The forgotten turbinate: the role of the superior turbinate in endoscopic sinus surgery.

The fate of the middle turbinate in endoscopic sinus surgery has been a subject of debate for some time. The superior turbinate's role, however, has been largely passed over. Past anatomic descriptions and illustrations have given surgeons the incorrect impression that this structure is well superior and out of the field of dissection. Injury to the superior turbinate may account for postoperative hyposmia. The superior turbinate also serves as a constant landmark for the sphenoethmoidal recess, and a limited resection allows the surgeon to identify and include the natural ostium of the sphenoid sinus in the sphenoidotomy. The embryology and anatomy of the superior turbinate are reviewed. An approach to the natural ostium of the sphenoid sinus from the lateral side of the middle turbinate, using the superior turbinate as a guide, is described.

Endoscopic sinonasal surgery in the management of primary headaches.

Primary headaches (migraine, cluster, tension-type) are common disorders thought to be unrelated to nasal and sinus abnormalities. We present data on 19 patients with refractory primary headaches in the absence of significant sinus symptoms. The majority of patients responded with decreased pain to office application of nasal anaesthesia. A high prevalence of sinonasal abnormalities was found on coronal CT scans. Seventy-nine per cent responded with either decreased pain severity or headache frequency after endoscopic sinonasal surgery. We discuss possible underlying mechanisms to explain these findings.

[Laparoscopy: access with open versus closed technique]. / Laparoscopia: accesso con metodo aperto verso chiuso.

Pneumoperitoneum in diagnostic or therapeutic laparoscopy can be achieved by an open or a closed technique. The authors, on the basis of their experience, compare both techniques, concluding that open method is safer, because of the lack of major complications observed in the closed method and with only few minor complications.

Pneumatized superior turbinate as a cause of referred migraine headache.

Three patients with typical (common) migraine unresponsive to conventional therapy were evaluated with complete otolaryngologic examination, diagnostic nasal endoscopy, and coronal sinus computed tomography (CT). Enlargement of the superior turbinate due to pneumatization, with accompanying mucosal contact, was found in each case. Application of topical or injected anesthetic to the superior turbinate lessened or relieved headache, and subsequent endoscopic sinonasal surgery succeeded in providing significant headache relief (follow-up of 6 to 14 months). This is the first report of superior turbinate variations/abnormalities causing migraine, or indeed any type of headache. A discussion of the mechanism of referred pain from mucosal contact is offered after a discussion of each case.

Sinus headaches reconsidered: referred cephalgia of rhinologic origin masquerading as refractory primary headaches.

Headache associated with acute sinusitis is a well-recognized entity; the diagnosis is easily made due to the associated nasal and sinus symptoms. However, the phenomenon of referred headache from chronic sinusitis or intranasal abnormalities or both without upper respiratory symptoms is not well understood. Only recently have the nasal and sinus cavities been adequately visualized by both the human eye and radiographic techniques; a fact that may account for the historic neglect in considering this region a factor in headache etiology. Modern techniques employed in the workup of sinusitis, namely the use of rigid nasal endoscopes and coronal-plane CT scanning, have greatly enhanced the clinician's ability to evaluate and diagnose pathology in this area. This report describes a series of patients presenting with various primary headache syndromes without significant nasal or sinus symptoms who failed to respond to conventional antiheadache therapy. On nasal endoscopic and coronal CT examinations, various intranasal and sinus abnormalities were found (either anatomic variations or subclinical inflammation). Medical and/or surgical therapy addressing the sinonasal pathology resulted in improvement in every case, ranging from decreased severity of attacks to total resolution of headaches. A model explaining the possible mechanism of referred vascular-type headache from sinus and nasal origin is proposed.

[Hemorrhagic necrotic acute pancreatitis: analysis of our case series in the light of the most recent diagnostic and therapeutic criteria]. / La pancreatite acuta necrotico emorragica: analisi della nostra casistica alla luce dei più recenti criteri diagnostici e terapeutici.

During the period between 1-1-1979 and 30-9-1992, 43 cases of hemorrhagic necrotic acute pancreatitis were referred to the authors' attention. Six patients were not operated, 12 underwent emergency surgery and laparotomy was postponed in 25 cases. The introduction of sophisticated diagnostic methods, such as Eco, CT, ERCP, intensive medical therapy and postoperative NPT have allowed a more rational surgical approach in terms of timing and extent to be adopted, operating on patients who are metabolically more stable. NPT is a useful tool in the latter postoperative stage. In the series of patients undergoing emergency laparotomy there was a mortality rate of 66%. The mortality rate fell to 16% in those patients in whom surgery was postponed.

Osteoma of the internal auditory canal. Case report and literature review.

Osteomas of the internal auditory canal are rare lesions, with only 12 reported cases in the world literature. Symptoms are those of eighth nerve compression, and include unilateral hearing loss and vestibular weakness, thus mimicking symptoms of acoustic neuroma. We report a patient with an osteoma of the internal auditory canal, along with a review of the literature. We note age and sex characteristics from the literature, give evidence of localized trauma as a possible etiologic factor for this lesion, and discuss the pitfalls of relying exclusively on magnetic resonance imaging in the workup of suspected retrocochlear lesions.

