The Validity of Training Endoscopic Sinus and Skull Base Surgery Techniques on the Experimental Head Model.

OBJECTIVES: The aim of this study was to better understand the usual learning curve in acquiring endonasal endoscopic sinus and skull base surgery (ESSBS) techniques during the novice training on the lamb's head model. METHODS: Ten novices were asked to perform 10 bilateral dissections on the particular lamb's head each. The dissections were uniform, consisted of 10 well-defined steps, beginning from the simple removal of the inferior turbinate, and ending with more complicated procedures like cerebrospinal fluid leak repair, Draf 3 procedure for the frontal sinus and elevation of the nasal septal flap. The dissections have been supervised by experienced surgeons. A set of standard ESSBS instruments and 0° and 45° endoscopes have been used under the navigational system. The time required to complete each step has been measured in minutes. RESULTS: In general and quite expectedly, time rates have been obviously lowering as the number of the dissections performed has been growing in each of the participants. CONCLUSION: Training of the endonasal ESSBS techniques on the lamb's head proved to be useful for novices in getting basic surgical skills in the field. Because of the high degree of anatomic similarity and high level of the anatomic dimensions congruency between the lamb's head and human head (sheep's head has bigger dimensions!) it proved to be an essential preparation for the human cadaveric dissection. The median values of the time rates having been needed to complete the particular of the 10 steps in the last novices' dissections could be accepted as an orientation, just suggesting that once the time needed to complete 1 of the 10 steps has been and achieved by the particular novice, this could be an approximate sign of the maturity for the exercises on human cadaver head.

Sinus septi nasi: Anatomical study.

The aim of this study was to perform a pioneering investigation into the incidence of pneumatization in human skulls. A total of 93 human skulls (≥20 years of age, 69 males, 24 females) were included in the study. The skulls were scanned in a fixed position using cone beam computed tomography (CBCT). The pneumatized space parameters within the nasal septum-width, length, and height-were measured. Two types of finding were identified: (a) Pneumatization, named "sinus septi nasi" (SSN), and (b) "spongy bone" (SB). The results showed SSN in 32 of the 93 skulls (34.4%). The SSN formations were from 0.5 to 4.2 mm wide, 3.5 to 18.8 mm long, and 3.8 to 17.7 mm high. Tumefactions filled with SB were found in 61 of the 93 skulls (65.59%). These were not suitable for precise measurements since the outer borders were not strictly and well defined on CT scans (perhaps because of the preparation process). In conclusion, the perpendicular plate of the ethmoidal bone is not always compact bone; in 34.4% of cases, it shows a degree of pneumatization. In contrast, an enlarged formation filled with SB is present in 65.59% of cases. The possible sources of pneumatization of this little-investigated region are discussed: sphenoid sinus, frontal sinus, and vomeronasal organ. Clin. Anat. 30:312-317, 2017. © 2017 Wiley Periodicals, Inc.

An anatomical study of pneumatized crista galli.

The literature data on the incidence of pneumatization of the crista galli based on patients' computed tomography (CT) scans ranges from 3 to 37.5%. This study investigated for the first time the incidence of crista galli pneumatization based on CT scans of human skulls. The study examined 102 randomly selected human skulls (≥20 years of age; 76 males, 26 females). Skulls were scanned in a fixed position using cone beam computed tomography (CBCT) with a field of view of 145 × 130 mm and an isotropic voxel size of 0.25 mm. The scans were recorded in Digital Images and Communications in Medicine format. The CBCT images were analyzed using OnDemand3DTM software. A 2-mm contiguous slice thickness was used in the axial and coronal planes. The width, length, and height (cranial-caudal dimension) of the pneumatized space within the crista galli were measured. The crista galli was found to be pneumatized in even 68 (66.6%) of the 102 skulls. Two types of pneumatized crista galli (PCG) were identified: PCG alone (surrounded by bony walls) and PCG + spongiosis (surrounded by spongy bone). Of the 68 pneumatized skulls, 31 were PCG alone (45.58%) and 37 were PCG + spongiosis (54.42%). The pneumatized regions had a width of 0.9-6.6 mm, length of 2.8-12.9 mm, and height of 3.6-17.1 mm. No statistically significant differences have been found regarding the sex and age. Regarding the proportions of pneumatization, the three types of crista galli have been determined resulting in new, practical classification: type S (small), type M (moderate), and type L (large). The crista galli is not always a compact bone; in some cases, it is filled with spongy bone or pneumatized. In respect of proportions of pneumatization, there are three types of pneumatized crista galli: small, moderate, and large. Pneumatized crista galli can play an important role in clinical work, both as an inflamed sinus or other pathologies (sinusitis cristae galli, mucocoelae) or as a morphologic barrier in neurosurgical approaches to some tumors of the anterior skull base.

