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Pediatric Pharyngeal Flap

last modified on: Fri, 05/12/2017 - 15:27

  1. GENERAL CONSIDERATIONS
    1. The indications 
      1. Indications:
      2. Complications:
        1. Risks include: obstructive sleep apnea, nasal stricture, hyponasal speech, continued VPI
  2. PREOPERATIVE PREPARATIONS
    1. Consent
      1. Informed consent should be obtained
    2. Consent and last note should be hanging including speech & swallow evaluation with pictures of VNE. Images of cerebral angio looking at the carotid placement in the posterior pharynx should be on the viewer.
    3. Unasyn or the equivalent should be administered pre-operatively by the anesthetist.
    4. If there is going to be an EUA, then make sure the microscope is in the room and ready to go.
    5. The patient should be positioned supine on the bed with head hanging off of the Phillipine board and a Rae tube taped in the midline to the bottom lip and chin.
    6. Epinephrine 1:200,000 with 5 U of Vitrase (Hylauronidase) per mL should be drawn up in 1 cc syringes with 27 guage needles.
    7. Hibiclens should be used for scrub by the scrub nurse when the patient is properly positioned.
  3. Other Considerations:
    1. Anatomy
  4. NURSING CONSIDERATIONS
    1. Room Setup
    2. Instrumentation and Equipment
    3. Medications (specific to nursing)
    4. Prep and Drape
    5. Drains and Dressings
    6. Special Considerations
  5. ANESTHESIA CONSIDERATIONS 
  6. OPERATIVE PROCEDURE
    1. Place the Dingman mouth gag, the prongs should rest on the molars. About 5cc of epinephrine 1:200,000 with 5 U of Vitrase per mL should be injected into the projected incision lines at the uvula and anteriorly to the soft hard palate junction as well as in the posterior pharyngeal wall.
    2. Doppler should be used to rule out medialized carotid arteries in the OR or with radiographic imaging if there is concern for Velocardiofacial syndrome.
    3. After 3-5 minutes you may make your incisions using a 15 blade scalpel. Incise the posterior pharyngeal wall creating an arrow approximately 2 cm across with the apex extending to the level of the bottom of the uvula or the lowest point that you can still see posterior pharyngeal wall mucosa with the Dingman in place and the base extending to a level above the soft palate.
    4. Begin lifting the flap in its mid portion using a Steven’s scissors and baby Jankauer to begin the dissection. You should be able to elevate the flap in a bloodless plane off of the underlying pre-cervical fascia. Place the curved scissors underneath the midportion of the flap and spread until you see your tips on the other side. Once you’ve extended your cut across and beneath the pharyngeal constrictor musculature off of the pre-vertebral fascia in the midline incise the remaining mucosal attachments with a Steven’s scissor and then elevate the pharyngeal flap up and down its length using a Kitner to push the mucosa / muscle flap superiorly.
    5. Turn your attention to the soft palate. Incise the soft palate in the midline through and through from a point starting above the uvula extending down through the tip of the uvula. Divide the soft palate into two flaps extending this division infero-laterally to the lateral pharyngeal wall. This division should elevate the mucosa off of the anterior tonsillar pillar.
    6. Place two 3.5 cuffless ET tubes in the nares such that they extend past the soft palate adjacent to the lateral pharyngeal wall (these tubes serve as sizers for you lateral pharyngeal ports – you want your ports to be 1 ½ the diameter of these tubes).
    7. Next place a 3’0 Vicryl vertical mattress suture from the inferior apex of the posterior pharyngeal flap to the apex of the palatal incision. This serves to roll the pharyngeal flap up and under so that the mucosalized surface of the pharyngeal flap now faces superiorly into the nasopharynx.
    8. Starting on the right suture the superior lateral border of the pharyngeal flap to the superior medial border of the inferiorly based palatal flap. Start at the apex closest to the oral stoma and work your way down with subsequent stitches attaching the pharyngeal flap to the posterior palatal flap. Check the port size with a 30 degree endoscope and as you get to a point where your port size is appropriate throw your stitches closer together so if one rips out the port size doesn’t enlarge significantly.
    9. When you ports are appropriately sutured trim the ET tubes with @ 2 cm of tube beyond the naris and place a through and through septal suture with one arm looped over the columella to hold the tubes in place.
    10. Turn your attention to the medial posterior palatal flaps and using an interrupted 3’0 Vicryl suture close them from posterior tacking them on the raw surface of the pharyngeal flap as high as possible and working your way around the back side of the uvula to the front side of the uvula and up the soft palate. Place midline mattress sutures grabbing some deep soft tissue on the front side of the soft palate if you need to obliterate a large dead space.
    11. Finally with one or two 3’0 Vicryl sutures reapproximate the mucosal edges of the posterior pharyngeal wall leaving a significant opening at the bottom and the top for drainage and to prevent flap strangulation respectively.
    12. Aspirate the stomach contents, carefully remove the Dingman holding the ET tube in place.
  7. POST OPERATIVE CARE
    1. Armboards x 3 weeks (if the patient is under 4). No spoons, forks, or sharp implements.
    2. Unasyn x 24 hrs and Amoxicillin x 1 week
    3. Cup diet (sippy cup with the nozzle cut off).
    4. Follow up 3 weeks
    5. If tolerated while in house (no respiratory depression) may use Lortab elixir x 1 week prn, liberally.
  8. SUGGESTED READING

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