Indocyanine green fluorescence visualizes landmark arteries for endoscopic sinus and skull base surgery.

OBJECTIVE: Landmark arteries during endoscopic sinus surgery are currently identified on the basis of anatomy, CT imaging and navigation, and Doppler flowmetry. However, the advantage of intraoperative fluorescence imaging during endoscopic sinus surgery has not been demonstrated. This study aimed to investigate whether Indocyanine Green (ICG) is useful for visualizing landmark arteries during endoscopic sinus and skull base surgery. METHODS: Eight patients who underwent endoscopic sinus and pituitary surgeries and consented to study participation were included. After planned procedures were performed as usual, landmark arteries were examined by ICG endoscope. Recorded video and preoperative CT images were analyzed for identification of five landmark arteries: anterior ethmoidal artery (AEA), posterior ethmoidal artery (PEA), internal carotid artery (ICA), sphenopalatine artery (SPA), and postnasal artery (PNA). Identification of arteries was evaluated three grades: identifiable, locatable, unrecognizable. RESULTS: Eight patients and eleven sides were evaluated. The ICG dose was 2.5 mg/body and a single shot was sufficient for evaluation. 100 % of AEA was identified (9/9 sides), 86 % of PNA (6/7 sides), 56 % of ICA (5/9 sides), and 25 % of PEA and SPA (2/8 sides). CONCLUSION: ICG could visualize landmark arteries, even thin arteries like AEA, during endoscopic sinus and skull base surgeries. Visualization was affected by thickness of bone or soft tissue above arteries, blood clots, sensitivity setting, and angle and distance of near-infrared light irradiation. ICG visualization of landmark arteries may help avoid vascular injuries during endoscopic sinus and skull base surgeries, particularly of AEA, PNA and ICA.

Searching for the cheese: does ethmoid pneumatization affect the location of the anterior ethmoid artery?

Endoscopic sinus surgery is a widely used technique in otolaryngologic practice. To avoid complications, the locations of important anatomical structures, such as the anterior ethmoid artery (AEA), should be determined preoperatively. We want to evaluate the effect of ethmoid cavity pneumatization on the location of the AEA and to determine consistent landmark(s) for locating the AEA. 524 consecutive patients undergoing sinus CT scans between February and October 2012 were reviewed retrospectively. After the exclusion criteria were applied, 150 CT scans (300 sides) were selected for the study. A statistically significant positive correlation was found between ethmoid pneumatization and the distance of the AEA to the attachment of the inferior turbinate to the lateral nasal wall (Spearman's rho = 0.305; p < 0.001). Likewise, a statistically significant positive correlation was found between ethmoid pneumatization and the distance between the AEA and the frontonasal junction (Spearman's rho = 0.219; p < 0.001). We found that the artery was located mostly between the second and third lamellae [n 211 (71 %) cases]. There was no statistically significant correlation between ethmoid pneumatization and AEA location in terms of the lamellae. Increased ethmoid volume increases the distance of the AEA from the frontonasal junction and the lateral attachment of the inferior turbinate. However, increased pneumatization of the ethmoid cavity did not affect AEA localization in terms of the lamellae. Based on our findings, we suggest that using the lamellae to locate the AEA is reliable.

Pilot study comparing total intravenous anesthesia to inhalational anesthesia in endoscopic sinus surgery: novel approach of blood flow quantification.

OBJECTIVES: We compared anesthesia with sevoflurane-remifentanil hydrochloride (SR) to total intravenous anesthesia with propofol-remifentanil hydrochloride (PR) in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis in terms of sinonasal mucosal blood flow, the surgical field visualization score, and blood loss. METHODS: We performed a double-blinded prospective study at a tertiary care center in 23 adults scheduled to undergo endoscopic sinus surgery for chronic rhinosinusitis. The patients were randomized to receive SR or PR. The sinonasal mucosal blood flow was measured by optical rhinometry. The surgical field visualization score was based on the Boezaart scale. RESULTS: The groups had similar clinical characteristics. During the 60- to 90-minute and 90- to 120-minute operative time windows, the blood flow was significantly greater in the PR group than in the SR group (p = 0.04 and p = 0.03, respectively). The amounts of blood loss in the PR and SR groups were 152.9 +/- 161.3 mL and 355.9 +/- 393.4 mL, respectively (p = 0.12). The median ratios of the surgical field visualization score to the number of sinuses operated on in the PR and SR groups were 2.1 and 1.8, respectively (p = 0.52). CONCLUSIONS: The intraoperative blood flow, as determined by optical rhinometry, was significantly greater with anesthesia with PR than with anesthesia with SR, 1 hour into the procedure; however, this difference did not translate into differences in the amounts of operative blood loss or in the surgical field visualization scores.

