1. Patient Selection
<ol>
	<li>Consider inclusion of patients with the following tonsil-related diseases: recurrent tonsillitis; dysphagia caused by large tonsils; tonsil stones; obstructive sleep apnea related to tonsils.</li>
	<li>Include only adult patients.</li>
	<li>Check for allergies, specifically to local anesthetics.</li>
	<li>Assess the gag-reflex intensity using the GSI (Table 1). For adequate CO2LT treatment, full visualization of the tonsils is required and patients need to be able to hold their breath for at least 15 s at a time.</li>
	<li>In patients with a GSI &#62; 2 consider the following exercise to decrease the gag-reflex intensity.
	<ol>
		<li>Inform the patient that the gag-reflex can be (partially) faded-out by training.</li>
		<li>Explain to the patient that the exercise will be uncomfortable in the first few days to weeks.</li>
		<li>Advise the patient to use their toothbrush to gently touch / brush their tongue base and tonsils each time they brush their teeth (preferably twice a day). Instruct the patient to increase pressure when performing this procedure each sequential day.</li>
	</ol>
	</li>
	<li>Exclude the following patients: with Friedman grade IV (kissing) tonsils; with undertreated coagulation disorders; using any form of anticoagulants; with an active tonsil infection / peritonsillar abscess; women who are pregnant; those who are uncooperative during tonsil examination.</li>
</ol>
2. Informed Consent and Pre-operative Instruction Visit
<ol>
	<li>Obtain written informed consent including the following.
	<ol>
		<li>Explain the intervention to the patient as follows: &#34;The tonsil(s) will be partially evaporated using a laser beam. Local anesthesia will be used to numb the tissue and therefore you will be fully awake and mentally present during treatment. No pain is expected during treatment and low to moderate pain may occur in the first days after treatment. Treatment will take approximately 10-15 min per tonsil. If no complications occur, admission to the floor after treatment is not necessary and you will be able to leave the hospital in 30 min to an hour after treatment, accompanied by a friend or relative that is able to drive you.&#34;</li>
		<li>Explain alternative treatment options (where applicable: expectant management, conventional tonsillectomy or antibiotics).</li>
		<li>Explain possible complications of the CO2LT including: per- and post-operative bleeding, infection, incomplete resolution of tonsil disease; need for a second tonsillotomy or a tonsillectomy, pain, allergic reaction to anesthetic, temporary change of taste, (temporary) damage to surrounding structures.</li>
	</ol>
	</li>
	<li>Instruct the patient not to eat any heavy meals on the day of treatment.</li>
	<li>Instruct the patient to take 1,000 mg acetaminophen (paracetamol) 30 min before treatment if acetaminophen is not contraindicated in that specific patient (including, but not limited to active liver disease and liver failure).</li>
	<li>Ask patients with a troublesome gag-reflex during examination to reduce the gag-reflex by rubbing their tongue base and tonsils with their toothbrush at least twice a day for 1 min, preferably for at least 2 weeks.</li>
</ol>
3. Preparation of Patient and Equipment
<ol>
	<li>Attach the laser pen to the CO&#173;2-laser machine.</li>
	<li>Make sure that the correct settings are chosen (Figure 1) such as (i) continuous laser beam, (ii) 15-30 W intensity depending on the size of the tonsil; generally, start at 18 W and increase the power up to 30 W depending on the size of the tonsils and patient&#39;s cooperation, (iii) shape-size of 2-4 mm depending on the size of the (remainder of the) tonsil, (iv) shape: round.</li>
	<li>Make sure that the surgeon, the surgical technologist, and the patient are wearing laser safety glasses.</li>
	<li>Make sure that the surgeon and the surgical technologist are wearing appropriate protective surgical masks.</li>
	<li>Confirm that the headlight for the surgeon is working.</li>
	<li>Confirm that a pulse oximeter for patient monitoring is present.</li>
	<li>Confirm that wooden tongue depressors are within reach. 
	CAUTION: Do not use metal depressors, since they can reflect the laser beam.</li>
</ol>
4. Time-out Procedure
<ol>
	<li>Ask the patient for their name and date of birth.</li>
	<li>Ask the patient for the intervention that will take place.</li>
	<li>Ask the patient for the side of treatment.</li>
	<li>Ask the patient for any allergies, specifically for local anesthetics and medications.</li>
	<li>Check with the surgical technologist if all equipment is present.</li>
	<li>Check if the laser-indication light of the operating room is switched on and all windows are covered for laser safety.</li>
</ol>
5. Patient Instructions Before Surgery
<ol>
