Prelacrimal window approach to the maxillary sinus: a systematic review and meta-analysis of the literature.

BACKGROUND: The prelacrimal window approach (PLWA) is a minimally invasive surgical technique that has been proposed as an alternative to the traditional approaches to access the maxillary sinus. METHODOLOGY: A systematic review with meta-analysis was performed following PRISMA guidelines and identified 368 articles for initial review of which 14 (610 participants) met the criteria for meta-analysis. Four databases, including PubMed, Google Scholar, Web of Science and Scopus, were searched to identify relevant articles. Two independent reviewers conducted the eligibility assessment for the included studies. Methodology quality and risk of bias were evaluated by New Castle Ottawa scale. The outcomes assessed were recurrence of the pathology, postoperative morbidity including epiphora, dry nose, facial, gingival numbness, epistaxis or local infection. RESULTS: The present data suggest a significant reduction in the recurrence rate of maxillary sinus pathology following PLWA when compared to conventional surgery (endoscopic medial maxillectomy, endoscopic sinus surgery and the Caldwell-Luc operation). The rates of epiphora, facial or gingival numbness, epistaxis or infection requiring intervention, were not significantly different between the procedures. CONCLUSIONS: Maxillary sinus pathology can be effectively treated using the PLWA technique, as it has been shown to result in a lower recurrence rate compared to conventional surgeries.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall.

BACKGROUND: The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip. METHODOLOGY: Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the 'shoulder' of the inferior turbinate and the pyriform aperture. RESULTS: The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78 ± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the 'shoulder' of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides. CONCLUSIONS: We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

[Negative effects of stripe conchotomy on intranasal conditioning]. / Negative Auswirkungen der Streifenconchotomie auf die intranasale Klimatisierung.

OBJECTIVE: Partial resection of the caudal part of the inferior turbinate including the head is still performed in rhinosurgery ("stripe conchotomy"). However, extensive resections of the turbinate affect nasal airflow and intranasal conditioning. The aim of this study was to determine the effect of partial resection of the inferior turbinate including its head on intranasal air flow as well as warming and humidification of the inspired air by means of computational fluid dynamics. MATERIALS AND METHODS: A bilateral, realistic nasal model was created based on the CT scan of a patient. A unilateral partial resection of the lower turbinate on the right side had been performed externally. A numerical simulation was performed to analyze intranasal air flow patterns, temperature, and humidity distribution of the inspired air. RESULTS: Due to the partial resection of the lower turbinate on the right side, the flow pattern was significantly altered compared to the opposite side. Resection leads to a centered and higher velocity in the inferior nasal meatus as well as to reduced heating and humidification of the inhaled air compared to the untouched left nasal cavity. CONCLUSION: Partial resection of the caudal part of the inferior turbinate may lead to disturbed intranasal conditioning of inspired air if performed too radically. Therefore, if possible, this procedure should be avoided and a more gentle mucosal procedure chosen.

Long-term results after restoring nasal tip support using auricular cartilage as an intercrural columellar strut graft: the "I-Beam" technique.

BACKGROUND: The lack of nasal tip support resulting in poor protection and projection of the nose is a common cause of nasal obstruction and cosmetic impairment. Although septal cartilage is preferred for restoration of nasal tip support, there is often not enough septal cartilage available. We describe an intercrural columellar strut graft in a circumferential soft tissue pocket: the I-Beam technique. METHODOLOGY: In this cohort study over an 8-year period the clinical and biometrical long-term results after restoration of nasal tip support with an autologous auricular cartilage graft, the I-Beam technique, is evaluated. RESULTS: Out of the 72 consecutive septorhinoplasties with the I-Beam technique, we studied 66 patients in the median long-term follow-up of 89 months. In all patients a significant improvement in nasal tip projection was found. A functional improvement in nasal breathing was achieved in 86%. The overall satisfaction with the I-Beam graft was of 83%. No deterioration in smell perception was found after surgery. CONCLUSIONS: The I-Beam technique using back-to-back sutured autologous auricular cartilage is a safe and effective technique and gives long-term structural support and enhances tip projection.

