Maxillary sinusitis developed as sequelae of accidental middle turbinectomy that occurred during nasotracheal intubation: a case report.

BACKGROUND: Nasotracheal intubation is a very useful technique for orofacial or dental surgery. However, the technique itself can be more traumatic than that of orotracheal intubation. Complications such as turbinectomy or bleeding are often reported. However, little is known about the follow-up of patients after these complications. CASE PRESENTATION: The present case describes an accidental middle turbinectomy that led to endotracheal tube obstruction during nasotracheal intubation, and discusses its long-term follow-up. A 19-year-old man underwent mandibular surgery under general anesthesia and nasotracheal intubation. His right middle turbinate was completely avulsed and became firmly occluded within the tube during nasotracheal intubation. The nasotracheal intubation was performed again and the operation was completed safely. The patient was discharged without sequelae after postoperative care. However, he had symptoms of nasal obstruction and sleep disturbance for 3 months postoperatively. Synechiae were detected between the nasal septum and lateral nasal wall on a right rhinoscopic examination and facial computed tomography at 3 months postoperatively. Additionally, he showed ipsilateral maxillary sinusitis on facial computed tomography at the 2-year follow-up examination. CONCLUSIONS: Nasotracheal intubation can cause late complications as well as early complications. Therefore, if nasotracheal intubation is to be performed, the anesthesiologist should identify the nasal anatomy of the patient accurately and prepare appropriately. In addition, if complications occur, follow-up observation should be performed.

Comparative Study of the Effectiveness of sub mucosal Partial Inferior Turbinectomy and Out fracture of Inferior Turbinate in the Nasal Respiratory Function of Rhinoplasty Patients.

INTRODUCTION: The inferior turbinate is a critical and dynamic structure during rhinoplasty in the internal valve. Many surgeons try to preventively reduce its resistance against the path in the post-rhinoplasty period. To this end, the two methods of "sub mucosal partial inferior turbinectomy" and "inferior turbinate out fracture" are compared in the present study. METHODS: In this clinical study, 110 rhinoplasty candidates were randomly divided into two groups, namely sub mucosal partial inferior turbinectomy and out fracture of the inferior turbinate. To assess the complications, the Sino-Nasal Outcome Test (SNOT-22) was used prior to surgical intervention, and 1, 2, 3, 6, and 12 months following the rhinoplasty procedures. RESULTS: Based on the results of this clinical study and according to the SNOT-22 questionnaire, there was no significant difference between the two groups prior to surgery and a month following the surgery (P > 0.05). However, the average SNOT-22 score for the sub mucosal partial inferior turbinectomy group was significantly lower than that of the group with the out fracture of the inferior turbinate, 2, 3, 6, and 12 months following the surgery. CONCLUSION: Both "sub mucosal partial inferior turbinectomy" and "out fracture of inferior turbinate" are effective methods in improving the respiratory function of rhinoplasty patients, yet the former method is more effective than the latter as regards improving the respiratory function of patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Iatrogenic Through-and-Through Conchal Defect Secondary to Auricular Cartilage Graft.

BACKGROUND: Over the past few years, conchal cartilage has been most often used in rhinoplasty. The donor site complications following conchal cartilage graft harvesting are scar formation, hematoma formation, and delayed wound healing, although hematoma is one of the most important and common complications. A complete conchal defect as a complication of auricular cartilage graft harvesting has not been previously reported in the literature. The authors report an unusual case of an iatrogenic conchal defect resulting from conchal cartilage graft harvesting that was treated using a posterior auricular island flap. METHODS: A 24-year-old male with a left conchal inflammation and perforation visited our plastic surgery department after receiving augmentation rhinoplasty and tip plasty using a conchal cartilage graft. A tight dressing had been applied to the ear, and postoperative infection was uncontrolled, which resulted in iatrogenic conchal perforation. RESULTS: A tie-over bolster dressing has been widely used to prevent hematoma following conchal cartilage graft harvesting with an associated donor site complication. However, a tight tie-over dressing and inappropriate postoperative care can cause complete through-and-through conchal defects. The posterior auricular island flap provides an elegant means of reconstructing conchal defects. CONCLUSIONS: In the described case, aesthetic reconstruction of a conspicuous iatrogenic conchal defect was achieved with minimal scarring using the posterior auricular island flap. To the best of our knowledge, this report is the first to describe reconstruction of an iatrogenic defect in the concha as a complication of auricular cartilage graft harvesting. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Potential Significance of Concha Bullosa During Nasotracheal Intubation.

