Advanced Levels of Chronic Venous Insufficiency are Related to an Increased in Arterial Stiffness.

BACKGROUND: Chronic venous insufficiency (CVI) is characterized by progressive inflammatory changes. Inflammatory damage occurs in the veins, adjacent tissues, and can lead to structural changes in the arteries. The aim of this study is to analyze whether the degree of CVI is associated with arterial stiffness. METHODS: Cross-sectional study including patients with CVI classified by clinical, etiological, anatomical, and pathophysiological classification (CEAP) 1 to 6. We performed correlation between the degree of CVI, central and peripheral arterial pressure, and arterial stiffness measured by brachial artery oscillometry. RESULTS: We evaluated 70 patients, 53 of whom were women with a mean age of 54.7 years. Patients with advanced degrees of venous insufficiency CEAP 4,5,6, had higher levels of systolic, diastolic, central, and peripheral arterial pressures compared to those with early stages (CEAP 1,2,3). The CEAP 4,5,6 group had higher arterial stiffness indices than the CEAP 1,2,3 group: pulse wave velocity (PWV) 9.3 m/s vs. 7.0 m/s, P < 0.001; augmentation pressure (AP) 8.0 mm Hg vs. 6.3 mm Hg; P = 0.04. There was a positive correlation between the degree of venous insufficiency measured by the venous clinical severity score, villalta score and CEAP classification, and the arterial stiffness indices (Spearman's coefficient = 0.62 for PWV and CEAP, P < 0.01). The factors influencing PWV were age, peripheral systolic arterial pressure (SAPp), and AP. CONCLUSIONS: There is a correlation between the degree of venous disease and arterial structural changes characterized by arterial pressure and stiffness indices. Degenerative changes secondary to venous insufficiency are associated with impairment of the arterial system, which has implications for the development of cardiovascular disease.

The Endoscopic Anatomy of the External Acoustic Meatus and of the Middle Ear in Dry Temporal Bones: A Study Conducted Using Digital and Mobile Device Technology

Abstract Introduction The endoscopic anatomy of the middle ear (ME) and of the external acoustic meatus (EAM) has been described in cadavers, in fresh temporal bones, or in vivo using conventional video recording, but not in dry bones or using an alternative inspection and recording technique. Objective To study the anatomy of the ME and of the EAM in dry temporal bones using a smartphone-endoscope system. Methods The EAM and the ME were studied in dry temporal bones using an endoscopic transcanal approach with a telescope connected to a smartphone (M-scope mobile endoscope app and adaptador, GBEF Telefonia, São Paulo, SP, Brazil). Results Out of 50 specimens, 2 had exostosis of the EAM and 3 contained remains of the tympanic membrane. The anterior wall of the EAM was prominent in 10/48 specimens (20.8%). Ossicles were seen in 13/45 (28.8%), stapes at the oval window were seen in 12/45 (26.6%), and the incus was seen in 1/45 (2.2%) specimens. The facial canal was open and protruding in 15/45 (33.3%) and in 7/45 (15.5%) specimens, respectively. Of the 45 MEs evaluated, type A was predominant for finiculus (93.3%), subiculum (100%), and ponticulus (95.6%). The rest were type B. None was classified as type C. According to its position in relation to the round window, the fustis was classified into type A (68.9%) or B (31.1%). The pyramidal eminence, the bony portion of the Eustachian tube, the semicanal of the tensor tympani muscle, and the cochleariform process were visualized completely or partially in all cases. Conclusion The use of a smartphone-based endoscopic transcanal procedure in dry temporal bones allowed the evaluation of anatomical variations in the EAM and in the ME.

The Endoscopic Anatomy of the External Acoustic Meatus and of the Middle Ear in Dry Temporal Bones: A Study Conducted Using Digital and Mobile Device Technology.

Introduction The endoscopic anatomy of the middle ear (ME) and of the external acoustic meatus (EAM) has been described in cadavers, in fresh temporal bones, or in vivo using conventional video recording, but not in dry bones or using an alternative inspection and recording technique. Objective To study the anatomy of the ME and of the EAM in dry temporal bones using a smartphone-endoscope system. Methods The EAM and the ME were studied in dry temporal bones using an endoscopic transcanal approach with a telescope connected to a smartphone (M-scope mobile endoscope app and adaptador, GBEF Telefonia, São Paulo, SP, Brazil). Results Out of 50 specimens, 2 had exostosis of the EAM and 3 contained remains of the tympanic membrane. The anterior wall of the EAM was prominent in 10/48 specimens (20.8%). Ossicles were seen in 13/45 (28.8%), stapes at the oval window were seen in 12/45 (26.6%), and the incus was seen in 1/45 (2.2%) specimens. The facial canal was open and protruding in 15/45 (33.3%) and in 7/45 (15.5%) specimens, respectively. Of the 45 MEs evaluated, type A was predominant for finiculus (93.3%), subiculum (100%), and ponticulus (95.6%). The rest were type B. None was classified as type C. According to its position in relation to the round window, the fustis was classified into type A (68.9%) or B (31.1%). The pyramidal eminence, the bony portion of the Eustachian tube, the semicanal of the tensor tympani muscle, and the cochleariform process were visualized completely or partially in all cases. Conclusion The use of a smartphone-based endoscopic transcanal procedure in dry temporal bones allowed the evaluation of anatomical variations in the EAM and in the ME.

