What are the advantages of the endoscopic canine fossa approach in treating maxillary sinus aspergillomas?

Aspergilloma of the maxillary sinus is a non-invasive mycotic infection of the immunocompetent host. Nowadays its treatment remains surgical removal, and endoscopic endonasal middle meatus antrostomy is retained as the most popular approach. In our experience, a complementary endoscopic canine fossa approach is often needed to achieve a complete resection of the fungus ball. This fact led us to ask ourselves if an isolated endoscopic canine fossa approach had any advantages over the endonasal middle meatus antrostomy. In this paper we retrospectively analyse the results of the surgical treatment of 31 patients presenting maxillary sinus aspergillomas. These patients were all operated between January 1997 and January 2003 in our Otolaryngology Department. They were divided in three groups. Group A included 10 patients operated through an endonasal middle meatotomy only, group B included 9 patients who were operated through a combined approach (endonasal middle meatus antrostomy and endoscopic canine fossa approach), and group C included 12 patients who were operated through an endoscopic canine fossa approach alone. No recurrences were noted in any group, but in group B three patients presented mild complications like persistent purulent discharge through the meatotomy and nasal crusting. The endoscopic canine fossa approach offers several advantages over other techniques. These include an optimal visualization of all maxillary sinus walls and recesses, the possibility of performing the procedure under local anaesthesia and on an outpatient basis, the preservation of the anatomy and physiology of the natural maxillary ostium and an easy removal of the eventual foreign bodies of dental origin in the sinusal cavity that could favourite the development of an aspergilloma.     

Antrochoanal polyp and obstructive sleep apnoea in children

Antrochoanal polyps were first documented in the 18th century. They represent one of the most common types of nasal polyps in children without cystic fibrosis. Only a few reports on children who had a history of snoring due to an antrochoanal polyp and only two cases where the antrochoanal polyp caused documented obstructive sleep apnoea (OSA) have been published so far. This report adds a third case of paediatric OSA induced by an antrochoanal polyp in a 12-year-old boy. After endonasal endoscopically-controlled polypectomy and a recurrence, transoral osteoplastic antrotomy in combination with endoscopic endonasal polypectomy eliminated the antrochoanal polyp and OSA was resolved. The authors have reviewed essential historical aspects about children suffering from snoring and/or OSA caused by an antrochoanal polyp.     

Sphenochoanal polyp: report of two cases

OBJECTIVE: Report of 2 cases of sphenochoanal polyp. MATERIAL AND METHOD: We present two cases of sphenochoanal polyp aged of 22 and 53. They were operated by endonasal endoscopic approach. They are still free of symptoms and no recurrence are observed after 13 and 56 months of follow-up. CONCLUSION: The clinical, radiological and pathological features of the sphenochoanal polyp are reviewed. Different etiopathogenic hypothesis are discussed and particular the gastroesophageal reflux. The treatment is surgical.     

Intranasal ethmoidectomy in nasal polyposis in children. Indications and results.

Nasal polyposis in children is a rare pathology that is difficult to treat, with results that are often disappointing. The aim of this paper is focused on the surgical possibilities of ethmoidectomy by endonasal approach. Thirty-nine ethmoidectomies were performed in 24 children with a mean age of 12 years (cystic fibrosis, n = 7; Woakes' syndrome, n = 2; isolated polyposis, n = 15). The decision for surgical treatment was based upon the severity of initial symptoms, principally nasal obstruction, lack of improvement after medical treatment, and the assurance of good surgical follow-up. Twenty-three children were followed up for a mean of 3 years. Complete recurrence was noted in 13% of the cases (n = 3). In all the other cases, including those with partial recurrence, the lives of the children were transformed. Ethmoidectomy by endonasal approach is reliable if the appropriate surgical techniques are strictly followed. It has proven its efficacy in children with nasal polyposis with results that are very encouraging compared to previously proposed therapies.     

