Therapeutic endoscopy of the paranasal sinuses

This paper is mainly concerned with describing and demonstrating the technique of paranasal endoscopies--maxillary, frontal, sphenoidal--, illustrated by diagrams. The improvement of technique in diagnosis and therapy of the paranasal sinuses has proved essentially successful. Indications for therapeutic endoscopy of paranasal sinuses are: 1. Purulent sinusitis. 2. Polypous and purulent sinusitis in children. 3. The so-called "mucosinus". 4. Removal of solitary cysts. 5. Removal of tooth fillings and roots. The different procedures are described.

[Indication and treatment of frontobasal rhinoliquorrhoea from the ent-surgical and neurosurgical point of view (author's transl)]

This paper deals with some special questions based on joint neuro-rhinosurgical diagnostic and treatment of frontobasal injuries with rhinoliquorrhoea. The indications of the rhinosurgical transfronto-orbital approach with debridement of paranasal sinuses in the same stage are defined. Detailed technical instructions are given for treatment of "midline fractures". The transfrontal intradural approach of the neurosurgeon should be prefered: 1. If there is rhinoliquorrhoea combined with an extensive fracture of anterior skull base. 2. In cases of frontobasal liquor fistual--no matter of localisation and extension--with increasing spaceoccupation should the intracranial decompression be combined with duraplasty. Cerebral lesions with no progressive intracranial pressure should be treated first of all conservatively. The operative treatment of paranasal sinuses is not necessary in every case after transfrontal intradural surgery. X-ray controls have shown the spontaneous healing.

[Osteoradionecrosis resulting from cobalt-60 therapy for head and neck tumors (author's transl)]

From 1966--1974, 628 patients were irradiated with Cobalt-60 as treatment for tumors of the head and neck. Tumor doses ranged from 6200 R to 8000 R. An osteoradionecrosis was discovered in 17 patients, and was mostly localized in the mandible. Most of the patients developed the necrosis during the first two years following completion of their radiation, although necrosis was also found up to 9 years following therapy. Prophylactic treatment of teeth should be completed before beginning radiation therapy, but such does not exclude the risk of necrosis.

[Facial reconstruction (author's transl)]

The radical tumour surgery and an adequate covering of defects in the face area are preferably combined in one operation. On ten examples of a total of 58 cases methods of covering of one, two and three layers of cheeck defects were demonstrated.

[Otorhinolaryngological-neurosurgical problems on the skull base (author's transl)]

Adequate tumour surgery on the skull base is, because of the close connection with vital blood vessels and nerve structures, difficult and full of risks. From six rare cases, an account is given here, of experiences which were gained by the combined ENT and neurosurgical team work. Singularly, the approach to processes of the frontal, middle and hind skull base is discussed. Through diagnosis, and when indicated, combined operative team work between the Otolaryngologist and the Neurosurgeon, using microsurgical operative techniques, reorganizational advancements regarding the maintenance of function and functional reconstruction, in the surgery of the base of skull, are possible. Under this aspect, endeavors must be made in this area, by slow growing benign new growths, to establish an early diagnosis, and the earliest possible operation, thus promoting the chances of preservation of the remaining undamaged blood vessels and nerve structures.

[Microsurgical and phoniatric aspects in treatment of so-called benign vocal cord lesions (author's transl)]

Following a brief characterization of so-called benign vocal cord lesions (Kleinsasser) with corresponding illustrative aids, the microsurgical as well as the speech therapy is dealt more intensively, as it has been found by the authors to be successful. A therapy schedule is set up consisting of pre- and postoperative teamwork between the surgeon and the phoniatrician whereby the results of the microsurgical treatment can be further improved.

[Reconstruction of nasal defects using local flaps]

Of the various procedures available for the reconstruction of nasal defects, examples of local flaps are demonstrated. These local flaps preserve the aesthetic and function of the nose since they prevent ugly scar retractions. An early surgical intervention minimizes the extent of the operation although radically performed and gives optimal results.

