[Endoscopic dacryocystorhinostomy: a modified technique]. / Dacriocistorrinostomía endoscópica: técnica modificada.

Dacryocystorhinostomy (DCR) is a surgical technique which has been adopted by otolaryngologists in the last years, because of the improvement in the endonasal approach by means of endoscopes. Although the results with the different techniques regarding permeability of the lacrimal duct are similar, we present some modifications in the surgical technique which contribute to a better postoperatory mucosal recovery, due to its more functional and less aggressive nature, improving the cost-benefit ratio. Two groups are compared, the first one (96 DCR) performing osteotomies with a chisel, without doing lacrimal duct and mucosa flaps, the second one (40 DCR) applying the modified technique using Smith-Kerrison forceps to perform osteotomies and creating lacrimal duct and mucosa flaps. Final results referred to permeability are similar (92.7% vs 87.5%). No major complications were found, and the most common minor complication was postoperative eyelid hematoma in cases of orbital fat exposure (5 cases vs 7 cases).

[Factors helping in the decision to change intubation for tracheotomy in critical patients]. / Estudio de los factores que ayudan a la decisión del paso de intubación a traqueotomía en pacientes críticos.

We carry out a prospective study in order to determine the prognostic factors in the development of injuries of upper airways, and their influence in the decision to perform a tracheotomy. The time to tracheotomy was previously stated, according to the type of patient (neurological or non-neurological). This study includes the clinical data and the upper airways endoscopic exploration of 654 patients with oro-tracheal intubation and mechanical ventilation for more than 48 hours in a 6 year period. Three endoscopic explorations were carried out in the first month (early exploration), with two additional explorations at six and twelve months (late exploration). Using a multivariable statistical study we have analysed the prognostic factors and the risk groups for the development of later injuries of the upper airway of these patients. The later endoscopic exploration of the upper airways has shown injuries in 30 of 280 cases (11%). In this study, the main factor that determines the development of injuries of the upper airway was the time of intubation. The risk groups to develop later lesions of the upper airways include: patients with pathological background, patients with medical admissions, non-neurological patients and patients with serious lesions in the earlier endoscopic exploration. We conclude that it is necessary to state the time to perform a tracheotomy in patients with oro-tracheal intubation. It must be based on the own experience, the patient's clinical condition and the disease that caused hospital admission.

[Airway management in ICU patients with mechanical ventilation]. / Mantenimiento de la vía aérea en pacientes de UCI bajo ventilación mecánica.

A prospective protocol for the management of the airway was applied to patients in the ICU. Acute complications due to intubation and tracheotomy as well as laryngo-tracheal lesions were studied in 125 consecutive patients during one year from the moment of extubation. Thirty four cases (27%) needed reintubation, and 58 tracheotomies were performed (46%). The average length of intubation was of 10 +/- 7 days. Sixty five patients (53%) had acute complications due to intubation and 30 (52%) had acute complications due to the traccotomy. The high incidence of laryngo-tracheal lesions in the 85 patients who underwent early exploration (76 cases [90%]) was reduced in those who underwent late exploration (11 cases [20%]). Analysis of possible prognostic factors in the development of late lesions allows us to affirm that a reduction in the length of intubation diminishes the presence of late lesions. We recommend the avoidance of oro-tracheal intubation prolonged for more than 10 days by the early carrying out of tracheotomy.

[Post-mortem study of laryngotracheal lesions produced by prolonged intubation and/or tracheotomy]. / Estudio necrópsico de las lesiones laringotraqueales por intubación prolongada y/o traqueotomía.

Injuries of the laryngotracheal axis caused by prolonged intubation in critically ill patients raise the issue of the timing of tracheotomy in intubated patients. In 1992 a prospective study was begun in intensive care patients with intubation lasting more than 48 hours. Eight months later, post-mortem data on the laryngotracheal axis of deceased patients was added to our prospective study protocol. The study was closed with 125 cases (52 deceased). The clinical data of 73 surviving patients was compared with that of 18 post-mortem cases. The macroscopic results of the post-mortem study are summarized by grading the lesions according to a personal modification of the Lindholm classification. All cases had laryngotracheal injuries. Only 15% of the lesions were located in the tracheal region. Five cases were classified as grade 2, with an average orotracheal intubation of 9 days, 9 cases as grade 3 with 15 days intubation, and 4 cases as grade 4 with 21 days intubation. We concluded that the severity of laryngotracheal injuries in the early post-mortem exploration was related with the duration of intubation.

[Grading system for nasosinusal polyposis treated by functional endoscopic surgery]. / Sistema de estadiaje de la poliposis nasosinusal tratada mediante cirugía endoscópica funcional.

A system for grading nasosinusal polyposis treated by functional endoscopic sinus surgery is needed. We propose our CER system, which was designed for easy use and reliable classification of polyposis involvement. Four levels, from zero to four, are added as suffixes to three letters. These levels indicate increasing intensity and are used to categorize the clinical (C), endoscopic (E) and radiological, (R) grade of polyposis. The same system was used for postoperative follow-up and criteria were established for defining the surgical result as good, average, or poor.

[Lesions of the laryngotracheal axis due to prolonged intubation and/or tracheotomy. Preliminary data of a follow-up guidelines]. / Lesiones del eje laringotraqueal por intubación prolongada y/o traqueotomía. Datos preliminares de un protocolo de seguimiento.

Lesions caused by prolonged intubation and tracheostomy when performed in critically ill patients to keep the airways opened are a permanent topic of discussion between intensive care professionals and otolaryngologists. We present a prospective study of such complications following the guidelines elaborated by the intensive care unit and the otolaryngology department of our hospital. The outcomes obtained in the first-year follow up allow us to verify a high incidence of such lesions in the initial period (87%) and a markedly decreased frequency in the following twelve months (17%). Results also show the relation between prolonged intubation and the appearance of laryngotracheal lesions. We conclude that it is very important to reduce the intubation period by performing an earlier tracheostomy.