The transcaruncular approach to the medial orbital wall

OBJECTIVE: To demonstrate the safety and use of the transcaruncular approach as a surgical technique that provides rapid exposure of the medial orbital wall and apex through a small cosmetic conjunctival incision. METHODS: The transcaruncular anterior orbitotomy incision is made through the conjunctiva, between the plica and caruncle, with dissection to a subperiorbital plane along the medial orbital wall. This technique was used in 49 patients (58 orbits) between July 1995 and December 2000. The patients' ages ranged from 5 to 89 years (mean, 50 y). RESULTS: The transcaruncular anterior orbitotomy approach provided appropriate surgical exposure in all cases of orbital decompression for thyroid-related orbitopathy (in 33 orbits [26 patients]); for biopsy of medial orbital or orbital apex masses in 12 patients; and for drainage of an orbital abscess or marsupialization of a mucocele in 7 orbits (6 patients). Five patients (6 orbits) underwent a transcaruncular approach for release of medial rectus entrapment after fracture. The single complication was 1 patient who required a revision procedure for treatment of medial fornix scarring with resolution of diplopia. CONCLUSIONS: The transcaruncular approach provides a safe, rapid, and cosmetically pleasing surgical approach to the medial orbital wall and orbital apex. This technique can be used for a variety of indications.     

经鼻填充鼻中隔软骨修复眶内侧壁骨折

目的：探讨应用鼻内镜填充鼻中隔软骨,修复眶内侧壁骨折,经鼻做眼部手术的可能性。方法：选取眶内侧壁骨折患者11例（11眼）,术前检查均有不同程度的眼球内陷、复视、视力减退症状,行眼眶CT诊有眶内容物疝入筛窦并伴积液,其中6例内直肌肿胀。手术开始在内镜直视指引下,经鼻腔开放筛窦,摘除筛房,暴露骨折的纸板,将疝入物回纳眶内,鼻中隔软骨覆盖骨折区。结果：患者手术后全部治愈。双眼突出度相差≤1mm,平均0.11mm。视力较术前不改变或者略有改善。鼻内镜检查见筛窦术腔上皮化,填充的鼻中隔软骨无移动,无感染及排斥现象。结论：经鼻填充鼻中隔软骨修复眶内侧壁骨折方法简便,成功率高。自体鼻中隔软骨无排斥反应。     

Endoscope-assisted image-guided approach to the pituitary gland: preliminary cadaveric study

The microscopic transsphenoidal approach to the pituitary gland is the current standard technique used by neurosurgeons to operate the pituitary gland. The endoscopic transsphenoidal approach to the pituitary gland is a current trend because more neurosurgeons are becoming familiar with the use of endoscopes. The use of associated image-guided surgery (or surgical navigation technology; these names are equivalent and are used interchangeably) allows a precise approach that increases the safety and efficacy of a surgical procedure. The InstaTrack system (GE Medical Systems Navigation and Visualization, Inc., Lawrence, MA) is a frameless electromagnetic navigational system used in this study. The objectives of this preliminary and conceptual cadaveric study (three heads) are to get familiarized with the use of image guidance and the study of the endoscopic anatomy of this region and to investigate the technical requirements and benefits of possible future shifting from microscopic towards endoscopic image guidance.     

鼻内镜下鼻中隔软骨修复治疗爆裂性眼眶内侧壁骨折

目的：探讨鼻内镜下鼻中隔软骨修复治疗爆裂性眼眶内侧壁骨折的临床效果。方法：在鼻内镜下将骨折复位,将眶内容物还纳,以自体鼻中隔软骨植入骨折缺损处修复眶壁缺损,观察患者手术前后视力、复视、眼球突出度和眼位变化。结果：术后随访3个月～4年,28例患者术后均未出现患眼明显视力下降和视力丧失,术后眼球内陷度数为（1．5±0．6）mm,与术前（3．6±1．1）mm相比,差异有统计学意义（P〈0．05）。术后3个月,25例患者复视完全消失,2例患者第一眼位无复视,但仍有周边复视,1例术后第一眼位复视仍存在。26例术后眼球运动基本恢复正常,2例外展稍受限,但较术前好转。以上28例患者均未发现填充物移位、感染或排异反应。结论：鼻内镜下鼻中隔软骨修复爆裂性眼眶内侧壁骨折具有手术人路简捷、视野清晰、操作简便、损伤小、无面部瘢痕等优点,效果确信可靠。     

