The efficacy of esmolol,remifentanil and nitroglycerin in controlled hypotension for functional endoscopic sinus surgery

IntroductionControlled hypotension is a reversible procedure in which the patient’s baseline mean arterial blood pressure is reduced by 30% and sustained at 60–70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures.ObjectivesThe purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency.MethodsThe research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon’s satisfaction.ResultsBetween May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15–51), 43.0 mL (21–105) and 40.0 mL (26–97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon’s satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001).ConclusionLess volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients’ characteristics and advantages/disadvantages of the drugs.     

Endonasal endoscopic oncologic resection and reconstruction of the anterior skull base in the elderly: A single-center retrospective study

IntroductionIn old and frail patients, oncologic anterior skull-base surgery through an endonasal endoscopic approach avoids the morbidity incurred by transfacial and transcranial approaches, sometimes considered unreasonable, although surgery remains the gold standard treatment for sinonasal cancer.ObjectivesTo assess the functional and oncologic results of this surgery in over-70 year-olds.Material and methodsA single-center retrospective study included all patients aged over 70 years at surgery, who underwent endonasal endoscopic oncologic resection and reconstruction of the anterior skull base, between October 2008 and October 2018.ResultsFifteen procedures in 13 patients met the inclusion criteria. Mean hospital stay was 7 days. All resections were considered R0, apart from one case with positive dura-mater margins (6.7%). All patients had complete radio-surgical treatment, in accordance with the REFCOR recommendations. Two cases of meningitis were reported (13.3%). At a median follow-up of 27 months, 4 patients presented local recurrence, 1 of whom also had lung metastases. Two patients died of disease-related or treatment-related causes.ConclusionThis technique is a feasible treatment in patients aged over 70 years, providing good functional results, and acceptable oncologic outcome.     

Controlling the surgical field during a large endoscopic vascular injury

Objectives:

Since the advent of endonasal skull base surgery, internal carotid artery (ICA) injury has been considered the most dramatic and challenging intraoperative complication. A large vascular injury creates an immediately challenging surgical scenario with rapid blood loss that may result in exsanguination of the patient. Recently we have developed an animal model of the endoscopic, endonasal vascular injury. We describe important surgical steps required in managing the surgical field during a catastrophic vascular event.

Methods:

A total of 42 endoscopic carotid artery injuries and 25 endoscopic venous injuries were performed. Throughout the injuries, the “two‐surgeon” technique was used to achieve surgical field control. Videoendoscopy was performed throughout the implementation of these surgical techniques.

Results:

Techniques found useful in controlling the surgical field included the two‐surgeon technique, careful selection of the most appropriate nostril for endoscope positioning, large bore suction placement, suction guidance of the vascular stream through the contralateral nostril, and avoidance of suction obstruction. Only once the surgical field could be controlled can the injury site be addressed.

Conclusions:

Controlling the endoscopic endonasal surgical field during vascular injuries relies on the cooperation of the surgical team and a step‐based approach including careful endoscopic maneuvering within the nasal corridor, and appropriate suction selection and positioning with respect to the endoscope. Laryngoscope, 2011     

Integración de la cirugía endoscópica en una unidad de base de cráneo: experiencia en los primeros 72 casos

IntroductionA multidisciplinary team is essential to develop and expand the indications in endonasal endoscopic skull base surgery.The aim of this study was to present our experience in a group of patients with skull base lesions treated using endonasal endoscopic approach.MethodsFrom January 2008 to January 2012, 72 patients with skull base involvement were diagnosed and treated in our centre.ResultsThe mean patient age was 53 years. The different pathologies included 36 pituitary adenomas, 10 cerebrospinal fluid leaks and 5 inverted papillomas as the most frequent pathologies. We performed a transsphenoidal transellar approach in 45 cases, a transmaxillary transpterygoid approach in 4 cases and a transnasal expanded approach in 6 cases. We performed an ethmoidal/sphenoidal approach in 12 patients and a Draf IIb/III procedure in four cases. Total resection was achieved in 61% of patients with pituitary adenomas, subtotal in 22% and partial in 17%. Successful repair was achieved in 86% of CSF leaks. No recurrences were observed in patients with inverted papilloma. Complications were observed in 21 patients (29%), 6 being major complications.ConclusionsOur centre stresses the importance of multidisciplinary collaboration in endoscopic endonasal skull base surgery.     