Anatomy of the sphenopalatine artery and its implications for transnasal neurosurgery.

BACKGROUND: The knowledge of sinonasal vasculature is inevitable in transnasal neurosurgery. We performed an anatomical study on the sphenopalatine artery from the perspective of skull base procedures. METHODOLOGY: To analyse the anatomical landmarks of the sphenopalatine artery, arterial skull corrosion casts (26 head halves) underwent endoscopic transnasal phantom surgery. Furthermore, we performed microsurgical dissection on formaldehyde-fixated cadavers with arterial perfusion (14 head halves) as well as studied Cone Beam CT-scans of anonymised patients and cadavers (115 head sides). RESULTS: In our cadaveric material, the sphenopalatine foramen is located at the transition of the superior and middle nasal meatus (95.0%) or in the superior nasal meatus (5.0%). It is the main entry point of the branches of the sphenopalatine artery into the nasal cavity. In most cadaveric cases (25.0%), at this level there are 2 branches superiorly and 1 vessel inferiorly to the ethmoid crest. An average of 2.4 vessels leave the sphenopalatine foramen superiorly to the ethmoid crest, 97.8% of them belong to the sphenopalatine arterys posterior septal branches. An average of 2.1 branches leave the sphenopalatine foramen inferiorly to the ethmoid crest; all of them belong to the posterior lateral nasal branches. There are no cases with a single artery at the plane of the sphenopalatine foramen. We describe a triangular bony structure bordering the sphenopalatine foramen anteriorly which is built up by the palatine and ethmoid bone as well as the maxilla. According to the radiographic studies, this triangular prominence is surrounded superiorly by a posterior ethmoid cell (57.4%), the sphenoid sinus (41.7%) or the orbit (0.9%) with a varying contribution of the superior nasal meatus; inferolaterally by the maxillary sinus (98.3%) or the pterygopalatine and infratemporal fossa (1.7%) and inferomedially by the middle nasal meatus. The medial vertex of the bony triangle corresponds to the ethmoid crest of the palatine bone. In transnasal endoscopic surgery, the posterior lateral nasal branches of the sphenopalatine artery appear at the triangle's inferomedial edge, the posterior septal branches emerge at its superior edge. CONCLUSIONS: The triangular bony structure is a landmark to find and differentiate the posterior lateral nasal and posterior septal branches of the sphenopalatine artery and to identify the sphenoid sinus.

Anterior maxillary wall and lacrimal duct relationship - CT analysis for prelacrimal access to the maxillary sinus.

BACKGROUND: The distance between the anterior wall of the maxillary sinus and the nasolacrimal duct shows a large individual variation. METHODOLOGY: To evaluate the feasibility of accessing the maxillary sinus through a prelacrimal window access (PLWA), a series of 100 paranasal CT scans from adult patients was analysed retrospectively. The distance between the anterior maxillary wall and the anterior border of the lacrimal duct (= prelacrimal window) were measured in 200 sides. RESULTS: A distance of more the 7 mm was found in 12.5% maxillary sinuses and would enable straight forward PLWA. A distance between smaller than 7mm and larger than 3mm was present in 56.5% of sinuses, and would make surgical access more demanding. In 31.5% of maxillary sinuses the distance was smaller than or equal to 3mm and in these patients this approach would be difficult without transecting the nasolacrimal duct. CONCLUSION: Only in 12.5% of sinuses a prelacrimal endoscopic access is readily feasible, while in 56.5% temporary tear sac dislocation is required and in 31.5% lacrimal sac dislocation is always needed along with a significant amount of bone removal to enable PLWA.

[Advances in the surgical treatment of tumors of the pituitary region : rhino-neurosurgical transnasal endoscopic surgery]. / Fortschritte in der chirurgischen Behandlung von Tumoren der Hypophysenregion : Rhinoneurochirurgische transnasale endoskopische Operationstechnik.

