Prelacrimal window approach to the maxillary sinus: a systematic review and meta-analysis of the literature.

BACKGROUND: The prelacrimal window approach (PLWA) is a minimally invasive surgical technique that has been proposed as an alternative to the traditional approaches to access the maxillary sinus. METHODOLOGY: A systematic review with meta-analysis was performed following PRISMA guidelines and identified 368 articles for initial review of which 14 (610 participants) met the criteria for meta-analysis. Four databases, including PubMed, Google Scholar, Web of Science and Scopus, were searched to identify relevant articles. Two independent reviewers conducted the eligibility assessment for the included studies. Methodology quality and risk of bias were evaluated by New Castle Ottawa scale. The outcomes assessed were recurrence of the pathology, postoperative morbidity including epiphora, dry nose, facial, gingival numbness, epistaxis or local infection. RESULTS: The present data suggest a significant reduction in the recurrence rate of maxillary sinus pathology following PLWA when compared to conventional surgery (endoscopic medial maxillectomy, endoscopic sinus surgery and the Caldwell-Luc operation). The rates of epiphora, facial or gingival numbness, epistaxis or infection requiring intervention, were not significantly different between the procedures. CONCLUSIONS: Maxillary sinus pathology can be effectively treated using the PLWA technique, as it has been shown to result in a lower recurrence rate compared to conventional surgeries.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall.

BACKGROUND: The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip. METHODOLOGY: Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the 'shoulder' of the inferior turbinate and the pyriform aperture. RESULTS: The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78 ± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the 'shoulder' of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides. CONCLUSIONS: We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

Long-term results after restoring nasal tip support using auricular cartilage as an intercrural columellar strut graft: the "I-Beam" technique.

BACKGROUND: The lack of nasal tip support resulting in poor protection and projection of the nose is a common cause of nasal obstruction and cosmetic impairment. Although septal cartilage is preferred for restoration of nasal tip support, there is often not enough septal cartilage available. We describe an intercrural columellar strut graft in a circumferential soft tissue pocket: the I-Beam technique. METHODOLOGY: In this cohort study over an 8-year period the clinical and biometrical long-term results after restoration of nasal tip support with an autologous auricular cartilage graft, the I-Beam technique, is evaluated. RESULTS: Out of the 72 consecutive septorhinoplasties with the I-Beam technique, we studied 66 patients in the median long-term follow-up of 89 months. In all patients a significant improvement in nasal tip projection was found. A functional improvement in nasal breathing was achieved in 86%. The overall satisfaction with the I-Beam graft was of 83%. No deterioration in smell perception was found after surgery. CONCLUSIONS: The I-Beam technique using back-to-back sutured autologous auricular cartilage is a safe and effective technique and gives long-term structural support and enhances tip projection.

Anterior maxillary wall and lacrimal duct relationship - CT analysis for prelacrimal access to the maxillary sinus.

BACKGROUND: The distance between the anterior wall of the maxillary sinus and the nasolacrimal duct shows a large individual variation. METHODOLOGY: To evaluate the feasibility of accessing the maxillary sinus through a prelacrimal window access (PLWA), a series of 100 paranasal CT scans from adult patients was analysed retrospectively. The distance between the anterior maxillary wall and the anterior border of the lacrimal duct (= prelacrimal window) were measured in 200 sides. RESULTS: A distance of more the 7 mm was found in 12.5% maxillary sinuses and would enable straight forward PLWA. A distance between smaller than 7mm and larger than 3mm was present in 56.5% of sinuses, and would make surgical access more demanding. In 31.5% of maxillary sinuses the distance was smaller than or equal to 3mm and in these patients this approach would be difficult without transecting the nasolacrimal duct. CONCLUSION: Only in 12.5% of sinuses a prelacrimal endoscopic access is readily feasible, while in 56.5% temporary tear sac dislocation is required and in 31.5% lacrimal sac dislocation is always needed along with a significant amount of bone removal to enable PLWA.

[Advances in the surgical treatment of tumors of the pituitary region : rhino-neurosurgical transnasal endoscopic surgery]. / Fortschritte in der chirurgischen Behandlung von Tumoren der Hypophysenregion : Rhinoneurochirurgische transnasale endoskopische Operationstechnik.

Conventional microscopic surgery of pituitary adenomas offers excellent results with regard to local tumour control and endocrine function. Overall patient morbidity and mortality is low. However, recent studies demonstrate further improvements in tumour resection control and more favourable endocrine/ophthalmologic results when endoscopic techniques are applied, as well as an overall reduction in peri-interventional morbidity. Additionally, use of endoscopic techniques in rhino-neurosurgical cooperation achieved better specifically rhinologic results and improved subjective comfort for patients. The cooperative rhino-neurosurgical approach not only allows for optimal treatment of the primary pituitary pathology, but also treatment of additional nasal and paranasal pathologies, such as a deviated septum or disturbed drainage of the paranasal sinus.