Referred headache of rhinogenic origin in the absence of sinusitis.

Nasal signs and symptoms commonly accompany cephalgia in some headache syndromes. Head pain associated with sinusitis is also fairly well-recognized. However, referred cephalgia of rhinogenic origin, in the absence of sinonasal symptoms or disease, is poorly understood. We report a case of a patient with chronic and severe headache for whom neurological and neurosurgical evaluation failed to reveal an etiology, but who possessed an intranasal anatomical variant (without sinusitis). Her headache resolved after endoscopic nasal surgery. We discuss the mechanisms of such referred pain, and the recent technological advances that made the diagnosis and treatment of this disorder possible.

[Our experience in tailoring definitive terminal colostomies and in the follow-up of such patients]. / Nostra esperienza nel confezionamento delle colostomie terminali definitive e nel follow-up di tali pazienti.

Between January 1983 and July 31, 1988 at the 1st Division of General Surgery of Cuneo S. Croce Hospital, 57 patients (33 m, 24 f) were subjected to abdomino-perineal amputation for rectal A.D.K. A definitive colostomy was fashioned for all patients. Neostoma complications were encountered in 33% of cases. 91% of patients completed the rehabilitative programme and 40% saw satisfactory results as regards the regularisation of the alvus and return to social life.

[Colorectal neoplasms in young patients]. / Neoplasie del colon retto in pazienti giovani.

The prognostic factors regarding colon-rectal cancers in the under-40s are examined. A personal series of 15 cases shows that the incidence of tumour recurrence is higher and the disease-free interval shorter than in patients not selected for age and that 5-year survival is much less. These results permit the hypothesis of greater aggressiveness in colorectal cancers in the young, something that justifies the severer prognosis by comparison with the elderly population.

[Acute mesenteric infarct. I. Identification of predisposing factors and definition of the criteria of "cautious clinical monitoring" of the main groups of patients at risk]. / Infarto mesenterico acuto. Nota I. Identificazione dei fattori predisponenti e definizione dei criteri di "monitorizzazione clinica cautelativa" dei principali gruppi di pazienti "a rischio".

On the basis of experience acquired through 11 cases of acute mesenteric infarction personally observed over a 10-year period (1-1-1978-31-12-1987) and on the basis of a review on the literature, the usefulness for the purposes of early diagnosis and consequent early treatment of monitoring the essential, typical biological and clinical parameters of patients at risk of acute mesenteric infarction are reported.

[Acute mesenteric infarct. II. Problems of early diagnosis]. / Infarto mesenterico acuto. Nota II. Problemi di diagnosi precoce.

The symptomatology and diagnostic procedure adopted in 11 cases of acute mesenteric infarction are examined. Stress is laid on the importance of early, aetiologically accurate diagnosis for the purpose of instituting profitable treatment. In order to comply with such needs it is essential to perform urgent selective arteriography and/or urgent laparoscopy which only with rare exceptions is carried out even in hospitals that should be better equipped.

[Acute mesenteric infarct. III. Therapeutic problems]. / Infarto mesenterico acuto. Nota III. Problemi terapeutici.

The treatment adopted in 11 cases of acute mesenteric infarction is described: 6 cases involved arterial occlusion due to embolism and 5 arterial occlusion due to thrombosis. Six explorative laparotomies, 4 intestinal resections and one embolectomy of the superior mesenteric artery were carried out. Mortality was 63%. Stress is therefore laid on the need for very early, etiopathogenetic accurate diagnosis so as to commence treatment during the phase of reversible ischaemic intestinal lesion, targeting treatment to the cause of the ischaemia. The problem of the postoperative treatment problem is then discussed with special regard to the treatment of shock, the prevention of recurrences and the short intestine syndrome.

[Importance of preoperative monitoring in a case of hypochloric and hypokalemic dehydration subsequent to upper intestinal occlusion, caused by biliary ileus]. / Importanza del monitoraggio pre-operatorio in un caso di disidratazione ipocloremica ed ipokaliemica conseguente ad occlusione intestinale alta, da ileo biliare.

A personally observed case of biliary ileus triggers this description of its clinical features, blood chemical and diagnostic aspects and surgical treatment. Emphasis is placed on the importance of the preoperative rehydration and restoration of the electrolyte balance in patients with upper intestinal occlusion which reduces the risk involved in subsequent surgery.

[Heterotopic autotransplant of the spleen after splenectomy in traumatic rupture. Personal experience and scintigraphic follow-up]. / L'autotrapianto eterotopico di milza dopo splenectomia per rottura traumatica. Esperienza personale e follow-up scintigrafico.

Certain aspects of OPSI (Overwhelming Post-Splenectomy Infection) are examined, mainly its considerable gravity, its relatively high incidence, especially in children; its difficult prophylaxis with a report on personal experience of ectopic autotransplant of spleen tissue in two young patients after splenectomy for traumatic rupture. The technique was found to be simple and quickly performed. Scintigraphic follow-up for over 4 years after the operation showed satisfactory growth in the transplanted spleen tissue.