Conventional microscopic surgery of pituitary adenomas offers excellent results with regard to local tumour control and endocrine function. Overall patient morbidity and mortality is low. However, recent studies demonstrate further improvements in tumour resection control and more favourable endocrine/ophthalmologic results when endoscopic techniques are applied, as well as an overall reduction in peri-interventional morbidity. Additionally, use of endoscopic techniques in rhino-neurosurgical cooperation achieved better specifically rhinologic results and improved subjective comfort for patients. The cooperative rhino-neurosurgical approach not only allows for optimal treatment of the primary pituitary pathology, but also treatment of additional nasal and paranasal pathologies, such as a deviated septum or disturbed drainage of the paranasal sinus.

Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training.

BACKGROUND: The aim of this multicentre study was to systematically analyse the strengths and weaknesses in the surgical training for endoscopic sinus surgery (ESS) and identify measures that may improve training. METHODOLOGY: Using a structured questionnaire, 133 participants of ESS courses in seven centres in Germany, Switzerland and Australia were asked about their experiences during their dissection courses and how they perceived their course could be improved. RESULTS: Gaining confidence in handling of instruments and endoscopes was only a problem for participants with little experience in ESS. The majority of the participants, independent from their level of training, considered infundibulotomy and anterior ethmoidectomy as the easiest dissection steps, whilst surgery of the frontal sinus posed a considerable challenge for many surgeons even those with a higher level of training. Participants with and without ESS experience thought that emphasis on anatomy was the most important improvement that could be made during their surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their surgical skills and their confidence when performing ESS. CONCLUSIONS: ESS dissection courses are considered beneficial by surgical trainees. Participants felt that more emphasis on sinus anatomy in conjunction with private study is essential to maximize their skills in surgical dissection. For beginners with ESS, an infundibulotomy and anterior ethmoidectomy were thought to be the best initial procedures to help develop endoscopic surgical skills.

Olfaction after endoscopic sinus surgery: long-term results.

Loss of olfactory function is one of the main symptoms in patients with chronic rhinosinusitis. This prospective, non-randomized interventional study reports five years results of olfaction of patients with chronic rhinosinusitis who underwent endoscopic sinus surgery in conjunction with topical medical treatment. Forty-five patients with chronic rhinosinusitis who underwent endoscopic sinus surgery were evaluated preoperatively, after three months and 34 (76%) of them after five years. Olfactory function was assessed by a subjective visual analogue scale, by a screening test of olfaction with Smell Diskettes and by measuring the N-Butanol threshold. Patient`s subjective sense of olfaction using a visual analogue scale was improved in 79% at 5 years. Objective measurements by Smell Diskettes improved in 53% at 5 years whilst the quantitative measurement by the N-Butanol threshold improved in 85% at 5 years. The high percentage of patients with improvement of olfaction five years after surgery indicates that endoscopic sinus surgery in conjunction with continued topical treatment leads to a long term improvement of the sense of smell. However, it was found that - measured by the sensitive N-Butanol threshold - up to 9% had no improvement and 6% had deterioration in their olfaction at 5 years after endoscopic sinus surgery. This fact has to be considered in the preoperative counselling of patients.

Limitations of balloon sinuplasty in frontal sinus surgery.

Balloon sinuplasty is a tool that is used to treat selected patients with paranasal sinus pathologies. No studies have investigated the aetiology of failed access to the frontal sinus. The aim of our study was to specify the intraoperative technical failure rate and to analyse the aetiology of the failed access to predict potential technical difficulties before surgery. We retrospectively analysed the charts of patients who underwent balloon sinuplasty from November 2007 to July 2010 at three different ENT-Centres. CT-analysis of the patients with failed access was performed. Of the 104 frontal sinuses, dilation of 12 (12%) sinuses failed. The anatomy of all failed cases revealed variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or agger-nasi-cell) or osteoneogenesis. In one patient, a lymphoma was overlooked during a balloon only procedure. The lymphoma was diagnosed 6 months later with a biopsy during functional endoscopic sinus surgery. In complex anatomical situations of the frontal recess, balloon sinuplasty may be challenging or impossible. In these situations, it is essential to have knowledge of classical functional endoscopic sinus surgery of the frontal recess area. The drawbacks of not including a histopathologic exam should be considered in balloon only procedures.

