Endoscopic precaruncular medial transorbital and endonasal multiport approaches to the contralateral skull base: a clinicoanatomical study.

OBJECTIVE: Minimally invasive endoscopic endonasal multiport approaches create additional visualization angles to treat skull base pathologies. The sublabial contralateral transmaxillary (CTM) approach and superior eyelid lateral transorbital approach, frequently used nowadays, have been referred to as the "third port" when used alongside the endoscopic endonasal approach (EEA). The endoscopic precaruncular contralateral medial transorbital (cMTO) corridor, on the other hand, is an underrecognized but unique port that has been used to repair CSF rhinorrhea originating from the lateral sphenoid sinus recess. However, no anatomical feasibility studies or clinical experience exists to assess its benefits and demonstrate its potential role in multiport endoscopic access to the other contralateral skull base areas. In this study, the authors explored the application and potential utility of multiport EEA combined with the endoscopic cMTO approach (EEA/cMTO) to three target areas of the contralateral skull base: lateral recess of sphenoid sinus (LRSS), petrous apex (PA) and petroclival region, and retrocarotid clinoidocavernous space (CCS). METHODS: Ten cadaveric specimens (20 sides) were dissected bilaterally under stereotactic navigation guidance to access contralateral LRSS via EEA/cMTO. The PA and petroclival region and retrocarotid CCS were exposed via EEA alone, EEA/cMTO, and EEA combined with the sublabial CTM approach (EEA/CTM). Qualitative and quantitative assessments, including working distance and visualization angle to the PA, were recorded. Clinical application of EEA/cMTO is demonstrated in a lateral sphenoid sinus CSF leak repair. RESULTS: During the qualitative assessment, multiport EEA/cMTO provides superior visualization from a high vantage point and better instrument maneuverability than multiport EEA/CTM for the PA and retrocarotid CCS, while maintaining a similar lateral trajectory. The cMTO approach has significantly shorter working distances to all three target areas compared with the CTM approach and EEA. The mean distances to the LRSS, PA, and retrocarotid CCS were 50.69 ± 4.28 mm (p < 0.05), 67.11 ± 5.05 mm (p < 0.001), and 50.32 ± 3.6 mm (p < 0.001), respectively. The mean visualization angles to the PA obtained by multiport EEA/cMTO and EEA/CTM were 28.4° ± 3.27° and 24.42° ± 5.02° (p < 0.005), respectively. CONCLUSIONS: Multiport EEA/cMTO to the contralateral LRSS offers the advantage of preserving the pterygopalatine fossa contents and the vidian nerve, which are frequently sacrificed during a transpterygoid approach. This approach also offers superior visualization and better instrument maneuverability compared with EEA/CTM for targeting the petroclival region and retrocarotid CCS.

Contralateral Precaruncular Approach to the Lateral Sphenoid Sinus-A Case Report Detailing a New, Multiportal Approach to Lesions, and Defects in the Lateral Aspect of Well-Pneumatized Sphenoid Sinuses.

INTRODUCTION: Conventional surgical approaches to the lateral aspect of a well-pneumatized sphenoid sinus are associated with significant surgical morbidity. Transorbital endoscopic approaches have recently gained favor as an alternative approach to the skull base. We describe the use of a contralateral precaruncular endoscopic approach to provide a surgical pathway to the lateral aspect of the sphenoid sinus, allowing for improved and direct visualization of the surgical field, with limited morbidity. CASE REPORT: A 60-year-old female patient, with a spontaneous cerebrospinal fluid leak from a Sternberg canal defect in the sphenoid sinus, underwent repair of the defect at Groote Schuur Hospital (Cape Town, South Africa). A contralateral precaruncular approach, using the left medial orbital portal, was utilized to access the defect in the lateral aspect of a well-pneumatized right sphenoid sinus. Computer modeling software was used to predetermine the surgical pathway, and the case was performed under navigation guidance. Adequate surgical access was obtained to the lateral sphenoid sinus and sinus defect, with superior visualization compared to a pure transnasal or transpterygoid approach to the lateral sphenoid sinus. CONCLUSIONS: This case validates the use of computer simulation to plan and decide on the best operative approaches in skull base surgery and describes the contralateral precaruncular approach as a surgical pathway to the lateral sphenoid sinus. Advantages of the contralateral precaruncular approach include a direct trajectory toward the sinus defect, easy access with a standard 18-cm, 4-mm, 0-degree rigid endoscope, and straight instruments, with sparing of the pterygoid base and contents of the pterygopalatine fossa.

Use of surgical sealant in the prevention of pharyngocutaneous fistula after total laryngectomy.

