Surgical treatment of 186 sinonasal inverted papillomas and analysis of the immunohistochemical and molecular features associated with recurrences.

INTRODUCTION: Inverted papillomas (IP) are benign epithelial tumors with a tendency to be locally invasive and with disposition to recur. The aim of our study is to present the results of IP treatment, considering pathological, immunohistochemical and molecular features of recurrence. MATERIAL AND METHODS: From 1978 to 2020, 186 sinonasal IPs surgeries corresponding to 152 patients were treated in our center. We performed a pathology evaluation of all the recurrent cases reviewing the histological diagnosis, the presence of mixed component other than IP, the koilocytic changes, the p16 over expression and HPV-DNA detection. RESULTS: Overall recurrence rate was 19 % (35/186). The 35 IP recurrences correspond to 22 patients, 9 of whom presented a single recurrence (single recurrence group) while 13 of them presented more than one recurrence (multi-recurrent group). Immunohistochemical analysis showed a higher percentage of p16 overexpression (54 % vs 33 % p = 0.415) and HPV-DNA presence (23 % vs 0 % p = 0.240) in the multi-recurrent group compared with single recurrence group. In addition, the revision showed more IP with exophytic papilloma focus (38 vs 22 % p = 0.648) and a higher proportion of IP with koilocytotic changes (61 % vs 22 % p = 0.099) in the multirecurrent group. There is no significant difference between groups in our results. CONCLUSION: The analysis of our patients may differentiate between two groups with recurrent papillomas. A single recurrence group where the cause of recurrence is probably an anatomical problem related to an incomplete resection, and a second pattern, the multi-recurrence group, where HPV infection may be the main cause of recurrence.

"The Accessory Ethmoidal Canal Does Not Necessarily Contain an Arterial Structure".

Introduction: The aim of our study is to describe the prevalence of the accessory ethmoidal artery in endonasal endoscopic cadaver dissections and to identify its intraorbital origin. Material and Methods: From 2018 to 2020, thirty-four nasal dissections were performed in seventeen adult cadaveric heads. We performed a complete ethmoidectomy to identify the ethmoidal canals. Then, we removed the bony canal and the lamina papiracea to verify the injected vessel and to confirm the vascular structure inside the canal. Results: We found the anterior ethmoidal canal (AEC) and the posterior ethmoidal canal (PEC) in 100% of nasal cavities (34/34). We identified 4 accessory ethmoidal canals (AcEC) in the 34 nasal fossae dissected (12%). All AEC contained an arterial vessel. The AcEC contained an arterial vascular structure in 2 cases, a neural structure in other specimen, and in the fourth case no structure could be verified. In 32 of 34 nasal cavities, the PEC contained an artery and only in 2 cases the PEC did not contain any vascular structure. In these specimens, we observed that the AcEC with an arterial vessel inside (6%) was closer to the posterior canal than the anterior canal. Conclusion: According to our findings, we can suggest that the presence of a canal does not necessarily imply the presence of an arterial vessel, and that presence of the accessory ethmoidal artery could be associated with the absence of posterior ethmoidal artery.

Management of Patients With Graves Orbitopathy Using Endonasal Endoscopic Techniques.

OBJECTIVE: The aim of the authors' study is to show their surgical results in orbital decompression using different endonasal endoscopic techniques. These approaches are according to the degree of proptosis and the presence or not of sight threatening. METHODS: The authors performed 31 orbital decompressions on 20 Graves orbitopathy patients. Average age at surgery was 52 years. There were 5 males and 15 females. Five patients were diagnosed as having severe or for sight-threatening Graves orbitopathy. These included 3 men and 2 women having an average age of 54 years old. Minimum postsurgical follow-up was 12 months in all patients. RESULTS: Orbital decompression was performed in 15 patients for proptosis and in 5 patients for urgent sight threat. Thirteen orbits showed mild proptosis and 18 orbits presented moderate proptosis. In patients without sight threatening reduction of proptosis had a mean value of 2.8 mm as determined by exophtalmometry, being 3.3 mm when measured on magnetic resonance imaging. The mean millimeter in mild proptosis was between 1.5 and 1.7 and between 3.4 and 4.2 in moderate proptosis. In patients having sight threat mean visual acuity after surgery improved from 0.6 to 0.9.Only 1 patient without diplopia preoperative developed diplopia after surgery (17%). In 55% of patients strabismus and/or eyelid surgery were required.In postoperative follow-up, 2 patients developed a mucocele and 1 patient developed corneal erosion. CONCLUSION: The authors recommend the preservation of the periorbital sling and the anterior ethmoido-maxillary angle in patients with mild-moderate exophthalmos and without threatened vision. In case of sight threatening the authors resected the most periorbita as much as possible.Evidence-based medicine Level V.

