Technical Note: First Use of Endonasal Confocal Laser Endomicroscopy - Feasibility and Proof of Concept

Abstract Introduction Probe-based confocal laser endomicroscopy (p-CLE) is a method for real-time in vivo visualization of mucosal changes on a cellular level. Due to the size of the endoscopes, it was mainly used in the gastrointestinal tract so far. First investigations on head and neck carcinoma described the oropharyngeal application. The further miniaturization of the laser probe now allows endonasal application and, thus, first experiences with the investigation of endonasal neoplasms. Objectives The aim of the present investigation is to elucidate, based on the morphological criteria validated in the oropharynx, whether these criteria be transferred in a similar way to the endonasal mucosa. Methods We conducted p-CLE (Cellvizio, Paris, France) with intravenous fluorescein staining in endoscopic sinus surgery in a patient with sinonasal inverted papilloma and a histologically confirmed squamous cell carcinoma. We compared the cellular visualization of pathological changes with those of healthy mucosa in the same specimen, and also with our former findings in the oropharynx. Results Endonasal p-CLE proved to be quite feasible in the surgical setting, and the transfer of malignancy criteria in analogy to histological examination could be optically retraced. Furthermore, additional criteria for tissue dignity assessment were obtained. Conclusion Our results suggest that endonasal application of p-CLE represents a valuable extension of the diagnostic repertoire available to date by an additional realtime analysis of the nasal mucosa. This is of particular value in surgically challenging anatomical areas such as the paranasal sinuses.

Effect of nasal septum deviation on the curative effect of endonasal endoscopic dacryocystorhinostomy / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To explore the effect of nasal septum deviation(NSD)on the curative effect of endonasal endoscopic dacryocystorhinostomy(EES-DCR).<p>METHODS: Totally 84 patients(84 eyes)who have been diagnosed with chronic dacryocystitis in our hospital from June 2017 to May 2019 were collected and then the patients were divided them into two groups according to whether NSD existed through the preoperative nasal endoscopy. Group A included 42 patients(42 eyes)who had no NSD while Group B included 42 patients(42 eyes)who had NSD(mild or moderate). The EES-DCR was performed under general anesthesia in both groups. The preoperative treatment indexes, evaluative efficacy after 6mo follow up and nasal adhesion were compared between the two groups after operation.<p>RESULTS: The operation time and intraoperative blood loss of group B(69.9±13.1min, 51.8±16.4mL)exceeded group A(53.4±11.7min, 24.9±12.0mL)respectively(<i>P</i><0.05), while the hospitalization time between two groups showed no difference(<i>P</i>>0.05). Follow up for 6mo: the effective rate of group A was 86% while group B was 71%(<i>P</i>>0.05); No nasal adhesion was found in group A while 12% incidence existed in group B, with no difference between the two groups(<i>P</i>>0.05).<p>CONCLUSION: Patients who have chronic dacryocystitis combined with mild or moderate NSD do not need to perform a septoplasty simultaneously if the symptom does not accompany by nasal dysfunction. Only by performing the EES-DCR can achieve a quite good result.

Effect of different absorbable anastomotic stoma packing materials on endonasal endoscopic dacryocystorhinostomy / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To compare the effect of self-crosslinking sodium hyaluronic gel, Nasopore, and gelatin sponge in endonasal endoscopic dacryocystorhinostomy(En-DCR).<p>METHODS:Totally 72 patients(90 eyes)of chronic dacryocystitis admitted to our hospital from June 2019 to June 2020, and randomly divide them into three groups. Self-crosslinking sodium hyaluronic gel(group A), Nasopore(group B), and gelfoam(group C)were used during the En-DCR. Comfort level, bleeding, complication and epiphora, lacrimal situation were observed 2wk, 1, 2, 3, 6mo after surgery. Comparison of cure rate and effective rate.<p>RESULTS: The patients were followed up for 6mo after operation. The cure rate of lacrimal system reconstruction was 97% in group A, 89% in group B and 94% in group C. There was no meaningful statistical difference among the three groups(<i>P</i>>0.05). The effective rate of lacrimal system reconstruction was 91% in group A, 56% in group B and 87% in group C(<i>P</i><0.05). There was significant statistical difference between groups A and B or between groups B and C(<i>P</i><0.0167), however, there was no meaningful statistical difference between groups A and C(<i>P</i>>0.0167). Postoperative comfort level was better and bleeding was more severe in the group of A than in group B(<i>P</i><0.0167). In terms of complications, there was less scar proliferation in group A than in group B(<i>P</i><0.0167), the rate of synechiae in groups A and B was higher than in group C(<i>P</i><0.0167).<p>CONCLUSION:Intraoperative application of self-crosslinking sodium hyaluronic gel to packing the anastomotic stoma makes the procedure simple and can effectively inhibit scar proliferation and conducive to the epithelialization of the anastomotic stoma, improve the cure rate of En-DCR. In addition, with more comfort. It is a simple, safe, comfortable and efficient absorbable anastomotic stoma packing material.