Alternative products to treat allergic rhinitis and alternative routes for allergy immunotherapy.

BACKGROUND: Some alternative products instead of immunotherapy are used in patients with allergic rhinitis (AR). METHODS: In this paper, alternative products to treat allergic rhinitis and alternative routes for allergy immunotherapy are reviewed. RESULTS: Alternative products and methods used instead of immunotherapy are tea therapy, acupuncture, Nigella sativa, cinnamon bark, Spanish needle, acerola, capsaicin (Capsicum annum), allergen-absorbing ointment, and cellulose powder. N. sativa has been used in AR treatment due to its anti-inflammatory effects. N. sativa oil also inhibits the cyclooxygenase and 5-lipoxygenase pathways of arachidonic acid metabolism. The beneficial effects of N. sativa seed supplementation on the symptoms of AR may be due to its antihistaminic properties. To improve the efficacy of immunotherapy, some measures are taken regarding known immunotherapy applications and alternative routes of intralymphatic immunotherapy and epicutaneous immunotherapy are used. CONCLUSION: There are alternative routes and products to improve the efficacy of immunotherapy.

Septoplasty in children.

OBJECTIVES: Physicians have long had concerns about the potential harmful effects of pediatric septoplasties on the nasoseptal growth process because septal cartilage is important for the growth and development of the face. METHODS: In this review article, pediatric septoplasty and its indications are discussed, together with a literature survey. In addition, overviews of development of the nasal skeleton from neonate to adult, nasal growth, and cartilaginous septum are presented. Important issues and comments on pediatric septoplasties are provided. RESULTS: During septoplasty procedures, elevation of the mucoperichondrium unilaterally or bilaterally does not negatively affect growth of the face. Stabilization of the septum may be easier when mucosal elevation is performed unilaterally. The nasal floor mucosa should not be elevated so to avoid damage to the incisive nerves. Corrections and limited excisions may be done from the cartilaginous septum. Separation of the septal cartilage from the perpendicular plate, especially at the dorsal part, should not be performed because this area is important for the length and height of the nasal septum and nasal dorsum. Incisions or excisions should not be performed through the growing and supporting zones, especially at the sphenoethmoid dorsal zone. CONCLUSION: If there are severe breathing problems related to the septal deviation, septoplasty should be performed. In the majority of cases, septal surgery may be conducted in 6-year-old children. However, if necessary, septal surgery may be performed in younger children and even at birth.

Alternative products to treat allergic rhinitis and alternative routes for allergy immunotherapy.

BACKGROUND: Some alternative products instead of immunotherapy are used in patients with allergic rhinitis (AR). METHODS: In this paper, alternative products to treat allergic rhinitis and alternative routes for allergy immunotherapy are reviewed. RESULTS: Alternative products and methods used instead of immunotherapy are tea therapy, acupuncture, Nigella sativa, cinnamon bark, Spanish needle, acerola, capsaicin (Capsicum annum), allergen-absorbing ointment, and cellulose powder. N. sativa has been used in AR treatment due to its anti-inflammatory effects. N. sativa oil also inhibits the cyclooxygenase and 5-lipoxygenase pathways of arachidonic acid metabolism. The beneficial effects of N. sativa seed supplementation on the symptoms of AR may be due to its antihistaminic properties. To improve the efficacy of immunotherapy, some measures are taken regarding known immunotherapy applications and alternative routes of intralymphatic immunotherapy and epicutaneous immunotherapy are used. CONCLUSION: There are alternative routes and products to improve the efficacy of immunotherapy.

