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BackTable / ENT / Podcast / Transcript #75
Podcast Transcript: Technology and 3D Imaging for Endoscopic Skull Base Surgery in Children
with Dr. Cristobal Langdon
In this episode of BackTable ENT, Dr. Gopi Shah discusses 3D imaging and other surgical technology with Dr. Cristobal Langdon, an academic and private practice rhinologist and skull base surgeon working at Hospital Sant Joan de Déu Barcelona. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Common Pathologies for Pediatric Skull Base Surgery
(2) Pre-Operative Visits for Skull Base Surgery
(3) Using 3D Models & VR in Planning for Complex Pediatric Skull Base Surgery
(4) Neuronavigation and Intraoperative Techniques in Pediatric Skull Base Surgery
(5) Autologous Grafting Materials & Packing Options to Optimize Reconstruction
(6) Post-Operative Care in Pediatric Skull Base Surgery: Rinses & Scar Prevention
(7) Integrating Technology & Compassion in Pediatric Skull Base Procedures
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[Dr. Gopi Shah]
Hello, everyone, and welcome to The BackTable ENT Podcast, where we bring you the best and brightest from our field with the hopes that you can take something from our show to your practice. My name is Gopi Shah. I'm a pediatric ENT, and I'll be your host for the show today. We have a very, very special guest today. We have Dr. Cristobal Langdon. Dr. Cristobal Langdon is a passionate rhinology and skull-based internal student. He specializes in rhinology and skull-based surgery and rhinoblasty. Now he divides his time as a consultant at the Pediatric Referral Center Hospital at Sant Joan de Déu, and his private practice in Barcelona, Spain. He is here to talk to us today about technology and 3D imaging and skull-based surgery. Welcome to the show, Cristobal.
[Dr. Cristobal Langdon]
Thank you very much, Gopi. It's a pleasure to be here. I'm very excited.
[Dr. Gopi Shah]
For our listeners, I got to meet Cristobal through LinkedIn. It was a LinkedIn case that you'd posted. It was a cool use of 3D surgery for a skull base. Maybe, was it a chordoma, Cristobal?
[Dr. Cristobal Langdon]
Yes.
[Dr. Gopi Shah]
It was pretty cool, and so I thought it was a great way to reach out, and LinkedIn linked us, so I'm excited to talk to you today. Cristobal, tell us first about yourself and your practice.
[Dr. Cristobal Langdon]
Actually, I work here in Barcelona, but I'm from Chile. I came to Spain to do my residency. I trained in the hospital clinic, and there, I stayed there for eight years as a rhinologist and a skull-based surgeon, and there's where I found this passion team, and I think it gets stick to me, so I really started to working with them and then realizing that there is a lot of work to do and it's really nice surgery, and I started working there, then went up and did the pediatric cases, and that's when the relationship with the pediatrics started.
I really loved the work there, and then they offered me a place there. The idea was to be half and a half, but that wasn't possible. Yes, I decided to go there, give it a chance, and the main reason was because I think that the children need the best of the best because you're helping a future citizen and maybe a future Einstein or whatever, so I think they deserve it. Nowadays, I'm doing mainly rhinology. Actually, in the center there, I'm doing only rhinology and skull-based pediatrics, and then I started out my private practice where I do mainly rhinoplasty.
[Dr. Gopi Shah]
My focus for the last several years was also pediatric sinus and skull base, and I love kids. I absolutely love kids. I love the families. I love the multidisciplinary approach in the pediatric world. Do you have neurosurgical ophthalmology colleagues? Who are the specialists that you work with?
[Dr. Cristobal Langdon]
I work side-by-side with an ophthalmologist that is actually a Chilean colleague, so we are two Chileans in the team, and then Dr. José Hinojosa. He's an amazing neurosurgeon. He's the head of the department there, and we are really bonding together and creating a really nice team to work. For us, at least for me, the neuroradiologist, and nowadays the engineers, they are part of the team, and they are a really, really important part of the team. I really work side-to-side with them in every case.
[Dr. Gopi Shah]
Absolutely. My partners in Dallas, my neurosurgeon, he was the best, Dr. Dale Swift, a couple of years older than me, an experience that had the breadth and depth working next to him in the OR. I learned so much. I didn't realize the amount of decision-making on the fly that I would learn watching him operate. Then my ophthalmology colleague on the children's side, Dr. Kamel Itani in Dallas was amazing. Neuroradiology, Dr. Tim Booth, you can't live without a great neuroradiologist. Tell me about the engineer. What is the role of the engineer? What do they do?
