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 out-
comes and expectations.
3. Cooperation and motivation of the child is imperative for diligent
wound care, sun protection, and avoidance of even minor trauma dur-
ing the healing phase.
4. As with any cosmetic procedure, if the anticipation is indirect improve-
ment in social life, school performance, etc, the surgeon is destined to
have an unhappy patient.
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 differ-
ent 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. Ten-
sion free closure and good soft tissue techniques are paramount for optimal
results.
• Incisions are made in the margin of normal tissue immediately periph-
eral to the scar.
• Slight beveling away from the scar will facilitate skin edge eversion dur-
ing 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 adja-
cent tissue expansion.
• In the initial stages, all incisions are made within the scar to prevent dam-
age 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 length-
en 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 usual-
ly the pre-existing scar, which can be excised concurrently (Figure 29–13).
• 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.
• Angles between the central and lateral limbs determine the amount of
elongation in the vector of the central limb.
♦ 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 perpen-
dicular to the vector of elongation.
Figure 29–13 Z-plasty scar revi-

sion. Scar from previous injury
has caused contracture distortion
of vermilion edge (A). Result fol-
lowing 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, edi-
tors. Local flaps in facial recon-
struction. St. Louis: Mosby;
1995. p. 131–50). A B
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 29–14).
• The scar is excised.
• Skin margins are evenly undermined.
• Interlocking mini-flaps are created using a No 11 scalpel perpendicular
to the skin surface.
♦ 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 29–15) is preferable for very
long scars, because a long W-plasty creates a recognizable repeating
pattern. Although more challenging and time consuming, a geomet-
ric 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 reticu-
lar dermis. The desired result is a more subtle transition of color and sur-
face from the surrounding skin to the scar. Individuals with darker skin,
hormonal changes due to pregnancy or exogenous replacement, or a histo-
ry 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.
Figure 29–14 Scar excision with

W-plasty closure. (Reprinted with
permission from Thomas JR,
Frost TW. Scar revision and cam-
ouflage. In: Baker SR, Swanson
reconstruction. St. Louis: Mosby;
1995. p. 587–95).
Figure 29–15 Scar excision with

geometric broken line closure.
Thomas JR, Frost TW. Scar revi-
sion and camouflage. In: Baker
SR, Swanson NA, editors. Local
flaps in facial reconstruction. St.
Louis: Mosby; 1995. p. 587–95).
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the reattachment of a severed ear part. Plast Reconstr Surg 1971;48:219–23.
14. Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: person-
al experience with 1200 cases. Plast Reconstr Surg 1999;104:319–34.
15. Park SS, Wang TD. Temporoparietal fascial flap in auricular reconstruction. Facial Plast Surg
1995;11:330–7.
16. Park SS, Cook TA. Reconstructive rhinoplasty. Facial Plast Surg 1997;13:309–16.
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;123:539–42.
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;35:1–24.
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, Bum-
sted RM, editors. Pediatric facial plastic and reconstructive surgery. New York: Raven Press;
1993. p. 317–35.
22. Frodel JL, Wang TD. Z-plasty. In: Baker SR, Swanson NA, editors. Local flaps in facial recon-
struction. St. Louis: Mosby; 1995. p. 131–50.
23. Park SS. Scar revision through W-plasty. Facial Plastic Surgery Clinics of North America
1998;6:157–61.
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. 587–95.
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.1–7 Conventional repair using rib car-
tilage 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 appear-
ance at arm’s 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 suffi-
ciently for actual patient use.10,11
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 con-
tralateral 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.
• General anesthesia is given for all surgical stages.
Preparation
• Measure the normal contralateral ear (Figure 30–1), 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 par-
allel with the nasal dorsum).
• Measurements from the normal ear are used in reconstructing the
microtic ear (Figure 30–2).
• Note the position of each lobule viewed en face (Figure 30–3); the
microtic lobule lies more superiorly.
Figure 30–1 Preoperative mea-

surements of a normal contralat-
eral ear. Relationship of the
superior auricle to the brow (A).
Distance from the lateral can-
thus 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 703
Figure 30–2 Measurements for

the malformed ear are taken
from the normal ear.
Figure 30–3 An en face view

reveals a difference in vertical
height and relationships of the
superior and inferior aspects of
the auricle.
• Create a template from the normal ear using an X-ray film and a mark-
er (Figure 30–4). 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 child’s 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 trans-
position, and (3) creation of a functional postauricular sulcus. A fourth
stage, to add a tragus or to perform a contralateral “otoplasty” of the nor-
mal 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 30–4 An X-ray film

template is created from the
normal ear.
STAGE 1: RIB HARVEST

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 cartilagi-
nous 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 con-
tralateral ribs (Figure 30–5).
• 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 30–5).
3. A fourth rib (floating) can be harvested more caudad as needed.
Figure 30–5 Rib harvest procedure.

• Repair the pleura, if entered, with a pursestring suture, which is tight-

ened 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 ster-
ile 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 float-
ing rib on what will be the exterior surface of the helix. The rib will
curl, which facilitates creating a helix (Figure 30–6). Preserve the
perichondrium on the inner curve.
• Place the film template on the upper two ribs with the synchondro-
sis. Carve around the template with a scalpel to create the shape of the
auricle (Figure 30–7).
• Suture the helix (lower free rib) to the base (upper two ribs of the syn-
chondrosis) using a 4-0 clear nylon suture (Figure 30–8).
♦ 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 30–6 Creation of a helix.

Shaving the perichondrium and
cartilage on one side of the rib
allows the rib to curl.
Figure 30–7 Shaping of the

auricle. A solid block is carved as
a base using the X-ray template.
Figure 30–8 A helix is attached

to the base ribs.
• Draw the outline of the fossa triangularis and the scaphoid fossa. Use
a scalpel and septal gouge to carve these areas to create realistic con-
tours (Figure 30–9).
• Keep the cartilage moist.
Skin pocket preparation
• Place the template over the malformed ear. Using preoperative mea-
surements, locate and outline the correct position.
• Create a 2-3 cm vertical pre-auricular incision (Figure 3–10). 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 30–11).
• 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 Pro-
lene suture (Figure 30–12). Tiny skin fenestrations are closed with a
6-0 mild chromic suture.
• Apply a mastoid dressing.
Figure 30–9 Carving of the scapha, fossa triangularis, and antitragus features.
Figure 30–10 A template is placed over the malformed ear Figure 30–11 Elevation of the skin pocket.
to outline the correct position for the incision.
Figure 30–12 The framework is

inserted and the incision is
closed. Two suction drains are
preferred.
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 surgeon’s 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 30–13A). Mark the area of exci-
sion, as well as the area for transfer, over the lower area of the framework.
• Remove the skin over the framework. Preserve the subcutaneous con-
nective tissue over the framework.
• Elevate the lobule-like remnant, retaining the inferior pedicle. Rotate
the remnant posteriorly to the lower framework (Figure 30–13B).
• 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 surgeon’s discretion.
• The mastoid dressing and sutures are removed after 1 week.
A B
Figure 30–13 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.
STAGE 3: SEPARATION FROM THE HEAD AND

CREATION OF A FUNCTIONAL POSTAURICULAR
SULCUS
Procedure
• Obtain a skin graft.
♦ 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 scis-
sors until translucent and flexible.
• Incise the skin along the helical rim to the depth that preserves connec-
tive tissue over the cartilage (Figure 30–14A). 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 con-
nective tissue over the cartilage (Figure 30–14B). 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 30–14C). 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
30–14C).
• 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.
Figure 30–14 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 under-
mine. C, The lined region repre-
sents one skin graft, and the
unlined region represents the sec-
ond skin graft on the side of the
head between the intentionally
retracted scalp and the sulcus.
B C
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 cir-
cumstances. Given excess rib at the first stage, a neotragus can be creat-
ed from rib spanning the helical root to lobule area. In other patients,
the malformed cartilaginous remnant with overlying skin can be con-
toured 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 antero-
superiorly.
♦ Observe for skin breakdown, and allow to demarcate.
♦ The skin may re-epithelialize if the area is small. To promote re-
epithelialization, 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.
Figure 30–15 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;66:1–12.
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. 113–127.
3. Eavey RD. Management strategies for congenital ear malformations. Pediatr Clin North Am
1989;36:1521–34.
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. 435–47.
5. Eavey RD. Ear malformations: what a pediatrician can do to assist with auricular reconstruc-
tion. Pediatr Clin North Am 1996;43:1233–44.
6. Eavey RD, Ryan DP. Refinements in pediatric microtia reconstruction. Arch Otolaryngol Head
Neck Surg 1996;122:617–20.
7. Eavey RD. Microtia repair: creation of a functional postauricular sulcus. Otolaryngol Head
Neck Surg 1999;120:789–93.
8. Tjellstrom A. Five years experience with bone-anchored auricular prosthesis. Otolaryngol Head
Neck Surg 1985;93:366–72.
9. Davis J. Severe microtia and radical auriculoplasty. In: Davis J, editor. Otoplasty. Aesthetic and
reconstruction techniques. New York: Thieme-Verlag; 1997. p. 66–100.
10. Cao Y, Vacanti JP, Paige KT, et al. Transplantation of chondrocytes utilizing a polymer-cell con-
struct to produce tissue engineered cartilage in the shape of a human ear. Plast Reconstr Surg
1997;100:297–302.
11. Eavey RD. [Discussant for article reference #10]. Plast Reconstr Surg 1997;100:303–4.
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 31–1 and 31–2).
• The parts of the cartilage of the auricle that are prominent on the ante-
rior surface will be depressions on the posterior surface, and vice versa.
For example, the fossa triangularis on the anterior surface is the emi-
nentia 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 matura-
tion and the child is old enough to understand the problem, desires the
operation, and can cooperate with the postoperative care, which is usu-
ally 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.
Figure 31–1 The anatomy of

the anterior surface of auricular
cartilage.
Figure 31–2 The anatomy of

the posterior surface of auricular
cartilage.
Otoplasty for the Prominent Ear 719
• 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 postoper-
ative symmetry of the ears.
• 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.
♦ 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 for-
ward toward the face when the contralateral ear is being operated on.
♦ During bilateral surgery, the surgeon should not repeatedly turn the
patient’s head from side to side, because movement of the endotra-
cheal tube may traumatize the subglottis.
• Cotton pledgets can be placed into the external auditory canal to pre-
vent blood from entering and forming a clot, which, when present in
the postoperative period, can be troublesome to both the surgeon and
the patient.
Procedure
• By folding the pinna back into the desired position, the amount of
redundant postauricular skin to be excised is estimated (Figure 31–3).
• An elliptical portion of skin to be excised is outlined with methylene
blue and injected with lidocaine and epinephrine (Figure 31–4).
• The excess skin is excised from the postauricular incisions and discard-
ed (Figure 31–5).
• Undermining of postauricular skin and the perichondrium to the emi-
nentia scaphae is done, exposing the cauda helicus and fissura antitrago-
helicina (Figure 31–6).
Figure 31–3 The pinna folded

back into desired position to esti-
mate the amount of redundant
postauricular skin to be excised.
Figure 31–4 An elliptical por-

tion of skin to be excised is out-
lined with methylene blue and
injected with local anesthetic
agent.
Figure 31–5 Postauricular skin

is excised and discarded.
Figure 31–6 Undermining of

the postauricular skin and the
perichondrium.
• 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 auri-
cle (Figure 31–7).
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 inci-
sions are then performed (Figure 31–8):
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 sur-
faces, leaving a new antihelix attached in the middle.
Figure 31–7 Dashed line shown

on the anterior surface of the
auricle marks the position of the
incisions to be made on the pos-
terior 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 31–8 Incisions are made

along the outer edge of the emi-
nentia scaphae and the eminen-
tia conchae.
• 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 Mer-
silene suture (Figure 31–9). 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 31–10).
• The postauricular wound is closed with an interrupted absorbable suture
(Figure 31–11); 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 ante-
rior 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 pre-
sent, 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 bilat-
eral otoplasty in 16 children (30 ears), aged 4-17 years (mean 8.2), with
an average follow-up of 4.6 years:3
♦ 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.
Figure 31–9 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 31–10 Two small bolsters made of

Adaptic are placed on the anterior surface of
the auricle on each side of the new antihelix.

wound is closed.
REFERENCES
1. Becker OJ. Surgical correction of the abnormally protruding ear. Arch Otolaryngol
1949;50:541–60.
2. Becker OJ. Correction of the protruding deformed ear. Br J Plast Surg 1952;5:187–96.
3. Lee D, Bluestone CD. The Becker technique for otoplasty: modified and revisited with long-
term outcomes. Laryngoscope 2000;100:949–54.
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 par-
ticularly true with regard to craniomaxillofacial trauma. There are behav-
ioral, 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 32–1). 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 cra-
nial 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 develop-
ment. 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 rudi-
mentary with very small maxillary and ethmoid sinuses (see Figure
32–1). 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.
Because of the above factors, pediatric craniofacial injury patterns are dif-
ferent 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 sub-
condylar region, and nasal fractures, are most common.
• Fractures in early childhood are caused most often by motor vehicle acci-
dents. 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 32–1 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 729
EVALUATION AND MANAGEMENT

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 immobi-
lization 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 max-
illofacial fractures.
• Axial and coronal CT scans are performed to determine the nature and
extent of injuries including the degree of soft tissue involvement, partic-
ularly of the orbital contents. The anterior cranial fossa, orbits, and eth-
moid region as well as the mandibular condyles and rami typically are
best visualized with coronal scanning. Axial scans best show the zygo-
matic arches, palate, pterygoid plates, mandibular body, and symphysis.
• Imaging is facilitated with new fast spiral CT scanners. Rarely, but per-
haps 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 green-
stick 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,
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 distur-
bance 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 epi-
nephrine, and irrigation, are not repeated. Pressure dressings are frequent-
ly used over dissected areas. Occasionally drains are used. Suction drains
should be used carefully if located where they might pull sinus or oral secre-
tions 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 vis-
ible external scars.
• Occasionally when a large laceration in this area accompanies fron-
tonasoethmoid trauma, treatment can be effected through the lacera-
tion 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.
• 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 expo-
sure 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 need-
ed 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 surgeon’s 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.
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 pos-
terior to allow for an adequate pericranial flap, if needed (Figure 32–2).
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 tem-
poralis muscle and fat pad are left undisturbed to limit postoperative
pain and edema, and to avoid long-term soft tissue wasting in the tem-
ple region.
• Elevation is performed subgaleal laterally over the temporalis muscle (Fig-
ure 32–3) and anteriorly 1 to 2 cm above the orbits (see Figure 32–2).
• Periosteum may need to be incised along the superior temporalis line.
• The temporal branch of the facial nerve is protected by carefully elevat-
ing the temporoparietal fascia or by incising the superficial layer of deep
temporal fascia below the temporal line of fusion (see Figure 32–3).
• 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 per-
icranial flap, if used.
• When elevating the periorbita, the surgeon should avoid periosteal vio-
lation 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 associat-
ed with suture or staple removal.
• A pressure dressing is applied.
Figure 32–2 Wavy coronal inci-

sion with pericranium incised
just above orbits.
Figure 32–3 Detail of temporal

dissection of coronal incision
protecting temporal branch of
facial nerve.
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 patient’s
hair is wet.
• The temporal branch of the facial nerve can be cut, stretched, or other-
wise injured if care is not taken to elevate in the proper plane. Hypes-
thesia 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 vis-
ible defect.
Procedure
• The lateral one-third of the superior lid crease between the brow and lat-
eral canthus is incised with a No 15 blade (Figure 32–4).
• 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 32–5).
• 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.
Figure 32–4 Superior lid crease

incision.
Figure 32–5 Lateral orbital rim

exposure through superior lid
crease incision.
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 32–6).
• 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 32–7) 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 orbital floor is explored and repaired, as needed.
• The periosteum is approximated.
• Conjunctival edges are aligned, but closure is optional. If the conjuncti-
va is closed, knots must be buried.
• The inferior cantholysis is repaired by suturing the inferior canthal ten-
don 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 ectro-
pion.
• The globe may be damaged if sufficient care is not taken.
Figure 32–6 Lateral canthotomy

with inferior cantholysis.
Transconjunctival incision (bro-
ken line).
Figure 32–7 Transconjunctival

incision with preseptal dissection
down to the orbital floor.
VESTIBULAR OR CANINE FOSSA INCISION

