Our experience with the surgical management of paranasal sinus osteomas.

The aim of this work is to describe our experience with the management of osteomas of the fronto-ethmoidal region, and to evaluate the limits and possibilities of different approaches: endonasal endoscopic versus external surgical resection of symptomatic osteomas. A review of 26 patients with detected osteomas in tertiary health care center was accomplished. We analysed the 26 adult patients, which detected paranasal sinus (PNS) osteomas--patients who underwent paranasal sinus CT examinations almost exclusively for other reasons. We analysed the patient's symptoms, localization and size of osteomas, clinical and imaging signs, in relation to adjacent structures. Of the 26 cases, 16 located in the etmoid sinus, eight in the frontal sinus, of which two with orbital one with an ethmoid extension, and one isolated maxillary and sphenoid sinus were involved. We treated 11 patients with endoscopic (eight cases) and external surgical approaches (three cases). Besides this surgical excision; 15 cases were kept in follow up, because of asymptomatic nature of the PNS osteomas or patients lack of consent. While the extranasal approach is still a part of the treatment concept for removing osteomas; over the last years, in suitable cases, the endoscopically controlled endonasal approach has greatly gained importance due to the improved surgical equipment and experience.

[Head and neck space infection presenting with Herpes Simplex virus]. / Bas boyun alan enfeksiyonu ile Herpes Simpleks virüs birlikteligi.

A six-year-old girl was admitted to our clinic with the complaints of swelling, trismus, pain in the submandibular, submental and masticator area and vesicular lesions on the mandibular branch of trigeminal nerve (C5, V3). We present this case of head and neck space infection presenting with Herpes Simplex virus, as it is rarely seen.

Nasal reconstruction by modified bilobed forehead flap.

Paramedian forehead flaps, which are supplied by supratrochlear artery and have structural compatibility with nasal skin, have been successfully used for nasal reconstruction for many years. However, removing this flap from midline as perpendicular to natural lines of forehead may lead to marked scar. A flap extending to lateral in parallel to natural lines of forehead results in ipsilateral elevation of eyebrow. In this article, we aimed to demonstrate a flap technique called as "modified bilobed forehead flap technique". In this technique, pedicle of the flap is supplied by supratrochlear artery at one side and the flap is removed at the contralateral side of the lesion using parallel incision to natural lines of forehead. Another flap with a half thickness of the original flap is removed from contralateral frontal region and interpolated to the site where the original flap is removed to prevent the asymmetrical elevation of eyebrow ipsilateral to flap removal. The aim of this technique is to utilize masking effect of natural lines of forehead, while the basic method is bilobed flap technique. Secondary benefits of this technique include forehead lifting and bilateral eyebrow lifting.

[Anterior approach in otoplasty]. / Otoplastide anteriyor yaklasim teknigi.

Prominent ear deformity is an autosomal dominant inherited anomaly of the external ear. It's found to be affecting approximately 5% of the population. It most frequently results from two reasons, one being the poor developmental of the antihelix and the other being the overdevelopment of the conchal bowl. This condition can cause psychological problems in school-age children. One or more anatomical problems of prominent ear may be existing in the individuals. Several surgical methods were developed for these problems. More than 200 surgical techniques have been described up to date in otoplasty. These techniques are mostly focused on creating antihelix or on shaping the conchal bowl or the lobule. Anterior otoplasty that provides an easier and direct approach was discussed. In this technique, formation of the anti-helical fold by excision of a crescent shaped cartilage, if required, and by using subdermal pull sutures under direct visualization were discussed. Thus our technique enabled obtaining the new level of the conchal bowl ridge.

[Superior semicircular canal dehiscence syndrome: report of three cases]. / Süperiyor semisirküler kanal dehissansi sendromu: üç olgu sunumu.

Superior semicircular canal dehiscence syndrome is a newly defined and rare disease. The disease shows itself with vertigo and nystagmus induced by loud noise and pressure. Vertigo and nystagmus induced by loud noise is named as Tullio's phenomenon and nystagmus induced by pressure is named as Hennebert's sign. The definitive diagnosis is made by the demonstration of bone defect in superior semicircular channel with high-resolution computed tomography.

