Endoscopic localization of the sphenopalatine foramen: do measurements matter?

The objective of this study was to evaluate different methods and measurements for localization of the sphenopalatine foramen (SPF) during endoscopic transnasal exposure. The study design consisted of descriptive anatomical study and the setting was in Microsurgical Cadaver Dissection Lab. Sixteen lateral nasal walls were dissected endoscopically to identify and localize the SPF. Multiple measurements were obtained from nasal sill (NS) to SPF, ethmoid crest (EC), and other related landmarks. The results showed that EC was identified in all sides with different degrees of projection. SPF extended below the inferior edge of EC, i.e., lying both in the superior and middle meatus, in 12 sides (75 %), while it was laying only in the superior meatus in 4 sides (25 %). An accessory foramen was identified in 3 sides (18.7 %), all of which were located in middle meatus. The distance from NS to SPF ranged widely from 55 to 76 mm (mean ± SD 64.4 ± 6 mm). The average angle of elevation formed between SPF to NS and nasal floor was 11.4° (range 11-12°). Although many previous studies have reported measurements to SPF, we do not believe these measurements are of practical help due to the wide range of measurements and the lack of standard reference points. The main constant landmark for SPF remains the EC. Since SPF frequently extends below EC, the mucoperiosteal flap should be extended below the inferior edge of this crest to avoid missing the middle meatal part of SPF or any accessory foramina.

Endoscopic Orientation of Juxta-pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications.

Introduction In sphenoid sinuses with ill-defined carotid bony landmarks, accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications, which is particularly reported in the endoscopic endonasal transsphenoidal approaches (EETAs). Objectives To describe an anatomical model for the endoscopic orientation of the juxta-pituitary segment of the ICA in relation to the lateral opticocarotid recess (OCR) as a nearby bony landmark. Methods Dissection was performed progressively, simulating the EETA, in twenty fresh adult cadavers. After reducing the posterior and lateral walls of the sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" on the juxta-pituitary segment of the ICA and lateral margins of the pituitary gland. Results The current results have enabled us to divide the region between the lateral OCRs into 3 compartments: 2 lateral parasellar compartments contain juxta-pituitary segments of the ICA with a mean width of 8 mm and a narrow range from 7 mm to 10 mm; and a central intercarotid sellar compartment represents the safe region for bone drilling, showing widely variable widths ranging from 9 mm to 20mm. In all specimens, the variation in the width of the intercarotid compartment correlated with the distance between both lateral OCRs. Conclusion The present study improves surgeon awareness of the variations in the course of the ICA through the EETA along sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements taken in the present study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with a higher risk of injury.

Endoscopic Orientation of Juxta-Pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications.

Accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications reported in the endoscopic endonasal transsphenoidal approaches (EETA) particularly, in sphenoid sinuses with ill-defined carotid bony landmarks. The purpose of this study was to describe an anatomical model for the endoscopic orientation of juxta-pituitary segment of ICA in relation to the lateral optico-carotid recess (OCR) as a nearby bony landmark. Cadaveric dissection was conducted progressively in twenty fresh adult cadavers simulating the EETA. After reducing posterior and lateral walls of sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" of the juxta-pituitary segment of ICA and lateral margins of the pituitary gland. Current results have enabled us to divide the region between lateral OCRs into three compartments. Two lateral parasellar compartments contain juxta-pituitary segments of ICA showing a mean width of 8 mm; with a narrow range of 7-10 mm; and a central inter-carotid sellar compartment represents the safe region for bone drilling showing widely variable widths ranging between 9 to 20 mm. In all specimens; variation in the width of the inter-carotid compartment correlated with the distance between both lateral OCRs. This study improves surgeons' awareness of the ICA course variations in the EETA through sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements gathered from this study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with higher risk of injury.

Outcome and Complications of Frontal Sinus Stenting: A Case Presentation and Literature Review.

INTRODUCTION: Frontal sinus surgery remains challenging to manage because of its complex anatomy and narrow outflow tract. A number of studies suggest the success of frontal sinus stenting to reduce postoperative complications in endoscopic frontal sinus surgery. However, failure and complications of frontal sinus stenting may occur. METHOD: We present a case of frontal sinus stenting with migration of the stent and erosion of the lamina papyracea together with a granulomatous reaction around the stent. PubMed and Medline search was also conducted to study the current evidence on frontal sinus stenting benefits and complications. RESULTS: Still there are no guidelines or universally accepted indications for the use of frontal sinus stenting in the literature. A limited number of studies suggest the success of frontal sinus stenting to reduce postoperative stenosis in endoscopic frontal sinus surgery. However, failure and complications of frontal sinus stenting may occur. Infection, pain, edema, and stent obstruction may also occur. Our case report also highlights the potential of orbital complications as well as the consequences of inducing a granulomatous reaction. CONCLUSION: The value of frontal sinus stenting is still a subject of debate. Complications of frontal sinus stenting are not uncommon and thus necessitate regular follow-up.

