Endoscopic expanded endonasal approach: preliminary experience with the new 3D endoscope.

The recent introduction of the 3D endoscope for endonasal surgery has been welcomed because of its promise to overcome the main limitation of endoscopy, namely the lack of stereoscopic vision. This innovation particularly regarded the most complex transnasal surgery of the skull base. We therefore discuss our early experience as ENT surgeons with the use of a purely 3D endoscopic expanded endonasal approach for supradiaphragmatic lesions in 10 consecutive patients. This article will focus on the surgical technique, the complications, the outcome, and more importantly the advantages and limitations of the new device. We believe that the new 3D system shows its main drawback when surgery is conducted in the narrow nasal spaces. Nevertheless, the improved knowledge of the three-dimensional nasal anatomy enabled the ENT surgeon to perform a more selective demolition of the nasal structures even in the anterior part of the nose. The depth perception obtained with the 3D system also permitted a better understanding of the plasticity of the surgical defects, increasing the confidence to perform successful skull base plasties. We believe that, for both the ENT surgeon and the neurosurgeon, the expanded endonasal approach is the main indication for this exciting tool, although larger prospective studies are needed to determine the equality to the 2D HD endoscope in oncological terms.

Transnasal 3D endoscopic skull base surgery: questionnaire-based analysis of the learning curve in 52 procedures.

In the past decade, surgical treatment of skull base pathologies has greatly advanced through the advent of the endoscope and later of the high definition endoscope. Recently a new type of three dimensional (3D) scope has been introduced to permit the surgeon a real stereoscopic vision of the operating field and to overcome the limitations of the 2D endoscopic set up. As with all new technologies a formalized adaptation period is essential for the surgeon to secure steady outcomes and low complications. To determine the subjective difficulties that one may encounter during this sensitive period we therefore devised and analyzed a questionnaire that evaluated the first ten procedures with the 3D device of junior and senior ENT and neurosurgeons. 52 consecutive patients were treated with purely 3D transnasal endoscopy for skull base pathologies. Sensation of strain or dizziness, difficulties in anatomical orientation and difficulties in performing the surgical gesture were assessed for each surgeon. The learning curve and difficulties of junior and senior surgeons are discussed and strategies to overcome the initial problems are devised. Our results confirm that after only few procedures, the advantages of the 3D endoscopic system including better visualization and depth perception are able to outweigh the inconveniences that go hand in hand with the learning of a new skill set.

Traumatic brain injury in the elderly: considerations in a series of 103 patients older than 70.

AIM: Mortality and morbidity due to brain injury in the elderly population is a growing clinical problem: among older patients, those >70 years have a considerably higher risk both in terms of mortality and morbidity. Thereafter, the reasons influencing outcome have not been clearly examined: in the present study we addressed these questions considering the main clinical characteristics exerting a significant impact on the outcome of patients aged > 70, with emphasis for the severity of brain injury and anticoagulant (CAW) treatments. METHODS: We performed a retrospective analysis of 103 consecutive isolated head injury patients older than 70, admitted at our Department in the period November 2004-November 2009. The clinical variables considered were as follow: age, sex, type of TBI, GCS, pre-TBI use of anti-coagulants (aspirin, warfarin, clopidogrel), INR at admission (INR values were subdivided in values >1.25 as at risk for hemorrhagic events and <1.25 as normal), initial CT scan classification looking at the presence of subarachnoid hemorrhage (t-SAH) or mass lesions; the main outcome measure was the Glasgow Outcome Scale. RESULTS: The most frequent cause of TBI was accidental fall (65%): 39 were in CAW therapies and in 36 cases the cause of falling down injury was recorded due to a sincopal event (arterial hypotension, atrial fibrillation); in the older patients an accidental fall is significantly related to the TBI, while in the patients aged 70-75 years, TBI is related to a traffic accident (P=0.002). Moreover the cause of TBI correlates with the CAW treatment, the accidental fall being significantly more frequent in patients in CAW treatment (P=0.003). Overall mortality rate is significantly related to an elevated INR class, to presence of t-SAH (16/50 patients) and subdural hematoma (26/46). CONCLUSION: The results of the present study show that in a population of patients aged > 70, TBI is a high risk event if patient has concurrent treatment with CAW therapies and if an accidental fall is the cause of TBI. In these cases the finding of t-SAH represents a high-risk parameter for mortality but not for morbidity.