Transnasal endoscopy-guided percutaneous access to the sphenopalatine ganglion for neurostimulation in the treatment of primary headache: operative technique and feasibility

Abstract Objectives: Cluster headache is considered a trigeminal autonomic cephalalgia and may present with characteristic symptoms of sympathetic/parasympathetic activation on the affected side of the face, such as nasal discharge, tearing, and conjunctival injection. Invasive therapies targeting the sphenopalatine ganglion have been performed in these headache syndromes and can have a medication-sparing effect, especially in refractory, difficult-to-manage cases. The gate control theory of pain suggests that electric pulses delivered to nerve tissues can modulate neuronal activity, thus aiding in management of nociceptive or neuropathic pain, and studies have demonstrated the efficacy and safety of sphenopalatine ganglion neurostimulation. Within this context, we sought to assess the feasibility of a new surgical technique for neurostimulation of the sphenopalatine ganglion in a cadaver dissection model. Methods: The technique was developed through dissection of two cadaver heads. We divided the procedure into two stages: an endonasal endoscopic approach to expose the sphenopalatine ganglion and confirm electrode placement, and a cervicofacial approach to introduce the electrode array and position the internal pulse-generator unit. Computed tomography was performed to confirm implant placement at the end of the procedure. Results: The pulse-generator unit was successfully placed through a retroauricular incision, as is already standard for cochlear implant placement. This should reduce the incidence of perioperative sequelae, especially pain and swelling in the oral region, which are a common complication of previous approaches used for this purpose. Control imaging confirmed proper electrode placement. The device used in this study allows the patient to modulate the intensity of the stimulus, reducing or even obviating the need for drug therapy. Conclusion: The novel technique described herein, based on percutaneous access guided by transmaxillary endoscopy, can provide great precision in electrode array positioning and decreased perioperative morbidity, combining the advantages of endoscopic approaches with those of the retroauricular route. Level of evidence: 3.

Nasal polyposis: more than a chronic inflammatory disorder-a disease of mechanical dysfunction - the São paulo position

Introduction: The importance of our study lies in the fact that we have demonstrated the occurrence ofmechanical dysfunction within polypoid tissues, which promotes the development of polyps in the nasal cavity. Objective: To change the paradigm of nasal polyposis (NP). In this new conception, the chronic nasal inflammatory process that occurs in response to allergies, to pollution, to changes in the epithelial barrier, or to other factors is merely the trigger of the development of the disease in individuals with a genetic predisposition to an abnormal tissue remodeling process, which leads to a derangement of the mechanical properties of the nasal mucosa and, consequently, allows it to grow unchecked. Data: Synthesis We propose a fundamentally new approach to intervening in the pathological process of NP, addressing biomechanical properties, fluid dynamics, and the concept of surface tension. Conclusion: The incorporation of biomechanical knowledge into our understanding of NP provides a new perspective to help elucidate the physiology and the pathology of nasal polyps, and new avenues for the treatment and cure of NP (AU)

Breaking paradigms in severe epistaxis: the importance of looking for the S-point / Quebrando paradigmas na epistaxe grave: a importância de procurar o S-point

Abstract Introduction: Since the introduction of nasal endoscopy into the field of Otorhinolaryngology, the treatment paradigm for cases of severe epistaxis has shifted toward early and precise identification of the bleeding site. Although severe epistaxis is usually considered to arise from posterior bleeding, an arterial vascular pedicle in the superior portion of the nasal septum, around the axilla projection of the middle turbinate, posterior to the septal body, frequently has been observed. That vascular pedicle was named the Stamm's S-point. Objective: The aim of this study was to describe the S-point and report cases of severe epistaxis originating from it. Methods: A retrospective case series study was conducted. Nine patients with spontaneous severe epistaxis, where the S-point was identified as the source of bleeding, were treated between March 2016 and March 2017. Results: Male predominance (77.8%) with age average of 59.3 years old were reported. Most cases presented comorbidities (88.9%) and were not taking acetylsalicylic acid (66.7%). A predominance of left sided involvement (55.6%) and anteroposterior bleeding being the principal initial presentation (77.8%) was seen. Six patients (66.7%) presented with hemoglobin levels below 10 g/dL, and four (44.4%) required blood transfusion. Cauterization of S-point was performed in all patients, with complete resolution of bleeding. No patient experienced recurrence of severe epistaxis. Conclusion: The Stamm's S-point, a novel source of spontaneous severe epistaxis, is reported, and its cauterization was effective and safe. Otolaryngologists must actively seek this site of bleeding in cases of severe epistaxis.