Indication
• Exposure of the lower midface
Procedure
• A scalpel is used to incise the mucosa (Figure 32–8).
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 32–8).
• The circumvestibular (nasal vestibule) incision allows midfacial deglov-
ing 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.
Figure 32–8 Circumvestibular

incision exposing maxilla with
pyriform crest elevation allowing
greater superior retraction of soft
tissue.
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 32–9).
• 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 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 32–10).
• Dissection is continued in the subplatysmal plane. Use of the Hays-
Martin maneuver helps to protect the marginal nerve, which is
retracted superiorly (see Figure 32–10).
• The periosteum along the inferior border of the mandible is incised
and elevated to expose the fracture site.
• The periosteum, platysma, subcutaneous tissue, and skin are closed in
layers.
Figure 32–9 Submental incision.
Figure 32–10 Submandibular

incision.
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 auricu-
lar contour closely (Figure 32–11).
• An inferior limb can be used if needed, as in a parotidectomy incision.
• The plane of dissection is close to the tragal perichondrium. A sub-
perichondrial 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 per-
formed cautiously to avoid facial nerve trauma.
• A submandibular incision may be added, if necessary, for complete
exposure.
• 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 32–12).
• 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 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.
Figure 32–11 Preauricular

incision.
Figure 32–12 Approach to the

ramus and condyle with cranial
nerve VII anatomy. Retro-
mandibular incision is posterior
and inferior to the angle. The
approach is similar to the sub-
mandibular 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.)
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 elec-
trosurgery (Figure 32–13). 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.
• 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
32–14).
• 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 maxillo-
mandibular 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.
• 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 frac-
ture and hardware with possible osteomyelitis.
• The mental nerve can be damaged during the incision and dissection,
and is at risk from stretch during retraction.
• 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 manage-
ment. Prevention includes pressure dressings.
• Facial nerve damage rarely occurs from the transbuccal trocar.
Figure 32–13 Anterior vestibular

sulcus incision.
Figure 32–14 Posterior vestibular

sulcus incision.
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 cir-
cumdental wires, and therefore require an acrylic splint with circum-
mandibular 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 erupt-
ed and have adequate root structure to again support interdental wiring
for maxillomandibular fixation.
Options for interdental fixation include Ivy loops, arch bars with cir-
cumdental 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 patient’s 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 32–15 and
32–16.
Figure 32–15 Skeletal suspen-

sion wiring via pyriform crest
wires and circum-mandibular
wires.
Figure 32–16 Lateral view of

pyriform crest and circum-
mandibular wires.
• Maxillary suspension wires (Figure 32–17) may be placed circumzygo-

matic, superior orbital, or at the nasal spine or pyriform crest.
• Skeletal suspension wires are connected intraorally with a third wire
(Figure 32–18), 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 gin-
gival 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.
♦ Temporomandibular joint ankylosis may occur after an extended
period of fixation.
♦ Tooth decay may be caused by inadequate dental hygiene.
Figure 32–17 Alternative maxil-

lary suspension sites: the zygo-
matic arch, the nasal spine or
pyriform crest, and the frontal
bone with screw and pullout wire.
• 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.
♦ 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 32–18 Detail of connec-

tion between the skeletal suspen-
sion wires and an intraoral wire.
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 mor-
bidity, but restoration of premorbid occlusion is also critical to maintain-
ing normal function. Basic concepts of occlusion include the following:
• The angle classification of occlusion (class I, II, or III) refers to the rela-
tionship of the first molars of the mandible and the maxilla to each other
(Figure 32–19).
• Normal occlusion (class I) is defined as the mesial buccal cusp of the
maxillary first molar articulating with the buccal groove of the mandibu-
lar 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 32–19 Angle classifica-

tion of occlusion based on the
relationship of the maxillary and
mandibular first molars.
• 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 erup-
tion. In these situations, wear facets on the teeth, dental midlines, and
close examination of the fracture edges all must be used to assist in accu-
rate fracture reduction and re-establishment of the premorbid occlusion.
Indication
• Fractures of the mandible or maxillofacial skeleton (Figure 32–20)
Figure 32–20 Recommended

primary plating locations for
craniomaxillofacial fractures.
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 32–20 and
Table 32–1).
• 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 frac-
tures, 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 inade-
quate 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 palpa-
ble 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.
• 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 32–1 Pediatric plate applications*

Location Recommended Size Range (mm)
Anterior skull and orbits 1.0–1.5

Maxilla
Buttresses 1.3–1.5
Intervening bone 1.0–1.5
Mandible† 1.5–2.0
* 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 pro-
cedure allows for earlier surgical intervention with lower risks of aggrava-
tion 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 ligaments—temporary
removal of the disarticulated nasal bony structure may allow for better
control of the repair
• Associated trauma to the anterior skull base, particularly with a commu-

nication between the sinonasal cavities and the anterior fossa—the sub-
cranial 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 devel-
opment 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 32–21).
♦ 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 identi-
fication 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 32–22).
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 decreas-
es 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.
Figure 32–21 Osteotomies out-

lined and pre-plated.
Figure 32–22 Retraction of

periorbita, laterally exposing
medial orbital wall cut.
♦ Alternatively an osteotome may be passed horizontally from one side

to the other behind the glabella and the nasal bones (Figure 32–23).
♦ 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 32–24). 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 sphe-
noid sinuses also can be obtained. If optic nerve decompression is need-
ed, 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 surgeon’s 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 accessi-
ble 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 32–25):
♦ 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 contralat-
eral 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 mid-
line incision must be made in the pericranium to allow passage of the
nasal bones. Blood supply comes from the supratrochlear and supraor-
bital vessels, so a midline incision should not be a problem.
♦ The pericranial flap is fixed in place, and the bone flap is positioned
and fixed with the plates in its original position.
Figure 32–23 Transverse

osteotomy of anterior cranial
fossa in region of crista galli.
Figure 32–24 Exposure after

removal of the subcranial bone
flap.
Figure 32–25 Centripetal sus-

pension wiring of medial canthal
tendons.
♦ 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 32–25). 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 dis-
cretion 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 cor-
tex 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 rec-
ommended to harvest outer table calvarium in situ because of the relative
thinness of the skull and higher risk of inner table penetration. Full-thick-
ness 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 thick-
ness, and it becomes safer to consider in situ outer table harvesting.
Indication
• Bone loss after fracture reduction, particularly in buttress areas, in chil-
dren aged 5 years or older
Procedure
• Adequate exposure of cranium is obtained for grafting.
♦ 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.
• To harvest the bone graft ex-situ
♦ Craniotomy is performed in the usual fashion with a cranial perfora-
tor and craniotome (Figure 32–26).
♦ The craniotomy bone flap is removed and split away from the patient
with chisels or saws into inner and outer tables (see Figure 32–26).
♦ One of the tables is returned to the cranial defect and is fixated with
sutures or plating.
Figure 32–26 Calvarial bone

graft harvesting techniques.
In situ harvest on skull’s right;
full-thickness with ex situ
splitting on skull’s left.
• 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, saucer-
izing peripherally to allow an adequate tangential angle for separating
tables (see Figure 32–26).
♦ 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;6:501–10.
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; 2000:941–69.
Koltai PJ. Craniofacial skeletal trauma in childhood. In: Cotton RT, Myer CM, editors. Practical
pediatric otolaryngology. Philadelphia: Lippincott-Raven; 1999:729–58.
Loder RT. Skull thickness and halo-pin placement in children: the effects of race, gender, and later-
ality. J Pediatr Orthop 1996;16:340–3.
Posnick JC. Facial fractures in the pediatric patient. In: Ferraro JW, editor. Fundamentals of max-
illofacial surgery. New York: Springer; 1997:215–23.
Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Max-
illofacial Surg 1993;51:836–44.
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;118:605–14.
Raveh J, Redli M, Markwalder TM. Operative management of 194 cases of combined maxillofacial-
frontobasal fractures: principles and surgical modifications. J Oral Maxillofacial Surg
1984;42:555–64.
Raveh J, Vuillemin T, Sutter F. Subcranial management of 395 combined frontobasal-midface frac-

tures. Arch Otolaryngol Head Neck Surg 1988;114:1114–22.
Senders CW. Pediatric facial trauma. In: Wetmore RF, Muntz HR, McGill TJ, editors. Pediatric oto-
laryngology. New York: Thieme Medical Publishers; 2000:497–512.
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;
1996:880–92.
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 den-
tal 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 treat-
ment 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 orthodon-
tic dental rehabilitation.
The cleft palate team coordinator oversees treatment and services by
team members, including reconstructive surgeons, otolaryngologists, audi-
ologists, speech pathologists, dentists and orthodontists. This involves reg-
ular “team appointments,” in which the patient and parents are seen by all
of the team specialists, and an individualized plan is formulated. In addi-
tion, the patient and family are aided by nursing specialists, social workers,
and medical geneticists as part of the concept of comprehensive team care.
CLEFT LIP REPAIR

The most common procedures in the United States for correcting unilater-
al and bilateral cleft lip are described, including the occasionally needed
preliminary lip adhesion. In general, the anesthetic needs and considera-
tions, 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.
• 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 patient’s anesthetic.
• A small amount (usually less than 1cc) of local anesthetic with a vaso-
constrictor (1% lidocaine with 1:100,000 epinephrine) may be infiltrat-
ed into the labial sulci and the areas of the intranasal incisions for hemo-
stasis, if desired.
• The endotracheal tube is taped to the midline of the chin without dis-
torting the lower lip.
• A small roll is placed under the infant’s shoulders to slightly extend the
neck.
• The surgeon sits at the patient’s 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 facili-
tates definitive lip closure (cheiloplasty) by decreasing tension, improv-
ing nasal symmetry, and narrowing alveolar clefts.
• Patients with asymmetric bilateral cleft lip may benefit from lip adhe-
sion, 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 extu-
bation, and is usually removed in the recovery room once respiratory sta-
tus 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 patient’s fingers.
Cleft Lip and Cleft Palate 765
• 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 Cupid’s 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 tech-
nique 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 flex-
ible 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 bilater-
al 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.
• As described above under Cleft Lip Repair.
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 assess-
ment and adjustment during the procedure are needed for best results.
Surgical landmarks
• The following points (Figure 33–1A) are determined, measured with
calipers, and marked with gentian violet:
1. Nasal alar base
2. Cupid’s bow peak (lateral)
3. Cupid’s bow peak (low point)
4. Cupid’s bow peak (medial)
♦ 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 Cupid’s
bow into position, does not extend into the normal philtral col-
umn, but creates its mirror image. The rotation incision curves lat-
erally at the junction of the columella and the lip.
6. The limit of the back-cut of the rotation incision, which is neces-
sary in most cases to achieve enough downward rotation of the
Cupid’s bow.
• Cleft side (advancement flap)
7. Cupid’s 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 dis-
tance 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% lido-
caine with 1:100,000 epinephrine.
• All incisions (Figure 33–1B) are made with a 6300 Beaver blade or a
No 15 Bard-Parker blade.
• The rotation incision (4 to 5, see Figure 33–1A) 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 Cupid’s bow peaks (2 and 4) to
A B
Figure 33–1 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 Cupid’s 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.
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 orbic-
ularis oris sutures (Figure 33–1C). It also produces more normal con-
vexity to the lip.
• The orbicularis oris muscles are approximated with interrupted 4-0
or 5-0 Vicryl (Figure 33–1D). Assessment of lip length and symme-
try 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 whis-
tle-tip deformity).
• The position of the alar base is determined, and it is sutured into
position (Figure 33–1D). 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 Cupid’s bow, a small incision at the
VCJ is made at 3. If the position of Cupid’s 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 approximat-
ed and everted (Figure 33–1E). 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.
Figure 33–1 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.
E
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 patient’s 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 incom-
plete 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 bilat-
eral cleft lip [one side wide and complete, the other incomplete, for
example]), the definitive bilateral lip repair follows 3 to 4 months later.
Procedure
Surgical landmarks
• The following points (Figure 33–2A) 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 Cupid’s bow)
2. Right prolabium Cupid’s bow peak (measured 2.5 to 3 mm later-
al to 1)
3. Left prolabium Cupid’s bow peak (measured 2.5 to 3 mm lateral to 1)
4. Right prolabium columella junction
5. Left prolabium columella junction
♦ 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)
9. Superior extent of left lateral lip flap

♦ Vermilion flaps (represented by ★ in Figures 33–2 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 premax-
illa, 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 33–2B) to create the central pro-
labium flap (the future philtrum) and the two lateral forked flaps (to
be used later to reconstruct the columella). The three flaps are under-
mined 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.
A B
Figure 33–2 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.
• The lateral lip incisions are then made (Figure 33–2C) and extended
a variable distance along the alar crease. It is often necessary to mod-
ify 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 33–2D).
• 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 per-
formed for additional release if needed.
• The remaining mucosa and vermilion of the prolabium and premax-
illa are pedicled inferiorly and sutured to the superior attachment of
the premaxilla at the nasal spine (see Figure 33–2D).
Figure 33–2 C, Remaining pro-

labium mucosa is advanced
superiorly and sutured to line
the anterior premaxilla; the lat-
eral lip flaps are incised.
D, Small lateral vermilion flaps
are created on the lateral lip
elements.
D
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 33–2E).
• The orbicularis oris muscle from the lateral lip elements is advanced
medially and closed with several interrupted sutures of 4-0 Vicryl
(Figure 33–2F).
• The edges of the vermilion flaps are closed with 5-0 Vicryl (deep), 5-
0 chromic (inner mucosa), and 7-0 nylon (outer mucosa). A small
space posterior to the flaps is left open for inserting the “e” flap (Fig-
ure 33–2G).
E F
Figure 33–2 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.
G
• The philtrum flap is fitted into position between the lateral lip flaps
and sutured in place with 7-0 nylon (Figure 33–2H).
• 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 posi-
tion under the nostrils with 5-0 Vicryl for the deeper tissues and 7-0
nylon for the skin edges (Figure 33–2I). These two small flaps are
considered “banked” for future use in reconstructing the columella.
• As described above under Cleft Lip Repair
Figure 33–2 H, The “e” flap is

tucked into its pocket and
sutured into position. I, The
philtrum and forked flaps are
sutured into position.
I
LIP ADHESION
UNILATERAL LIP ADHESION

