2025 Pediatric Surgery Update Course - Updates in Management of Neck Pathologies

This is all you're here. Yes, not move, just move. All right, so Dr. Dan Van Alman is cannot be with us because now Dan lives in the UAE. He'll be there for a couple of years working on Cincinnati Children's and the UAE. So he is not here. So we found the the better, smarter, faster, stronger vision version of Dan, which is his son, Doug Van Alman. So Doug, are you there? I'm here, can you give me your cut? Yeah. It's a Doug. We've got a hard act to follow here. Just a little bit. So I'll let Dan moderate the session. But Doug is one of our absolute spectacular hardcore E&T's that does all the most complex stuff. And we've been asking him to talk about some easier things than the stuff he does every day. But Doug, thanks for joining us. Yeah, thanks for having me. So I'm going to go through some of the innovative approaches. We have some of the head neck pathology that you made. Come across. So can everybody see slides of that? We can do it. All right. So this is the first clinical scenario. So this was a four year old who came in with some painless neck swelling after a viral illness. Had a CT scan that was done. And you can see this cystic mass that extends from a thyroid up to the puriform sinus there. She was treated with some orlean ofiotics. And she got improvement in the swelling of her mass. Next slide. But I would like to know what you all, how you to approach this. We've got an audience poll in the next slide. If you can advance, farming. I'll get it. Yeah. Well, they're waiting with. Would you say most people just jump to CT scan for neck swelling? Or is this is this something? That's going to buy us. Yeah, I find we get a lot of CT scans that are performed in the emergency department before we've seen the patient. I think that's just part of the a little bit part of the CYA practice that has just come, you know, along with the evolution of things. But so yeah, I do find that a lot of times we have imaging before we've been consulted. Okay. We have the results. I know. All right. Can you see it done? Yeah, so it looks like we get, fair amount of people would get some more imaging. We'd have a couple of people do perkycane strainage. This is a branchial cleft cyst. And so we try it possible to avoid doing any interventions on these. And so we're ready to kind of resolve the issue. I and B's sometimes make it a little bit more challenging to go and remove these in the future. Traditionally, you know, with some of these, particularly the type three and type four branchial cleft cysts, you can get some associated thyroiditis. And occasionally you have the perform of a hemifyroid at me. If you get in there, it's really stuck to make sure you excise for lesion. The interesting thing with these type three, type four, branchial cleft cysts is that they typically have a tract going up to the piriform sinuscane, advanced next slide. And if you can start that video, hopefully you can appreciate that little sinus right there. And you can actually use a little bug-been, caudery probe, and caud arise this sinus, and it resolves the lesion prevents for currents. So you can see us sort of pulling that probe back. And then you'll see the caudalization right there. Doug, what do you have to be worried about? I love this because a lot of us do this for like H-type or recurrent fistulas, not H-type, so much, but recurrence. So if we do this, what do we have to watch out for? So it's, I mean, honestly, just putting that having a tube in there, you're using bogey electrocodery, making sure that you have a low F-2. And you're using your safe fire precautions for using a bogey in the, and what could be an open airway scenario. And the biggest thing is just watching out for recurrence. It can take more than one, just like for a moscopic, prepares a TES. Sometimes it takes a second time. So watching out for repeat swelling. I've also thrown a stitch in them as well. You can do that in a scopically. But how do you, do we need to go? Like just at the orifice? You don't need to go deep. Yeah. You can really just insert the coterie just tip, centimeter or so paths and cotterize. And yeah, you don't need to bogey the whole tract. Has anybody in here used a bug B for recurrent TES? Or this? Has anyone done this? No. Has anyone used a bug B for anything other than a recurrent TES? And who, if they saw a type three or four, break a cleft with send a TNT in that, do it themselves? Or really? Well, would anybody do it themselves? Now I will. I would call it ENT for my first, I would. I would call it do it with them. And then after that, I think if it's just orifice. Because you're going to excited. That's one of the study that I talk about. Yeah. So go ahead, Doug. Yeah, so you can go next to the next slide. There it is. OK, so this is a study looking at the comparison of doing that endoscopic approach versus an open excision. And the outcome of recurrences of quigland. So it really does suggest that you can potentially avoid some of the morbidity with an open approach. Particularly if you're talking about having to deal with thyroid potential, recurrent, racial, nerve injury, this can save a lot of heartache for the patient. All right. So this is a next case. So this was a seven-year-old who came to us, had a history of TDEA, had a repair, and what came was having some chronic cough, as well as some food impaction issues. She was referred specifically for the esophageal diverticulum, but we were involved to evaluate the airway as well. If you could click on one of the, start one of those videos, that'd be great. She'd had a couple dilations in the past without improvement. And so that right side is the esophagoscopy. This is the esophageal and asthma, it's just right here. And as you back up, you can see there's