[Pantopaque cisternography in diagnosis of acustic neuromas (author's transl)]

In 6 out of 37 patients, examined by pantopaque cisternography the suspect of a acustic neuroma could be strengthened. All of these tumors showed growth beyond the internal auditory meatus. Smaller intrameatal tumors were not found. The indication for cisternography were made almost according to the demands from Fisch and Wegmüller, therefore it is asked, wether it should not be better to follow the methods of Valvassori who sometimes performes cisternography based on audiometric findings alone. As results of our own experience and similar cases reported elsewhere, this seems justified. Because of the small amount of contrast medium used the side-effects of Pantopaque-cisternography are practically nil.

[To the differential diagnosis of cranial nerve lesions: the progressive necrotising external otitis (author's transl)]

A review of necrotising external otitis, a relatively unknown and dangerous disease, brings out that, initially, it has three characteristics: a granulating necrotising ostitis of the external meatus, extreme pain and a yellowish green secretion. It is always caused by a pseudomonas infection and in almost all cases the patients suffer from diabetes mellitus. If the condition is not recognized in good time and an extensive debridement of the bone involved not performed promptly, ostomyelitis of the base of the skull may follow with involvement of cranial nerves. Severe chronic osteomyelitis of cervical vertebrae occurred in one of our cases. The neurologist must bear this disease in mind in the differential diagnosis when cranial nerves are affected because the nerve disturbances may become evident only after the local condition has subsided or the nerve deficits may be more prominent than and obscure the local ear condition. The most commonly involved nerve is the facial although there may be multiple cranial nerves involved including the third through the twelfth. If the cervical vertebrae become affected there may be nerve root lesions. A torpid meningoencephalitis may also occur. Close cooperation between otologists and neurologists is necessary to recognize and treat these conditions properly.

[Headache and dependence on mixed analgesic preparations]

Six cases out of 38 women patients with persistent headache and abuse of analgesics are described in more detail. From the observations, inferences are drawn for a more specific and critical prescription of analgesics. The continuous taking of commercially available mixed preparations implicates among other risks the danger of the development or deterioration of chronic headaches. The main cause for the dependence is the barbiturate portion which is a common feature of the drugs taken.

[The endoscopy of paranasal sinuses. Diagnostic and therapeutic possibilities (author's transl)]

This paper deals with further experiences in endoscopy of the maxillary sinus and in possibilities of endoscopy of frontal and sphenoidal sinuses. Some coloured photographs taken during endoscopy are shown. As the result of 301 sinuscopies of maxillary sinus performed, it could be shown that in 36% of the cases x-ray findings didn't exactly correspond with the endoscopy findings. In further 22% there was no correlation at all between the x-rays and findings at operation. This shows the great importance of sinuscopy and reveals its diagnostic values. The author used the endoscopy of the maxillary sinus not only for diagnostic purposes but for the treatment of chronic purulent sinusitis as well as complete removal of the socalled solitary cysts of the mucous membrane. A therapeutic gap between the two extreme (conservative treatment on one side and radical surgery Caldwell-Luc on the other side) ist bridged using this method. Finally the indications for endoscopy of maxillary and frontal sinuses are shown clearly in a table.

Leber's miliary aneurysms associated with telangiectasia of the nasal mucosa

A 20-year-old woman, treated with cryopexy and xenon- and argon-laser photocoagulation for Leber's miliary aneurysms in her right eye, suffered from repeated epistaxis. She underwent an endoscopy that showed an unusual number of telangiectatic veins. Laboratory results and routine physical and neurologic examinations showed normal values. Dematologic examination revealed no signs of hereditary hemorrhagic telangiectasis (Osler's disease). Nevertheless, it seems reasonable to assume that the combination of microvascular disturbances in one eye and in the nasal mucous membrane is not a coincidental finding.