	<li>Ask the patient to inhale deeply, followed by breathing out slowly during treatment.</li>
	<li>Explain to the patient that he/she is in control and can signal at any time, which will lead to a pause of the laser-treatment.</li>
	<li>Instruct the patient to use his/her hand to signal if they wish to pause treatment by tapping the surgeon&#8217;s leg.</li>
	<li>Instruct the patient not to swallow any liquids during treatment to prevent aspiration and laryngospasms. Provide a kidney basin to the patient to spit any liquids into when necessary.</li>
	<li>Reassure the patient not to panic if they experience a feeling as if their airway is blocked, as this is due to local anesthesia of the pharynx region. Remind the patient again that the treatment can be paused at any moment.</li>
</ol>
6. Positioning the Patient and Inspection of the Tonsils
<ol>
	<li>Place the pulse oximeter on the patient&#39;s index finger and confirm that it is functioning correctly.</li>
	<li>Position the patient in an upright position using the chair / table controls.</li>
	<li>Set the height of the chair / table so that the surgeon can stand straight comfortably while performing the laser treatment.</li>
	<li>Ask the patient to make any adjustments to the seating to ensure comfortable and safe positioning.</li>
	<li>Inspect both tonsils and exclude active inflammation.</li>
	<li>Assess the gag-reflex using the GSI and judge the feasibility of the laser treatment. For adequate CO2LT treatment, the surgeon should be able to fully visualize the tonsils and patients need to be able to hold their breath for at least 15 s.</li>
</ol>
7. Anesthesia of the Tonsil
<ol>
	<li>Tell the patient that the tonsils will be anesthetized one at a time.</li>
	<li>In case of a significant gag-reflex (GSI grade 2-3) use xylocaine-spray or superficial anesthesia of the tongue-base and pharynx to reduce the gag-reflex.</li>
	<li>Take an ampule with local anesthetic and inject ~0.2 mL slowly into the upper pole, ~0.2 mL into the mid-pole and 0.2 mL into the lower-pole of the tonsil. 
	NOTE: Optionally, the tonsil-pillars can be infiltrated as well. This is recommended when the tonsils are hidden behind the pillars or to decrease the gag-reflex.</li>
	<li>Instruct the patient not to swallow any local anesthetic, but to spit it out.</li>
	<li>Reassure the patient that any feeling of throat tightness is due to the anesthetic; not due to any actual obstruction.</li>
</ol>
8. Laser-treatment of the Tonsil
<ol>
	<li>Ask the patient to breathe in deeply and exhale slowly.</li>
	<li>Have the surgical technologist hold the smoke suction close to the opening of the mouth, without blocking the surgeon&#39;s view.</li>
	<li>Use two wooden tongue blades to depress the tongue / tongue-base and expose the tonsil.</li>
	<li>During the patient&#8217;s exhalation, laser the lymphatic tissue of the lobules in a sweeping motion.</li>
	<li>Stop when the patient taps your (the surgeon&#39;s) leg.</li>
	<li>Let the patient catch his/her breath again and repeat steps 8.1&#8211;8.4 until complete cryptolysis is accomplished.</li>
	<li>If necessary, inject extra local anesthetic (with or without epinephrine).</li>
</ol>
9. Tips for Laser Treatment
<ol>
	<li>In case of peroperative hemorrhage: laser the spot that is bleeding &#34;out of focus&#34;. This will lead to burning of the lymphatic tissue with crust formation with a similar effect as coagulation (opposed to evaporation when using the laser &#39;in focus&#39;). Alternatively, use a (bipolar) coagulation device to stop the bleeding.</li>
	<li>Use the wooden tongue blades to press against the anterior tonsillar pillar to expose the tonsil further.</li>
	<li>Use the wooden tongue blades to press against the upper part of the tonsil pillars to expose the upper lobule of the tonsil.</li>
	<li>Use the wooden tongue blades to scoop up the lower tonsil lobule and expose it for laser treatment (one can leave them scooped up on the tongue blades).</li>
</ol>
10. Instructions After Treatment
<ol>
	<li>Give the patient a popsicle for a minimum of 30 min of postoperative observation.</li>
	<li>Instruct the patient not to drink or eat anything else for 2 h until the local anesthetic has worn off to prevent aspiration.</li>
	<li>Instruct the patient not to drink / eat hot (temperature) or spicy drinks/food or food with hard crusts for a week to prevent postoperative bleeding.</li>
	<li>Tell the patient to take pain medication only if necessary. 
	NOTE: We advise a maximum of 1,000 mg acetaminophen (paracetamol) 4 times a day, if necessary.</li>
	<li>Tell the patient to refrain from strenuous physical exercise for a week.</li>
	<li>Advise the patient to go to the nearest emergency department in case a postoperative bleeding occurs. Advise the patient to contact the ENT department in case of a postoperative infection (e.g., fever).</li>
</ol>