[Dr. Cristobal Langdon]
Yes, actually in Sant Joan de Déu, when I arrived, I've been there for a year. Sant Joan de Déu has, it's part of the hospital, but it's like a foundation inside of the hospital. They have this group of engineers, mathematicians, and physicists. They create this group in order to create and to facilitate our living as a doctor. They are really good. Actually, we are the first hospital in Spain that has all the accreditation to do 3D printing, 3D molds. They were the ones that did not create like the rules or the law, but we are the first to have this accreditation. They are really a nice group and they really love what they do. They really always-- every day they are pushing us and say, "Hey, we have this technology. We can prove this technology." I'm a technology freak. I'm always like, "Look what these guys are doing." We have to do it.
(1) Common Pathologies for Pediatric Skull Base Surgery
[Dr. Gopi Shah]
Absolutely. Before we get into some of the technology, what are the common pediatric skull-based pathologies that you see and how do they usually present to you?
[Dr. Cristobal Langdon]
Mainly hypophysis and, I don't know, Rathke’s cleft, some meningiomas, chordomas, gliomas. We do a lot of biopsies because, in children's chemo and all these, they work really nice. We do a lot of biopsies. Usually at least all the cases are referred from another hospital, going to the neuro or going directly to us or to the ophthalmologist. To be honest, usually it's via neurosurgery or via ophthalmologist. Because now we are trying to get known that we are doing this thing and we have the possibility and all the armamentarium to do this thing. That they send cases to me is really rare. We are working on that.
[Dr. Gopi Shah]
Most of the cases for us also came through our neurosurgery, because in endocrinology, if they had an initial presentation, they would send it to neurosurgery, they would sometimes have their tumor boards. Then if it was going to be a transnasal endoscopic approach, then that's when I would get involved as well.
[Dr. Cristobal Langdon]
In the hospital, we have this tumor board, this neuro tumor board and body tumor board. I'm in both. Sometimes they start talking about some cases and I have to raise my hand and say, "Hey, maybe we can do this." Nowadays, we don't open the whole face. We don't destroy these kids' faces. We go through the holes and it's really safe and it's with pretty good results. Actually, the oncologist and the radiotherapy say, "Ah, it's really, you can do that?" "Yes, yes we can do so." That's another route that can have some patients. We have to fight a little bit in a good way.
[Dr. Gopi Shah]
Tell me first, before we get into that, tell me the age range that you normally see.
[Dr. Cristobal Langdon]
From newborn to 21. Actually, the eldest patients, like over 18, are really special cases. We have been treating them since when they were kids and we just follow up. To be honest, if we receive a new case of 21, it would be a little bit tricky to treat it at the hospital. We have to send them to an adult. Less is a really rare disease and a really rare scenario.
(2) Pre-Operative Visits for Skull Base Surgery
[Dr. Gopi Shah]
What's your initial clinic visit? Do you do them all in clinic before surgery or do you meet some of the patients in the hospital on the day of surgery?
[Dr. Cristobal Langdon]
I visit the patient every Wednesday in my clinic. Usually for these patients, I only visit the patient that they're more tricky or I see some anomalies in the MRI or CT scan. If not, because of the politics of the hospital, they don't want us to make a lot of visits to the kids. We try to reduce the visits as much as possible. If I really need to visit a patient in this complex skull base procedure, for example, I always visit the patient. I always scope every patient with a flexible because [chuckles] less rigid. Unless I see something interesting on the nose or on the mouth or whatever, I change to a rigid and record it. I try to record every scope and I have a library. It's just a training deformity that I have that we use to record everything. I think it's helped. Now it's helped when you have to give talks and when you have to explain. Even when you are planning the surgery, it helps a lot, so.
[Dr. Gopi Shah]
I would say I would probably see a lot of our patients in our outpatient clinic at least one time before surgery. That being said, there were definitely a handful of patients that were either admitted through the emergency room because of visual deficits or families that traveled. They lived very far away and were comfortable meeting me the day of surgery. Those patients I would potentially see in the morning of or if they were already admitted a day or two before. I usually, if I'm going to scope a kid, I also use flexible scope because it's hard enough to sometimes even get close to the child's nose. Rigid, if they move just like a millimeter or two, it's going to cause a nosebleed or hurt them or something.
I usually do flex and I will look at the imaging first. If I don't, I used to scope everybody and then it depended on the child and if I was going to be able to get that look and some would just get so, you couldn't get near them. Probably 80% of the time I did, but there was probably a good number that didn't always, which always made me nervous because I wanted to see the mucosa. I want to make sure I wasn't missing anything that the MRI or CT didn't show, but the majority of them would get it. You've seen the patient, you're planning for surgery. Tell me about preparation for surgery and some of the technology that you use.