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 proce-
dure 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 greatest—high 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.
Procedure
Landmarks and incisions
• The landmarks for a definitive procedure are determined (see rota-
tion-advancement method, Figure 33–1A) 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 33–3A).
Flap elevation and undermining
• A 6300 Beaver blade is used to incise and elevate the cleft edge
mucosal flaps (Figure 33–3B).
• An incision is made along the pyramidal aperture of the nasal
vestibule (dotted line in Figure 33–3B); 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 con-
servative 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 33–3C).
2. Mucosal sutures, usually three or four 4-0 or 5-0 chromic are
placed to approximate the inner lip mucosa.
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 33–3D).
• 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 defin-
itive repair.
• Maxillary growth disturbance is controversial with no definitive human
subject data; however, not dissecting the maxillary periosteum will
decrease any risk.
A B
C D
Figure 33–3 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 Cupid’s 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.
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.
Procedure
• Landmarks for a definitive (one stage) procedure are determined (see
Bilateral Cleft Lip Repair, Figure 33–2A) and marked with gentian
violet. The cleft edge mucosa/vermilion flaps are placed well away
from the definitive landmarks (Figure 33-4A).
• 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 33–4B).
• The prolabium should not be elevated from the premaxilla. Under-
mining of the lateral lip elements from the maxilla should be mini-
mal, just enough to allow for adequate release, and in the suprape-
riosteal 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 33–4C). Starting at the lateral lip orbicularis oris mus-
cle, 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 con-
tinuing 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 inter-
rupted chromic sutures (Figure 33–4D).
Complications
• As described above under Unilateral Lip Adhesion
A B
C D
Figure 33–4 Bilateral lip adhesion. A, The lip is marked as if for complete lip repair; adhesion incisions are made on the pro-
labium 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 mucos-
al 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.
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:
♦ Optimum maxillofacial growth occurs when palatoplasty is delayed
until after age 18 months, but this may result in more secondary pro-
cedures 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 clo-
sure, 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.
• General anesthesia via oral endotracheal intubation, preferably with an
oral RAE tube, administered by an experienced pediatric anesthesiolo-
gist, 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 exces-
sive 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 patient’s shoulders to slightly extend the neck
into Rose’s position.
• The surgeon sits or stands at the head of the table. Headlight illumina-
tion is desirable.
Procedures
• Many methods of palatoplasty have been described.
• 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, involv-
ing 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 postopera-
tive 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 postopera-
tive 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 pha-
ryngeal obstruction. This suture is removed in the recovery room.
• Severe or prolonged upper airway obstruction is uncommon unless an
underlying anomaly (eg, Robin’s 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 fis-
tula 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.
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 usu-
ally bilateral if the hard palate is affected.
• As described above under Cleft Palate Repair
Procedure
• Figure 33–5A 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 33–5B). The
neurovascular bundle is located medial to this incision.
• The medial and lateral incisions are connected with an oblique inci-
sion with the apex oriented toward the location of the future canine
(see Figure 33–5B). 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 33–5 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.
A B

• Mucoperiosteal flaps are elevated by blunt dissection with a Freer ele-
vator (Figure 33–5C).
• 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 incis-
ing the periosteum on both sides of the bundle’s attachment to the flap
(see inset in Figure 33–5C). 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 medi-
al 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.
C D
Figure 33–5 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.
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 33–5D). 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 hor-
izontal mattress sutures of 3-0 Vicryl, to approximate the velar mus-
cles (see Figure 33–5D).
• Using 4-0 Vicryl, the periosteum of the flaps is closed, proceeding
anteriorly toward the flap’s 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 33–5E).
• The exposed bone at the lateral relaxation incision sites and the dissec-
tion over the hamulus is backed with microfibrillar collagen (Avitene or
Instat) for hemostasis and bony coverage (see Figure 33–5E).
Figure 33–5 E, The oral mucosa

is sutured and the tips of the
flaps secured anteriorly. Microfib-
rillar collagen is packed into the
lateral relaxation incisions.
E
TWO-FLAP PALATOPLASTY
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 creat-
ing bilateral vomer flaps to close both sides of the nasal floor.
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 33–6A).
• 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 inci-
sion is similar to that on the greater segment, except that the anteri-
or aspect of the incision is brought forward to the alveolar ridge.
Figure 33–6 Two-flap palato-

plasty. Landmarks and incisions.
Note the position of the neu-
rovascular bundles (VB).
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 33–6B). The nasal floor mucoperiosteum is
elevated on the lesser palatal segment.
• Dissection of the neurovascular bundles and lateral relaxation inci-
sions 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 33–6C). 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 33–6D).
• Microfibrillar collagen is packed into the lateral relaxation incisions.
Figure 33–6 B, Cleft edges are

incised and flaps elevated,
preserving the neurovascular
bundles.
Figure 33–6 C, The nasal floor

and nasopharyngeal mucosa are
sutured. Several horizontal mat-
tress sutures approximate the lev-
ator muscular sling. D, The oral
mucosa is sutured and the flap
tips secured anteriorly. Microfib-
rillar collagen is packed into the
lateral relaxation incisions.
D
DOUBLE REVERSING Z-PLASTY (FURLOW

PALATOPLASTY)
Indications
• Submucous cleft palate or isolated soft palate cleft. The procedure con-
sists of a soft palatal lengthening Z-plasty with overlap of the muco-
muscular 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.
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 33–7A) 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 lev-
ator muscles are elevated attached to the oral mucosa (Figure 33–7B).
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 33–7C).
• 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 clos-
ing the nasopharyngeal incisions with interrupted 4-0 and 5-0 Vicryl
sutures (Figure 33–7D).
• The oral mucosal flaps are then interdigitated and the tips are placed
into position with 4-0 Vicryl suture.
A B
C D
Figure 33–7 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 (patient’s
right side) and oral mucomuscular (patient’s 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 over-
lap. E, The oral flaps are interdigitated and sutured.
E
• 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.
BIBLIOGRAPHY
Bardach J, Morris H. Multidisciplinary management of cleft lip and palate. Philadelphia: WB Saun-
ders; 1990.
Furlow LT Jr. Cleft repair by double opposing z-plasty. Plast Reconstr Surg 1986;78:724–6.
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 char-
acteristic head shape. Surgery is described below for correcting plagio-
cephaly (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.
♦ Monogenic syndromes are usually autosomal dominant including
Apert’s, Crouzon’s, and Pfeiffer’s. Recessively dominant syndromes
include Antley-Bixler, Carpenter’s, 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.
Secondary craniosynostosis refers to craniosynostosis caused by an established dis-

order, including hematologic processes (sickle cell anemia, thalassemia, con-
genital hemolytic icterus, and polycythemia vera), metabolic disease (hyperthy-
roidism, 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 intrauter-
ine 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 patient’s care are considered. Members of the team typically
come from several disciplines including anesthesiology, audiology, den-
tistry, genetics, neurology, neurosurgery, ophthalmology, oral surgery, oto-
laryngology, 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 anes-
thesiologist, 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 consen-
sus 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 malforma-
tions 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. Propo-
nents of early correction argue that early surgical intervention allows the
normal rapid brain growth during early development to promote nor-
mal 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
Craniosynostosis 793
synostosis thus leading to tailored treatment plans. Later surgical inter-

vention also allows for better bone development and relies less on brain
growth. Treatment becomes easier to determine if the etiology is known.
Given the complexity of craniosynostosis surgery, close communication
must exist between the surgeon and anesthesiologist. A preoperative anes-
thesia 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 child’s condition prior to surgery.
• Airway anomalies should be ascertained and precautions should be
taken. Syndromes such as Pierre Robin, Treacher Collins, and Beckwith-
Wiedemann are associated with micrognathia, retrognathia, or
mandibular hypoplasia.
• To prevent injuries during intubation and positioning of the child dur-
ing 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.
Procedures
No 1. Unilateral coronal craniosynostosis
• Plagiocephaly refers to the asymmetric morphology that results in uni-
lateral retrusion of the forehead with contralateral protrusion, caused by
premature fusion of a unilateral coronal suture (Figures 34–1A 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 inferi-
or displacement of the contralateral eye.
• Correction involves opening the coronal suture with forehead advance-
ment. 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 cran-
iotomy is performed.
• Osteotomies (Figure 34–2A) mobilize the supraorbital bar, which
consists of the glabella and upper one-half of the orbits. In the tem-
poral 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 fix-
ation (Figure 34–2B). The bifrontal craniotomy bone flap is replaced
and secured to the supraorbital bar anteriorly with rigid fixation.
• Correction of plagiocephaly caused by unilateral coronal craniosyn-
ostosis 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.
A B
Figure 34–1 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.
A B
Figure 34–2 Surgical correction of unilateral coronal craniosynostosis. A, Osteotomies. B, Bone advancement and rigid fixation.
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 34–3). The basilar sutures may also be fused.
• Nonsyndromic cases have nasoethmoidal retrusion with normal intel-
ligence. Syndromic cases (Apert’s or Crouzon’s) 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 supraor-
bital 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 34–4A).
• The supraorbital bar is advanced forward into the new position bilat-
erally (Figure 34–4B) 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.
Figure 34–3 Brachycephaly

caused by bilateral coronal cran-
iosynostosis compared with nor-
mal skull position (dotted line).
Sagittal shortening involves pri-
marily the lower forehead and
cranial base; the skull has com-
pensatory widening.
A B
Figure 34–4 Surgical correction of bilateral coronal craniosynostosis. A, Osteotomies. B, Bone advancement.
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 34–5).
• Bitemporal narrowing and orbital hypotelorism are not uncommon.
Mental retardation may be present because trigonocephaly is associ-
ated with holoprosencephaly and agenesis of the corpus callosum.
• Reconstruction requires a frontal orbital remodeling including re-
opening 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 fol-
lowing mobilization of the supraorbital bar (Figure 34–6A).
• The supraorbital bar is removed and remodeled on a sterile table (Fig-
ure 34–6B). An osteotomy is created in the midline portion of the
bar, through the area of the fused metopic suture.
♦ 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 34–5 Trigonocephaly

caused by metopic craniosynos-
tosis compared with normal
skull position (dotted line).
Note sharp angulation at the
midforehead with keel-shaped
frontal deformity.
♦ 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 con-
tour 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 34–6C).
• 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 fix-
ation (see Figure 34–6C).
Figure 34–6 Surgical correction of metopic craniosynostosis.

A, Osteotomies. B, Remodeling of the supraorbital bar with
midline osteotomy and lateral contouring. C, Bone advance-
ment and rigid fixation.
C
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 34–7). 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 posterior-
ly exposing the entire cranial vault, the occiput, and the upper half of
the orbits anteriorly.
• Multiple craniotomy bone flaps are created (Figure 34–8A) 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 34–8B).
• The bone flaps are secured with rigid fixation.
Figure 34–7 Scaphocephaly

caused by sagittal craniosynosto-
sis compared with normal skull
position (dotted line). The skull
is lengthened and narrowed, cre-
ating a boat-shaped appearance.
Figure 34–8 Surgical correction

of sagittal craniosynostosis. A,
Osteotomies. B, Bone reposi-
tioning and rigid fixation.
B
No 5. Lambdoidal craniosynostosis
• Posterior plagiocephaly refers to the asymmetry of the occiput caused
by unilateral fusion of a lambdoidal suture (Figure 34–9). The ipsi-
lateral occipitomastoid region is flattened and the contralateral coro-
nal 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 direc-
tion 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 34–10A). 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 34–10B). 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 34–9 Posterior plagio-

cephaly caused by lambdoidal
craniosynostosis compared with
normal skull position (dotted
line). Note flattening of the ipsi-
lateral occipitomastoid region.
• Patients usually require close observation for 24 to 48 hours after

surgery. Neurologic status should be monitored closely for altered men-
tal 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 provid-
ed by the neurosurgeon.
Figure 34–10 Surgical correc-

tion of lambdoidal craniosynos-
tosis. A, Osteotomies. B, Bone
advancement and repositioning.
B
Complications
• Mortality for craniofacial procedures is estimated between 1.5 and
2.0%.5 Mechanisms of mortality include massive hemorrhage, meningi-
tis, respiratory obstruction, and hypovolemia. Death may also be caused
by cerebral edema and respiratory infections. Careful preoperative plan-
ning, 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, typical-
ly for 5 days. If the patient develops postoperative signs of central ner-
vous 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, tender-
ness, 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 conser-
vative 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 encoun-
tered if the venous sinus is violated. In this case, the craniotomy flap
must be quickly removed and the bleeding must be controlled. Occlu-
sion 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 evi-
dence 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 treat-
ed 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 evacu-
ated with surgery.
• Seizures may arise from a number of causes including increase in intracra-
nial pressure, cerebral trauma or laceration, hemorrhage, cerebral infarc-
tion, 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.
• Cerebral spinal fluid (CSF) leakage can best be addressed preventively with
meticulous closure of all dural defects created or encountered. Reinforce-
ment of dural tears can be accomplished utilizing the paracranial flap.
♦ 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 aceta-
zolamide with diuretics to diminish CSF production may be attempt-
ed 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 car-
ing for the drain should be trained to keep the drain at an appropri-
ate level so that neither excessive nor inadequate drainage occurs.
♦ If CSF drainage persists despite the above measures, it may be neces-
sary 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. Treat-
ment 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 camou-
flaged 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 patient’s history in the
preoperative setting. A craniofacial team approach also helps to mini-
mize 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
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.
♦ The risk of air embolism increases if the patient is in a sitting posi-
tion, 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
patient’s 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. Cohen MM Jr. Syndromes with craniosynostosis. In: Cohen MM Jr, editor. Craniosynostosis:
diagnosis, evaluation, and management. New York: Raven Press; 1986. p. 413–590.
2. Moss ML, Greenberg SV. Postnatal growth of the human skull base. Angle Orthod
1955;25:77–84.
3. Park EA, Powers GF. Acrocephaly and scaphocephaly with symmetrically disturbed malforma-
tion of the extremities. Am J Dis Child 1920;20:235–315.
4. Clarren SK, Smith DW, Hanson JW. Helmet treatment for plagiocephaly and congenital mus-
cular torticollis. J Pediatr 1979;94:43–6.
5. 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.
6. 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.
C H A P T E R 35
I NFORMATION FOR PARENTS

AND C AREGIVERS
Most families are too anxious during the baseline office visit or surgical encounter to effi-
ciently 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 child’s 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
35–1).2–4 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 pri-
vate 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 con-
cept of risk. Moreover, the true risk of anesthesia may be substantially less
than 1:50,000, which is based on historical estimates. The current anes-
thesia fatality rate is estimated at approximately 1:250,000.5 Risk, howev-
er, is significantly higher for inpatient surgery, children under 12 months
of age, or when the child has underlying systemic disease.
Your Child and General Anesthesia
During general anesthesia, your child breathes a carefully prepared mixture of oxygen and anes-
thetic 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 dif-
ficult 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 surg-
eries (less than 20 to 30 minutes) in young children are performed with mask anesthesia, includ-
ing ear tube insertion, repair of tongue-tie, and removal of small growths or lesions. Tube anes-
thesia (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.
Isn’t Anesthesia Risky?

General anesthesia is one of the safest experiences in your child’s life because they are moni-
tored 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 activi-
ties 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 child’s den-
tist 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 chil-
dren 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 35–1 Education sheet for general anesthesia.