Is there any relationship between the frontal cell and the Agger nasi cell and the localization of the anterior ethmoid artery?

OBJECTIVES: In this article, we examined the effect of the presence or absence of a frontal cell or an Agger nasi cell on the localization of the anterior ethmoid artery. PATIENTS AND METHODS: Coronal paranasal sinus computed tomography scans on 110 sides of 61 patients (35 males, 26 females; mean age 35.6 ± 12.7 years; range 15 to 72 years) who underwent surgery for septal deviation, concha bullosa, antrochoanal polyp between September 2006 and February 2008 were retrospectively evaluated and the anterior ethmoid foramen localization was measured according to the anterior nasal spine. The correlations of these measurements with the presence and absence of a frontal cell and an Agger nasi cell were investigated. RESULTS: The measurement of the anterior ethmoidal foramen according to anterior nasal spine was 18.2 ± 8.8 mm in the absence of an Agger nasi cell and was 20.3 ± 6.6 mm in the presence of an Agger nasi cell. This distance was measured as 20.0 ± 7.3 mm when the frontal cell was not determined. This measurement was 20.2 ± 6.5 mm in the presence of a frontal cell. According to the frontal cell types the results of the measurements were 20.5 ± 5.9 mm, 18.9 ± 8 mm, 20.6 ± 7.3 mm, for type 1, type 2 and type 3, respectively. Our results revealed that there were no significant relationship between the presence or absence of a frontal cell and an Agger nasi cell and the localization of the anterior ethmoidal foramen. CONCLUSION: The results of this study showed that the presence or absence of these cells does not affect localization of the anterior ethmoid artery.

Development of an Experimental Model for Studying the Nasosinusal and Skull Base Arterial and Venous Systems Using Iodinated Contrast and Latex in Cadavers.

BACKGROUND: Cadaver dissection remains one of the most reliable and safest ways to study anatomy, whereas computed tomography angiography (CTA) is an essential technology for enabling students to become familiar with human anatomy and surgical planning. Thus, the convergence of both radiologic and anatomic information is important for surgical success, especially in regions of complex anatomy such as the nasosinusal and skull base regions. Here we propose an experimental model in formalinized cadaver heads consisting of intravascular injection of colored latex and iodinated contrast mixture, followed by CTA scans of the nasosinusal and skull base arterial and venous systems before dissection. METHODS: Six cadaver heads that had been preserved for >5 years in 10% formaldehyde were immersed for 72 hours in a solution containing a dimethyldiethanol mono/dialkyloyl ester quaternary ammonium salt. In 5 of these heads, a mixture composed of latex, tissue ink, and iodinated contrast (Ultravist 300) was injected into the vascular system. CTA scans were performed sequentially after the injection, followed by endonasal and macroscopic dissections. RESULTS: There was good radiologic and macroscopic vessel uptake in 4 specimens, allowing a detailed anatomic study. CONCLUSIONS: An experimental model was made feasible by injecting iodinated contrast and colored latex into formalinized cadavers for CTA evaluation of the nasosinusal and skull base arterial and venous systems before performing dissections.

Anterior ethmoidal artery evaluation on coronal CT scans.

UNLABELLED: The anterior ethmoidal artery (AEA) is an important point for frontal and ethmoid sinuses surgery. CT scans can identify landmarks to help the surgeon find the AEA. AIM: To identify the landmarks of the AEA on the orbital medial wall and on the lateral wall of the olfactory fossa. and to correlate the presence of supraorbital ethmoidal cells with spotting the anterior ethmoidal artery canal. MATERIALS AND METHODS: Retrospective review of 198 direct coronal paranasal sinuses computed tomography (CT) scans from August to December, 2006. RESULTS: Supraorbital pneumatization was seen in 35% (70 scans). The AEA canal was seen in 41% (81 scans). The anterior ethmoidal sulcus was seen in 98% (194 scans) and the anterior ethmoidal foramen was seen in all the scans (100%). CONCLUSION: The anterior ethmoidal foramen and the anterior ethmoidal sulcus were anatomical landmarks present in almost 100% of the scans studied. There was a correlation between the presence of supraorbital pneumatization and AEA canal visualization.

