Absceso de cavum y oftalmoplejía secundarios a otitis externa maligna

We present a rare case of ophthalmoplegia, labyrinthitis and abscess of cavum secondary to skull base osteomyelitis by malignant external otitis. Since symptoms persisted in spite of antibiotic therapy, surgical drainage using a transnasal endoscopic approach was performed.     

Transnasal endoscopic drainage of a medial subperiosteal orbital abscess

The exact incidence of orbital complications due to sinusitis in children is unknown. However, a medial subperiosteal orbital abscess is the most common serious complication to occur. Surgical intervention is mandatory whenever antibiotic treatment fails. Most authors prefer open surgical procedures such as external ethmoidectomy, while others recommend transnasal endoscopic drainage as the first attempt at sinus decompression. Five out of 12 children with proven subperiosteal orbital abscess and sinusitis on computed tomographic scans failed antibiotic treatment and required surgical drainage. Transnasal endoscopic drainage of the abscess was performed on four patients, while one child underwent external ethmoidectomy. Our experience with endoscopic surgery in these four cases is discussed, along with a brief review of the advantage of this procedure over external surgery. Received: 7 February 1997 / Accepted: 12 November 1997     

Masked pseudomonal skull base osteomyelitis presenting with a bilateral Xth cranial nerve palsy

Skull base osteomyelitis classically presents as a complication of severe external otitis, middle ear, mastoid or sinus infection and can lead to multiple lower cranial nerve palsies when the jugular foramen is involved as a consequence of widespread involvement of the skull base. Bilateral skull base osteomyelitis is a recognized phenomenon, but has not previously been reported secondary to pseudomonal infection in the absence of a clinically obvious focus of infection. We report the case of a 77-year-old diabetic patient who presented with dysphonia and dysphagia and had a bilateral Xth cranial nerve palsy. No focus of infection was evident on presentation. Subsequent radiological investigation confirmed the diagnosis of bilateral skull base osteomyelitis.     

内镜经鼻手术治疗鼻源性脑脓肿临床分析并文献回顾

目的探讨鼻源性脑脓肿的发病原因、临床表现、诊断、治疗及预后，并分析鼻源性脑脓肿内镜手术的可行性,旨在提高耳鼻咽喉医生对该病的认识和治疗水平。方法报道3例鼻源性脑脓肿，并复习相关国内外文献。 结果本组3例患者均行鼻源性脑脓肿内镜手术，2例经手术治疗后痊愈，1例转神经外科行立体定向下脑脓肿穿刺置管术+脑室穿刺外引流术治疗后痊愈。 结论鼻源性脑脓肿少见，且症状多不典型。临床除传统治疗方式外，根据患者病情，鼻内镜手术可作为一种新的治疗手段。     

Cosmetic considerations in surgery for orbital subperiosteal abscess in children: experience with a combined transcaruncular and transnasal endoscopic approach

OBJECTIVE: To evaluate the outcomes of a new surgical approach in children with acute sinusitis and medial orbital subperiosteal abscess. DESIGN: Case series. SETTING: Tertiary pediatric hospital. PATIENTS: Eleven children aged 6 weeks to 13 years with orbital subperiosteal abscess and acute sinusitis who met indication for surgery by visual compromise and/or refractory course to medical therapy. INTERVENTION: The medial orbital abscess was drained via a transcaruncular approach, which provided access to the medial orbital wall. An endoscopic ethmoidectomy was also performed. MAIN OUTCOME MEASURES: Judgment of cosmetic appearance by surgeon and family, resolution of symptoms, length of hospital stay, and complications. RESULTS: All children had prompt resolution of symptoms after surgical drainage. Cosmetic outcome was excellent in all patients with no cutaneous scar or eyelid malposition. After edema and cellulitis had resolved, no family member could tell a difference in appearance between the eyes. No complications of these combined procedures were identified. One patient who had initially undergone transnasal endoscopic orbital drainage alone experienced a recurrence of infection 17 days later. He was then treated by the combined transcaruncular and endoscopic approach with prompt resolution of his symptoms. One of 4 patients treated initially with transcaruncular approach alone without endoscopic ethmoidectomy had recurrence of acute sinusitis and orbital abscess 16 months later and was successfully treated with an endoscopic approach. CONCLUSIONS: The combined endoscopic and transcaruncular surgical approach to medial orbital subperiosteal abscess and acute sinusitis provides a cosmetically superior outcome compared with standard orbital approaches requiring a cutaneous incision. The transcaruncular approach can be considered as an alternative or adjunct approach to the medial orbit, with the same cosmetic advantages as transnasal endoscopic drainage.     

Endoscopic surgery for the treatment of pediatric subperiosteal orbital abscess: A report of 10 cases

Introduction

The pediatric subperiosteal abscess is considered an infectious process characterized by an abscess pocket localized between the lamina papiracea and the periorbita. Usually the surgical management is used to drain the collection of pus.