Management of the vertebral artery at the craniocervical junction.

OBJECTIVES: To study the surgical anatomy of the vertebral artery at the craniocervical junction and its related structures defining reliable landmarks for its safe exposure. DESIGN: Ten sides of 5 fresh cadavers were dissected using the lateral approach to the craniocervical junction. RESULTS: Experience gained in studying the anatomic details of the vertebral artery at the craniocervical junction in cadavers from its exit at the transverse foramen of the second cervical vertebra to the vertebrobasilar junction provided the initial background for us to use the lateral approaches to the skull base to safely manage 4 cases with pathology reaching the close vicinity of vertebral artery at the craniocervical junction. CONCLUSION: Thorough knowledge of the anatomy of the vertebral artery is mandatory before attempting surgery at the craniocervical junction. There are reliable landmarks that, when followed, could facilitate safe exposure and identification of the artery.

Follow-up of 366 ears after tympanostomy tube insertion: why is it draining?

OBJECTIVE: Tympanostomy tube insertion is one of the most frequently performed procedures in otolaryngology. Complications, such as otorrhea, tympanosclerosis, and cholesteatoma, have been reported in the literature after its application. STUDY DESIGN: This study reports the complications encountered with 239 children (439 ears) with a follow-up of 7 to 73 months (median, 29 months) after tympanostomy tube insertion. Hearing results and middle ear pressures were compared and complications were noted in 366 ears that were available for the study. RESULTS: Otorrhea developed in 3 (0.8%) cases. Tympanosclerosis was seen in 74 (20.2%) cases. Tympanic membrane perforation, retraction pocket, granulation tissue, and atelectasis were seen in 4.6%, 5.2%, 1.1%, and 6%, respectively. No patients developed cholesteatoma after tube insertion. Hearing results were improved postoperatively in 93.4% of patients (median, 14.2 dB) and worse in 6.6% of patients (median, 8.3 dB). The average extrusion time was 7.3 months for grommet and 16.3 months for T-tubes. CONCLUSION: Multifactor etiologies show some unsolved or misunderstood underlying pathology, or unmentioned environmental factor such as atopy due to rich flora and humidity might exist to consider in the pathophysiology of the otorrhea.

Hammer-chisel technique in endoscopic dacryocystorhinostomy.

We performed a prospective evaluation of endoscopic hammer-chisel dacryocystorhinostomy (DCR) procedures on 62 eyes of 44 patients (40 female and 4 male) with chronic epiphora or dacryocystitis (26 unilateral and 18 bilateral). The technique included chisel removal of bone over the lacrimal sac. The follow-up period was 12 to 54 months (mean, 28 months), and the patients' ages ranged from 17 to 67 years (mean, 35.5 years). The success rate of the consecutive endoscopic hammer-chisel DCR procedures was 87%. During operation, 8 patients had mild mucosal hemorrhage, which did not prevent the successful completion of the operation. Excellent patient tolerance was observed, with minimal morbidity and no major complications. As compared to the external approach, endoscopic hammer-chisel DCR is less traumatic, is less time-consuming, and is practical and cosmetically convenient, with minimal perioperative and postoperative complications. It also allows the simultaneous correction of any intranasal disease. It requires minimal instrumentation and is a relatively easy and fast technique.

Effects of partial neuromuscular blockade on facial nerve monitorization in otologic surgery.

