Transpalatal approach for vidian neurectomy

Interdisciplinary management of skull base surgery

Skull base surgery remains one of the challenging areas in the field of cranio-maxillofacial surgery, otolaryngology and neurosurgery. Subsequent reconstruction of bone and soft tissue are an essential component to restore function and appearance after ablative surgery. Establishment of interdisciplinary tumor boards with presentation of the individual patient cases have become standard. Multiplanar reconstruction using MRI or CT imaging techniques combined with virtual 3D planning allow precise planning of the procedures. Intraoperative navigation helps for complete resection of malignant findings with safety margins; surgical approaches provide a good overview of the surgical site. Reconstruction using local flaps have a low complication rate with equally reliable results in reconstruction of small tissue defects. Free flap surgery makes reconstruction of large tissue defects possible. Alloplastic materials are alternatively used for reconstruction of bone defects. Based on selected patients, treatment algorithms and standard surgical procedures in extracerebral skull base surgery will be illustrated. Current techniques and new approaches will be discussed with emphasize on hard and soft tissue reconstruction.

The anatomical and radiological evaluation of the Vidian canal on cone-beam computed tomography images

INTRODUCTION

The aim of this study is to explore the anatomy of the Vidian nerve to elucidate the appropriate surgical approach based on preoperative cone-beam computed tomography (CBCT) images.

MATERIALS AND METHODS

The Vidian canal and its surrounding structures were morphometrically evaluated retrospectively in CBCT images of 400 cases by the Planmeca Romexis program. The types of the Vidian canal were determined and seven parameters were measured from the images.

RESULTS

Three types of the Vidian canal according to the relationship with the sphenoid bone were found as follows: the Vidian canal totally protruded into the sphenoid sinus (19.75%), partially protruded into sphenoid sinus (44.37%) and embedded inside bony tissue of the body of sphenoid bone (35.87%). The position of the Vidian canal was medial (34.62%), on the same line (55.12%) and lateral (10.25%) to the medial plate of the pterygoid process. The distance between the Vidian canal and the vomerine crest, the mid-sagittal plane, the round foramen, the palatovaginal canal, and the superior wall of the sphenoid sinus, the length of the Vidian canal and the angle between the Vidian canal and the sagittal plane was found to be 16.69 ± 2.14, 13.80 ± 2.00, 8.88 ± 1.60, 5.83 ± 1.37, 23.98 ± 2.68, 13.29 ± 1.71 mm and 25.78° ± 3.68° in males, 14.62 ± 1.66, 11.43 ± 1.28, 8.51 ± 1.63, 5.78 ± 0.57, 22.37 ± 2.07, 12.91 ± 1.26 mm and 23.43° ± 3.07° in females, respectively.

CONCLUSIONS

Our results may assist with proper treatment for surgical procedures around the Vidian canal with a high success rate and minimal complications. Therefore, the results obtained in this study contribute to the literature.

A systematic review of the evidence base for vidian neurectomy in managing rhinitis

Background:

Vidian neurectomy has been proposed as a surgical option for rhinitis refractory to medical treatment. However, the evidence base for its benefit remains controversial.

Methods:

A systematic review was performed. Studies reporting original data on patients with rhinitis treated by vidian neurectomy were included. Patient-reported outcome measures were the primary outcome investigated; specific peri-operative morbidities were the secondary outcome.

Results:

A total of 1012 articles fulfilled the search criteria, 32 of which were included in the study. Patient-reported outcome measures were compared before and after surgery in eight studies. There were 529 patients represented in these trials. Significant improvement in rhinorrhoea was reported in all eight studies. Temporary dry eyes was reported in 24.63 per cent of cases (272 out of 1104 cases). There was no report of cranial nerve deficit or eye movement disturbance.

Conclusion:

Endoscopic vidian neurectomy does have a role in the surgical management of refractory rhinitis, particularly in patients with non-allergic rhinitis, but a well-designed cohort trial would be advantageous to clarify long-term outcomes.

Is There a Relationship Between Optic Canal, Foramen Rotundum, and Vidian Canal?

OBJECTIVES

In this retrospective study, we investigated the relationship between paranasal sinus, optic canal, foramen rotundum, and vidian canal measurements.

METHODS

Computed tomographic (CT) images of 320 adult subjects and 640 sides (right and left) were used. Paranasal sinus dimensions, optic canal (OC), foramen rotundum (FR), vidian canal (VC), bilateral FR (FRFR), bilateral vidian canal (VCVC), VC-foramen rotundum (VCFR), and VC-optic canal (VCOC) distances were measured.

RESULTS

Right VCFR (6.06 mm), and right and left VCOC values (20.34 and 20.31 mm) of the males were significantly higher than those of the females (5.50, 18.91, and 18.80 mm, respectively). Foramen rotundum, OC, and VC values were positively correlated with each other. There was also positive correlation between FR width and maxillary sinus height. Increase of OC width was related to increase in FR width and area, VCVC distance; and decrease in maxillary sinus width. There was positive correlation between FRFR, VCVC, VCFR, and VCOC distance values. There was negative correlation between VC width and area; VCVC, VCFR, and VCOC distance; and maxillary sinus, ethmoid sinus, and sphenoid sinus measurement values. As these sinuses pneumatized more, VC width and area values decreased.

CONCLUSION

As a conclusion, the paranasal sinus, OC, VC, and FR values showed relationship with each other. Before performing craniofacial and/or skull base surgeries, CT view should be taken to evaluate the localization and the course and dimensions of the OC and vidian nerve. It should be kept in mind that in the presence of more pneumatized paranasal sinuses in CT views, VC dimensions decreased.