Diplopia secondary to endoscopic sinus surgery

Objective—Diplopia after endoscopic sinus surgery (ESS) is rare but very serious. In this study, we investigated the characteristics, prognosis and treatment of diplopia occurring after ESS.

Material and Methods—A retrospective analysis was carried out to investigate three patients with diplopia after ESS referred to us from other hospitals.

Results—In one case, an improvement in ocular motility was seen after surgical treatment. In the other cases, no improvement was observed, despite surgical treatment.

Conclusion—In order to prevent diplopia after ESS, the surgeon must possess a complete anatomical knowledge obtained by means of cadaveric dissection, the ability to carefully read preoperative CT scans and the necessary surgical experience.     

Image guidance systems for minimally invasive sinus and skull base surgery in children

Objective

The use of image guidance for sinonasal and skull base surgery has been well-characterized in adults but there is limited information on the use of these systems in the pediatric population, despite their widespread use. The aim of this study is to evaluate the use of image guidance systems to facilitate an endoscopic minimally invasive approach to sinonasal and skull base surgery in a pediatric population.

Methods

A retrospective cohort study was performed at a tertiary pediatric hospital. Thirty-three children presented with complications of sinusitis, tumors, traumatic, or congenital lesions of the skull base and underwent endoscopic surgery using image guidance from March 2000 to April 2007. Patient variables including diagnosis, extent of disease, and complications were extracted from paper and computer charts. Additional surgical variables including set-up time, accuracy, surgeon satisfaction index and number of uses per case were also reviewed.

Results

Twenty-eight patients (85%) underwent sinonasal surgery and five (15%) underwent skull base surgery. Indications included infectious complications of acute sinusitis (N = 15), neoplasms (N = 12), choanal atresia (N = 4), and cerebrospinal fluid leak (N = 2). Thirty-one patients (94%) required only one procedure. No surgical complications were reported. Surgeon satisfaction, mean accuracy and number of uses per procedure increased over time (p < 0.05).

Conclusions

Image guidance systems are safe and effective tools that facilitate a minimally invasive approach to sinonasal and skull base surgery in children. Consistent with adult literature, usage and surgeon comfort increased with experience. The additional anatomical information obtained by image guidance systems facilitates a minimally invasive endoscopic approach for sinonasal and skull base pathologies.     

影像导航系统在复杂鼻内镜手术中的作用和评价

目的：对影像导航系统在复杂鼻内镜手术中的作用进行评价。方法：使用影像导航系统对305例行鼻内镜手术的患者进行导航。对导航系统的精确性,总的手术时间,术者的满意程度,以及术中、术后的并发症进行详细记录分析。结果：305例患者中有301例（98．7％）影像导航系统提供了误差0.5～2．0mm（平均1．2mm）的解剖定位。术者增强了自信心,提高了手术的安全因素。未见术中及术后并发症发生。总的手术时间和常规鼻内镜手术时间基本相同。结论：影像导航系统是处理复杂鼻内镜手术很有价值的工具。     

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.     

Simulation-based training in endoscopic endonasal surgery: Assessment of the cyrano simulator

PurposeEndoscopic endonasal surgery requires many skills: a learning program was developed with progressive steps, on a surgical simulator (Cyrano) designed to train junior surgeons in the acquisition of basic endoscopic surgery skills and to assess their progress. The main objective of this study was to establish the construct validity of these exercises and to refine objective criteria to establish students’ level.Material and methodsThirty volunteers with varying experience in endoscopic endonasal surgery were blindly evaluated on 4 modules according to objective and subjective criteria.ResultsTen beginner, 11 intermediate and 9 expert level participants were included. For each exercise, at least one criterion was discriminant for level of expertise. Weighted scores succeeded in discriminating groups. Interpretation of a single criterion must remain cautious and evaluation should rather rely on composite scores, which better reflect the participants’ level. Useful criteria and their reference values are specific of each exercise. Face and content validity were rated at 3.92/5 and 4.59/5 respectively (5-level Likert scale).ConclusionThe construct/face/content validity of the proposed modules have been verified. Most of the modules tested here were physically not realistic, but they were all rated as highly relevant for surgical training by the participants.     