Abordaje endoscópico al cavum de Meckel: resección endoscópica endonasal de schwannoma del nervio trigémino / Endoscopic approach to the Meckel's cave: endonasal endoscopic resection of a trigeminal schwannoma

RESUMEN El cavum de Meckel (CM) es un divertículo localizado en la fosa media adyacente al seno cavernoso. Las neoplasias de esta región son extremadamente raras y representan un desafío para el cirujano debido a las estructuras neurovasculares que se encuentran en la región. Para los tumores ubicados en esta área se han descrito diversos abordajes quirúrgicos, los cuales no logran una adecuada exposición a la porción anteromedial del CM. En la última década, se ha postulado el abordaje endoscópico endonasal extendido (AEE) como una alternativa quirúrgica para el manejo de lesiones ubicadas en esta región. Se presenta el caso de un paciente portador de un schwannoma del nervio trigémino situado en el CM derecho tratado mediante AEE.

ABSTRACT The Meckel's cave (CM) is a diverticulum located in the middle fossa adjacent to the cavernous sinus. The neoplasms of this region are extremely rare and represent a challenge for the surgeon due to the neurovascular structures that occupy and surround the parasellar region. For tumors located in this area, several surgical approaches have been described, all of which do not achieve an adequate exposure to the anteromedial portion of CM. In the last decade, the extended endonasal endoscopic approach (EEA) has been postulated as an alternative for the surgical management of tumors located in this region. We present the case of a patient with a trigeminal schwannoma located in the right CM treated by EEA.

Cirugía hipofisiaria endoscópica transesfenoidal, con realización de colgajo nasoseptal: evaluación del impacto de la técnica en la olfación:. serie de casos / Endoscopic pitituary surgery transsphenoidal, with nasoseptal flap: assessment of the impact of the technique in the olfaction: cases series

Introducción: La cirugía endoscópica transesfenoidal en la exéresis de patología hipofisaria ha sido ratificada dentro de la mejores opciones para conseguir abordajes exitosos. Para cerrar la brecha ósea, se puede utilizar el colgajo nasoseptal, el cual lograría un cierre adecuado y seguro, evitando complicaciones como persistencia de fístulas de líquido cefalorraquídeo. Dentro de los probables efectos secundarios de este colgajo se señala la presencia de anosmia o hiposmia. Objetivo: Nuestro objetivo es mostrar los resultados obtenidos empleando la técnica del colgajo nasoseptal y la evaluación del olfato posoperatorio. Material y método: Incluimos 14 pacientes con diagnóstico de adenoma hipofisiario intervenidos en nuestro servicio entre diciembre 2014 a diciembre 2015. Se evaluaron diversos parámetros entre otros, olfatometría pre y posoperatorias. A todos se les realizó la técnica endoscópica transesfenoidal. Efectuando la disección del colgajo con la técnica tipo Hadad. La exéresis tumoral fue realizada por neurocirujano, se cubrió la osteotomía con este colgajo. Resultados: De los 14 pacientes, 13 llegaron al estado olfativo preoperatorio. 1 paciente se mantuvo hipósmico mantenidamente. En nuestro estudio, no hemos encontrado deterioro significativo en la calidad del sentido del olfato. Así como tampoco observamos otras complicaciones. Conclusiones: Esta experiencia aún inicial, estimamos que podría ya esbozar una tendencia de mantención de la función olfativa en este tipo de cirugía.

