The endoscopic transseptal approach for choanal atresia repair.

BACKGROUND: There are many standard repair options for choanal atresia including puncture, dilatation and drilling of the atretic plate. Most of these techniques involve postoperative stenting, which may promote granulation and scarring, with possible progression to restenosis. This article describes a novel approach for choanal atresia repair without postoperative stenting. METHODS: This article describes our experience with this choanal atresia repair technique utilized in 16 pediatric patients and 1 adult patient across multiple tertiary pediatric and rhinology centers during 2008 through 2015. Seven cases were bilateral and 10 were unilateral. Surgery was performed using an endoscopic transseptal approach with preservation of the mucosa and creation of flaps. No stents or packing was used. The main outcome measures were: response to treatment based on endoscopic examination, need for further revision and incidence of complications. RESULTS: All patients underwent routine postoperative endoscopic inspection of their nasal cavity, postnasal space, and assessment of neochoanal patency. The neochoanae of all patients remained patent to a minimum follow-up duration of 9 months with most patients follow up for 2 years or more. Two neonatal patients required transfusion postoperation from intraoperative bleeding. Two pediatric patients developed postoperative respiratory complications. One patient required revision surgery for nasal vestibule scarring from incision made on the nasal alar to facilitate the initial endoscopic approach. CONCLUSION: This novel endoscopic transseptal repair technique is effective in the management of choanal atresia. Careful fashioning of mucosal flaps and the omission of stenting has resulted in lasting patency of the neochoanae.

The effect of blood pressure and cardiac output on the quality of the surgical field and middle cerebral artery blood flow during endoscopic sinus surgery.

BACKGROUND: A clear surgical field is critical during endoscopic sinus surgery (ESS). Hypotensive anesthesia and cardiac output (CO) may optimize the surgical field; however, evidence of their effect on bleeding and cerebral blood flow is conflicting. The aim of this study was to evaluate the effect of blood pressure (BP) and CO on intraoperative bleeding and middle cerebral artery blood flow velocity (Vmca ) during ESS. METHODS: This was a prospective randomized controlled trial. Patients undergoing ESS for chronic rhinosinusitis at a tertiary institution in 2013 were randomized to receive BP manipulation using target-controlled noradrenaline infusion during surgery to either their left or right sinuses. The contralateral side in each patient served as control. Bleeding was scored using a 0 to 10 point bleeding assessment scale (BAS, 0-10) and Vmca was measured using transcranial Doppler ultrasonography every 10 minutes or when surgically opportune, and time-matched with BP and CO. Data was analyzed using Bland-Altman methods. RESULTS: A total of 105 time points were collected across a mean arterial pressure (MAP) range of 32 to 118 mmHg. Significant correlations were demonstrated between MAP and Vmca (r = 0.7, p < 0.0001), MAP and BAS (r = 0.50, p < 0.0001), CO and Vmca (r = 0.57, p < 0.0001), and CO and BAS (r = 0.42, p < 0.0001). The best surgical fields were seen at 40 to 59 mmHg MAP. However, MAP below 60 mmHg produced >50% reduction in Vmca in more than 10% of time points. CONCLUSION: Balancing surgical visibility with organ perfusion remains a challenge. The results of this study show that moderate hypotension significantly improves the surgical field; however reducing BP below 60 mmHg may risk cerebral hypoperfusion.

The relationship between hypotension, cerebral flow, and the surgical field during endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Hypotensive anesthesia is often used in endoscopic sinus surgery (ESS) to improve surgical visibility; however, its safety and efficacy in this role are yet to be justified. This study aimed to evaluate the effect of hypotensive anesthesia on both real-time middle cerebral artery blood flow velocity (Vmca) and the severity of surgical bleeding in patients undergoing ESS. STUDY DESIGN: Prospective, observational cohort study. METHODS: Thirty-two patients undergoing hypotensive anesthesia for ESS at a single tertiary institution during February 2011 to July 2012 were recruited for the study. Transcranial Doppler ultrasonography measured periodic Vmca, which were time-matched for hemodynamic and respiratory factors. One-minute video segments corresponding with each Vmca reading were randomized and distributed to two blinded observers for bleeding assessment. RESULTS: Three hundred and fifty-six data time points were recorded for systolic, diastolic, and mean arterial blood pressure (MAP), pulse rate, respiratory rate, end-tidal carbon dioxide concentration, Vmca, and bleeding assessment score (BAS). A direct relationship exists between MAP and Vmca (r = 0.77, P < .0001) as well as MAP and BAS (r = 0.36, P < .0001). MAP levels above 60 mm Hg maintained at least 50% of baseline Vmca flow in almost 90% of all time points. CONCLUSIONS: Hypotensive anesthesia is an effective method of controlling intraoperative bleeding during endoscopic sinus surgery; however the effect is clinically small in low MAP ranges. In otherwise healthy patients undergoing ESS with general anesthesia, reducing MAP to below 60 mm Hg may increase the risk of cerebral ischemia.