Esophagoscopy without Sedation [VIDEO]

Here is a video demonstrating how esophagoscopy can be performed in the office without any sedation. The esophagus is the tube that connects the mouth to the stomach. The exam, called trans-nasal esophagoscopy (TNE), can be performed in any patient as long as the nose is large enough to accommodate the endoscope and lack a severe gag reflex. A very thin disposable sheath (like a condom) is used to protect endoscope and maintain sterility between patient use.

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Ear Tube Placement in Kids WITHOUT Sedation (Starting at 12 Months of Age)

A recent report describes how using a relatively old technology, ear tube placement can now be performed in children starting at 12 months of age with chronic ear infections or hearing loss due to fluid buildup without the need for sedation of any kind nor aggressive restraints (ie papoose). Historically, ear tube placement in the office without sedation is typically performed starting at around 12 years of age using standard local anesthesia techniques. Any younger, a child could not be trusted to stay still during the procedure due to presence of some discomfort.

In any case, a Texan ear group reports how they accomplished this simple procedure at such young ages.

First, the ear canal is cleaned as much as possible of all earwax and debris. The ear canal is than filled with an anesthetic liquid (concoction of lidocaine, epinephrine, and sodium bicarbonate). Over 10 minutes, iontophoresis was than used to induce profound local anesthesia to the ear canal and eardrum. The liquid was than suctioned out and ear tube placement was performed with a reported 90% success rate (78 of 86 ears; 17 subjects were 3 years old or younger; 8 were 12 months old).

The key to success required 3 "new" elements.

• Iontophoresis device made by Acclarent. There are other iontophoresis devices in the market (Medtronic and Otomed), but none adapted for simultaneous bilateral ear canal usage that works within 10 minutes. Iontophoresis works by applying a gentle electric current in order to actively move charged drug molecules into the skin. In this particular case, positively charged lidocaine and epinephrine.
• Optimal anesthetic solution for iontophoresis. Dubbed "EMGIM", it contains 1:12,000 epinephrine with 3.3% lidocaine hydrochloride and 0.7% sodium bicarbonate. The solution is prepared fresh prior to use by combining 10 mL of 4% lidocaine hydrochloride with 1 mL of 1:1,000 epinephrine. After mixing the lidocaine and epinephrine, 1 mL of 8.4% sodium bicarbonate is added.
• Ear tube delivery device and placement system. Typically, a competent ENT can place an ear tube in about 10-20 seconds. However, when dealing with kids who may potentially move unexpectedly and operating within a very small ear canal space, a faster and more reliable way of placing a tube was required. Hence, this new device. [link]

Of course, during the actual procedure, age-appropriate distraction was needed to minimize movement, especially given aggressive restraint was not used.

Sounds great as sedation is something to be avoided if at all possible. However, there is one problem... the Acclarent iontophoresis device is NOT yet FDA approved contrary to what the report states (direct communication with Acclarent executives October 1, 2013). Hopefully in 2014. As such, beyond a research setting, this in-office technique is not yet available for use in the United States.

As an aside, there are FDA-approved iontophoresis devices for use in pediatric head and neck surgical procedures mainly for sub-cutaneous mass excisions and abscess incision and drainage. Check out Phoresor for such applications using lidocaine infused electrodes. It's even sold on Amazon.


References:
Otologic Iontophoresis: A No-Papoose Technique. Annals of Otology. Rhinology & Laryngology 122(8):487-491. Aug 2013.

In-Office Tympanostomy Tube Placement Under Local Anesthesia Using a Novel Tube Delivery Device. Triological Meeting Poster. Dec 2012.

Iontophoresis: a needle-free, electrical system of local anesthesia delivery for pediatric surgical office procedures. J Pediatr Surg. 1999 Jun;34(6):946-9.

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New Video on Awake Tonsil Cryptolysis to Address Tonsil Stones

A new video has been uploaded describing a minimally invasive technique to address tonsil stones called tonsil cryptolysis.

This technique accomplishes the same thing as laser cryptolysis but at lower cost and increased safety. Just like laser cryptolysis, this procedure can be done awake without any sedation using only local anesthesia (the caveat being that the patient must have minimal/no gag reflex with easy visualization of the tonsils).

Watch the video below or on YouTube. Read more about this procedure here.

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In-Office Sinus Surgery Without General Anesthesia

There has been tremendous advances in sinus surgery over the past decade. From the elimination of nasal packing after most routine sinus surgery to the more recent use of balloons to open the sinus cavities, patient comfort has improved greatly after this particular operation. What used to be a several week recovery may now only be a few days.

Balloon sinuplasty in particular has been revolutionary in the surgical treatment of chronic sinusitis. Though sinus surgery normally is performed under general anesthesia, balloon sinuplasty now allows this operation to be performed awake WITHOUT sedation using local anesthesia only.

At its essence, sinus surgery "opens" up blocked sinus cavities to allow drainage and ventilation. Traditional sinus surgery "removes" tissue to accomplish this goal whereas balloon sinuplasty stretches open the sinus cavity without the need for tissue removal.

Given the lack of tissue removal with balloon sinuplasty, there is less pain and faster recovery after the procedure.

What are the steps?

After adequate anesthesia of the nose using both topical and injectable numbing medicine... Step 1 Under endoscopic guidance, the balloon catheter is introduced into the nasal cavity and guided towards the target sinus cavity opening. Depending on the system used, a sinus guidewire or sinus illumination may be used to help with the guidance.
Step 2 Once the sinus balloon catheter is correctly positioned across the blocked sinus opening, the balloon is gradually inflated to stretch open the ostia.
Step 3 After several seconds, the sinus balloon catheter is then deflated and removed leaving an enlarged sinus opening allowing for the return of sinus drainage. There is little to no disruption to mucosal lining.

Of course, not all patients are candidates for balloon sinuplasty, let alone this procedure to be done awake with local anesthesia alone.

In particular, balloon sinuplasty can only address blockages involving the frontal, maxillary, and sphenoid sinus cavities. Ethmoid sinus cavities can NOT be corrected using this method.

Also, balloon sinuplasty does not allow for tissue biopsies (by definition, the advantage of balloon sinuplasty is the lack of need to remove any sinus or nasal tissues). As such, if there are any masses present including nasal polyps, traditional sinus surgery is the better way to go.

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Tonsillectomy Circa 1940s [video]

I encountered this interesting video of tonsillectomy being performed in a child with sedation (but NO intubation) performed circa 1940s.


Of course, nowadays, tonsillectomy is performed under general anesthesia with intubation for airway protection. Here's a video of the way it is now done.

That is, unless, you practice in other parts of the world where modern medicine is not up to United States standards. In those nations, tonsillectomy is STILL being performed WITHOUT general anesthesia or any sedation for that matter. In fact, here's a blog I wrote earlier this year showing a graphic video depicting tonsillectomy being recently performed in a young child WITHOUT any sedation.

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