Nuestra experiencia en el manejo de las complicaciones orbitarias en la rinosinusitis aguda / Our experience in the management of orbital complications in acute rinosinusitis

ANTECEDENTES Y OBJETIVO: La propagación de una infección a partir de los senos paranasales es poco frecuente pero grave. Entre un 4 y un 20% de las rinosinusitis se pueden complicar; de ellas, las orbitarias (60-75%) son las más prevalentes. La gran mayoría se presentan en la edad pediátrica, si bien en la edad adulta son más graves. Nuestro objetivo es analizar las características epidemiológicas de estos pacientes así como plantear un protocolo de actuación ante esta situación. MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo de 21 pacientes diagnosticados de una complicación orbitaria en el curso de una rinosinusitis aguda entre 2005 y 2018. El diagnóstico se basó en la historia clínica, la exploración endoscópica y las pruebas de imagen. Todos los pacientes recibieron antibioterapia intravenosa y fueron valorados por oftalmología. Se llevó a cabo un tratamiento quirúrgico urgente en caso de existir un absceso o mala evolución con el tratamiento médico. RESULTADOS: La edad media de los pacientes fue de 24 años. El 52% fueron varones y el 48% mujeres. Según la clasificación de Chandler, el 43% (9/21) fueron celulitis preseptales (7 adultos y 2 niños), el 10% (2/21) celulitis orbitarias (un adulto y un niño), el 43% (9/21) abscesos subperiósticos (2 adultos y 7 niños), hubo un caso de absceso orbitario en un adulto y ningún caso de trombosis de seno cavernoso. Se solicitó una TC a todos los pacientes y se optó por el tratamiento quirúrgico en caso de absceso subperióstico u orbitario, a excepción de 2 abscesos de pequeño tamaño (< 4 mm), subperiósticos mediales y en edad pediátrica (< 4 años) que presentaron una correcta evolución con tratamiento conservador. El abordaje quirúrgico fue por vía endoscópica endonasal: se resecó la lámina papirácea y se mantuvo intacta la periórbita en el caso de abscesos subperiósticos, pero se incidió en ella en el absceso orbitario. Se complementó con un abordaje externo palpebral en los 4 casos que presentaron una colección en el techo de la órbita o en la pared lateral. Dos pacientes adultos jóvenes (10%) presentaron de manera concomitante una complicación intracraneal. CONCLUSIONES: Las complicaciones orbitarias de la rinosinusitis aguda son poco frecuentes pero potencialmente graves. Es importante conocerlas y sospecharlas para actuar con rapidez. El tratamiento multidisciplinar, la localización y la extensión del cuadro son esenciales para el correcto manejo de estas complicaciones. El abordaje quirúrgico se realiza mediante endoscopia endonasal. Su limitación son las colecciones localizadas en el techo de la órbita o en pared lateral, en las que se tendrá que complementar la actuación con un abordaje externo palpebral

BACKGROUND AND OBJECTIVE: The spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60-75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm. MATERIALS AND METHODS: We carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management. RESULTS: The average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (< 4 years) with a small and medial subperiosteal abscess (< 4 mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly. CONCLUSION: Orbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required

Our experience in the management of orbital complications in acute rhinosinusitis. / Nuestra experiencia en el manejo de las complicaciones orbitarias en la rinosinusitis aguda.

BACKGROUND AND OBJECTIVE: The spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60-75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm. MATERIALS AND METHODS: We carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management. RESULTS: The average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (<4 years) with a small and medial subperiosteal abscess (<4mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly. CONCLUSION: Orbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required.