The effect of blood pressure and cardiac output on the quality of the surgical field and middle cerebral artery blood flow during endoscopic sinus surgery.

BACKGROUND: A clear surgical field is critical during endoscopic sinus surgery (ESS). Hypotensive anesthesia and cardiac output (CO) may optimize the surgical field; however, evidence of their effect on bleeding and cerebral blood flow is conflicting. The aim of this study was to evaluate the effect of blood pressure (BP) and CO on intraoperative bleeding and middle cerebral artery blood flow velocity (Vmca ) during ESS. METHODS: This was a prospective randomized controlled trial. Patients undergoing ESS for chronic rhinosinusitis at a tertiary institution in 2013 were randomized to receive BP manipulation using target-controlled noradrenaline infusion during surgery to either their left or right sinuses. The contralateral side in each patient served as control. Bleeding was scored using a 0 to 10 point bleeding assessment scale (BAS, 0-10) and Vmca was measured using transcranial Doppler ultrasonography every 10 minutes or when surgically opportune, and time-matched with BP and CO. Data was analyzed using Bland-Altman methods. RESULTS: A total of 105 time points were collected across a mean arterial pressure (MAP) range of 32 to 118 mmHg. Significant correlations were demonstrated between MAP and Vmca (r = 0.7, p < 0.0001), MAP and BAS (r = 0.50, p < 0.0001), CO and Vmca (r = 0.57, p < 0.0001), and CO and BAS (r = 0.42, p < 0.0001). The best surgical fields were seen at 40 to 59 mmHg MAP. However, MAP below 60 mmHg produced >50% reduction in Vmca in more than 10% of time points. CONCLUSION: Balancing surgical visibility with organ perfusion remains a challenge. The results of this study show that moderate hypotension significantly improves the surgical field; however reducing BP below 60 mmHg may risk cerebral hypoperfusion.

Management of arterial injury during endoscopic sinus and skull base surgery.

PURPOSE OF REVIEW: The most feared complication during endonasal surgery is a carotid artery injury. The sheep model of carotid injury provides training for this event by giving a realistic endoscopic experience of major vascular injuries and tissue hemostasis. RECENT FINDINGS: The sheep model of carotid artery injury recreates the narrow nasal confines and high-flow/high-pressure vascular injury accurately reproducing the endoscopic challenges seen in such vascular emergencies. This has led to the development of surgical techniques that quickly and effectively control the field of bleeding and achieve reliable hemostasis including the crushed muscle patch new direct vascular closure technologies. Vascular emergency simulation training is achieving better outcomes for our patients. SUMMARY: All skull base surgeons are at risk of the unexpected carotid artery injury and recently, the sheep model not only effectively recreates this situation but has identified clinically tried and tested techniques at managing this situation and is improving patient outcomes.

Venous Abnormalities Leading to Tinnitus: Imaging Evaluation.

Venous anomalies are the most commonly identified abnormality by imaging in the work-up for pulse synchronous tinnitus. Potential diagnoses include idiopathic intracranial hypertension, sigmoid sinus wall anomalies, transverse and sigmoid sinus stenosis, jugular bulb anomalies, and prominent posterior fossa emissary veins. These causes are discussed in detail along with the association between sigmoid sinus wall anomalies and idiopathic intracranial hypertension.

The masquerade of vasculitis: head and neck diagnosis and management.

Wegener's granulomatosis and forms of giant cell arteritis result from vasculitis and masquerade with symptoms of common head and neck disease entities. Recognition of the manifestations of vasculitis can be made early in the disease course and confirmed pathologically, allowing effective therapy. Current therapy of Wegener's granulomatosis with Cytoxin and Imuran and steroids for giant cell arteritis frequently results in reversal of head and neck involvement, prevention of systemic disease, and prolonged survival.

Anatomic variations of the arteries of the nasal fossa.

