[Augmentation of the temporal fossa with Ionos bone cement]

To compensate for the loss of tissue after transferring the temporalis muscle, it is advisable to fill the temporalis fossa for aesthetic reasons. In so doing, we have used IONOS bone cement to augment the fossa after muscle transfers. Twelve procedures have been performed within the past 3 years. The average follow-up time has been 23 months. Surgery was required in 6 cases following delayed reconstruction to rehabilitate the paralyzed face after loss of facial nerve function, four times to stabilize a duraplasty at the skull base and twice for aesthetic facial augmentation. A prefabricated IONOS implant (IONOROC implant) was attached to the squama temporalis with fresh bone cement. In all cases a good aesthetic result was achieved. A temporary seroma occurred in 6 patients (50% of the cases) but resolved in 1-2 weeks without requiring further care. However, we now recommend that suction drainage be inserted for approximately 1 week after surgery. In two cases the IONOS implant had to be removed because of an infection.

Management of dural lesions occurring during endonasal sinus surgery

BACKGROUND

Dural lesions incurred during endonasal sinus surgery must be repaired surgically because of the risk of potentially fatal late meningitis.

DESIGN

Retrospective survey.

SETTING

Ear, nose, and throat department of a university teaching hospital.

PATIENTS

Consecutive sample of 47 patients who had undergone duraplasty for repair of a dural lesion that occurred as a complication of endonasal sinus surgery. Forty-two patients were interviewed after an average postoperative period of more than 5 years.

INTERVENTION

Endonasal duraplasty, external duraplasty (fronto-orbital or transfrontal extradural approach) by underlay or onlay technique.

MAIN OUTCOME MEASURES

Fluorescein test (intrathecal administration of fluorescein sodium and subsequent nasal endoscopy), subjective complaints, history of meningitis, cerebrospinal fluid rhinorrhea, or hyposmia.

RESULTS

There were 44 endonasal and 3 external duraplasties (2 by the fronto-orbital and 1 by the transfrontal extradural approach); the underlay technique was used in 25 and the onlay technique in 22. The fluorescein test, performed in 43% (20/47) of the patients was negative in all cases. Twenty-six percent of the patients had had 1 or more episodes of bacterial sinusitis without meningitis. Duraplasty was clinically intact in 100%. Postoperative olfactory disturbances were reported in 17%.

CONCLUSIONS

Duraplasty can be performed satisfactorily by the endonasal route, thus avoiding the disadvantages of the fronto-orbital approach (visible scar, risk of damage to the supraorbital nerve, and removal of bone from the floor of the frontal sinus with a tendency to stenosis of the nasofrontal duct and subsequent mucocele). Allogeneic connective tissue in combination with fibrin glue has proved suitable as a graft material.

[Papillary tumor of the endolymphatic sac]

A papillary neoplasm that was presumed to originate from the endolymphatic sac was described by Heffner in 1989. This tumor was considered to be a "low-grade adenocarcinoma" because of its behavior: slow growth, local destruction and failure to metastasize. The clinical manifestations are hearing loss, vertigo, facial nerve paralysis and/or cerebellar disorders. Endolymphatic sac tumors have previously been mistaken for such neoplasms as paraganglioma, choroid plexus papilloma and carcinoma, adenomatous tumor of the middle ear and secondary metastases. The diagnosis of this neoplasm is facilitated by CT and MRI. The treatment of choice is total removal of tumor as soon as possible and requires clinical awareness of this rare but important pathologic entity.

[Individual learning curves with reference to endonasal micro-endoscopic pan-sinus operation]

BACKGROUND

We examined how surgeons in training will develop into experienced surgeons in sinus surgery by analysing their individual learning curve.

METHODS

In a retrospective study we evaluated complications in 818 surgical procedures (362 revisions = 44.3%) performed by four different surgeons.

RESULTS

We found a dural lesion in six cases (0.75%), opening of the periosteum of the orbit in 30 cases (3.7%), and control of bleeding from the anterior ethmoidal artery in 36 cases (4.4%). No lesions of the internal carotid artery or lacrimal duct system occurred. The complications were not distributed equally. We observed a three-phase learning process which we describe using the example of a traffic light: red with a high risk of complications, yellow with a minor one, and green for the experienced surgeon. The first phase consists of the first 20 procedures, yellow from the 20th to the 100th, and green for procedures performed thereafter.