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</ol>

Open access publication of this manuscript was supported by Lumenis.

This paper describes the steps to perform a CO2LT. To our knowledge, this is the first article to describe this intervention in such detail. Outpatient CO2LT under local anesthesia is a novel surgical method and therefore the presented procedural details have mostly been developed through hands-on experience of the authors.
As for any surgical intervention, pre-operative patient selection is important. For CO2LT, a relatively calm and cooperative patient without a procedure-restricting gag-reflex is desirable. Therefore, an adequate assessment of limitations due to patient anxiety pertaining to the procedure and gag-reflex are of great importance to reach consistent treatment effects. Furthermore, we advise not to perform CO2LT on patients with grade IV (Friedman grading), or &#8220;kissing-tonsils&#8221; because of the risks of damaging surrounding tissues with the laser-beam.
In our experience, leaving the tonsil capsule intact and limiting the tissue damage reduces post-operative pain, recovery time and post-operative morbidity compared to tonsillectomy under general anesthesia. This is in agreement with current literature16,17,18,19,20,21,22,23,24,25,26. Despite the potential incomplete resolution of tonsil disease with CO2LT, many patients prefer CO2LT over tonsillectomy when informed of their options. This preference has been consistently reported prospectively (pre-surgery) and retrospectively (at follow-up)12. We therefore believe that CO2LT fills a gap in treatment options for tonsil-related disease, both from the doctors&#39;&#160;and the patients&#39;&#160;perspective. Current ongoing studies should provide further insight into the value of CO2LT in adults with tonsil diseases13.
There is a wide variety of techniques and devices available to perform a tonsillotomy, each with its own potential pros and cons. Utilized surgical devices besides the CO2-laser include microdebriders, coblators, surgical scissors, radiofrequency ablation probes, interstitial thermal therapy instruments and diode lasers. There is no conclusive evidence favoring any one instrument over another for tonsillotomy in adults27. Microdebriders, coblators and CO2-lasers are among the most frequently used instruments for tonsillotomy28. Reports on effectiveness, pain and postoperative complications vary, but current evidence suggests equal efficacy of tonsillotomy compared to tonsillectomy with less postoperative pain and complications27,28, independent of the method of tonsillotomy.
Even though tonsil-surgery under local anesthesia has been described since decades, it is not performed often in current practice16,29,30,31. Many otolaryngologists are uncomfortable with the idea of tonsil surgery under local anesthesia. This may partly be due to a lack of experience with this specific form of tonsil surgery as well as due to concerns over the airway and bleeding control30.
CO2LT has some clear logistical advantages. First, using only local anesthetics obviates the need for an anesthesia team. Second, the operation can be performed in the outpatient setting and there is no need for an operation room. Third, the surgical instruments used with CO2LT are non-disposable and only the laser pen needs to be sterilized after use. Sterilization of the laser pen is a simple procedure for any central sterile services department. These factors all lead to cost-reduction. On the other hand, the use of a laser requires a specialized intervention room meeting the local laser safety standards.
We currently exclude patients with a history of peritonsillar abscess because of the intrinsic risk in those patients of recurrent peritonsillar abscess (14%)32. The risk of recurrence is zero in patients after tonsillectomy33. In tonsillotomy, residual tissue may lead to a recurrence of an abscess. We also advise to exclude patients on anticoagulants or with bleeding disorders from treatment with CO2LT. Even though our experience is that bleeding sites can easily be managed with the CO2-laser, or if necessary, with bipolar coagulation. The fact that the patient is conscious and not intubated might complicate per-operative treatment of more profound bleeding due to decreased coagulation. If necessary, the patient can be brought under full anesthesia and the bleeding site can be stopped with diathermy or ligation, similar to postoperative bleeding after tonsillectomy. In our &#62;1,000 patient experience, such an event has never occurred. We estimate the need to use bipolar coagulation under local anesthesia to be around 2% of cases.
Furthermore, as of yet we have never had to stop a CO2LT case early due to an uncooperative patient. Incidentally a strong gag-reflex has led to suboptimal laser-treatment of the lower part of the tonsil. In those cases, sending the patient home with our gag-reflex training scheme led to successful treatment of the remaining tonsil tissue during a subsequent CO2LT procedure. It is important to note that these numbers and procedural characteristics are based on personal experience of the authors at a single center and should be evaluated in further studies.

