Endoscope-Assisted Microsurgical Removal of an Epidermoid Tumor within the Cavernous Sinus

Epidermoid tumor of the cavernous sinus is rare. The aim of this case report is to discuss the role of neuroendoscopes in the removal of such lesions. A 21-year-old man presented with 6-year history of progressive headache, diplopia, and visual disturbance. Work-up revealed an epidermoid tumor located in the right cavernous sinus. An extradural transcavernous approach was utilized via a traditional frontotemporal craniotomy with endoscopic assistance. The postoperative course was uneventful with immediate improvement of the patient''s headache. Postoperative magnetic resonance imaging demonstrated complete removal of the tumor. There were no signs of recurrence during a 2-year follow-up period. The endoscope is a useful tool for removing epidermoid tumors from the cavernous sinus and enhances visualization of areas that would otherwise be difficult to visualize with microscopes alone. Endoscopes also help minimize the retraction of neurovascular structures.     

A rare case report of an solitary neurofibroma in postcricoid region of hypopharynx

Rationale:Postcricoid neurofibroma is an extremely rare hypopharynx tumor that can be challenging in both diagnosis and treatment. This case sheds light on the possibility of treatment with transoral microsurgery before pursuing open cervical incisions.Patient concerns: A 43-year-old man presented with a four months history of a persistent foreign body sensation and mild dysphagia. Indirect and direct laryngoscopy at admission revealed a round and smooth submucosal mass in the postcricoid region.Diagnosis:A laryngeal enhanced computed tomography and laryngoscopy suggested that the tumor located in hypopharynx, with clear boundary and slightly strengthened edge. A supporting laryngoscopy surgery was performed under general anesthesia and a biopsy confirmed solitary neurofibroma of the postcricoid region.Interventions:The tumor was successfully resected en bloc transorally through supporting laryngoscope, and obviated the need for open cervical surgery and tracheostomy.Outcomes:The patient recovered well without any intraoperative or postoperative complication and was discharged from hospital 2 days after surgery. There was no recurrence after 6 months follow-up.Lessons:Postcricoid neurofibroma is an extremely rare hypopharynx tumor that can be diagnostically challenging. To the best of our knowledge, this is the first case reported of solitary neurofibroma originating from the postcricoid region of the hypopharynx and was surgically removed with transoral surgery through supporting laryngoscope.     

Targeted Endodontic Microsurgery: Implications of the Greater Palatine Artery

IntroductionTargeted Endodontic Microsurgery (TEMS) combines trephine burs and 3D-printed guides to make flapless maxillary palatal root-end surgery possible. This study assessed the location of the greater palatine artery (GPA), the relationship of the GPA to maxillary molar root ends, and the feasibility of flapless palatal-approach TEMS.MethodsThree endodontists analyzed 250 cone-beam computed tomographic images of maxillary molars for (1) transition morphology between the hard palate and the alveolar process adjacent to first and second molars as an indication of the most likely location of the GPA, (2) the superior-inferior relationship between the GPA and root ends, and (3) the feasibility of palatal-approach TEMS.ResultsPalatal transition morphology included 20% Spine, 72% Bridge, and 8% Smooth. GPA position as related to palatal root ends was classified as 34% superior, 40% adjacent, and 21% inferior. Five percent of classifications were undefined. TEMS was deemed feasible for 47% of maxillary first molars and 52% of second molars, and was significantly more feasible with GPAs superior to palatal root ends. Reasons for infeasibility included GPA proximity and unfavorable resection angle or level. Maxillary first molar palatal roots were 11.13 ± 2.68 mm from the greater palatine foramen (GPF) and 2.37 ± 1.46 mm from the GPA. Second molar palatal roots were 4.94 ± 2.55 mm from the GPF and 2.53 ± 1.77 mm from the GPA.ConclusionsPalatal transition morphology and GPA position adjacent to maxillary molars, as manifested in cone-beam computed tomographic coronal views, suggested maxillary palatal root TEMS could be accomplished with a 2-mm safety margin in 47% of first molars and 52% of second molars. Historical paradigms that do not consider flapless palatal surgical approaches may need to be revised.     

Selective Retreatment and Sinus Lift: An Alternative Approach to Surgically Manage the Palatal Roots of Maxillary Molars

Endodontic microsurgery on the palatal root of maxillary molars presents a clinical challenge because of the root position and approximation from the maxillary sinus floor. Attempting a buccal or a palatal approach to address the root is associated with limited accessibility and visibility as well as the risk of injury to the maxillary sinus membrane and/or the greater palatine nerves and vessels. If all the maxillary molar roots require surgical intervention, two flaps may even be needed, which can make the procedure technically more difficult and lengthier. This case report presents 2 clinical cases in which apicoectomy was needed on the palatal roots of maxillary molars. The treatment includes selective nonsurgical retreatment of the palatal root and obturation using a root repair material followed by a surgical intervention from a buccal approach to treat the buccal roots, sinus lift using piezosurgery, and root resection of the palatal root. The approach was successful in both cases without any untoward events. We monitored the radiographic changes using cone-beam computed tomographic imaging immediately after the surgery and at multiple follow-up appointments. The cone-beam computed tomographic images revealed healing of the periapical disease around all the roots up to 14 and 24 months and apical repositioning of the maxillary sinus floor.     

