Cricopharyngeal Myotomy

Anatomy and Rationale

Indications

Surgical Approaches

1. Open Transcervical Myotomy

1. Subplatysmal flaps are raised; SCM retracted laterally
2. Strap muscles retracted medially; omohyoid may be divided
3. Middle thyroid veins ligated; thyroid lobe reflected forward
4. Carotid sheath retracted laterally; pharynx/larynx rotated to the right
5. Identify and protect the recurrent laryngeal nerve (enters larynx just inferior to the cricothyroid joint)
6. Blunt dissection to posterior pharynx; diverticulum identified (aided by endoscopic packing / transillumination / nasogastric tube or bougie within the lumen)
7. A 48 Fr Maloney bougie is placed in the esophagus as a guide
8. The myotomy is created: division begins at the cricopharyngeus and extends 5-6 cm distally through the full thickness of circular muscle fibres down to mucosa
9. The muscle fibres are pushed apart to create at least a 1 cm gap
10. Diverticulum is then managed (excision, suspension, or inversion) depending on size

• Scott-Brown's Otorhinolaryngology, p. 864; Fischer's Mastery of Surgery, p. 2816

2. Endoscopic Approaches

• Requires a diverticulum >2-3 cm for adequate stapler placement
• Patients are fed liquids immediately and discharged the next day
• Residual lateral "pouches" may appear on imaging but are rarely symptomatic if the myotomy is complete

Myotomy in Post-Laryngectomy Patients (TEP Speech)

Postoperative Care

• Small drain left in the neck after open surgery
• Barium swallow on postoperative day 1 to confirm no leak
• Liquid diet initiated if swallow study satisfactory
• Dietary advancement over several weeks
• Nasogastric tube placed intraoperatively as a precaution; not left routinely - Fischer's Mastery of Surgery, p. 2817

Complications

Key Points

• Myotomy length must be at least 4-5 cm - short myotomy is a common cause of failure
• Always performed with ZD surgery - recurrence is significantly higher without it
• Recurrent laryngeal nerve protection is the most important step during open dissection
• Postoperative manometry: peak pharyngeal pressure unchanged; resting UES pressure reduced but not eliminated; sphincter length shortened - Schwartz's Principles of Surgery, p. 475
• A systematic review (PMID 39353299) from 2024 on pediatric cricopharyngeal achalasia confirms myotomy as the definitive management in the pediatric population as well

Balloon Eustachian Tube Dilation (BET / Balloon Eustachian Tuboplasty)

Background and Rationale

Anatomy - Critical Concept

1. It is in close proximity to the internal carotid artery (risk of catastrophic injury if the carotid is dehiscent into the lumen)
2. It is unlikely to be the site of obstructive pathology
3. FDA-approved balloons are specifically designed not to extend beyond the isthmus

Indications (Box 131.1 - Cummings)

• Chronic symptoms of obstructive ETD for ≥3 months
• Symptoms persistent despite appropriate directed medical therapy
• Objective pathologic findings on dynamic endoscopic examination of the ET lumen (e.g., inflamed mucosa or lymphoid hyperplasia/cobblestoning compromising tubal opening)

• Persistent OME or tympanic membrane with negative pressure on insufflation AND type B or C tympanogram
• Consistent history of baro-challenge (e.g., air travel, diving)
• Other objective evidence of obstructive dysfunction

• Patulous ET (BET would worsen symptoms)
• Nasopharyngeal mass (must be excluded by nasopharyngoscopy before any intervention)
• Unilateral effusion in adults requires contrast-enhanced imaging before surgery

Technique

1. A guide catheter containing the balloon is advanced through the nasal cavity using a 30- or 45-degree angled endoscope
2. If the ET lumen is not readily visible, the guide catheter is used to gently reflect the torus tubarius posteriorly and turned upward toward the ear
3. The balloon is advanced out of the guide catheter along the anterolateral wall of the cartilaginous ET, coursing tangentially; the cartilaginous skeleton becomes increasingly circumferential superiorly and guides the catheter safely
4. The catheter advances until it meets gentle resistance at the isthmus (bony-cartilaginous junction); catheter length is cross-checked to confirm it cannot be within the bony portion
5. The balloon is inflated with saline to 10-12 atmospheres for a duration of up to 2 minutes
   • A reduced duration may be used for less severe inflammatory pathology to avoid creating a patulous ET
6. The guide catheter is braced against the nasal floor to prevent extrusion of the balloon during inflation
7. After the allotted time, the balloon is deflated and withdrawn into the guide catheter (to prevent mucosal excoriation on withdrawal)
8. The lumen is suctioned and inspected for mucosal injuries
9. Procedure repeated on the contralateral side if indicated

