How we do it: endoscopic tracheal dilatation technique using a supraglottic airway device and non-occlusive balloon.

BACKGROUND: Tracheal stenosis can be difficult to manage. Dilatation can relieve acute symptoms, avoid emergency tracheostomy and may be curative, but traditional dilators risk injury and obstruction in an already critical airway. This paper describes a novel technique for conducting tracheobronchial dilatation with a non-occlusive balloon through a supraglottic airway device, performed under endoscopic guidance. TECHNICAL DESCRIPTION: A supraglottic airway device is placed whilst the patient is under total intravenous anaesthesia with mechanical ventilation. Using a multiport airway adaptor, inspection is performed by flexible endoscopy and a guidewire is placed through the stenosis. A non-occlusive balloon is advanced over the guidewire and positioned using the endoscope reinserted through the second adaptor port. Ventilation can thus be continued throughout dilatation under vision. CONCLUSION: This technique has revolutionised our approach to tracheal dilatation in our institution. It avoids tracheostomy, and can be safely and reliably performed by junior staff in the emergency setting after adequate training.

How we do it: using the nasion as a landmark for identifying the anterior ethmoidal artery.

BACKGROUND: In severe refractory epistaxis, the anterior ethmoidal artery may need to be ligated. Previously described endonasal or transorbital approaches are not always effective, or they have suboptimal aesthetic outcomes. This paper describes a safe and effective surgical technique, with a consistent landmark allowing quick identification. TECHNICAL DESCRIPTION: A transcaruncular incision is made, oriented medially in the direction of the medial orbital wall towards the level of the nasion. Once onto bone, a subperiosteal plane is developed and an endoscope is used to dissect posteriorly at the level of the nasion, until the anterior ethmoidal artery is identified, and subsequently ligated. CONCLUSION: The nasion is an easy, constant landmark to use for ligation of the anterior ethmoidal artery in refractory epistaxis. The traditional method of identifying the anterior ethmoidal artery is not applicable or constant enough for use during the transorbital approach. The described technique avoids injury to surrounding structures and has a satisfactory aesthetic outcome.

Tips and tricks for maximising access to the middle cranial fossa using the superior lateral orbital portal.

BACKGROUND: Transorbital endoscopic approaches are becoming increasingly popular for skull base pathologies; the superior lateral orbital portal is one such approach to the middle cranial fossa. This paper provides a technical description that maximises the surgical portal and minimises morbidity. TECHNICAL DESCRIPTION: A superior lid crease incision is made extending laterally and the orbital rim is exposed. A subperiosteal dissection of the lateral and superior orbit is performed, with elevation of periosteum off Whitnall's tubercle, ligation of the recurrent branch of the middle meningeal artery, and identification of the superior orbital fissure. The lacrimal keyhole is then drilled away. The middle cranial fossa is accessed by drilling posterior to the orbital rim to expose: the temporalis muscle anterior-laterally, the dura of the temporal lobe posterior-laterally, the anterior cranial fossa superiorly and the periorbita medially. CONCLUSION: These surgical steps can maximise the surgical portal and minimise morbidity, with avoidance of injury to surrounding structures.

Transorbital Endoscopic Surgery for Sphenoid Wing Meningioma: Long-Term Outcomes and Surgical Technique.

Sphenoid wing meningiomas are benign tumors that can result in proptosis, visual impairment, and pain. Traditional open surgical approaches are associated with significant morbidity. Transorbital endoscopic surgery has been developed as a minimally invasive approach to gain access to these tumors and address the main presenting symptoms. Case series reporting transorbital endoscopic resection of sphenoid wing meningiomas using combined endonasal, pre-caruncular, and extended superior eyelid approaches have demonstrated stable and/or improved short- and medium-term visual outcomes. Earlier medial optic nerve decompression appears to result in more favorable long-term visual outcomes. Transorbital endoscopic surgery therefore represents an emerging minimally invasive alternative to deal with these challenging lesions.

'Smart' grommets.

OBJECTIVE: A novel, smartphone-based technique for endoscopic grommet insertion is presented.Results and conclusionThis method is both cost-effective and time-saving, offering a valuable alternative to the traditional microscope-based method in a resource-constrained setting.