Abordaje endoscópico endonasal para el tratamiento de los angiofibromas juveniles

Background and objectivesJuvenile angiofibroma (JA) is a benign tumour, for which the treatment of choice is surgery. It may be associated with significant morbidity because of its anatomical location and its locally destructive growth pattern. Severe haemorrhage constitutes a high risk in JA and its surgical management can be complex. The management of JA remains a challenge. The objective of this study was to review a series of patients with JA treated via the endonasal/endoscopic approach.Material and methodsMedical records of patients operated for JA were reviewed. Main outcome measures: tumour stage, intraoperative blood loss, complications and persistence/recurrence rates.ResultsA total of 30 male patients and one female were included. The mean age was 17 years. Using the Radkowski classification, one JA was classified as stage I, 5 stage IIA, 9 stage IIB, 4 stage IIC, 10 stage IIIA and 2 stage IIIB. Thirty-nine percent of the JA was classified as advanced stage JA (IIIA and IIIB). The mean blood loss was 1.156 mL Except in one case, no significant complications were observed. Tumour persistence/recurrence was observed in 2 JA (6%), at the end of the follow-up. Mean postoperative follow-up time was 86 months.ConclusionsThis retrospective study supports the notion that endonasal endoscopic approaches for a JA are a feasible option associated with good long-term results.     

Endoscopic endonasal approaches to the craniovertebral junction: The Otolaryngologist's perspective

ObjectiveTo review indications and techniques for the endoscopic endonasal approach to the craniovertebral junction (CVJ), analyze postoperative outcomes, and discuss important technical considerations.MethodsA retrospective analysis was performed on all patients undergoing endonasal endoscopic approaches to the CVJ from May 2007 to June 2017. Demographic information, presenting symptoms, imaging results, treatment course, postoperative functional status, and follow-up were recorded.ResultsThere was a total of 30 patients in this series, with a mean follow-up of 11.7 months. The average age was 33.6 years (range, 5–75 years), with 18 females and 12 males. The majority of patients (n = 22, 73.3%) had Chiari malformation type 1 with basilar invagination and symptomatic cervicomedullary compression as the indication for surgery. Intraoperative cerebrospinal fluid leak (CSF) was noted in 3 cases of odontoid resection and a single case of skull base resection. There were no postoperative CSF leaks. Overall, 81% of patients resumed regular diet by post-operative day 2 (range, 0–8 days). Severe postoperative dysphagia occurred in two cases with one requiring gastrostomy tube placement and another utilizing total parenteral nutrition for support prior to eventual gastrostomy. On average, patients were extubated by postoperative day 0.93 (range 0–3 days), with 85% extubated by postoperative day 1. A tracheotomy was required in one patient.ConclusionThe endonasal endoscopic approach is a valuable technique for access to the CVJ with minimal disruption of respiratory and alimentary function.     

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group

BackgroundCervical spondylodiscitis is a rare but severe complication of pharyngeal surgery.Material and methodsThis multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017.ObjectivesTo describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications.ResultsSeven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6 days. The interval between surgery and spondylodiscitis diagnosis ranged from 20 days to 4.5 months, for a mean 2.1 months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%).ConclusionThis French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.     

Endoscopic dacryocystorhinostomy

The endonasal surgical approach of the lacrymal sac assisted by video-endoscopy is carried out today with high success rates. Despite the satisfactory results reached with the traditional external approach, it has the disadvantage of requiring a skin incision and a consequent local scar. With the development and enhancement of the endonasal techniques, the endoscopic approach is increasingly preferred by surgeons.ObjectiveThis paper reviews the lacrymal system anatomy, the preoperative assessment and the technical details of the endoscopic assisted approach which may provide better surgical outcomes for patients. We will also briefly discuss complications and causes for surgical failure.MethodologyThis is a review of the experience of the authors in the past 10 years of employing the endoscopic technique for the lacrymal sac surgery.ConclusionOutcomes regarding the endoscopic dacryocystorhinostomy are, at leas, equal to those from the traditional external approach. Notwithstanding, the joint work between the otorhinolaryngologist and the ophthalmologist is of great benefit to patients with epiphora.     