Methods

Between January 2006 and January 2009, 10 patients of age under 18-year-old underwent through a transnasal endoscopic approach at the University of Bologna, Sant’Orsola Malpighi Hospital for the treatment of a subperiosteal orbital abscess. All these patients were taken to the operative room in order to drain the abscess only after that the CT scan was accomplished and it demonstrated the presence of a subperiosteal orbital abscess.

Results

The transnasal endoscopic approach was used alone in 9 cases while it was associated with an external approach in one case for the treatment of a superolateral based subperiosteal orbital abscess. In all cases the exudate was obtained during the surgical procedure for the microbiological examination, although only 2 out of 10 cases had positive abscess cultures for Streptococcus pneumoniae.

Conclusions

The transnasal endoscopic approach is an effective surgical treatment to drain the collection of pus in all medially based subperiosteal orbital abscess, while it can be associated with an external approach for the treatment of a superolateral based subperiosteal orbital abscess.     

Versatility of the pedicled nasoseptal flap in the complicated basal skull fractures

With the advancement of transnasal endoscopic technique, endoscopic repair of basal skull fractures has considerably substituted former external approaches. The endoscopically feasible pedicled flap, named nasoseptal flap has been extending its range of application, since it was introduced for the reconstruction of the defect after resection of skull base tumors. We introduce two patients with complicated basal skull fractures at different sites who were successfully treated by the transnasal endoscopic approach using nasoseptal flap.     

Malignant external otitis

Malignant external otitis or skull base osteomyelitis and osteoradionecrosis of the skull base and the skull are potentially life-threatening conditions. The standard methods of treatment involve the use of antibiotics, local treatment and, where necessary, surgical excision of necrotic tissue. These approaches do not provide a complete cure in many cases. Severe functional deficits and even death can occur in advanced stages. We conducted a long-term retrospective follow-up study and report on a multimodal approach that we have been using with great success since 1987. The four cornerstones of this treatment are surgical debridement, combinations of antibiotics, specific immunoglobulins, and adjunctive hyperbaric oxygen therapy. This multimodal treatment approach has proved to be highly effective in improving the survival and quality of life of the patients concerned. These excellent outcomes justify the high costs that this therapy admittedly involves.     

Necrotizing external otitis in a patient caused by Klebsiella pneumoniae

Necrotizing external otitis is a potentially life-threatening infection involving the temporal and adjacent bones. The most frequent pathogen is attributed to Pseudomonas aeruginosa, but is rarely caused by Klebsiella pneumoniae. Recently, we encountered a 47-year-old diabetic man with a swollen obliterated external ear canal with granulation tissue on the right ear. Image study demonstrated skull base osteomyelitis, epidural abscess and cerebral venous sinus thrombi. It was later proved to be necrotizing external otitis caused by Klebsiella pneumoniae. He then underwent craniotomy for drainage of the epidural abscess, followed by intravenous ciprofloxacin and metronidazole for 2 consecutive weeks until both pus and blood cultures depicted no growth of pathogens. Based on this case, synergistic antibiotic therapy using a third-generation cephalosporin or quinolone (ciprofloxacin), accompanied by metronidazole, and even a short-term aminoglycoside is recommended for the treatment of severe Klebsiella-induced necrotizing external otitis. Surgical intervention should be limited without shedding of the pathogens.     

Tuberculous petrous apicitis

Tuberculous osteomyelitis of the temporal bone is a rare and dangerous entity that should be included in the differential diagnoses of infectious processes of the base of skull. A 21-year-old man presented with petrous apicitis, extradural and retromandibular abscesses, and paresis of the facial nerve. Immediate middle fossa craniotomy and drainage of the extradural abscess, in combination with a mastoidectomy, incision and drainage of the facial abscess, and antimicrobial therapy for gram-positive cocci, failed to check the destructive nature of the infection. The patient subsequently developed labyrinthitis, sensorineural hearing loss, and meningitis. Intraoperative biopsy specimens confirmed the presence of tuberculoid granulomas, and the infectious process responded to triple-drug therapy. Tuberculosis of the temporal bone should not always be considered an indolent infection. The management of tuberculous infection of the temporal bone is outlined.     