Endoscopic Medial Maxillectomy With Preservation of Inferior Turbinate: Assessing Results by Acoustic Rhinometry.

BACKGROUND: The aim of this study is to demonstrate the effectiveness of the Endoscopic Medial Maxillectomy technique with the preservation of the nasal anatomy and function of the inferior turbinate. METHODS: From January 2005 to December 2016, the authors performed 27 Endoscopic Medial Maxillectomy with preservation of inferior turbinate on 26 patients. The most frequent pathologies diagnosed were inverted papillomas (13/27) and antrochoanal polyps (7/27). There were 21 primary lesions and 6 patients had been previously treated. There were 19 males and 7 females. On 11 patients the authors could perform an acoustic rhinometry at 4 months postoperatively. RESULTS: The authors did not find any recurrences. In all cases the authors note the presence of the C-notch being the narrowest area of the nasal cavity, on both the surgical and nonsurgical nasal fossa. The mean area for the C-notch in the nonsurgical nasal cavities was 0.50 cm (0.18-0.82) and it was 0.57 cm (0.08-1.06) in the surgical nasal cavities. The increase of the C-notch after nasal decongestion was 0.10 cm in nonsurgical cavities and it was 0.03 cm in the surgical cavities. The mean distance for the C-notch was 2.18 cm and 2.36 cm before and after nasal decongestion in the nonsurgical fossae. In the surgical cavities were 2.31 and 2.37  cm respectively. CONCLUSIONS: The authors' rhinometrics data suggest that Endoscopic Medial Maxillectomy with preservation of inferior turbinate is an effective technique that preserves the anatomic structure and the functions of the inferior turbinate after its resection and reposition.

Anatomical Correlation Between Nasal Vascularisation and the Design of the Endonasal Pedicle Flaps.

Arteries that supply the nasal septum and the lateral nasal wall include vessels that originate from the external carotid artery and from the internal carotid artery. A variety of local endonasal pedicle flaps can be used in different anatomical areas for endoscopic skull base reconstruction. The main flaps are based on terminal branches of the sphenopalatine artery and on anterior ethmoidal artery. This study will describe the anatomy of these vessels and their relationship with the main flaps.

Surgical Anatomy of the Medial Wall of the Orbit in 14 Human Cadavers.

Objective The aim of our study is to present the anatomical landmarks to perform an endoscopic endonasal approach to the medial wall of the orbit (EEAMO). Material and Methods We performed 14 complete nasal and orbital endoscopic dissections in 7 adult cadaveric heads. Results The EEAMO provides a surgical corridor between the medial rectus muscle superiorly and the inferior rectus muscle inferiorly .The mean distance between the ethmoidal crest and medial rectus muscle was 1.5 cm (range, 1.3-1.9 cm). The width of the medial rectus muscle was 1.2 cm (range, 1-1.5 cm). The main vascular structure in this retrobulbar space was the ophthalmic artery that crosses over the optic nerve in 86% of the cases. In its intraorbital route, the anterior ethmoidal artery and the ethmoidal nerves were situated inferior to the superior oblique muscle in all cases. The posterior ethmoidal artery was found superior to it. We could identify the inferior division of the oculomotor nerve in this surgical approach. Conclusions The EEAMO allows adequate exposure of the space between the medial rectus muscle and the inferior rectus muscle. The location of the ethmoidal crest of the palatine bone, and its relationship with the medial rectus muscle, is a useful anatomical landmark for this surgical approach.

Bola fúngica sinusal: análisis de nuestra casuística / Fungus ball of the paranasal sinuses: Analysis of our serie of patients