Paranasal sinus mucoceles: surgical management and long term results

BACKGROUND: The aim of this study was to determine the best surgical approach in the treatment of paranasal sinus mucoceles according to their localization. MATERIAL AND METHODS: A retrospective analysis was carried out in 255 patients with 290 sinus mucoceles who were treated surgically at the ENT-Department of the Hospital Fulda gAG between 1983 and 2001. This series include 125 frontal sinus, 23 frontoethmoid, 41 ethmoid, 72 maxillary sinus and 26 sphenoid mucoceles. The patients' history, presenting symptoms, radiological findings, and surgical management were reviewed. Of them, 185 patients were followed by endoscopic and CT or MRI control during a period of up to 19 years, median follow-up was 12 years. RESULTS: In 168 out of 255 patients (66 %) the mucoceles were arisen due to previous sinus surgery, in 37 cases (14 %) after traumatic lesions, in 5 patients (2 %) due to chronic sinusitis and in 2 cases (<1 %) according to tumors. In 43 cases (17 %) no causes were found. In 78.8 % the previous operation was performed via an external approach, either according to Jansen/Ritter or Caldwell-Luc, contrary to 1.5 % after endonasal surgery. The median period until mucocele appearance was 15 years for maxillary sinus, 13 years for frontoethmoid, 10 years for ethmoid, and 8 years for frontal and sphenoid sinus celes, respectively. 201 mucoceles (69.3 %) have been operated endonasal micro-endoscopically, 18.6 % via the osteoplastic approach, 10 % endoscopically combined with an osteoplastic procedure and only 2 % according to Jansen/Ritter. Thereafter, recurrence of mucoceles was found in 4 patients only ( = 2.2 %; related to the endonasal approach = 1.6 %). CONCLUSION: Frontoethmoidal, ethmoidal, sphenoidal and maxillary sinus mucoceles are excellent indication for exclusively endonasal micro-endoscopic surgery. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located frontal or maxillary sinus mucoceles.     

Cuerpos extraños en seno maxilar

IntroductionForeign bodies in maxillary sinus (FBMS), whatever their origin or nature, are an unusual clinical condition. Diagnosis is based on the radiological findings in a clinical context of unilateral chronic rhinosinusitis. Treatment is the surgical removal of the intrasinusal foreign body.Patients and methodsTo identify FBMS, the records of 68 patients with unilateral chronic rhinosinusitis operated on from 2000 to 2007 were reviewed.ResultsFrom 68 records reviewed, we found 11 (16 %) FBMS. Ten (91 %) of these 11 foreign bodies were thought to come from the teeth and the last 1 (9 %) had a non odontogenic origin. Eight of the 11 (73 %) patients with FBMS presented with chronic maxillary sinusitis symptoms and all patients showed radiological findings. Treatment was the surgical removal of the foreign body, in 9 (82 %) patients through endonasal approach by functional endoscopic sinus surgery (FEES) and in the other 2 (18 %) patients a mixed surgical procedure by endonasal meatotomy and oral antrotomy was required.ConclusionsChronic maxillary sinusitis showing FBMS is rare and it must be suspected with a prior history of dental procedures. The most frequent source of FBMS is material of odontogenic origin, and non-odontogenic origin secondary to an external injury in an accident or assault is much more unusual. We also review the nature of these foreign bodies, their clinical implications and treatment options.     

Sphenochoanal polyp: endoscopic surgery

Sphenochoanal polyp is a rare entity originating from sphenoid sinus. It may be confused with antrochoanal polyp on anterior rhinoscopy because of its similar appearance. Computerized tomography and nasal endoscopy have contributed to an increase of accuracy in the diagnosis of these masses. Simple polypectomy that leaves some part of the polyp inside the sphenoid sinus carries a high risk of recurrence. Destructive external approaches to gain access to the sphenoid sinus are also not advisable in children for a benign disease. We present two cases of sphenochoanal polyps in two children that were operated by endonasal endoscopic approach. They were free of symptoms after surgery. No complications and recurrences were observed at 28 and 18 months of follow-up periods respectively.     

歪鼻矫正术两种术式的探讨

目的 比较部分歪鼻（鼻中隔偏曲伴鼻梁歪斜）矫正术的两种术式，探讨鼻外径路术式的适应证。方法 选择58例鼻中隔偏曲伴软骨锥偏斜的患者，37例行鼻外径路矫正术，21例行鼻内径路矫正术，其中6例在鼻内镜辅助下。结果 鼻外径路术式治愈22例，有效31例；鼻内径路术式治愈4例，有效9例。两种术式的疗效经卡方检验，有统计学意义（P〈0．01）。提示在本组病例中，鼻外径路术式的疗效优于鼻内径路术式。结论 鼻外径路术式适用于鼻中隔框架亚区的畸形纠正。     

