小钻孔鼻内双入路内镜下额窦开放术的临床价值研究

目的：探索小钻孔、鼻内双入路内镜下额窦开放术的临床价值。方法：根据术前鼻内镜及CT检查结果进行评估,挑选术中可能出现引流通道识别困难的26例慢性额窦炎患者进行研究。双入路组11例（13侧）,采用小钻孔、鼻内双入路内镜下额窦开放术,首先在额窦前壁钻直径4～5mm骨孔,通过注水冲洗、光照、顺行法放入导管等方法显示额窦引流通道位置,经鼻内、鼻外双入路行额窦开放术;鼻内镜组15例（18侧）,常规行鼻内镜下额窦开放术,采用Friedman的“钩突径路”术式。术后定期随访处理。结果：双入路组均顺利找到额窦开口,完成额窦开放,无手术并发症;鼻内镜组出现眶纸板损伤2例,筛前动脉损伤1例。随访10～24个月,双人路组额窦口通畅11侧（85％）,狭窄2侧;鼻内镜组通畅15侧（83％）,狭窄3侧;两组均无完全堵塞者。结论：前壁小钻孔、鼻内双入路内镜下额窦开放术治疗慢性额窦炎安全性高,疗效好,可提高术者对额窦引流通道解剖认知水平及额窦手术技能,值得在基层医院推广。     

Endoscopic modified lothrop procedure: an alternative for frontal osteoma excision

PURPOSE: To describe three cases of frontal osteoma which were safely removed with a stereotactic-assisted, endoscopic modified Lothrop approach (EMLP). METHOD: Retrospective case review. RESULTS: Three patients presented with extensive frontal sinus osteomas. Two underwent an EMLP and one patient with osteoma extending significantly into the orbit had an EMLP for removal of the medial frontal sinus component combined with an anterior orbitotomy to remove the orbital extension. In all cases stereotactic localization was utilized to ensure preservation of the skull base. Post-operatively, one patient required debridement of oedema at the junction of a lateral mucocele and the frontal sinus. The other two patients remained well post-operatively with no complications. At follow-up, there was no tumour recurrence. CONCLUSION: A stereotactic-assisted, EMLP with or without an orbital approach may be considered for the removal of large frontal osteomas and may provide a less invasive alternative to traditional external approaches.     

Modified Lynch procedure for chronic frontal sinus diseases: rationale, technique, and long-term results

The modified Lynch operation (Neel-Lake) differs in several ways from the operation described by Lynch. The operation begins with an intranasal anterior ethmoidectomy. The agger nasi cells are removed by curetting forward between the frontal process of the maxilla and the septum. The middle turbinate, normal-appearing mucosa of the frontal-ethmoid complex, and frontal process of the superior maxilla are preserved. Bone removal is limited in most cases to the anterior floor of the frontal sinus, a portion of the lacrimal bone, and the bone over the anterior ethmoid cells. Another important difference is the use of soft, nonreactive material (thin Silastic sheeting) to stent the nasal-frontal passageway. Removal of all the mucosa of the frontal-ethmoid-sphenoid complex is unnecessary for a good postoperative result, and the remaining normal mucosa hastens the process of reepithelialization of the nasal-frontal duct. The patients in our original study group have been observed for a period of 5 to 20 years (mean, 13.5 years) after the surgical procedure. This is the longest period of follow-up for any group of patients reported in the literature. The incidence of failures increased from 7% (one duct) to 20% (3 of 15 ducts) after an additional 7 years of follow-up.     

Revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement: the frontal sinus rescue procedure

Frontal sinusitis after middle turbinate resection occurs because of stenosis of the frontal ostium by soft tissue scarring or residual bony fragments (which are pulled to the medial orbital wall by scar contracture). Standard endoscopic techniques cannot address this problem; however, revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement (the frontal sinus rescue procedure) relieves this bony stenosis and incorporates a mucosal flap that minimizes postoperative stenosis.     

Combined endoscopic trephination and endoscopic frontal sinusotomy for management of complex frontal sinus pathology