BACKGROUND: Pharyngocutaneous fistula is a major wound complication of total laryngectomy. Surgical sealants may be used to increase the strength and/or integrity of surgical repairs. The purpose of this study was to present our evaluation of the feasibility and utility of the application of sealant to the pharyngeal repair with the aim of reducing pharyngocutaneous fistula incidence. METHODS: This was a prospective single-blind randomized controlled study; patients undergoing primary total laryngectomy for advanced carcinoma of the larynx were randomized into control and treatment (albumin-polyaldehyde sealant applied to pharyngeal repair) groups. Relevant patient, disease, and management-related factors were recorded. RESULTS: Forty-five patients were included (23 controls and 22 who received treatments). No difference in the incidence of pharyngocutaneous fistula was observed between the 2 groups. No treatment-related complications occurred. CONCLUSION: Feasibility of application of an albumin-polyaldehyde surgical sealant to the pharyngeal repair was demonstrated, however, a pharyngocutaneous fistula-preventative effect was not observed. Larger animal and clinical studies are encouraged to clarify this finding.

Primary atypical carcinoid tumour of the sphenoid sinus rostrum.

Primary carcinoid tumors of the nasal cavity and sinuses are exceedingly rare. An accurate histopathological diagnosis is crucial to optimal investigation and management. We present a case of a primary atypical carcinoid tumor arising from the sphenoid rostrum without evidence of associated carcinoid syndrome. This rare but important differential diagnosis of a nasal tumor is discussed and important unique management issues are highlighted.

Endotracheal tube cuff pressures - the worrying reality: a comparative audit of intra-operative versus emergency intubations.

OBJECTIVES: The primary aim was to assess the need for objective cuff pressure monitoring in the theatre complex and trauma centre at Groote Schuur Hospital, Cape Town, South Africa. Secondary aims were to determine whether the tube size, tube make or place of intubation affected cuff pressure. METHOD: Endotracheal tube cuff pressures of 91 patients in the trauma centre and 100 patients in the theatre complex were randomly measured using a Mallinckrodt cuff pressure gauge. The measurements were recorded on a standardised data sheet and transferred to an electronic database for analysis. RESULTS: There was a significant difference between cuff pressures in the trauma centre and those in the theatre complex (p<0.001), the means being 55 cmH2O and 25 cmH2O, respectively. The site of intubation had a significant (p=0.001) effect on cuff pressures, with mean pressures as follows: on scene - 71 cmH2O; referral hospital - 57 cmH2O; and Groote Schuur trauma centre - 42 cmH2O. Only 30% of cuff pressures measured in the trauma centre were below 30 cmH2O, and, alarmingly, 17% were between 91 and 120 cmH2O. In the theatre complex, 77% of cuff pressures were in the acceptable range. Digital balloon palpation corresponded poorly (correlation coefficient 0.47) with measured cuff pressure, and statistical analysis showed that it tended to underestimate the pressure at higher cuff pressures. CONCLUSION: The risk of a high cuff pressure is roughly two- to threefold higher in emergency patients than in theatre patients. These unacceptably high cuff pressures are especially concerning in view of the fact that many trauma patients are hypotensive and therefore more susceptible to mucosal ischaemia.

Malignant proliferating trichilemmal tumor involving the sinuses.

Proliferating trichilemmal tumor (PTT) is a rare adnexal neoplasm that arises from the outer sheath of the hair follicle. It is believed that PTTs originate in trichilemmal cysts. These tumors have the potential for malignant transformation; when this occurs, the tumor is known as a malignant PTT (MPTT). Recurrence after simple local excision is common, and it can cause considerable morbidity. We report a case of MPTT that was initially diagnosed as a benign PTT. The primary tumor had arisen from the skin over the glabella. It was excised, but it recurred 3 years postoperatively. The recurrent tumor involved the eyelid, nasal cavity, and frontal and ethmoid sinuses, and it extended into the orbit. The recurrent tumor was excised via combined endoscopic and open surgery. As far as we know, this is the first documented case of an MPTT that involved the sinuses.

South African survey on disinfection techniques for the flexible nasopharyngoscope.

This random survey was to determine the flexible nasopharyngoscope disinfection practice employed by South African otolaryngologists and to establish whether a breach in the disinfection process exists. The study also aimed to identify organisms most likely to be transmitted via endoscopy and to propose a protocol for the disinfection of the flexible nasopharyngoscope. A questionnaire regarding disinfection techniques used for the flexible nasopharyngoscope was sent to 90 otolaryngologists in South Africa. All provinces were equally represented in the survey. Forty-five otolaryngologists out of a total of 90 participated in the study. Many of the otolaryngologists had no access to a flexible nasopharyngoscope and were therefore not included in the study. Fewer than 50 per cent of the 45 surgeons washed the instrument with soap/detergent and water after use. Only 42 per cent of surgeons used a FDA-approved disinfectant, 52 per cent of which immersed the scope for a shorter period than the recommended contact time. Of the 58 per cent using non-FDA-approved products, 33 per cent used only a 70 per cent Isopropyl alcohol wipe, without immersion of the scope in disinfectant solution. The remaining 25 per cent used non-FDA-approved disinfectants either by wiping or limited immersion of the scope. Of the 45 surgeons, 49 per cent used a different method of disinfection for high-risk patients. Strict guidelines have been proposed for the disinfection of this semi-critical device by the Association of Professionals for Infection Control (APIC) and the Centers for Disease Control (CDC). These guidelines are currently not being followed by many South African otolaryngologists. There is therefore a real risk of transmitting infectious diseases, especially tuberculosis, via endoscopy.