Intraoperative Tracheostomy Tube Customization

Objectives: This article describes how to make a customized tracheostomy tube immediately in the operating room setting. This is particularly critical when a commercial customized tracheostomy tube cannot be readily obtained. Study Design: Case presentation. Methods/Results: A 73-year-old female was seen in our clinic for management of a recurrent invasive paraganglioma of the thyroid. She underwent a total laryngopharyngectomy, cervical esophagectomy, and anterolateral thigh free flap reconstruction followed by post-operative radiation. In follow-up, the patient presented with dyspnea related to two areas of stenosis, one at the level of her stoma and one at the distal trachea. The patient was therefore taken to the operating room urgently for dilation and placement of a tracheostomy tube. Available tracheostomy tubes were tried and ill fitting as each tube narrowed the patient’s stoma or abutted her distal granulation tissue. To custom create a tracheostomy tube, we used a standard rib shearer to shorten a #6 uncuffed tracheostomy tube by 2 cm. The edges were further smoothed and beveled using sand paper and a diamond burr drill. The finished product was a wide diameter tube with a custom length suited to our patient. Conclusions: Although a simple solution, the use of a rib shearer provides a quick and feasible solution to creating custom length tracheostomy tubes in situations where custom length tubes are needed yet unavailable.

Multi-Layered e-PTFE Facial Reconstruction for HIV Lipoatrophy

Importance: Facial lipoatrophy is a common problem among the Human Immunodeficiency Virus (HIV) population. With highly active antiretroviral therapy, these patients are able to delay the evolution of the disease and live many more years;however, more than half of them are faced with difficulties in their social and professional lives secondary to the physical changes of their faces. Observations: The majority of HIV-positive patients exhibit significant facial soft tissue loss, especially in the buccal fat pad resulting in accentuation of the malar eminence and the inferior orbital rim. Reconstruction has been performed with many temporary and permanent methods, but no single satisfactory procedure has been universally adopted. Conclusions and Relevance: We present a new method of addressing the resulting facial hollowing by tailoring a multi-layered e-PTFE sheet in a customized fashion to camouflage the specific atrophic areas in the face. Our patient demonstrated a significant improvement in both cosmesis and social re-integration. A detailed surgical description along with a review of the literature is reported.

Introduction

Since its inception with the invention of the laryngeal mirror and the early work of Horace Green, Chevalier Jackson, Johann Czermak, Morrell McKenzie, and others in the mid-19th Century, the field of laryngology has grown exponentially. With the introduction of suspension laryngoscopy and general anesthesia, surgeons were able to work with both hands. The addition of the operative microscope allowed visualization not previously possible. In the mid-20th Century, the CO2 laser permitted laryngeal surgery to performed with unprecedented precision and hemostasis. The 1970's saw the advent of flexible laryngoscopes and stroboscopy which took our diagnostic capabilities to new levels. The distal chip laryngoscopes which followed along with the fiber-based lasers, allowed procedures to be done in the office setting with superior visualization and exactness. And the story continues……