Transnasal endoscopic repair of anterior skull base fistulas

CSF rhinorrhea is the leakage of CSF from the subarachnoid space through the nose. CSF rhinorrhea or liquorrhea commonly occurs following head trauma [frontobasal skull fractures], as a result of intracranial surgery, or destructive lesions, however, CSF rhinorrhea may be spontaneous. The incidence of CSF fistula after ESS is less than 1% yet it represents since recently a common cause of iatrogenic CSF fistula. A spinal fluid leak from the intracranial space to the nasal respiratory tract is potentially very serious because of the risk of an ascending infection which could produce fulminant meningitis, hence the importance of the prompt diagnosis and treatment of such condition. Since the introduction of transnasal endoscopic techniques the morbidity of surgical repair has been significantly reduced when compared with previous intracranial techniques. Is to evaluate the endoscopic endonasal approach in terms of morbidity and efficacy to control CSF fistulas. 43 cases of CSF rhinorrhea operated in the period between 1999 to 2006 are included in this retrospective study. Patients' data preoperatively as regarding history, examination and investigations, as well as operative details and postoperative care and outcome are carefully reviewed, analyzed and compared to the literature. Endoscopic transnasal repair of CSF fistulas in our study had an excellent outcome with a success rate of 95% in the first attempt and reaching up to 100% in the second attempt without any significant postoperative complication. Our leak sites were mainly found in the ethmoidal region [in 67.4%]. The endoscopic repair of CSF Rhinorrhea provides a safe and efficient technique for closure of the anterior and middle skull base sinonasal defects with minimal morbidity and hospital stay

Tracheotomy in ICU patients: factors affecting the final outcome retrospective study

In 1989 the National Association of Medical Directors of Respiratory Care recommended that endotracheal intubation be used only for patients requiring less that 10 days of artificial ventilation and that tracheotomy should be placed in patients who still require artificial ventilation 21 days after admission. However, during our practice in King Fahd Specialist Hospital in Buraidah - KSA, we noticed that there was a difference in the final outcome between medical and surgical tracheotomized ICU patients as well as between the elderly and the young in favor of the surgical and young patients. To study the outcome of tracheostomized critically ill ICU patients. Files of tracheostomized ICU patients in King Fahd Specialized Hospital were reviewed and analyzed to find the effect of the admitting diagnosis and age on the final outcome. Patients were divided according to the diagnosis on admission in 2 groups [medical and surgical group]. Surgical group patients were significantly younger with less hospital stay and more favorable outcome compared to the medical group. Further grouping of the patients was done according to the age [above and below 60 years], results showed that younger patients has a more favorable outcome compared to the elderly ones. Critically ill medical and elderly patients carry worse prognosis compared to surgical and younger patients

Evaluation of multimodal approach for minimizing post-tonsillectomy morbidity in pediatric patients a prospective randomized study

Tonsillectomy is a very common paediatric day-cast procedure that is associated with significant postoperative pain. Pain control continues to be a challenge for adenotonsillectomy patients. To study the effect of combination of pre-emptive analgesia with acetaminophen, pre-induction dose of dexamethasone and intra-operative infiltration olbupivacain on post-tonsillectomy pain and morbidity in young children. A prospective, randomized study, done over a total of 100 children, aged 3 to 12 years, undergoing tonsillectomy or adenotonsillectomy operation, in KFSH, Buraidah in KSA. Patients were randomly divided into two groups. Group 1, received acetaminophen 35mg/kg supp. Or 15mg/kg orally, and IV 0.5mg/kg of dexamethasone in the ward just before sending to OR and local infiltration of 2mL of bupivacain 0.5% in each tonsil bed after the completion of surgery but before the patient's recovery from anaesthesia. Group 2 was placebo. Both groups received standard anaesthetic technique by the same anaesthetist and were operated using the same cold tonsil dissection technique by the one ENT surgeon. Modified objective pain score [OPS] was chosen as the primary end-point of the study. Time to first analgesic dose, total dose of analgesia in the first 24 hours, time to 100mL of oral intake and incidence of vomiting were registered as secondary end-points, as well as the length of hospital stay. The average modified objective pain score was significantly lower in the study group at all measurement timings. Dose of analgesia given in the first 24 hours was lower and time to first analgesic dose was longer in the study group. Also time to 100mL of oral intake was shorter in the study group. The incidence of late vomiting was significantly more frequent in the placebo group. Seven patients in the placebo group and none in the study group had a delayed discharge from the hospital [more than a 24-h stay] because of poor oral intake, this was statistically significant. The additive effect of the multimodal approach has dramatically minimized post-tonsillectomy pain and vomiting as well as improved postoperative oral intake and consequently reduced the period of hospital stay in pediatric patients undergoing tonsillectomy operation