Introducción y objetivos: La bola fúngica es la forma más frecuente de rinosinusitis fúngica. El objetivo de nuestro estudio es analizar las características clínicas y los resultados de la cirugía en nuestra serie de pacientes. Métodos: Se analizaron retrospectivamente 35 pacientes con bola fúngica tratados en nuestro centro entre 2006 y 2014. Resultados: La edad media fue de 55 años. El 49% de los pacientes fueron varones y el 51% mujeres. El 75% se localizaron en el seno maxilar y el 25% restante en el seno esfenoidal. La clínica más frecuente fue obstrucción nasal, rinorrea y algias craneofaciales. El 69% de pacientes mostró microcalcificaciones intrasinusales en la tomografía computerizada. Todos los pacientes fueron intervenidos quirúrgicamente, sin registrarse recidivas. Conclusiones: Las manifestaciones clínicas de la bola fúngica son muy inespecíficas, por lo que el diagnóstico de sospecha se hace mediante endoscopia y estudio de imagen. El estudio histopatológico confirma el diagnóstico. La cirugía endoscópica nasosinusal es la base del tratamiento de la bola fúngica, limitándose a la apertura del seno (o senos) afecto, y exéresis completa de la lesión. La tasa de complicaciones postoperatorias es muy baja, y no es necesario tratamiento antifúngico oral o tópico concomitante (AU)

Introduction and objectives: The fungus ball is the most frequent type of fungal rhino-sinusitis. The objective of this study is to analyze the clinical and surgical features of our patients. Methods: Retrospective analysis of 35 patients with fungus ball treated in our centre between 2006 and 2014. Results: Mean age was 55 years old. 49% were men and 51% women. 75% involved the maxillary sinus, whereas 25% involved the sphenoid. 69% of our patients showed microcalcifications in the CT study. All the patients were surgically treated, with no cases of recurrence. Conclusions: Clinical manifestations of fungus ball are non-specific, therefore endoscopy and image study are mandatory. The definitive diagnosis is made by histopathological study of the lesion. Endoscopic sinus surgery is the treatment of choice, with opening of the diseased sinus and complete removal of the fungus ball. The frequency of complications is very low. No oral or topical antimycotic treatments are necessary (AU)

A unilateral septal flap based on the anterior ethmoidal artery (Castelnuovo's flap): CT cadaver study.

OBJECTIVE: We describe our experience for repair septal perforation with a septal flap and we analyse the route of the septal branch of the anterior ethmoidal artery (AEA) in the septum area with a radiological anatomy study in order to perform this flap. STUDY DESIGN: We carry out a prospective analysis with computed tomography scan in the cadaver heads and we perform an endoscopic technique in the patients. METHODS: Ten nasal cavities were analysed in five adult cadaveric heads and two patients diagnosed with anterior septal perforation were surgically treated. Measurements in the cadaveric heads were obtained from a sagittal plane of the nasal septum. The anterior point corresponds to the projection of the anterior insertion of the middle turbinate in the frontal process of the maxilla over the nasal septum. The posterior point was obtained with a vertical line passing through the entrance of the AEA in the nasal septum. RESULTS: The mean distance between the anterior point and the posterior point was 7.35 mm with a standard deviation of 0.95 mm. The lowest value was 5.5 mm and the highest value was 8.7 mm. We observed good epithelialisation and closure of the perforation in all patients. CONCLUSION: The unilateral septal flap pedicle by anterior ethmoidal artery may be used for small and medium perforations with a pedicle smaller than 1 cm posterior to the axilla.

Fungus ball of the paranasal sinuses: Analysis of our serie of patients. / Bola fúngica sinusal: análisis de nuestra casuística.

INTRODUCTION AND OBJECTIVES: The fungus ball is the most frequent type of fungal rhino-sinusitis. The objective of this study is to analyze the clinical and surgical features of our patients. METHODS: Retrospective analysis of 35 patients with fungus ball treated in our centre between 2006 and 2014. RESULTS: Mean age was 55 years old. 49% were men and 51% women. 75% involved the maxillary sinus, whereas 25% involved the sphenoid. 69% of our patients showed microcalcifications in the CT study. All the patients were surgically treated, with no cases of recurrence. CONCLUSIONS: Clinical manifestations of fungus ball are non-specific, therefore endoscopy and image study are mandatory. The definitive diagnosis is made by histopathological study of the lesion. Endoscopic sinus surgery is the treatment of choice, with opening of the diseased sinus and complete removal of the fungus ball. The frequency of complications is very low. No oral or topical antimycotic treatments are necessary.