OBJECTIVE: This study was performed for knowledge about the vascular supply of the nasal fossa and a description of the site of division and number of branches of the sphenopalatine artery. STUDY DESIGN: This study was performed on 10 fresh nonembalmed cadavers. Anatomic variations of nasal fossa arteries were studied. METHODS: First, 10 cephalic anatomic preparations were injected with red color latex into the right and left carotid arteries. Then, these specimens were sagittaly cut to dissect the sphenopalatine artery. Twenty vascularization cases were studied for the external branch of the sphenopalatine artery, and 10 cases were studied for the internal branch. RESULTS: The principal observations were: 1. the sphenopalatine artery division is 18 times in the infratemporal fossa and twice in the nasal fossa; 2. the nasopalatine artery supplies blood to the lower part of the septum and its anterosuperior area; and 3. the vascularization of the external wall is via the sphenopalatine artery through the arteries of the meatus and conchae. CONCLUSION: This study defines the vascular territories of the nasal fossa arteries and includes photographs of dissections.

Vascular lesions of the paranasal sinuses and nasal cavity.

The vascular supply to the face and paranasal sinuses is predominantly derived from branches of the external carotid artery. An extensive collateral arterial network exists between branches of the external carotid artery and the internal carotid artery that is important in the assessment of head and neck vascular disease. We illustrate the normal vascular anatomy and correlate cross-sectional and angiographic images of head and neck vascular disease, with a focus on lesions affecting the paranasal sinuses and nasal cavity.

Blood flow measurements in rabbit sinus mucosa. A comparison between fluorescein flowmetry and blood flow measurements with microspheres and Rb86Cl.

The blood flow of the sinus mucosa was studied in 14 rabbits of the New Zealand White strain. The blood flow was determined by fluorescein flowmetry and the values were compared with those obtained from the same sinus mucosa with use of Sn113 radioactively labelled microspheres and with Rb86Cl. One sinus cavity in each animal received nose drops prior to the blood flow measurement. The blood flow index in the sinus mucosa was 0.039 +/- 0.019 density units Xs-1 and was significantly reduced to 0.016 +/- 0.011 density units Xs-1 by administration of nose drops. Blood flow in the sinus mucosa was 1.0 +/- 0.53 ml X min-1 X g-1 as measured with microspheres and 0.52 +/- 0.12 ml X min-1 X g-1 with the Rb86Cl method. Following administration of nose drops the values were reduced to 0.29 +/- 0.13 and 0.22 +/- 0.07 ml X min-1 X g-1 respectively. There was a significant difference in blood flow obtained with the Rb86Cl and microsphere methods in the sinus mucosa without decongestion. This might be explained by possible shunting of blood in the mucosa due to hyperaemia caused by the surgical trauma to the sinus.

Pathophysiology of the paranasal sinuses.

The maxillary ostium is narrower when the subject is recumbent than when sitting. The oxygen content in the sinus is related to the patency of the ostium and to some extent to its size. A 90% gas exchange in the sinus normally requires only 5 minutes. The exchange is faster during nasal than during oral breathing. The mucosa of the maxillary sinus has a relatively high blood flow. Oxygen absorption by the mucosa is normally perfusion limited. A considerable part of the absorbed oxygen is utilized directly by the mucosa and not taken up by the blood flow.

Orbital sinus blood sampling in rats as performed by different animal technicians: the influence of technique and expertise.

In this study the influence of orbital sinus blood sampling on clinical signs was studied within the framework of various nutritional experiments. In order to assess the clinical signs in a random design, the rats were punctured in either the left or the right orbit. Thus, the effect of puncture within rats could be determined by comparing the left and right eye. Four animal technicians punctured a total of 303 rats, using different techniques. Orbital sinus blood sampling caused clinically visible alterations. The type, frequency and prognosis of the alterations differed with the person performing the puncture. Two experienced animal technicians were able to perform the technique without causing a statistically significant increase in alterations in punctured orbits. One less experienced animal technician caused severe abnormalities. The use of either a Pasteur pipette or a haematocrit capillary did not necessarily produce different results. Neither did puncturing the lateral vs the medial canthus of the orbit. By not applying chloramphenicol eye ointment in the conjunctival sac after puncture, the number of abnormalities in 'ocular discharge' and 'corneal alterations' in the punctured orbits was significantly decreased. Four punctures in the same orbit with 14-day intervals by a skilled animal technician did not cause a significant increase in abnormalities.