[Dr. Cristobal Langdon]
Regarding preparation, yes. We usually scan and do MRI on every kid. If we are going with navigation, we can talk about that. We do a CT scan. This patient, at least since I'm at the hospital, usually they have CT and MRI, both. Not that I asked them, but the oncologist or the neuro or in the emergency room, they ask it already. Usually we have both. That's really good. If not, it depends. If it's a intrathecal tumor, I prefer MRI and it's a tumor on both sides or yes. Maybe I prefer CT scan, but at least up to date, I haven't had the opportunity to decide which I have to ask. I have both and then we can talk more extensively.
When we are doing this reconstruction and models and things, we need to do some special Anchor CT scan or Anchor MRI and another special imaging technique. Usually it's CT, MRI. Then as for the pre-op treatment, actually I don't give any unless the kid needs it for their other pathologies. If not, I don't give antiviral, I don't give corticoids, oxymetazoline, whatever. It's just straight to the OR.
[Dr. Gopi Shah]
We usually have both as well. You're right. Most of the kids would have a CT and MRI, which is great. The MRI obviously is great for soft tissue, tumor differential. The CT I liked a lot, especially like you said, when it's bilateral, when you're worried about carotids, after carotid recess and more of the bony anatomy. Also looking at the sphenoid and how well pneumatized. On the MRI, you don't always appreciate that because you can't really tell bone, but that CT, that cue ball sphenoid, not under-pneumatized, it's going to be tricky. If you can see that ahead of time, at least you're prepared to have that struggle a little bit.
[Dr. Cristobal Langdon]
Yes. Regarding the time of surgery, because of course you have a conchal sphenoid, you will need more time to go to the places.
[Dr. Gopi Shah]
Absolutely. It's like touch drill. You don't have the landmarks.
[Dr. Cristobal Langdon]
Exactly.
(3) Using 3D Models & VR in Planning for Complex Pediatric Skull Base Surgery
[Dr. Gopi Shah]
It's like a cue ball mastoid. That's what I would tell the residents because you have no air cells. You don't have anything to follow. The distance and the depth and even fitting the scopes and working with forehands can be difficult. We used navigation pretty much for anything that was truly skull base with neurosurgery. In terms of the recon, you said, okay, they come to you. Then if we need more imaging, it would be a CT angio or an angio MRI. How do you decide which cases you're going to do a recon on or, go further with preparation with some of the 3D models?
[Dr. Cristobal Langdon]
The easy answer would be that when we are not sure if going from it front, it's the best way. We really like to do a reconstruction and then see the case in all 3-dimensions and try with the neuron, try to see which is the better way, the better approach. That's easy. Then to be honest, when there is a complex case like the chordoma that you saw in Lincoln, this is because I wanted to do the surgery on the model before I go with the kit. Because the patient had radiotherapy and we are going to do a big chordoma, a lot of radiotherapy there. We wanted to see if we could reach and we had to go behind the odontoid and we didn't want to destabilize the cervical atlantoid joint and we didn't have to do a spine fixation.
We talked with the neuroscientist, okay, let's try it, let's print it, let's try it if the scope of our scope and the different angles allow us to safely remove this tumor. There are both two reasons. Now we have a pending case, this meningocele of Meckel's cave, but it's really posterior. We're deciding which is the best approach if we go from in front, from lateral, from the ear, because it has a facial palsy. We are going to print this case and do the surgery and try to decide which is the best way.
[Dr. Gopi Shah]
That's amazing. The models are big enough to where you can simulate instrumentation.
[Dr. Cristobal Langdon]
No, it's one-to-one. That's the amazing thing because when they printed this model, I realized, whoa, this is really tiny. [chuckles] It would be difficult. It's really tiny and the nostrils and nasal fossa, it's small. That case, then we did another case, I went to Leuven to do a similar case, regrettably was far more advanced tumor, far more difficult one, and we couldn't achieve cross total resection and we printed and yes, but the model really gives you an idea of what you're going to do. If not, if on the MRI, the MRI on this big screen, you say, "Oh, that's easy." Yes. You go there, ping pong, ping pong. Then you have the model. I told the engineers, "This is correct. This is the size. Are you sure?" Yes. I have to think twice before I go. Yes, I think that's an important part of this technology.
[Dr. Gopi Shah]
What percentage of your cases then do you usually have a model for those reasons?
[Dr. Cristobal Langdon]
Actually the printer that allows us to do this is brand new. I think that the first model was the one that we published on LinkedIn. Now we are preparing a paper, but because of the technology of this printing they allow us to print in different textures. It's a really nice brand new technology printer.