Reversible canal wall down mastoidectomy for acquired cholesteatomas: preliminary results

OBJECTIVES: The educational objectives were to discuss a new technique to manage acquired cholesteatomas and to compare this with standard approaches used for cholesteatoma removal. The study objective was to determine the feasibility of using a new approach, the reversible canal wall down approach, in conjunction with bone cement to remove acquired cholesteatomas and, potentially, preserve the ossicular chain. STUDY DESIGN: Retrospective review of five patients who underwent resection of their acquired cholesteatomas using a technique that maximizes exposure, yet preserves the posterior canal wall and, potentially, the ossicular chain. METHODS: In the setting of a tertiary otological referral center, five consecutive patients with acquired cholesteatomas underwent reversible canal wall down surgery. Four patients were male (ages, 41, 53, 26, and 10 y), and one patient was a woman [age, 51 y]). A reversible canal wall down mastoidectomy approach was used in the patients. Main outcome measures were intraoperative findings with respect to cholesteatoma removal and postoperative clinical examination, including postoperative audiograms. RESULTS: Five patients had dry ears postoperatively. One patient initially had granulation tissue forming on the posterior ear canal. This eventually resolved. The patients who had a postoperative audiogram after cholesteatoma resection with ossicular chain preservation noted an improvement or stabilization in their hearing. CONCLUSIONS: Using the reversible canal wall down approach in conjunction with bone cement, one is able to obtain excellent exposure of the cholesteatoma and, potentially, preserve the ossicular chain. This approach may be particularly useful in revision cholesteatoma surgery or in cases of acquired cholesteatoma in which the surgeon may be able to preserve the ossicular chain.     

鼻内镜下手术治疗急诊期鼻中隔骨折

目的 探讨提高急诊期鼻中隔骨折诊治效果的方法。方法 对35例急诊期鼻中隔骨折患者．行鼻内镜下鼻中隔粘膜下矫正术进行治疗。结果 随访31例，治愈28例，好转3例。结论 鼻内镜下鼻中隔骨折急诊期行鼻中隔粘膜下矫正术可获得较好疗效。     

Tympanometry and isolated fracture of the stapes

Introduction

Temporal bone fractures are frequently associated with ossicular dislocations or fractures, most commonly involving the incus. To our knowledge, isolated fracture of the posterior crus of the stapes has not been previously reported.

Outcome analysis of functional endoscopie sinonasal surgery for paediatric rhinosinusitis using the Lund-Mackay-Kennedy scoring system

There are very few indications for surgical management of chronic rhinosinusitis in children. This has been partly due to the fact that the definition of what qualifies as racalcitrant sinusitis in children is still obscure. There is also significant evidence in literature that surgery, especially radical surgery, on the nose and sinuses in children would result in some interference with the growth of the facio-maxillary skeleton. The advent of Functional Endoscopie sino-nasal Surgery ( F. E. S. S. ) in recent years has changed the philosophy of surgery for paediatric rhinosinusitis and has proven to be an effective choice of management in difficult cases. We persent here our experience and preliminary results with the use of FESS in nine children with sinonasal disorders including cystic fibrosis. The usefulness of the recently described Lund- mackay and Kennedy Scoring System for chronic rhinosinusitis in terms of symptom score, radiological score, endoscopie score and surgical score has been demonstrated.     