Introduction: Transsphenoidal endoscopic surgery resection of pituitary pathology has been ratified within the best options for successful approaches. To close the gap bone, you can use the nasoseptal flap, which achieved an adequate and secure closure, preventing complications such as persistent cerebrospinal fluid leaks. Among possible side effects of this flap anosmia-hyposmia noted. Aim: Our goal is to show the results obtained using the technique of nasoseptal flap and postoperative evaluation of smell. Material and method: We included 14 patients with a diagnosis of pituitary adenoma surgery in our department between December 2014 to December 2015. Various parameters were evaluated pre and post operative, specially olfactory function. All underwent transsphenoidal endoscopic technique. Performing dissection flap with the technical type Hadad. The tumor resection was performed by neurosurgeon, osteotomy covered with this flap. Results: Of the 14 patients, 13 reached the olfactory preoperative state. 1 patient remained with hyposmia. In our study, we found no significant deterioration in the quality of the sense of smell. Not other complications were found. Conclusions: This is an initial experience, and we estimate that could outline a trend of maintaining olfactory function in this surgery approach.

Endoscopic endonasal dacryocystorhinostomy combined with stent implantation as treatment for acute dacryocystitis / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To discuss the feasibility and clinical efficacy of endoscopic endonasal dacryocystorhinostomy(EN-DCR)combined with stent implantation for treatment of acute dacryocystitis. <p>METHODS: A total of 31 patients(32 eyes)presenting with acute dacryocystitis were treated with EN-DCR combined with stent implantation under antibiotic cover from April 2014 to December 2015. These patients were followed up for 3 to 12mo. <p>RESULTS: The medial canthal edema and erythema was gradually reducing within 48h in all patients. The hospitalization time took 2 to 8d(average 3.8±1.6d). Patients underwent removal of stent about 3mo after surgery. Thirty-one eyes showed no symptoms such as lacrimation or pus discharging, and irrigation of lacrimal duct was unobstructed. Irrigation of lacrimal duct was passable in 1 of 32 patients who has a relative narrow ostial. Results in this series, 31 cases were cured,1case improved, the total cure rate was 97%. <p>CONCLUSION: There is no evidence shown that EN-DCR combined with stent implantation can increase the risk of spreading infection through tissue planes, causing septicemia, and exacerbating inflammation. Instead, it has advantages like gradual reduction in inflammatory symptoms, economic benefits of reduced patient stay, maintenance of the orbicularis muscle lacrimal pump and absence of external scar. It is indicated that EN-DCR combined with stent implantation is a safe and feasible surgical procedure for patients with acute dacryocystitis.

Reporting of Randomised Clinical Trials in Skull Base Surgery: A Fourteen-Year Review.

Skull base surgery has experienced dramatic advances in the last decade. Recently, various surgical disciplines have conducted reviews of quality of randomised controlled trials (RCTs). This is the first review to our knowledge regarding RCT quality within skull base surgery. Systematic review of skull base surgery RCTs published between 2000 and 2014 were conducted. Literature search provided 96 papers. Duplicates and trials which did not meet our inclusion criteria were excluded. This left 28 papers for analysis. A total of 1785 patients participated across trials. Consolidated Standards of Reporting Trials statement (CONSORT) and Jadad scale were used assess to the quality of reporting. These were our main outcome measures. The mean CONSORT score prior to 2011 was 16.9 (n = 17, range; 13 – 22), and post 2011 was 17.5 (n = 11, range; 12 – 22). The mean Jadad score was 3.1 (n = 28, range 2 – 5). CONSORT were found to increase significantly with both increasing sample size (rho=0.467, p=0.012) and Jadad scores (rho=0.540, p=0.003). Linear regression showed CONSORT increase by 0.36 (95% CI: 0.02 – 0.70, p=0.041) for each additional 10 patients included, and by 1.50 (95% CI: 0.58 – 0.24, p=0.002) for each increase of one in the JADAD score. There are common omissions related to randomization, sample size calculations and availability of protocols. RCTs in skull base surgery are comparable to other surgical disciplines. We recommend utilisation of the CONSORT statement during protocol formation of RCTs to improve reporting of trials.

