鼻内镜下经鼻丘径路治疗慢性额窦炎

目的探讨鼻内镜下鼻丘径路治疗慢性额窦炎的疗效。方法对慢性额窦炎27例在鼻内镜下通过切除鼻丘气房暴露额窦开口,开放额窦。结果27例全部开放成功。除3侧眶周青紫外,无并发症发生。鼻内镜检查额窦口引流良好。27例术后随访6个月,18例额窦炎症状全部消失,7例明显改善,2例无明显改善。结论鼻内镜下经鼻丘径路微创治疗慢性额窦炎手术安全有效,值得在临床推广。     

Single-stage strategy for management of anterior table frontal sinus fractures involving the frontal sinus outflow tract

Treatment of frontal sinus fractures has been controversial for years. The aim of treatment, besides cosmetic restoration, is to create a “safe” sinus especially in those with evidence of injury to the frontal sinus outflow tract. Early and late complications include acute and chronic sinusitis, mucocoele and mucopyocoele formation, brain abscess and osteomyelitis. Osteoplastic flap with frontal sinus obliteration or cranialisation is most commonly performed. With the advent of modern endoscopic and advanced imaging techniques, endoscopic sinus surgery for treatment of diseases of the frontal sinus is ever increasing. In this paper, we describe our successful experience using a single-stage, combined open and transnasal endoscopic technique in management of patients with anterior table frontal sinus fractures involving the frontal sinus outflow tract.     

The endoscopic modified Lothrop procedure for salvage of chronic frontal sinusitis after osteoplastic flap failure

OBJECTIVE: While reported results utilizing the osteoplastic flap procedure are very good, some patients fail the surgery due to recurrent or persistent frontal sinus disease. This study was performed to evaluate the utility of the endoscopic modified Lothrop sinus surgery for osteoplastic flap failure. STUDY DESIGN AND SETTING: A retrospective chart analysis and telephone survey of 10 patients from outside our institution for whom an osteoplastic flap with fat obliteration failed were salvaged using a computerized endoscopic modified Lothrop procedure. RESULTS: The main complaints were headache/pressure and recurrent infection. The usual pathology was chronic sinusitis and/or mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. Symptomatic clinical improvement was noted in more than 90% of patients. CONCLUSION: Salvage endoscopic modified Lothrop sinus surgery is recommended for a limited number of traditional osteoplastic flap failures. Computerized surgical navigation may help avoid complications in situations with abnormal anatomy and previous dissection. SIGNIFICANCE: The endoscopic modified Lothrop procedure should be considered to salvage failed osteoplastic flap sinus obliteration.     

A targeted endoscopic approach to chronic isolated frontal sinusitis.

OBJECTIVE: Chronic isolated frontal sinusitis occurs infrequently. In this condition, most of the ethmoid cells are well aerated and the frontal sinus is involved secondary to anatomical obstruction or inflammatory changes confined to the frontal recess. The purpose of this study was to evaluate a targeted endoscopic technique where standard anterior ethmoidectomy is unnecessary in the treatment of chronic isolated frontal sinusitis. STUDY DESIGN AND SETTING: This retrospective study was conducted in a large university-affiliated hospital and included 11 patients with chronic isolated frontal sinusitis who underwent endoscopic sinus surgery limited to the frontal sinus outflow. The ethmoid bulla was untouched in all cases. Follow-up continued for 19 to 40 months (mean 28.6 months). RESULTS: Frontal sinus outflow patency was verified in 9 patients (81.8%). Nine patients, including one with an apparent nonpatent frontal ostium, reported improvement. Two patients-one of whom had a patent frontal ostium-reported no improvement. There were no complications. CONCLUSION: Chronic isolated frontal sinusitis can be effectively treated in selected cases by a targeted endoscopic procedure, limited to reestablishment of frontal sinus outflow. EBM rating: C-4.     

Endoscopic frontal sinus obliteration: a new technique for the treatment of chronic frontal sinusitis.

OBJECTIVES: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic technique for frontal sinus obliteration. STUDY DESIGN AND SETTING: Retrospective case-control. Thirty-five patients underwent frontal sinus obliteration using either an endoscopic (n=10) or conventional osteoplastic flap (n=25) technique from 1994 to 2004 at an academic medical center. RESULTS: Patients undergoing endoscopic obliteration had less blood loss (P = 0.006), decreased operative time (P = 0.016), and a shorter hospital stay (P = 0.003) compared to osteoplastic control subjects. All 3 surgical complications occurred in the control group. No patients required additional surgery for frontal sinusitis. CONCLUSIONS: The endoscopic approach to frontal sinus obliteration appears to reduce patient morbidity and should be considered in the surgical management of advanced frontal sinus disease. SIGNIFICANCE: This is the first report of a minimally-invasive technique for frontal sinus obliteration.     