a little ledge that's been formed. And essentially that's just a dilated upper pouch. You can start the other video, that'd be great. And then this is the bronchoscopy video. So as you go through, you can see that there's some granulation tissue along the back wall. And then as we advance a little further, this was the original TDEF. And this we explored this and that was closed. But as we probe that area where the granulation tissue was, you can see that there's a second fairly large of infisciala there. And these second fiscialas, particular or each type of fiscialas, they can be really hard to deal with endoscopic, sometimes. And so next slide, please. So this was the esophageal gram showing that mismatch in that little outpouching. And then I want to know, how the group typically deals with cervical TDEFs that could advance the next slide. I got a full question there. So do you, you know, approach it laterally? Do you interpose any tissue? Do you do anything to the esophagus at the same time? And then would anyone consider going through the trachea? No. You don't do the occipate? Wait, yeah. So Doug, you're talking about an H type, right? Yeah. So you have a group of pediatric surgeons that many of us inclined thoracoscopically. So I think that might be another choice to put up there, which is debated on which is easier. Yeah, well, this is really high. So this is in the net. Yeah? OK. Hi. Yeah, there's this has been the debate, Doug. I think sometimes it's very, very hard to get if it's really high, but there are people in here. Or the orthoscopically, yeah. Yeah. There are people that push forward. I should have put it in other. I think it's tough. I don't know. I can tell you from personal experience having an H type that did with the ENT guys was really high. It was way easier than trying to go up the orthoscopically and trying to divide it. I mean, I think we got to do what's right for the patients and eat or ego a little bit by the same. We can do anything through the chest, because through the neck, in some circumstances, it's probably better. I agree. There are H type people that are in the tongue and there are H type people that are inside the thorax. So I agree. You choose your bottle. But I agree that 85% of them you can do it orthoscopically. But some of them are really, really high. If you do the bronchoscopically, it's like right under the cords or high, really high. Yeah, they shouldn't be done. What I've done is put a guide wire through the trachea and pull it out through the suffocates and then tick an x-ray with the patient on the table and see how far above or below the carina, or so the carina, the clavicle is. So that makes an easier decision. So you can actually kind of extend the neck and pull it up for a cervical repair or actually do the opposite and push for a thoracoscopic repair. All right, let's talk us through. Keep going. I can see the pole results. Let's see. The pole results showed lateral with the inner precision of muscle. Okay. Yeah. So, yeah, obviously if you can put anything intervening there, that's always helpful to prevent facial recurrence. I think especially in younger kids and in the TEFEA population, it's always, you gotta be a little careful about how much bulk you put behind there too, right? You've gotta get that potentially already has intrusion of a posterior trachea wall and then you put some bulk behind there. Sometimes that can make some of the obstruction worse too. But I totally agree, I'll prevent more occurrence up front. This is really important. So if you can advance to the next slide and start that video. So we elected to do a trans-tracheal repair and so this is a video that shows we got a distal tracheotomy here with the ET tube. You can do a bronchoscopy to help localize the level of the fistula and then make a tracheotomy over the fistula. You can divide those that work through the tracheotomy to divide the layers of the esophagus and trachealis and then close the esophageal side. This is us putting a little bit of sternal periostium in as an interposition graft and then closing the back wall of the trachea and that gets a three layer closure there and they'll see hopefully that closure there of the back wall and then you can close the tracheotomy and decision. And this is a really nice way to deal with a high fistula and completely takes recurrent laryngeal nerve injury out of the picture. So is anybody done this in the room? I didn't do it to the tracheide. Since 90 people don't get the answer I want to look for trachea. So Doug, the question in the room is the benefits of going through the trachea? I think you talked about recurrent laryngeal laryngeal nerve injury. Yeah, yeah, it's really, recurrent laryngeal nerve injury I think is under reported. You know, it really involves having a regimented a group in place or a protocol where you have people look and I think a lot of times you don't necessarily always look before and after. You can also have kids compensate for those nerve injuries sometimes for quite some time but if it is a true paralysis over time that muscle atrophies they have long-term voice problems and potentially have issues with aspiration as well. Hey, Doug, in this picture, is that end of tracheotube going distal to your tracheotomy? Yeah, so you have another hole in the trachea distal too? Correct. And you can just close that at the end. If there's enough room for that, it makes it makes it like these years in terms of while you're working. Otherwise you can go in and out with a or you can have a tube that sits proximal and pull it back if you need to and you have to work a little bit intermittently with having the ETG going in and out. So that's doable. It's a little bit more of a pain. So particularly on a bigger kid in this scenario where you have room to make a separate trachea