[Dr. Gopi Shah]
That's amazing. From an ENT standpoint, what kinds of teaching or information do your engineers need to know from your perspective? Are there tweaks or-- I know you talked about size and making the size a little bit more one-to-one. What else did you have to help convey?
[Dr. Cristobal Langdon]
To be honest, the one who works more is the neuroradiologist, Dr. Gómez Chiari. They have to do the segmentation. That's really, really there. The work is doing the segmentation and doing the fusion between the CT scan and MRI. From my side, I go with them and say, "Okay, we need to localize." For example, in that case, hypoglossal canal, hypoglossal nerve, six nerve, we have to really try to see both carotids, in that case it was both jugular bulbs and yes, and the pition. Then they have to segment all this information in order for the engineers to print them. They give them STL is like a format of the archive and they post-process it on special software. They first do a 3D reconstruction. Then we check if the 3D reconstruction is okay. Then they print it.
[Dr. Gopi Shah]
I was going to say, when you're looking at it or doing the simulation to see if your instruments fit, do you do that in the lab? Do you go to the OR in a special room? How do you actually test it?
[Dr. Cristobal Langdon]
Yes. I'm working to have a really nice lab, but this is one of my goals from this '22, '23 year, because yes, I'm only one year in the hospital, so I just arrived and we are working on that. Yes, that's the goal. Actually this is really new information. I tried it on Friday, but we are preparing, like going to Metaverse and doing surgery there.
[Dr. Gopi Shah]
I was going to ask you. I think that's the next step?
[Dr. Cristobal Langdon]
No, it's the present, it's the future, it's the present. I did it on Friday. They know I'm so passionate. They call me, "Hey, Cristobal, please come here. We have to show you something." "What?" "No, no, please come." Right there, they put these goggles on and I have the same case that I did. Yes, you can do everything. It's amazing. It's an amazing technology.
[Dr. Gopi Shah]
You can share, you can teach, you can prepare everything.
[Dr. Cristobal Langdon]
Yes. You will be able to do a surgery and maybe, okay, let's talk to Gopi and Gopi, please connect. If you have four, five, six, 20 eyes looking at you and giving you some instruction, the better.
[Dr. Gopi Shah]
Absolutely. To me, that's also the future of surgical education, surgical training, continuing surgical training advancement. I agree. It's right here. It's right now. What else? Anything else that I'm missing from the preparation side before we go to the intra-op side?
[Dr. Cristobal Langdon]
Olfactory to all patients. We use the sniffing sticks, the children's sniffing stick that is validated for Spain. We try to do questionnaires, quality of life questionnaires to all patients.
[Dr. Gopi Shah]
Yes. Which one do you use for your pediatric school-based patients?
[Dr. Cristobal Langdon]
Now I'm using the SN5. Over 12 years, I've been using SNOP22. Then I really like the visual analog scales regarding nasal abstraction and binary.
[Dr. Gopi Shah]
Kids get the visual analog very well. [laughs]
[Dr. Cristobal Langdon]
Yes, exactly.
(4) Neuronavigation and Intraoperative Techniques in Pediatric Skull Base Surgery
[Dr. Gopi Shah]
In the OR, you said you will use image guidance.
[Dr. Cristobal Langdon]
In complex cases, I do. To be honest, we always train and I train without. Not because we don't believe in it or because we are lazy. I think that's what could be the real reason. For medical legal reasons, at least here in Spain, it's not that necessary. On the contrary, in the States, I think there's no way you go inside without navigation. The other issue is, for example, when I do some cases in my OR we don't have navigation. We have a really good view, but it's from the neurosurgeon. When we do complex cases, we do neurosurgical navigation. If not, we don't use it. I would like to have one. To be honest, it doesn't matter to me. Now we will publish in the course, but we are starting the first pediatric ENT fellowship.
We are going to announce it in the course. Just for that reason, I think it would be important for us to have navigation because it really shortens the learning curve of the fellow. On the other hand, this is just my opinion. I think neuronavigation doesn't allow you to really understand the anatomy and your patient because you trust too much on that. Because I really have to study, I really have to have the CT scan in my brain. I do it in like five minutes, but it gets stuck in my brain. I always know where I am, but I understand that's not ideal. We need to mix the two.
Sometimes I've missed neuronavigation. It takes more time if you don't have it. If you have, and you're completely sure, okay, you go ahead. If not, you have to be more gentle with everything.
[Dr. Gopi Shah]
I find it helpful. I agree that you can't rely on it. I think the more and more that you do, and depending on the patient's pathology, there's going to be times where you don't really look at it. Then there's going to be times where it's the under-pneumatized sphenoid sinus or my neurosurgical colleague trying to figure out how much tumor to take out or not. It definitely has its role, but you're right. It can't be the crutch. We can't just depend on that. When you're teaching, it's very helpful to make sure we're all on the same page. [laughs] We got to be on the same page.