• Cummings Otolaryngology, p. 2519-2520

Outcomes

Risks and Complications

• Cummings Otolaryngology, p. 1993-1997

Current Evidence (2024-2026)

• BET vs. non-surgical treatment at ≤3 months: low-certainty evidence of reduced ETDQ-7 symptoms (MD -1.66, 95% CI -2.16 to -1.16) and improved tympanometry (RR 2.51, 95% CI 1.82-3.48)
• Evidence at 3-12 months was very uncertain
• No studies were rated overall low risk of bias
• Conclusion: BET may provide short-term symptomatic benefit, but long-term high-quality RCT evidence is still needed

• BDET increased the chance of achieving a Type A tympanogram (RR 4.68, 95% CI 2.88-7.51 vs. control)
• When combined with cartilage tympanoplasty for adhesive otitis media: significant air-bone gap closure at 3 months (3.82 dB) and 6 months (4.06 dB)
• Level of Evidence: 1a

Adjunctive Procedures

• Tympanostomy tubes - for immediate middle ear ventilation while waiting for long-term ET improvement
• Tympanoplasty (especially cartilage) - evidence shows improved air-bone gap closure
• Medical treatment of underlying inflammatory disease (nasal steroids, antihistamines, PPI for LPR) - should be optimized before and after dilation
• Adenoidectomy in appropriate patients

Key Points Summary

• BET targets only the cartilaginous ET (~25 mm); the bony ET is never dilated due to carotid proximity
• Inflation parameters: 10-12 atm saline, up to 2 minutes
• Pre-procedure dynamic nasopharyngoscopy is mandatory to confirm obstructive pathology and exclude nasopharyngeal mass
• Must exclude patulous ETD before performing BET (it would worsen symptoms)
• The 2025 Cochrane review confirms short-term benefit with low-certainty evidence; a 2026 meta-analysis (Level 1a) confirms significant tympanometric improvement
• Long-term durability and optimal patient selection criteria remain active areas of research

Microdebrider in ENT Surgery

What Is a Microdebrider?

Components and Settings

ENT Applications

1. Functional Endoscopic Sinus Surgery (FESS) / Nasal Polypectomy

• Primary polyp surgery: polyps are gelatinous with minimal blood supply - the microdebrider removes them rapidly with low blood loss
• Revision polypectomy (scarred, vascular polyps): the instrument significantly reduces blood loss and improves visualization by quickly debulking polyps while simultaneously suctioning blood, keeping the field clear
• Allows systematic clearance - first anteriorly and inferiorly until landmarks (middle turbinate, orbit, skull base) are identified, then methodical ethmoidectomy
• Used to remove the inferomedial vertical basal lamella to open the posterior ethmoid in posterior ethmoidectomy
• Blade angulation can be changed to address frontal recess, sphenoid, or maxillary sinus
• Cummings Otolaryngology, p. 583, 892

2. Inferior Turbinate Reduction

• A small incision is made at the anterior end of the inferior turbinate
• A submucosal tunnel is created
• A 2 mm oscillating mini-microdebrider blade is introduced submucosally
• The erectile tissue (inferior and medial turbinate) is partially resected from within
• Post-operative nasal packing is not necessary
• All overlying mucosa is preserved, maintaining mucociliary function
• Can be combined with posterior nasal nerve division at the sphenopalatine foramen (FITS - functional inferior turbinosurgery) to also address autonomic control

• Mucosa is debrided down to periosteum along the medial aspect and inferior edge of the anterior two-thirds of the turbinate
• Bleeding is minimal as long as periosteum is undisturbed
• Normal mucosa regenerates within 6-12 weeks; mucociliary clearance problems have not been observed
• Also used in turbinoplasty to remove the lateral mucosal leaf while the medial mucosa is repositioned as a "neoturbinate"
• Scott-Brown's Otorhinolaryngology Vol. 1, p. 1210-1213