Análisis clínico y resultados quirúrgicos en 58 mucoceles nasosinusales / Clinical analysis and surgical results of 58 paranasal sinus mucoceles

Introducción: Los mucoceles son lesiones benignas que afectan a los senos paranasales, de crecimiento lento, con capacidad de reabsorción ósea. Exponemos nuestra experiencia en el tratamiento quirúrgico de estas lesiones. Métodos: Se realizó un estudio retrospectivo de 58 mucoceles nasosinusales diagnósticados en 54 pacientes entre los años 1989-2012. Se analizaron las diferentes localizaciones, distribución por edad y sexo, características clínicas, tipo de abordaje quirúrgico, recidivas y complicaciones. Resultados: La edad media de los pacientes en el momento del diagnóstico fue de 59 años. El 57% de los pacientes (31/54) fueron varones y el 43% (23/54) mujeres. En el 55% de los casos (32/58) el mucocele estaba localizado en el seno frontal o en la región frontoetmoidal, un 14% (8/58) en el seno etmoidal, un 24% (14/58) en el seno maxilar y un 7% (4/58) en seno esfenoidal. En el 55% de los casos se identificó algún factor predisponente, siendo el 45% mucoceles primarios. El 71% de los pacientes fueron tratados con un abordaje endonasal endoscópico y en el 29% se realizó un abordaje abierto o combinado. Observamos un total de 4 recidivas (7%), 2 en el grupo abordaje endonasal endoscópico y 2 en el grupo tratado con cirugía abierta. Conclusiones: El tratamiento de elección de los mucoceles nasosinusales es la arsupialización por vía endonasal endoscópica, siendo una técnica segura y con buenos resultados (AU)

Introduction: Mucoceles are slow-growing, benign lesions found in the paranasal sinuses that are locally destructive, causing bony resorption an displacement of adjacent structures. We present our experience in the surgical treatment of these lesions. Methods: This was a retrospective review of 58 paranasal sinus mucoceles in 54 patients between 1989 and 2012. We describe patient age and sex, mucocele location, clinical features, surgical approaches employed, recurrence and complications. Results: The mean age of patients in this series was 59 years; there were 31 males (57%) and 23 females (43%). Thirty-two cases (55%) were located in the frontal or ethmoid-frontal system, 8 (14%) in the ethmoid sinus, 14 (24%) in the maxillary sinus and 4 (7%) in sphenoid sinus. Predisposing factors were present in 55% of the patients and 45% cases were primary. Endoscopic treatment was given to 71% of mucocele patients, while 29% were treated with external or combined approaches. Recurrence appeared in 4 patients (7%), 2 in the endoscopic surgery group and 2 in the external surgery group. Conclusions: The procedure of choice for management of paranasal sinus mucoceles is endoscopic drainage. It is a safe approach that gives good results (AU)

Management of sinonasal mucosal melanomas and comparison of classification staging systems.

OBJECTIVE: The aim of this study was to describe treatment results in patients with sinonasal mucosal melanomas (SMMs) and to compare three different classification staging systems. MATERIALS AND METHODS: From 1988 to 2013, we performed a retrospective study of 20 patients with primary sinonasal melanomas. The median age at diagnosis was 71 years. There were 10 males and 10 females. RESULTS: Nine SMMs (45%) were originated in the ethmoidal sinus complex, four (20%) in the inferior turbinate, three (15%) in the nasal septum, two (10%) in the maxillary sinus, and two (10%) in the nasal vestibule. Local recurrence was diagnosed in eight patients (40%), and six out of 20 patients (30%) developed distant metastasis during the course of their disease. The adjusted survival rates at three and five years were 47% and 34%, respectively. The adjusted three-year survival rate according to the sinonasal staging system 7th edition for SMM (TNM-SMM) was 60% in T3 stage, 50% in T4a stage, and 34% in T4b stage (p = 0.05). According to Thompson's staging system, survival was 33% for group one, 58% for group two, and 0% for group three (p = 0.006). With the sinonasal staging system 7th edition for carcinoma (TNM-CAR) survival was 33% in T1, 100% in T2 and T3, 0% in T4a, and 34% in T4b (p = 0.006). CONCLUSIONS: Our experience confirms the distribution of patients according to survival rates was better with the TNM-SMM than with Thompson's or the TNM-CAR systems.