Cirugía endoscópica endonasal extendida a la región Petro-Clival / Ápex Petroso. Reporte de un caso y revisión de la literatura / Endonasal endoscopic surgery extended to the Petro-Clival / Petrópe region. Case report and literature review

INTRODUCCIÓN: las indicaciones de la cirugía endoscópica endonasal en el tratamiento de tumores de base de cráneo continúan expandiéndose, sobre todo para los tumores extradurales, como son los cordomas. A partir de un caso, nuestro objetivo fue revisar la literatura relevante de estos desafiantes tumores operados bajo esta técnica. CASO CLÍNICO: paciente de 59 de edad con antecedentes de depresión mayor, que comenzó con un cuadro de diplopía por compromiso del VI par izquierdo. Los estudios (CT y RM) mostraron un proceso expansivo en la región del ápex petroso. Se realizó un abordaje endoscópico extendido a la región petro-clival con resección tumoral subtotal. Buena evolución postquirúrgica con desaparición de su diplopía. El diagnóstico histológico fue de Cordoma Condroide. Se indicó radioterapia adyuvante. DISCUSIÓN: a partir del conocimiento y la experiencia en el manejo endoscópico de la patología intraselar se desarrollaron abordajes para el tratamiento de patologías que comprometen la fosa anterior, media e inclusive la fosa posterior. Actualmente, los abordajes endoscópicos, se han extendido a otras áreas de la base de cráneo que de otro modo presentan un reto técnico para la exposición a través de los abordajes transcraneales habituales. El abordaje endoscópico endonasal ofrece una ruta quirúrgica adecuada para la resección del tumor que se presenta en este caso. Las vías que pueden ser utilizados para llegar a la región petroclival a través de la acceso endonasal incluyen la medial (con o sin la movilización de ACI) y la infrapetrosa transterigoidea. En este reporte de caso se analizan las indicaciones del abordaje endoscópico endonasal basado en una revisión de la literatura. CONCLUSIÓN: el abordaje endoscópico endonasal extendido se presenta como una alternativa segura para el tratamiento de determinadas lesiones petro-clivales. Se requieren más estudios anatómicos y clínicos para establecer mejor el rol de este tipo de técnicas en el manejo de las lesiones localizadas en esta región

INTRODUCTION: indications for endoscopic endonasal surgery for the treatment of skull base tumors continue to expand, particularly for extradural tumors, such as chordomas. Based on this case report presentation, we aim to review the literature on the endoscopic technique relevant to the management of these challenging tumors. CASE REPORT: a 59 year-old woman who presented with diplopia due to left sixth nerve palsy underwent imaging studies (CT, MRI) that revealed a mainly intra-osseous expansive process of the left petrous apex. An expanded endoscopic endonasal approach to the petroclival region was performed and the tumor was subtotally resected. The patient recovered from surgery with resolved diplopia. Histopathology was compatible with chondroid chordoma. The radiation therapy was indicated after surgery. DISCUSSION: built upon the bulk experience on the treatment of intrasellar pathology, endonasal endoscopic approaches have been developed for the treatment of skull base lesions involving the anterior, middle and even posterior cranial fossae. Nowadays, the use of these techniques has spread to other areas of the skull base, which otherwise present as a formidable technical challenge for exposure through transcranial approaches. The endonasal endoscopic approach provides an adequate surgical corridor for the resection of the tumor presented in this case report. The alternative corridors that can be utilized to reach the petroclival region through the endonasal endoscopic route include the medial corridor (with or without ICA mobilization) and the transpterygoid infrapetrous corridor. In this article, we discuss the indications for the endoscopic endonasal approach for the case presented, and discuss our choice of approach based on our review of the literature. CONCLUSION: the extended endoscopic endonasal approach presents as a safe alternative for the treatment of select petroclival lesions. Further anatomical and clinical studies are required to better establish the role of the endoscopic endonasal approach for lesions located in this region

Clinical research on the treatment of dacryocystitis combined with canalicular obstruction by dacryocystorhinostomy with canalicular intubation / 国际眼科杂志(Guoji Yanke Zazhi)

AlM: To investigate the clinical efficacy of treatment of dacryocystitis combined with canalicular obstruction by endonasal endoscopic dacryocystorhinostomy with canalicular intubation. METHODS: A total of 27 cases of dacryocystitis combined with canalicular obstruction were treated by endonasal endoscopic dacryocystorhinostomy with canalicular intubation. Canalicular obstruction was treated by laser under dacryoendoscopy and antegrade intubation. RESULTS: For 27 cases, operations were successful, with no complications. All patients were followed up for 6mo, 25 were cured, 2 were effective with no failed. The cure rate was 93%. CONCLUSlON:Treatment of dacryocystitis combined with canalicular obstruction by endonasal endoscopic dacryocystorhinostomy with canalicular intubation has clear field, minimal invasion, quick recovery, exact effect and less recurrence, so it is worthy of promotion.