Breathing straws.

Following nasal, septal or endoscopic surgery, it is common practice to insert nasal packs in both nasal cavities to achieve haemostasis, if there has been any bleeding at the end of the procedure. However, such packs make it difficult for patients to breathe, mainly in the first post-operative night which leads to discomfort and poor sleep. To enable patients to breathe better with nasal packs in situ, we describe a simple technique using trimmed straws and wrapped Netcell packs for post-operative care following septal surgery, rhinoplasty and endoscopic sinus surgery. These packs also assist suction of any blood or mucous from the post-nasal space.

Nontraumatic skull base defects with spontaneous CSF rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients.

BACKGROUND AND PURPOSE: Defects at the skull base leading to spontaneous CSF rhinorrhea are rare lesions. The purpose of our study was to correlate CT and MR findings regarding the location and content of CSF leaks in 27 patients with endoscopic sinus surgery observations. MATERIALS AND METHODS: Imaging studies in 27 patients with intermittent CSF rhinorrhea (CT in every patient including 10 examinations with intrathecal contrast, plain CT in 2 patients, and MR in 15 patients) were analyzed and were retrospectively blinded to intraoperative findings. RESULTS: CT depicted a small endoscopy-confirmed osseous defect in 3 different locations: 1) within the ethmoid in 15 instances (53.6% of defects) most commonly at the level of the anterior ethmoid artery (8/15); 2) adjacent to the inferolateral recess of the sphenoid sinus in 7 patients including one patient with bilateral lesions (8/28 defects, 28.6%); 3) within the midline sphenoid sinus in 5 of 28 instances (17.9%). Lateral sphenoid defects (3.5 +/- 0.80 mm) were larger than those in ethmoid (2.7 +/- 0.77 mm, P < or = 0.029) or midsphenoid location (2.4 +/- 0.65 mm, P < or = 0.026). With endoscopy proven arachnoid herniation in 24 instances as reference, MR was correct in 14 of 15 instances (93.3%), CT cisternography in 5 of 8 instances (62.5%). Plain CT in 1 patient was negative. CONCLUSION: In patients with a history of spontaneous CSF rhinorrhea, CT was required to detect osseous defects at specific sites of predilection. MR enabled differentiating the contents of herniated tissue and allowed identification of arachnoid tissue as a previously hardly recognized imaging finding.

The surgeon's view of the anterior ethmoid artery.

OBJECTIVES: To define the relationship of the anterior ethmoid artery to the frontal recess and secondly whether the degree of pneumatisation of the suprabullar recess/supraorbital cell correlates with the distance between the anterior ethmoid artery and the skull base thus making it more vulnerable to damage during surgery. METHOD: Thirty-four cadaver head sides were perfused with pink latex. All specimens had high-resolution computed tomography (CT) scans using bone windows in the axial, coronal and sagittal planes. The specimen's nasal septum was removed and the ethmoid sinuses dissected to locate the anterior ethmoid artery. Calipers were used to measure distance between the artery and the frontal recess and from the skull base. RESULTS: The anterior ethmoid artery was found in all the specimens and scans. The distance between the anterior ethmoid artery and the posterior wall of the frontal recess was 11 mm (range 6-15 mm). In all specimens, the artery was seen between the second and third lamella. The commonest location of the artery was in the suprabullar recess (85.3%). Supraorbital cells were seen in 16 specimens. The ethmoid sinuses were well pneumatised with a large supraorbital cell in 10 of these specimens and in these the artery was lying 3.7 mm (range 1-8 mm) away from the skull base. Six specimens had poor pneumatisation and a small supraorbital cell and in these the artery was found close to or with in the skull base. In specimens without a supraorbital cell, the artery lay at the skull base in all but one. CONCLUSIONS: The position of the anterior ethmoidal artery is very variable. The artery is found between the second and third lamella. When the ethmoid sinuses are more pneumatised and in particular when there is a supraorbital cell, the artery lies below the skull base. A good strategy is to identify the degree of pneumatisation of the ethmoid sinuses from CT scans preoperatively to see if the artery is at an increased risk of being damaged.