Lamb's head: The model for novice education in endoscopic sinus surgery.

Structured training in endonasal endoscopic sinus surgery (EESS) and skull base surgery is essential considering serious potential complications. We have developed a detailed concept on training these surgical skills on the lamb's head. This simple and extremely cheap model offers the possibility of training even more demanding and advanced procedures in human endonasal endoscopic surgery such as: frontal sinus surgery, orbital decompression, cerebrospinal fluid-leak repair followed also by the naso-septal flap, etc. Unfortunately, the sphenoid sinus surgery cannot be practiced since quadrupeds do not have this sinus. Still, despite this anatomical limitation, it seems that the lamb's head can be very useful even for the surgeons already practicing EESS, but in a limited edition because of a lack of the experience and dexterity. Only after gaining the essential surgical skills of this demanding field it makes sense to go for the expensive trainings on the human cadaveric model.

Type 5 and 6 nasal septal deformities: Could we predict and prevent acute coronary syndrome attacks in the future?

Undisturbed nasal breathing is essential for normal breathing physiology as a whole. Nasal septal deformities (NSD) are well known as a factor which can remarkably and substantially affect the quality of nasal and pulmonary breathing. However, it is well known that type 5 and type 6 nasal septal deformities may cause only a moderate, unilateral nasal obstruction or none at all. The effects of nasal obstruction on the respiratory and cardiovascular systems have been well studied so far: right ventricle problems, ischemic heart diseases, sleep disorders, mucociliary clearance system disturbances, paranasal sinus pathology, have all been described as a result of impaired nasal breathing. The connection between the upper and lower respiratory systems has been recognized in allergic rhinitis and asthma as well, resulting in the united airways concept. Most recently, the ostensible connection between chronic rhinosinusitis (CRS) and acute myocardial infarction has been said to be proven. However, the results of this study might have not been well founded since there are no direct and clear proofs that CRS as a chronic inflammatory process has anything to do with the acute coronary syndrome (ACS). On the other hand, a large international study on the incidence of NSD in CRS patients, based on the Mladina classification, showed that NSD were present in a high incidence and that the most frequent deformities were types 5 (36.18%) and 7 (29.92%). The vast majority of those types 7 consisted of types 3 and (again) types 5 or types 6 (76.32%). The fact that in CRS patients a remarkably high incidence of type 5 septal deformity can be seen, gives rise to thinking that this factor perhaps plays a role in the onset of ACS. Acute coronary syndrome is one of the leading causes of death all over the world. Traditional risk factors such as family history, overweight body, smoking, stress, hypertension, hypercholesterolemia, diabetes mellitus, coronary artery calcium score, C-reactive protein, lipoprotein, homocysteine, lipoprotein-associated phospholipase A2, as well as high-density lipoprotein functionality perhaps cannot account for the entire risk for incident coronary events. Several other potential risk factors have been identified in an effort to improve risk assessment for ACS. This article reviews one of them: the possible influence of an unusual, so far unknown predisposing factor: type 5 or type 6 nasal septal deformities. They have been found as pure, isolated types or as a part of combined nasal septal deformity (type 7).

Clinical Implications of Nasal Septal Deformities.

The first attempts to systematize septal distortions have been given by Cottle who defined four groups of septal deformities: subluxation, large spurs, caudal deflection and tension septum. Fortunately, the variations of the septal deformities show a certain order, thus enabling more precise classification. Mladina was the first to make user-friendly classification of septal deformities in six basic types. He also described the seventh type, named "Passali deformity", which presents individually, but is always a well-defined combination between some of the previous six types. Mladina types of septal deformities (SD) are divided in two main groups: so called "vertical" deformities (types 1, 2, 3 and 4), and "horizontal" ones (types 5 and 6). This classification was immediately well accepted by rhinologists worldwide and started to be cited from the very beginning. Since then it has been continuously cited increasingly more often, thus making Mladina classification a gold standard whenever clinical researches on nasal septum are concerned. More than forty clinical studies based on this classification have been performed to date. It is extremely important to make a strict distinction between the types of SD since all of them play some specific role in the nasal and general physiology in man.

