Irrigation-suction straw sheath system for a rigid endoscope during endonasal endoscopic pituitary surgery.

OBJECTIVE: One of the most problematic conditions during endonasal endoscopic pituitary surgery is blurred endoscopic vision caused by blood or bone dust. To address this problem we used a new device, the irrigation-suction straw sheath system originally developed for endoscopic sinus surgery in rhinology, for the endoscopic pituitary surgery. METHODS: The irrigation-suction straw system (K-endosheath; Koken Co., Tokyo, Japan) consists of a flattened disposable straw catheter which can be attached on a rigid endoscope. When the endoscope is inserted into the oblong catheter, two gaps remain on either side of the endoscope. Through each of these gaps irrigation and continuous suction are performed respectively. RESULTS: Clear vision could be immediately obtained by pressing the button to release the irrigation water onto the endoscope's front lens. Even targeted irrigation during drilling was possible. Above all, continuous suction was useful to clear the operative field of blood, smoke, or bone dust, ensuring the safety and uninterrupted progress of the procedure. CONCLUSION: This irrigation-suction system has proved to be very useful and easy to use for endonasal endoscopic pituitary surgery. Further development of such new devices and instruments specialized for endonasal endoscopic pituitary surgery will promote the increased use of this minimally invasive technique in neurosurgery.

Mechanism allowing an insect to survive complete dehydration and extreme temperatures.

Cryptobiosis describes the state of an organism whose body water is completely dehydrated and metabolic activity has become undetectable. Our study aimed to elucidate the physiological mechanism of cryptobiosis in the highest cryptobiotic invertebrate, Polypedilum vanderplanki. Larvae of this insect rapidly accumulated a large amount of the carbohydrate, trehalose, (18% of dry body mass) during desiccation for 2 days, suggesting that a high level of trehalose accumulation contributed to the successful induction of cryptobiosis in P. vanderplanki as well as in other lower cryptobiotic organisms. When larvae deprived of the brain, suboesophageal ganglion (SG) and thoracic ganglia (TG) were completely dehydrated and then rehydrated, they were able to recover and move actively. During desiccation, such larvae also accumulated trehalose, although only about half as much as the intact larvae. It is concluded that the brain, SG and TG do not affect the induction and termination of cryptobiosis, and hence in this higher multicellular animal cryptobiosis is independent of brain, SG and TG regulation, just as in plants or in unicellular organisms.

Treatment of intractable diseased tissue in the maxillary sinus after endoscopic sinus surgery with high-pressure water jet and preservation of the periosteum.

OBJECTIVE: To describe a new high-pressure water jet (HPWJ) treatment to remove intractable diseased mucosa persisting in the maxillary sinus several months after endoscopic sinus surgery (ESS) while preserving the periosteum. DESIGN: A retrospective review of HPWJ treatment in 45 consecutive patients with at least 12 months follow-up. SETTING: A private surgicenter in Japan. PATIENTS: Patients (25 male and 20 female) ranged in age from 8 to 59 years. All patients had diffuse intractable lesions in the opened maxillary sinus after the initial ESS, with or without disease of the ethmoid and other major sinuses. MAIN OUTCOME MEASURES: Resolution of diffuse intractable disease in the maxillary sinus and postoperative change in the size of the cavity were evaluated using nasal endoscopy and computed tomographic scan. RESULTS: Twenty-six (81%) of 32 sides in 25 patients with isolated persistent maxillary sinus disease were restored after HPWJ procedures; 25 (93%) of 27 sides in 20 patients who also had ethmoiditis also were restored. In the latter group, ethmoiditis recurred in 5 sides, which also included 2 sides of unrestored maxillary sinuses. Of the 51 restored sides, 33 (65%) were restored within 3 months after HPWJ treatment under endoscopic observation. No complications were seen during the surgery. Except for 1 side in 1 patient from which all diseased mucosa was removed almost completely, along with the periosteum, no reduction of the cavity by scar tissue formation was observed. This method did not affect the development of the maxillary bone in children. CONCLUSION: Removing diffuse intractable diseased mucosa in the maxillary sinus while preserving the periosteum with HPWJ treatment is an effective surgical therapy that fulfills the ultimate purpose of ESS.

