Endoscopic repair of bilateral choanal atresia in neonates: anesthetic and surgical implications

Bilateral Choanal Atresia patients are usually in respiratory distress at birth. Such patients [neonates] have unique anesthetic and surgical requirements regarding equipment, intravenous access, fluid and drug therapy, anesthetic dosage, and environmental control. An understanding of the basic differences in physiology, pharmacologic and pharmaco-dynamic responses, and the underlying pathology of the surgical problem is essential for the development of a safe anesthetic/surgical plane. To describe and evaluate the outcome of the anesthetic / endoscopic transeptal approach for the repair of bilateral choanal atresia in neonates. A prospective analysis of a case series of neonates with bilateral choanal atresia who were treated by the endoscopic transeptal approach between July 2003 and December 2005 was undertaken. Endotracheal intubation was performed under adequate plane of general [inhalational/narcotic] anesthesia. Adequate depth of general [inhalational/narcotic] anesthesia with spontaneous and gentelly assisted ventilation were appropriate till the end of surgery. The endoscopic approach was performed using 4-mm 0° telescope. A laterally based trapezoid shaped septal mucosal flap was created on each side using a radiofrequency needle. The flaps were elevated in a swinging door fashion to expose the atretic plate and the vomer. After removal of the posterior bony septum and widening of the choana, the flaps were trimmed and applied to the exposed lateral bony rim of the choana. All patients were stented bilaterally for three to four weeks postoperatively. Neonatal/infant Pain Scale [NIPS] was used to assess the wellbeing and pain status of neonates in the immediate postoperative period. The study group included 14 neonates aged 2 to 25 days at the time of surgery. Follow up ranged from 4 to 36 months with a mean of 17.3 +/- 9.3 months. All neonates had a smooth anesthesia course, with minimal blood loss. Postoperatively, all have 0 to 1 score in the NIPS. Recovery was uneventful in all cases except for one case that developed bleeding in the immediate postoperative period and was controlled under endoscopic guidance. One case died three months following stent removal from uncompensated heart failure due to concomitant ventricular septal defect. An adequate functional nasal breathing and appropriate feeding with sufficient weight gain were maintained during the entire follow-up period. The described anesthetic/endoscopic technique was very adequate. It offered excellent visualization of the choana and allowed maximal widening of the choana while preserving the mucosa along the entire circumference of the newly created choana and hence less risk of postoperative stenosis

Paranasal mucoceles: usual and unusual

The aim of this study was to review the usual and unusual aspects regarding the clinical presentation, diagnosis, and treatment of paranasal sinus mucoceles. Special emphasis was given to the role of endoscopic marsupialization either alone or in combination with a limited external procedure in creating a functioning epithelialized pathway between the mucocele and the sinonasal cavity. The medical records of all patients with mucoceles who were treated by the author over a five-year period were reviewed. There were 37 mucoceles, including 12 frontoethmoidal, 11 sphenoidal/sphenoethmoidal, 7 maxillary and 7 lesions arising from aberrant locations within the sinonasal complex. CT scan was the initial diagnostic modality in all patients. In ten patients, MRI was carried out to confirm the diagnosis. Endoscopic marsupialization was the only surgical modality in 32 patients. Four patients underwent surgery via combined endoscopic and limited external approach. Recurrence was reported in one patient 6 months following endoscopic marsupialization of sphenoid mucocele. Postoperative endoscopic examination showed a widely patent healed opening in 33 cases and asymptomatic cicatricial narrowing in 2 cases. The author concluded that well-planned simple or extended endoscopic technique either alone or in combination with a limited external procedure is uniquely suited to the management of virtually all mucoceles

Endoscopic coagulation of sphenopalatine neurovascular bundle for intractable allergic rhinitis: a histopathological study

Manifestations of allergic rhinitis are due to a primary immunologic response which leads to a battery of neurovascular reactions. The sphenopalatine foramen [SPF] transmits both the blood and nerve supply to and from the nasal mucosa. We aimed at controlling the allergic reaction by endoscopically coagulating the neurovascular bundle at the SPF. The results were evaluated in patients with intractable allergic rhinitis by comparing the histopathological changes in biopsy specimens from the middle turbinate on the operated sides with control biopsies from the unoperated sides both at 1 month and at 2 years postoperatively. Qualitative and morphometric quantitative histopathological evaluation of the middle turbinate mucosa showed dramatic diminution of the mucosal reactivity and inflammatory cellular infiltrate compared with the control levels at one month postoperatively: At 2 years postoperatively, there is a gradual weaning of these effects Endoscopic coagulation of the sphenopalatine neurovascular bundle is a minimally invasive technique that seems promising in controlling intractable allergic rhinitis that fails to respond to medical treatment