Critical Cases

October 2017

  1. Free Radial Artery Forearm Flap: Free Radial Artery Forearm Flap was done to reconstruct defect after excision for Ca Alveolus.
  2. MicroLaryngeal LASER Surgery in an Obese Patient with Obstructive Sleep Apnea Syndrome : A middle aged obese patient with Obstructive Sleep Apnea Syndrome was posted for MicroLaryngeal LASER Surgery. Anesthesia in such patients is challenging. During induction patient can have airway obstruction. For LASER surgery patient is intubated with small sized Endotracheal Tube. In an obese patient, ventilation with small size tube can lead to high airway pressures, inadequate ventilation of some regions of the lung and ventilation perfusion mismatch. After reversal of anesthesia obese patients tend to hypoventilate and recovery from anesthesia may be delayed. With careful titration of anesthesia doses, patient had smooth anesthesia course and good recovery.

September 2017

  1. Cochlear  Implant Surgeries -Two Cochlear Implant Surgeries on boys age 2 yr and 5 yr were conducted by Dr. Milind Kirtane. Dr. Harsh and Dr. Gauri assisted Dr. Kirtane during the surgeries.
  2. Juvenile Recurrent Laryngeal Papillomas – Two boys age 4 yr and 7 yr are chronic patients of JRLP. They are undergoing multiple settings of CO2LASER excision of the papillomas.
  3. Endoscopic CSF Leak Repair – was done on a young lady. Free Fibula micro vascular Flap was performed after excision of cancer mandible in a young male patient.

August 2017

  1. A girl with tracheal stenosis underwent cricotracheal resection anastomosis for reconstruction of the airway, Check endoscopy 3 weeks later showed good patient airway. Repeat endoscopy 1 month later showed adequate airway patency. 1 week after endoscopy patient was decannulated successfully.
  2. End to End Tracheal Resection Anastamosis  An adult lady had undergone tracheoplasty elsewhere. Montgomery’s T tube had been inserted, but the procedure was not successful. At our clinic we attempted tracheal dilatation on 3-4 occasions but patient continued to have distress. Hence End to End Tracheal Resection Anastamosis done. Tracheostomy tube was removed on 4th day of surgery. Patient was comfortable and discharged 1 week post op.

 

July 2017

  1. A girl with tracheal stenosis underwent cricotracheal resection anastomosis for reconstruction of the airway, Check endoscopy 3 weeks later showed good patient airway.
  2. An adult lady with papillomas underwent laser excision. Due to the multiple previous surgeries (some of them with cold steel at another centre) she had developed a glottic web which was causing her respiratory distress. The web was laserized & good airway achieved.

June  2017 

An elderly lady having facial palsy due to mastoiditis was operated upon by mastoidectomy. Post surgery her facial palsy recovered completely.

Trans nasal endoscopic pituitary macroadenoma excision done at CIIMS with neurosurgeon Dr. Pankaj Sarda.

Tracheal Stenosis:  A young lady was operated elsewhere for tracheal stenosis. Montgomery T tube was inserted. 6 weeks after the surgery the T tube was removed but patient had to be tracheostomised as she had respiratory distress. She is now undergoing CO2 LASER vaporization of stricture and tracheal dilatation.

Endoscopic CSF leak repair: was done in a young female patient.

Juvenile Recurrent papillomatasis: A 3 year old girl was totally aphonic due to laryngeal papillomas. Cautious spontaneous inhalational induction was done and papillomas excised with CO2 LASER.

Free Fibula Micro Vascular Flap: was done for Mandibular defect after excision of alveolar cancer.

Post Tonsillectomy Secondary Hemorrhage: Post tonsillectomy a young boy had secondary hemorrhage due to infection. Coagulation profile was normal. 3rd generation IV antibiotics were given. He had two episodes of massive bleeding every 3rd day. On examination under general anaesthesia no specific bleeder was found in tonsillar bed. Angiography was also done but no specific bleeding vessel or aneurysm was located. Finally the bleeding was controlled spontaneously after 10 days.

Chronic Kidney Disease with Oral Cancer: A middle aged adult male was operated for oral cancer. He had chronic kidney disease with high levels of blood urea, serum creatinive and potassium. All precautions were taken to avoid any nephrotoxic drugs, use relaxants not dependent on kidneys clearance and to maintain renal perfusion. Patient had uneventful recovery after 7 hrs surgery.

Glomus tympanicum: A patient having a co -existing cholesteatoma along with a glomus  tympanicum  in right ear was operated .The glomus tumor was very large and had feeders from ICA which made surgical challenging.

 

April & May  2017

  1. Awake Blind Nasal Intubation- was done for a patient with zero mouth opening, posted for surgery of trismus.
  2. UvuloPalato  Pharyngo Plasty-  Adult male patient with obstructive Sleep Apnea Syndrome was posted for LASER  assisted . UvuloPalato Pharyngo Plasty. He had a difficult airway with Mallampatti Grade IV short mandible and large tongue.

              Awake nasal intubation was performed.

  1. Decanulation of tracheal stenosis: Young female patient suffering from tracheal stenosis   for more than 1 year was successfully decannulated.
  2. Subglottic Web- A 2 ½ year old female child was referred for CO2 LASER excision of  subglottic web . She had undergone long term intubation and ventilation leading to the formation of  web. Effective subglottic diameter was only 2.4 mm. Patient was intubated with a 2.5 mm tube and LASER vaporization of the web was done.
  3. Free Antero Lateral Thigh Flap was done for closure of defect after excision of oral malignancy.
  4. Juvenile Recurrent Laryngeal Papillomatious – 10 year old boy has been undergoing repeated CO2 LASER excision of papillomas. Now the papillomas are fairly under control.
  5. Temporal Bone Resection: We achieved a land mark by performing a Temporal Bone Resection with Pinna resection with Total Parotidectomy and PMMC Flap. This is a very rare surgery and performed in our clinic for the 1st time in Vidarbha. 