[Clinical analysis and surgical results of 58 paranasal sinus mucoceles]. / Análisis clínico y resultados quirúrgicos en 58 mucoceles nasosinusales.

INTRODUCTION: Mucoceles are slow-growing, benign lesions found in the paranasal sinuses that are locally destructive, causing bony resorption an displacement of adjacent structures. We present our experience in the surgical treatment of these lesions. METHODS: This was a retrospective review of 58 paranasal sinus mucoceles in 54 patients between 1989 and 2012. We describe patient age and sex, mucocele location, clinical features, surgical approaches employed, recurrence and complications. RESULTS: The mean age of patients in this series was 59 years; there were 31 males (57%) and 23 females (43%). Thirty-two cases (55%) were located in the frontal or ethmoid-frontal system, 8 (14%) in the ethmoid sinus, 14 (24%) in the maxillary sinus and 4 (7%) in sphenoid sinus. Predisposing factors were present in 55% of the patients and 45% cases were primary. Endoscopic treatment was given to 71% of mucocele patients, while 29% were treated with external or combined approaches. Recurrence appeared in 4 patients (7%), 2 in the endoscopic surgery group and 2 in the external surgery group. CONCLUSIONS: The procedure of choice for management of paranasal sinus mucoceles is endoscopic drainage. It is a safe approach that gives good results.

Colgajos pediculados procedentes de la arteria esfenopalatina: estudio anatómico y quirúrgico / Pedicle flaps based on the sphenopalatine artery: Anatomical and surgical study

Introducción: Los colgajos locales pediculados a la arteria esfenopalatina permiten reconstruir amplios defectos de la base del cráneo (BC). Material y métodos: De enero de 2008 a enero de 2013 se analizaron 64 lesiones con afectación de la BC intervenidos con un abordaje endonasal endoscópico que requirieron una reconstrucción con colgajos locales pediculados a la arteria esfenopalatina. Adicionalmente se estudiaron cuatro fosas nasales correspondientes a dos cabezas de cadáver donde se analizaron endoscópicamente las medidas y la flexibilidad de cada uno de los colgajos. Resultados: Grupo quirúrgico. Se emplearon 64 colgajos nasoseptales (CNS), en cuatro casos asociados a un colgajo cornete medio (CCM) y en un caso complementado con un colgajo del cornete inferior (CCI). Se evidenciaron 5 fístulas postquirúrgicas (8%). Un 7% de los pacientes con lesiones iniciales presentaron una anosmia definitiva. Disección anatómica. La longitud del CNS varió entre 5,2 cm y 7,7 cm oscilando la anchura entre 3 cm y 4,5 cm. El CCI presentó una distancia anteroposterior entre 4,2 cm y 5 cm y una anchura entre 1,2 cm y 2,8 cm. La longitud media del CCM varió entre 3,5 cm y 4,2 cm con una anchura entre 1,4 cm y 1,9 cm. Conclusión: El CNS es el colgajo local que presenta una mejor versatilidad en el sellado de los defectos craneales, siendo los colgajos pediculados a la arteria nasal posterolateral una excelente alternativa (AU)

Introduction: Local pedicle flaps based on the sphenopalatine artery make it possible to reconstruct large defects of the skull base (SB). Material and methods: From January 2008 to January 2013, 64 lesions with involvement of SB were analysed. These lesions were treated using endoscopic endonasal approach and required a pedicle flap based on the sphenopalatine artery. In addition, measurements and flexibility of the flaps were examined in 4 cadaveric nasal cavities. Results: Surgical group. Sixty-four nasoseptal flaps (NSF) were used, in 4 cases associated with a middle turbinate flap (MTF), and in 1 case supplemented with an inferior turbinate flap (ITF). Five cerebrospinal fluid fistulas (8%) were noted. Among patients with initial lesions, 7% presented an anosmia. Cadaveric group. The length of the NSF varied between 5.2 cm and 7.7 cm and the width ranged from 3 cm to 4.5 cm. The ITF provided an anterior-posterior distance between 4.2 cm and 5 cm, with a width between 1.2 cm and 2.8 cm. The mean length of MTFs varied between 3.5 cm and 4.2 cm, with a width between 1.4 cm and 1.9 cm. Conclusion: The most versatile local flap for the reconstruction of skull base defects is the NSF, and flaps pedicled to the posterolateral nasal artery offer an excellent alternative (AU)

[Pedicle flaps based on the sphenopalatine artery: anatomical and surgical study]. / Colgajos pediculados procedentes de la arteria esfenopalatina: estudio anatómico y quirúrgico.