3. Adenoidectomy

• The microdebrider (along with Coblation and suction coagulator) is a direct-vision technique for adenoidectomy, superior to blind curettage in terms of precision
• Allows controlled removal under endoscopic view, reducing the risk of velopharyngeal insufficiency
• In a randomized controlled trial, the microdebrider was 20% faster than the curettage technique
• Disadvantage: high unit cost compared to suction coagulator
• Advantage: single-use blades abolish the risk of cross-infection transmission
• Allows deliberate preservation of adenoid tissue at the inferior nasopharynx where VPI is a risk
• Scott-Brown's Otorhinolaryngology Vol. 2, p. 6314-6323

4. Powered Intracapsular Tonsillectomy and Adenoidectomy (PITA)

• The bulk of tonsillar tissue is removed while deliberately preserving the tonsillar capsule as a "biologic dressing" over the pharyngeal constrictor musculature
• Decreased thermal injury to tonsillar fossa musculature
• Benefits: reduced postoperative pain, decreased analgesic use, and potentially reduced hemorrhage risk compared to monopolar electrocautery tonsillectomy
• Limitation: risk of tonsillar tissue regrowth and possible re-infection from residual tonsil tissue
• Both retrospective and small prospective studies confirm significantly less postoperative pain and decreased analgesic use vs. monopolar electrocautery
• Cummings Otolaryngology, p. 3525

5. Laryngeal Papillomatosis (Recurrent Respiratory Papillomatosis - RRP)

• A non-serrated laryngeal blade is used at 300-700 rpm - low speed allows papillomas to be suctioned into the debrider with minimal cutting trauma to surrounding normal laryngeal tissues
• No thermal trauma (unlike CO2 laser)
• Under direct microlaryngoscopic control, it is extremely precise with minimal mucosal damage
• The laryngeal blade geometry allows gentle but comprehensive removal with minimal contamination of the lower respiratory tract with blood or papilloma fragments
• Compared with CO2 laser: retrospective studies show good disease clearance, shorter procedure time, less post-operative pain, and no incidence of delayed soft-tissue complications (vocal fold fibrosis, interarytenoid fibrosis)
• CO2 laser remains preferred by some surgeons for hemostasis in highly vascular disease; the microdebrider is advantageous in children and for frequent debridements
• Scott-Brown's Otorhinolaryngology Vol. 2, p. 3037-3055

6. Central Airway / Tracheobronchial Disease

• Used endoscopically via rigid bronchoscope for debulking of endobronchial tumours and managing airway obstruction from laryngotracheal carcinoma
• Allows tissue removal under direct vision with simultaneous suction, maintaining a clear airway
• Listed alongside laser, argon plasma coagulation, and cryotherapy as a tool for managing central airway disorders
• Murray & Nadel's Respiratory Medicine; Cummings Otolaryngology

Advantages of the Microdebrider

Disadvantages and Limitations

Safety Considerations

• In FESS: always identify the lamina papyracea (orbital wall) and skull base before using the microdebrider - inadvertent application can cause orbital fat herniation, CSF leak, or intracranial penetration
• In turbinate surgery: restrict to mucosal-preserving submucosal technique when concurrent FESS is performed; reserve direct mucosal debridement for gross hypertrophy
• In laryngeal work: work at low rpm (300-700) with a non-serrated blade to avoid injury to true vocal fold mucosa; do not apply over the anterior commissure without careful judgment to avoid webbing
• In adenoidectomy: maintain endoscopic vision to preserve a cuff of adenoid tissue inferiorly near the ET orifice and velopharyngeal port

Summary of Blade Types by Application

Endoscopic vs. Microscopic Ear Surgery

Historical Context

Fundamental Differences

The Endoscope in Middle Ear Surgery

Key Anatomical Advantage

• Sinus tympani - the most common site of cholesteatoma recurrence; depth and variants clearly seen with angled endoscopes; previously required blind or mastoidectomy-based approaches
• Retrotympanum - many anatomic variations; clearly visualized endoscopically
• Hypotympanum - inferior to the tympanic annulus
• Protympanum - anterior region containing the bony ET
• Anterior epitympanum / supratubal recess - behind the tensor fold
• Epitympanic diaphragm and tympanic isthmus - middle ear ventilation pathways