Information for Parents and Caregivers 809
PROCEDURE EDUCATION SHEETS

The educational sheets reproduced in this chapter are offered as practical
examples that can be adapted to any practitioner’s specific circumstances.
Sheets are included for the following commonly performed pediatric oto-
laryngology procedures:
• Tympanostomy tubes (Figure 35–2). 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 35–3). 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 35–4). 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 35–5). 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 35–6). 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 35–7). The sheet is self-explanatory.
• Ear tube removal with paper-patch tympanoplasty (Figure 35–8). The
sheet is self-explanatory.
• Laryngoscopy and bronchoscopy (Figure 35–9). This sheet is most applic-
able to diagnostic procedures, but may also be used for laser surgery or
biopsies.
• Frenuloplasty (Figure 35–10). The sheet is self-explanatory.
What to Expect after Ear Tube Insertion
Congratulations! Now that your child has ear tubes you can finally relax. If you follow the sug-
gestions 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 mid-
dle 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 glad-
ly fit them with soft ear plugs.
Tube Check-Ups
Please schedule an office visit within 2 months after surgery to check your child’s tubes and
hearing. Additional check-ups are required every 6 months while the tubes remain in place (usu-
ally 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 child’s 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 child’s regular doctor doesn’t see the tube (don’t worry — it can’t
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 ____________________ Relation to child _______________________
Child’s name _________________________ Date ________________________________
Figure 35–2 Education sheet for tympanostomy tubes.

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 unnec-
essary. 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 child’s discomfort
by (1) encouraging adequate food and liquid intake, (2) making sure they take all of the pre-
scribed 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 lib-
erally, 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 tem-
porary 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.
Parent or Guardian __________________ Relation to child _______________________
Child’s name _______________________ Date ________________________________
Figure 35–3 Education sheet for adenoidectomy.

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

There’s no doubt about it: tonsillectomy does not top the list of ways children like to have fun.
You can, however, minimize your child’s 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.

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 ________________________ Relation to child _________________
Child’s name _____________________________ Date __________________________
Figure 35–4 Education sheet for tonsillectomy.

What to Expect after Endoscopic Sinus Surgery
Endoscopic sinus surgery is a safe and effective procedure that will provide your child with last-
ing 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 surgi-
cal 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 heal-
ing (spray each nostril 2-3 times daily). Gentle nose-blowing is allowed, but forceful nose-blow-
ing should be discourages.
Activity & Pain

There are no strict rules for activity after surgery, other than to avoid contact sports, heavy exer-
tion, 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.

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.
Parent or Guardian _________________________ Relation to child ________________
Child’s name ______________________________ Date _________________________
Figure 35–5 Education sheet for endoscopic sinus surgery.

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 child’s dis-
comfort 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 avoid-
ed because they may cause bleeding. Codeine and other narcotic pain relievers are generally
unnecessary.

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 com-
mon, 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 cov-
ered 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 aceta-
minophen (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).
Parent or Guardian _______________________ Relation to child ________________
Child’s name ____________________________ Date _________________________
Figure 35–6 Education sheet for head and neck surgery.

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 child’s hair by plac-
ing 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 force-
fully, 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 oint-
ment). 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 ibupro-
fen products (Motrin, Advil) are avoided because they can increase the chance of bleeding.
Codeine may be prescribed if mastoid surgery was performed.

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 liq-
uid 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
(don’t 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).
Parent or Guardian )_______________________ Relation to child ________________
Child’s name ____________________________ Date _________________________
Figure 35–7 Education sheet for middle-ear and mastoid surgery.

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 insuf-
ficient, 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. Swim-
ming 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 fall-
en out. Water precautions are not required after the small opening in the eardrum has closed.

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 dis-
comfort. 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).
Parent or Guardian _________________________ Relation to child ________________
Child’s name ______________________________ Date _________________________
Figure 35–8 Education sheet for ear tube removal with paper-patch tympanoplasty.
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 mus-
cle aches for several days, because of certain medications given during the procedure. Any dis-
comfort 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 usual-
ly resume a normal diet. If a laser was used, however, your child’s 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 nor-
mal 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 worseænot betteræas the days go by (3) there are persistent swallowing
troubles that interfere with your child’s ability to maintain an adequate diet, (4) your child devel-
ops a progressive or persistent cough following surgery, or (5) fever is 102 degrees or higher
despite acetaminophen (Tylenol).
Parent or Guardian ___________________ Relation to child ______________________
Child’s name ________________________ Date _______________________________
Figure 35–9 Education sheet for laryngoscopy and bronchoscopy.

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 chew-
ing (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 pre-
scribed, please be sure to finish all of the medication.

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.
Parent or Guardian ___________________ Relation to child _______________________
Child’s name ________________________ Date ________________________________
Figure 35–10 Education sheet for frenuloplasty.

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
35–1) and the relevant procedure sheet (see Figures 35–2 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 patient’s
medical chart on, or before, the day of surgery.
3. In the holding area prior to surgery, the surgeon gives the parent or care-
giver 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 care-
giver 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 deliri-
um” may occur when anesthesia wears off quickly, and usually lasts
about 30 minutes. Parents are encouraged to hold, reassure, and re-ori-
ent 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, rela-
tives, 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 35–11 was developed. This
sheet is used as follows:
1. At the first postoperative visit after tube insertion, the parent or caregiv-
er is given the instruction sheet, and a signed copy is kept in the med-
ical 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 “instruc-
tion manual” for the child’s 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 ).
How to Care for Your Child’s Ear Tubes (Page 1 of 2)
Your Insurance Policy

Ear tubes are your child’s insurance policy against infections, middle-ear fluid, and the tempo-
rary hearing problems that accompany them. Consider this sheet a “policy holder’s” 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 child’s 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 child’s 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 need-
ed. 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 child’s tubes fall out,
you should return for a final re-check after 6-12 months.
Figure 35–11 Education sheet for tympanostomy tube care. A, side one.
How to Care for Your Child’s 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 Vase-
line 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 child’s
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 problemsæsclerosis, pockets, and perforationsæalso occur in ears with-
out tubes; they usually relate more to your child’s underlying ear disease than to the tube itself.
When to Call Us
Please call our office if (1) your child’s regular doctor doesn’t 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 35–11 Education sheet for tympanostomy tube care. B, side two.
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 35–2).
SATISFACTION VS EFFICIENCY
Most pediatric otolaryngology surgery is brief and may be performed rapid-
ly 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 start-
ing point for informed discussion, which should promote optimal out-
comes yet maximize efficiency.
REFERENCES
1. Lashley M, Talley W, Lands LC, Keyerslingk EW. Informed proxy consent: communication
between pediatric surgeons and surrogates about surgery. Pediatrics 2000;105:591–7.
2. Holzman RS. Morbidity and mortality in pediatric anesthesia. Pediatr Clin North Amer
1994;41:239–56.
3. Laudan L. The book of risks: fascinating facts about the chances we take every day. New York:
John Wiley & Sons, Inc; 1994.
4. Laudan L. Danger ahead: the risks you really face on life’s highway. New York: John Wiley &
Sons, Inc; 1997.
5. Cotrell JE, Golden S. Under the mask: a guide to feeling secure and comfortable during anes-
thesia and surgery. New Brunswick (NJ): Rutgers University Press; 2001.
6. 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;126:718–21.
7. Lesperance MM, Schneider B, Garetz SL, et al. Substituting a telephone call for pediatric ade-
notonsillecotmy postoperative visits. Arch Otolaryngol Head Neck Surg 2001;127:227–8.
8. 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.
315–36.
9. Moen MC, Kvæner KJ, Haugeto O, Mair IWS. Quality of care in pediatric daycare surgery: a
cross-sectional study. Int J Pediatr Otorhinolaryngol 2000;52:17–23.
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 consider-

ations 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 read-
er 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 docu-
mented 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 post-
poned to allow time for further investigation of the cause of the tem-
perature 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 his-
tory, 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 out-
patient procedures may have up to 4 ounces of clear liquids (water, apple
juice, soda, or jello) until 2 hours before surgery.
• 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 adminis-
ter 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 com-
mence with the pulse oximeter, with other monitors placed after the
induction.
• Intramuscular induction using ketamine is preferred for extremely unco-
operative 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 awak-
ening, 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 cry-
ing, disorientation, or wild thrashing for up to 30 minutes after arriving
in the PACU.
• Anesthesia- or surgery-related complications that can arise in the imme-
diate postoperative period include pain, bleeding, and residual anesthet-
ic effects of narcotics, inhalation agents, and drugs used for neuromus-
cular 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 rea-
sons 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 chil-
dren. An in-depth knowledge of pediatric airway anatomy and physiol-
ogy 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 per-
formed 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 compli-
cated 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 dele-
terious 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 succinyl-
choline 3 mg/kg in the deltoid muscle can break laryngospasm.
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 inhala-
tion 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 signifi-
cantly higher for nonpediatric anesthesiologists. The risk of cardiac
arrest was significantly reduced when a pediatric anesthesiologist (pedi-
atric fellowship training or the equivalent) supervised the case.
Postoperative Nausea and Vomiting
• Unpleasant postoperative nausea and vomiting (PONV) is most com-
mon 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 intra-
venously during tonsillectomy) also have antiemetic effects. Droperidol
10-25 µg/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 intra-
venous 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 neu-
rologic 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; anes-
thesia 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 inhala-
tion 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 operat-
ing 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 fre-
quently used agents for sedation in the pediatric ICU. Midazolam has a
short half-life and is administered by continuous infusion in a dose rang-
ing 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 res-
piratory and cardiovascular system. It can be administered by continu-
ous 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, ambula-
tory, and pediatric ICU patients. Propofol can be administered by intra-
venous bolus of 0.5-3.0 mg/kg or by intravenous infusion at 25-300
µg/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 µg/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.
• 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 manage-
ment 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 pedi-
atric anesthesiologists. J Clin Anesth 1991;3:433–7.
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. Smith’s 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.
Abbé flap, 680, 681 velopharyngeal examination, 381. See also Velopha-
Abscess ryngeal insufficiency
deep neck, 465–489. See also under Infections Adenopathy, cervical, 441–463. See also Cervical
septal, drainage of, 339–340, 340 adenopathy
Acquired cholesteatoma, 109–116. See also under Adhesives, tissue, 676
Cholesteatoma Advancement flap ossiculoplasty, 78–80, 78–80
Acquired perilymphatic fistula, 123–136. See also Air cells, plugging of, 216, 216
Perilymphatic fistula Air embolism, in craniofacial procedures, 806
Acute “coalescent” mastoiditis, 91–92, 94 Airway management, perioperative, 825
Acute mastoid osteitis, 92, 94 Airway obstruction
Adenoidectomy, 379–387. See also Tonsillectomy after tonsillectomy, 396
anesthetic considerations, 380 after uvulopalatopharyngoplasty (UPPP), 405
complications, 386–387 Airway physiology, 555
indications, 381 Airway procedures. See also Endoscopy; Tracheostomy;
parent/caregiver information, 811 Tracheotomy
partial superior, 382 endoscopy, 555–583
postoperative care, 386 tracheotomy, 585–596
preoperative evaluation, 379–380 Alfentanil, 557
preparation, 380–381 Alopecia, postoperative, in craniofacial procedures, 805
primary, 382 Analgesia
procedure, 382, 382–387, 383 patient-controlled, 828
procedures postoperative, 827–828
curette adenoidectomy, 384, 385 Anatomy
microdebrider (shaver) adenoidectomy, 384–386, facial nerve, 137–139, 138
385, 387 fascial layers of neck, 465–466, 467
secondary (revision), 382 Anesthesia, pediatric, 823–828
suction coagulator (liquefaction) adenoidectomy, challenges in, 825–827
384 general, 823–825
selection, 382 in pediatric ICU, 827
830 Index
postoperative pain management, 827–828 Anticholinergics, as anesthesia adjuncts, 557–558

preoperative evaluation and management, 823 Antral aspiration and lavage, 341, 341–342
Anesthetic considerations. See also Anesthesia; Antrostomy, endoscopic. See Endoscopic ethmoidecto-
Anesthetics my/antrostomy
in adenoidectomy/tonsillectomy, 380 Apnea
in cervical biopsy procedures, 442, 448, 455 obstructive sleep apnea syndrome. See
in choanal atresia repair, 306 Adenoidectomy; Tonsillectomy;
in cleft lip/cleft palate repair, 764, 780 Uvulopalatopharyngoplasty (UPPP)
in congenital neck malformations, 491, 496, 499, of prematurity, 826
504, 508, 512 Aspiration
in craniosynostosis correction, 793 fine-needle, cervical, 442–447, 443, 444, 445, 447
in drooling correction, 427, 433–434, 438 myringotomy, 4–5
in ear canal reconstruction, 187, 189 needle of middle ear, 1–3. See also Tympanocentesis;
in endaural approach, 27, 27 Tympanostomy tube
in endoscopic ethmoidectomy/antrostomy, 320–321 Aspiration and lavage, antral, 341, 341–342
in endoscopy, 556–558, 563, 569–570, 578 Atelectasis
in facial nerve procedures, 140, 152, 157 of middle ear, tympanostomy tube insertion and, 6
in facial soft tissue surgery, 673–674 of pars tensa, 58
in inflammatory sinonasal disease, 339, 341, 342, Atlantoaxial subluxation (Grisel’s syndrome), as com-
344, 346, 348, 350 plication of adenoidectomy/tonsillectomy,
in laryngotracheal surgery, 598, 602, 604, 606, 608, 386, 396
612, 616, 620, 624, 626 Atresia, congenital aural, 211–219. See also Congenital
in laser surgery, 636–639, 642, 644, 646, 648, 650, aural atresia
652, 654, 658, 660, 663, 665 Atropine, 558
in myringoplasty, 41, 42, 43 Attic cholesteatoma, 117–121. See also Pars flaccida
in neck drainage procedures, 468, 472, 475, 477, attic cholesteatoma
478, 482, 483, 486,488 Attic retraction pocket, surgical approach, 26–27
in parotidectomy, 515–516 Augmentation laryngoplasty
in postauricular approach, 32, 32 with cartilage graft, 616–618, 617, 619
in posterosuperior quadrant acquired cholesteatoma, with cartilage stent, 620, 620–622, 621, 623
112 Auricular repair, 682–685
in rhinoplasty, 282 avulsions, 684, 685
in septoplasty, 265, 268–269 composite defects, 684
in thyroid surgery, 540 cutaneous defects, 682–683
in tongue surgery, 367, 369, 372, 376 helical rim defects, 683, 683–684
in tracheotomy, 585 hematoma, 682
in transcanal approach, 22, 22 lacerations, 682
in tympanostomy tube insertion, 7 for microtia, 701–715
in tympanostomy tube removal, 17 anesthetic considerations, 702
Anesthetics general considerations, 701
adjunctives to, 557–558 indications and timing, 702
inhaled, 556–557 preparation, 702, 702–704, 703, 704
local, 673–674 procedure overview, 704
neuromuscular relaxants/blockade, 558 stage 1: rib harvest, 705, 705–710, 706, 707,
topical, 557, 673 708, 709
sodium bicarbonate with, 674 stage 2: lobule transposition, 710, 711
Ankyloglossia, 376, 377 stage 3: separation from head and creation of
Anterior pedicle flap, 64, 64 functional postauricular sulcus, 712, 713
Anterior vestibular sulcus incision, 744, 745 stage 4: optional creation of tragus or
Anterosuperior middle-ear congenital cholesteatoma, contralateral otoplasty, 714, 715
106, 106–108, 107, 108 otoplasty for prominent (lop) ear, 717–726
Index 831
anatomical considerations, 717, 718 Canine fossa incision, 738, 739