Osteoplastic flap for obliteration of the frontal sinus: five years' experience.

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses.     

Osteoplastic flap for obliteration of the frontal sinus: Five years’ experience

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses. (Otolaryngol Head Neck Surg 1999;121:731-5.)     

Concomitant Transsphenoidal Approach to the Anterior Skull Base and Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

Objectives To describe outcomes of endoscopic resection of sellar tumors with concomitant endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS).Design Retrospective chart review.Setting Tertiary care medical center.Participants Patients who underwent endoscopic transsphenoidal surgery for excision of anterior skull base lesions and simultaneous functional endoscopic sinus surgery (FESS) for CRS between January 2006 and January 2011 by senior authors (MRR and JJE).Main Outcomes Measured Short- and long-term postoperative complications.Results Fourteen patients were identified. Average follow-up was 27 months. All patients had preoperative symptoms consistent with CRS. No patients were treated with preoperative antibiotics. Surgical pathology revealed chronic sinusitis in all specimens. Pathology of the intracranial lesions included 11 pituitary macroadenomas, one craniopharyngioma, one chondrosarcoma, and one cholesterol granuloma. Short-term postoperative morbidities included a sphenoid polyp, one adhesion, and one case of pharyngitis. Long-term outcomes included one frontoethmoidal mucocele, one recurrence of nasal polyps, and three cases of acute sinusitis. There were no intracranial complications for the entire follow-up period.Conclusions Transsphenoidal surgery can safely be performed in the setting of CRS without increased risk of intracranial complications.     

Transorbital Neuroendoscopic Management of Sinogenic Complications Involving the Frontal Sinus,Orbit, and Anterior Cranial Fossa

Transnasal endoscopic surgery has remained at the forefront of surgical management of sinogenic complications involving the frontal sinus, orbit, and anterior skull base. However, the difficulty in accessing certain areas of these anatomical regions can potentially limit its use. Transorbital neuroendoscopic surgery (TONES) was recently introduced to transgress the limits of transnasal endoscopic surgery; the access that it provides could add additional surgical pathways for treating sinogenic complications involving the frontal sinus, orbit, and anterior cranial fossa. We describe a prospective series of 13 patients who underwent TONES for the management of various sinogenic complications, including epidural abscess, orbital abscess, and fronto-orbital mucocele or mucopyocele, as well as subperiosteal abscess presenting with orbital apex syndrome. The primary outcome measurement was the efficacy of TONES in treating these pathologies. TONES provided effective access to the frontal sinus, orbit, and the anterior cranial fossa. All patients demonstrated postoperative resolution of initial clinical symptoms with well-hidden surgical scars. There were no ophthalmologic complications or recurrence of pathology. Based on our experience, TONES appears to provide a valuable addition to the current surgical armamentarium for treating selected complications of sinusitis.     

Olfactory neuroblastoma (esthesioneuroblastoma): report of six cases treated by a novel combination of endoscopic surgery and radiosurgery.

Microsurgical techniques have considerably improved the results of surgical treatment for esthesioneuroblastoma (olfactory neuroblastoma). Nevertheless, these rare tumours of the frontal skull base are still associated with high rates of tumour recurrence and mortality, thus remaining a challenge even for experienced surgeons. A novel therapeutic approach that combines endoscopic sinus surgery and radiosurgery (gamma knife) is presented here. Six patients (3 males, 3 females) aged between 27 and 75 years (median 38 years) were treated between August 1993 and July 1999. Following paranasal and nasal endoscopic sinus surgery, marginal irradiation doses ranging from 16 to 34 Gy were applied radiosurgically involving up to 7 isocentres. At present, the median follow-up period is 57 months (range: 9 - 79 months). Without mortality, tumour control was achieved in all patients. One patient, who had to undergo additional craniotomy because of extensive neoplastic infiltration, developed postoperative liquorrhea. In another case the clinical course was complicated by a bilateral frontal sinusitis. All patients complained of nasal discharge and crusts. However, a preoperative Karnovsky Index ranging from 80 to 100 % remained stable in four patients whereas an improvement was observed in two patients. Based on the favourable results observed so far, the combination of endoscopic sinus surgery and radiosurgery can be considered as promising new option for the treatment of esthesioneuroblastoma that merits further investigation.     

The surgery of frontal sinus infection.

A clinical and surgical review of 37 patients treated for acute and chronic frontal sinusitis at Groote Schuur Hospital during the 6-year period 1967-1972, is presented. The mode of clinical presentation of this disease and its complications are discussed, and the surgical management of frontal sinus disease as practised at this hospital is described.     