BACKGROUND: The advances in endoscopic sinus surgery have revolutionized the management of frontal sinus disease. Despite the successes, the purely endoscopic approach has its limitations, especially in patients with alterations in anatomy caused by previous surgical intervention or complex frontal sinus pneumatization patterns. The purpose of this study was to evaluate the efficacy of combined endoscopic trephination and endoscopic frontal sinusotomy (the above and below approach) in the management of these difficult cases. METHODS: Chart review was performed on patients undergoing the combined approach from October 1999 to June 2004. Demographic data, symptomatology, comorbidity, previous surgery, and primary pathology were determined. Outcome was assessed based on subjective symptom relief and objective endoscopic patency. RESULTS: Twenty-two patients with a mean age of 49.2 years underwent the combined approach. The primary pathology included mucoceles (15 patients), frontal sinusitis (2 patients), inverted papilloma (2 patients), osteoma (1 patient), fibrous dysplasia (1 patient), and pneumocephalus (1 patient). A total of 25 above and below procedures (22 primary and 3 revision procedures) were performed to manage the pathology. Postoperatively, headaches resolved in 47%, improved in 35%, and remained unchanged in 18% of the patients. Orbital symptoms resolved in 63%, improved in 25%, and remained unchanged in 12% of the patients. Endoscopic patency of the frontal sinusotomy was confirmed in 19 of 22 cases (86%) at a mean follow-up of 16.2 months. CONCLUSION: Management of complex frontal sinus pathology may require adjunct approaches in conjunction to the standard endoscopic techniques. In this series, the above and below approach was used successfully in 22 patients. The combined approach may serve as an important adjunct for management of complex frontal sinus disease.     

Hydroxyapatite: an alternative method of frontal sinus obliteration

Obliteration of the frontal sinus may be necessary for the treatment of chronic sinusitis, infectious complications, trauma, and benign and malignant neoplasms. Hydroxyapatite cement (HAC) is a relatively new material that is approved for the repair of cranial defects. HAC has been successfully used to obliterate the frontal sinus in 19 patients with few minor complications and the avoidance of donor site morbidity. Compared with other alloplastic materials, HAC has the advantages of easy use, biocompatibility, and osseointegration.     

Endoscopic dacrocystorhinostomy: long-term results and evolution of surgical technique

This study evaluated the long-term results of endoscopic dacrocystorhinostomy (DCR) performed as a day-case procedure under local anaesthesia. It assessed the patient satisfaction with the procedure by retrospective review and a questionnaire survey. Seventy patients were referred for endoscopic DCR to the senior author between 1997 and 2000. A success rate of 92 per cent was achieved at three months and it was possible to perform 85 per cent of cases under local anaesthetic; 91 per cent were discharged on the same day. Long-term follow up by postal survey revealed that the watering eye had improved following surgery in 83 per cent (follow up range = eight to 66 months; mean = 28.6 months). Eighty-eight per cent were satisfied with the tolerability of the procedure under local anaesthesia. The authors describe changes in technique, which evolved with their experience of the procedure. Endoscopic dacrocystorhinostomy can be performed safely and successfully as a day-case procedure under local anaesthesia with excellent results and with great satisfaction to the patients.     

Draf Ⅱ b额窦手术及其变通术式的临床应用

目的 回顾性总结额窦DrafⅡb手术及其变通术式的临床疗效,探讨和归纳手术适应证及影响预后的因素.方法 选择2004-2010年接受鼻内镜下额窦Draf Ⅱb手术的单侧额窦病变患者32例,其中男25例,女7例;复发额窦内翻性乳头状瘤15例,额窦黏液囊肿6例,复发额窦炎4例,额窦骨瘤3例,额窦脑膜脑膨出伴脑脊液鼻漏2例,单纯脑膜脑膨出和急性额窦炎各1例.术前行鼻窦CT扫描,肿瘤患者同时行鼻窦MRI检查.脑膜脑膨出与脑脊液鼻漏患者同时行磁共振脑池造影.全身麻醉下,主要采用0°内镜、高速鼻钻及动力系统行Draf Ⅱb及变通方式Draf Ⅱb 1～3型.术后1周行鼻窦CT扫描,作为随访基线,术后在鼻内镜下随访.结果 32例患者中行Draf Ⅱb手术19例,其中额窦内翻性乳头状瘤12例,额窦黏液囊肿4例,复发额窦炎2例,额窦骨瘤1例;Draf Ⅱb-1型5例,其中额窦内翻性乳头状瘤和复发额窦炎各2例,额窦骨瘤1例;DrafⅡb-2型6例,其中额窦脑膜脑膨出3例,额窦内翻性乳头状瘤、急性额窦炎和额窦骨瘤各1例;Draf Ⅱb-3型2例,均为额窦黏液囊肿.术后随访8～73个月,额窦口开放良好22例,狭窄7例,闭锁3例.再手术2例,均为内翻性乳头状瘤.无手术中、手术后并发症.结论 鼻内镜下额窦Draf Ⅱb手术及其变通术式Draf Ⅱb1～3型,适用于额窦复杂病变,并可根据病变和解剖特点加以变化和选择,有较好临床应用前景.     