The authors experienced a case of severe epistaxis caused by accidental partial middle turbinectomy during nasotracheal intubation, which the patient had bilateral concha bullosa narrowing the nasal airway. Although anesthesiologist checked nasal airway through subjective symptoms and the size of both nostrils, they tend to overlook common anatomic variation, concha bullosa, and can injure turbinate structures. Therefore, preoperative computed tomography images should be carefully evaluated for the possibility of concha bullosa, which narrows nasal airway and induces the traumatic injury or epistaxis during nasotracheal intubation.

Middle turbinectomy after nasotracheal intubation.

Nasotracheal intubation (NTI) is used for maintaining airway access during maxillofacial surgery or in cases of severe oral trauma. We describe a case of middle turbinectomy complication as a result of NTI. The purposes of this paper are to raise awareness of this complication and review associated imaging findings.

Skull base injury with extensive pneumocephalus after transnasal endotracheal intubation.

Iatrogenic injuries of the frontal skull base commonly occur during endoscopic sinus surgery. In this paper, we present a rare case of cranial base injury after transnasal endotracheal intubation for dental surgery. A 61-year-old otherwise healthy man presented at the emergency department with headache, right leg weakness and watery nasal discharge on the left side. He underwent a dental surgery under general anaesthesia with transnasal endotracheal intubation 2 days earlier. A CT of the head showed a bone defect of the left skull base with a bifrontal pneumocephalus. Urgent endoscopic sinus surgery with exposure of the skull base was performed. The anterior part of the middle nasal turbinate was found dislocated and resulted in an injury of the lateral lamella of the cribriform plate. After endoscopic reconstruction of the bone defect, the patient showed a rapid improvement of symptoms. Two years after surgery the patient is free of symptoms.

Clinical significance of middle turbinate lateralization after endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: To investigate the clinical significance of middle turbinate lateralization (MTL) occurrence postendoscopic sinus surgery (ESS) for chronic rhinosinusitis, namely, association with postoperative symptoms and eventual need for undergoing revision surgery. STUDY DESIGN: Retrospective chart review of consecutive postoperative follow-up appointments (November 2009-May 2011) for patients who had had full-house ESS (post hoc analysis). METHODS: Endoscopic video recordings were reviewed by a blinded reviewer to determine occurrence of MTL (any portion of the middle turbinate touching the lateral nasal wall). Postoperative symptom questionnaires using the Adelaide scoring system were collected. Records were reviewed to determine the need for revision surgeries during follow-up. RESULTS: A total of 151 patients had follow-up with video endoscopy from 2009 to 2011. No statistically significant association between MTL and symptoms was found (P > .05). Of the patients with MTL, 21% required revision versus 9% in those who had no MTL (P = .07). Log-rank test showed that there was a statistically significant difference between the revision surgery survival curves for the MTL and no-MTL groups (P = .03). Controlling for the inability to examine the frontal sinus, the difference between the two survival functions increased (P = .005). CONCLUSIONS: MTL was not associated with patient-reported symptoms, but may be associated with a more rapid need for future revision surgery. We hypothesize that this effect is related to interference with the frontal sinus.

Turbinate-septal suture for middle turbinate medialization: a prospective randomized trial.

OBJECTIVES/HYPOTHESIS: One of the primary goals of endoscopic sinus surgery (ESS) is to create widely patent paranasal sinus ostia, but lateralization of the middle turbinate (MT) after ESS can obstruct otherwise patent ethmoid and maxillary sinuses. The aim of this study was to evaluate the effectiveness of turbinate-septal suturing in preventing lateralization of the MT. STUDY DESIGN: A prospective, randomized, blinded controlled study. METHODS: The study was performed in 120 patients who had undergone ESS. The patients were randomized to receive nasal (group A) or turbinate-septal suture plus nasal packing (group B). Postoperative lateralization of the MT and synechia formation were assessed as the primary outcome 3 months post-ESS. The Lund-Kennedy Scores at 1 week, 2 week, and 1 month after ESS were assessed as the secondary outcomes. RESULTS: A total of 120 patients were enrolled (60 patients in each group). Group B had a significantly lower rate of MT lateralization compared to group A after 3 months of surgery (6 of 120 sides vs. 19 of 120 sides; P < 0.01). Synechia formation rates in groups B were also significantly lower than those in group A (4 of 120 sides vs. 13 of 120 sides; P = 0.023). CONCLUSION: Middle turbinate-septal suturing medialization during ESS is an effective method for preventing lateralization of the MT.