The potential role of hyaluronan in minimizing symptoms and preventing exacerbations of chronic rhinosinusitis.

BACKGROUND: This study was designed to prospectively evaluate the role of nebulized hyaluronic acid (HA) given for 10 days/mo over 3 months as adjunct treatment to minimize symptoms and preventing exacerbation of chronic rhinosinusitis (CRS). METHODS: Thirty-nine eligible patients were randomized to receive nebulized 9-mg sodium hyaluronate nasal washes plus saline solution (21 patients) or 5 mL of saline alone (18 patients), according to an open-label, parallel-group design, with blind observer assessment. A questionnaire about main CRS discomfort and nasal endoscopy for mucous discharge and/or mucosal edema of nasal cavities was used to assess primary outcomes of treatments. Secondary outcome measures included side effects and satisfaction. RESULTS: HA significantly improved quality of life in CRS patients according to the CRS questionnaire (16± 3.72 versus 11.52 ± 4.28; p < 0.001), contrary to saline group scores (18.92 ± 3.09 versus 18.21 ± 3.21; p = 0.55). The HA group showed significantly reduced osteomeatal edema (2.42 versus 1.52; p < 0.001) and secretions (0.95 versus 0.42; p < 0.001), whereas there was no statistically significant difference in the saline group. The compliance to the treatment was similar in both groups and no side effects were recorded. CONCLUSION: The results of this study suggested that intermittent treatment with topical 9-mg sodium hyaluronate plays a role in minimizing symptoms and could prevent exacerbations of CRS.

The potential role of hyaluronic acid in postoperative radiofrequency surgery for chronic inferior turbinate hypertrophy.

BACKGROUND: We prospectively evaluated the efficacy of hyaluronic acid (HA) as an adjuvant treatment to hasten the improvement of nasal respiration and to minimize patients' discomfort in the postoperative radiofrequency volumetric tissue reduction (RFVTR) of inferior turbinates. METHODS: We enrolled 57 patients randomly assigned into two groups, HA (22 patients) and saline group (35 patients), which received isotonic saline nasal irrigation. We used the monopolar device somnoplasty for all patients. Visual analogic scale (VAS) and nasal endoscopy were used to assess the outcomes of the treatments during the 1st month of follow-up. RESULTS: The mean VAS score of the HA group at the 1st week was significantly lower than the control group (3.36 ± 1.89 versus 6.95 ± 1.52; p < 0.05). The VAS score remained significantly lower in the HA group also at the 2nd week (3.43 ± 1.27 versus 5.75±1.39; p < 0.05), becoming similar to the control group at the 4th week (p = ns). Since the first visit the HA group also showed significantly lower crust score than the saline group (p < 0.05), and there was no crust found in either group at the last visit. The compliance to treatment was similar in both groups. CONCLUSION: The results of this prospective study suggest a role of HA as a supportive treatment for faster improvement of nasal respiration, also minimizing patients' discomfort in postoperative nasal surgery, promoting nasal mucosa healing in postoperative RFVTR for inferior turbinate hypertrophy.

Training cerebrospinal fluid leak repair with nasoseptal flap on the lamb's head.

BACKGROUND: One of the major challenges of cranial base surgery is reconstruction of dural defects and cerebrospinal fluid leak closure. Various grafting methods have been used for smaller skull base defects with great success. The indications for endoscopic reconstruction have recently evolved to encompass much larger breeches in the skull base following tumor removal, thus emphasizing the need for vascularized tissue flaps for reconstruction. METHODS: Some authors proposed a pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium, which is very vascularized and has quite a large surface. It is also long enough to easily cover even larger defects of the skull base. The elevation of a nasoseptal flap is based on a particularly advanced surgical technique and thus requires proper training before being performed in a real patient. RESULTS: Anatomical differences between human and lamb heads were observed and explained although they do not affect the procedure of the elevation of the nasoseptal flap. CONCLUSIONS: The lamb's head has been shown to be an ideal model for the adequate training of the surgical skills required for this demanding procedure.

Bilateral respiratory epithelial adenomatoid hamartoma of the olfactory cleft penetrating into the endocranium.