Recurrent tonsil disease is a common health problem resulting in frequent visits to outpatient clinics, antimicrobial treatments, and missed work days1. Tonsillectomy2 is currently the most used surgical intervention for tonsil-related complaints in adults. During a tonsillectomy, the patient is brought under general anesthesia and the entire tonsil, including the tonsil capsule, is removed followed by diathermy coagulation of any bleeding sites. This intervention is rather invasive and associated with significant post-operative morbidity and a long, typically painful, recovery period3,4. An alternative to tonsillectomy is tonsillotomy, which is the partial intra-capsular removal of the tonsil tissue.
Both tonsillectomy and tonsillotomy have been performed for millennia 5,6. The first descriptions of subtotal tonsil removal date back to 1 BC6. Since that time many techniques for tonsil removal have been developed including the use of scalpels, microdebriders7, coblators8, electrosurgical scissors9, diode-lasers10, radiofrequency probes11 and CO2-lasers12.
CO2-lasertonsillotomy under local anesthesia (CO2LT) for the treatment of tonsil-related complaints is a fairly novel surgical treatment, which is gaining popularity as an alternative for the classic tonsillectomy. Recent studies have shown a shorter and less painful recovery period, but similar overall patient-satisfaction with CO2LT treatment when compared to conventional tonsillectomy12,13. During a CO2LT the tonsil is locally anesthetized and only the lobules of lymphatic tonsillar tissue are removed. The tonsillar capsule, through which blood vessels, nerves and lymphatic vessels pass, is left intact. Leaving the tonsillar-capsule intact likely leads to a reduced rate of post-operative bleeding, reduced post-operative pain, and a shorter recovery time14.
A potential problem with leaving the tonsillar capsule intact can be the incomplete resolution of the tonsil-related complaints, resulting in the need for a secondary CO2LT in a subset of patients12. Furthermore, to be eligible for CO2LT treatment patients must be able to remain calm during treatment and their gag reflex intensity should not limit treatment possibilities. The gag reflex is a physiological reflex to protect the airway15, which can only be partly blunted by local anesthesia in the mouth and pharynx; a particularly strong gag reflex can compromise the safe performance of a CO2LT. To assess the severity of the reflex the Gagging Severity Index (GSI) can be used15. The GSI is an index ranging from 1 (very mild) to 5 (very severe) [Table 1] and was originally developed in dentistry to classify the intensity of the gagging reflex and its consequences for dental treatments. In any patient with a GSI grade 3 or more the gagging reflex should first be reduced to increase the odds that the CO2LT procedure will be successful. We advise patients to try to fade out their gag-reflex by &#34;brushing&#34;&#160;their tongue-base and tonsils each time they brush their teeth. We have found this exercise to be capable of reducing the gag reflex intensity in most patients by 1-2 GSI points.&#160;