OBJECTIVE: Neuromuscular blockade (NMB) is administered as part of a general anesthetic in order to keep the patient immobilized during surgery and has been known to hinder intraoperative neuromonitorization. The aim of this study was to determine the effects of different levels of NMB on electrical stimulation thresholds of the facial nerve during otologic surgery. MATERIAL AND METHODS: Intraoperative facial nerve monitorization was performed in 29 patients with advanced middle ear disease. Electromyographic (EMG) responses were recorded by insertion of needle electrodes into the orbicularis oris and orbicularis oculi muscles. Minimal facial nerve stimulations causing EMG responses in the facial musculature were measured during full recovery from the effects of muscular relaxants and with 25%, 50%, 75% and 100% levels of NMB. These defined NMB levels were maintained by the administration of a drip infusion of atracurium and were assessed objectively by recording the hypothenar muscle action. RESULTS: All of the patients had detectable EMG responses of the facial musculature at the 50% and 75% levels of NMB in response to the electrical stimulation of the facial nerve. The corresponding mean stimulation thresholds were 0.10 +/- 0.08 and 0.11 +/- 0.09 mA, respectively. No responses were measured in 31% of the patients when the level of peripheral NMB was 100%. CONCLUSION: This study suggests that a regulated 50% level of peripheral NMB provides reliable intraoperative EMG monitoring of the facial musculature in response to electrical stimulation and adequate anesthesia, with full immobilization of the patient.

[Dural bone defects and encephalocele associated with chronic otitis media or its surgery]. / Kronik otit veya cerrahisi sonrasinda olusan dural kemik defektleri ve ensefalosel.

OBJECTIVES: We investigated the incidence of dural bone defects and encephalocele following radical mastoidectomy or open cavity tympanoplasty. PATIENTS AND METHODS: We retrospectively evaluated 190 operations of 182 patients (97 males, 85 females; mean age 30.6 years; range 9 to 70 years) who underwent radical mastoidectomy (n=89) or open cavity tympanoplasty (n=101). Follow-up examinations included otomicroscopy. Patients with documented dural bone defects on examination or operation records were further evaluated by axial and coronal computed tomography scans of the temporal bone. Those with suspected encephalocele were studied by magnetic resonance imaging. RESULTS: Dural bone defects were detected in 17 patients perioperatively. Of these, 14 defects were associated with chronic otitis media. Three iatrogenic bone defects were induced during obliteration of lateral sinus thrombosis. The mastoid tegmen was the most common site of defects (41%) and the most common etiologic factor was cholesteatoma (84%). Encephalocele was detected in one patient in whom radical mastoidectomy with lateral sinus obliteration was performed due to lateral sinus thrombophlebitis. Encephalomalasia was found nearby the defect area in two patients. CONCLUSION: Dural bone defects associated with chronic otitis media are not rare, the most common cause being cholesteatoma. Repair of dural lacerations requires watertight closure to prevent the occurrence of encephalocele.

[The effect of endoscopic sinus surgery on quality of life]. / Endoskopik sinüs cerrahisinin yasam kalitesi üzerine etkisi.

OBJECTIVES: We assessed the effects of endoscopic sinus surgery on quality of life of patients with nasal polyposis or chronic sinusitis. PATIENTS AND METHODS: Thirty patients (5 females, 25 males; mean age 36 years; range 17 to 58 years) who underwent endoscopic sinus surgery were prospectively evaluated. The diagnoses were nasal polyposis in 15 patients and chronic sinusitis in 15 patients. Primary and revision operations were performed in 23 patients and seven patients, respectively. The quality of life was evaluated before and six months after surgery with the use of the Chronic Sinusitis Survey (CSS), and Medical Outcomes Study Short Form-12 (SF-12). Prior to administration, the two questionnaires were translated and adapted to Turkish. Computed tomography (CT) findings were scored before and six months after surgery according to the Lund-Mackay system. The results of the surveys were compared with CT scores. RESULTS: The postoperative SF-12 and CSS scores of all the patients improved significantly. Computed tomography scores were not found in correlation with improvements in the SF-12 and CSS scores. CONCLUSION: Endoscopic sinus surgery results in significant improvement in the quality of life of patients with nasal polyposis and chronic sinusitis, which may not be reflected by CT scores.

[Approaches to twisted noses and results of treatment]. / Carpik burunlara yaklasim ve sonuçlarimiz.