Extended endoscopic frontal sinus surgery to interrupted nasofrontal communication caused by scarring of the anterior ethmoid: long-term results.

OBJECTIVE: To examine the long-term results of extended endoscopic frontal sinus surgery, including removal of the floor of the frontal sinus (Draf type II procedure) and the median drainage operation (Draf type III procedure or modified Lothrop procedure), for obstructive frontal sinusitis caused by postoperative scar formation, with the emphasis on the long-term success of the median drainage procedure. DESIGN: Retrospective review of 22 consecutive cases of extended endonasal frontal sinus surgery in patients with obstructive frontal sinusitis caused by postoperative scarring. SETTING: The procedures were performed at a private surgicenter in Japan. PATIENTS: Twenty-two patients (15 males and 7 females) ranging in age from 14 to 61 years. All patients had scar formation in the anterior ethmoid, either with or without middle turbinate lateralization or ethmoiditis. Three patients underwent Draf type II procedure followed by Draf type III procedure because of surgical failure of the type II procedure. MAIN OUTCOME MEASURES: Restoration of communication to the frontal sinus was evaluated by computed tomography. All patients were examined at least 12 months after surgery or stent removal. RESULTS: Of the 16 patients who underwent the type III procedure, in 14 (88%) the patency of the opening to the frontal sinus and an aerated sinus were confirmed. Of 12 sides in 9 patients who underwent Draf type III procedure, 5 sides (42%) were also confirmed as "cured." CONCLUSIONS: The median drainage operation (Draf type III procedure) on the frontal sinus showed excellent long-term results compared with the type II procedure. Extended endoscopic frontal sinus surgery, particularly the median drainage procedure, is useful in the functional treatment of obstructive frontal sinusitis caused by postoperative scarring.

Bilateral facial palsy caused by bilateral masked mastoiditis.

Acquired simultaneous bilateral facial palsy caused by bilateral masked mastoiditis in a 25-month-old girl is reported. After the administration of antibiotics for 10 days for treatment of bilateral acute otitis media, overt signs of otitis media diminished as bilateral facial palsy ensued. For diagnosis of masked mastoiditis, brain magnetic resonance imaging was of significant value in our case. The findings in this case suggest that masked mastoiditis should be considered as a cause of bilateral facial palsy, as well as unilateral facial palsy.

Sequence requirement for replication initiation at the rat aldolase B locus implicated in its functional correlation with transcriptional regulation.

Transcription promoter of the aldolase B gene was previously shown to be centered on an initiation region of DNA replication in rat hepatoma cells in vivo. Here, we defined an essential region required for replication in a plasmid form upon transfection. Deletion analyses around the origin region revealed that the proximal 200 bp promoter was necessary, but not sufficient for replication as flanking sequence restored replication activity. Therefore, the 200 bp region seemed to cooperate with the flanking sequence to play an important role in replication. Electrophoretic mobility shift assays using nuclear extracts from synchronously growing hepatoma cells showed that some protein factors bound to this region in a cell cycle-regulated manner. Since transcription of the aldolase B gene is repressed in the hepatoma cells, the cell cycle-regulated protein-binding is considered to be involved in regulation of replication initiation.

[Combined macro-micro-endoscopic technique (COMMET) in endonasal sinus surgery: II. Objective assessment and results].