<table><tbody><tr><td>Carpule syringe and local anesthetic (e.g., xyloca&amp;iuml;ne:adrenaline 1:80.000)</td><td>n/a</td><td>n/a</td><td>n/a</td></tr><tr><td>CO&lt;sub&gt;2&lt;/sub&gt; Laser system</td><td>Lumenis</td><td>AcuPulse DUO CO2 laser</td><td>F125 CO&lt;sub&gt;2&lt;/sub&gt; Laser System</td></tr><tr><td>Coagulation device&amp;nbsp;</td><td>Erbe</td><td>Erbe ICC 80 Surgical Generator With Footswitch</td><td>n/a</td></tr><tr><td>Laser safety goggles</td><td>Lumenis</td><td>Laservision goggles AX0000068&amp;nbsp;</td><td>n/a</td></tr><tr><td>Operating chair</td><td>n/a</td><td>n/a</td><td>With possibilities for the patient to sit upright (e.g., opthalmic chair or dental chair)</td></tr><tr><td>Operating room which meets the local laser-safety standards</td><td>n/a</td><td>n/a</td><td>n/a</td></tr><tr><td>Suction device</td><td>TBH</td><td>TBH LN 100 or 2000</td><td>Air suction and filtration device</td></tr><tr><td>Surgical masks</td><td>3M</td><td>3M 7502 mask with 2138 P3 filters</td><td>n/a</td></tr><tr><td>Wooden tongue depressor</td><td>n/a</td><td>n/a</td><td>Do not use metal tongue depressors</td></tr></tbody></table>

co2-lasertonsillotomy under local anesthesia in adults

Tonsil-related complaints are very common among the adult population. Tonsillectomy under general anesthesia is currently the most performed surgical treatment in adults for such complaints. Unfortunately, tonsillectomy is an invasive treatment associated with a high complication rate and a long recovery time. Complications and a long recovery time are mostly related to removing the vascular and densely innervated capsule of the tonsils. Recently, CO2-lasertonsillotomy under local anesthesia has been demonstrated to be a viable alternative treatment for tonsil-related disease with a significantly shorter and less painful recovery period. The milder side-effect profile of CO2-lasertonsillotomy is likely related to leaving the tonsil capsule intact. The aim of the current report is to present a concise protocol detailing the execution of CO2-lasertonsillotomy under local anesthesia. This intervention has been performed successfully in our hospital in more than 1,000 patients and has been found to be safe and to be associated with a steep learning curve.

In a previously published prospective study in 107 patients with one year follow-up, postoperative questionnaires were used to assess recovery rate and recurrence of tonsil-related symptoms for CO2LT compared to conventional tonsillectomy12. Forty-six patients underwent conventional tonsillectomy under general anesthesia and 61 patients underwent CO2LT. In total, 72.5% of patients in the CO2LT group were cured from their tonsil-related symptoms. Three patients (7.5%) in the CO2LT group required revision surgery for recurring tonsil complaints. In the tonsillectomy group, 97.2% of patients were cured after initial treatment. The overall satisfaction rate was similar in both treatment groups, but the mean pain intensity scores two weeks post-operatively were 5.4 (out of 10, range 0-9) after tonsillotomy and 7.7 (out of 10, range 2-10) after tonsillectomy leading to longer (9.9 vs. 5.4) use and use of stronger pain medication (NSAIDs / opioids versus acetaminophen) after tonsillectomy. Days to full recovery and number of post-operative bleeding events were both significantly higher in the tonsillectomy group (Figure 2).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/59702/59702fig1.jpg" /> 
Figure 1: Photo of laser settings. Standard laser settings for CO2LT on the laser system used. <a href="https://www.jove.com/files/ftp_upload/59702/59702fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/59702/59702fig2a.jpg" /> 
Figure 2: Patient reported recovery after tonsillotomy and tonsillectomy. Cumulative percentage of patients that reported complete recovery postoperatively after tonsillotomy (TO) and tonsillectomy (TE). Data were previously published by Lourijssen et al.12. <a href="https://www.jove.com/files/ftp_upload/59702/59702fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Dickinson and Fiske</td>
			<td rowspan="2">Definition and characteristics of grade of reflex</td>
		</tr>
		<tr>
			<td>Gagging Severity Index grades</td>
		</tr>
		<tr>
			<td>Grade I</td>
			<td>Very mild, occasional and controlled by the patient.</td>
		</tr>
		<tr>
			<td rowspan="2">Grade 2</td>
			<td>Moderate, control is required by the patient</td>
		</tr>
		<tr>
			<td>with reassurance from the dental team.</td>
		</tr>
		<tr>
			<td>Grade 3</td>
			<td>Moderate, consistent and limits treatment options.</td>
		</tr>
		<tr>
			<td>Grade 4</td>
			<td>Severe and treatment is impossible.</td>
		</tr>
		<tr>
			<td rowspan="2">Grade 5</td>
			<td>Very severe, affecting patient behavior</td>
		</tr>
		<tr>
			<td>and dental attendance and making treatment impossible.</td>
		</tr>
	</tbody>
</table>
Table 1: Gagging Severity Index (GSI) score15.