Draf额窦鼻内引流术的疗效观察

目的探讨Draf额窦鼻内引流术的临床疗效。方法回顾性分析2009年12月～2012年6月因额窦良性病变行Draf额窦鼻内引流术49例（68侧）的临床资料,以鼻部主观症状评分及内窥镜复查为观察指标,参考慢性鼻窦炎内镜手术疗效评定标准评价疗效。结果全组随访12～37个月,平均17．5月,总有效率80．9％（55／68）,其中Draf I型有效率80．0％（36／45）,Draf IIa／b型81．0％（17／21）,DrafⅢ型100％（2／2）。术中及术后无严重及永久并发症。结论Draf额窦鼻内引流术对于额窦内的炎症及良性病变不失为一种好的选择,避免了不必要的鼻外径路手术,同时有较为确定的疗效。在术式的选择上要兼顾额窦的解剖、病变的性质、范围等。     

Effects of different chlorhexidine pretreatments on adhesion of metal brackets in vitro

Complications associated to group-A streptococcal pharyingitis include non-suppurative complications such as acute rheumatic fever and glomerulonephritis and suppurative complications such as peritonsillar or retropharyngeal abscess, sinusitis, mastoiditis, otitis media, meningitis, brain abscess, or thrombosis of the intracranial venous sinuses. We described a case of a 15-year-old patient with a history of acute pharyngodinia early followed by improvise fever and a progressive formation of a diffuse orbital edema, corneal hyperaemia, diplopia and severe decrease of visual acuity. The patient was surgically treated with functional endoscopic sinus surgery (FESS) after the response of a maxillofacial computed tomography scans that showed a pansinusitis complicated by a left orbital cellulites. Numerous colonies of Streptococcus pyogenes were found in the samples of pus and an antibiotic therapy with meropenem was initiated on the basis of the sensitivity test to antibiotics. The patient was finally discharged with diagnosis of left orbital cellulites with periorbital abscess, endophtalmitis and acute pansinusitis as a consequence of streptococcal pharyngitis. The case highlights the possible unusual complication of a group-A streptococcal pharyingitis in a immunocompetent child and the needing of a prompt surgical and medical approach toward the maxillofacial complications associated to the infection.     

Characteristics of sinus-related pain

OBJECTIVES: The goal of this study was to determine possible distinctive features of facial pain when caused by chronic sinusitis and to validate the pain characteristics previously described in the literature. METHODS: Included were 82 patients with radiographic and endoscopic evidence of chronic sinusitis and significant facial pain who underwent functional endoscopic sinus surgery and were available for 1-year follow-up. A modified McGill pain questionnaire was filled out before surgery, and follow-up data were obtained at 1 year. RESULTS: At 1 year 38% of patients had persistent facial pain despite the lack of any evidence of persistent sinusitis. A consistent use of pain adjectives and other distinctive features was noted in patients reporting improvement of headache. There was no correlation between the severity of pain and the extent or location of mucosal disease. The site of pain did not correlate with the site of disease. CONCLUSIONS: Sinusitis-related pain has distinctive features that set it apart from primary headache disorders and other causes of facial pain. Nonsinus causes account for the headache in 1 of 3 patients undergoing sinus surgery.     

Use of anteriorly based pericranial flap in frontal sinus obliteration.

OBJECTIVE: In an era of endoscopic sinus surgery, frontal sinus obliteration continues to remain an important treatment option in chronic frontal sinus disease. Numerous avascular obliterative materials including fat, muscle, cancellous bone, and hydroxyapatite have been used in this procedure. In this article, we describe a vascularized anteriorly based pericranial flap to obliterate frontal sinus. STUDY DESIGN: Retrospective chart review of patients referred to tertiary care hospital between 1996 and 2003. METHODS: Records of the patients who underwent this procedure were reviewed. Demographics, indications, and immediate and late complications were recorded. A phone questionnaire was used to assess patient satisfaction with the outcome. RESULTS: A total of 12 patients underwent frontal sinus obliteration with this technique. Mean follow-up was 40 months. None of the patients developed recurrent frontal sinusitis. All of the patients were pleased with the outcome. CONCLUSION: Pericranial flap is a highly vascularized flap that is easily harvested and is an effective and viable modality for obliterating frontal sinus. EBM rating: C-4.     

Fractures of the frontal sinus

It is not possible to establish rigid guidelines for the treatment of frontal sinus fractures. However, this series demonstrates that aggressive treatment of the sinus with damage to the frontal sinus drainage system will produce a "safe" sinus. The individual surgeon must base his or her treatment philosophy on the type and severity of injuries being treated, the patient population involved, and his or her experience with each of the treatment options. All patients must be made to realize that they have a life-long risk for delayed complications following any type of reconstructive procedure on the frontal sinus. It is hoped that patients who do experience complications will seek treatment when the first symptoms of a frontal sinusitis arise, rather than allowing the infection to progress to a more severe state that is life-threatening or may require disfiguring surgery.     