Combined external and endoscopic frontal sinusotomy with stent placement: a retrospective review

OBJECTIVES: To examine the long-term results of combined external and endoscopic frontal sinusotomy using frontal sinus stents and to compare our results with those reported for the endoscopic Lothrop procedure. STUDY DESIGN: We performed a retrospective review of 40 patients with chronic frontal sinusitis refractory to medical management who underwent a total of 62 combined external and endoscopic frontal sinusotomies with stent placement. All procedures were performed by the senior author at Vanderbilt University Medical Center. MAIN OUTCOME MEASURES: Postoperative nasofrontal duct patency and subjective patient improvement based on the last clinical examination. RESULTS: The overall patency rate of the nasofrontal duct was 79% (95% confidence interval [CI] of +/-10%.) The overall subjective patient improvement rate was 78% (95% CI of +/-14%.). The average length of stent placement was 5 weeks. The mean patient follow-up time was 12 months. There were no surgical complications. The nasofrontal duct patency rate and patient improvement rate from our study did not differ statistically from results reported by other authors using the endoscopic Lothrop procedure. CONCLUSION: We have found endoscopic frontal sinusotomy, in conjunction with external frontal sinusotomy and placement of frontal sinus stents, to be as effective in obtaining frontal sinus patency rates and overall patient improvement rates as the endoscopic Lothrop procedure.     

Image-guided trephination of the frontal sinus: an adjunct to endoscopic technique

Frontal sinus pathology that is superiorly or laterally positioned may be difficult to manage with standard endoscopic techniques. With the assistance of computed tomography image-guidance systems, a directed trephination can be performed to reach these areas in lieu of performing an osteoplastic flap. The image-guided frontal trephination procedure offers a minimally invasive, mucosal-sparing technique with less potential morbidity than an osteoplastic flap. Two illustrative cases will be presented to highlight indications and technique.     

鼻内镜下额隐窝解剖特征与额窦开放手术

目的　通过术中鼻内镜下解剖额隐窝 ,总结与内镜额窦手术相关的镜下额窦引流通道解剖特征 ,探讨额窦鼻内镜手术相关问题。方法　病例资料为慢性鼻窦炎、鼻息肉患者 30 1例 ( 5 6 2侧 ) ,有前期手术史者除外。术前鼻窦CT扫描证实合并额窦炎者 2 80例 ( 4 79侧 ) ,术前根据CT扫描判定额窦引流方式 ;术中以钩突为参考标志 ,2 5 0例 ( 4 2 1侧 )行鼻内镜下额窦开放手术 ,并对鼻内镜下额隐窝解剖结构特征进行分型。结果　冠状CT扫描提示额窦开口于钩突与中鼻甲之间为 2 0 3侧( 4 8 2 % ) ;额窦开口于钩突和眶纸板之间 2 18侧 ( 5 1 8% )。对应上述规律的鼻内镜下额隐窝解剖特征分型 :前者属Ⅰ型 2 0 3侧 ( 4 8 2 % ) ,后者属Ⅱ型 2 18侧 ( 5 1 8% )。结论　以额窦口为中心的额隐窝鼻内镜下解剖特征及分型 ,对额窦开放手术有重要意义 ;钩突上部为CT扫描和术中定位额窦口解剖参考标志     

Glomus tympanicum tumour: an alternative surgical technique

Glomus tympanicum tumour is one of the commonest neoplasms of the middle ear. It is more common in females. The most common presenting symptom is pulsatile tinnitus. A retrotympanic mass is found in the middle ear in all the cases. Computed tomography (CT) scan is the investigation of choice, however in difficult cases magnetic resonance imaging (MRI) can be helpful. Surgery is regarded as the gold standard of treatment in spite of the fact that radiation therapy has also been advocated in the literature. In this series 17 cases of glomus tympanicum treated at Gruppo Otologico Piacenza - Rome (Italy) were analysed retrospectively. A simple and safe technique has been described. All the cases were female and treated by surgery. The tumour was removed completely in all the cases and the ossicular chain kept intact. Recurrence was encountered in only one case after nine years. Surgical removal of the tumour is recommended as the treatment of choice with the following advantages: complete removal, a low complication rate, a low recurrence rate, acceptable hearing level and minimum morbidity.     

Melker cricothyrotomy kit: an alternative to the surgical technique

Emergent cricothyrotomy is a potentially lifesaving procedure central to acute airway algorithms. In most cases in which cricothyrotomy is indicated, the acuteness of the airway precludes subspecialty consultation before performance of the procedure. The academic environment is an exception, in which the responsibility of securing a "difficult" cricothyroid airway may fall upon junior otolaryngology residents. Described here is the use of the Melker Emergency Cricothyrotomy Kit, a prepackaged kit that uses a wire-guided percutaneous dilational technique (the Seldinger technique) and a procedure-specific polyvinylchloride airway catheter. The wire-guided technique may add a margin of safety for a relatively inexperienced resident performing cricothyrotomy. Furthermore, a newly released version of the kit includes instrumentation for insertion of the Melker airway catheter by the classic surgical technique in addition to that required for the Seldinger technique, which may enable even a seasoned surgeon to secure the airway faster and more safely.