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CO2-Lasertonsillotomy Under Local Anesthesia in Adults

CO2-lasertonsillotomy under local anesthesia is an interesting alternative treatment method for tonsillectomy under general anesthesia for tonsil-related complaints in adults. This report presents a step-by-step protocol detailing the execution of CO2-lasertonsillotomy under local anesthesia.

CO2-Lasertonsillotomy Under Local Anesthesia in Adults

Tonsil-related complaints are very common among the adult population. Tonsillectomy under general anesthesia is currently the most performed surgical ...

co2-lasertonsillotomy-under-local-anesthesia-in-adults

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24.2K Views.  HagaZiekenhuis. Deze carbon dioxide-laser tonsillotomie techniek resulteert in minder perioperatieve complicaties zoals bloeden;patiënten ervaren minder postoperatieve pijn ook. De belangrijkste voordelen van deze techniek ten opzichte van klassieke dissectie tonsillectomie zijn het gebrek aan algemene anesthesie en patiënten sneller herstellen. Het aantonen van deze procedure met mij zal Rozemarie Van Geet, die zal optreden als de chirurgische technoloog voor deze interventie.Voordat u met een proc...

Video: CO2-Lasertonsillotomy Under Local Anesthesia in Adults

Guidelines for Elective Pediatric Fiberoptic Intubation

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.

We describe guidelines to perform a safe and efficient elective fiberoptic intubation in pediatric patients while maintaining spontaneous ventilation.

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small ...

Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can jeopardize their spontaneous breathing, topical anesthesia of the airway is a popular technique. The spray-as-you-go technique represents one of the simplest opportunities to anesthetize the airway mucosa. The application of local anesthetic through the working channel of the flexible endoscope is a widespread practice for anesthetists as well as pulmonologists. There is neither need for additional devices nor special training as a pre-requisite to perform this technique. However, a known clinical problem is the coughing and gagging reflex that may occur when the liquid anesthetic strikes the airway mucosa and other sensitive structures like the vocal cords. This can be avoided by the use of oxygen applied through the working channel with the aim of fogging the local anesthetic into finer particles. Furthermore, the oxygen flow provides a higher oxygen supply and contributes to a better view, dispersing mucus secretions and blood away from the lens. Using an atomizer with a high oxygen flow of 10 L/min we maximized these benefits, caused less coughing and had more satisfied and therefore cooperative patients. Possible, but very rare complications of using oxygen flow including gastric insufflation, organ rupture or barotrauma did not arise. We attribute the complication-free use of high oxygen flow to the design of the set, which permits flow and pressure release.

The topical anesthetic lidocaine was atomized using a high oxygen flow through the working channel of a flexible intubating endoscope to achieve topical airway anesthesia for awake endotracheal intubation. We prefer this modified spray-as-you-go technique for endoscopic intubation to classical bolus application because of higher patient satisfaction and better compliance.