Outcomes following Purely Endoscopic Endonasal Resection of Pituitary adenomas.

Background: The use of endoscope for the management of pituitary adenoma is not new. The better magnification and illumination provided by the endoscope gives better outcome than microscopic pituitary surgery. Objective: To find out the benefits of endoscope in relation to microscopic surgery. Materials and Methods: We performed 45 cases of pituitary adenoma surgery by endoscopic endonasal approach from July 2008 to July 2010. Results: Forty five cases underwent endoscopic transsphenoidal approach. Gross total removal was done in 35 cases and subtotal removal was done in 10 cases. Residual tumours were seen in 10 cases (22%) in postoperative follow-up MRI scan. Visual improvement was satisfactory, and hormonal improvement of functional adenoma was nice. Postoperative visual acuity and visual field were improved in 75% cases. There were 37% cases of temporary diabetes insipidus and about 4.5% cases of permanent diabetes insipidus. The average duration of follow-up was 20 months. One patient required reexploration to correct visual deterioration in the immediate postoperative period. There were 4.5% cases of CSF leak and 6.6% mortality. Mortality was due to electrolyte imbalance and improper management of infection and hydrocephalus. Conclusion: Endoscopic endonasal pituitary surgery now has become a gold standard surgery for most of the pituitary adenomas because of its better advantages in relation to microscopic surgery and less complications and less hospital stay.

Endonasal Endoscopic Transsphenoidal Pituitary Surgery for Pituitary Adenoma: A retrospective Analysis Of Surgical Outcome

The purpose of this retrospective joint rhino-neurosurgical study from January 1998 until September 2009 is to document the demographic data, clinical presentations, radiological findings, approaches and incidence of residual tumour. Forty-seven patients with pituitary adenoma underwent trans-sphenoidal hypophysectomy of which 25 patients with complete medical and radiological data were included in the study. The medical and radiological data were analyzed. There were 12 males and 13 females with age ranging from 17 to 76 years old (mean 49.2). Fourteen of the patients were Chinese, eight Malays and three Indians. Twelve of the patients had functioning tumour of which five each presented with acromegaly and Cushing disease respectively and two with amenorrhoea. The rest of 13 patients had non functioning tumour presenting with visual disturbances. Sixteen of the patients had pituitary macroadenomas and the rest 9 microadenomas. Eighteen patients had undergone transcollumellar trans-sphenoidal hypophysectomy and the rest 7 patients had undergone transnasal transsphenoidal hypophysectomy. About 68.8% of pituitary macroadenomas had residual tumour, compared to only 22.2% of patient with pituitary microadenomas. Radiologically, about 45.5% of residual macroadenoma had suprasellar extension and the majority had spread to suprasellar cistern and carvenous sinus (54.5%). About 16.6% of patients had undergone post operative radiotherapy. In conclusion, this study showed that patient with pituitary macroadenomas had higher incidence of residual tumour compared to pituitary microadenomas

Endonasal Endoscopic Reduction of Blowout Fractures of the Medial Orbital Walls / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Until recently, blowout fractures (BOFs) of the medial orbital walls were treated using external approach. With recent advances in endoscopy, many cases of BOFs of the medial orbital walls are now treated endonasaly using an endoscope. This article describes endonasal endoscopic reduction (EER) of BOFs of the medial orbital walls and reports the clinical results. MATERIALS AND METHODS: Twelve patients with BOFs of the medial orbital walls underwent EER. Their records were reviewed for surgical indications, operative techniques, operative results, and postoperative complications. RESULTS: Surgical indications were persistent diplopia, limitation of eye movement, and significant enophthalmos. Ten patients showed complete resolution of symptoms after the operation. One patient underwent medial wall reconstruction with transorbital approach after failure of EER, and is now free of symptoms. Another patient with both zygomatic fracture and BOF of the orbital floor remained enophthalmic after EER. There were no other significant complications postoperatively. CONCLUSION: The results indicate that EER is a safe and effective method of treating BOFs of the medial orbital walls.