CONCLUSIONS

Each inexperienced surgeon has to determine his position on the learning curve. He or she should be supervised accordingly.

[Orbital hematomas]

BACKGROUND

Orbital hematomas may occur spontaneously, as a result of vascular anomalities, or they may be induced by trauma or occur following paranasal sinus surgery. The retrobulbar hematoma requires special attention because of its potential compression of the optic nerve may compromise vision or cause blindness.

PATIENTS AND METHODS

We report on four cases: two subperiostal orbital hematomas, a spontaneous retrobulbar hematoma, and one orbital hematoma due to trauma.

RESULTS

In one case a vascular anomality was detected by angiography. Though temporary blindness occurred in this case, it was possible to preserve 30% vision by surgery. An infected subperiostal hematoma was successfully treated using an endonasal approach. Two cases (a traumatic and a subperiostal orbital hematoma) required no operative treatment.

CONCLUSIONS

The diagnosis of an orbital hematoma should be made as quickly as possible to permit adequate early therapy. Decrease of vision or blindness caused by orbital hematoma may be improved through a lateral canthotomy as emergency measure and subsequently by draining the hematoma to relieve compression of the optic nerve.

[Dynamic imaging of gastric ulcer healing using the most modern Morph-Software]

The presentation of gastric ulcer healing taken from video endoscopy as a dynamic process could not be realized till now. The documentation of the dynamic healing process shattered either on the patient's compliance or on the inconstancy of the image cut due to wobbling. The replay should be performed as a time lapse whereby the picture disturbances would become an essential part.-Instead of presenting a continuous film, instant takes of ulcer healing were processed. A dynamic effect was produced by computer-assisted production of intermediate pictures. A video was created in which short video sequences in definite time intervals were recorded endoscopically. Single stills-so-called original pictures-fitting together from each sequence were selected and spliced together. The missing intermediate pictures were made with a special computer technique according to the mathematical concept of interpolation. With this technique, the dynamic documentation of gastric ulcer healing in a 47-year-old male patient was performed. The technique enables an almost natural and real observation of ulcer healing and promises new physiological and patho-physiological knowledge in gastroenterologic endoscopy.

[Dura-plasty in the area lf the sphenoid sinus]

BACKGROUND

Surgical treatment of CSF leakage in the sphenoid sinus is difficult for several reasons: 1. the close neighbourhood between the sphenoid sinus and the internal carotid artery, the cavernous sinus and cranial nerves (II, III, IV, VI), 2. a strong liquorrhoea caused by basal cisterns surrounding the sphenoid sinus, 3. it can be difficult to visualise completely the sphenoid sinus depending on the extent of pneumatisation.

MATERIALS AND METHODS

In this retrospective study 20 cases of duraplasty around the sphenoid sinus were evaluated. The approach, materials, operative techniques and results are described.

RESULTS

90% of the dura lesions were closed successfully by one operation (average follow-up time 5 years). Including our two revisions all defects have been sealed effectively.

CONCLUSIONS

Currently, the endonasal approach using microscope and endoscope is the technique of choice for dura repair in the sphenoid sinus. The different techniques and materials vary in order of size, location and etiology of the dura lesion.

[Effects of postoperative care on wound healing after endonasal paranasal sinus surgery]

BACKGROUND

There is no standard for postoperative care after paranasal sinus surgery.

METHODS

In a prospective study we evaluated the influence of modifications of postoperative care on wound healing after paranasal sinus surgery. We used a new method of documenting the natural dynamics of wound healing after endonasal paranasal sinus surgery that combines morphing and time-lapse video. Computer-assisted morphing means transformation of one shape into another by means of two-dimensional interpolation. The computer reconstructs the changes between the single frames taken by videoendoscopy at each examination by morphing. Editing all single frames from videoendoscopy and from morphing together resulted in a 60-second video showing wound healing over a period of six months. We documented wound healing 23 operations. Twelve patients with chronic polypoid sinusitis of similar extent were documented in a similar manner. Minimal postoperative care consisted of packing the operative cavity with rubber fingers for three days and irrigation with Ems brine. The effect of long-term packing and topical application of budesonide were studied. Analysis consisted of evaluating the time-lapse videos and final flexible endoscopy of the sinuses.