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can ...

Transcanalicular Diode Laser-assisted Dacryocystorhinostomy for the Treatment of Primary Acquired Nasolacrimal Duct Obstruction

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), a relatively invasive procedure that can be performed after failure of recanalizing treatments. However, with progress in the field of diode laser technology, new approaches have emerged. Laser-assisted transcanalicular DCR with subsequent bicanalicular silicon intubation is a new option showing great promise as a viable minimally invasive procedure. Under permanent endoscopic visual control from the nasal cavity, a diode laser fiber is inserted into the lacrimal sac and laser energy is applied to create a bony ostium between the lacrimal sac and the nasal cavity. Since no skin incision needs to be made, advantages of this method comprise the sparing of the skin as well as the medial palpebral structures and the physiological palpebral-canalicular pump mechanism. The duration of surgery as well as reconvalescence is generally shorter than with external DCR. Complications include silicon tube prolapse, mild swelling and, rarely, canalicular infection and thermal injury. One-year functional success rates, defined as complete resolution of symptoms and ostium patency, are high, yet still range behind those of external DCR. However, secondary external DCR after failure of laser-assisted DCR can be performed without difficulty. Thus, laser-assisted transcanalicular DCR is a valid option that should be considered as a second-step procedure after failure of recanalization procedures and before external DCR.

The goal of this protocol is to present transcanalicular laser-assisted dacryocystorhinostomy as a minimally invasive approach in the treatment of primary acquired nasolacrimal duct obstruction.

Today&#39;s gold standard in the treatment of infrasaccal primary acquired nasolacrimal duct obstruction (PANDO) is external dacryocystorhinostomy (DCR), ...

Isolation of Tonsillar Mononuclear Cells to Study Ex Vivo Innate Immune Responses in a Human Mucosal Lymphoid Tissue

Studying isolated cells from mucosa-associated lymphoid tissues (MALT) allows understanding of immune cells response in pathologies involving mucosal immunity, because they can model host-pathogen interactions in the tissue. While isolated cells derived from tissues were the first cell culture model, their use has been neglected because tissue can be hard to obtain. In the present protocol, we explain how to easily process and culture tonsillar mononuclear cells (TMCs) from healthy human tonsils to study innate immune responses upon activation, mimicking viral infection in mucosal tissues. Isolation of TMCs from the tonsils is quick, because the tonsils barely have any epithelium and yield up to billions of all major immune cell types. This method allows detection of cytokine production using several techniques, including immunoassays, qPCR, microscopy, flow cytometry, etc., similar to the use of peripheral mononuclear cells (PBMCs) from blood. Furthermore, TMCs show a higher sensitivity to drug testing than PBMCs, which needs to be considered for future toxicity assays. Thus, ex vivo TMCs cultures are an easy and accessible mucosal model.

In the present protocol, we explain how to easily process and culture tonsillar mononuclear cells from healthy humans undergoing partial surgical tonsillectomy to study innate immune responses upon activation, mimicking viral infection in mucosal tissues.

Studying isolated cells from mucosa-associated lymphoid tissues (MALT) allows understanding of immune cells response in pathologies involving mucosal ...

Immunology and Infection

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is almost completely reserved to a few referral centers that deal with a large proportion of this pathology. Practice on human specimens is not always possible for ethical, economic, or availability reasons. The aim of this study is to provide a reproducible method for the organization of a laryngeal laboratory on ex vivo animal models where it is possible to approach, learn, and refine laryngeal techniques. Porcine and ovine larynges are ideal, affordable, models to simulate laryngeal surgery given their similarity to the human larynx in their anatomical layout and tissue composition. Herein, the surgical steps of transoral laser surgery, open partial horizontal laryngectomy, and total laryngectomy are reported. The merging of endoscopic and exoscopic views guarantees an inside-out perspective, which is vital for the comprehension of the complex laryngeal anatomy. The method was successfully adopted during three sessions of a dissection course &#34;Lary-Gym&#34;. Further perspectives on robotic surgical training are described.