To optimize success in sinus surgery, we use a combined macro-micro-endoscopic technique (COMMET). This technique effectively combines use of the headlamp, microscope, and endoscope according to the demands of each anatomical region. Between April 1991 and March 1994, we successfully performed this technique on 461 patients (798 sides). According to CT scans, about 40% of the patients had pansinusitis, and about 30% of the patients had anterior and posterior ethmoiditis combined with inflammation of other sinuses. Hence, severe cases requiring total ethmoidectomy accounted for about 70% of all sides. All patients were operated on under general anesthesia. The objective of this operation was restoration of drainage and ventilation, and then to allow recovery of the reversible mucosal lesions. The goal of surgery was to normalize all paranasal sinuses. In many patients, there is little correlation between postoperative objective findings in the paranasal sinuses and subjective improvement. Therefore, postoperative subjective improvement cannot be used as the criterion for evaluating the improvement of sinus disease. Hence, we established an objective grading system based on CT and endoscopic findings and evaluated improvements in each sinus after drainage and ventilation had been restored. The rates of normalization over 1 year following surgery (mean follow-up time was 19-20 months) were 64% in the frontal sinus, 72% in the anterior ethmoid sinus, 68% in the maxillary sinus, 90% in the posterior ethmoid sinus and 80% in the sphenoid sinus. The results differed from sinus to sinus, suggesting that there are different factors impairing recovery in each sinus.(ABSTRACT TRUNCATED AT 250 WORDS)

[Combined-macro-micro endoscopic technique as the most advantageous endonasal sinus surgery especially for severe sinusitis: theory and surgical technique].

Functional endonasal sinus surgery (FESS) is becoming the procedure of choice for the surgical treatment of chronic sinusitis. The operation has been made possible by the introduction of the endoscope to sinus surgery. The endoscope allows a more detailed observation of ethmoid lesions, and provides direct visual access to the paranasal region which is not visible through the anterior nares. A technique which involves the exclusive use of endoscopy, endoscopic sinus surgery, presents several problems however, especially in cases of polyposis or those with excessive bleeding. For ideal sinus surgery, tools must guarantee the greatest possible safety, ease, and accuracy. None of the currently available tools is independently able to fully satisfy all three of these requirements, not even the endoscope. The anatomical region being operated on determines which of these three requirements is most critical in each phase of the surgery. Ease is most important in the nasal cavity, which has no exceptionally dangerous regions to be operated on. The quickest and simplest operation is most expedient for minimizing blood loss in severe polyposis. To achieve this objective, macroscopic manipulation using a headlamp is most suitable. There is no need to use the endoscope or microscope to remove polyps in the nasal cavity. Because almost all of the risks in sinus surgery are encountered in the ethmoid region, operation in this area demands the safest method. For example if the ethmoid cavity is filled with massive polyps, it is sometimes difficult to endoscopically detect whether orbital fat has broken into the ethmoid. To discriminate between fat and a polypoid lesion or to distinguish dura from mucoperiost during surgery, the microscope is clearly the superior tool. In region where dead angles prevent accurate manipulation, use of the endoscope is essential. To optimize success in sinus surgery using the currently available tools, the author describes a combined macro-micro-endoscopic technique (COMMET) which effectively combines use of the headlamp, the microscope, and the endoscope according to the demands of each anatomical region.

Reconstruction of the cervical trachea with a free forearm flap.

With the aim of voice restoration after repair of a total defect or obstruction of the cervical trachea, we developed a new method of total cervical tracheal reconstruction with a free forearm flap. The forearm flap is inverted to form a tube and then interposed between the subglottic trachea and an adjacent cutaneous fistula created at the upper portion of the tracheostoma. A permanent tracheostoma is preserved, and an L-shaped silicone tube is inserted in the reconstructed cervical trachea and the tracheostoma as a stent. In two patients, both became able to speak.

Ulceration and stenosis of the hypopharynx and its surgical management.

Two patients presented with ulcerative lesions of the hypopharynx. One patient developed dysphagia due to a stenotic hypopharynx which followed an ulcerating mucosal lesion. The stenotic site was reconstructed using a subcutaneous pedicle flap. The advantages of this method are possibility of a one-stage operation and a good cosmetic result. In our review of the medical literature, we were unable to find other cases with a similar manifestation treated by surgery. The most likely diagnostic possibilities are Behçet's disease and Crohn's disease. Differential diagnoses are discussed.