RESULTS

Wound healing after complete endonasal sinus surgery varies greatly. In the first 7-12 days blood crusts covered the whole wound. Granulation was visible for 2-4 weeks. The increasingly edematous swelling reached its maximum in the 3rd-5th week and decreased in 7th-12th week. A macroscopically normal mucosa was observed from the 12th-18th weeks. Subepithelial changes occurred for longer than 6 months.

CONCLUSIONS

The following measures are recommended for decreasing postoperative granulations, edema and swelling: minimizing the surgical trauma, long-term packing with a occlusive, nonadherent material (rubber finger packing), topical steroids (Budesonide). Stenosis of paranasal sinuses due to excessive scarring could not be prevented (especially in the frontal sinus).

[Chemotherapy of juvenile angiofibroma--an alternative?]

Since February 1979, 22 juvenile angiofibromas have been treated among 312 tumors of the skull base managed in the ENT Department, Fulda. According to a general staff consensus the treatment of choice was complete surgical removal. This was achieved in 20 cases with one operation and in one case with two operations. In addition to removal of tumor, functional and aesthetic aspects had to be considered as aims of operative treatment, including among others preservation of the facial skeleton, infraorbital nerve, nasolacrimal drainage system and vision. In rare cases complete excision of the tumor is not possible. The value of cytostatic therapy is demonstrated in one patient with uncommonly advanced disease. Considering the extensive regression of tumor achieved in this case after chemotherapy with Adriamycin and decarbazine, one has to raise the question if the chemotherapeutic approach was more than just palliative. From our experience chemotherapy should be considered a possible alternative to radiation in the management of unresectable juvenile angiofibromas.

Surgery of the lacrimal system

Several surgical techniques of the lacrimal system are presented and analyzed regarding indications and results. Endonasal dacryocystorhinostomy is performed in cases of postsaccal stenosis. Pre- and intrasaccal stenosis are operated on with conjunctivorhinostomy or with placement of Heermann-Jones tubes. After interruption of the canaliculi, splinting and primary suturing are best suited. During tumor surgery, the nasolacrimal duct can be temporarily or permanently relocated in the soft tissues of the cheek. Performing these techniques, a good lacrimal drainage is usually achieved. The results are based upon subjective and objective findings.

Magnetic resonance imaging after frontal sinus surgery with fat obliteration

The obliteration of the frontal sinus via an osteoplastic approach is performed with the aim of achieving a permanent 'switching off' by final and conclusive clearing out. For this, freshly harvested abdominal fat has shown itself to be the best clinically. It is possible to demonstrate the vitality of fat transplanted into the frontal sinus without an operation, i.e. by a macroscopical and histological examination using magnetic resonance imaging (MRI). The magnetic resonance examinations were carried out on a supraconductive 0.5 T Magnet (Gyroscan T.S.II, Philips Medicine Systems, Eindhoven, Netherlands) with a quadrature (square) head spool. We produced T1-weighted spin echo images (TR: 450-550 ms; TE: 20-25 ms), T2-weighted fast spin echo images or in double-echo technique in transverse orientation (Turbo SE or TR: 2000-2500 ms; TE: 50-90 ms) and short tau inversion recovery (STIR) sequences for fat suppression (TJ: 140 ms; TR: 1400 ms; TE: 30 ms). The fat implanted into the frontal sinus of 11 patients aged 22-65 years, having undergone an osteoplastic frontal sinus operation with obliteration, was examined post-operatively by MRI. Objectives were the time-dependent distribution of portions of vital fatty or connective tissue, the eventual development of necroses or cysts as well as recurrences, inflammatory complications or re-epithelization of the frontal sinus four to 24 months post-operatively. In only six out of 11 cases was vital fatty tissue found. Fatty necrosis occurred five times, whereas in four cases a transformation into granulation tissue and in one case into connective tissue could be seen. All 11 patients were complaint-free. Long-term observations are needed to see if differences in the recurrence rate of frontal sinus disease are dependent on whether the implanted fat remains vital or necrosed and transformed.

[Association of gastroesophageal reflux and chronic laryngitis]

There is some evidence from anglo-american clinical and experimental studies that gastro-esophageal reflux is more common in patients with laryngitis. Within the framework of an open study, 32 patients with reflux esophagitis and laryngitis were treated with 20 mg omeprazole daily. After 4 weeks at the latest, in all cases inflammation of the esophagus and larynx had healed completely and the patients were without complaints. Suggesting that reflux is the underlying etiology patients with laryngitis seem to benefit from omeprazole.