Impaired sense of smell in patients with nasal surgery.

The aim of the study was to determine the incidence of olfactory disorders before and following nasal and paranasal sinus surgery. It was a prospective observational study. Over a 6-month period, all patients who had been listed for nasal and paranasal sinus surgery underwent preoperative and postoperative evaluation of their sense of smell. A questionnaire and the 'Smell Diskettes Test' were used to assess olfaction. One hundred and eighty-four patients were studied. Preoperatively, 19 patients (10.3%) had an impaired sense of smell (8.1% before septoplasty, 6.1% before rhinoplasty and 17.1% before endoscopic sinus surgery). Only 16 (84%) of these patients were aware of their impaired sense of smell. Following surgery, four patients (2.5%) who were normal preoperatively developed impaired olfaction on questioning, and this was supported by testing it. In the subgroup that had a septoplasty, no patient developed hyposmia compared to one patient (2.6%) after rhinoplasty and one patient (3%) after endoscopic sinus surgery. No patient developed anosmia. Preoperatively, 10.3% of patients had an altered sense of smell, making it desirable that this is documented in order to avoid postoperative claims that this was caused by surgery. It also helps to audit the results of surgery.

Prevention of acute mastoiditis: fact or fiction?

Acute mastoiditis is the most common complication of acute otitis media (AOM). In recent years routine antibiotic treatment for acute middle ear infections was questioned and even abandoned in some countries. The goal of our study was to investigate the influence of antibiotic treatment on the occurrence and clinical outcome of acute mastoiditis and to analyze the bacteriological findings. A retrospective case record study of 48 patients with 50 episodes of acute mastoiditis hospitalized at our tertiary-care center between 1992 and 1999 was performed. Twenty-three patients (48%) received antibiotic treatment before admission whereas 25 (52%) did not. The group of patients without antibiotic pretreatment were younger (mean, 6 years) than patients with antibiotics (mean, 18 years) and their referral was delayed. The most common isolated single pathogen was Streptococcus pneumoniae. All pneumococci were sensitive to penicillin. Acute mastoiditis may be the first clinical sign of a middle ear infection, especially in very young children. Adequate antibiotic pretreatment cannot invariably prevent the development of acute mastoiditis even in the absence of penicillin resistant pathogens.

[Does antibiotic therapy hinder the course of peritonsillar abscesses?]. / Verhindert eine antibiotische Therapie die Entstehung von Peritonsillarabszessen?

INTRODUCTION: Peritonsillar abscess (quinsy) is a complication of acute bacterial tonsillitis. In a prospective study, the influence of antibiotic therapy on the clinical course in patients with quinsy was analysed. METHOD: History and clinical signs in patients with quinsy referred to our hospital were assessed by a structured questionnaire. Pus was cultured under aerobic and anaerobic conditions. RESULTS: 40 patients were enrolled in the study, 18 of whom (45%) were treated with antibiotics prior to admission. There was no significant difference in history and clinical signs between the patients with antibiotics and the group without. The microbiological results showed a dominant role of anaerobic bacteria without significant difference between the two groups of patients. DISCUSSION: Antibiotic therapy did not prevent the occurrence of peritonsillar abscess in 45% of our patients and had no influence on the clinical course of the disease. A possible reason for these findings is that the onset of antibiotic therapy was too late in the disease process, or, in some cases, that an antibiotic drug with an inadequate antimicrobiological spectrum was chosen.

[Effect of antibiotics on the occurrence and course of acute mastoiditis]. / Einfluss von Antibiotika auf Entstehung und Verlauf der akuten Mastoiditis.