Endoscopic trans-sphenoid approach to pituitary tumors Kasr El-Eini Cairo University hospitals experience

Over the last decades pituitary surgery has been one of the models of the minimally invasive surgeries. Horsley performed the first reported pituitary operation in 1889 through a trans-cranial approach. Schloffer was the first to introduce the trans-sphenoid approach in 1907. Gushing popularized the sublabial trans-septal approach in 1910 and with the introduction of the operating microscope and intra-operative fluoroscopy in the 1950s and 1960s, the trans-septal approach became the gold standard for pituitary surgery. In the 1980s and 1990s, the nasal endoscope became the standard of care in surgery of the nose and PNS. Trans-sphenoidal hypophysectomy is becoming progressively less invasive. Recent endoscopic techniques avoid nasal or intraoral incisions, use of nasal specula and nasal packing for some operators. To present the endoscopic trans-sphenoidal approach for surgical treatment of pituitary adenomas and to evaluate its results and complications. From 1996 to 2006 in the Departments of Otorhinohryngology and Neurosurgery in Cairo University Hospital, 310 patients with pituitary adenomas were operated using the trans-sphenoidal endoscopic approach, among which 197 patients had giant adenomas with supra or para sellar extensions. Complete tumor removal was accomplished in 284 patients [91.6%]. Mortality rate was 3 patients [0.97%]. Morbidity rate was 68 patients [21.9%] in the form of transient diabetes insipidus in 64 patients [20.6%], intraoperative CSF leak in 2 patients [0.6%], bilateral visual loss in 1 patient [0.3%] and tension pneumocephalus in 1 patient [0.3%]. The endoscopic trans-sphenoid approach is the management of choice for pituitary adenomas including invasive type. The surgery can be done with minimal morbidity and more radically than classic transsphenoidal surgery. Invasion of the cavernous sinus is no longer a taboo and could he attempted in 68.2% of the cases with a parasellar extension

Clinical under-staging of laryngeal carcinoma, pathological study and clinical application

There is clinical evidence of the safety and efficacy of conservation techniques for laryngeal carcinoma, but the supporting pathological data are incomplete. To formulate a surgical strategy, it is important to be able to predict, for tumors at any given mucosal site, the extent and the likelihood of invasion of the laryngeal spaces and the structures comprising the laryngeal framework. To demonstrate the potential for invasion of the laryngeal framework by laryngeal carcinoma at different sub-sites of the larynx and the effect of this invasion as regards clinically and surgically. This study was conducted upon forty-four patients suffering from laryngeal carcinoma, presenting to the ENT department in Cairo University Hospital from 2000 to 2004. All patients were treated surgically in the form either of total or partial laryngectomy. Every laryngectomy specimen was subjected to histopathological preparation and whole-organ section with special stress on cartilage invasion. Cartilage invasion of the laryngeal framework was proved histopathologically in 65.9% of patients. Cartilage invasion was detected in 81.9% of patients with anterior commissure carcinoma included in this study. There is increased incidence of laryngeal framework invasion with increased tumor size and more commonly in ossified or partially ossified cartilage. All Patients subjected to deep X-ray therapy or laser management as the sole treatment of their anterior commissure carcinoma presented with tumor recurrence and were subjected to more radical surgery. These findings reflect the aggressiveness of laryngeal carcinoma and may alter the planning of treatment, however, larger number of patients in further studies is required to detect the long term effects of these findings