Cranialization of the frontal sinus--the final remedy for refractory chronic frontal sinusitis.

OBJECT: Chronic sinusitis can be a debilitating disease with significant impact on quality of life. Frontal sinusitis has a relatively low prevalence, but complications can be severe due to its anatomical location. After failure of conservative measures, typically endoscopic procedures are performed to improve the drainage of the frontal sinus. The cranialization of the frontal sinus is the final surgical measure, in which the affected frontal sinus is truly removed. In this study the authors describe the surgical technique of cranialization of the frontal sinus for refractory chronic frontal sinusitis, systematically search the literature for its application, and assess patient satisfaction in a cohort of consecutively treated patients after long-term follow-up. METHODS: A consecutive cohort of 15 patients with refractory chronic frontal sinusitis was treated by cranialization of the frontal sinus and followed over a 20-year period (1989-2008) for the direct results and complications of the surgery. Long-term follow-up (mean 6.5 years) was obtained to assess the long-term effects of the cranialization. RESULTS: In all patients the signs and symptoms of chronic frontal sinusitis responded very well to the cranialization. Five patients had surgical complications, of which 2 were serious. One patient died of an unrelated cause and 1 patient was lost to follow-up. The remaining 13 patients had a long-term follow-up, which revealed that 12 of them thought that their life was better after the surgical procedure. CONCLUSIONS: Cranialization of the frontal sinus deserves consideration as the final remedy for refractory chronic frontal sinusitis after definite failure of other options.

[Treatment of the obstructive sleep-apnea syndrome in adults]. / Behandeling van het obstructieve slaapapneusyndroom bij volwassenen.

When treating the obstructive sleep-apnoea syndrome (OSAS), conservative management and the correction of treatable stenoses in the upper airway should be considered first. If these measures are neither effective nor applicable, then continuous positive airway pressure (CPAP) is the preferred treatment. Surgical interventions should only be considered after failure of non-surgical treatment modalities. Pharmacological management of OSAS is usually only indicated as a form of supplementary treatment in specific patients. Oral-appliance therapy appears to be of value in the management of OSAS and, in specific groups of patients, seems likely to offer a good alternative to CPAP in the future.

Laser surgery in lingual tonsil hyperplasia.

Modern techniques have reduced the long existing reluctance to perform lingual tonsillectomy. The results of treatment of hyperplasia of the lingual tonsil with the carbon dioxide laser in 32 patients are presented. After exposure with a special endoscope the lingual tonsil can be vaporized or excised under microscopic control with promising results, far superior to the results obtained with other surgical techniques. Since the success rate of the surgery depends on the diagnostic criteria for applying this therapy, a careful selection of patients is essential.

[Epistaxis caused by an acquired thrombocytopathy]. / Epistaxis door verworven trombocytopathie.

Epistaxis may be the sole manifestation of a platelet aggregation dysfunction. Bleeding time according to Ivy within normal ranges does not exclude a severe disturbance of primary haemostasis. In two women (aged 53 and 76 yr, respectively) persistent epistaxis could not be stopped by local therapy. The bleeding time according to Ivy was within normal ranges in both cases. In one patient a bleeding disorder was not recognized as laboratory screening tests were normal and her situation became life-threatening. Anamnesis, clinical history and platelet aggregation tests led to the correct diagnosis; in one patient the relation with acetylsalicylic acid treatment was clear. After administration of platelet concentrate the bleeding stopped within a few hours in both cases and did not recur.

Nasal antrostomy.

With chronic maxillary sinusitis the pathological changes in the diseased mucosa used to be considered irreversible, thus necessitating its radical removal, which is only possible with the Caldwell-Luc operation. The discovery of the reversibility of the pathology caused a shift from the Caldwell-Luc towards endonasal procedures, of which the inferior meatal antrostomy became the most widely used. Nasendoscopy, later combined with computed tomography, led to the development of the concept of the osteomeatal unit, and hence the functional endoscopic sinus surgery, which is concentrated round the infundibulum region. In view of possible risks and complications of that method it is propagated here to differentiate between these two techniques: When the focus of chronic sinusitis appears to be situated in the infundibulum/anterior ethmoid region, the functional endoscopic surgery seems preferable; For cases where the inflammatory process was restricted largely to the maxillary sinus a modified inferior meatal antrostomy technique proved to have a 92% success rate in 378 sinuses.

Endoscopic surgery of the nasal fontanel. A new approach to recurrent sinusitis.

For the treatment of recurrent maxillary sinusitis, the middle meatus offers a good site to make an extra ostium, ie, the posterior nasal fontanel. The fontanel is situated near the natural maxillary ostium in the middle meatus, and this site is a more physiologic place, therefore, to create an antrostomy compared with the inferior meatus. Moreover, a surgical ostium has little inclination to become obliterated in this area. A special instrument was designed to perforate the fontanel. Nasoendoscopy gives an excellent view of the area and makes it possible to avoid complications.

Endoscopic antrostomy in the nasal fontanelle.

One of the causes of recurrent maxillary sinusitis may be a too narrow natural ostium, which becomes blocked easily. As the mucus transport inside the sinus is directed towards the ostium, i.e, towards the middle nasal meatus, the most suitable place for an artificial extra ostium is in the middle meatus. In the posterior fontanelle such an ostium can be made comparatively easily under endoscopic control. For this purpose a special coagulating perforating instrument has been designed.