OBJECTIVES: The aim of this study was to address the multiplicity of surgical techniques and pitfalls in the treatment of twisted noses. PATIENTS AND METHODS: Fifty-nine patients (43 males, 16 females; mean age 27 years; range 17 to 47 years) with vertical axis deviation of the nose were surgically treated. Thirty patients had C-type and 29 patients had I-type twisted noses. Deviation angles were measured before nd at least six months after the operation. Correction of deviations was graded according to the ideal angular values and the two groups were compared. RESULTS: Significant correction was achieved in both types of twisted noses (p < 0.01). The results of the I-twisted noses were significantly closer to the ideal angles compared to those of the C-twisted noses (p < 0.05). Three patients underwent revision surgery. CONCLUSION: To correct functional and aesthetic problems in twisted noses, an external approach can be employed to straighten the nose by releasing, mobilizing, aligning and reinforcing the nasal anatomic structures. Cartilage grafts may be used to camouflage persistent deformities. C-twisted noses require more experience in, and familiarization with, a large number of surgical techniques.

Is there any relationship between the clinical, radiological and histopathologic findings in sinonasal polyposis?

OBJECTIVE: The aim of this study was to assess the relationship between clinical, radiological and histopathological findings in nasal polyposis. MATERIAL AND METHOD: This was a retrospective study of 85 patients with nasal polyposis who were treated by endoscopic sinus surgery between the years of 2005 and 2010. All patients underwent preoperative paranasal sinus Computerized Tomography scan in the coronal plane and these images was evaluated with Lund-Mackay scores. The biopsy materials diagnosed as nasal polyp were identified by archive scanning at the pathology department. The Haematoxylin-Eosin stained preparations of the biopsy materials were re-evaluated. All of the results were analyzed by using the SPSS 13.0 soft ware program. Statistical significance was determined as p-value < 0.05. RESULTS: When the patients with (16.4%) and without (83.6%) bronchial asthma were compared regarding the eosinophil, lymphocyte, neutrophil, macrophage, mast cells and goblet cells/ epithelial cell rate, no statistical significance was found (p > 0.05). There was a positive relationship between the preoperative complaint durations and the total Lund-Mackay scores (r=0.270, p=0.012). The neutrophil amount (16.53 ± 19.87) on the preparations of the patients with metaplasia was higher than the neutrophil amount (8.71 ± 23.98) on the preparations of the patients without metaplasia (p=0.001). Radiologically, there was a positive correlation between the infiltration of anterior-posterior sinuses by the polyp tissues and the Lund-Mackay score of the nasal cavity. CONCLUSION: There was a positive correlation between preoperative complaint duration and squamous metaplasia; and there was also a positive correlation between the preoperative complaint duration and the total Lund-Mackay score. There was no histopathological difference between the polypoid infiltration of the front and rear group sinuses.

The relationship between posterior septum deviation and depth of maxillopalatal arch.

OBJECTIVE: To investigate the relationship between depth of maxillopalatal arch and deviation of posterior septum. METHODS: This study is based on paranasal sinus CT (PNSCT) scan in the coronal plane evaluation, and sinus paranasal scans were obtained from the database. One-hundred and fifty PNSCT scans were randomly chosen among the PNSCT scans which belong to adult (18 and older) patients. All scans were divided to three different groups. The first group constituted by those patients who had more convex deviation. The second group had those patients with either crest or spur deviations. The last group (control group) had no septum deviation. The data collected from each group were statistically compared. EXCLUSION CRITERIA: CT imaging which has a chronic sinusitis, nasal cavity mass, and nasal polyps. MAIN OUTCOME MEASURES: angle and distance measures were taken on maxillopalatal arch and posterior nasal septum. RESULTS: Strongly positive correlation between posterior septum deviation and depth of maxillopalatal arch was determined (r=0.479, p=0.001). CONCLUSION: These findings suggest that posterior septum deviations are considered as a result of increase in maxillopalatal depth.

Management of acoustic neuroma in the only hearing ear.

Patients with acoustic neuroma in their only hearing ear are not frequently seen in clinical practice. Managing this group of patients is a challenge to both the patient and surgeon. In this study we report on five cases of acoustic neuroma in an only hearing ear. Our decision for conservative management of those patients with regular follow-up using auditory brain stem response and magnetic resonance imaging is discussed. Other management options currently available are reviewed as well.