[Dr. Cristobal Langdon]
What would be amazing is that we can have a neuronavigation that updates the tumor status.
[Dr. Gopi Shah]
Oh God, that would be amazing. Maybe that's the future. Maybe in the metaverse, Cristobal, you're going to create that there.
[Dr. Cristobal Langdon]
Exactly. Yes, sure.
[Dr. Gopi Shah]
When you do have navigation, do you have instruments that are image guided? I think that can sometimes be controversial too. Some people like image guide instruments and people don't use them. Some people use them just for teaching. Any thoughts on that?
[Dr. Cristobal Langdon]
Yes. I tried some of these neuro-navigated instruments back in the hospital where I did mainly adults or only adults. They are nice to be honest. I don't think they are better than normal instruments. Nowadays we don't have navigational instruments. We only have the pointer and it works fine. Regarding navigation during surgery, at least for me, it's more important the echo doppler than the navigation, yes.
[Dr. Gopi Shah]
Yes, I agree. Ours is pretty much just the pointer when we need it. We don't tend to use navigational instruments, although I think the ability is there. Again, in those rare cases where it's super under-pneumatized, which might be maybe once a year, that might be a time to use it. Technically I don't tend to use those very much. In the OR, when you do have navigation, do you-- like the CT? Do you ever fuse the CT and MRI? Do you just do MRI? What do you like?
[Dr. Cristobal Langdon]
We do the fusion, yes. Always.
[Dr. Gopi Shah]
Then really quickly for CSF leaks, do you ever consider using intrathecal fluorescein or any of the light or anything like that in those cases? Those aren't as common, but every once in a while they'll come in too.
[Dr. Cristobal Langdon]
Yes, sure. When we are going, for example, for a CSF leak and we have to find this leak, we put fluorescein always. We don't use the blue light and it doesn't help. You can see the fluorescein bright in there. What we don't do is to put fluorescein on every case, just on the cases where we are going to look up for the CSF.
[Dr. Gopi Shah]
For us as well, it definitely was rare, I can only think of maybe in the last nine years, maybe two or three times that we've used intrathecal fluorescein. Those were rare cases where we just-- on the imaging, you had a beta two positive sample, but the imaging just wasn't quite as obvious. Maybe something like that. It's something where it's just like, I'm pretty sure there's something going on or every once in a while there's some history, but those can be really tricky. We're not doing it on the encephalocele that you find or see or the obvious, but it's every once in a while where it's just not quite matching up.
I agree with the special light thing, we never use any of that either. What else? Am I missing anything? Do you tend to probably use four millimeter scopes, ever using the 2.7 for any reason? Anything else I'm missing? I'm just trying to think of other special pediatric intra-op skull base things.
[Dr. Cristobal Langdon]
Actually for the skull base, I've always tried to use the four millimeters. If not, we use the otologic. I think it's three millimeters for the endoscopic tympanoplasty. I think it's not 2.5, it's three millimeters scope. The issue, at least what we have, it's that it's a little bit blurry on the outside. I don't know why. It's not as good as the normal one, the normal four millimeter, actually the last case we have to do, we did a glioma of the nasopharynx. Actually I published, I think in LinkedIn, it's really nice case because we were able to see the middle ear through the mouth.
Look it up. It's really amazing. It's really nice.
[Dr. Gopi Shah]
Was it through the Eustachian tube? [laughs] I'm just kidding.
[Dr. Cristobal Langdon]
Yes, exactly. Because we follow the tumor through the Eustachian tube, we remove it and then, "Oh, what is that? What?" We were inside the middle ear. It's amazing. I used the otologic scope. It was an eight days old girl. Yes, eight days. Really newborn.
[Dr. Gopi Shah]
Wow. At some point, maybe this is a different podcast, but I'd love to get into repair techniques. Drain, no drain. There's so much, I feel like in a pediatric that we don't necessarily have as much data or information as we do on the adult side. Age and obviously tumor type, all that stuff makes such a difference. I guess just really quickly, nasal septal flaps, I assume you use those when you need to, when there's a high flow leak or when do you tend to use them?
[Dr. Cristobal Langdon]
I use it when we are trespassing a cistern because automatically it's a high flow CSF leak. The issue is that the nasal septal flap in kids, it's really, really small. Yes, I don't trust it too much. I do a really multi-layer reconstruction and then put the flap, but I trust more on the multi-layer than on the flap because it's really small flap in kids.