anesthetic consideration, 719 Canthal anatomy, 691
complications and long-term outcomes, 724 Canthal tendon injury, 690, 691
indications, 717–719 Carbon dioxide (CO2) laser, 633–639634
postoperative care, 724 Cardiac arrest, anesthesia and, 826
preparation, 719 Carotid artery injury, in tonsillectomy, 393, 396
procedure, 720, 720–724, 721, 723, 725 Carotid artery ligation, in post-tonsillectomy hemor-
Avulsions rhage, 397, 397–401, 398, 399, 400, 401
auricular, 684, 685 Carotid space, drainage, 487, 487–488
lip, 680 Cartilage graft, in augmentation laryngoplasty,
nasal, 687 616–618, 617, 619
parotid duct, 694 Cartilage graft tympanoplasty, 66–72
Cartilage-perichondrial graft, 71, 71
Benzodiazepines, 827 Cartilaginous framework injuries, nasal, 686–687
Bicoronal deformity craniosynostosis, 796, 797 Caustic ingestion, 580–582, 583
Biopsy Cautery. See Electrocautery
cervical Cerebrospinal fluid leakage, postoperative, in
incisional, 448–451, 449, 451 craniofacial procedures, 805
percutaneous needle, 442–447, 443, 444, 445, 447 Cervical adenopathy, 441–463
thyroid, 540 functional (modified) neck dissection, 452,
Bivona tracheostomy tubes, 587 452–462, 453, 454, 455, 459, 461
Bleeding, post-tonsillectomy, 380, 395, 397–401. See incisional biopsy, 448–451, 449, 451
also Carotid artery ligation percutaneous needle biopsy, 442–447, 443, 444,
Bone flaps, devitalization of, 804 445, 447
Bone grafts/grafting, maxillofacial, 758–760, 759 preliminary considerations, 441–442
Brachycephaly, 796, 797 Cervical fascia, 465–466, 467
Branchial cleft fistula, first, 499–500, 501 CHARGE association, 299
Branchial cleft fistula, second and third, 504–506, Choanal atresia
505, 506 defined, 299
Branchial pouch sinus, fourth, 507, 507–510, 509, transnasal repair, 300–306, 301, 302, 303.304, 305
511 transpalatal repair, 306–312, 307, 308, 309, 310,
Broken line closures, 698, 699 311
Bronchoscopy, 569–577 Cholesteatoma, 52, 98, 100–121. See also Mastoid-
anesthetic considerations, 569–570 ectomy
indications, 569 acquired, 109–116
instrumentation, 570, 571, 572 posterosuperior quadrant, 111–116
parent/caregiver information, 817 anesthetic considerations, 112
postoperative care, 577 extending into epitympanum, 114, 114
procedures, 572–577 extending into mastoid gas cells, 115, 115
diagnostic bronchoscopy, 574, 575 extensive, 116, 116
foreign body removal, 576 indications, 111, 111
introducing bronchoscope, 572, 573, 574 in posterior mesotympanum, facial recess, and
therapeutic bronchoscopy, 577 sinus tympani, 112, 112, 113
Brunk incision, 307, 307 postoperative care, 116
Buckingham mirror, 70, 70 selection of procedure, 109–110
Bupivacaine, 673–674 staging, 110
Burrow’s triangle, 676,677 surgical planning, 110–111
canal wall–up vs. canal wall–down mastoidectomy,
Caldwell-Luc procedure, 342–344, 343 101–102
Canalicular anatomy, 691, 691 classification, 100–101
Canalicular repair, 692, 692 congenital, 103–108
832 Index
anterosuperior middle ear, 106, 106–108, 107, 108 anesthetic considerations, 222
intratympanic membrane, 104, 104, 105 complications, 247t, 247–248
postoperative care, 108 indications, 222
facial nerve complications, 140 preparation, 222
follow-up visits, 103 principles and devices, 221–222
otologic telescope in, 102 procedure, 223–246
pars flaccida attic, 117–121 positioning implant, 223, 224
anesthetic considerations, 118 planning the flap, 223, 225
confined to anterior epitympanum, 118, 118, 119 incisions, 223–227, 225, 227
extending into mastoid, 120, 120 creating the well, 228, 229
extensive, 121, 121 tie-down holes, 230, 230–232, 231
indications, 117, 117 mastoidectomy, 232, 233
surgery in children vs. adults, 101 facial recess, 233, 234
surgical approach, 21, 22, 27 cochleostomy, 234–236, 235, 237, 239
timing of ossiculoplasty, 102–103 device placement and electrode insertion,
Chronic suppurative otitis media, 140 238–242, 240, 241, 242
Chronic suppurative otitis media, 92, 94, 96 securing implant, 242, 242–244, 243, 244
Cleft lip/cleft palate, 763–790 closure, 244–246, 245, 246
cleft lip repair, 764–774 postoperative care, 247
anesthetic considerations, 764 Cochleostomy, 234–236, 235, 237, 239
bilateral, 770–774 Complete (cortical, simple) mastoidectomy, 91–95, 93,
indications, 770 95
procedure, 770–773, 771, 772, 773, 774 Compound muscle action potential (CMAP), 182
complications, 765 Conchal-cartilage graft, 71, 71
postoperative care, 764–765 Congenital aural atresia, 211–219
unilateral, 765–769 contraindications, 212
indications, 765 indications, 211–212
procedure, 766, 766–768, 767, 769 postoperative care, 218
cleft palate repair, 780–790 preoperative evaluation, 211
anesthetic considerations and preparation, 780 procedure, 212–219, 213, 214, 215, 216, 217, 218,
complications, 780 219
palatoplasty Congenital cholesteatoma, 103–108. See also under
double reversing Z-plasty (Furlow), 788–790, 789 Cholesteatoma
selection, 780–781 Congenital malformations, 299–317. See also under
two-flap, 785, 785–786, 786, 787 specific lesions
V to Y pushback, 782, 782–784, 783, 784 nasal, 299–317. See also under Nasal surgery and
postoperative care, 781 specific lesions
timing, 780 of neck, 491–514
general considerations, 763 cystic hygroma (lymphangioma), 496–498
lip adhesion, 775–780 fibromatosis colli, 512, 513
bilateral first branchial cleft fistula, 498–500, 501
indications, 778 fourth branchial pouch sinus, 507, 507–510, 509,
procedure, 778, 779 511
unilateral pre-auricular pit or fistula, 502, 503
complications, 776 second and third branchial cleft fistula, 504–506,
indications, 775 505, 506
procedure, 775–776, 777 thyroglossal duct cyst, 482, 491–494, 493, 495
Congenital nasal malformations, 299–317 Congenital perilymphatic fistula, 123–136. See also
Coagulation tests, before adenoidectomy/tonsillectomy, Perilymphatic fistula
379–380 Coronal incision, 732–734, 733. See also
Cochlear implantation, 221–249 Craniosynostosis
Index 833
Cortical (simple, complete) mastoidectomy, 91–95, 93, Dermabrasion, in scar repair, 699
95 Dermoids, nasal, 300
Cranial nerve examination, 672 Desflurane, 556
Craniofacial growth, 727–728, 729 Devitalization of bone flaps, 804
Craniofacial surgery. See Craniosynostosis Dexamethasone, in postoperative nausea and vomiting,
Craniosynostosis, 791–806 826
classification and etiology, 791–792 Direct transnasal sphenoidotomy, 358–363, 359, 361,
primary, 791 363
secondary, 792 Discontinuity, ossicular, 75, 77t
surgical correction, 792–806 Dorsal augmentation graft, nasal, 289, 289, 290
anesthetic considerations, 793 Double reversing Z-plasty (Furlow) palatoplasty,
bicoronal deformity, 796, 797 788–790, 789
complications, 804–806 Down syndrome, 9
indications, 792–793 preoperative evaluation in, 380
lambdoidal deformity, 802, 802–803, 803 Drainage
metopic deformity, 798, 798, –799, 799 of deep neck infections, 465–489. See also under
preparation, 793 Infections
sagittal deformity, 800, 801 septal abscess or hematoma, 339–340, 340
unilateral coronal deformity, 794, 795 Drooling, 427–440
Cricoid split (laryngeal decompression) with hyoid parotid duct ligation, 436–437, 437
interposition, 612–614, 613, 615 selection of procedure, 428t
Cricotracheal resection, 626–630, 627, 629, 631 submandibular duct ligation, 438–440, 439
Curette adenoidectomy, 384, 385 submandibular duct relocation, 433–435, 435
Cutaneous defects with sublingual gland excision, 427–432, 429,
auricular, 682–683 430, 431, 433
nasal, 686 tympanic neurectomy, 438
Cystic fibrosis, endoscopic sinus surgery in, 334, Droperidol, in postoperative nausea and vomiting, 826
334–337, 335, 336 Duct(s)
Cystic hygroma (lymphangioma), 496–498 parotid
Cystic lesions ligation, 428t, 436–437, 437
epiglottic, 642, 643 repair, 694
intracordal, 648, 649 trauma to, 672
ranula, 532–538 submandibular. See also under Drooling
thyroglossal duct cysts, 482, 491–494, 493, 495 ligation, 438–440, 439
of tongue, 367–378. See also Tongue relocation, 427–433, 428t, 448–440
vallecular, 644, 645
ventricular, 646, 647 Ear canal, 185–219
congenital aural atresia repair, 211–219
Dacryocystorhinostomy, 348–350, 349, 351 contraindications, 212
endoscopic, 350, 351 indications, 211–212
external (open), 348, 349 postoperative care, 218
“Danger” space of neck, drainage, 488–489 preoperative evaluation, 211
Debridement, 673 procedure, 212–219, 213, 214, 215, 216, 217,
Decompression, laryngeal (cricoid split) with hyoid 218, 219
interposition, 612–614, 613, 615 principles of surgery, 185–186
Dehiscence, of soft tissue wounds, 678 reconstruction of external, 186–206
Dehydration, post-tonsillectomy, 395 anatomic considerations, 186–187, 187
Dental examination, in facial trauma, 672 anesthetic considerations, 187–188
Dental injury indications, 186
in adenoidectomy, 386 procedure
in tonsillectomy, 396 canal wall–down procedure, 204, 204–205, 205
834 Index
canal wall–up procedure, 206 parent/caregiver information, 813

elimination of obstructions, 200–203, 201, 202, postoperative care, 330
203 preoperative evaluation, 320
endaural approach, 188, 188, 189t, 189–193, preparation, 322, 322
190, 191, 192, 193 procedure, 322–330, 325, 326, 327, 328, 329, 330
postauricular approach, 188, 189, 189t, 194, Endoscopic-guided cautery, in epistaxis, 254, 254
194–200, 195, 196, 197, 198, 199, 200 Endoscopic sinus surgery, parent/caregiver information,
selection, 188, 188, 189t 813
skin grafting of external auditory canal, 207–210 Endoscopy
indications, 207 bronchoscopy, 569–577
postoperative care, 210 anesthetic considerations, 569–570
preparation, 207 indications, 569
procedure, 207, 207–210, 208, 209, 210 instrumentation, 570, 571, 572
Ear surgery. See Auricular repair; Otoplasty postoperative care, 577
Education, of parents and caregivers, 807–822. See also procedure, 572–577
Parent/caregiver information diagnostic bronchoscopy, 574, 575
Effusion, chronic middle-ear, 6, 7 foreign body removal, 576
Electrocautery introducing bronchoscope, 572, 573, 574
in epistaxis therapeutic bronchoscopy, 577
endoscopic-guided, 254, 254 esophagoscopy, 578–582
local, 253 anesthetic considerations, 578
in tonsillectomy, 389, 390, 390–393, 391, 392, 393 indications, 578
versus laser dissection, 388 instrumentation, 578, 579
Electromyography (EMG), 183 procedure
Electroneurography, 182 caustic ingestion, 580–582, 583
Electrophysiologic testing, facial nerve, 182–183 foreign body removal, 579–580, 581
Embolism, air, in craniofacial procedures, 806 introducing bronchoscope, 578, 579
EMLA Cream, 673 laryngoscopy, 564–569
Endaural approach anesthetic considerations, 563
anesthetic considerations, 27, 27 indications, 563
in external ear canal reconstruction, 188, 188, 189t, instrumentation, 563, 563–564
189–193, 190, 191, 192, 193 procedure, 564–569
indications, 26 diagnostic laryngoscopy, 566
postsurgical care, 31 introducing laryngoscope, 564, 564–566, 565,
preparation, 27 566
procedure, 27–31, 28, 29, 30, 31 laser laryngoscopy, 568–569
Endaural medial fascia graft tympanoplasty, 52–57, therapeutic laryngoscopy, 567, 567
53–57. See also Endaural approach pharyngoscopy, 562, 562
Endonasal approach photographic documentation, 559, 559–561
to rhinoplasty, 281t, 282–291, 283, 285, 287, 288- physiological considerations, 555
291 principles of endoscopic surgery, 556–558. See also
to septoplasty, 264-267 Anesthetics
Endoscopic arytenoidectomy, 598, 599 Endotracheal tube fire, in laser procedures, 635
Endoscopic dacryocystorhinostomy, 350, 351 Epiglottic cysts, 642, 643
Endoscopic ethmoidectomy/antrostomy, 319–338 Epistaxis, 251–257
anatomic considerations, 322–323, 323 anatomical classification, 251–252, 252
anesthetic considerations, 320–321 arterial ligation, 257
complications, 332, 333 endoscopic-guided cautery, 254, 254
in cystic fibrosis, 334, 334–337, 335, 336 local cautery, 253
indications, 319–320 packing
instrumentation, 321 anterior, 253–254
Index 835
posterior, 255, 255–256, 256 procedure, 159–170159