Pre-caruncular approach to the medial orbit and landmarks for anterior ethmoidal artery ligation: a cadaveric study.

OBJECTIVE: In epistaxis and skull base surgery, the anterior ethmoidal artery sometimes needs to be ligated. We describe a novel, quick and scar-free surgical technique to ligate this artery with salient landmarks allowing rapid identification. PATIENTS AND METHODS: Twenty medial orbital walls from 10 randomly selected fresh-frozen, non-formalinised cadaver heads were examined. Dissection was performed by a pre-caruncular external approach to expose the AEA in all cases. RESULTS: The Horner's muscle and nasion, two salient landmarks, have been identified for use during the pre-caruncular approach. DISCUSSION/CONCLUSION: The pre-caruncular approach is a novel combined open and endoscopic surgical approach to the anterior ethmoidal artery. It is a simple, quick and scar-free technique. The identification of the artery is easy when using the two anatomic landmarks we describe in our study, that is Horner's muscle and the nasion.

Disease Management Project Breast Cancer in Hesse - 5-Year Survival Data: Successful Model of Intersectoral Communication for Quality Assurance.

Introduction: The Disease Management Project Breast Cancer (DMP Breast Cancer) was first launched in Hesse in 2004. The project is supported by the health insurance companies in Hesse and the Professional Association of Gynaecologists in Hesse. The aim is to offer structured treatment programmes to all women diagnosed with breast cancer in Hesse by creating intersectoral cooperations between coordinating clinics, associated hospitals and gynaecologists in private practice who registered in the DMP programme. Method: Between 1 January 2005 and 30 June 2011, 13 973 women were enrolled in the DMP programme. Results: After data cleansing, survival rates were calculated for a total of 11 214 women. The 5-year overall survival (OS) rate was 86.3 %; survival rates according to tumour stage on presentation were 92.2 % (pT1) and 82.3 % (pT2), respectively. The impact of steroid hormone receptor status on survival (87.8 % for receptor-positive cancers vs. 78.9 % for receptor-negative cancers) and of age at first diagnosis on survival (≤ 35 years = 91 %) were calculated. Conclusion: The project showed that intersectoral cooperation led to significant improvements in the quality of treatment over time, as measured by quality indicators and outcomes after treatment.

Endoscopic resection of skull base tumours utilising the ultrasonic dissector.

OBJECTIVE: We report the use and benefits of the ultrasonic dissector in the resection of difficult skull base lesions. METHOD: Five case reports are presented, and the utilisation of ultrasonic dissectors in otorhinolaryngology is reviewed. RESULTS: The ultrasonic dissector was found to be a useful tool during the endoscopic resection of poorly accessible skull base tumours. Safe dissection and complete removal of all five lesions were achieved without any vascular injury. To our knowledge, this is the first report of the use of the ultrasonic dissector for the resection of sinonasal and skull base tumours. CONCLUSION: The ultrasonic dissector was found to be particularly useful during the endoscopic transnasal approach to the petrous apex. During minimally invasive endonasal surgery, benefits include the length of the instrument, speed and precision of dissection, and low risk of vascular injury.

Cerebrospinal fluid rhinorrhoea after nasal packing for epistaxis: case report.

OBJECTIVE: We report a case of traumatic cerebrospinal fluid rhinorrhoea following nasal packing with a Rapid Rhino inflatable balloon pack, as treatment for epistaxis. METHOD: Case report and review of the literature regarding this complication. RESULTS: A thorough literature search was performed using PubMed. To our best knowledge, there have been no previous reports of cerebrospinal fluid rhinorrhoea following nasal packing. In our case, cerebrospinal fluid leakage occurred due to fracture of the middle turbinate at its superior skull base insertion. The cerebrospinal fluid leak resolved spontaneously without the need for surgical intervention. CONCLUSION: This case report highlights not only the need for an appreciation of sinonasal anatomy and the potential risks associated with nasal packing, but also the need for adequate training in the use of commercially available nasal packs by medical practitioners attending patients with epistaxis.

Peroral drainage of post-traumatic sialocoeles: report of three cases.