[Neuropsychiatric disorders induced by MDMA ("Ecstasy")]. / Troubles neuropsychiatriques liés à la MDMA ("ecstasy").

If neurotoxicity of MDMA (ecstasy) is now well documented in animals, it is not the same in humans. MDMA intoxication puts the problem of its possible link with the serotonin syndrome and the neuroleptic malignant syndrome. Neuropathological consequences following MDMA intake have been reported, including hemorrhaging and cerebral infarction, cerebral venous sinus thrombosis, and acute inflammatory CNS disease. However, the physiopathology of these complications remains unclear. In the same way, there have been various reports that have attributed MDMA to precipitating the onset of a wide range of psychiatric disorders including sleep disorders, cognitive disorders, panic attacks, depression, flashbacks, psychosis and severe paranoia. Findings suggest that these psychiatric manifestations might be consequences of MDMA induced brain serotonin neurotoxic lesions. All these data are examined from a critical review of the literature.

[Lateral sinus thrombophlebitis].

Lateral sinus thrombophlebitis (LST) is an intracranial complication of otitis media. Its incidence has markedly decreased in the era of antibiotic therapy but mortality is still high. A 13-year-old girl presented with fever, ear discharge and torticollis. On the day of admission LST was diagnosed from the clinical presentation and CT-scan. She was operated immediately and intravenous antibiotics were administered. Despite the rapid intervention, the course was protracted, with recurrent events of septic pulmonary embolism. Despite internal jugular vein ligation, fever continued and anticoagulant therapy was begun. The possibility of LST should be considered in patients with ear discharge and fever. CT-scan enables early diagnosis of LST and MRI has a role in detecting additional intracranial septal foci. Surgical intervention should be early and aggressive. The efficacy of jugular vein ligation is unclear; anticoagulant therapy should be considered.

[Treatment policy in thrombophlebitis lesions of the sigmoid sinus and internal jugular vein during intensive use of antibiotics]. / Taktika lecheniia tromboflebiticheskikh porazhenii sigmovidnogo sinusa i vnutrennei iaremnoi veny v period massivnogo primeneniia antibiotikov.

152 patients were admitted to the ENT hospital with the diagnosis thrombophlebitis of the sygmoid sinus (62.1% of the total number of the admitted patients with otogenic intracranial complications). The surgery was made early upon the admission. The authors advocate radical removal of the thrombus before, the start of hemorrhage from both sinus parts. In case of the absence of low hemorrhage the intervention on the internal jugular vein was decided on day 1-3 after the basic surgery depending on the clinical course. It is thought that in postoperative period antibiotic therapy should be supplemented with immune preparations made of donor blood, UV radiation of autoblood and hyperbaric oxygenation.

[Endoscopic study on the effects of controlled pressure on the mucosa of the nasal cavity and paranasal sinuses]. / Endoskopicheskoe issledovanie vliianiia upravliaemogo davleniia na slizistuiu obolochku polosti nosa i okolonosovykh pazukh.

Endoscopy with fiber endoscope Olimpus FNL-10 was performed to study the effects of controlled pressure on nasal mucosa. In 15 patients with aggravated chronic purulent sinusitis maxillary mucosa alterations were assessed using sinus-catheter and maxillary microsinusotomy. 12 patients with the same diagnosis underwent nasal mucosa examination with sinus catheter . The experiments with controlled pressure in the nasal cavity and paranasal sinuses demonstrate that the above pressure causes no damage to the mucosa, though it enhances hyperemia and diminishes edema in the area of osteomeatal complex as a result of changing the pressure (+) and (-).

[Aspiration cavernosotomy in vascular chronic hypertrophic rhinitis]. / Aspiratsionnaia kavernozotomiia pri sosudistoi forme khronicheskogo gipertroficheskogo rinita.

Sparing surgical intervention in the nasal cavity of children with chronic hypertrophic rhinitis and normalization of nasal breathing are important targets for pediatric rhinosurgeons. The technique of aspiration cavernosotomy in a vascular variant of nasal cavity hypertrophy including processes of vascular cut and one-stage aspiration of blood from the wound channel and nasal cavity meet the requirements of low-invasive surgery and maximally provides the safety of the nasal mucosa in the best traditions of submucous vasotomy. The instruments for aspiration cavernosotomy, technique of its conduction, surgical treatment results in 12 children and adolescents are described.