Nasal endoscopic repair of cerebrospinal fluid rhinorrhea

The surgical management of Cerebro-spinal Fluid (CSF) rhinorrhea has been modified these last years due to the improvement of endoscopic sinus surgery techniques allowing the treatment of selective dural tears by the endonasal route. Over a period of 6 years, 27 patients with CSF rhinorrhea were operated on by the endonasal approach under optical guidance. CSF rhinorrhea was due, in 20 cases, to surgical iatrogenic trauma, in 4 cases to head injury, and in 1 case it was secondary to a conservative medical treatment of a pituitary adenoma. In 2 cases the cause was unknown. The average follow-up in this series was 24.7 months. The technique used was successful in 22 patients (81.5%). Considering these results and others reported in the literature, we think the use of the endonasal approach with optical guidance should always be considered as a valuable alternative to open surgery and should be discussed in all cases of CSF rhinorrhea with neurosurgeons.     

Juvenile angiofibromas: changing surgical concept over the last 20 years

OBJECTIVES: Nasopharyngeal angiofibroma is a rare tumor. Several surgical approaches have been established, including transpalatal, lateral rhinotomy, craniofacial, and midface degloving procedures. More recently, less invasive endonasal approaches have been used. In a retrospective study, we analyzed the outcome of surgical treatment for angiofibroma to determine whether an endonasal approach was as effective as other, more invasive techniques for removing the tumors. METHODS: Thirty patients with histologically confirmed angiofibromas were treated by surgical removal at two institutions during a 20-year period. Tumors were staged according to size and extension on the basis of imaging and surgical findings using the Fisch classification. Specific analysis of the operative approaches and recurrence rate by stage were included. Recurrent or residual disease was handled by surgical excision. RESULTS: The number of patients treated increased during the last 10 years in both institutions, but no major changes in distribution of tumor stages were observed. In the most recent years, the endonasal approach has been favored. All 30 patients remain alive and free of disease. CONCLUSIONS: During the last 12 years, we have undergone a marked shift toward endonasal procedures while the tumor stages of the patients treated remained the same. Our results demonstrate that angiofibromas may be managed successfully using less invasive techniques, thereby reducing morbidity, without increasing the chance of recurrence.     

Surgical strategy in paranasal sinus mucoceles

INTRODUCTION: The aim of this retrospective study is to describe the surgical management of paranasal sinus mucoceles. MATERIALS & METHODS: In the period from 1981 through 2000, 45 patients were treated for symptomatic mucoceles. The mucoceles were most frequently found in the anterior ethmoidofrontal system. 13 patients were operated via a bicoronal transfrontal extradural approach. A complete marsupialization under endonasal endoscopic control was performed in 21 cases. Eleven patients were operated via a trans-facial approach. RESULTS: The follow up period was 4.7 years (2 to 15 years) on average for endonasal approaches and 11 years on average (2 to 20 years) for the other approaches. All patients were free of complaints immediately after the operation. Nine cases were lost to follow-up. Cysts recurred in 5 patients. CONCLUSION: We recommend an endoscopic approach to the treatment of mucoceles as the surgical procedure of choice. In high and lateral extended frontal mucoceles, a trans-frontal extradural approach is still recommended. Long term follow-up is necessary to obtain an accurate assessment of the results.     

Endonasal carbon-dioxide laser assisted dacryocystorhinostomy verses external dacryocystorhinostomy

This is a prospective, non-randomized study to evaluate and compare the results, morbidity and surgical time for endonasal carbon-dioxide laser assisted dacryocystorhinostomy and external dacryocystorhinostomy. 70 consecutive patients of chronic dacryocystitis with nasolacrimal duct obstruction were selected for the study. 36 patients under went endonasal CO2 laser assisted dacryocystorhinostomy and 34 had external dacryocystorhinostomy. Selection of the type of operation was left to the patient's choice. All the patients had preoperative counseling and both the procedures were explained in detail with their advantages and disadvantages. Patients not willing for the external incision were selected for endonasal laser assisted dacryocystorhinostomy and others were operated via external approach. Silicone tubes were put in all the patients for three months after surgery. The final follow up was 12 months after the removal of silicone tubes. The patency of the lacrimal passage was confirmed by irrigation, and patients were questioned about their symptoms. The success rates, 12 months after removal of silicone tubes were 100% in endonasal CO2 laser assisted dacryocystorhinostomy and 88.24% in external dacryocystorhinostomy. The surgical time of endonasal laser assisted dacryocystorhinostomy was 38 minutes as compared to 62 in external dacryocystorhinostomy. Complication rate in both groups was almost equal. Thus, we came to the conclusion that Endonasal CO2 laser assisted dacryocystorhinostomy is a better surgical option to external dacryocystorhinostomy in cases of chronic dacryocystitis with nasolacrimal duct obstruction, with shorter surgical time.     