Repair of oroantral fistula via modified endoscopic medial maxillectomy with free nasal mucoperichondrial-osteal graft

Background: Many techniques have been proposed to close an oroantral fistula (OAF), with most of them involving transoral repairs with oral soft tissue flaps. An additional Caldwell-Luc approach or endoscopic sinus surgery (ESS) is required to address coexisting maxillary sinusitis.

Objectives: This study presents the endonasal closure of an OAF through modified endoscopic medial maxillectomy (MEMM) with a free nasal mucoperichondrial-osteal graft.

Materials and methods: Sixteen OAF patients who underwent closure operations in our department from May 2013 to June 2018 were retrospectively reviewed.

Results: The main cause of OAF was maxillary dental cysts (56.25%). The OAF size ranged from 2?×?2 to 10?×?15?mm. The first molar (62.5%) was the most frequently involved tooth. All closures were made via MEMM, using nasal mucoperichondrial-osteal grafts harvested from the septum or nasal base. All patients were followed up for at least six months. Successful closure after a single procedure was achieved in 93.75% of cases. No obvious complications or recurrences were observed.

Conclusions: Endonasal repair of OAFs via MEMM with free nasal mucosal grafts is feasible and promising. The approach preserves the normal oral and nasal physiology after surgery. It could be used alone for the closure of small to medium-sized OAFs.     

Endoscopic endonasal surgery for paranasal sinus mucoceles

Paranasal sinus mucoceles are benign, space-occupying, cystic lesions that require a surgical treatment. An endoscopic endonasal marsupialisation is nowadays the surgical approach of choice in most of the cases. The aim of the present study is to validate this option and to determine the clinical characteristics of paranasal sinus mucoceles. A retrospective study based on the clinical experience of several ENT surgeons was performed using a standardised questionnaire. The respondents participate to a report on endoscopic endonasal surgery for non-inflammatory disease in Belgium. One hundred and fourty patients presenting 178 mucoceles were included in this study. Primitive mucoceles were reported in 35% of the patients, posttraumatic mucoceles in 2.1% and postoperative mucoceles in 62.9%. The time interval between first rhinologic procedure and the mucocele diagnosis was respectively 24.4 months after FESS and 108.3 months after an external procedure. Paranasal sinus mucoceles predominantly occur in the fronto-ethmoidal region (64%), followed by the maxillary sinus (18.6%), the sphenoid sinus (8.4%) and the posterior ethmoid sinus (6.7%). Uncommon locations were also reported in 2.3% (Inferior turbinate, middle turbinate, pterygomaxillary space). Endoscopic endonasal marsupialisation (combined with an external procedure for 8 patients) was successful in 97.9% of the patients. Only 3 patients showed recurrence. Endoscopic endonasal marsupialisation of paranasal sinus mucoceles is a reliable therapeutic option with favorable results and is supported by the questioned ENT surgeons in Belgium.     

Paraganglioma of the maxillary sinus

Primary paragangliomas of the paranasal sinuses are very rare conditions with only few cases described in the literature. Paragangliomas are locally aggressive, often recur and can metastasize. Usually, open surgery is used to resect such tumors from the sinonasal tract. Here, a case of a large paraganglioma of the left maxillary sinus and nasal cavity, which was successfully removed using the Onyx^® embolic agent two days prior to minimally invasive image guided endoscopic sinus surgery, is reported. This case demonstrates that large vascular tumors of the sinonasal tract can be successfully managed by endoscopic endonasal sinus surgery. The patient has no evidence of recurrence after 12 months of follow-up.     