婴幼儿鼻腔先天性占位的诊断及鼻内镜手术治疗

目的 探讨婴幼儿鼻腔先天性占位的诊断与鼻内镜手术治疗。方法 总结分析12例婴幼儿鼻腔先天性占位的临床表现、鼻内镜检查、CT及MRI影像学及术中表现。结果 脑膜脑膨出3例,神经胶质瘤1例,错构瘤3例,畸胎瘤1例,血管瘤3例,胚胎性横纹肌肉瘤1例。结论 婴幼儿鼻腔先天性占位良性多见,治疗以手术完全切除为主,术前鼻内镜检查、增强薄层CT及增强MRI影像学检查对术前诊断、手术方式选择和手术风险评估十分必要。鼻内镜手术可以完全切除大多数病变,并且具有创伤小、视野清晰等优点。     

经鼻内窦镜手术关颅底外科的应用

为探讨经鼻内窥镜行颅底手术的可行性，笔者开展了经鼻内窥镜颅底外科手术５４例。结果显示：１０例脑脊液鼻漏修补术一次获得成功；１１例接受视神经管减压术，６例于术后１１ｄ－１个月伤侧恢复光感和眼前指数，余５例术后无明显改善；３例蝶鞍充填术的患者术后头痛症状消失；１７例垂体瘤、３例筛窥癌、８例鼻咽癌和１例造釉细胞瘤均获得完全切除；１例侵袭性垂体腺瘤大部切除。无严重并发症发生。提示：经鼻内窥镜颅底手术简便、     

Parapharyngeal and retropharyngeal space abscess: an unusual complication of chronic suppurative otitis media

Parapharyngeal and retropharyngeal abscess as a complication of cholesteatoma is an uncommon entity. We present the unusual case of a 32-year-old man with chronic suppurative otitis media, presenting with parapharyngeal and retropharyngeal abscess. This was treated with incision and drainage of the abscess followed by modified radical mastoidectomy for chronic suppurative otitis media.     

经鼻内窥镜手术在颅底外科的应用

为探讨经鼻内窥镜行颅底手术的可行性，笔者开展了经易内窥镜颅底外科手术54例。结果显示：10例脑脊液鼻漏修补术均一次获得成功；11例接受视神经管减压术，6例于术后11d～1个月伤侧恢复光感和眼前指数，余5例术后无明显改善；3例蝶鞍充填术的患者术后者痛症状消失；17例垂体瘤、3例筛窦癌、8例鼻咽癌和1例造釉细胞瘤均获得完全切除；1例侵袭性垂体腺瘤大部切除。无严重并发症发生。提示：经鼻内窥镜颅底手术简便、安全、有效，是一项临床可以开展与应用的外科技术，但须掌握好此类手术的适应证。     

Endoscopic approach to lesions of the sphenoid sinus, orbital apex, and clivus

OBJECTIVE: The expanding role of endoscopic management of sinonasal disorders includes approaches to the skull base. In this report, we review our experience approaching lesions of the sphenoid sinus, orbital apex, and clivus via a transnasal endoscopic technique. DESIGN: A retrospective, case series review of 15 patients presenting with skull base lesions approached via an endoscopic approach was performed. Emphasis was placed on analyzing the preoperative planning strategy and the surgical technique. SETTING: Academic referral center. RESULTS: We reviewed the medical records of 15 patients who underwent an endoscopic approach to the sphenoid sinus, orbital apex, or clivus. Ten patients presented with lesions of the sphenoid sinus and clivus. The lesions in this patient group included metastasis to the cavernous sinus and clivus (3); fibrous dysplasia (2); plasmacytoma of the clivus (2); and 1 patient each with cholesterol granuloma, meningoencephalocele, and recurrent teratoma. Five patients presented with lesions of the orbital apex. These included invasive fungal sinusitis (2), mucopyocele (2), and pseudotumor (1). Image-guided surgical navigation was used in each case, and all approaches consisted of entirely endoscopic transnasal techniques. CONCLUSIONS: Endoscopic approaches to the skull base are possible because of advancements in technology now available to the rhinologic surgeon. This report highlights the preoperative strategies and surgical techniques used in approaching lesions of the sphenoid sinus, orbital apex, and clivus. These extended techniques should provide a more direct, less invasive, and more cost-effective method for approaching select skull base lesions.     

Craniofacial resection for malignant nasal and paranasal sinus tumors assisted with the endoscope

Background

Craniofacial resection is regarded as the treatment of choice for paranasal malignant tumors invading the skull base. Even with this approach, the surgical view remains obscured when tumors in the deep nasal and paranasal sinuses are resected. Endoscopy provides a wide and clear surgical view in the deep and narrow nasal cavity. We report two patients who underwent craniofacial resection assisted with endoscope.

Methods

Two patients with malignant paranasal sinus tumor invading the anterior skull base underwent endoscope-assisted craniofacial resection.

Results

To avoid a limited surgical view in the sinonasal cavity, we performed craniofacial resection with endoscopic osteotomy and several procedures in the nasal cavity. The neurosurgeon performed anterior skull base osteotomy at an appropriate site from above, while the otolaryngologist provided illumination with the endoscope from below and preserved the adjacent structures. The patients recovered uneventfully and the endoscopic examinations of both patients 18 months after the surgery showed no recurrence.