Long-term Success and Survival of Endodontic Microsurgery

IntroductionHealed rates of endodontic microsurgery (EMS) may decrease over time, but research on the long-term outcomes is scarce. The aims of this retrospective cohort study were to evaluate the 5- to 9-year healed and survival rates of EMS, to identify associations between prognostic factors and healing status, and to compare the short-term (1- to 2-year) with long-term (5- to 9-year) outcomes.MethodsOne hundred fifty-one eligible patients (166 teeth) who underwent EMS in 2007–2010 were invited for a follow-up examination. Eighty-three patients (94 teeth) participated in the study. Survival status and reasons for extraction of all teeth were determined, and survival rates were calculated by Kaplan-Meier analyses. Outcomes were determined on the basis of clinical and radiographic findings and associated with potential prognostic variables via multivariate Cox regression analyses.ResultsThirty-two teeth were extracted: 6 because of endodontic failure, 20 for unrelated reasons, and 6 for unknown reasons. Outcomes were categorized as healed and not healed. Multivariate analysis revealed that adjusted hazard ratio for failure was 5.95 times higher (95% confidence interval, 1.54–22.91) for teeth treated with intermediate restorative material than with mineral trioxide aggregate and 3.38 times higher (95% confidence interval, 1.05–10.9) for teeth with no known history of nonsurgical retreatment. Teeth classified as healed in the 1- to 2-year review mostly remained healed at 5- to 9-year review (45/48 teeth); those with uncertain healing had varied outcomes at long-term review.ConclusionsEMS results in high long-term healed (78.3%, 72/92 teeth) and survival (95.2%) rates. Root-end filling material and nonsurgical retreatment before EMS may influence the long-term outcome.     

Endodontic Microsurgery with Orthodontic Treatment in a Mandibular Left Molar with Symptomatic Apical Periodontitis

Endodontic microsurgery has reduced the degree of treatment trauma compared with traditional apical surgery and further increased the success rate of natural teeth retention. However, when root apices of the mandibular posterior teeth are far from the buccal cortical bone surface or near to the inferior alveolar nerve, the operational difficulty of endodontic microsurgery increased greatly. Orthodontic treatments may be helpful to decrease the difficulties. In this case, the roots of a highly calcified mandibular molar diagnosed as previously initiated, symptomatic apical periodontitis were moved initially buccally by orthodontic treatment in 2 months. Then, endodontic microsurgery was completed. The tooth remained asymptomatic and functional with a radiographically healing periapical lesion at the 4-, 12-, and 24-month follow-ups.     

Mr lymphangiography: How i do it

Lymphedema is a chronic progressive edematous disease that in the United States is most commonly related to malignancy and its treatment. Lymphaticovenular anastomosis is a recently introduced microsurgical treatment option for lymphedema that requires the identification and mapping of individual lymphatic channels. While nuclear medicine lymphoscintigraphy has been the primary imaging modality performed to evaluate suspected lymphedema, lymphoscintigraphy does not provide the spatial information necessary for presurgical planning. High‐resolution dynamic 3D magnetic resonance imaging (MRI) can noninvasively image abnormal lymphatic channels to both diagnose lymphedema and depict the location and number of individual lymphatic channels for surgical planning. MR lymphangiography can be performed at 1.5T or 3.0T using multichannel phased array surface coils. The main components of the exam are a heavily T₂‐weighted 3D sequence to define the severity and extent of edema, a high‐resolution dynamic 3D gradient echo imaging after intracutaneous contrast injection to visualize lymphatic channels, and a delayed 3D gradient echo sequence after intravenous contrast to define veins. This article reviews the pathophysiology and microsurgical treatment of lymphedema, presents the imaging protocol used at our institution, and describes exam interpretation and the image postprocessing performed for surgical planning. J. MAGN. RESON. IMAGING 2015;42:1465–1477.     

显微手术治疗脑胶质瘤的临床疗效探讨

目的对显微手术治疗脑胶质瘤的临床疗效及复发影响因素进行探讨。方法回顾性分析2010年1月至2013年1月运用显微手术治疗96例脑胶质瘤患者的临床资料,分析其手术疗效和复发影响因素。结果所选患者使用显微外科手术肿瘤全切74例,占77.1%,次全切19例,占19.8%,部分切除3例,占3.1%;出院时恢复良好57例(59.4%),基本好转26例(27.1%),显效8例(8.3%),进步5例(5.2%),无1例死亡;随访1~3年,所有患者获得随访,恢复正常者58例,占60.4%,38例复发,其中19例再次手术,死亡3例(非手术死亡),15例拒绝再次手术,死亡6例;低级别胶质瘤复发的发生率为15.4%,明显低于高级别胶质瘤的68.2%,差异有统计学意义(P0.05);年龄小于等于40岁的发生率为29.2%,明显低于大于40岁的50%,差异有统计学意义(P0.05);全切组的复发发生率为16.2%,明显低于次全切、部分切除的72.7%,差异有统计学意义(P0.05)。结论显微手术可明显提高肿瘤全切率,使手术疗效大大提高,从而提高生活质量,降低复发率及病死率;且术后的复发率与肿瘤组织分型、年龄、手术方式有关。