Respiratory epithelial adenomatoid hamartomas (REAHs) of the nose and paranasal sinuses are relatively rare. These tumors usually do not extend over the boundaries of the nose and sinuses. The authors presented a 65-year-old man experiencing progressive hyposmia, followed by intermittent stubborn headache. The symptoms lasted for almost 2 years and were getting worse very slowly. Fiberendoscopy showed relatively discrete polypoid tissue occupying the olfactory cleft bilaterally. The computed tomography and magnetic resonance imaging suggested the possible lack of the cribriform plate and the unity and uniformity of the tissues located both in the endocranium and high in the nasal cavity. The clinical picture resembled very much a esthesineuroblastoma.The patient underwent endoscopic sinus surgery under the general hypotensive anesthesia. Frozen sections during the surgery showed REAH. The entire tumor was removed in a piece meal way, including both olfactory bulbs because they were involved within the pathologic tissue as well.This case showed that REAH could also be a locally aggressive process, penetrating even into the endocranium.

[Endoscopic transsphenoidal pituitary surgery]. / Endoskopska transsfenoidalna hipofizna kirurgija.

Endoscopic surgery has been performed in our Department since 1996 as assistance in micro-neurosurgical procedures. In the same way the endoscope was used in transsphenoidal pituitary surgery, but from the beginning of 2004 we started with "pure" endoscopic surgery. We present our experience with the first ninety patients to demonstrate our way of operating. Endoscopic pituitary surgery is performed through a natural nasal air pathway without any incisions. A 4-mm endoscope is placed in front of the tumor in the sphenoidal sinus and the tumor is removed with specially designed surgical tools. Postoperative nasal packing is not necessary and postoperative discomfort is minimal so the hospital stay lasts 3 days. The first control was after one month. There were eighteen recurrences of tumors.

Nasal polyposis: from pathogenesis to treatment, an update.

Nasal polyps (NP) are common benign degeneration of nasal sinus mucosa with a prevalence around 4% in the adult population. The causes are still uncertain but there is a strong association with allergy, infection, asthma and aspirin sensitivity. Histologically, the presence of a large quantity of extracellular fluid, mast cell degranulation and eosinophilia has been demonstrated. Typically the patients show nasal obstruction, anosmia and rhinorrhoea. Nasal endoscopic examination and CT imaging allow evaluation of the disease extension. A combined medical and surgical treatment is recommended for symptoms control in preventing symptomatic NP recurrence. We will review the current knowledge in the pathogenesis and treatment of this complex disease entity.

Video-rhino-hygrometer: a new method for evaluation of nasal breathing after nasal surgery.

BACKGROUND: Nasal obstruction is one of the most frequent symptoms in the ear, nose, and throat (ENT) setting. It can be evaluated either subjectively or objectively. In a subjective way, a visual analog scale (VAS) and the Sino-Nasal Outcome Test 20 (SNOT 20) can rapidly quantify the degree of obstruction, whereas the most commonly used objective methods are nasal endoscopy and active anterior rhinomanometry (AAR). It is still a matter of controversy to what extent the sense of nasal obstruction is associated with objective measures for nasal space and airflow. The aim of the study was to evaluate nasal breathing before and after functional nasal surgery by video-rhino-hygrometer (VRH) comparing the results with widely accepted methods. METHODS: Twenty patient candidates for septoplasty and inferior turbinate reduction were included in the study. SNOT-20, VAS, nasal endoscopy, and AAR were analyzed and compared with VRH values. RESULTS: Before surgery VRH showed variability of nasal respiratory flow between individuals and between nostrils. After surgery we had an increase (p < 0.05) of airflow in both nostrils. VRH data were found to be correlated with VAS and SNOT-20 values (p < 0.05) both pre- and postoperatively. Despite the statistically significant correlation of AAR with SNOT-20 and VAS, no statistically significant correlation between AAR and VRH was found. CONCLUSION: VRH provides an immediate, easy, and noninvasive assessment of nasal respiration. For these reasons it can be used, in association with rhinoscopic data and other instrumental tests, to evaluate nasal breathing in daily ENT practice.