360° around the orbit: key surgical anatomy of the microsurgical and endoscopic cranio-orbital and orbitocranial approaches.

OBJECTIVE: Several pathologies either invade or arise within the orbit. These include meningiomas, schwannomas, and cavernous hemangiomas among others. Although several studies describing various approaches to the orbit are available, no study describes all cranio-orbital and orbitocranial approaches with clear, surgically oriented anatomical descriptions. As such, this study aimed to provide a comprehensive guide to the microsurgical and endoscopic approaches to and through the orbit. METHODS: Six formalin-fixed, latex-injected cadaveric head specimens were dissected in the surgical anatomy laboratory at the authors' institution. In each specimen, the following approaches were modularly performed: endoscopic transorbital approaches (ETOAs), including a lateral transorbital approach and a superior eyelid crease approach; endoscopic endonasal approaches (EEAs), including those to the medial orbit and optic canal; and transcranial approaches, including a supraorbital approach, a fronto-orbital approach, and a 3-piece orbito-zygomatic approach. Each pertinent step was 3D photograph-documented with macroscopic and endoscopic techniques as previously described. RESULTS: Endoscopic endonasal approaches to the orbit afforded excellent access to the medial orbit and medial optic canal. Regarding ETOAs, the lateral transorbital approach afforded excellent access to the floor of the middle fossa and, once the lateral orbital rim was removed, the cavernous sinus could be dissected and the petrous apex drilled. The superior eyelid approach provides excellent access to the anterior cranial fossa just superior to the orbit, as well as the dura of the lesser wing of the sphenoid. Craniotomy-based approaches provided excellent access to the anterior and middle cranial fossa and the cavernous sinus, except the supraorbital approach had limited access to the middle fossa. CONCLUSIONS: This study outlines the essential surgical steps for major cranio-orbital and orbitocranial approaches. Endoscopic endonasal approaches offer direct medial access, potentially providing bilateral exposure to optic canals. ETOAs serve as both orbital access and as a corridor to surrounding regions. Cranio-orbital approaches follow a lateral-to-medial, superior-to-inferior trajectory, progressively allowing removal of protective bony structures for proportional orbit access.

Assessing the effect of absorbable steroid sinus implant: a state-of-the-art systematic review.

OBJECTIVES: Endoscopic sinus surgery is not a definitive treatment for chronic rhinosinusitis (CRS). The use of sinus stents after surgery to maintain sinus patency and deliver local steroids has gained popularity. The first steroid-eluting bioabsorbable implant (SEBI) approved for this indication, later Propel, was developed in 2011. This state-of-the-art review aims to summarize the available evidence, as well as to point out potential pitfalls and lack of specific analyses to guide future research on this new therapeutic option. DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE, SciELO. REVIEW METHODS: Nine research questions were defined: Are steroid-eluting Sinus implants useful for the control of CRS symptoms after surgery? Do they improve surgical field healing after CRS surgery? Do they decrease polyp regrowth after ESS? Do they decrease the need for ESS? Are they useful in symptom control as in-office procedure? Are they better than other steroid-impregnated resorbable materials? Do they have a positive impact on olfaction? Are they safe? Are they cost-effective? Retrieved articles were reviewed by two authors. RESULTS: Twenty nine studies were included: 3 metanalysis, 1 systematic review, 10 randomized clinical trials, 4 quasi-experimental studies, 1 retrospective cohort study, 4 cost studies, 3 case series and 2 expert consensus. The review encompassed a population of 3,012 patients treated with SEBI and 2826 controls. CONCLUSIONS: This is the first state-of-the-art review assessing steroid eluting bioabsorbable stent evidence. Despite the effort in recent years, still several questions remain unanswered. This review will hopefully guide future research efforts to better define the role of SEBI in the otolaryngology practice.

Una técnica simple y segura para el tratamiento de las rinolicuorreas por pequeños defectos: colgajo libre de superposición «overlay» de mucosa nasal / A simple and reliable technique for the treatment of rhinoliquorrhoea from small defects: Free nasal mucosa overlay graft

INTRODUCCIÓN: Las fístulas de líquido cefalorraquídeo hacia las cavidades nasosinusales (rinolicuorreas) constituyen un proceso con dificultades diagnósticas y también terapéuticas. El abordaje transnasal endoscópico es el método de elección, pero con numerosas variantes posibles. El objeto de este trabajo es hacer una revisión crítica del protocolo diagnóstico y terapéutico que nosotros aplicamos desde hace 11 años. MATERIAL Y MÉTODOS: Treinta y un pacientes intervenidos. El diagnóstico se fundamenta en el análisis bioquímico de la rinorrea, la TAC y la RNM. Tratamiento: se realiza mediante cirugía endoscópica tras la inyección intratecal preoperatoria de 2cc de fluoresceína al 5%. El cierre se efectúa mediante un injerto libre de mucosa de cornete medio superpuesta, «overlay». RESULTADOS: Dos pacientes presentaron meningitis como primer signo. En todos los pacientes se diagnosticó la rinolicuorrea mediante el análisis bioquímico del moco. La TAC y la RNM dieron indicios claros para la localización del punto de fuga. El defecto basicraneal fue siempre menor de 1cm. La fluoresceína permitió visualizar la zona fistulosa sin necesidad de otros instrumentos y no tuvo efectos secundarios. Un paciente sufrió un absceso frontal en el postoperatorio que evolucionó favorablemente. Todas las fístulas se cerraron y solo hubo una recidiva a los 10años que empezó como una meningitis neumocócica. DISCUSIÓN Y CONCLUSIONES: Nuestro protocolo quirúrgico, fundamentado en el uso de fluoresceína intratecal y la colocación de un injerto libre de mucosa nasal sobrepuesto -«overlay»- sobre la zona fistulosa consigue resultados muy satisfactorios a largo plazo para el tratamiento de las rinolicuorreas por pequeños defectos basicraneales

INTRODUCTION: Cerebrospinal fluid leaks to the sinonasal cavities (rhinoliquorrhoea) represent a process with diagnostic and therapeutic difficulties. The endoscopic transnasal approach is the method of choice, but with many possible variants. The purpose of this paper was to make a critical review of our diagnostic and therapeutic protocol used for 11years.MATERIAL AND METHODS: We operated on 31patients. The diagnosis was based on the biochemical analysis of rhinorrhoea, CT and MRI. TREATMENT: endoscopic nasal surgery after preoperative intrathecal injection of 5% fluorescein (2cc). Closure was performed using a free overlay graft from middle turbinate mucosa. RESULTS: Two patients had meningitis as the first sign. All patients were diagnosed by biochemical analysis of rhinorrhoea. CT and MRI gave clear evidence of the leakage location. The skull base defect was always less than 1cm. Fluorescein allowed clear visualisation of the fistulous area without other instruments and produced no side effects. One patient had a postoperative frontal abscess, which evolved favourably. All fistulas were closed and there was only one recurrence at 10years, which debuted as pneumococcal meningitis. DISCUSSION AND CONCLUSIONS: Our surgical protocol, based on the use of intrathecal fluorescein and free grafting of middle turbinate mucosa overlay onto the fistulous area, achieves successful long-term results in the management of rhinoliquorrhoea secondary to small skull base defects (AU)

Pseudotumor de rinofaringe tuberculoso / Tuberculous Pseudotumor of the Rhinopharynx

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