Esophagoscopy, 578–582 identification of nerve, 164, 164–166, 167
anesthetic considerations, 578 incision and exposure, 160, 160–163, 161, 162,
indications, 578 164
instrumentation, 578, 579 superficial and deep parotidectomy, 166–170,
procedure 167, 168, 169
caustic ingestion, 580–582, 583 extratemporal exploration and repair: trauma,
foreign body removal, 579–580, 581 171–183
introducing bronchoscope, 578, 579 indications, 171
Estlander flap, 680, 681 postoperative care, 174
Ethmoidectomy preparation, 171
endoscopic. See Endoscopic ethmoidectomy/ procedure, 171, 171–175, 172, 173, 175
antrostomy extratemporal repair, rerouting, and grafting,
external, 344–345, 345 176–182
Eustachian tube closure, surgical approach, 27 indications, 176
Eustachian tube dysfunction, 129–135. See also postoperative care, 181
Perilymphatic fistula preparation, 177
classification, 129 procedure, 177–182
fistulous tube: catheter obstruction, 132–135, 133, great articular nerve graft, 177
134 hypoglossal–facial anastomosis, 180, 181
obliteration, 129–131, 131 interposition grafting, 179–180, 181
tympanostomy tube insertion and, 6 sural nerve graft, 177–178, 178, 179
Eustachian tube injury, as complication of intratemporal exploration and decompression,
adenoidectomy, 386 139–150
Exploration, wound, 673 anesthetic considerations, 140
External approach indications, 140
to rhinoplasty, 291–298, 292, 293, 294, 295, 296, preparation, 141, 141–142
297 procedure, 142–148, 143
to septoplasty, 268–280 exploration, 148, 149
anesthetic considerations, 268–269 mastoidectomy, 144, 144–146, 145
indications/contraindications, 268, 269 nerve identification, 146–148, 147
procedure, 270, 270–280, 271, 272, 273, 275, postoperative care, 148–149
276, 277, 278, 279 intratemporal repair, rerouting, and grafting,
External carotid artery ligation, 397–401. See also 150–156, 694–695
Carotid artery ligation anesthetic considerations, 152
External ethmoidectomy, 344–345, 345 indications, 151–152
Extratemporal segment, of facial nerve, 138, 139 postoperative care, 156
Extubation, 826–827 principles of repair, 150–151
Eyebrow injuries, 692, 693 procedure, 152–156, 153
Eyelid injuries, 688–690 exploration, 148, 149, 153
interposition grafting, 154–156, 155, 156
Facial nerve anastomosis, 525 mastoidectomy, 144, 145, 152
Facial nerve surgery, 138–184 rerouting, 154, 155
anatomy, 137–139, 138 Facial paralysis, 139–149. See also Facial nerve
electrophysiologic testing, 182–183 procedures
extratemporal exploration and repair: lesions, Facial recess, 233, 234
157–170 Facial trauma, 671–700. See also Soft tissue surgery
anesthetic considerations, 157 Fat-plug graft myringoplasty, 41–48. See also under
indications, 157 Myringoplasty
postoperative care, 170 Fentanyl, 557
preparation, 158, 158–159 Fibromatosis colli, 512, 513
836 Index
Fine-needle aspiration Glioma, nasal, 300. See also Congenital nasal

cervical, 442–447, 443, 444, 445, 447 malformations
thyroid, 540 Glottic hemangioma, 663–664, 664
Fire, endotracheal tube, in laser procedures, 635 Glottic stenosis, posterior, 606, 607
Fistula Glottic web excision, 604–605, 605
branchial cleft Glycopyrrolate, 558
first, 498–500, 501 Grafts/grafting
second and third, 504–506, 505, 506 bone, maxillofacial, 758–760, 759
perilymphatic, 123–136. See also Perilymphatic fistula cartilage, in augmentation laryngoplasty, 616–618,
pre-auricular, 502, 503 617, 619
tracheocutaneous, 593, 593–594, 594, 595 cartilage-perichondrial, 71, 71
Fistulous eustachian tube, catheter obstruction in, conchal-cartilage, 71, 71
132–135, 133, 134 dorsal augmentation, 290, 290, 291
Fixation external auditory canal, 207, 207–210, 208, 209,
complications, 748–749, 752–753 210
maxillomandibular, 746–751, 747, 748, 749 facial nerve, 176–182
ossicular, 75, 77t indications, 176
rigid internal, 750, 750–753, 751, 753t postoperative care, 181
Flap(s). See also Palatoplasty preparation, 177
Abbe, 680, 681 procedure, 177–182
anterior pedicle, 64, 64 great articular nerve graft, 177
bone, devitalization of, 804 hypoglossal–facial anastomosis, 180, 181
in ear canal reconstruction, 193, 193 interposition grafting, 179–180, 181
Estlander, 680, 681 sural nerve graft, 177–178, 178, 179
Koerner, 35–38, 60, 60–61, 61, 68, 69 great articular nerve, 177
mucoperiosteal, 308, 308, 309, 310 hyoid interposition, 614, 615
pharyngeal interposition, of facial nerve, 179–180, 181
rolled, 415–416, 416 myringoplasty
superiorly based, 408–414, 409, 410, 413, 414 fat-plug graft, 45, 45, 46
tympanomeatal, 29–31, 55, 55, 56 perichondrial graft, 44, 44
Foreign body removal in septoplasty, 276, 276–280, 277, 278, 279
bronchoscopic, 576 sural nerve, 177–178, 178, 179
esophagoscopic, 579–580, 581 temporalis fascia, 54, 54
Four E’s mnemonic, 635 tissue selection for, 42
Fracture, nasal. See also Rhinoplasty tympanoplasty
closed reduction, 260, 260–263, 261, 263 cartilage graft, 66–72
Frenuloplasty, 376, 377. See also Tongue surgery endaural medial fascia graft, 52–57, 53–57. See
parent/caregiver information, 818 also Endaural approach
Frontal sinus trephination, 346, 347 fat-plug graft, 22–26, 49
Functional (modified) neck dissection, 452, 452–462, lateral fascia graft, 58–65, 58–66
453, 454, 455, 459, 461 postauricular medial cartilage-fascia, 67–72, 68–71
Furlow (double reversing Z-plasty) palatoplasty, postauricular medial fascia graft, 49–51, 50, 51
788–790, 789 transcanal medial fascia or fat-plug graft, 22–26,
49. See also Transcanal approach
Gland(s) Granulomas, vocal process, 650, 651
salivary, 515–538. See also Salivary gland procedures Great articular nerve graft, 177
sublingual, excision, 427, 431, 432. See also Grisel’s syndrome (atlantoaxial subluxation), as compli-
Drooling cation of adenoidectomy/tonsillectomy,
submandibular, excision, 526–531, 527, 528, 386, 396
529530, 531 Grommet-type tympanostomy tube insertion, 6–11,
Glasscock dressing, 31 7, 8, 9
Index 837
Halothane, 556 Infections

Halving technique, in wound closure, 676, 677 deep neck
Head and neck surgery, parent/caregiver information, “danger” space drainage, 488–489
814 masticator space drainage, 475–476
Head trauma, 140. See also Facial nerve procedures; parotid space drainage, 477, 477–478, 479
Maxillofacial surgery peritonsillar space drainage, 480, 481
Helical rim defects, auricular, 683, 683–684 pharyngomaxillary (lateral pharyngeal) space
Heliox administration, 558 drainage, 472–474, 473, 474
Hemangioma prevertebral space drainage, 486
glottic, 663–664, 664 retropharyngeal space drainage, 482–486, 485
laryngeal, 663–664, 664 submandibular space drainage, 468–470, 469, 471
Hematoma vascular (carotid) space drainage, 487, 487–488
auricular, 682 visceral space drainage, 482
septal, drainage, 339–340, 340 of facial soft tissue wounds, 678
Hemorrhage mastoiditis, 91–92, 96
postoperative, in craniofacial procedures, 804 postoperative, in craniofacial procedures, 804
post-tonsillectomy, 380, 395, 397–401. See also upper respiratory, anesthesia and, 825
Carotid artery ligation Infiltration anesthetics, 673–674
Hopkins rod-lens telescope, 70, 70 Inflammatory disease, sinonasal, 339–351
Hygroma, cystic (lymphangioma), 496–498 septal abscess or hematoma, 339–340, 340
Hyoid interposition grafts, 614, 615 Internal approach, to septoplasty, 264–267
Hyperflex tracheostomy tubes, 587 anesthetic considerations, 265
Hypernasality indications/contraindications, 264, 264–265
after uvulopalatopharyngoplasty (UPPP), 405 preparation, 265
as complication of adenoidectomy, 386 procedure, 265, 265–266, 267
Hypertrophic scars, 678 Interposition grafting, facial nerve, 154–156, 155, 156
Hypoglossal–facial nerve anastomosis, 180, 181 Intracordal cysts, 648, 649
Intracranial segment, of facial nerve, 137, 138
Iatrogenic complications Intraoral ranula excision, 536–538, 537
of adenoidectomy, 386 Intratemporal segment, of facial nerve, 137–138, 138
facial nerve injury, 140. See also Facial nerve Intratympanic membrane congenital cholesteatoma,
procedures 104, 104, 105
of tonsillectomy, 396 Isoflurane, 557
Incisional biopsy, cervical, 448–451, 449, 451
Incisions Keloids, 678
coronal, 732–734, 733 Ketamine, 827
laryngotracheal, 619 Ketorolac tromethamine, contraindications, 380
preauricular, 742, 743 Koerner flap, 35, 35, 60, 60–61, 61, 68, 69
for repair of choanal atresia, 307, 307
retromandibular, 742, 743 Labyrinthine segment, of facial nerve, 138, 138
submandibular, 740, 741 Lacerations
submental, 740, 741 auricular, 682
superior lid crease, 734, 735 eyelid, 688–690, 689
transconjunctival, 736, 737 facial nerve, 171–176
vestibular or canine fossa, 738, 739 lip, 678–680, 679, 681
vestibular sulcus parotid duct, 694
anterior, 744, 745 Lambdoidal craniosynostosis, 802, 802–803, 803
posterior, 744, 745 Laryngeal decompression (cricoid split) with hyoid
Incus interposition, 81, 81 interposition, 612–614, 613, 615
Incus prostheses, 76 Laryngeal hemangioma, 663–664, 664
Incus-stapes prostheses, 76 Laryngeal mask, 380
838 Index
Laryngeal nerve, 552 laryngeal papillomatosis, 652, 653

injury to, 552–553 laryngeal webs, 654, 655–657
recurrent Reinke’s edema and vocal cord polyps, 660–662,
anatomic localization, 546–547, 547 661, 662, 663
anomalous (nonrecurrent), 547 subglottic stenosis, 665, 665–666, 666
monitoring, 540, 541 tracheal stenosis, 668
superior, 548, 552–553 vocal cord nodules, 658, 659
Laryngeal papillomatosis, 652, 653 vocal process granulomas, 650, 651
Laryngeal separation, 608–610, 609, 610, 611 posterior glottic stenosis repair, 606, 607
Laryngeal webs, 654, 655–657 segmental tracheal resection, 624–626, 625
Laryngoscopes, 563, 563–564 supraglottoplasty, 602, 603
Laryngoscopy, 564–569 Laser laryngoscopy, 568–569
anesthetic considerations, 563 Laser myringotomy, 4
indications, 563 Lasers
instrumentation, 563, 563–564 carbon dioxide (CO2), 633–639, 634
parent/caregiver information, 817 neodymium-yttrium-aluminum-garnet (Nd:YAG)
procedure, 564–569 laser, 639–641, 641
diagnostic laryngoscopy, 566 potassium-titanyl-phosphate (KTP), 639
introducing laryngoscope, 564, 564–566, 565, 566 Laser surgery, laryngotracheal
laser laryngoscopy, 568–569 cysts
therapeutic laryngoscopy, 567, 567 epiglottic, 642, 643
Laryngospasm, anesthesia and, 825 intracordal, 648, 649
Laryngotracheal surgery, 597–669 vallecular, 644, 645
arytenoidectomy, 597–600 ventricular, 646, 647
anesthetic considerations, 598 instrumentation
indications, 597 carbon dioxide laser, 633–639, 634
preparation, 598 neodymium-yttrium-aluminum-garnet (Nd:YAG)
procedure laser, 639–641, 641
endoscopic arytenoidectomy, 598, 599 potassium-titanyl-phosphate (KTP) laser, 639
open technique, 600, 601 laryngeal and glottic hemangiomas, 663–664, 664
postoperative care, 600 laryngeal webs, 654, 655–657
augmentation laryngoplasty Reinke’s edema and vocal cord polyps, 660–662,
with cartilage graft, 616–618, 617, 619 661, 662, 663
with cartilage stent, 620, 620–622, 621, 623 subglottic stenosis, 665, 665–666, 666
cricotracheal resection, 626–630, 627, 629, 631 tracheal stenosis, 668
glottic web excision, 604–605, 605 vocal cord nodules, 658, 659
laryngeal decompression (cricoid split) with hyoid vocal process granulomas, 650, 651
interposition, 612–614, 613, 615 Laser tonsillectomy, versus electrocautery, 388
laryngeal separation, 608–610, 609, 610, 611 Lateral fascia graft tympanoplasty, 58–65, 58–66
laser surgery, 633–669 Lateral rhinotomy, 312–315, 313. See also Nasal
cysts surgery
epiglottic, 642, 643 Lavage, antral, 341, 341–342
intracordal, 648, 649 Lempert procedures, modified, 27–31. See also
vallecular, 644, 645 Endaural approach
ventricular, 646, 647 Lidocaine, 673–674
instrumentation intravenous, 557
carbon dioxide (CO2) laser, 633–639634 topical, 557
neodymium-yttrium-aluminum-garnet Lingual nerve palsy, after tonsillectomy, 396
(Nd:YAG) laser, 639–641, 641 Liquefaction (suction coagulator) adenoidectomy, 384
potassium-titanyl-phosphate (KTP) laser, 639 Lymphangioma (cystic hygroma), 496–498
laryngeal and glottic hemangiomas, 663–664, 664 Lymph node dissection. See Cervical adenopathy
Index 839
Magnetic stimulation testing, 183 intraoral

Mandibular exposure, 731 anterior vestibular sulcus incision, 744, 745
extraoral complications, 744–745
complications, 742 posterior vestibular sulcus incision, 744, 745
preauricular incision, 742, 743 nasoethmoid, naso-orbital ethmoid, and skull base
retromandibular incision, 742, 743 trauma/subcranial approach, 753–757,
submandibular incision, 740, 741 755, 757
submental incision, 740, 741 superior lid crease incision, 734, 735
intraoral transconjunctival incision, 736, 737
anterior vestibular sulcus incision, 744, 745 vestibular or canine fossa incision, 738, 739
complications, 744–745 Maximal stimulation testing (MST), 182
posterior vestibular sulcus incision, 744, 745 Medial fascia or fat-plug graft myringoplasty, 41–48.
Masses. See Cystic lesions; Neoplasia See also under Myringoplasty
Masticator space, drainage, 475–476 Metopic craniosynostosis, 798, 798, –799, 799
Mastoid, surgical approaches, 21–38 Microdebrider (shaver) adenoidectomy, 384–386, 385,
endaural, 26–31, 27, 28, 29, 30, 31 387
postauricular, 32, 32–38, 33, 34, 35, 36, 37 Microdebrider technology, versus laser surgery, 652
transcanal, 21–26, 22, 23, 24, 25, 26 Microdebrider tips, 336
Mastoidectomy, 91–100. See also Cholesteatoma Microtia repair, 701–715
canal wall–up vs. canal wall–down, 101–102 anesthetic considerations, 702
in cochlear implantation, 232, 233 general considerations, 701
in facial nerve procedures, 144, 144–146, 145, 152 indications and timing, 702
modified radical, 96–98, 97 preparation, 702, 702–704, 703, 704
radical, 98–99, 99 procedure overview, 704
simple (cortical, complete), 91–95, 93, 95 stage 1: rib harvest, 705, 705–710, 706, 707, 708,
tympanomastoidectomy, 100 709
Mastoiditis, 91, 96 stage 2: lobule transposition, 710, 711
acute “coalescent,” 91–92 stage 3: separation from head and creation of
Mastoid subsegment, of facial nerve, 138, 139 functional postauricular sulcus, 712, 713
Maxillofacial trauma, 727–761. See also Facial nerve stage 4: optional creation of tragus or contralateral
repair; Facial trauma; Soft tissue repair otoplasty, 714, 715
anatomical considerations, 727–728, 729 Midazolam, in postoperative nausea and vomiting, 826
bone grafting, 758–760, 759 Middle ear, surgical approaches, 21–38
coronal incision, 732–734, 733 endaural, 26–31, 27, 28, 29, 30, 31
evaluation and management, 729–732 postauricular, 32, 32–38, 33, 34, 35, 36, 37
definitive management, 729–730 transcanal, 21–26, 22, 23, 24, 25, 26
initial management, 729 Middle-ear/mastoid surgery, parent/caregiver
surgical exposure, 730–731 information, 815
mandible, 731 Mitomycin C, topical use in nasal surgery, 303
skull and upper orbits, 730–731 Modified radical mastoidectomy, 96–98, 97
fixation Morphine, 557
complications, 748–749, 752–753 Mortality
maxillomandibular, 746–751, 747, 748, 749 in anesthesia, 807, 808
rigid internal, 750, 750–753, 751, 753t in craniofacial procedures, 804
mandibular exposure Mucocele, 372–375. See also Tongue surgery
extraoral Mucoperiosteal flap, 308, 308, 309, 310
complications, 742 Mucosal injuries, nasal, 687
preauricular incision, 742, 743 Muscle relaxants, 558
retromandibular incision, 742, 743 Myringoplasty
submandibular incision, 740, 741 approach and technique selection, 40–41
submental incision, 740, 741 fat-plug graft, 45, 45, 46, 48, 48
840 Index
with medial fascia or fat-plug graft, 41–48 external approach, 268–280