INTRODUCTION: Local pedicle flaps based on the sphenopalatine artery make it possible to reconstruct large defects of the skull base (SB). MATERIAL AND METHODS: From January 2008 to January 2013, 64 lesions with involvement of SB were analysed. These lesions were treated using endoscopic endonasal approach and required a pedicle flap based on the sphenopalatine artery. In addition, measurements and flexibility of the flaps were examined in 4 cadaveric nasal cavities. RESULTS: Surgical group. Sixty-four nasoseptal flaps (NSF) were used, in 4 cases associated with a middle turbinate flap (MTF), and in 1 case supplemented with an inferior turbinate flap (ITF). Five cerebrospinal fluid fistulas (8%) were noted. Among patients with initial lesions, 7% presented an anosmia. Cadaveric group. The length of the NSF varied between 5.2 cm and 7.7 cm and the width ranged from 3 cm to 4.5 cm. The ITF provided an anterior-posterior distance between 4.2 cm and 5 cm, with a width between 1.2 cm and 2.8 cm. The mean length of MTFs varied between 3.5 cm and 4.2 cm, with a width between 1.4 cm and 1.9 cm. CONCLUSION: The most versatile local flap for the reconstruction of skull base defects is the NSF, and flaps pedicled to the posterolateral nasal artery offer an excellent alternative.

Anatomical and surgical study of the sphenopalatine artery branches.

The sphenopalatine artery gives off two main branches: the posterior lateral nasal branch and the posterior septal branch. From 2007 to 2012 17 patients were treated with cauterization and/or ligature of the sphenopalatine artery with endonasal endoscopic approach. 90 nasal dissections were performed in 45 adult cadaveric heads. We evaluated the number of branches emerging from the sphenopalatine foramen and the presence of an accessory foramen. In the surgery group, we observed a single trunk in 76% of the patients (13/17) and a double trunk in 24% (4/17). We found an accessory foramen in four cases. We obtained a successful result in bleeding control in 88% of the cases. In the cadaver dissection group, 55 nasal cavities had a single arterial trunk (61%), 30 had 2 arterial trunks (33%) and in only 5 nasal fossae we observed 3 arterial trunks (6%). We were able to dissect four accessory foramina. We suggest that in most cases only one or two branches are found in the sphenopalatine foramen.

Integración de la cirugía endoscópica en una unidad de base de cráneo: experiencia en los primeros 72 casos / Endoscopic surgery in the skull base unit: Experience in the first 72 cases

Introducción: La formación de un equipo multidisciplinar es imprescindible para desarrollar y ampliar las indicaciones en la cirugía endonasal endoscópica de la base de cráneo. El objetivo de este trabajo es presentar nuestra experiencia en el grupo de pacientes con afectación de la base de cráneo intervenidos con un abordaje endonasal endoscópico. Métodos: De enero de 2008 a enero de 2012, 72 pacientes con afectación de la base de cráneo fueron diagnosticados y tratados en nuestro centro. Resultados: La edad media de los pacientes en el momento del diagnóstico fue de 53 años. Las diferentes patologías incluyeron 36 adenomas de hipófisis, 10 fístulas de líquido cefalorraquídeo y 5 papilomas invertidos como las más frecuentes. En 45 casos se llevó a cabo un abordaje transesfenoidal transellar, en 4 casos un abordaje transmaxilar transpterigoideo y en 6 casos un abordaje transnasal ampliado. En 12 pacientes se realizó un abordaje a través del etmoides y/o del seno esfenoidal y en 4 casos se utilizó un abordaje frontal tipo Draf IIb/III. En el 61% de los adenomas se consiguió una resección total, en el 22% subtotal y en el 17% parcial. El 86% de las fístulas de líquido cefalorraquídeo se repararon con éxito. No se evidenció ninguna recidiva en los papilomas invertidos intervenidos. En 21 pacientes (29%) ocurrió algún tipo de complicación, apareciendo 6 complicaciones de orden mayor. Conclusiones: Nuestro centro apuesta por la colaboración multidisciplinar en la cirugía endoscópica de la base de cráneo como línea de excelencia (AU)