(5) Autologous Grafting Materials & Packing Options to Optimize Reconstruction
[Dr. Gopi Shah]
Tell me about the multi-layer. Are you doing synthetic stuff, fat? Do you ever do cartilage or bone pate or anything like that?
[Dr. Cristobal Langdon]
No. I like fat. We had this lyophilicide, Facialata. It's like from a--
[Dr. Gopi Shah]
The thigh? The leg?
[Dr. Cristobal Langdon]
From another patient. Yes, exactly. In cases I really like Dura form and then fascia lata. When that fails, I really like to extract fascia lata from the patient or temporalis fascia. Depends from autologous material. In kids, I try not to do it because of the morbidity.
[Dr. Gopi Shah]
For us, if it was a large spatial defect intracranially that we needed to fill some space, we would get fat.
[Dr. Cristobal Langdon]
Yes, fat is amazing.
[Dr. Gopi Shah]
I agree. I never just relied on the nasal septal. We used a lot of biodesign and then every once in a while would get little bone chips or cartilage from the septum or the sphenoid rostrum. Actually my neurosurgeon, Dr. Swift, taught me that. At first, I was like, how is this going to-- it's rigid. He would just help tuck it in, like an inlay, like a plug, like a gasket almost. Then if there was a high flow leak or a pathology, like a craniofrenulum or something that we're like, we're going to need that nasal septal flap, then those kids got those as well. If you were going to use a nasal septal flap, did you usually harvest that at the beginning of the case or wait and see what you needed at the end?
[Dr. Cristobal Langdon]
Yes, exactly. Unless I already know that I will have to use it. For example, when we're going to the sphenoid, whatever, I do like this rescue, the so-called rescue flap, but it's no more than push down the pedicle and then remove everything, yes. If I need it, I raise the flap. If not, try to leave it as it is.
[Dr. Gopi Shah]
Yes, I agree. If it's a pathology that I know I'm going to use it on, such as a craniopharyngioma, we're going to raise it. Potentially somebody that's already been radiated and there's going to be extensive dissection. We're going to do it. I learned my lesson to just wait. Then after you've done your layers, do you usually do any packing, dissolved packing, mirror cells, anything like that?
[Dr. Cristobal Langdon]
Yes. I put like a Tissucol, Tisseel, yes, the glue, a little bit of that. Then I didn't really like Spongostan, but the one that is like a sponge, it's--
[Dr. Gopi Shah]
Gel foam or something like that.
[Dr. Cristobal Langdon]
Like gel foam. Yes, exactly. Not surgery cells. Surgery cells give a lot of crust. I really like the foam and that's it. No nasal packing. Because in the kids, I try to do everything so in order to not to touch it afterwards. Then just see it a couple of weeks later in the outpatient clinic with the scope and see if they are doing the correct raises and that's it.
[Dr. Gopi Shah]
For me, it was Tisseel. Every once in a while, if I had like wanted to tack up the edges, I would roll a little bit of surgery cell because it's sticky. It does crust. I put it at the corners of the flap just to help it stick almost. I like gel foam, but I also would use, sometimes I would just, I got in the habit of then just sticking into the sphenoid space, larger nasopores that could help fill and hold that would dissolve as well. I used a mirror cell maybe once, twice.
I don't like those in children, the gloved mirror cell and attach it to the face. I think it was like a ethmoid roof. There was like a bullet, like she got shot with like a BB gun close and it somehow it lodged near the ethmoid roof. I wanted the flap to like, hold, it was like a free mucosal graft. I think for her, I did, but to be honest, who knows, I had some packing and then I put the mirror cell in and under it. Who knows how much it actually held up, but the kids are miserable and I don't make it a part of my routine. Then I was just like, I think nasopore or something a little bit bulky that dissolves on its own will help and do the job.
Then what are your thoughts on post-op saline? I guess two questions, one, when do you start and two, do you go straight to rinses? Do you start with mist? What's your regimen?
(6) Post-Operative Care in Pediatric Skull Base Surgery: Rinses & Scar Prevention
[Dr. Cristobal Langdon]
I've loved nasal rinses and nasal touches. I think for me it's the ultimate treatment. In cases where we had a CSF leak, I started with this mist. We have here a mist that is with hyaluronic acid that I tried on myself and on my kids and it's really, really nice. For the last six months, I've been using that for the first week or two weeks. Then we do douches, like in kids, little kids, a hundred millimeters each side and older 200 millimeters every 12 hours, yes, twice a day.
