Contributors: Vincent Couloigner
We describe the excision of a nasal encephalocele obstructing the left nasal fossa with an anterior subcutaneous portion deforming the nasal pyramid in a four-year-old girl using endoscopic surgery combined to a Rethi approach. The anterior skull base defect was reconstructed using autologous conchal cartilage and temporal fascia.
Editor Recruited By: Sanjay Parikh, MD, FACS
DOI: http://dx.doi.org/10.17797/udewjr2ge7
Contributors: Ehab Hanna and Peleg Horowitz
Anterior skull base sinonasal malignancy previously biopsied as esthesioneurobastoma. Tumor extension through the left cribiriform plate and left lamina papyracea.
Author Recruited By: Dr. Ehab Hanna
Contributors: Timothy R. DeKlotz
With the widespread use of the endoscope in pituitary surgery, many technical nuances have emerged. Some surgeons still use a sublabial incision and a speculum, despite using the endoscope for visualization, while others favor approaches that are purely endonasal. Some surgical teams, using an endoscope-holder, work sequentially and individually, while others prefers two surgeons working together simultaneously. In this video, we demonstrate an endoscopic endonasal approach, in which the tumor resection is performed with a 4-hand technique with both surgeons working simultaneously.
DOI#: http://dx.doi.org/10.17797//bdxmmtst16
Concha bullosa represents a benign entity that can present problems for the endoscopic sinus surgeon by limiting access and visualization to the middle meatus. Additionally, this may be a significant contributor to a patient’s nasal obstruction, or the leading factor for osteomeatal complex obstruction. Endoscopic removal provides a quick, safe, and reliable means to deal with this issue and provide the appropriate surgery for the patient.
A 4 year-old boy presented to our tertiary center with acute left ethmoiditis and a subperiosteal orbital abscess. He presented with exophtalmia but had no visual impairment or limitation of ocular mobility.
CT-scan found a 8 mm large subperiosteal orbital abscess with no further complications.
Surgery was decided using a combined approach to drain the abscess and to obtain a bacterial sample: first external (incision in the inner canthus area) and then endonasal (functional endoscopic sinus surgery – FESS) to open the middle meatus and ethmoid.
External approach: 10 mm incision in the inner canthus region, elevation of the lamina papyracea periosteum until the abscess was reached. Rubber drain was put in place for irrigation.
Endonasal approach: after careful CT-scan examination, endonasal surgery was performed with a 30° rigid endoscope. The middle turbinate was medialised to expose the middle meatus, uncinectomy and antrostomy followed by anterior and posterior ethmoidectomy was performed.
Antibiotics were given intravenously for 5 days and saline irrigation on the drain was performed during 2 days. Patient was discharged after 5 days.
Dynamic internal nasal valve collapse is common form of nasal valve collapse that can be difficult to address surgically. There have been many surgical techniques described to stabilize and improve the function of the internal nasal valve. Our presented technique is a simple and reproducible surgical technique that has proved reliable in treatment of dynamic internal nasal valve collapse. This video clearly describes and demonstrates our internal nasal valve stabilization technique.
A 58-year-old female on Plavix presented to the ER with recurrent left-sided epistaxis after two prior endoscopic control of epistaxis at an outside hospital. The patient’s hemoglobin and hematocrit at presentation were 8.3 gm/dL and 25.4%. Given the unilateral presentation, antiplatelet therapy, and recently failed endoscopic control, the patient was taken to the operating room for transnasal endoscopic sphenopalatine artery ligation (TESPAL) with bipolar cautery.
Contributors:
Mathew Geltzeiler and Eric Wang
A 51 year-old male presented to an outside otolaryngologist with recurrent facial pain and congestion. He was found to have a left-sided nasal mass. A work-up was performed, complete with biopsy, which was diagnosed as non-intestinal type adenocarcinoma. He underwent resection via the endoscopic endonasal transcribriform approach. In this video publication, we present our preferred method of reconstruction for sinonasal malignancies treated by endoscopic transcribriform resection using a multilayered closure with the following: a subdural DuraGen inlay graft, a fascia lata onlay graft, and an extradural, extracranial onlay pericranial flap via nasionectomy. A lumbar drain was placed at the end of the case for CSF diversion until the fifth postoperative day.
Contributors:
Paul A. Gardner, MD, Eric W. Wang, MD, Juan C. Fernandez-Miranda, MD, and Carl H. Snyderman, MD, MBA
A 31 year-old male presented with diplopia and was found to have left sixth nerve palsy on physical examination. Work-up with MRI revealed a hypointense mass on T2 images involving the mid to lower clivus with penetration of the posterior fossa dura. The patient had no complaints of nasal obstruction, no prior nasal surgery or nasal trauma. Intraoperative frozen section analysis revealed chordoma.
Author Note: minute 3:41 “rostrum” was spelled incorrectly.
Contributor:
Eric Wang
A 49-year-old female presented with a one-year history of right frontal headaches, not controlled despite OTC medication. Work up with head CT revealed an osteoma of the right frontal sinus. The patient experienced no improvement in headache severity and elected to have surgical intervention.
Methods: ENT Fusion Navigation system was used during the entire case. A ball-tip probe was used to fracture out the uncinate bone and a backbiter was used to remove the uncinate in its entirety. The natural ostium of the right maxillary sinus was then visualized. Again, the backbiter was used to remove tissue anterior to the natural ostium. A straight Tru-Cut was used to remove the ostium towards the posterior fontanelle. The right middle turbinate was resected in order to gain sufficient access for the resection of the osteoma. In order to remove the right middle turbinate, a turbinate scissors were used to make 3 cuts along the attachment of the middle turbinate and this was pulled down. A down biter was used to open up the maxillary sinus inferiorly. There was no tissue seen in the maxillary sinus. After this was done, an ethmoidectomy was performed by placing a J-curette behind the ethmoid bulla point anteriorly. This ethmoid bulla was removed along with several other anterior ethmoid cells. After this was done, a frontal sinus seeker was used to identify the right frontal osteoma. The patient did not have a right frontal sinus. Instead, an osteoma was in the area of what would have been the right frontal sinus or nasal frontal outflow tract. Image guidance was meticulously used to identify the osteoma. A 70-degree frontal drill was used and this osteoma was slowly drilled to remove as much as possible. Drilling was done from the posterior edge of the osteoma up to the skull base superiorly, to the lamina papyracea laterally and all bone that could be safely removed was removed. A right frontal propel stent was placed in the bony cavity created by the drill out and after this, the sinus was irrigated and suctioned.
Results: The patient was sent to recovery in good condition and no adverse reactions were reported by the surgeon or patient.
Surgeons: Alissa Kanaan, MD. Zachary V. Anderson, MD.
Institution: Department of Otolaryngology – Head and Neck Surgery at the University of Arkansas for Medical Sciences.
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