Introduction: A multidisciplinary team is essential to develop and expand the indications in endonasal endoscopic skull base surgery. The aim of this study was to present our experience in a group of patients with skull base lesions treated using endonasal endoscopic approach. Methods: From January 2008 to January 2012, 72 patients with skull base involvement were diagnosed and treated in our centre. Results: The mean patient age was 53 years. The different pathologies included 36 pituitary adenomas, 10 cerebrospinal fluid leaks and 5 inverted papillomas as the most frequent pathologies. We performed a transsphenoidal transellar approach in 45 cases, a transmaxillary transpterygoid approach in 4 cases and a transnasal expanded approach in 6 cases. We performed an ethmoidal/sphenoidal approach in 12 patients and a Draf IIb/III procedure in four cases. Total resection was achieved in 61% of patients with pituitary adenomas, subtotal in 22% and partial in 17%. Successful repair was achieved in 86% of CSF leaks. No recurrences were observed in patients with inverted papilloma. Complications were observed in 21 patients (29%), 6 being major complications. Conclusions: Our centre stresses the importance of multidisciplinary collaboration in endoscopic endonasal skull base surgery (AU)

Endoscopic surgery in the skull base unit: experience in the first 72 cases.

INTRODUCTION: A multidisciplinary team is essential to develop and expand the indications in endonasal endoscopic skull base surgery. The aim of this study was to present our experience in a group of patients with skull base lesions treated using endonasal endoscopic approach. METHODS: From January 2008 to January 2012, 72 patients with skull base involvement were diagnosed and treated in our centre. RESULTS: The mean patient age was 53 years. The different pathologies included 36 pituitary adenomas, 10 cerebrospinal fluid leaks and 5 inverted papillomas as the most frequent pathologies. We performed a transsphenoidal transellar approach in 45 cases, a transmaxillary transpterygoid approach in 4 cases and a transnasal expanded approach in 6 cases. We performed an ethmoidal/sphenoidal approach in 12 patients and a Draf IIb/III procedure in four cases. Total resection was achieved in 61% of patients with pituitary adenomas, subtotal in 22% and partial in 17%. Successful repair was achieved in 86% of CSF leaks. No recurrences were observed in patients with inverted papilloma. Complications were observed in 21 patients (29%), 6 being major complications. CONCLUSIONS: Our centre stresses the importance of multidisciplinary collaboration in endoscopic endonasal skull base surgery.

Endonasal endoscopic scalpel-forceps dacryocystorhinostomy vs endocanalicular diode laser dacryocystorhinostomy.

Purpose. To compare the efficacy of endonasal endoscopic dacryocystorhinostomy and endocanalicular diode laser dacryocystorhinostomy. Materials and methods. A total of 126 dacryocystorhinostomies were performed in 111 patients with epiphora. In 55% of cases (69/126) we performed an endonasal endoscopic dacryocystorhinostomy and in 45% (57/126) we carried out an endocanalicular dacryocystorhinostomy using diode laser. The mean age at diagnosis was 63 years. The mean age was higher in the endocanalicular group than in the endonasal endoscopic group: 64 versus 62 years. There were 25 men (23%) and 86 women (77%). Results. Successful results were achieved in 73% of patients (92/126). In the endonasal endoscopic group, 83% of patients (57/69) were symptom free compared to 62% of patients (35/57) in the laser diode group. A bicanalicular nasal silicone tube was left in place for a mean of 2.32 months in the endoscopic endonasal group and for 2.82 months in the laser diode group (p=0.164). Median time of recurrence after removal of the tube was 3.56 months (range 0-9.6): 2.84 months in the laser diode group and 4.87 months in the endonasal endoscopic group (p=0.069). Conclusions. The endonasal endoscopic approach achieved better results for nasolacrimal obstruction than the endocanalicular laser diode technique.