Applications of Co2 laser in endoscopic surgery for sinonasal neoplasms

ObjectiveThe aim of the study is to assess safety, effectiveness, and potential advantages of CO? fiber laser during endoscopic endonasal surgery for the resection of sinonasal neoplasms.We present text, images, and videos to show our experience with this new device recently introduced in endoscopic endonasal surgery and as a potential tool for educational purpose.MethodsSix patients affected by benign or malignant sinonasal tumors who underwent endoscopic resection between January and May 2021 were enrolled in the study.Surgical approach was conducted via standardized centripetal endonasal technique.During the surgery we evaluated instrument ergonomics, quality in section on both healthy tissue and tumor, coagulation, and bleeding control from major vessels.ResultsIn our experience, CO? fiber laser has proved to have good ergonomics, as well as to be a safe and effective tool for the resection of both neoplastic and healthy tissues. Cauterization was efficient only in vessels with average diameter lower than 1 cm.Prolonged procedural time, costs, and necessity of learning-curve and expertise are possible drawbacks.ConclusionCo2-fiber laser is an effective tool which can aid the surgeon during endoscopic endonasal approach to sinonasal neoplasms.     

Treatment and outcomes of endoscopic surgery and traditional open resection in sinonasal mucosal melanoma

Objective: The optimal surgical approach for sinonasal mucosal melanoma (SNM) remains under debate. We aimed to compare the therapeutic efficacy of traditional open resection and endoscopic surgery for patients with SNM treated at a single center.

Methods: Thirty-three patients diagnosed with SNM who underwent surgery between January 1995 and June 2014 at a single institution were retrospectively analyzed; 18 patients were treated using an open resection approach and 15 using an endoscopic resection approach for the primary tumor. The associations between open resection and endoscopic resection with treatment-related survival outcomes were assessed using the Kaplan–Meier method and log-rank test.

Results: The most common presenting symptoms were epistaxis and abstraction; the nasal cavity was the most common anatomic location. The open resection and endoscopic resection groups did not have significantly different demographic or tumor characteristics. Overall survival (p?=?.66) and disease-free survival (p?=?.73) were modest and did not differ significantly between the open resection and endoscopic resection groups.

Conclusions: This retrospective study indicates that the endoscopic endonasal approach is an effective treatment for SNM in selected cases and, when performed by a skilled surgeon, can enable successful radical resection with a similar efficacy as traditional open resection.     

来源于后组筛窦的后鼻孔息肉的诊断和治疗

目的:探讨后组筛窦的后鼻孔息肉(CP)的临床特征、诊断以及鼻内镜下手术方法.方法:总结2002年1月～2007年6月收治的11例后组筛窦的CP患者的临床资料,分析其临床表现、鼻腔及鼻窦内病变情况、鼻内镜手术方法及注意要点以及临床疗效.结果:11例均在鼻内镜下完成手术.术中见11例CP根部均来自后组筛窦开口处.后组筛窦内3例(27.3%)伴有囊肿,5例(45.4%)窦内有明显息肉,3例(27.3%)表现为窦内黏膜水肿息肉样变.术中无明显并发症,术后随访6个月～3年,平均1.2年,无息肉复发者.结论:后组筛窦的CP多来自后筛窦口,可能由窦内囊肿演变而成.鼻内镜下切除息肉同时需开放后组筛窦清除窦内病变,彻底清除病变后不易复发.     

Management and outcome after internal carotid artery laceration during surgery of the paranasal sinuses

Abstract

Conclusions. The injury to the cavernous portion of the internal carotid artery (ICA) during endonasal sinus surgery is a potentially fatal complication, which can be prevented by systematic analysis of preoperative CT imaging in order to exclude vascular malformations. Immediate management is critical and requires interdisciplinary cooperation between the otolaryngologist and interventional neuroradiologist. Objective. The purpose of this article is to present two cases of injury to the cavernous portion of the ICA during routine endonasal sinus surgery for chronic sinusitis and to review the management and outcome of this vascular emergency. Patients and methods. A database of all patients surgically treated for chronic sinusitis between 1994 and 2004 was reviewed retrospectively. Additionally a review of the literature for all published case reports of ICA injury was performed. Results. We report two cases of ICA lacerations that occurred during routine endoscopic sinus surgery. Both patients were successfully treated by employing neuroradiological procedures including balloon and/or coil occlusion of various portions of the cavernous ICA. According to the literature the outcome depends on the presence or absence of vascular anomalies or aneurysm of the ICA with a very poor prognosis in cases of laceration of a pre-existing and unrecognized aneurysm.