Zum chirurgischen Behandlungskonzept bei invertierten Papillomen der Nase und Nasennebenhöhlen

Introduction

Inverted papillomas require radical resection because of their high recurrence rate and expansive growth and the risk of malignant degeneration. Since the late 1980s surgical resection has been performed predominantly as an endoscopy-/microscopy-aided procedure through an endonasal approach. The extranasal approach is only used in the case of papillomas in unusual locations or ones that have expanded to an exceptional degree. The goal of the present study was a comparative evaluation of the results of this relatively new treatment strategy and of external sinus surgery in our own patients, with particular reference to the recurrence rate.

Patients and methods

Since 1989 a total of 80 patients have undergone surgery for inverted papilloma and have been followed up at regular intervals by means of endoscopic examinations. In any patients with a recurrence the revision operation was carried out through an extranasal approach when the papilloma was in the anterior or laterocaudal maxillary sinus or in the frontal sinus; in all other cases an endonasal approach was used for the revision surgery. The mean period of follow-up was 43 months (range 15 months to 16years).

Results

In most patients (n=64, 80%) the endonasal surgical approach was used for the primary surgical treatment, while in 16 patients (20%) an extranasal approach was used initially. In 2 patients (2.6%) a squamous cell carcinoma was discovered adjacent to the papilloma. These two therapeutic special cases were not considered evaluable in the analysis of recurrences. Recurrences were seen in 14 patients (17.9%, n=78), in 11 patients after endonasal surgery (17.5%, n=11) and in 3 (20%, n=15) after extranasal resection. The majority of recurrences developed in patients with T3 papillomas.

Conclusions

The recurrence rates observed after endonasal resection are comparable to those after extranasal surgery. Thus, a primary endonasal approach does not mean any prognostic disadvantage. This approach should therefore be given preference over extranasal approaches whenever possible, because there are fewer side-effects and recovery is faster than after extranasal surgery.     

Long-term results of endonasal sinus surgery in sinonasal papillomas

OBJECTIVE: To assess the value of endonasal sinus surgery in the management of sinonasal papillomas. STUDY DESIGN: Retrospective study including 43 patients operated on for sinonasal papilloma in a long-term follow-up. METHODS: In 26 cases (60%) an endonasal approach, in eight cases (19%) an external approach, and in four cases (9%) a combined procedure was performed to remove these tumors. Five septal lesions (12%) were resected under direct vision. The original sections and charts of all patients were reviewed to assess clinical data. Follow-up information was available for 42 of our patients (98%) with a mean follow-up of 62 months. RESULTS: Histologic examination revealed 34 cases of inverted papilloma (79%), five cases of exophytic papilloma (12%), and four cases of columnar cell papilloma (9%). Malignancy occurred in 4 of 43 patients (9%), and recurrences developed in 8 of 42 patients (19%). Two of these recurrences happened after endoscopic sinus surgery (two inverted papillomas), three after lateral rhinotomy (three inverted papillomas), one after a combined procedure (one inverted papilloma), and two after simple resection (two exophytic papilloma). CONCLUSIONS: In keeping with our experience, the endonasal endoscopic approach, often in combination with a medial maxillectomy, is favored for the treatment of sinonasal papilloma because of a lower recurrence rate and a better cosmetic result. In some larger tumors and lesions in difficult locations, better visualization can be obtained by a combined external and endonasal approach.     