anesthetic considerations, 42 anesthetic considerations, 268–269
indications, 41–42 indications/contraindications, 268, 269
preparation, 42 procedure, 270, 270–280, 271, 272, 273, 275,
procedure, 42–48, 43–48 276, 277, 278, 279
tissue selection for graft, 42 internal approach, 264–267
perichondrial graft, 44, 44 anesthetic considerations, 265
Myringotomy, 4, 4–5. See also Tympanostomy tubes indications/contraindications, 264, 264–265
laser, 4 preparation, 265
procedure, 265, 265–266, 267
Narcotic analgesics, 827 postoperative care, 280
Nasal dermoids, 300. See also Congenital special considerations, 280
malformations soft tissue repair, 686–687
Nasal fracture, closed reduction, 260, 260–263, 261, avulsion, 687
263 cartilaginous framework injuries, 686–687
Nasal glioma, 300 cutaneous defects, 686
Nasal malformations, congenital, 299–317. See also mucosal injuries, 687
under Nasal surgery and specific lesions Nasal teratoma, 300. See also Congenital malformations
Nasal splint, 291 Nasal tip deformity, 286–289, 287, 288, 289, 293,
Nasal surgery, 259–298 293–296, 294, 295, 296. See also
congenital nasal malformations, 299–317 Rhinoplasty
choanal atresia Nasoethmoid, naso-orbital ethmoid, and skull base
transnasal repair, 300–306, 301, 302, 303.304, trauma/subcranial approach, 753–757,
305 755, 757
transpalatal repair, 306–312, 307, 308, 309, Nasopharyngeal stenosis, as complication of ade-
310, 311 noidectomy, 386
lateral rhinotomy, 312–315, 313 Nasopharyngoscopy, in velopharyngeal insufficiency,
overview of lesions, 299–300 407. See also Velopharyngeal insufficiency
sublabial approach, 315, 315–316, 316 Nausea and vomiting, postoperative, 826
fracture: closed reduction, 260, 260–263, 261, 263 Neck, fascial layers, 465–466, 467
in inflammatory sinonasal disease, 339–351 Neck dissection
antral aspiration and lavage, 341, 341–342 functional (modified), 452, 452–462, 453, 454,
Caldwell-Luc procedure, 342–344, 343 455, 457, 459, 461
dacryocystorhinostomy, 348–350, 349, 351 radical, 453, 454, 457
external ethmoidectomy, 344–345, 345 Neck surgery
frontal sinus trephination, 346, 347 in cervical adenopathy, 441–463
septal abscess or hematoma, 339–340, 340 cervical needle biopsy, 448–451, 449, 451
principles, 259–260 functional (modified) neck dissection, 452,
rhinoplasty, 281–298 452–462, 453, 454, 455, 459, 461
anesthetic considerations, 282 percutaneous needle biopsy, 442–447, 443, 444,
approach selection, 281, 281t 445, 447
complications, 298 preliminary considerations, 441–442
indications, 281 in congenital malformations, 491–514
postoperative care, 298 cystic hygroma (lymphangioma), 496–498
procedure fibromatosis colli, 512, 513
endonasal approach, 281t, 282–291, 283, 285, first branchial cleft fistula, 498–500, 501
287, 288, 289, 290, 291 fourth branchial pouch sinus, 507, 507–510, 509,
external approach, 291–298, 292, 293, 294, 511
295, 296, 297 pre-auricular pit or fistula, 502, 503
with septoplasty, 280 second and third branchial cleft fistula, 504–506,
septoplasty, 264–280 505, 506
Index 841
thyroglossal duct cyst, 482, 491–494, 493, 495 Opioids, as adjunctives to anesthesia, 557
in deep neck infections, 465–489 Oropharyngeal stenosis, in tonsillectomy, 396
anatomical considerations, 465–466, 467 Ossicular discontinuity, 75, 77t
“danger” space drainage, 488–489 Ossicular fixation, 75, 77t
masticator space drainage, 475–476 Ossiculoplasty, 75–89
parotid space drainage, 477, 477–478, 479 advancement flap, 78–80, 78–80
peritonsillar space drainage, 480, 481 etiologic considerations, 75
pharyngomaxillary (lateral pharyngeal) space incus interposition, 81, 81
drainage, 472–474, 473, 474 outcomes and prognostic factors, 85–87, 86t
prevertebral space drainage, 486 partial ossicular replacement prosthesis (PORP), 82,
retropharyngeal space drainage, 482–486, 485 82, 86t
submandibular space drainage, 468–470, 469, 471 recommendations, 87–88
vascular (carotid) space drainage, 487, 487–488 reconstruction options, 76, 77t
visceral space drainage, 482 surgical approach, 22
thyroidectomy, 539–554 timing of, 102–103
anesthetic considerations, 540 total ossicular replacement prosthesis (TORP), 76,
postoperative care, 552–554 83–84, 83–84, 86t
preoperative evaluation, 539–540 Osteitis, acute mastoid, 92, 94
preparation, 540–543, 541, 542 Otitis media
procedure, 540–552, 543, 544, 545, 546, 547, chronic suppurative, 140
548, 549, 551, 553 chronic suppurative, 92, 94, 96
Necrosis, scalp, in craniofacial procedures, 805 facial nerve complications, 140
Needle aspiration, 1–3 tympanostomy tube insertion and, 6
of middle ear. See also Fine-needle aspiration; Otoplasty
Tympanocentesis; Tympanostomy tube in microtia, 701–715. See also under Auricular repair
Neodymium-yttrium-aluminum-garnet (Nd:YAG) in prominent (lop) ear, 717–726. See also under
laser, 639–641, 641 Auricular repair
Neoplasia Otorrhea, postsurgical, 9, 17
cervical, 441–463. See also Cervical adenopathy and Otosclerosis, surgical approach, 22
specific procedures Owens incision, 307, 307
of tongue, 367–378. See also Tongue
Nerve excitability testing (NET), 182 Pain, management of postoperative, 827–828
Neurectomy, tympanic, 438 Palatoplasty, 780–790
Neuroma, facial nerve, 140 anesthetic considerations and preparation, 780
Neuromuscular blockade, 558 complications, 780
Neurovascular preservation, in cervical biopsy postoperative care, 781
procedures, 442, 448, 455 procedures
Newborn vs. adult temporal bone, 521 double reversing Z-plasty (Furlow), 788–790, 789
Nodules, vocal cord, 658, 659 selection, 780–781
two-flap, 785, 785–786, 786, 787
Obliteration, of eustachian tube, 129–131, 131 V to Y pushback, 782, 782–784, 783, 784
Obstetric trauma, facial nerve, 140. See also Facial timing, 763, 780
nerve procedures Papillomatosis, laryngeal, 652, 653
Obstructive sleep apnea syndrome. See Adenoidecto- Paralysis, facial, 139–149. See also Facial nerve surgery
my; Tonsillectomy; Uvulopalato Parent/caregiver information, 807–822
pharyngoplasty (UPPP) anesthesia education sheet, 807, 808
Ondansetron, in postoperative nausea and vomiting, procedure education sheets, 822
826 adenoidectomy, 811
Ophthalmologic complications, in craniofacial ear tube insertion, 810
procedures, 805 ear tube removal, 816
Opiate analgesics, 827 endoscopic sinus surgery, 813
842 Index
frenuloplasty, 818 indications, 124

head & neck surgery, 814 postoperative care, 128
laryngoscopy and bronchoscopy, 817 preoperative evaluation, 124
middle-ear/mastoid surgery, 815 procedure, 125, 125–128, 126, 127
tonsillectomy, 812 Periorbital injuries, 688–693
satisfaction versus efficiency, 822 eyelid injuries, 688–690
Parotid duct anatomical considerations, 688, 689
ligation, 428t, 436–437, 437. See also Drooling lacerations, 688–690, 689
repair, 694 medial, 690–693
anatomical considerations, 694 canalicular anatomy, 691, 691
avulsion, 694 canalicular repair, 692, 692
laceration, 694 canthal anatomy, 691
trauma to, 672 canthal tendon injury, 690, 691
Parotidectomy eyebrow injuries, 692, 693
anatomic considerations, 521 Peritonsillar space, drainage, 480, 481
facial nerve anastomosis, 525 Pharyngomaxillary (lateral pharyngeal) space, drainage,
postoperative care, 170, 524 472–474, 473, 474
preparation, 158, 158–159 Pharyngoplasty, sphincter, 419–421, 421
procedure, 159–170, 159, 516, 516–526, 517, 518, Pharyngoscopy, 562, 562
519, 521, 522, 523, 525 Photodocumentation
anesthetic considerations, 515–516 of endoscopy, 559, 559–561
identification of facial nerve, 164, 164–166, 167 of facial soft tissue surgery, 672
incision and exposure, 160, 160–163, 161, 162, Plagiocephaly, 794, 795
164, 517 posterior, 802, 802–803, 803
indications, 515 Plunging ranula excision, 532–534, 533, 534, 535
preparation, 515–516 Pneumocephaly, postoperative, in craniofacial
superficial and deep parotidectomy, 166–170, 167, procedures, 805
168, 169 Polyps, vocal cord, 660–662, 661, 662, 663
total parotidectomy, 522-524 Postauricular approach
Parotid space, drainage, 477, 477–478, 479 anesthesia, 32, 32
Pars flaccida attic cholesteatoma, 117–121 in external ear canal reconstruction, 188, 189, 189t,
anesthetic considerations, 118 194, 194–200, 195, 196, 197, 198, 199,
confined to anterior epitympanum, 118, 118, 119 200
extending into mastoid, 120, 120 indications, 32
extensive, 121, 121 preparation, 33
indications, 117, 117 procedure, 33, 33–38, 34, 35, 36, 37
Pars tensa Postauricular medial fascia graft tympanoplasty, 49–51,
atelectasis, 58 50, 51
perforation, 58 Posterior glottic stenosis repair, 606, 607
Partial ossicular replacement prosthesis (PORP), 76, Posterior pharyngeal wall augmentation, 417–419, 418
82, 82, 86t Posterior vestibular sulcus incision, 744, 745
Patient-controlled analgesia, 828 Posterosuperior quadrant acquired cholesteatoma
Pedicle flap, anterior, 64, 64 extending into epitympanum, 114, 114
Percutaneous needle biopsy, cervical, 442–447, 443, extending into mastoid gas cells, 115, 115
444, 445, 447 extensive, 116, 116
Perichondrial graft myringoplasty, 44, 44 in posterior mesotympanum, facial recess, and sinus
Perilymphatic fistula, 123–136. See also Eustachian tympani, 112, 112, 113
tube dysfunction postoperative care, 116
acquired, 123 Postoperative nausea and vomiting, 826
congenital, 123–128 Potassium-titanyl-phosphate (KTP) laser, 639
anesthetic considerations, 124–125 Preauricular incision, 742, 743
Index 843
Preauricular pit or fistula, 502, 503 external approach, 291–298, 292, 293, 294, 295,
Prematurity, apnea of, 826 296, 297
Prevertebral space, drainage, 486 with septoplasty, 280
Prominent (lop) ear, 717–726 Rhinotomy, lateral, 312–315, 313. See also Nasal
anatomical considerations, 717, 718 surgery
anesthetic consideration, 719 Rolled pharyngeal flap, 415–416, 416
complications and long-term outcomes, 724 Ruddy incision, 307, 307
indications, 717–719
postoperative care, 724 Sagittal craniosynostosis, 800, 801
preparation, 719 Salivary gland surgery, 515–538. See also Parotid glands
procedure, 720, 720–724, 721, 723, 725 parotidectomy, 515–526, 516, 517, 518, 519, 521,
Propofol, 557, 827 522, 523, 525
Prostheses, ossicular replacement ranula excision, 532–538
partial (PORP), 76, 82, 82, 86t, 87 intraoral, 536–538, 537
total (TORP), 76, 83–84, 83–84, 86t, 87 plunging, 532–534, 533, 534, 535
types of, 76 submandibular gland excision, 526–531, 527, 528,
Pulmonary edema, post-tonsillectomy, 396 529530, 531
Pyriform aperture stenosis, 300. See also Congenital Scalp necrosis, in craniofacial procedures, 805
malformations Scaphocephaly, 800, 801
Scar revision, 695–699
Quadrilateral cartilage (QC). See Septoplasty broken line closures, 698, 699
dermabrasion, 699
Radical mastoidectomy, 98–99, 99 indications and timing, 696
modified, 96–98, 97 serial excision, 696
Radiologic evaluation, in thyroid surgery, 539 simple excision, 696
Radioscintigraphy, thyroid, 539 Z-plasty, 696–697, 697
Ranula Scars, hypertrophic, 678
excision Scopolamine, 558
intraoral, 536–538, 537 Second and third branchial cleft fistula, 504–506, 505,
plunging, 532–534, 533, 534, 535 506
formation, in drooling correction procedures, 435 Sedation, 827. See also Anesthesia; Anesthetic
Recurrent laryngeal nerve considerations
anatomic localization, 546–547, 547 Segmental tracheal resection, 624––626, 625
anomalous (nonrecurrent), 547 Seizures, postoperative, in craniofacial procedures,
injury to, 552–553 804
monitoring, 540, 541 Septal abscess, drainage, 339–340, 340
Reinke’s edema and vocal cord polyps, 660–662, 661, Septal hematoma, drainage, 339–340, 340
662, 663 Septoplasty, 264–280
Remifentanil, 557 external approach, 268–280
Retraction pocket defect, 66, 68 anesthetic considerations, 268–269
Retromandibular incision, 742, 743 indications/contraindications, 268, 269
Retropharyngeal space, drainage, 482–486, 485 procedure, 270, 270–280, 271, 272, 273, 275,
Rhinoplasty, 281–298 276, 277, 278, 279
anesthetic considerations, 282 internal approach, 264–267
approach selection, 281, 281t anesthetic considerations, 265
complications, 298 indications/contraindications, 264, 264–265
indications, 281 preparation, 265
postoperative care, 298 procedure, 265, 265–266, 267
procedure postoperative care, 280
endonasal approach, 281t, 282–291, 283, 285, special considerations, 280
287, 288, 289, 290, 291 Sevoflurane, 556
844 Index
Shaver (microdebrider) adenoidectomy, 384–386, 385, preparation, 672–673