[Current aspects of frontal sinus surgery. IV: On therapy of frontal sinus osteoma]

Osteomas are the most common benign tumors of frontal sinus. We evaluated 15 patients with osteomas of the frontal sinus who were managed between 1979 and 1992. The average duration of follow-up was 33 months. In 4 cases osteomas were removed completely via the endonasal route using a microscope and endoscope. We recommend performing a frontal sinus drainage-type 3 primarily. Indications are osteomas of the posterior wall of the frontal sinus located close to the infundibulum. For osteomas of the anterior wall and those located laterally or for very large osteomas we prefer the osteoplastic approach. Apart from the excellent exposure this latter procedure also provides good aesthetic results after carefully placed incisions and precise replacement of the bone flap. We recommend the bicoronal incision in patients with large frontal sinuses, women, or in the presence of good hair growth. Incisions are best placed in a frontal crease in patients with hair loss or a, small frontal sinus.

[Behavior of fatty tissue in frontal sinus obliteration]

The purpose of obliterating the frontal sinus is to provide a permanent solution to the underlying problem. The material of choice for obliteration is freshly removed abdominal fat. Using magnetic resonance imaging, one can assess the vitality of fat tissue in an obliterated frontal sinus without surgery. Eight patients ranging in age from 22 to 65 years underwent osteoplastic frontal sinus surgery with fat obliteration. The freshly implanted abdominal fat was postoperatively investigated using magnetic resonance tomography. The magnetic resonance examinations were carried out on a supraconductive 0.5 T Magnet (Gyroscan T S II, Philips Medicine Systems, Eindhoven, Netherlands) with a square head spool. We produced T1-weighted spin echo images (TR: 450-550 ms, TE: 20-25 ms), T2-weighted fast spin echo images or in double echo technique in transverse orientation (Tubo SE or TR-2000-2500 ms, TE: 50, 90 ms) and STIR sequences for fat suppression (TJ: 140 ms, TR: 1400 ms, TE: 30 ms). Our goal was to determine the time-dependent distribution of vital fat or fibrous tissue, development of necrosis, cysts, recurrences, inflammatory complications, or re-epithelization of the frontal sinus. Six to 24 months postoperatively, we found vital fat tissue in only three of eight cases. In the other five cases fat necrosis was present. The frontal sinus was filled by granulation tissue or fibrous tissue (once). It is not yet possible to determine when the fat changes to connective tissue. This process varies between individual patients. All eight patients were free of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aspects of frontal sinus surgery. III: Indications and results of osteoplastic frontal sinus operation]

The osteoplastic approach is indicated for frontal sinus surgery if optimal exposure of the entire frontal sinus is required for possibly complete removal of the mucous membrane and sinus obliteration. In a retrospective study we evaluated 75 patients whose osteoplastic frontal sinus operations were performed in Fulda between 1979 and 1992 and examined indications for surgery, complications and outcome. All patients were examined clinically and subjective complaints were recorded. Indications for surgery were trauma (43), acute and chronic infections (19), tumors (11) and sinus pneumatoceles (2). The overall aesthetic and functional outcome was excellent. Revision was necessary in one only patient, who had forced air into his frontal sinus by nose-blowing too early to create a threat of infection. No serious complications occurred, such as surgery-related meningeal injury or impaired or double vision. One patient needed a blood transfusion because of hemorrhage due to operation (1.3%). The main advantage of the coronal incision used was preservation of the supraorbital nerve bundle without subsequent nerve dysfunctions. Besides optimal exposure of the whole frontal sinus, precise replacement of the osteoplastic flap and choice of incision also lead to a good aesthetic result.