Minimally Invasive Technique for Repairing CSF Leaks Due to Defects of Posterior Table of Frontal Sinus

Objective Cerebrospinal fluid (CSF) leaks from the frontoethmoid and sphenoid region can be easily dealt with endoscopic approaches, but CSF rhinorrhea due to frontal sinus fractures are difficult to treat solely by the nasal endoscopic approach and may require external repair. The technique described targets defects of the posterior table of the frontal sinus where conventional osteoplastic approach of obliteration is usually done. This technique is minimally invasive and involves repair using an endoscope via a frontal trephine. Methods We have treated five cases of traumatic CSF rhinorrhea with this technique, and the mean follow-up is 1 year (range: 10–14 months). The frontal sinus is opened by making a small stab incision (frontal trephine), and the defect site is localized by visualization via endoscope through the trephine. The repair is then performed with fat, bone graft, and fibrin glue. Results Closure of the defect was achieved in a single stage in all the patients, and none of them had a recurrence of leak in the 1-year follow-up period. Conclusion This is a good technique for superiorly and laterally placed posterior table defects of the frontal sinus with minimal morbidity and excellent closure rates.     

Combined endoscopic surgery and radiosurgery as treatment modality for olfactory neuroblastoma (esthesioneuroblastoma)

Summary Object. Treatment of esthesioneuroblastoma (olfactory neuroblastoma) has been considerably improved by microsurgical techniques. Nevertheless, these rare tumours of the frontal skull base are still associated with high rates of tumour recurrence and mortality, thus remaining a challenge even for experienced surgeons. A novel therapeutic approach that combines endoscopic sinus surgery and Gamma Knife radiosurgery is presented here. Taking into account the rarity of the disease the present study comprises a relatively large series of patients treated in a similar manner.Methods. 14 patients (8 males, 6 females) aged 27–75 years (median 38) were treated between May 1993 and December 2003. This series comprises 12 newly diagnosed esthesioneuroblastomas. Two more patients had already previously undergone surgery (24/39 months earlier). Paranasal and nasal endoscopic sinus surgery was performed. Marginal irradiation doses ranging from 15–34Gy were given to the residual tumours by means of radiosurgery (Gamma Knife) involving 1–7 isocentres within 3 months after surgery. Median follow-up is 58 months (range 13–128).Results. There was no mortality. In all patients tumour control was achieved within the treated area. 4 patients underwent a second radiosurgical procedure 6–79 months (median 34 months) after initial radiosurgery. One patients had to undergo an additional craniotomy because of extensive neoplastic infiltration, 1 developed postoperative liquorrhea, 1 case was complicated by bilateral frontal sinusitis. All patients complained of nasal discharge and crusts. Karnovsky Index – preoperatively ranging from 80%–100% – remained stable in 12 patients, an improvement was observed in 2 cases.Conclusions. Based on the favourable results recorded so far, the combination of endoscopic sinus surgery and radiosurgery can be considered a promising treatment option for esthesioneuroblastoma that merits further consideration.     

鼻内镜手术治疗真菌性鼻窦炎19例

目的探讨鼻内镜手术冶疗真菌性鼻窦炎的疗效。方法2000年1月～2003年12月对19例真菌性鼻窦炎在鼻内镜下清理中鼻道息肉或肉芽，切除钩突，扩大各窦口，清除窦内病变。术中3％H2O2反复冲洗窦腔。中隔偏曲致病侧中鼻道狭窄影响窦口引流，一期行鼻中隔矫正术。结果术后5例症状缓解，14例症状消失。19例随访6～48个月，平均14个月，17例未复发，2例复发，再次行Caldwell-Luc手术，无一例并发症发生。结论鼻内镜手术治疗非侵袭型真菌性鼻窦炎有较好的临床疗效，但对严重上颌窦真菌病仍不能替代Caldwell-Lues手术。     

COMPLICATIONS OF THE CALDWELL-LUC OPERATION AND HOW TO AVOID THEM

The complications of the Caldwell-Luc operation were retrospectively studied in 1990. The case records were analysed and updated information from telephone interviews and posted questionnaires were available for most patients. One hundred and eighty-five patients with 216 procedures with a mean postoperative follow-up period of 33.5 months were studied. The commonest indication for the operation was for chronic sinusitis. There were three common complications found: facial swelling (61.9%), pain and/or numbness of the face (46.0%) and pain and/or numbness of the teeth/gums (30.9%). Rare complications are postoperative epistaxis (0.4%), oroantral fistulae (0.4%), epiphora (0.4%) and dental discoloration (0.4%). This paper discusses the pathophysiology of these complications and surgical techniques on how to avoid them. Although the use of the Caldwell-Luc operation has declined in recent years with the development of endoscopic sinus surgery, it still has occasional indications and a set of practical guidelines on how to prevent complications would be useful. The basis for treating chronic sinusitis with functional endoscopic sinus surgery at the expense of the more traditional form of treatment is also discussed.