International Survey of Operative Practices for Otologists and Neurotologists During the COVID-19 Crisis.

OBJECTIVE: To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally. STUDY DESIGN: Cross-sectional survey. METHODS: A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition. RESULTS: Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria.Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p < 0.001). 71.5% of providers did not perform an elective otologic or neurotologic operative procedure during the initial crisis period. 49.8% reported modifying their surgical technique due to the COVID-19 pandemic. Use of powered air-purifying respirators and filtering facepiece 2 or 3 (FFP2/FFP3) respirators were in minimal supply for 66.9% and 62.3% of respondents, respectively. CONCLUSION: The COVID-19 pandemic impacted the otology and neurotology community globally, resulting in significant changes in operative volume and case selection. Modification of surgical technique and shortages of personal protective equipment were frequently reported.

COVID-19 and ear endoscopy in otologic practices.

PURPOSE: Otolaryngologists have had to postpone the majority of surgical procedures in the current COVID-19 pandemic. Airborne transmission, beyond the projection of droplets from upper airways, expose healthcare workers to a risk of viral infection. Aerosol generating procedures (AGP) increase the risk of viral transmission to staff within the operating room. METHODS: Surgery of middle ear and mastoid is also considered an AGP, particularly mastoidectomy performed using a high-speed drill. The authors report their experience in endoscopic ear surgery as an alternative technique to reduce AGP in otologic procedures. RESULTS: Transcanal endoscopic ear surgery is a reliable technique used to manage many otologic conditions. CONCLUSION: The endoscopic approach may reduce the risk of viral transmission to operating room staff by reducing the need for mastoidectomy.

Future of Endoscopic Ear Surgery.

Endoscopic ear surgery has gained popularity in recent years, becoming standard practice in otology centers around the world as an adjunct to conventional microscopic surgery and as a sole tool for limited disease. During the last years, technical improvements and growing expertise in the handling of the endoscope allowed introducing an exclusive endoscopic approach to the middle ear, lateral skull base, middle cranial fossa, and posterior fossa/cerebellopontine angle pathologies. Endoscopic instrumentation, techniques, and knowledge have improved during the last few years, and in the future, endoscopic surgical techniques will gain even more importance in otologic surgery.

Endoscopic ear surgery.

OBJECTIVES: This article reviews the advantages and disadvantages of endoscopic ear surgery (EES). METHOD: Pubmed, Google and the Proquest Central Database at Kirikkale University were queried using the keywords "endoscopic ear surgery", "ear surgery" and "endoscopy" to identify the literature needed for the review. RESULTS: Endoscopes allow for enhanced surgical visualisation. The distal part of the apparatus is illuminated and contains lenses angled to allow a wider view of the operative area. Transcanal endoscopic techniques have transformed the external ear canal (EAC) into an operative gateway. The benefits EES can offer include wider views, enhanced imaging capabilities and increased magnification, and ways to see otherwise poorly visualisable portions of the middle ear. EES permits surgeons to operate using minimally invasive otological techniques. When compared with microscope-assisted surgery, endoscopic tympanoplasty has been shown to require a shorter operating time in some instances. There are a number of drawbacks to EES, however, which include the fact that it is a single-handed technique, that the light source may produce thermal injury and that visualisation using the endoscope is severely curtailed if bleeding is profuse. CONCLUSION: EES is a safe and effective technique. The current literature supports the idea that the results achieved by endoscopic methods are usually comparably beneficial to results obtained using conventional microscopic methods.

"M" line: New anatomical landmark for the maxillary sinus natural ostium.

OBJECTIVE: Describe a reliable anatomical landmark that can be used to locate the maxillary sinus natural ostium (MSNO) during endoscopic surgery, even if the uncinate process is preserved. DESIGN: Descriptive anatomical. SETTING: An anatomical and radiological study was performed to evaluate the consistency of the landmark, denominated "M" line. SUBJECTS AND METHODS: Dissections were performed in 57 cadaver heads (114 sides). In addition, 73 computerised tomography (CT) scans (146 sides) of patients with chronic inflammatory sinonasal disease were analysed using a three-dimensional (3D) reconstruction computer program. RESULTS: The "M" line crossed the MSNO in 112 dissected sides (98.2%) and 140 sides at CT 3D reconstruction (95.9%). CONCLUSION: The "M" line is a reliable anatomical landmark for predicting MSNO location. As such, it could improve and facilitate endoscopic sinus surgery, using traditional, minimally invasive or uncinate preserving techniques.