The purpose of this paper is to illustrate how to organize a reproducible laboratory for laryngeal surgery on affordable and closely similar animal laryngeal models in order to improve anatomical and surgical knowledge and skills.

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is ...

Combined Endoscopic and Transoral Approach for Total Maxillectomy

The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely practiced for resecting maxilla. Compared with the traditional approaches, the combined endoscopic and transoral approach has many advantages such as avoiding facial incisions and postoperative scars and better visualization of the surgical margin. However, this technique is complicated to master and possess several challenges. Here, we demonstrate this approach step-by-step to show how to perform a total maxillectomy. We also reported nine cases with malignant tumors originating from the maxilla, and for all of them total maxillectomy was performed with combined endoscopic and transoral approach. Our data showed that the combination of the endoscopic and transoral approach could be used to resect the total maxilla successfully, though the tumor extended to the infratemporal and pterygopalatine fossa should be treated very carefully to avoid its spread in the local area. Furthermore, besides denture, other reconstruction methods should be attempted to improve the postoperative quality of life after the total maxillectomy.

The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely ...

Full-Endoscopic Decompression for Thoracic Ossification of the Ligamentum Flavum Combined with Dural Ossification

Ossification of the ligamentum flavum (OLF) can result in spinal stenosis. Thoracic spinal cord compression due to spinal stenosis is a common cause of progressive thoracic myelopathy in Asian countries. The incidence of complications is high in open decompression surgeries for thoracic OLF. With dural ossification (DO), the risk of complications is even higher in thoracic OLF. We introduce a full-endoscopic decompression surgery for thoracic OLF combined with DO under local anesthesia. Hemilaminectomy is performed using a high-speed burr under the endoscopy first, and then decompression of the contralateral spinal canal is completed using an "over the top" technique. DO resection uses the eggshell technique; after the base of the DO is cut from the lamina, forceps or lamina rongeurs are typically used for removal. The dural defect left after resection does not need repair. Neurological function was improved, and no complications such as hematoma or neck pain occurred. On imaging, no pseudodural cyst, cerebrospinal fluid leakage, or wound complications were observed after the operation. Endoscopic surgery causes less damage to the posterior ligament complex, so no cases of persistent back pain complaints or secondary internal fixation requirements were found in this study. Full-endoscopic decompression can achieve good imaging and clinical effects in the treatment of thoracic OLF with DO.

We describe a minimally invasive surgery using a full-endoscopy system for the single segmental thoracic ossification of the ligamentum flavum, combined with dural ossification, at Hebei General Hospital.

Ossification of the ligamentum flavum (OLF) can result in spinal stenosis. Thoracic spinal cord compression due to spinal stenosis is a common cause of ...

Laminectomy for the Removal of Thoracic Ossification of the Ligamentum Flavum (TOLF) Using Ultrasonic and Conventional Osteotomes

Thoracic ossification of the ligamentum flavum (TOLF) is a common cause of progressive thoracic myelopathy. TOLF is typically treated with surgical decompression. A variety of surgical techniques, including laminoplasty, laminectomy, and lamina fenestration, are used for the effective treatment of TOLF. However, traditional methods are associated with a substantial risk of perioperative complications, including dural laceration and/or iatrogenic spinal cord injury. Therefore, it is important to develop an efficient and secure surgical technique for TOLF. Herein, we describe a method for laminectomyperformed at the thoracic spine using an ultrasonic osteotome combined with a conventional osteotome. This technique can reduce intraoperative complications. This is a relatively safe and easy-to-learn method that should be recommended for the treatment of TOLF.

Laminectomy for the Removal of Thoracic Ossification of the Ligamentum Flavum TOLF Using Ultrasonic and Conventional Osteotomes

We present a methodology for using an ultrasonic osteotome combined with a conventional osteotome for laminectomy in thoracic ossification of the ligamentum flavum. This is a relatively safe and easy-to-learn method that avoids the perioperative complications associated with the conventional method.

Thoracic ossification of the ligamentum flavum (TOLF) is a common cause of progressive thoracic myelopathy. TOLF is typically treated with surgical ...

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

CO₂-Lasertonsillotomy Under Local Anesthesia in Adults

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