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.

Magnetic toy ingestion leading to jejunocecal fistula in a child.

The accidental ingestion of a foreign body is a common problem in children, but ingestion of magnets is rare. When multiple magnets are ingested, they may attract each other and cause pressure necrosis through the bowel walls and eventually lead to serious complications like obstruction, perforation, and fistula formation. We report a case of a 5-year-old girl with jejunocecal fistula following ingestion of 2 magnet toys; it highlights the diagnostic challenge and the need for early surgical intervention in children especially when multiple magnets are ingested.

Endoscopic choanoplasty without stenting for congenital choanal atresia repair.

OBJECTIVE: To present our experience with an endoscopic technique for congenital choanal atresia transnasal repair without the use of intranasal stents. METHODS: Twenty-one patients with congenital choanal atresia (11 bilateral aged 2-27 days and 10 unilateral aged 2-16 years) were operated upon between December 2005 and January 2009, using an endoscopic choanoplasty technique in which a laterally based mucoperiosteal flap was elevated off the posterior nasal septum and atretic plate. Endoscopic resection of bony atresia including abnormally thickened vomer and pterygoid processes was done until a widely patent 'neo-uni-choana' was created. Two surgeons worked simultaneously using the "four-hand" technique. No stents were used. All patients received prophylactic systemic antibiotics and local steroid-antibiotic intranasal drops for 1 week postoperatively. Parents were taught to irrigate and clean both nasal cavities using frequent saline nasal drops and a portable home suction device. RESULTS: Preoperative computed tomography showed that among bilateral choanal atresia (BCA) patients, 9 (81.8%) were bony-membranous and 2 (18.2%) were pure bony atresia. All unilateral choanal atresia (UCA) cases had pure bony atresia. Two neonates with BCA had associated congenital cardiac anomalies. None had the CHARGE association. Operative time ranged from 30 to 75 min (mean 51.4+/-13.4 min.) for BCA and 35 to 90 min (mean 57.5+/-18 min.) for UCA repairs. Mean estimated intraoperative blood loss was 35.5+/-15.1 cc. in BCA and 204+/-105.6 cc. in UCA surgery. No intraoperative complications such as skull base damage or CSF leak were encountered. Patients were followed-up for periods ranging from 6 to 18 months in BCA and 12 to 24 months in UCA cases. Three BCA cases showed postoperative restenosis by granulation tissue that was successfully managed by endoscopic excision with good nasal breathing thereafter. Complications included mid-nasal synechiae, not interfering with nasal breathing, in three BCA cases and a small hard palate perforation in one UCA patient that healed conservatively, without further surgery needed. CONCLUSIONS: Transnasal endoscopic choanoplasty repair for both unilateral and bilateral choanal atresia without intranasal stenting was found to be an expedient and safe procedure that affords minimal blood loss, minimal complications with a high rate of success.