[Dr. Gopi Shah]
I agree. I think that initially I was so hesitant because I'm like, oh, if they have a CSF leak, I'm going to, it's going to be hard to tell if it's clear rhinorrhea from the rinse or the, like a leak. I used to be actually pretty hesitant to start anything for the first week. This was probably a couple of years ago in my first couple of years out. Then I was like, okay, calm down, and maybe if it was a high flow in the OR, we're happy with repair plus minus a drain, whatnot. I would probably start within 24 to 48 hours with the mist as well. I would have them do that a couple of times a day for about a week and then start rinses.
What I found is I wish I had started the rinses sooner because I started noticing more and more sneaky eye. The kids, they get little scar bands and it's not that big of a deal. Most of the time they don't get nasal obstruction. They don't usually have symptoms from it. I don't go back to the OR and debride and do all that stuff because it's more anesthesia for the kids. It depends, but it just drives me crazy because when it, you're like, "Oh, there's that sneaky eye."
[Dr. Cristobal Langdon]
It's true. The kids do like this nasty inflammatory reaction after the surgery is really-- everything is really, really swollen and a lot of fibrin and whatever. I haven't seen that in adults and the kid is really annoying as well, again. That's why a lot of rinses, a lot of rinses. The other thing is, yes, to be honest, I start this mist at 48 because when you have these complex cases, they go to the ICU, they stay there for, I don't know, one, two, three days or whatever. Usually I don't touch it in the ICU. I go there. I only, please, this thing going out from the nose is mucus, it's not CSFD, don't worry. Don't bother me. Just, okay. The kids--
[Dr. Gopi Shah]
I know. I look at, they show me all the Kleenexes [laughs] and I'm like, "I think it's fine."
[Dr. Cristobal Langdon]
Yes, exactly. It's really annoying. Then when they arrive to the room, I start the mist or whatever.
[Dr. Gopi Shah]
Then the other thing is I got in the habit of telling the families and showing them like on YouTube video about sinus rinses ahead of time, because for any sinus kid, whether it's skull base or routine sinus surgery, because it's like you said it, they don't do it. It can just because so many more problems to where they're sneaky and then we'll become symptomatic. [laughs]
[Dr. Cristobal Langdon]
Yes, exactly. Yes, true. I tell the parents, "Okay, look, you will have to fight with your kids." Because I have to fight. I have two kids, seven and eight. I remember when they were like four, I have to do it like these nasal rinses, but I have to fight with them. I put it like from the head with my wife in the arms and then do the rinse. You have to do it.
[Dr. Gopi Shah]
Yes. It's tough for sure.
[Dr. Cristobal Langdon]
The first time, the second time it's like a little bit traumatic, but then nowadays they do it themselves.
[Dr. Gopi Shah]
Some of them like it. Some of them, their nose clears up and they're like, "Oh." It's something they may want to actually try before surgery just to get used to it as well. It's not like a new learning thing after they've been through such a recovery. It's maybe makes it a little bit easier. Then do you debride ever in clinic? Do you ever have to go back to the OR?
[Dr. Cristobal Langdon]
Yes. I try to. I try.
[Dr. Gopi Shah]
Cristobal, be honest. [laughs]
[Dr. Cristobal Langdon]
You know how it is.
[Dr. Gopi Shah]
It's hard.
[Dr. Cristobal Langdon]
I don't put too much effort. I don't like, no, hold the kid and I will do it. No. If the kid wants to do it and he's fine, I do it. If not, and I've seen, to be honest, up to date, I haven't taken any kids to the OR to see the bridemen. In fact, this is because I'm really annoying with the rinses and whatever, to do debridemen in the clinic on adults, for me, it's the key issue I always do. I push harder and harder, but in kids there is no way. It's really difficult. I think it works because it just starts creating more damage to the nose, more inflammation.
[Dr. Gopi Shah]
Yes. Fortunately, again, even though they tend to scar very rarely, I can't think of any knock on wood where the scar band has caused nasal obstruction, thankfully, or some sinus. Now we have a CRS issue because they can't drain or whatnot. For me, maybe in an adolescent, if I can, just suction, even with a head, if I've done like a nasal septal flap, sometimes there's crust on that side and it can smell. I've had to put a headlight on the nasal speculum and just get the nasal cavity, get the crust out so it doesn't stink when that happens. Then, but like true debridement into the sphenoid cavity, that's not very common for me.
I think I can count on my hand, the number of kids that have let me do that. Usually they're girls who are like teenage girls. They're tough. Usually if I'm actually in there doing stuff in the sphenoid, it's probably been at least six weeks out after surgery. I don't get too aggressive with that stuff, at least in the sphenoid cavity. You said, I don't take anybody back for that because it's an extra anesthetic. Again, for my kids that have developed some scars or things like that, fortunately knock on wood, they haven't had any too many issues in it. If, and when, if that happens, then we'll deal with it. Maybe that'll be a couple of years down the line. If that happens, it'll be older.