OBJECTIVE: To discuss the technique and outcome of this simple procedure and the management of post-traumatic parotid sialocoeles, and to review the literature regarding this condition. CASE REPORT: We report the successful surgical treatment, by peroral drainage, of three patients with post-traumatic parotid sialocoele resistant to conservative management. DISCUSSION: We discuss the method and outcome of the surgical procedure performed, along with the causes, presentation and management of parotid sialocoele. CONCLUSION: Correct initial management of a parotid duct injury may prevent the formation of a sialocoele. When conservative treatment of post-traumatic parotid sialocoele fails, we advocate the surgical technique described in this report as it is effective, simple and carries minimal risk to the patient.

Retained knife blades in the ear, nose and throat: three cases.

OBJECTIVE: To discuss the management and to review the literature regarding retained knife blades in the head and neck. CASE REPORT: We present three cases in which patients presented with retained knife blades in the head and neck region; in two of these, the diagnosis was delayed by more than eight weeks. In all patients, the retained knife blade was removed through the pathway of insertion, without significant sequelae. DISCUSSION: The methods of removal, appropriate radiological investigations and patient profiles are discussed. CONCLUSIONS: We propose that radiography be performed on all patients presenting with facial stab injuries which are anything more than superficial. We further suggest that the direct extraction of sharp objects through the pathway of insertion is safe if radiological studies show no risk of vascular injury.

Alcohol sclerotherapy of human immunodeficiency virus related parotid lymphoepithelial cysts.

OBJECTIVE: The aim of the study was to determine the effectiveness of alcohol sclerotherapy in patients with human immunodeficiency virus related salivary gland disease. STUDY DESIGN: Prospective study investigating the effectiveness of alcohol as a sclerosing agent. SETTING: Tertiary referral hospital. PATIENTS: Eleven human immunodeficiency virus positive patients with benign lymphoepithelial cysts were included in the study, from July 2005 to September 2006. INTERVENTIONS: Alcohol sclerotherapy was performed under local anaesthesia, with alcohol infiltrated into the benign lymphoepithelial cysts. RESULTS: Alcohol injection sclerotherapy proved to be an effective, simple, cheap, ambulatory procedure for patients who did not qualify for antiretroviral treatment.

Endoscopic transnasal removal of migrated dental implants.

We report a case of migration of a dental implant into the maxillary sinus and discuss the benefits of endoscopic transnasal removal of such implants. As the sole approach, this technique has rarely been described. The most commonly used technique for retrieval of dental implants is the Caldwell-Luc procedure. This, however, has certain morbidity associated with it and may compromise subsequent implant insertion.

Revisiting the risks involved in using homograft ossicles in otological surgery.

Despite the fact that cartilage, cortical bone and corneal homograft tissue is still widely used in South Africa and that there has never been a reported case of human immunodeficiency virus or Creutzfeldt-Jakob disease infection transmission via this route, otolaryngologists are still reluctant to use homograft ossicles. In third world countries, such as South Africa, where ossicular prostheses are not always readily available due to financial constraints, the question arises as to whether we should be reconsidering the use of homograft ossicles. This review examines the risk of developing Creutzfeldt-Jakob disease or acquiring human immunodeficiency virus following the use of homograft ossicles during ossicular reconstruction, and discusses sterilization techniques that have proven effective in eradicating the human immunodeficiency virus and prions. For decades, homograft ossicles have been used worldwide in otological surgery, especially in patients lacking suitable autograft ossicles. There has never been a reported case of transmission of the human immunodeficiency virus, and no cases of transmissible spongiform encephalopathy have been reported in the literature after otological surgery involving only the use of homograft ossicles. There have only been two documented otological cases of Creutzfeldt-Jakob disease; these involved the use of cadaveric dura mater and pericardium for tympanic membrane grafting. The human immunodeficiency virus is easily inactivated by simple sterilisation techniques, and there is a statistically insignificant risk of transmitting this virus if proper sterilisation protocols are followed.

Pre-operative assessment of patients undergoing endoscopic, transnasal, transsphenoidal pituitary surgery.