Endoscopic transnasal study of the infratemporal fossa: a new orientation.

INTRODUCTION: The medial portion of the infratemporal fossa (ITF) is not infrequently involved in sinonasal and skull base pathologies. However, endoscopic view of the ITF remains unclear with lack of studies addressing this region from the endoscopic perspective. METHODS: Using an extended endoscopic approach, the pterygopalatine and infratemporal fossae were dissected in 10 sides of five adult cadaver heads. A plane of dissection along the pterygoid base and the infratemporal surface of the greater sphenoid wing was developed. High-quality images were produced by coupling the video camera to a digital recording system. RESULTS: The foramen rotundum, ovale, and spinosum were accessed and new landmarks were described from the endoscopic point of view. The sphenomandibularis muscle was also highlighted. Maxillary and mandibular nerves and middle meningeal artery were all identified. Columellar measurements to the foramen rotundum and ovale ranged from 6.1 to 8.0 cm for the former and 7.0 to 9.1 cm for the latter, with a mean of 6.75 cm and 7.78 cm respectively. CONCLUSION: The current study provides a novel endoscopic orientation to the medial ITF. Such knowledge should provide an anatomical basis for experienced surgeons to endoscopically address this region with more safety and efficacy.

Endoscopic and Radiologic Findings in Failed Dacryocystorhinostomy: Teaching Pearls for Success.

BACKGROUND: Although several studies have commented on causes of dacryocystorhinostomy (DCR) failure, detailed description of anatomical findings in such cases remains insufficient. OBJECTIVE: Our objective was primarily to analyze radiologic, endoscopic, and intraoperative findings in patients presenting with failed DCR and secondarily to assess the outcome of revision endoscopic DCR (endo-DCR) carried out at our institution. METHODS: Twenty-four failed DCRs presenting to our tertiary care center were retrospectively analyzed. Data collection included patients' history, diagnostic, and management data, as well as thorough analysis of sinonasal CT scans, along with endoscopic and intraoperative findings. Outcome was also assessed in 21 cases with revision endo-DCR performed. RESULTS: The anterior part of uncinate process was not previously removed in 15 sides (62.5%), with unopened agger nasi in 13 sides (54.2%). The lacrimal bone was detected covering the posterior sac despite removal of the anterior ascending process of maxilla in 9 sides (37.5%). Rhinostoma was anterior to lacrimal sac in 2 sides (8.3%) and was below the sac in 7 sides (29.2%). Fibrous membrane covered the rhinostoma despite removal of all sac-overlying bones in 6 sides (25%). Other findings included intranasal adhesions, septal deviation, lateralized middle turbinate, granulation tissue, foreign body reaction, and chronic sinusitis. Nineteen of the 21 revision endo-DCRs were successful (90.5%). CONCLUSION: This study provides a precise anatomical description of findings in cases of failed DCR. Such information is paramount in helping surgeons enhance their learning curve, refine the surgical technique, and improve patients' outcome.

Bilateral Simultaneous Endoscopic Dacryocystorhinostomy: Outcome and Impact on the Quality of Life of the Patients.

Introduction Bilateral simultaneous endoscopic dacryocystorhinostomy (endo-DCR) has received little attention in the literature, thus many surgeons continue to address bilateral nasolacrimal duct obstruction at two stages, rather than in the same setting. Objective To evaluate the feasibility and the outcome of simultaneous bilateral Endo-DCR and its impact on the quality of life of the patients. Methods We have conducted a retrospective analysis of patients who underwent bilateral simultaneous endo-DCR between March 2013 and February 2017 at our tertiary care institution. The reviewed data included clinical presentation; operative details; success rate; pre and postoperative evaluation of the symptoms of the patients, using the Nasolacrimal Duct Obstruction Symptom Score Questionnaire; satisfaction of the patients, and improvement in the quality of life, assessed by the Glasgow Benefit Inventory (GBI) questionnaire. Results Out of 128 cases in which endo-DCRs were performed, 13 were bilateral (26 sides). Postoperative success was documented in 24 of the 26 sides (92.3%), with a mean follow-up duration of 16.2 months. The two failed sides were reported in the same case. The preoperative symptom score ranged between 12 and 80 (mean ± standard deviation [SD]: 38.23 ± 15.7). The postoperative symptom score was significantly lower (mean ± SD: 5.4 ± 12.9). The success rates in unilateral and bilateral cases were comparable, with no statistically significant difference. A notable improvement in the quality of life of the patients was also reported, with a mean GBI score of 81.38 ± 12.37. Conclusion Our results support that a simultaneous bilateral endo-DCR is a safe procedure that offers a high success rate, spares the patient from the stress of a second surgery, provides the patient with a bilateral resolution of the symptoms, and confers an immediate improvement in the quality of life of the patients.