[Dr. Cristobal Langdon]
Exactly. You can deal with that later, yes.
(7) Integrating Technology & Compassion in Pediatric Skull Base Procedures
[Dr. Gopi Shah]
Yes, absolutely. As we slowly start to wrap up, any final pearls or pitfalls that you've learned with your experience in your pediatric school-based practice?
[Dr. Cristobal Langdon]
You really need to win the kid. You really need to be a friend of the kid. You have to achieve that they see you as a friend in order to do all these kinds of things. At least for me, I always try to explain everything because they know if you have kids, you see they realize everything. They are really super intelligent and they are more afraid if you don't talk to them. The parents for sure won't, unless they are really like really super rational parents. It's a little bit of an issue, but if you explain them in their words, why are you doing this?
Why is it helpful for that? I think that that's a good way of approaching these kids. Then, I don't know, I think now it's technology. For me, it's, we are becoming like technicians. At least for me, medicine is art, and then the science is done by the engineers. We are artists with the help of technology, but we need technology. You cannot do good surgery if you don't have technology. Even though you are the best, if you don't have technology, you won't go anywhere. I think that we should embrace technology and use it more. What I have realized is we have a lot of technology, but you don't see a lot of technology in medicine. GPS, you can recognize something from a satellite, but you cannot do a nice navigation system. It's no way. Nowadays, the TV are 8K, 4K was 10 years ago. Yes, it's amazing. Yes, but we are really behind the real technology in medicine. Yes, for sure, virtual reality and the metaverse are the present for me. You should go there and train, train. Now we create a simulation model.
It's a skill simulation model in order to improve your skills more than knowing the anatomy, because the anatomy is in the books. If you do a lot of CT scans or whatever, you will learn anatomy on YouTube or whatever. If you don't have skills, you don't train your skills, that doesn't help you anything. Yes, now we develop one and we are trying to put it on there for everybody to practice. I think it's practice, make the master.
[Dr. Gopi Shah]
A simulation model using virtual reality in the metaverse is the next step.
[Dr. Cristobal Langdon]
Yes, I don't know, but we created a 3D printing model in order to practice this movement. I had the opportunity to be a teacher in a lot of dissection courses and you really see people destroy the cadaver. They open the ethmoid, they open the anthrostomy, they do the spheno, they reach towards the, whatever, the cerebellum. You have to do it nicely, gently. You need to flow. Now that's the aim with this model is to really to practice these skills in order to reduce the damage you do inside these tiny spaces.
[Dr. Gopi Shah]
I love it. You need to flow. I love that. Cristobal, thank you so much for taking the time to do this podcast on BackTable ENT. I learned a ton. It was great to geek out and talk about something I love as well. If any of our listeners want to reach out to you or get in touch with you, where can they find you? Any social media or I guess LinkedIn?
[Dr. Cristobal Langdon]
Yes, they can find me on my email, Cristobal Langdon Gmail. They can find me on LinkedIn. I think it's Cristobal Langdon, Dr. Cristobal Langdon. I don't know. Instagram. Instagram, I think is drlangdon.orl. It's like otorrino, laryngologist. It's like ENT in Spanish. In Twitter, but actually I don't see too much Twitter nowadays. They can email me.
[Dr. Gopi Shah]
Just a quick plug, I think Cristobal is helping to organize a pediatric endoscopic ENT course. It's a three-day course in Barcelona. It's actually next week from the 18th through the 22nd. By the time that this podcast comes out, the course will be over. However, I wanted to plug it because it may be something that you may or may not continue to do. What do you think, Cristobal?
[Dr. Cristobal Langdon]
Yes, actually, we will record the course so it would be available. I think it's from November. It would be available online on the hospital webpage. We will try to do this course every year.
[Dr. Gopi Shah]
Awesome. I'm excited because one day is just endoscopic airway. Second day is endoscopic sinus, skull base, which I'm super excited about. I think the third day is endoscopic ear. I think I saw Dr. Daniel Marchione as one of the guest speakers, so I can't wait. All right. I think that's a wrap. Thank you.
[Dr. Cristobal Langdon]
Thank you, Gopi. Thank you very much.
Podcast Contributors
Dr. Cristobal Langdon
Dr. Cristobal Langdon is an academic and private practice rhinologist and skull base surgeon working at Hospital Sant Joan de Déu Barcelona.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2022, October 25). Ep. 75 – Technology and 3D Imaging for Endoscopic Skull Base Surgery in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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