Utilization and dissection for endoscopic sinus surgery training in the residency program.

OBJECTIVE: To develop an animal cadaver model that would allow residents to learn functional endoscopic sinus surgery as a complementary model. STUDY DESIGN: Prospective experimental study. PATIENTS AND METHODS: Two of our first-year residents were included in the study, and each operated on 5 sheep noses. All the routine steps of endoscopic sinus surgery were performed, except for sphenoidotomy, and their success and complication scores were recorded. The residents' performance for maxillary antrostomy, ethmoidectomy, and frontal sinusotomy in sheep cadaver noses were evaluated by the authors. Predissection and postdissection computer tomography assessed the completeness of dissection. Images were analyzed for maxillary antrostomy, frontal sinusotomy, residual ethmoid cells and partitions, and residual frontal recess cells. The first and last 5 sides of residents were analyzed together as the first 10 sides (group 1) and last 10 sides (group 2). RESULTS: Group 2 had significantly better outcomes for frontal sinusotomy and ethmoidectomy (P = 0.011 and P = 0.003, respectively). The mean duration of procedures for group 1 was 15.7 minutes and that for group 2 was 10.3 minutes (P = 0.000). The difference was not significant between the 2 groups when comparing the success rates of maxillary antrostomy and the complication rates (P > 0.05). CONCLUSIONS: The nasal cavity of the sheep is anatomically similar to the human nasal cavity, and the model using sheep cadaver for endoscopic sinus surgery training is a cost-effective and useful model for the first step of the learning curve.

A rare complication of nasotracheal intubation: accidental middle turbinectomy.

In this paper, we are presenting a rare case of accidental middle turbinectomy, a complication of nasotracheal intubation. We have reviewed the literature and addressed important parameters on nasotracheal intubation to avoid damage to the turbinates and its possible serious complications.

Penetrating injury of the maxilla by needlefish jaws.

INTRODUCTION: Needlefish penetrating injuries have become a worldwide problem, inflicting critical morbidities and even mortalities. This is the first published case of needlefish injury in the Mediterranean basin. CASE REPORT: A 29 year old man was admitted to Meir Medical Centre in Israel with a penetrating facial wound caused by elongated needlefish jaws. The severity of the wound contrasted greatly with the expected injury from collision with a fish inflicting a small penetration lesion. The rigid jaws penetrated the maxilla transversely and obliquely from the left canine-fossae, through the nasal cavity, and to the right maxillary sinus, with its tip reaching the right medial-inferior orbital wall. The needlefish jaws were completely removed using a combined endoscopic and external approach. The course of surgery and hospitalization was uneventful and the patient was discharged with no complications. CONCLUSIONS: Fish inflicted critical facial injuries might be dangerously underestimated prima facie. The impact might be energetic enough to penetrate deep facial and vital cranial structures, hence thorough examination and imaging are recommended. Needlefish species are now common in the tropical and subtropical regions of all oceans and therefore this phenomenon is of interest to worldwide trauma medical providers, fishermen, divers, and also to marine-biologists.

Harmartoma vascular de cornete inferior: reporte de dos casos / Vascular hamartoma of the lower turbinate: report on two cases

Un hamartoma es una malformación no neoplásica, compuesta por células maduras y tejidos originales del órgano en el que aparece. Los hamartomas del tracto nasosinusal tienen una incidencia muy baja y se localizan con mayor frecuencia en el tabique nasal. La histología publicada en la literatura está constituida principalmente por tejido epitelial. A continuación presentamos los casos de dos pacientes con hamartomas vasculares de cornete inferior, los primeros reportados en esta localización. En ambos se realizó una resección quirúrgica por vía endoscópica.