Resumo Introdução: Desde a introdução da endoscopia nasal no campo de otorrinolaringologia, o paradigma de tratamento para casos graves de epistaxe voltou-se para a identificação precoce e correta do local de sangramento. Embora a epistaxe grave seja geralmente considerada uma hemorragia posterior, um pedículo vascular arterial tem sido frequentemente observado na porção superior do septo nasal, ao redor da projeção da axila da concha média, posterior ao tubérculo septal. Esse pedículo vascular foi chamado de Stamm's S-point. Objetivo: Descrever o S-point e relatar casos graves de epistaxe que se originam nesse local. Método: Um estudo retrospectivo de série de casos foi conduzido. Nove pacientes com epistaxe grave espontânea, na qual o S-point foi identificado como a fonte do sangramento, foram tratados de março de 2016 a março de 2017. Resultados: Houve predominância do sexo masculino (77,8%) com média de 59,3 anos. A maioria dos casos apresentava comorbidades (88,9%), mas sem uso de ácido acetilsalicílico (66,7%). Observou-se predominância do lado esquerdo (55,6%) com sangramento anteroposterior como a principal apresentação inicial (77,8%). Seis pacientes (66,7%) apresentaram níveis de hemoglobina inferiores a 10 g/dL e quatro (44,4%) necessitaram de transfusão sanguínea. Cauterização do S-point foi feita em todos os pacientes, com resolução completa do sangramento. Nenhum paciente apresentou recorrência de epistaxe grave. Conclusão: O Stamm's S-point é relatado como uma nova região de origem de epistaxe grave espontânea e o tratamento feito com cauterização foi eficaz e seguro. Os otorrinolaringologistas devem buscar ativamente esse local de sangramento em casos de epistaxe grave.

Ortner's Syndrome: Secondary Laryngeal Paralysis Caused by a Great Thoracic Aorta Aneurysm

Introduction Recurrent laryngeal nerve injury caused by cardiovascular disease is a rare condition, and often it is the only prominent sign of an imminent break of an aortic artery aneurysm. Objective To report left laryngeal paralysis caused by a great aortic arch aneurysm and to highlight the importance of an otorhinolaryngologic evaluation along with a thoracic radiologic study. Resumed Report A 42-year-old man complained of thickness of his voice and dysphagia for 3 months, but no thoracic pain or other relevant complaints. Video laryngoscopy revealed immobility of his left vocal fold in the paramedian position. Imaging was obtained for investigation, including magnetic resonance imaging of his thorax, which showed a fusiform aneurysm in the aortic arch, leading to recurrent compression of the left laryngeal nerve. The patient was successfully treated with endovascular repair of the aneurysm. At 2-month follow-up, there was still no recovery of the laryngeal mobility. Conclusion An aortic artery aneurysm can suddenly break, requiring emergency heart surgery, and the results can be fatal in many cases. We suggest routine exam of the vocal folds in all patients with a heart condition, and we review the literature and suggest the use of imaging to reduce the number of emergency procedures. .