387 anesthetic considerations, 673–674
Shiley tracheostomy tubes, 587 facility selection, 672
Sialorrhea, See Drooling instruments and sutures, 673
Sickle cell disease, preoperative evaluation in, 380 photo documentation, 672
Simple (cortical, complete) mastoidectomy, 91–95, 93, wound care, 676
95 wound closure, 675–676, 677
Sinus surgery wound preparation, 674–675
endoscopic ethmoidectomy/antrostomy, 319–338 lip repair, 678–680, 679, 681
anatomic considerations, 322–323, 323 nasal repair, 686–687
anesthetic considerations, 320–321 avulsion, 687
complications, 332, 333 cartilaginous framework injuries, 686–687
in cystic fibrosis, 334, 334–337, 335, 336 cutaneous defects, 686
indications, 319–320 mucosal injuries, 687
instrumentation, 321 parotid duct repair, 694
postoperative care, 330 anatomical considerations, 694
preoperative evaluation, 320 avulsion, 694
preparation, 322, 322 laceration, 694
procedure, 322–330, 325, 326, 327, 328, 329, 330 periorbital injuries, 688–693
in inflammatory sinonasal disease, 339–351 eyelid injuries, 688–690
antral aspiration and lavage, 341, 341–342 anatomical considerations, 688, 689
Caldwell-Luc procedure, 342–344, 343 lacerations, 688–690, 689
dacryocystorhinostomy, 348–350, 349, 351 medial, 690–693
external ethmoidectomy, 344–345, 345 canalicular anatomy, 691, 691
frontal sinus trephination, 346, 347 canalicular repair, 692, 692
septal abscess or hematoma, 339–340, 340 canthal anatomy, 691
sphenoid sinus, 353–365 canthal tendon injury, 690, 691
direct transnasal sphenoidotomy, 358–363, 359, eyebrow injuries, 692, 693
361, 363 scar revision, 695–699
surgical approaches, 353–355 broken line closures, 698, 699
transnasal transethmoidal sphenoidotomy, dermabrasion, 699
355–356, 357 indications and timing, 696
Sinus tract, fourth branchial cleft, 507, 507–510, 509, serial excision, 696
511 simple excision, 696
Skull and upper orbits, surgical exposure, 730–731 Z-plasty, 696–697, 697
Soft tissue surgery, 671–700 Sphenoidotomy
auricular direct transnasal, 358–363, 359, 361, 363
microtia repair, 701–715. See also Microtia transnasal transethmoidal, 355–356, 357
for prominent ear (prominauris), 717–726. See also transorbital, 353, 354
Otoplasty transpalatal, 353, 354
auricular repair, 682–685 transseptal, 353, 354–355
avulsions, 684, 685 Sphincter pharyngoplasty, 419–421, 421
composite defects, 684 SPITE acronym, 85
cutaneous defects, 682–683 Stapedial muscle reflex testing, 183
helical rim defects, 683, 683–684 Steinzeug incision, 307, 307
hematoma, 682 Stenosis
lacerations, 682 ear canal, 185–210. See also under Ear canal
facial nerve repair, 694–695 nasopharyngeal, as complication of adenoidectomy,
general principles, 671–678 386
complications, 678 oropharyngeal, in tonsillectomy, 396
initial patient encounter, 671–672 posterior glottic, 606, 607
Index 845
pyriform aperture, 300. See also Congenital nasal Sutures

malformations in facial surgery, 675–676, 677
subglottic, 665, 665–666, 666 for soft tissue surgery, 673
tracheal, 668
velopharyngeal, after uvulopalatopharyngoplasty Temporal bone, newborn vs. adult, 521
(UPPP), 405 Temporalis fascia graft, 54, 54
Stents Teratoma, nasal, 300. See also Congenital malformations
cartilage, in augmentation laryngoplasty, 620, Thromboembolic complications, in craniofacial
620–622, 621, 623 procedures, 806
in repair of choanal atresia, 304, 304, 305, 311 Thyroglossal duct cyst, 482, 491–494, 493, 495
in sinus procedures, 330, 331 Thyroid biopsy, 540
Subcranial approach, 753–757, 755, 757 Thyroidectomy, 539–554
Subglottic stenosis, 665, 665–666, 666 anesthetic considerations, 540
Sublabial approach, 315, 315–316, 316 postoperative care, 552–554
Sublingual gland, excision, 427, 431, 432. See also preoperative evaluation, 539–540
Drooling preparation, 540–543, 541, 542
Subluxation, atlantoaxial (Grisel’s syndrome), as com- procedure, 540–552, 543, 544, 545, 546, 547, 548,
plication of adenoidectomy/tonsillectomy, 549, 551, 553
386, 387 Thyroid scanning, 539
Submandibular duct relocation, 428t, 433–435, 435 Thyroid tests, 539
with sublingual gland excision, 427–432, 428t, 429, Tissue adhesives, 676
430, 431, 433 Tissue conservation, in facial surgery, 673
Submandibular gland, excision, 526–531, 527, 528, Tongue surgery, 367–378
529530, 531 anterior lesions, 367–368, 368
Submandibular incision, 740, 741 base (mucocele), 372–375
Submandibular space, drainage, 468–470, 469, 471 intraoral approach, 372, 373
Submental incision, 740, 741 transcervical approach, 374, 375
Suction coagulator (liquefaction) adenoidectomy, frenuloplasty, 376, 377
384 macroglossia, 369–370, 370, 371
Sufentanil, 557 Tongue-tie. See Ankyloglossia
Sun exposure, of soft tissue wounds, 676 Tonsillectomy, 380–397. See also Adenoidectomy
Superior laryngeal nerve, 548, 552–553 anesthetic considerations, 380
injury to, 552–553 complications, 395–396
Superior lid crease incision, 734, 735 parent/caregiver information, 812
Superiorly based pharyngeal flap, 408–414, 409, 410, postoperative care, 395
413, 414 preoperative evaluation/coagulation studies, 379–380
Suppurative complications, tympanostomy tube preparation, 380–381
insertion and, 6 procedure, 383, 388–393, 389, 390, 391, 392, 394
Suppurative otitis media, 140 Total intravenous anesthesia (TIVA), 557
chronic, 92, 94, 96 Total ossicular replacement prosthesis (TORP), 76,
Supraglottoplasty, 602, 603 83–84, 83–84, 86t
Sural nerve graft, 177–178, 178, 179 Tracheal stenosis, 668
Surgical approaches. See also under specific procedures Tracheocutaneous fistula closure, 593, 593–594, 594,
in antral aspiration and lavage, 342 595
to middle ear and mastoid, 21–38 Tracheostomy, defined, 585
endaural, 26–31, 27, 28, 29, 30, 31 Tracheostomy tubes, 587, 587t. See also
postauricular, 32, 32–38, 33, 34, 35, 36, 37 Laryngotracheal procedures
transcanal, 21–26, 22, 23, 24, 25, 26 Tracheotomy, 585–596
to sphenoid sinus, 353–354 anesthetic considerations, 585
subcranial, 753–757, 755, 757 complications, 592
sublabial, 315, 315–316, 316 indications, 585
846 Index
instrumentation, 586, 587, 587t postauricular medial cartilage-fascia approach,

postoperative care, 592 67–72, 68–71
preparation, 585–586, 586 postauricular medial fascia graft, 49–51, 50, 51.
procedure, 588, 588–592, 589, 590, 591 See also Postauricular approach
tracheocutaneous fistula closure, 593, 593–594, 594, surgical approach, 21
595 transcanal medial fascia or fat-plug graft, 22–26, 49.
Transcanal approach, 21–26 See also Transcanal approach
anesthetic considerations, 22, 22 Tympanostomy tube insertion and, 6
indications, 21–22 Tympanoplasty, surgical approach, 26
postsurgical care, 26 Tympanostomy
preparation, 23 exploratory, 22
procedure, 23, 23–26, 24, 25, 26 “second-look,” 21–22
Transcanal medial fascia or fat-plug graft tympanoplas- Tympanostomy tubes
ty, 22–26, 49. See also Transcanal approach Armstrong, 16
Transconjunctival incision, 736, 737 extrusion of, 10–11
Transnasal repair, in choanal atresia, 300–306, 301, insertion, 72
302, 303.304, 305 grommet-type, 6–11
Transnasal sphenoidotomy, direct, 358–363, 359, 361, anesthetic considerations, 7
363 complications and sequelae, 10–11
Transnasal transethmoidal sphenoidotomy, 355–356, indications, 6
357 postoperative care, 9–10
Transorbital sphenoidotomy, 353, 354 procedure, 7, 7–9, 8, 9
Transpalatal repair, in choanal atresia, 306–312, 307, parental education, 810, 816, 819–822, 820–821
308, 309, 310, 311 Per-Lee, 12–13
Transpalatal sphenoidotomy, 353, 354 permanent insertion, 11–15
Transseptal sphenoidotomy, 353, 354–355 indications, 12
Trauma postoperative care, 15
facial, 671–700. See also Soft tissue surgery procedure, 12, 12–15, 13, 14, 15
head, 140. See also Facial nerve surgery removal, 16–19
maxillofacial, 727–761. See also Maxillofacial anesthetic considerations, 17
trauma case selection, 16
Trephination, frontal sinus, 346, 347 indications, 16–17
Trigonocephaly, 798, 798, –799, 799 postoperative care, 19
Tumors. See Neoplasia procedure, 17, 17–18, 18
Two-flap palatoplasty, 785, 785–786, 786, 787 T-tube, Richards, 14–15
Tympanic neurectomy, 438
Tympanic subsegment, of facial nerve, 138, 138 Ultrasonography, in thyroid evaluation, 539
Tympanocentesis, 1–3 Uncinectomy, 324–326, 325
anesthetic considerations, 1 Unilateral coronal craniosynostosis, 794, 795
indications, 1 Upper respiratory infection, anesthesia and, 825
postoperative care, 3 Uvulopalatopharyngoplasty (UPPP), 402–405
procedure, 2, 2–3, 3 complications, 405
Tympanomastoidectomy, 91, 92, 100. See also indications, 402
Mastoidectomy postoperative care, 405
Tympanomeatal flap, 29–31, 55, 55, 56 procedure, 402–404, 403, 404
Tympanoplasty, 50, 51
approach and technique selection, 41–42 Vallecular cysts, 644, 645
cartilage graft, 66–72 Vascular (carotid) space, drainage, 487, 487–488
endaural medial fascia graft, 52–57, 53–57. See also Velopharyngeal examination, before adenoidectomy,
Endaural approach 381
lateral fascia graft, 58–65, 58–66 Velopharyngeal insufficiency, 407–425
Index 847
general considerations, 407 anterior, 744, 745

lateral port revision posterior, 744, 745
enlarging, 424, 424–425 Visceral space, of neck, drainage, 482
narrowing, 422, 422–423 Visual acuity tests, 672
posterior pharyngeal wall augmentation, 417–419, Vocal cord nodules, 658, 659
418 Vocal cord paralysis. See Arytenoidectomy
rolled pharyngeal flap, 415–416, 416 Vocal process granulomas, 650, 651
sphincteroplasty, 419–421, 421 V to Y pushback palatoplasty, 782, 782–784, 783, 784
superiorly based pharyngeal flap, 408–414
flap positioning, 410, 413, 414 Webs, laryngeal, 654, 655–657
incisions, 409, 410 Wilson incision, 307, 307
surgical outcomes, 425 Wound care, in facial soft tissue surgery, 676
Velopharyngeal stenosis, after uvulopalatopharyngo- Wound closure, in facial surgery, 675–676, 677
plasty (UPPP), 405
Ventricular cysts, 646, 647 Xomed NIM II EMG endotracheal tube, 541
Vermilion border, 678
Vestibular or canine fossa incision, 738, 739 Z-plasty, 696–697, 697
Vestibular sulcus incision double reversing (Furlow) palatoplasty, 788–790, 789

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Surgical Atlas

RICHARD M. ROSENFELD, MD, MPH

Sales and Distribution

Surgical Atlas of Pediatric Otolaryngology is a unique and comprehensive ref-

A unique feature of the Surgical Atlas is that technical descriptions are

Richard M. Rosenfeld, MD, MPH

George Alexiades, MD Margaretha L. Casselbrant, MD, PhD

Michael J. Cunningham, MD Carlos Gonzalez, MD

Norman Friedman, MD Raymond L. Hilsinger Jr, MD

Ari J. Goldsmith, MD Andrew J. Hotaling, MD

Kevin J. Hulett, MD Scott C. Manning, MD

Reza Rahbar, DMD, MD Christopher E. Stevens, MD

2. Approaches to the Middle Ear and Mastoid ..................................................................................21

3. Myringoplasty and Tympanoplasty ................................................................................................39

5. Mastoidectomy and Cholesteatoma ...............................................................................................91

6. Perilymphatic Fistula and Eustachian Tube Surgery .......................................................................123

7. Facial Nerve Exploration and Repair .............................................................................................137

8. Ear Canal Stenosis and Atresia.......................................................................................................185

9. Cochlear Implants .........................................................................................................................221

11. Nasal and Septal Deformities.........................................................................................................259

12. Congenital Nasal Malformations ...................................................................................................299

13. Endoscopic Ethmoidectomy and Antrostomy................................................................................319

14. Inflammatory Sinonasal Disease ....................................................................................................339

15. Sphenoid Sinus Surgery .................................................................................................................353

ORAL AND PHARYNGEAL SURGERY

17. Tonsillectomy, Adenoidectomy, and UPPP ....................................................................................379

18. Velopharyngeal Insufficiency .........................................................................................................407

19. Surgery for Drooling......................................................................................................................427

HEAD AND NECK SURGERY

21. Deep Neck Infections ....................................................................................................................465

22. Congenital Malformations of the Neck

23. Salivary Gland Surgery ..................................................................................................................515

24. Thyroidectomy ..............................................................................................................................539

27. Surgery of the Larynx and Trachea.................................................................................................597

28. Laryngotracheal Laser Surgery .......................................................................................................633

j. Laryngeal and subglottic hemangiomas ............................................................................663

32. Maxillofacial Trauma .....................................................................................................................727

33. Cleft Lip and Cleft Palate Repair...................................................................................................763

34. Craniosynostosis ............................................................................................................................791

36. Pediatric Anesthesia .......................................................................................................................823

T YMPANOSTOMY T UBES AND

Figure 1–1 Ethyl alcohol (70%)

♦ Tympanocentesis is performed in the inferior portion of the tympan-

Figure 1–2 Alcohol is removed

Figure 1–3 A, A wide-field incision is made in the inferior

• Middle-ear effusion is aspirated with a small Baron or Fraser aspirator

Figure 1–4 A, A small Baron or

GROMMET-TYPE TYMPANOSTOMY TUBE INSERTION

Figure 1–5 An alligator forceps

♦ Forceps with a serrated (not smooth) edge are recommended to per-

Figure 1–6 Tympanostomy tube

♦ When the external auditory canal is small, such as in young infants, a

6 months until spontaneous extrusion occurs. Ideally, periodic examina-

parents that the tube is biocompatible, should not be associated with

PERMANENT TYMPANOSTOMY TUBE INSERTION

Figure 1–8 An incision is made

• A Per-Lee tube is preferred:

Figure 1–9 A Per-Lee tube is

• A Richards T-tube may also be used:

Figure 1–12 The Richards

Figure 1–13 A, The T-tube is

REMOVAL OF TYMPANOSTOMY TUBES AND

• Presence of retained bilateral tympanostomy tubes in children in whom

Figure 1–14 The myringotomy tube is gently removed using