Triangular uvulopalatal flap

Introduction:

Retropalatal region is the common site of obstruction in most patients with obstructive sleep apnoea syndrome. Uvulopalatopharyngoplasty (UPPP) has been used with reasonable degree of success to treat these patients. Powel etal introduced this procedure of triangular uvulopalatal flap technique to achieve the same result. This procedure has the additional benefit of reducing the width of the soft palate significantly. This procedure has lower morbidity and risk when compared to UPPP.

Procedure:

An incision is made about 1 cm behind the posterior end of hard palate. A triangular flap is created over the palatal mucosa as shown in the figure below. Dissection is performed between the submucosal adipose tissue and the underlying muscular tissue. Triangular shaped posterior pillar mucosa near the base of the uvula is excised. The triangular mucosal strip is carefully dissected and removed exposing the underlying muscle tissue. The uvula is reflected backwards and sutured to the soft palate.

Diagram showing the steps of triangular uvulopalatal flap

Advantages:

1. 
   
   This procedure causes significant widening of retropalatal airway
2. 
   
   Post operative scarring not only stabilized the soft palate it also stiffened it thus preventing its vibration during sleep.
3. 
   
   There is virtually no risk of post operative bleeding, because the deeper muscle layer is not injured.
4. 
   
   Post operative pain is really minimal.
5. 
   
   Since this procedure is purely a mucosal procedure there is no risk of voice change or swallowing difficulties after surgery
6. 
   
   Results of this procedure is more or less comparable to that of UPPP
7. 
   
   Snoring was reduced in 90% of these patients

 

Surgical management of bilateral abductor paralysis of vocal cords

Introduction:
     Bilateral abductor paralysis of vocal cords is a surgical emergency.  If it is noticed on the table extubation can be deferred.  Usually it is identified only during the first few days following surgery.  In these patient management of airway takes precedence over voice management.  Air way should be secured immediately by performing a tracheostomy.  In this article I attempt to discuss the role of various surgical modalities available in managing this problem.

Causes of bilateral abductor paralysis:

1. Surgical trauma (Total thyroidectomy)

2. Malignancies

3. Endotracheal intubation

4. Neurologic disorders

5. Idopathic (mostly viral infections)

6. Metabolic causes: Hypokalemia, Hypocalcemia and diabetes mellitus

Bilateral abductor paralysis of vocal cords following endotracheal intubation is caused by:

1. Dislocation of arytenoid cartilages
2. Anterior displacement of thryoid cartilage in relation to cricoid cartilage causing stretching and damage to the recurrent laryngeal nerve
3. Hyperextension of neck during difficult intubation procedures may cause stretching damage to the vagus nerve
4. Excessive cuff pressure may cause damage to the recurrent laryngeal nerve
5. Introduction of laryngeal mask may also damage the recurrent laryngeal nerve
6. Prolonged intubation may cause damage to the recurrent laryngeal nerves

Surgical causes of bilateral abductor paralysis:

1. Thyroid surgery

2. Parathyroid surgery

3. Esophageal surgery

4. Tracheal surgery

5. Brain stem surgery

Neurological causes of bilateral abductor paralysis:

1. Arnold chiari malformation

2. Meningomyelocele

3. Amyotrophic lateral sclerosis

4. Shy Drager syndrome

5. Hydrocephalus

Presenting features:

Stridor: Need to addressed first (tracheostomy)
Voice changes: Usually are minimal
Swallowing difficulties

Videolaryngoscopic examination: Shows both vocal cords to be in paramedian position.  Cords are not mobile.

Surgical procedures:

1. Posterior cordotomy (unilateral / bilateral).  Aspiration will be a problem if bilateral cordotomy is performed
2. Arytenoidectomy (partial / complete): Endoscopic / external
3. Cordopexy / lateralization of vocal cord

1. In all patients of bilateral abductor paralysis of vocal cords air way management takes precedence over voice. Air way should be secured immediately by performing tracheostomy.
2. Efforts should be made to decannulate the patient as early as possible
3. In patients who have failed the efforts of decannulation, surgical management becomes a necessity.
Posterior cordotomy can be performed in patients with mild / moderate compromise of the airway. This procedure is more conservative, and has very little risk of aspiration.
Posterior cordotomy was first performed by Kashima and Dennis in 1989.
Suspension laryngoscope is used to visualize the larynx.
If laser is available it is better to perform laser cordotomy, because bleeding is minimal when laser is used.
Incision is made over the posterior portion of the true cord, just in front of the vocal process of the arytenoid cartilage.
About 1/3 of the posterior portion of the vocal cord is removed. Care should be taken not to damage the ventricle as it would cause
irreversible damage to the patient's voice.

A novel method of handling Little's area bleeding

Introduction:

Many a time we would have faced problems cauterizing a Little's area bleed. This is basically due to the use of nasal speculum which obscures the field and also keeps one hand occupied. Bray in his " How I do it" describes how he put to use the Mallet spint.

Procedure:

A Mallet splint is a common tool used to treat Mallet (Trigger) finger. This splint is available in different sizes. It can be cut and introduced into the anterior nares. This keeps the nasal cavity open providing a good view of nasal septum area. It also has the advantage of leaving both the surgeon's hand free. The most proximal part of the Mallet splint is cut and shaped into a "U" shaped splint. This splint can be readily inserted into the nasal cavity. Since this splint is made of silastic, its memory holds the nasal cavity open.

Since both the hands of surgeon are free the bleeder can easily be cauterized either by electro or chemical cautery.

Figure showing Mallet splint

 Figure showing modified splint inside anterior nasal cavity