Congenital aural atresia: hearing rehabilitation using active middle-ear implants.

OBJECTIVE: To assess hearing rehabilitation in patients with congenital aural atresia using an active middle-ear implant (Vibrant Soundbridge). METHODS: Of a cohort of 70 microtia and atresia patients, 10 underwent Vibrant Soundbridge implantation between 2008 and 2021. Two of the 10 patients had binaural implantation, resulting in 12 ears for analysis. Pre- and post-operative audiometry data were analysed, and patient satisfaction was evaluated. Surgical issues regarding coupling sites and outcomes were analysed. RESULTS: Pure tone average (0.5, 1, 2 and 4 kHz) improved from a pre-operative mean (standard deviation) of 65.3 (8.7) dB HL to a post-operative mean of 26.8 (4.9) dB HL. This resulted in a mean pure tone average gain of 38.5 dB HL. The results indicate no obvious difference between stapes (n = 8) and incus (n = 4) coupling. The mean effective gain for 0.5, 1, 2 and 4 kHz was -17.8 dB HL (standard deviation = 4.3). Concerning effective gain, Vibrant Soundbridge performed best at 2 kHz. Patients reported high overall satisfaction, good sound quality and strongly improved directional hearing. CONCLUSION: An active middle-ear implant (Vibrant Soundbridge) allows hearing rehabilitation in selected atretic ears, and provides long-term hearing stability in children and adults.

Olfaction after endoscopic sinus surgery: long-term results.

Loss of olfactory function is one of the main symptoms in patients with chronic rhinosinusitis. This prospective, non-randomized interventional study reports five years results of olfaction of patients with chronic rhinosinusitis who underwent endoscopic sinus surgery in conjunction with topical medical treatment. Forty-five patients with chronic rhinosinusitis who underwent endoscopic sinus surgery were evaluated preoperatively, after three months and 34 (76%) of them after five years. Olfactory function was assessed by a subjective visual analogue scale, by a screening test of olfaction with Smell Diskettes and by measuring the N-Butanol threshold. Patient`s subjective sense of olfaction using a visual analogue scale was improved in 79% at 5 years. Objective measurements by Smell Diskettes improved in 53% at 5 years whilst the quantitative measurement by the N-Butanol threshold improved in 85% at 5 years. The high percentage of patients with improvement of olfaction five years after surgery indicates that endoscopic sinus surgery in conjunction with continued topical treatment leads to a long term improvement of the sense of smell. However, it was found that - measured by the sensitive N-Butanol threshold - up to 9% had no improvement and 6% had deterioration in their olfaction at 5 years after endoscopic sinus surgery. This fact has to be considered in the preoperative counselling of patients.

Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training.

BACKGROUND: The aim of this multicentre study was to systematically analyse the strengths and weaknesses in the surgical training for endoscopic sinus surgery (ESS) and identify measures that may improve training. METHODOLOGY: Using a structured questionnaire, 133 participants of ESS courses in seven centres in Germany, Switzerland and Australia were asked about their experiences during their dissection courses and how they perceived their course could be improved. RESULTS: Gaining confidence in handling of instruments and endoscopes was only a problem for participants with little experience in ESS. The majority of the participants, independent from their level of training, considered infundibulotomy and anterior ethmoidectomy as the easiest dissection steps, whilst surgery of the frontal sinus posed a considerable challenge for many surgeons even those with a higher level of training. Participants with and without ESS experience thought that emphasis on anatomy was the most important improvement that could be made during their surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their surgical skills and their confidence when performing ESS. CONCLUSIONS: ESS dissection courses are considered beneficial by surgical trainees. Participants felt that more emphasis on sinus anatomy in conjunction with private study is essential to maximize their skills in surgical dissection. For beginners with ESS, an infundibulotomy and anterior ethmoidectomy were thought to be the best initial procedures to help develop endoscopic surgical skills.

Limitations of balloon sinuplasty in frontal sinus surgery.

Balloon sinuplasty is a tool that is used to treat selected patients with paranasal sinus pathologies. No studies have investigated the aetiology of failed access to the frontal sinus. The aim of our study was to specify the intraoperative technical failure rate and to analyse the aetiology of the failed access to predict potential technical difficulties before surgery. We retrospectively analysed the charts of patients who underwent balloon sinuplasty from November 2007 to July 2010 at three different ENT-Centres. CT-analysis of the patients with failed access was performed. Of the 104 frontal sinuses, dilation of 12 (12%) sinuses failed. The anatomy of all failed cases revealed variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or agger-nasi-cell) or osteoneogenesis. In one patient, a lymphoma was overlooked during a balloon only procedure. The lymphoma was diagnosed 6 months later with a biopsy during functional endoscopic sinus surgery. In complex anatomical situations of the frontal recess, balloon sinuplasty may be challenging or impossible. In these situations, it is essential to have knowledge of classical functional endoscopic sinus surgery of the frontal recess area. The drawbacks of not including a histopathologic exam should be considered in balloon only procedures.