Identificação endonasal do ápice orbitário / Endonasal orbital apex identification

Introdução: As doenças que envolvem a órbita representam um complexo problema cirúrgico, principalmente as localizadas no ápice orbitário, por onde passam estruturas críticas e um espaço pequeno. O uso do endoscópio por via endonasal para abordagem cirúrgica das lesões do ápice orbitário é uma técnica recente, com poucas citações na literatura. É necessário o estudo de referências anatômicas objetivas que tornem a cirurgia mais segura. Objetivo: Descrever os parâmetros anatômicos utilizados na abordagem cirúrgica endonasal endoscópica, assim como avaliar a concordância entre os hemicrânios do mesmo cadáver e as diferenças conforme o gênero. Casuística e métodos: Estudo anatômico em 30 cadáveres adultos, ambas as fossas nasais foram dissecadas (n=60 hemicrânios). Sob visibilização endoscópica endonasal, realizou-se a dissecção do ápice orbitário. Mensuramos a distância entre a crista etmoidal e o arco coanal para o forame óptico e para a fissura orbitária superior. Os resultados foram registrados na ficha de protocolo do estudo. Resultados: Foram dissecados 30 cadáveres, 60 hemicrânios ou lados. O sexo masculino foi mais prevalente, representando 63,3% dos cadáveres (19/30), enquanto o sexo feminino representou 36,7% (11/30). 43,3% dos cadáveres eram da raça branca (13/30), 20%, pardos (6/30), e 36,7%, negros (11/30). A correlação entre os valores conforme o lado nas seguintes aferições foi observada: Crista etmoidal - Forame óptico, (r=0,748, p=0.0001); Crista etmoidal - Fissura Orbitária Superior (r=0.785, p=0.0001), Arco coanal - Forame óptico (r=0,835, p=0.0001); Arco coanal - Fissura orbitária superior (r=0.820, p=0.0001). Foi obtido um Kappa de 0,444 na avaliação da concordância entre os lados em relação ao posicionamento da artéria etmoidal anterior no forame óptico. Conclusões: A sistematização da abordagem do ápice orbitário facilita seu acesso cirúrgico e a compreensão da anatomia. A crista etmoidal e o arco coanal se mostraram...

Introduction: Diseases that affect the orbit pose a complex surgical challenge, particularly those involving the orbital apex, a small space through which critically important structures course. Endoscopic endonasal approaches to the surgical treatment of orbital apex lesions are a recent technique, with few citations in the literature. Research is still needed into objective anatomic landmarks that can improve surgical safety. Objective: To describe the anatomic landmarks used in endoscopic endonasal surgical approaches and assess agreement between placement of these landmarks in midsagittal sections of cadaver skulls and potential gender differences. Materials and methods: In this anatomic study, the nasal fossae of 30 adult cadavers were dissected (n=60 half-skulls). The orbital apex was dissected under endoscopic endonasal visualization. The distances between the ethmoidal crest and choanal arch to the optic foramen and to the superior orbital fissure were measured and recorded. Results: Overall, 30 cadavers were dissected for a total of 60 half-skulls or sides. The sample was predominantly male (63.3%, 19/30 cadavers); females accounted for the remaining 36.7% (11/30). Regarding skin color, 43.3% of cadavers were white (13/30), 20% were brown (6/30), and 36.7% were black (11/30). The following correlations between measurements according to side were observed: ethmoidal crest to optic foramen, r=0.748 (p=0.0001); ethmoidal crest to superior orbital fissure, r=0.785 (p=0.0001); choanal arch to optic foramen, r=0.835 (p=0.0001); choanal arch to superior orbital fissure, r=0.820 (p=0.0001). Analysis of the agreement of ophthalmic artery location within the optic foramen between skull halves revealed a kappa of 0.444. Conclusions: The approach systematization to the orbital apex will facilitate surgical access and improve understanding of the anatomy. In the cadavers studied in this sample, the ethmoidal crest and choanal arch were relevant structures and...

Giant Nasolabial Cyst Treated Using Neumann Incision: Case Report

A nasolabial cyst is an ectodermal development cyst. It presents as a fullness of canine fossa, nasal ala, or vestibule of the nose. It is rare and usually small. Treatment consists of complete surgical excision or transnasal endoscopic marsupialization. Objective: To describe a giant nasolabial cyst case treated using Neumann incision. Case Report: A 37-year-old man was referred to the otolaryngology department with nasal obstruction and nasal deformity. Computed tomography showed a nasal cystic lesion 4 × 4.5 × 5 cm wide. Surgical excision using Neumann incision was performed. Discussion: Neumann incision provides wide access to the nasal cavity and may be useful in nasolabial cyst treatment...