A Primary Clival Defect: Endoscopic Binostril Approach With Nasal Septal Flap Closure and Preservation of Septal Integrity.

Primary spontaneous cerebrospinal fluid (CSF) rhinorrhea is an unusual phenomenon that may occur anywhere along the skull base. However, CSF leaks originating from clival defects are rarely reported in the literature. The majority of reported cases were managed with microscopic techniques, using free grafts. The present study discusses a case of spontaneous CSF rhinorrhea from a clival defect closed with our transnasal operative approach using endoscopic techniques. The skull base defect was successfully managed with an endoscopic binostril approach to create a nasal septal flap pedicled at the sphenopalatine artery, while also preserving the integrity of the nasal septum.

Development of the international orbital Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system.

BACKGROUND: Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic-based staging system was developed. METHODS: An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed. RESULTS: Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty. CONCLUSION: Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high-quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH.

Transcanal endoscopic approach to lesions of the suprageniculate ganglion fossa.

OBJECTIVE: The aim of this paper would be to describe the first case series of exclusive transcanal endoscopic approach to treat lesions with limited extension at the suprageniculate fossa. This endoscopic approach allowed a complete removal of suprageniculate disesases with low complication rates using a minimally invasive surgical route. METHODS: This is a retrospective chart analysis and a surgery video recording review of these patients were performed in August 2015. From November 2011 to November 2015, 29 patients were submitted to an endoscopic transcanal lateral skull base surgery. From those 29 subjects, in 6 patients an exclusive endoscopic transcanal suprageniculate approach was performed to remove lesions located into the geniculate fossa. Surgical indications, pre-operative assessment, results were collected and the surgical technique were described. RESULTS: The final study group was composed of 6 patients. 3 male and 3 female; median age is 25.3 years old. In all 6 subjects it was possible to remove the lesions using an exclusive endoscopic transcanal suprageniculate approach. No intraoperaoperative complications were observed in any patients. The mean follow up period was 15.16 months. CONCLUSION: Exclusive endoscopic transcanal suprageniculate approach is definitely a minimally invasive technique and should be consider an optimal solution to treat lesions located in the suprageniculate fossa in some patients. We introduce a minimally invasive approach to the geniculate ganglion region in order to allow complete removal of suprageniculate disesases with low complication rates using a minimally invasive surgical route.

Endoscopic Management of Middle Ear Paragangliomas: A Case Series.

OBJECTIVE: To investigate the efficacy and safety of endoscopic middle ear paraganglioma (glomus tympanicum) resection. STUDY DESIGN: Case series with chart review. SETTING: Multi-institutional tertiary university medical centers. PATIENTS: Adult patients with middle ear paragangliomas treated via a transcanal endoscopic approach from 1/2012 to 11/2015. INTERVENTION: All tumors were initially approached via a transcanal endoscopic technique. An operating microscope was used only if the tumor could not be adequately visualized or resected with endoscopic techniques alone. MAIN OUTCOME MEASURES: The main outcome was completeness of tumor resection via the endoscopic technique. Secondary measures were resolution of pulsatile tinnitus, audiometric outcomes, surgical duration, and surgical complications. RESULTS: Endoscopic resection was attempted on 14 middle ear paragangliomas. Thirteen patients (93%) were women with a mean age of 61.6 years. The mean tumor size was 6.2 mm (SD, 3.3). Eleven cases (79%) had complete resection via an exclusive endoscopic approach. The mean surgical duration was 108.1 minutes (SD, 55.6). One case required use of an operating microscope via a transcanal route and two cases required postauricular incisions with mastoidectomy. There were no significant postoperative complications. Two patients (14%) had tympanic membrane perforations repaired intraoperatively without residual perforation on follow-up. All patients had normal postoperative facial nerve function. Pulsatile tinnitus resolved after surgery in all 13 patients who presented with this symptom preoperatively. The mean pure-tone average improved by 5.9 dB (SD, 4.6) after surgery. CONCLUSIONS: Endoscopic management of middle ear paraganglioma is safe, feasible, and effective.

The Fully Endoscopic Acoustic Neuroma Surgery.

Surgical approaches to vestibular schwannomas (VS) are widely known and extensively recorded. For the first time, an exclusive endoscopic approach to the internal acoustic canal (IAC) was described and used to safely remove a cochlear schwannoma involving IAC in March 2012. The aim of this article was to summarize indications and technique to treat intracanalicular VS by transcanal/transpromontorial endoscopic approach. Because management of intracanalicular VSs is complex and strongly debated, this kind of therapeutic option in the appropriate and selected cases could modify classic concepts of the management of this pathology.

