Missed skull base injury during sinonasal surgery: A dangerous scenario still existing.

Skull base injury is a known complication of sinonasal surgery. Cerebrospinal fluid (CSF) rhinorrhea has been reported to occur in 0 to 2.5% of these procedures. More extensive skull base injury may result in more serious complications. In this retrospective case series, we report on 7 cases of iatrogenic skull base injury due to sinonasal surgery that was missed by the operating surgeons. Included were 5 male and 2 female patients. Six patients sustained the skull base injury during endoscopic sinus surgery, and 1 patient was injured during septoplasty. Two patients presented with CSF rhinorrhea alone, 2 patients had repeated episodes of meningitis, 2 patients had other neurologic sequelae, and 1 patient had exotropia due to associated orbital injury. We conclude that skull base injury due to sinonasal surgery is still being missed; this oversight may lead to potentially fatal results. The true incidence of this complication is probably still unknown.

The prevalence of frontal cells and their relation to frontal sinusitis: a radiological study of the frontal recess area.

Background. The frontal recess area represents a challenge to ENT surgeons due to its narrow confines and variable anatomy. Several types of cells have been described in this area. The agger nasi cells are the most constant ones. The frontal cells, originally classified by Kuhn into 4 types, have been reported in the literature to exist in 20%-41% of frontal recesses. Aim of the Study. To identify the prevalence of frontal recess cells and their relation to frontal sinus disease. Methods. Coronal and axial CT scans of paranasal sinuses of 70 patients admitted for functional endoscopic sinus surgery (FESS) were reviewed to identify the agger nasi, frontal cells, and frontal sinus disease. Data was collated for right and left sides separately. Results. Of the 140 sides reviewed, 126 (90%) had agger nasi and 110 (78.571%) had frontal cells. 37 frontal sinuses were free of mucosal disease, 48 were partly opacified, and 50 were totally opacified. There was no significant difference found in frontal sinus mucosal disease in presence or absence of frontal cells or agger nasi. Conclusions. The current study shows that frontal cells might be underreported in the literature, as the prevalence identified is noticeably higher than previous studies.

The safe gate to the posterior paranasal sinuses: reassessing the role of the superior turbinate.

Surgery of the posterior ethmoid and sphenoid sinuses can be challenging. In 1999, a technique was described for identification of the superior turbinate and utilizing it as a landmark in endoscopic posterior ethmoidectomy and sphenoidotomy. Although this was more than a decade ago, it has not been supported by further studies. In our practice, we have routinely adopted this technique, and have modified it to allow further orientation during endoscopic surgery of the posterior sinuses. To describe a review of our technique, and to prospectively assess the value of the superior turbinate as a useful landmark during endoscopic posterior ethmoidectomy and sphenoidotomy. Fifty patients listed for endoscopic posterior ethmoidectomy with or without sphenoidotomy were included in a prospective study utilising our surgical technique. Data were collated for the success or failure of identification of the landmarks, and for any complications during the surgery. A total of 93 sides of endoscopic posterior ethmoidectomy and 73 sides of endoscopic sphenoidotomy were performed. The superior turbinate was identified in 100% of the cases. The coronal part of the superior turbinate basal lamella was identified in 60.22% of the cases, and the axial part in 88.17% of the cases. The natural sphenoid ostium was identified medial to the posterior part of the superior turbinate in 98.63% of the cases. The axial part of the superior turbinate basal lamella was a constant landmark for the level of the sphenoid ostium. The number of transverse septae between the axial part of the superior turbinate basal lamella and the skull base was studied, and was found never to exceed one septum. No major complications were recorded. One case of small posterior septal perforation was detected with no post-operative effects. Our study represents the first report of identifying the two parts of the superior turbinate basal lamella intra-operatively. It also represents the first report of using the axial basal lamella of the superior turbinate as a landmark for the level of the sphenoid sinus ostium, as well as a landmark for the level of the skull base. The superior turbinate represents a constant landmark for performing a safe posterior ethmoidectomy and sphenoidotomy.

Radiological findings in patients undergoing revision endoscopic sinus surgery: a retrospective case series study.

BACKGROUND: Functional endoscopic sinus surgery (FESS) is now a well-established strategy for the treatment of chronic rhinosinusitis which has not responded to medical treatment. There is a wide variation in the practice of FESS by various surgeons within the UK and in other countries. OBJECTIVES: To identify anatomic factors that may predispose to persistent or recurrent disease in patients undergoing revision FESS. METHODS: Retrospective review of axial and coronal CT scans of patients undergoing revision FESS between January 2005 and November 2008 in a tertiary referral centre in South West of England. RESULTS: The CT scans of 63 patients undergoing revision FESS were reviewed. Among the patients studied, 15.9% had significant deviation of the nasal septum. Lateralised middle turbinates were present in 11.1% of the studied sides, and residual uncinate processes were identified in 57.1% of the studied sides. There were residual cells in the frontal recess in 96% of the studied sides. There were persistent other anterior and posterior ethmoidal cells in 92.1% and 96% of the studied sides respectively. CONCLUSIONS: Analysis of CT scans of patients undergoing revision FESS shows persistent structures and non-dissected cells that may be responsible for persistence or recurrence of rhinosinusitis symptoms. Trials comparing the outcome of conservative FESS techniques with more radical sinus dissections are required.