眶-筛-蝶联合径路视神经减压术的临床应用

目的 :探讨提高视神经管内段损伤疗效的方法。方法 :采用眶 筛 蝶联合径路对 5 2例视神经管内段损伤进行减压术治疗 ,全程松解视神经。结果 :术后视力得到不同程度恢复者 2 2例 ,视力改善率为 42 .3%。其中继发性视力损伤 2 3例 ,视力提高者占 73.9% ;原发性视力损伤 2 9例 ,视力提高者占 17.2 %。随访 6个月 ,视力恢复至 0 .0 5～ 0 .6。结论 :眶 筛 蝶联合径路视神经减压术进路短 ,视野宽 ,便于操作 ;且解剖标志清楚 ,易定位 ,更安全 ,更适合筛、蝶窦发育不良 ,骨质增生者。     

冠状入路切除巨大眼眶骨瘤1例并67例文献复习

目的 探讨眼眶骨瘤的临床特征及其手术方法。方法 报道冠状入路经颅切除的巨大眼眶骨瘤1例病历资料,并通过Pubmed检索近10年中相关眼眶骨瘤的文献,查找病例数在3例及以上的非动物试验文献,进行汇总报告。结果 共6篇67例眼眶骨瘤文献入选,眼眶骨瘤最多源于额窦和筛窦骨瘤,其中全切55例（82.1%）,部分切除12例（17.9%）,手术方法包括经颅、经眶以及鼻内镜手术等。结论 眼眶骨瘤的手术路径需要综合考虑肿瘤的大小、位置,冠状切口经颅入路适用于眼眶内深在或者较大的肿瘤。     

Wegener's granulomatosis of the orbit: a clinicopathological study of 15 patients

OBJECTIVES: Wegener's granulomatosis is a granulomatous and necrotizing vasculitis that classically involves the respiratory and renal systems. The goal of the study was to define clinical and pathological characteristics in a subgroup of patients with the changes of Wegener's granulomatosis involving the orbit. STUDY DESIGN: Retrospective study. METHODS: A database search identified 15 patients with the histological changes of Wegener's granulomatosis of the orbit presenting over a 23-year period. A review of the histological specimens, radiological studies, and patient charts was performed. Additional follow-up data were obtained through patient interviews. RESULTS: Of 15 patients (median age, 54 y) with Wegener's granulomatosis of the orbit identified, the disease was limited to the orbit in 12 patients; 3 patients had additional sinonasal involvement. All patients underwent various surgical procedures followed by medical treatment (cyclophosphamide and prednisone). Specimens showed characteristic histopathological features of Wegener's granulomatosis. Follow-up data were available for 12 patients with a median period of 5 years. In the group with only orbital involvement, none of the patients developed systemic progression of Wegener's granulomatosis. Only one patient had multiple local recurrences and later developed contralateral orbital Wegener's granulomatosis. CONCLUSIONS: Wegener's granulomatosis limited to the orbit is a localized form of the disease without systemic progression. Diagnostic surgical procedures followed by aggressive medical treatment results in good outcome, although local recurrence may occur.     

Mastoidectomy reconstruction of the posterior wall and obliteration (MAPRO): preliminary results

Objective The skills of ear surgery are best developed by dissecting a temporal bone. However, only a limited number of trainees can be afforded this opportunity because of the scarcity of available bones. The aim of this study was to investigate the validity of a prototype temporal bone model for surgical training and education.

Material and Methods A simulated 3D model of a human temporal bone was made using a selective laser sintering method. The powder layers were laser-fused based on detailed CT data and accumulated to create a 3D structure. Conventional surgical instruments were used to dissect the model under a microscope.

Results The model was as hard as real bone and surface structures were accurately reproduced. The model could be shaved using a surgical drill, burr and suction irrigator in the same way as a real bone. The malleus and incus were reproduced. The semicircular canals and the oval and round window niches were identified. Cavity structures, such as the semicircular canal, vestibule, antrum and air cells, were filled with powder which had to be removed using a pick and suction irrigator during dissection. A magnified model was useful for educating medical students.

Conclusion This prototype 3D model made using selective laser sintering serves as a good educational tool for middle ear surgery.     

经结膜切口在眶底和眶下缘骨折中的应用

目的 :探讨眶底和眶下缘骨折的手术进路。方法 :对 15例眶底和眶下缘骨折采用经结膜切口进行治疗。结果 :所有病例都在经结膜切口下完成眶底和眶下缘骨折的复位和固定 ,术后伤口均一期愈合 ,无睑外翻、泪道损伤等并发症发生。结论 :经结膜切口是治疗眶底和眶下缘骨折的一种较为理想的手术进路 ,能提供足够的暴露并避免面部瘢痕形成。