Acute mastoiditis is the most common complication of acute otitis media. In the last years routine antibiotic treatment of acute otitis media was questioned and even abandoned in some countries. The goal of our study was to investigate the influence of antibiotic treatment on the occurrence and clinical outcome of acute mastoiditis and to analyse the bacteriological findings. In a retrospective chart review we identified all patients with the diagnosis of acute mastoiditis who had been referred to our tertiary-care centre between 1992 and 1999. We identified 48 patients with 50 episodes. 23 patients (48%) had received antibiotic treatment before admission whereas 25 (52%) had not. The patients with antibiotic pretreatment were older (18 years) than patients without antibiotics (6 years) and their referral was delayed. The most common isolated single pathogen was Streptococcus pneumoniae. All pneumococci were sensitive to penicillin. Acute mastoiditis may be the first clinical sign of a middle ear infection, especially in very young children. Adequate antibiotic pretreatment can not always prevent the development of acute mastoiditis even in the absence of penicillin resistant pathogens.

[Screening of olfaction with smell diskettes]. / Screeningtest des Geruchssinnes mit Riechdisketten.

BACKGROUND: Aim of the study was the development of a new screening test of olfaction with reusable diskettes as odorant applicators. METHODS: A screening test of olfaction was designed using 8 diskettes containing different odorants. The diskettes can be opened to release the odor and are closed after testing. The test was designed as a triple forced multiple choice test using a questionnaire, resulting in a score from 0 to 8 correct answers. Ninety-one volunteers with a normal sense of smell and 13 patients with subjective hyposmia or anosmia were tested to validate the developed test. The same volunteers were also tested with the sniffin' sticks test, another screening test of olfaction that is already validated. After testing, the volunteers were asked to compare the two tests. RESULTS: Among the 91 volunteers with normal sense of smell, 10 achieved a score of 7, and 81 a score of 8 in the smell disk test. The 13 patients with hyposmia or anosmia achieved a score between 0 and 5. Based on the test design, there is a probability of 99.74% that a person who achieves a score of 7 or 8 will have normal olfaction. In the sniffin' sticks test, 85 volunteers with normal sense of smell achieved a score in the normal range for this test (6-8) whereas 6 volunteers were below with a score of 4 or 5. The 13 patients with hyposmia or anosmia scored between 0 and 6. The smell disk test was preferred by 86 persons, the sniffin' sticks test by 5, and 12 assessed both tests as equal. CONCLUSIONS: The developed screening test is reliable for identifying patients with a normal sense of smell, and it can distinguish them from patients with hyposmia and anosmia. The diskettes proved to be reliable and comfortable applicators for odorants in clinical practice.

Long-term results of surgery for temporal bone paragangliomas.

OBJECTIVES: Assessment of the long-term results of surgery for temporal bone paragangliomas with special consideration of the patient's ability to cope with the functional deficits. STUDY DESIGN: Retrospective review of 36 patients who had undergone resection of a temporal bone paraganglioma 10 to 15 years previously. Assessment of the patients' subjective view of the functional outcome and quality of life by a questionnaire. METHODS: Clinical records were reviewed regarding size of tumor, technique of surgery, supportive therapy, and tumor recurrence. Patients were sent a 50-item questionnaire evaluating their quality of life and the preoperative and postoperative function of cranial nerves VII through XII. RESULTS: A complete tumor removal was achieved in 30 patients (83%). There was only one tumor recurrence. The major negative effects of surgery involved hearing and dysphagia, which deterioriated in 14 and 12 patients, respectively. Thirty-five of the 36 patients (97%) reported that, despite deterioration, the cranial nerve deficits were still acceptable. Seventy-five percent of the patients regained their preoperative quality of life and 97% returned to their previous occupation in 1 to 2 years. CONCLUSIONS: The otologic extradural approach allowed complete tumor removal in 83%, with minimal perioperative morbidity. No surgically induced central nervous system lesions occured. Tracheostomy was avoided and all patients resumed oral feeding. Full rehabilitation after removal of class C and CD paragangliomas may take 1 to 2 years. However, the fact that 97% of the patients finally resumed normal social life showed the ability of most patients to cope with the sequelae of surgery even in class C and CD paragangliomas.