[Imaging time-dependent changes in the nasal mucosa using the most modern morphing software]

Changes in the nasal mucous membrane lasting longer than 1-2 minutes have, until now, escaped dynamic observation. Even the congestion and decongestion of the turbinates during the nasal cycle and after application of vasoconstrictive nose drops have been documented only by instant stills. For this reason, we developed a method which permits documenting time-dependent endonasal mucosal changes with their natural dynamics on time-lapse video film. Instead of primarily recording a continuous video film, we processed instant stills. Computer interpolation of intermediate steps gives the viewer a dynamic impression. As continuous video endoscopy is not feasible, we produced the continuous film by recording video sequences of approximately 30 seconds length in defined time intervals endoscopically, selecting single stills (so-called original photographs) from each sequence, and splicing them, producing the missing intermediate photographs by a special computer technique (morphing), similar to mathematical interpolation. In this way we could demonstrate the changes of the right and left inferior turbinate during a nasal cycle of lasting five hours and the effect of xylometazolin nose drops on the nasal mucosa. The practical value of this technique, lies in the comprehensive realistic observation of dynamic processes of the nasal mucosa with respect to physiology and pathophysiology.

External rhinoplasty: its role in aesthetic and functional surgery of the nose

Over the past 25 years external rhinoplasty has become increasingly popular. Some rhinosurgeons recommend its use widely, even in routine cases. In our view, however, the classical endonasal approaches remain the first choice. Open rhinoplasty offers an excellent visualization and therefore facility of precise correction, but causes a larger area of wound and scarring. It should, therefore, be restricted to cases of particular difficulties. In the era of minimal invasive surgery, external rhinoplasty advocated as a standard procedure seems to be a drawback, particularly if the aesthetic problem is the leading one. Every facial plastic surgeon should master closed and external rhinoplasty to be able to decide which approach is the most suitable in each situation from the patient's point of view.

[Current aspects of frontal sinus surgery. II: External frontal sinus operation--osteoplastic approach]

Most inflammatory diseases of the frontal sinus requiring surgery can now be managed successfully by endonasal procedures. There remain, however, a number of problematic cases in which optimal exposure of the entire frontal sinus is required with possible complete removal of the mucous membrane and sinus obliteration. These remain indications for osteoplastic frontal sinus surgery. Depending on the individual situation, incisions can be chosen that are bicoronal, placed in a frontal crease or positioned below the eye-brow. Surgical techniques are described in detail. Osteoplastic surgery of the frontal sinus with fat obliteration is a reliable and safe method, particularly for management of so-called "difficult" frontal sinuses.

[Current aspects of frontal sinus surgery. I: Endonasal frontal sinus drainage in inflammatory diseases of the paranasal sinuses]

Most conditions of the frontal sinus requiring surgery can now be managed successfully by endonasal procedures. According to Draf, 3 types of frontal sinus drainage occur. Surgical techniques and indications are described. In a retrospective study we evaluated 132/648 patients who were on average 5 years postoperative. Forty-two patients had type 1, 43 patients had type 2 and 47 patients had type 3 drainage. Endoscopy revealed a normal mucosa in 56-67%, whole polyps were found in 9-15%. There was no recurrence of an orbital or endocranial complication. According to our definition of surgical success, there was a success rate of 83.4% with type 1 drainage, 83.7% with type 2 drainage and 89.4% with type 3 drainage. If there was only little chance for successful endonasal surgery with type 3 drainage, an external osteoplastic frontal sinus operation was performed for definitive therapy.

[Synovial cell sarcomas of the head- and neck area]

The synovial cell sarcoma is a malignant soft tissue tumour which mostly occurs associated with or in a large joint. To date, the histogenetic origin has been discussed controversially and there is still no agreement as to whether it arises from normal synovium of joints, tendon sheaths or bursae, specialised forms of mesenchymal tissue (arthrogenous mesenchyma) or ordinary connective tissue. The tumour rarely occurs in the head and neck region. Only about 76 cases world-wide have been described up to now. We report on a case of a 30-year old man with a synovial cell sarcoma of the temporomandibular joint and a case of a 70-year old man with a synovial cell sarcoma of the hypopharynx. In the first case, although all possible therapeutical efforts were made (radical operation, radiotherapy, chemotherapy), recurrence of the tumour occurred locally, as well as metastases in the lungs and bones. The patient died three and a half years after the initial diagnosis of the tumour. The second patient suffered multiple metastases in the lungs and bones one year after operation followed by chemotherapy. To the present time there is no general agreement on how to treat synovial cell sarcomas, but without doubt first of all radical surgical excision must be performed if possible. Additional radiation and/or multidrug chemotherapy may be useful in special cases. In our opinion every case of synovial cell sarcoma should be published because it is of importance to get to know new aspects and therapeutical possibilities of this rare disease.