Conclusions

Endoscopes were useful for the craniofacial resection at osteotomy, providing illumination from below and at the several procedures in the deep part of the nasal cavity. If a lateral rhinotomy incision is made, the combined transfacial and transnasal approaches avoid the limited working angle associated with the transnasal approach alone. Although an endoscopic approach is useful for treating sinonasal tumors, we should recognize its advantages and limitations.     

经鼻内镜手术治疗颅底脊索瘤

脊索瘤是一种起源于胚胎发育时期残留脊索组织的先天性低恶性肿瘤，多发生于骶尾部及颅底中线部位，尤其是斜坡区域，其预后与肿瘤切除程度密切相关，肿瘤完全切除的患者多能长期生存。由于颅底脊索瘤多呈浸润性生长，侵袭范围广，累及颅底重要神经、血管及脑组织等，手术完全切除极其困难，因此被认为是神经外科治疗的难题之一。近年来随着神经内镜技术的发展，以及术中神经导航系统、电生理监测、经鼻超声系统和多普勒超声血管探测仪等监测技术的广泛应用，经鼻内镜入路能在直视下最大可能地安全切除颅底脊索瘤，并尽可能保留重要神经、血管功能，其手术创伤小，术后脑脊液漏等并发症发生率低，并且患者生存质量明显提高，已成为颅底脊索瘤手术治疗的首选方法。为进一步全面认识经鼻内镜治疗颅底脊索瘤的疗效及优缺点，我们查阅了近年来国内外公开发表关于经鼻内镜手术治疗颅底脊索瘤的相关文献，并从术前肿瘤评估分型、手术策略、肿瘤手术切除程度及其影响因素以及术后并发症等几方面对其进行综述。     

Complicated necrotizing otitis externa

Necrotizing (malignant) otitis externa (NOE) is a rare and invasive infection originating in the external acoustic meatus seen most commonly in diabetes and other immunocompromised states. After a protracted course, disease can smolder and extend into the mastoid, skull base, dural sinuses, and intracranially. We present a case of NOE complicated by mastoiditis, dural sinus thrombosis, and Bezold’s abscess in an uncontrolled diabetic presenting with a prolonged course of facial nerve palsy. We stress the importance of maintaining a high index of clinical suspicion for NOE in diabetic patients and offering timely, aggressive treatment to mitigate its complications.     

Anatomical landmarks for transnasal endoscopic skull base surgery

Resection of midline skull base lesions involve approaches needing extensive neurovascular manipulation. Transnasal endoscopic approach (TEA) is minimally invasive and ideal for certain selected lesions of the anterior skull base. A thorough knowledge of endonasal endoscopic anatomy is essential to be well versed with its surgical applications and this is possible only by dedicated cadaveric dissections. The goal in this study was to understand endoscopic anatomy of the orbital apex, petrous apex and the pterygopalatine fossa. Six cadaveric heads (3 injected and 3 non injected) and 12 sides, were dissected using a TEA outlining systematically, the steps of surgical dissection and the landmarks encountered. Dissection done by the “2 nostril, 4 hands” technique, allows better transnasal instrumentation with two surgeons working in unison with each other. The main surgical landmarks for the orbital apex are the carotid artery protuberance in the lateral sphenoid wall, optic nerve canal, lateral optico-carotid recess, optic strut and the V2 nerve. Orbital apex includes structures passing through the superior and inferior orbital fissure and the optic nerve canal. Vidian nerve canal and the V2 are important landmarks for the petrous apex. Identification of the sphenopalatine artery, V2 and foramen rotundum are important during dissection of the pterygopalatine fossa. In conclusion, the major potential advantage of TEA to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, as against the open transcranial approaches which involve more neurovascular manipulation and brain retraction. Obviously, these approaches require close cooperation and collaboration between otorhinolaryngologists and neurosurgeons.     

Two cases of intractable malignant external otitis with skull base osteomyelitis alleviated by intraarterial antibiotic administration

Malignant external otitis (MEO) is a devastating external auditory canal infection usually occurring in the elderly with diabetes. MEO often progresses to potentially lethal skull base osteomyelitis (SBO) complications such as meningitis or multiple cranial nerve palsies. Poor vascularity in affected tissue due to diabetic microangiopathy and Pseudomonal infection is thought responsible for refractory infection. We conducted intraarterial antibiotic infusion (IA) in the external carotid artery of two subjects with intractable MEO deteriorating after long-term intravenous antibiotic administration with surgical debridement. IA raised the antibiotic concentration in infectious tissue. Clinical MEO manifestation was relieved just after starting IA, and IA therapy was followed by additional long-term intravenous and oral antibiotic administration, dramatically improving MEO while leaving only minimal infection at the skull base. These results demonstrate IA effectiveness in treating refractory MEO.