Endoscopic Techniques in Tympanoplasty.

The endoscope has transformed the way we observe, understand, and treat chronic ear disease. Improved view, exclusive transcanal techniques, assessment of ventilation routes and mastoid tissue preservation have led to decreased morbidity and functional enhancement of minimally invasive reconstruction of the middle ear. The philosophical identity of endoscopic ear surgery is evolving; new research, long-term results, and widespread acknowledgement of its postulates will undoubtedly define its role in otology.

Endoscopic Facial Nerve Surgery.

Tympanic facial nerve segment surgery has been traditionally performed using microscopic approaches, but currently, exclusive endoscopic approaches have been performed for traumatic, neoplastic, or inflammatory diseases, specially located at the geniculate ganglion, greater petrosal nerve, and second tract of the facial nerve, until the second genu. The tympanic segment of the facial nerve can be reached and visualized using an exclusive transcanal endoscopic approach, even in poorly accessible regions such as the second genu and geniculate ganglion, avoiding mastoidectomy, bony demolition, and meningeal or cerebral lobe tractions, with low complication rates using a minimally invasive surgical route.

Endoscopic Management of Middle Ear and Temporal Bone Lesions.

Tantamount to the management of temporal bone neoplasms is the ability to visualize the pathology and its relationship with the numerous critical structures housed therein. Transcanal endoscopic ear surgery provides the surgeon with an unparalleled view of the entire middle ear. This article presents the latest information on the usefulness of transcanal endoscopic ear surgery in the management of middle ear and temporal bone neoplasms.

Endoscopic endonasal orbital cavernous hemangioma resection: global experience in techniques and outcomes.

BACKGROUND: Endoscopic orbital surgery represents the next frontier in endonasal surgery. The current literature is largely composed of small, heterogeneous, case series with little consensus regarding optimal techniques. The purpose of this study was to combine the experience of multiple international centers to create a composite of the global experience on the endoscopic management of a single type of tumor, the orbital cavernous hemangioma (OCH). METHODS: This was a retrospective study of techniques for endoscopic OCH resection from 6 centers on 3 continents. Only primary data from strictly endoscopic resection of OCHs were included. Responses were analyzed to qualitatively identify points of both consensus and variability among the different groups. RESULTS: Data for a total of 23 patients, 10 (43.5%) male and 13 (56.5%) female were collected. The majority of lesions were intraconal (60.9%). The mean ± standard deviation (SD) surgical time was 150.7 ± 75.0 minutes with a mean blood loss of 82.7 ± 49.6 mL. Binarial approaches (26.1%) were used exclusively in the setting of intraconal lesions, which were associated with a higher rate of incomplete resection (31.3%), postoperative diplopia (25.0%), and the need for reconstruction (37.5%) than extraconal lesions. Orthotropia and symmetric orbital appearance were achieved in 60.9% and 78.3% of cases, respectively. CONCLUSION: Extraconal lesions were managed similarly; however, greater variability was evident for intraconal lesions. These included the laterality and number of hands in the approach, methods of medial rectus retraction, and the need for reconstruction. The increased technical complexity and disparity of techniques in addressing intraconal OCHs suggests that continued research into the optimal management of this subclass of lesions is of significant priority.

Report of endoscopic cochlear implantation.

OBJECTIVES: To report patient outcomes after transcanal endoscopic cochlear implantation for sensorineural hearing loss. PATIENTS: Males and female subjects more than 7 years old with sensorineural hearing loss (confirmed with audiologic studies) were selected. CT imaging was used to rule out any anatomic anomalies of the temporal bone. Smaller pediatric patients whose canal might still be growing and who might have a higher incidence of otitis media and otitis externa were excluded. Obese adults whose canal skin was too thick to allow good access down the ear canal were also excluded. INTERVENTION(S): Surgical (therapeutic). Endoscopic cochlear implantation using a transcanal approach. MAIN OUTCOME MEASURE(S): Implant position and function. Postoperative complications specifically related to transcanal approach and use of the endoscope. RESULTS: Twenty-five endoscopic cochlear implantations were performed in 24 ears on 11 female and 10 male subjects aged 7-65 years. Eight patients were implanted in Brazil, and 13 patients (17 yr) were implanted in the United States. All implants were fully inserted into the scala tympani, and 24 functioned normally with appropriate thresholds. Mean time of follow-up was 16 months (SD, ±7.2). The chorda tympani was sacrificed in 2 of 25 procedures, 12 EAC/TM tears occurred which healed by the second follow-up visit. No injury to the facial nerve was observed. One postoperative wound infection and 1 otitis externa each resolved with 1 week of antibiotics. Implant array was visible through the EACs skin but not exposed in 6 of 24 ears. CONCLUSION: Endoscopic cochlear implantation may become a viable, safe, and feasible alternative to the standard open transmastoid approach.