Endonasal micro-endoscopic resection of sinonasal inverted papilloma

BACKGROUND: The goal of this study was to assess the potentials and limitations of endonasal micro-endoscopic surgery in the treatment of sinonasal inverted papilloma (IP) and to demonstrate long-term results. PATIENTS AND METHODS: From 1989 to 2005, 64 patients underwent resection of IP via an endonasal approach using either the endoscope or microscope. Charts were reviewed retrospectively for presenting symptoms, radiological and intraoperative data. All patients were followed by endoscopic and MRI control during a period of up to 174 months, median follow-up was 78 months. RESULTS: Our study group consisted of 26 male and 38 female patients with an average age of 54.3 years. The majority of the patients (67 %) complained of unilateral nasal obstruction. 52 patients (81 %) were referred for primary surgery. In 12 cases (19 %) recurrent tumors were operated. According to the Krouse classification for IP the tumors were staged as T1 = 11 (17 %) cases, T2 = 37 (58 %) and T3 = 14 (22 %). In two patients a squamous cell carcinoma was associated with an IP ( = T4 stage). Most tumors were localized within the nasal cavity (72 %) or the anterior ethmoid (62 %). In 10 patients an infiltration of the bony skull base was present. During the follow-up period 6 patients developed recurrencies corresponding to an overall recurrence rate of 9.4 %. CONCLUSIONS: The advances in endonasal micro-endoscopic surgery allow both safe and effective removal of IP with low morbidity, and therefore it should be the approach of the first choice. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located IP. Close follow-up is mandatory to ensure the surgical success.     

Endonasal approach for nasal and paranasal sinus tumor removal.

Patients with benign (53) and malignant (22) tumors of the nose and paranasal sinuses were treated for tumor removal via an endonasal approach. Patient selection was based on tumor location (centrally) rather than histology. Tumors attainable by the endonasal approach were located in the nasal cavity, the ethmoid sinus, the sphenoid sinus and the medial wall of the maxillary sinus. Endonasal microscopic techniques including endonasal orbital decompression and endonasal closure of CSF-leaks were combined with surgical navigation tools in selected cases. Surgical trauma and morbidity could be minimized without compromising radicality of tumor removal. Postoperative hospitalization was comparable to the period needed after chronic inflammatory disease. Growing experience with endonasal techniques is leading towards a safe and effective treatment option for centrally located, selected tumors of the nose and paranasal sinuses.     

Endonasal surgical treatment of bilateral choanal atresia under optic control in the infant

The authors discuss the different approaches in surgical treatment of choanal atresia. They describe a method of endonasal approach under optic control. In this method an opening in the bony atresia is made via the nasal cavity with the aid of a surgical microscope and micro-instruments, while the posterior wall of the atretic plate is observed by means of a 110 degrees endoscope via the nasopharynx. This method is illustrated by a clinical case, with a four year follow-up.     

Endoscopic treatment of antrochoanal polyps

The antrochoanal polyp (Killian polyp) is an infrequent, benign neoplasm, which arises from the maxillary sinus to reach the ipsilateral choana. The treatment of this disease is essentially surgical, by means of a wide antrostomy. The aim of the study was to compare the results obtained on 23 consecutive cases of antrochoanal polyps endoscopically treated between February 1997 and January 2000 with those reported in the literature, with particular regard to the surgical technique adopted, the histological features, the patterns of its development and the clinical outcomes. The histology revealed in most of the cases a cystic aspect surrounded by edematous stroma. In all cases the polyp emerged from the middle meatus, mostly starting from the upper-lateral (zygomatic) wall of the antrum. All patients were endoscopically followed-up for an average period of 39 months (17–61). We observed two recurrences, both in pediatric cases who evidently underwent an incomplete surgical removal of antral mucosa at its inferior aspect, probably due to the fear of damaging the teeth buds. We did not observe any postsurgical complication. Our data indicate the endoscopic middle meatal antrostomy as the optimal approach, also for the revision cases and in children.     

Antrochoanal polyp: a comparative study of endoscopic endonasal surgery alone and endoscopic endonasal plus mini-Caldwell technique

Antrochoanal polyp (ACP) originates in the maxillary sinus. To diminish the regrowth rate of choanal polyp, a complete removal of the antral portion and its attachment is necessary. There are several methods for this purpose, but in this study two techniques were comparatively investigated. This retrospective study was conducted by analyzing the database of 40 operated patients for ACP, 19 of whom underwent an endoscopic endonasal removal of polyps and 21 experienced endoscopic endonasal surgery with mini-Caldwell operation. The two techniques were compared with regard to their complications and regrowth rate. It emerged that post-operative complications (bleeding, synechia, ostia stenosis) in both groups were mild and there was not any significant difference between the two groups. Out of 19 cases in the endoscopic endonasal surgery group, 4 had recurrences, while in the mini-Caldwell group we had no recurrence. (P = 0.042)). This result implies that, in order to prevent incomplete excision and recurrences, combined approaches (endoscopic endonasal surgery and mini-Caldwell) should be considered, particularly when the attachment site of the antral part of ACP is undetected.