OBJECTIVE: To demonstrate the importance of pre-operative ear, nose and throat assessment in patients undergoing endoscopic, transsphenoidal surgery for pituitary tumours. CASE REPORTS: Literature pertaining to the pre-operative otorhinolaryngological assessment and management of patients undergoing endoscopic anterior skull base surgery is sparse. We describe two cases from our series of 59 patients undergoing endoscopic pituitary surgery. The first case involved a young male patient with a large pituitary macroadenoma. His main complaint was visual impairment. He had no previous history of sinonasal pathology and did not complain of any nasal symptoms during the pre-operative neurosurgical assessment. At the time of surgery, a purulent nasal discharge was seen emanating from both middle meati. Surgery was abandoned due to the risk of post-operative meningitis, and postponed until the patient's chronic rhinosinusitis was optimally managed. The second patient was a 47-year-old woman with a large pituitary macroadenoma, who presented to the neurosurgical department with a main complaint of diplopia. She too gave no history of previous nasal problems, and she underwent uneventful surgery using the endoscopic, transnasal approach. Two weeks after surgery, she presented to the emergency unit with severe epistaxis. A previous diagnosis of hereditary haemorrhagic telangiectasia was discovered, and further surgical and medical intervention was required before the epistaxis was finally controlled. CONCLUSIONS: Pre-operative otorhinolaryngological assessment is essential prior to endoscopic pituitary or anterior skull base surgery. A thorough otorhinolaryngological history will determine whether any co-morbid diseases exist which could affect the surgical field. Nasal anatomy can be assessed via nasal endoscopy and sinusitis excluded. Computed tomography imaging is a valuable aid to decisions regarding additional procedures needed to optimise access to the pituitary fossa.

[Long-term locally-recurrent melanoma]. / Langfristig lokal rezidivierendes malignes Melanom.

Malignant melanoma is a highly malignant skin tumor with a widely variable individual course. Currently, approximately 75% of German patients can be cured of malignant melanoma by early diagnosis and excision, while more than 20% die of distant metastases of the melanoma. In contrast, there are single cases of long-term locally recurrent melanomas with neither complete cure nor development of distant metastases. We report on a female patient with a nevus-associated melanoma who was treated in 1968 with X-ray radiation (Dermopan, 100 Gy) with curative intent. In the following 31 years, the patient developed four phases of in-transit and satellite metastases in a zosteriform pattern as well as ilioinguinal lymph node metastasis. Since 1999, the patient has been free of recurrence. Besides the unusual biological features of this case, this report reflects the changes of paradigms in the therapy of melanoma over the last forty years.

Evaluation of the percutaneous intramyocardial injection for local myocardial treatment.

Therapeutic angiogenesis requires the induction of new blood vessel formation for the treatment of peripheral vascular and coronary artery disease. Efficacious application of this new therapy requires optimizing multiple factors, including the therapeutic agent, dosing, frequency of administration, and delivery modality. In this study, a helical needle drug infusion catheter was applied for optimal application of percutaneous intramyocardial delivery (PIMD). (125)Iodine-labeled albumin was injected by PIMD into the left ventricle myocardium in eight swine. After 1 hr, PIMD resulted in a high concentration of radiolabel at the treatment site; 16.4% +/- 2.1% of delivered and 81.4% +/- 2.6% of the total cardiac activity was concentrated at the site of delivery. The depth of needle penetration correlated with the myocardial retention of delivered protein. The myocardial retention of radiolabel in animals with shallow injections was 10.1% +/- 0.8%, compared to 18.9% +/- 3.3% retention after deep injections. The specific activity at the treatment site (radioactive counts per gram of tissue) was 115 +/- 36, 226 +/- 55, and 47 +/- 10 times higher compared to liver, lung, and kidney, respectively. Continuous coronary sinus and aortic blood sampling indicates that within 15 min following intramyocardial injection, a significant amount of nonretained protein is found within the coronary sinus. This study defines some of the parameters that can affect optimal application of PIMD and demonstrates that PIMD is a safe and efficient method for local drug delivery.

[Congenital melanocytic nevi]. / Kongenitale melanozytäre Nävi.

Congenital melanocytic nevi are benign skin tumours with a population-based prevalence of 1-6%. They run an increased life-time risk of transformation into malignant melanoma. Additionally, they can be associated with an involvement of the leptomeninges (neurocutaneous melanosis), and may cause considerable cosmetic and psychic problems. In contrast to the past, the risk of congenital melanocytic nevi developing into melanoma is now regarded as well-established. Thus, excision is recommended whenever possible. Large lesions which do not allow complete excision should be treated by dermabrasion within the first weeks of life.