Frecuencia de rinitis atrófica y grado de lesión de los cornetes nasales de cerdos en Yucatán, México / Frequency of atrophic rinitis and the degree of lesions in pig nasal turbinates from Yucatan, Mexico

Introducción.- El complejo respiratorio de los cerdos es uno de los principales síndromes que afectan a la industria porcina, debido al efecto negativo que tiene sobre los costos de producción por concepto de mortalidad, tratamientos, disminución en la ganancia diaria de peso y aumento en la conversión alimenticia. El objetivo de este estudio fue determinar la frecuencia de las lesiones macroscópicas en cornetes de cerdos finalizados obtenidos en el mercado municipal No. 32 de Mérida, Yucatán, México. Materiales y Métodos.- Se inspeccionaron 101 hocicos de cerdos de engorda finalizados adquiridos en el mercado municipal No. 32 de Mérida, Yucatán, México, de abril a junio de 1997. Con un rinómetro se determinó el grado de rinitis. A los casos positivos a rinitis atrófica progresiva (RAP) se les realizó un análisis histopatológico y bacteriológico. Resultados.- Cincuenta y cinco (54.5 por ciento) hocicos presentaron RAP. Treinta y tres (60.0 por ciento) cornetes nasales presentaron grado 2, 17 (30.9 por ciento) cornetes nasales con grado 3 y 5 (9.1 por ciento) cornetes nasales con grado 4. Se observó 1 (1.8 por ciento) caso con cuerpos de inclusión y correspondió al grado 4 de RAP. Se aislaron Pasteurella multocida en 2 (3.6 por ciento) casos positivos a RAP y correspondieron a los grados 2 y 4 y Bordetella bronchiseptica en 3 (5.5 por ciento) muestras y correspondieron a los grados 2, 3 y 4 de RAP. Discusión.- Las diferencias encontradas entre la RAP de este estudio y las reportadas por los diferentes autores, probablemente se debieron a la técnica utilizada. La baja frecuencia de aislamientos probablemente se debió a que las muestras fueron tomaron de cerdos sacrificados en el rastro, lo cual pudo favorecer la contaminación de las muestras. La RAP probablemente se asocia a los agentes etiológicos B bronchiseptica, P multocida y Citomegalovirus. En el estado de Yucatán, México, este es el primer reporte de un caso de rinitis atrófica con cuerpos de inclusión. Esto permite demostrar que la RAP es un padecimiento que no necesariamente guarda relación con un solo agente etiológico.

The forgotten turbinate: the role of the superior turbinate in endoscopic sinus surgery.

The fate of the middle turbinate in endoscopic sinus surgery has been a subject of debate for some time. The superior turbinate's role, however, has been largely passed over. Past anatomic descriptions and illustrations have given surgeons the incorrect impression that this structure is well superior and out of the field of dissection. Injury to the superior turbinate may account for postoperative hyposmia. The superior turbinate also serves as a constant landmark for the sphenoethmoidal recess, and a limited resection allows the surgeon to identify and include the natural ostium of the sphenoid sinus in the sphenoidotomy. The embryology and anatomy of the superior turbinate are reviewed. An approach to the natural ostium of the sphenoid sinus from the lateral side of the middle turbinate, using the superior turbinate as a guide, is described.

Nasoendotracheal tube obstruction secondary to inferior turbinate impaction.

This case report discusses one of the unusual complications of nasoendotracheal intubation, amputation of the inferior turbinate with its subsequent impaction of the nasoendotracheal tube. A healthy 19-year-old male underwent surgery for an open reduction and internal fixation of a fractured mandible. Several minutes after nasoendotracheal intubation, airway pressures increased, end-tidal carbon dioxide levels increased, and the patient became difficult to ventilate. The patient was extubated and then reintubated with a smaller-diameter nasoendotracheal tube through the same naris without further sequelae. After examination the tube was found to be occluded with an inferior turbinate. The increased airway pressure and elevated carbon dioxide levels were early signs of partial airway obstruction. Capnography was an important early warning device to provide information prior to changes in other vital signs. It allowed rapid detection of a potentially disastrous obstruction of the airway before the patient experienced severe cardiopulmonary complications. These facts should assist the anesthetist in focusing attention on the possible obstruction of the airway with a foreign body after nasoendotracheal intubation.