Endoscopic Orientation of Juxta-pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications

Abstract Introduction In sphenoid sinuses with ill-defined carotid bony landmarks, accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications, which is particularly reported in the endoscopic endonasal transsphenoidal approaches (EETAs). Objectives To describe an anatomical model for the endoscopic orientation of the juxta-pituitary segment of the ICA in relation to the lateral opticocarotid recess (OCR) as a nearby bony landmark. Methods Dissection was performed progressively, simulating the EETA, in twenty fresh adult cadavers. After reducing the posterior and lateral walls of the sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" on the juxta-pituitary segment of the ICA and lateral margins of the pituitary gland. Results The current results have enabled us to divide the region between the lateral OCRs into 3 compartments: 2 lateral parasellar compartments contain juxta-pituitary segments of the ICA with a mean width of 8 mm and a narrow range from 7 mm to 10 mm; and a central intercarotid sellar compartment represents the safe region for bone drilling, showing widely variable widths ranging from 9 mm to 20 mm. In all specimens, the variation in the width of the intercarotid compartment correlated with the distance between both lateral OCRs. Conclusion The present study improves surgeon awareness of the variations in the course of the ICA through the EETA along sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements taken in the present study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with a higher risk of injury.

Retromaxillary Pneumatization of Posterior Ethmoid Air Cells: Novel Description and Surgical Implications.

OBJECTIVE: Retromaxillary pneumatization of posterior ethmoid (PE) air cells is an area that is yet to have appropriate description in rhinologic literature. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: First, 524 sides in 262 paranasal sinus computed tomography scans were analyzed: 350 normal sides were examined for PE pneumatization lateral to the sagittal plane of the medial wall of maxillary sinus posteriorly, and 174 diseased sides were similarly reviewed to check how pathology may affect identification and measurements. Following that, 153 operated sides in 84 cases prepared for revision endoscopic sinus surgery (ESS) were studied for residual diseased cells at different anatomic locations. RESULTS: Overall, retromaxillary PE pneumatization was identifiable in 416 of the 524 sides (79.4%). Lateral retromaxillary extension varied from 0.5 to 12.3 mm (mean ± SD, 4.8 ± 2.3 mm). This area of pneumatization is bounded anteroinferiorly by the junction between the posterior and superior walls of the maxillary sinus. Three cell types were described depending on the degree of lateral extension (type I, <3 mm; type II, 3-6 mm; type III, >6 mm). This cell, which we refer to as the Herzallah cell, was distinguishable from the anterior ethmoid Haller cell and was found to have residual disease in 50.3% of cases prepared for revision ESS. CONCLUSION: Retromaxillary extension of PE air cells varies considerably and requires attention during ESS. Residual undissected retromaxillary cell is a common finding in revision ESS and can contribute to inadequate disease clearance.

Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility.

BACKGROUND: The presence of large number of pilgrims during Hajj in Makkah region increases the risk of respiratory diseases. In this study, we aimed to assess the bacteriology of acute rhinosinusitis (ARS) during Hajj season and to demonstrate the antimicrobial susceptibility patterns that should guide the clinicians towards more appropriate antibiotic use. METHODS: Patients with ARS presenting during Hajj season of 2014 were prospectively enrolled. According to EPOS2012 criteria. Sampling of sinus secretions was performed from the middle meatus adjacent to the maxillary sinus ostium via endoscopic guidance. Over all, the study has covered all ENT, emergency and outpatient departments in Hajj. RESULTS: Two hundred and twenty six patients with ARS were enrolled in the study. Pathogenic bacteria were identified in 93 (41.2%) patients. Of the 93 patients with bacterial ARS, Staphylococcus aureus was isolated in 46 (49.5%) patients, out of which 13 (28.3%) were methicillin-resistant Staphylococcus aureus (MRSA).The second most common group of bacterial isolates was Enterobacteriaceae such as Escherichia coli, and various Klebsiella species. Antibiotic sensitivity showed that methicillin-sensitive Staphylococcus aureus (MSSA) was also sensitive to cephalosporins, quinolones and clindamycin, while exhibiting relatively less sensitivity rates to amoxicillin-clavulinic acid and macrolides. CONCLUSION: Our study demonstrates the importance of assessing the bacteriology of ARS to help implement guidelines for proper treatment and prevention protocols during Hajj season.