March 2017

1.    Juvenile Recurrent Laryngeal Paillomatosis- A 4 year old boy is undergoing multiple procedures for CO 2 LASER vaporization of recurrent Laryngeal Papillomas.

2.    Total Thyroidectomy in a patient with large artic Aneurysm- A middle aged lady with large thoracic aortie aneurysm was posted for Total Thyroidectomy.
She was operated at a cardiac centre due to risk of rupture of aneurysm. The surgery was conducted uneventful.

3.    Subglottic Web- A 2 ½ year old girl came with history of meningoencephalitis when she was intubated and ventilated for prolonged period. Subsequently she developed a web in subglottic region. She had dyspnea with slightest exertion and was admitted two weeks back in stridor at another hospital with conservative management the patient was slightly better and she was referred to Dr. Madan Kapre.
CT scan of the child showed that in subglottic region her tracheal diameter was only 2.4 mm. Anesthesing and securing airway was risky due to possibility of airway obstruction and difficulty in introducing even 2.5 endotrachal tube.
The child was gradually induced with IV glycopyrnolate, fentanyl, propofol and O2, N2O and sevoflorane.
2.5 mm red rubber uncuffed endotracheal tube with stiletto could be introduced. 
The risk during LASER vaporization of the web was that sina the tube was uncuffed, there would be free O2 enriched gases in the larynx. As the tracheal lumen was very narrow there was no space for covering the endotracheal tube to prevent LASER punction. To ivercome these difficulties, just before Laserisation the endotracheal tube was disconnected from anaesthesia circuit. During Laserisation the endotracheal tube contained only air, so the risk of tube puncture and airway fire was minimized.
The web was successfully vaporized with CO 2 LASER and adequate tracheal lumen achieved. Subsequrently 4 mm endotracheal tube could be introduced easily. The patient made good recovery.

4.    Bilateral abduction Palsy in young child – A 7 year old girl came with history of head injury followed y frontal lobe syndrome requiring long term intubation and ventilation.. The child developed bilateral abduction and palsy leading to stridor and had to be tracheostomised.

5.    Kashima procedure was done using CO2 LASER. Adequate laryngeal inlet was achieved. On subsequent visit airway assessment will be done and if the laryngeal inlet remains adequate, the tracheostomy tube can be removed.

6.    Extensive thyroid malignancy with extranodal spread & nodes stuck to common carotid RLN & esophagus – underwent successful Total Thyroidectomy & Neck Clearance with Complete Clearance.


February 

1.    Juvenile Recurrent Laryngeal Paillomatosis- A child with recurrent laryngeal papillomatosis is undergoing treatment with multiple sittings of CO2 LASER vaporization. His larynx is now clear, but there are subglottic pailloma which have to be removed with cold steel instruments through the tracheostome.
2.    Botox injection done for spasmodic Dysphonic- Injection of botulinum toxic into the vocal folds was done in two patients of spasmodic dysphonia. This procedure was done under local anaesthesia with EMG guidance and for the other patient was done under general anaesthesia.
This procedure was done for the first time in Nagpur. Previously such procedures were only being done in one centre Mumbai and one centre Pune in Maharashtra. 
3.    CSF Leak Repair- CSF leak in a middle aged lady was repaired endoscopically with fascia lata and surgical glue.
4.    Nasopharyngeal Angiofibroma – A young boy presented with Nasopharyngeal Angiofibroma. Patient was operated after embolisation and blood loss was minimal.

January

1.    CSF Leak Repair- CSF leak from cribriform plate was repaired endoscopically in a middle aged lady. The leak was sealed with fascia lata graft and medical glue.


2.    Tracheal Stenosis- A young girl had tracheal stenosis post ventilation after suicidal attempt. She had undergone tracheostomy due to the narrow airway. CO2 LASER vaporization of the stenosis was done in 2 sittings. Further endoscopy revealed normal patent airway, so the tracheostomy tube could be removed and patient decannulated successfully. 


3.    Cochlear Implant Surgery- was performed on a 2 year old child who had profound sensorineural hearing loss. Dr. Harsh performed the surgery under the guidance of Dr. M.V. Kirtane and helped by Dr. Gauri.  

 

 

December

1.    Awake Blind Nasal Intubation A adult male patient had undergone Hemimandibulectomy several year back. He came for excision of CA Buccal Mucosa. Patient has also developed Trismus. Local Anaesthesia of the airway was achieved by Bilateral Superior Laryngeal Nerve Blocks. Transtracheal local anesthetic injections and Nebulisation with local anesthetic. The mouth opening was severely restricted and would not even admit magill forceps. So awake Blind Nasal Intubation was performed

 

2.      Rare tumour in Parapharyngeal Space- A middle aged lady had a rare tumor ( lipoepithelioma) in the neck. Major arteries were passing through the tumors hence the surgery was high risk. Patient also had strongly positive stress test so she was operated at Dr. Tambe’s critical care unit.
 

3.    Supraventricular Tachycardia- A male patient with no co – morbidities was to be operated for ca Tongue. After intubation, patient had severe tachycardia in the range of 160/min which persisted even after administration of  beta blocker and IV xylocard after consultation with cardiologist, surgery was postponed, patient awakened. Later a thorough cardiac evalution was done, patient  was given Tab Diltiazem and operated after 5 days uneventfully 

 

November

  1. Free Radial Artery Forearm Flap- was done for a patient operated for Ca Buccal Mucosa.
  2. Endoscopic CSF leak repair- was done for a middle aged lady patient.
  3. Antero lateral Thigh Flap- was done in a patient after excision of Ca Alveolus.