out of you lower and that should ideally be made about two rings below otherwise you risk just tearing through the trachea there and making one big hole. Isn't that spout, right? Yeah. All right, we'll keep that moving forward here. So this last scenario is a case. That was a little bit of a struggle from a diagnostic standpoint for me and I but I think it you know but lucidates some of the different ways that we deal assisted neck masses and kids and so this was a 16 year old who presented with right submandee blood swelling of a soft as painless and we can go the next slide there. Had a CT scan of course and so this is the cystic mass that's headed up underneath the mandible there. You can see that it in the axial view that it about the submandee blood gland on that right side next slide. All right. How would you treat this more imaging? Would you go after it which consider aspirating it plus or minus letter therapy? Had a bunch more people getting more imaging and then some aspirating it. Great. All right, Kee go the next slide there. So I decided to go with a cervical approach. My concern was was this coming or being involved with the submandee blood gland there. It can be really hard to differentiate a giant rannula from a lymphatic malformation at times. I went through the neck, excised this and of course a couple months later it came back. So he let me aspirate it in clinic. This is a technique you can use that potentially try to send this off for for amylase to see if it is saliva in the lesion. There's some technical challenges with that and I found this to be less helpful as I've gone through and tried to use this. A, the lab tends to have trouble running this thick fluid and then you can also have lymphatic malformations near glandular tissue that have some leaching of some of the saliva into it and get a false positive. I ended up kind of hedging my bets and treating this as assuming that this was a rannula and doing a sublingual gland excision, which should resolve that. But I also had our IR guys go in and do an aspiration and scleroid. Of course the thing came back again and I ended up getting an ultrasound as he was developing some of the swelling, which suggested it was lymphatic malformation and by removing all that sublingual glandular tissue that may be pretty confident that that's what it was and thankfully after a repeat aspiration scleroid result. Next slide. So this is, so from a rannula perspective, really removal of the sublingual gland has been the key best practice piece of this. When you have a cervical component of that, you can even aspirate that and as long as you remove the sublingual gland, it should go away because it's a pseudo-sys. There is a new technique that's being used called micro-marsupialization where if you can identify an intralural component, you can throw some silk sutures through the cyst, allow you let that sit for 30 days, it develops some fist gila and then you can cut the sutures out and it will spontaneously drain into the mouth. There's also been good data about using sclerotherapy for rannulas as well. So some lesson that invasive techniques that can be helpful. Next slide. So when we talk about lymphatic malformations, obviously you've got a mix of surgical and medical therapies, those medical treatments up there, undergoing clinical trials, you can go to the next slide for me. This was an algorithm that was recently published in the pediatric surgery literature. Obviously the component of that lymphatic malformation is gonna tell you what to use as far as surgical or medical treatment, but that's often multimodal. Next slide. So the new development is that there are now some gene panels that you can send for that really help guide medical therapy going forward. So particularly the PIK3CA mutations in lymphatic malformations suggest that that out-pelicid drug can be useful as a PI3K alpha inhibitor. And there's several different panels out there, but probably the biggest most comprehensive one is van seat, which is run in Seattle, at least that I'm aware of. That's gonna be a big thing going forward and helping to manage these lymphatic malformations. So you're saying if you have the PIK3CA mutation, the drugs like serolimus work better. So I have more effect. And it bit to the out-pelicid, yes, that you're a good candidate for that. And as we identify different mutations in these pathways, we're gonna be able to better use these drugs. There's some limitations out-pelicid you gotta wait till they're two. And so often right now, at least our group is putting kids on serolimus until they're ready for that. But there's some different drug profile, or as far as side effect profiles of these drugs, where we can potentially eliminate putting these kids on these medicines for long periods of time and not seen as good at outcomes. And then if you can go on, next slide for me. And then I just, this is the way we think a lot about pediatric neck masses when we're starting to go through and develop differentials. Can you go to the next slide for me? But I just wanna point out that these congenital development neck masses are really the ones that you have to do something special for. So you have to not just excise the mass, but you have to deal with the embryological component or an etiology to prevent that recurrence. And with that, I am happy to end and taking those questions or comments. Could you have a clock running in your office there? Cause you finished your literally two sessions. Exactly on time. So any questions for now? I can tell you that we will be sending everyone the high points, the articles, the things that everyone needs that you learned. Doug, this was phenomenal. My only regret was you weren't here in person, so next time. Yeah, me too. Thanks, buddy. Thank you. All right. Thank you guys. Thank you.