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Overview
Difficulties in positioning tip of balloon could be circumvented by placement of a dilating catheter through a channeled laryngoscopy if a dilating balloon with a hollow center were used (not used in this case). Alternatively, placement of a balloon through a larger steering sheath employing the two nostril technique could conceptually be used.
Modified Operative Note
Preoperative diagnosis: Posterior glottic scarring status post radiation with upper airway obstruction with trach dependency.
Postoperative diagnosis: Posterior glottic scarring status post radiation with upper airway obstruction with trach dependency.
Procedure performed:
1. Transnasal laryngoscopy and bronchoscopy to the carina, employing the VT scope with suction and then subsequently with the regular flexible laryngoscope
2. Dilation of posterior glottic and glottic scarring dilation transnasal placement of the CRE 10-12 mm balloon at 4 atmospheres
3. Tracheostomal plasty (dilation from a #6 to #7 metal Jackson tracheotomy with obturator in place)
4. Placement of a #8 short-term Montgomery cannula
Anesthesia: Nasal decongestant with 4% lidocaine/phenylephrine mixture, bilateral superior laryngeal nerve blocks wtih 2% lidocaine with 1:100,000 epinephrine, 4% lidocaine dripped on the vocal cords with indirect mirror exam with a curved applicator, lidocaine/epinephrine spray to the tracheostome, and use of viscous lidocaine on sequential dilators.
Description of procedure:
Following identification of the patient and informed consent the tracheotomy tube was changed to a new #6 showing the stoma to be clean. A #7 metal Jackson was used to dilate it to accommodate the Montgomery cannula. Images were taken. The flexible scope was placed through the right nostril with initial placement of the CRE balloon through the left nostril, but some difficulties in guiding it into the laryngeal introitus warranted removal and replacement through the same right nostril as the imaging scope allowing for manipulation, changing of the head position to introduce the tip of the CRE balloon dilator into the laryngeal introitus with insufflation up to 4 atmospheres (12 mm) held with him breathing through the tracheostome. The balloon was then deflated and removed, and the glottis inspected. The next stage of the procedure with placement of Montgomery cannula was then done with a separate laryngoscope, allowing for a view transnasally between the vocal cords after the #8 Montgomery cannula had been placed, demonstrating its position and indicating the differences in pushing it in and out to the patient and the impact on his breathing with it pushed back in. For safety purposes, after having it well fixed with a square metal base plate and the plug, we had the patient remove the Montgomery cannula himself and then had it replaced again. He was observed in the clinic for 45 minutes before discharge with the offer of overnight observation deferred in view of the safety with which he has maintained his previous tracheotomy tube. Instructions were detailed including the need for him to travel with a metal Jackson tube, which would be used to replace the Montgomery cannula were he to have difficulties. Eight rings were left on the Montgomery cannula with the understanding it would likely be trimmed back further once he becomes more familiar with it, to make the chance of retro-placement much less likely due to the larger extension anteriorly.