Endoscopes Used in Ear Surgery

Surgical Technique - Key Principles of EES

1. Transcanal approach: speculum slightly smaller than used with microscope inserted into the EAC to protect canal skin
2. Endoscope held in the non-dominant hand; only one instrument in the dominant hand at a time
3. Tympanomeatal flap elevated under endoscopic view
4. 0° scope for general survey; 30° scope for viewing beneath overhangs and into superior/posterior recesses
5. Camera properly oriented on the monitor before instruments are passed (disorientation from camera rotation causes trauma)
6. Hemostasis is critical - even minor bleeding obscures the lens; epinephrine-soaked pledgets, bipolar cautery used meticulously
7. The endoscope is withdrawn and reinserted with the view angle pre-rotated whenever a significant direction change is required
8. At conclusion, myringotomy margins inspected (under microscope if needed) to confirm minimal trauma

Applications: Procedure-by-Procedure Comparison

1. Tympanoplasty

• Graft success rate: comparable between techniques (no significant difference)
• Air-bone gap improvement: equivalent
• Endoscopic significantly better for: postoperative wound infection, dysgeusia (chorda tympani preservation), otitis externa, auricular numbness, and surgical duration
• Endoscopic benefits are greatest vs. the post-auricular microscopic approach (vs. transcanal microscopic, differences are smaller)

2. Stapedotomy (Otosclerosis)

• Surgical duration: no significant difference
• Air-bone gap improvement: equivalent (MD 1.04 dB, not significant)
• Endoscopic significantly better for:
  • Less chorda tympani nerve manipulation (RR 0.58)
  • Less dysgeusia (RR 0.33 - 67% reduction)
  • Less postoperative pain (SMD -1.59)
• CTN injury, facial nerve injury, TM perforation, dizziness: no significant difference

3. Cholesteatoma Surgery (TEES vs. Microscopic)

• Residual cholesteatoma: significantly LESS with endoscopic approach (RR 0.65; 95% CI 0.47-0.89) - 35% relative risk reduction
• TM perforation and graft displacement: no significant difference
• Postoperative taste disturbance, transient vertigo: no significant difference
• TEES does not yet demonstrate a significant improvement in recurrence rates (residual vs. recurrence distinction is important)

4. Ossiculoplasty

• Endoscopic approach provides excellent visualization of the oval window, round window, and stapes superstructure
• Prosthesis placement is technically demanding with one hand; many surgeons use a combined approach
• Hearing results assumed comparable to microscope-guided ossiculoplasty - Cummings Otolaryngology (cholesteatoma chapter), p. 82

5. Myringotomy / Grommets

• EES transcanal approach is fast and avoids speculum ear-stretching
• Endoscope allows clear visualization of the anterosuperior quadrant which is a common blind spot under the microscope

Advantages and Limitations Summary

Advantages of Endoscopic Ear Surgery

Limitations of Endoscopic Ear Surgery

The Combined (Hybrid) Approach

• Microscope for dissection + endoscope for inspection: The endoscope is used after microscopic removal to inspect hidden recesses (especially sinus tympani) for residual cholesteatoma - this alone has been shown to reduce residual disease rates
• Endoscope for middle ear + microscope for mastoid: TEES for the tympanic portion of cholesteatoma, then mastoidectomy under microscope if needed
• Endoscope to plan approach: Pre-dissection endoscopic survey guides whether TEES alone is feasible based on disease extent on CT and intraoperative findings

Current Consensus

• EES is no longer "promising" - it is a well-established technique with a solid evidence base
• For tympanoplasty: comparable graft success with fewer wound complications and shorter operative time endoscopically
• For stapedotomy: equivalent audiometric outcomes, but endoscopic approach significantly reduces chorda tympani disturbance and dysgeusia
• For cholesteatoma: endoscopic approach significantly reduces residual disease (35% RR reduction); TEES is the preferred approach for disease confined to the middle ear
• The microscope remains indispensable for extensive disease, mastoid surgery, and where two-handed technique is required
• Most modern otology units adopt a context-dependent hybrid strategy based on preoperative CT, disease extent, and surgeon expertise