Endoscopic vidian neurectomy: a prospective case series

BACKGROUND

Chronic refractory vasomotor rhinitis (VMR) is a debilitating condition that causes significant impairment of quality of life. The purpose of this study is to investigate the efficacy and potential side effects of endoscopic vidian neurectomy as treatment for patients with VMR.

METHODS

This study was a prospective, intent-to-follow case series. Inclusion criteria were as follows: (1) patients with debilitating VMR refractory to medical therapy and with significant impact on quality of life; (2) negative allergy history and skin testing; and (3) negative computed tomography (CT) scan to rule out skull-base defect or cerebrospinal fluid (CSF) fistula. Patients underwent bilateral vidian neurectomy via a pterygomaxillary approach. Prior to surgery all patients underwent formal ophthalmologic testing to quantify preoperative ocular and lacrimal function. Ophthalmologic testing was repeated postoperatively at approximately 3 months. Patients also completed surveys regarding rhinologic outcomes including the Sinusitis Symptom Questionnaire (SSQ) and the 22-item Sino-Nasal Outcome Test (SNOT-22) at the following time points: preoperatively, and 1 week, 4 weeks, 12 weeks, 6 months, 1 year, and 2 years postsurgery. Descriptive statistics and analysis of variance (ANOVA) were undertaken.

RESULTS

Eleven patients (22 sides) underwent bilateral vidian neurectomy with pathologic confirmation of nerve section in all cases. Average follow-up was 19.4 months. Statistically and clinically significant improvement was measured for both the SSQ and the SNOT-22 and compared with the patients' baseline scores (p < 0.0001). Subscores for rhinorrhea and nasal congestions were also statistically significantly improved (p < 0.05). No incidence of permanent or measureable dry eye has been reported.

CONCLUSION

The data suggests that vidian neurectomy is an effective, safe, and definitive treatment for most patients with VMR refractory to medical treatment.

Antegrade transsphenoidal vidian neurectomy: short-term surgical outcome analysis

BACKGROUND

Vidian neurectomy was an option for treating allergic rhinitis in the past but outcomes varied. A modified transsphenoidal approach is proposed to simplify endoscopic vidian neurectomy. The postoperative evaluation of rhinorrhea, sneezing, and recurrence was investigated.

METHODS

A total of 317 patients with refractory allergic rhinitis underwent 414 transsphenoidal vidian neurectomies from September 2006 to December 2010. A rigid nasal endoscope was used through a transsphenoidal approach to reach the vidian canal inside the sphenoid sinus (type I) or through its anterior opening into the pterygopalatine fossa (type II) and to cut or cauterize the vidian nerve. The surgical outcomes were analyzed for patients with at least 6 months of follow-up.

RESULTS

Our approach was successful in 90.3% of the 414 vidian neurectomies. Vidian neurectomy was successful via the type I approach in 27 sides and type II approach in 347 sides. The short-term surgical outcomes of 163 patients who underwent a total of 236 vidian neurectomies with at least 6 months of follow-up were analyzed. Immediate, complete cessation of sneezing and rhinorrhea occurred uniformly. Three recurrences were detected during the 1-2 years of follow-up. The symptom of dry eye was reported for 172 surgical sides, but only 6 had persistent symptoms for >6 months.

CONCLUSION

The transsphenoidal approach in a vidian neurectomy is a simple method that removes the need for sphenopalatine artery ligation and causes less surgical morbidity. However, the possibility of recurrence of this condition in the long term needs further investigation.

Endoscopic transsphenoidal vidian neurectomy

The purpose of this report is to describe a novel technique for endoscopic vidian neurectomy (EVN) based on preoperative computed tomography (CT) classification of the vidian canal (VC), and to present anatomical and surgical findings from an initial series. Retrospective study, consisting of medical chart review and patient interviews, of all preoperative CT-guided EVN procedures was performed from 2006 to 2010 at a tertiary-care medical center. A total of 89 patients with intractable rhinorrhea (77 males and 12 females, mean age 29 years, age range 16-57 years) underwent bilateral EVN. Configuration of the VC was classified into three types based on preoperative CT findings. The technique for surgical access of each of these configurations is presented. The most common configuration of the VC was type 2 (47%). A wide, direct, and safe exposure of the vidian nerve was achieved in all cases. 84 of 89 patients completed the questionnaires regarding the postoperative improvement in quality of life. Follow-up ranged from 2 to 42 months, with an average of 19.6 months. 77 of 84 (91.7%) patients were satisfied with their surgical result. Two patients underwent revision ETSVN due to relapsed symptoms. With the help of a preoperative CT scan of the paranasal sinuses, the vidian nerve can be identified precisely via an endoscopic intrasphenoidal or transsphenoidal approach, which provides an easy and reliable way to perform vidian neurectomy.

Historical, pathophysiological, and therapeutic aspects of vidian neurectomy

Vidian neurectomy yields dramatic relief of nasal hypersecretion in patients with allergic rhinitis. Clinical studies conducted on vidian neurectomized nasal mucosa have shown that nasal hypersecretion observed after challenging the nasal mucosa with antigen is caused by reflexively induced activation of the parasympathetic center secondary to stimulation of the sensory nerve terminals in the nasal mucosa by histamine. On the contrary, nasal mucosal swelling is caused mostly by the direct effects of chemical mediators on the nasal vasculature, although vascular reflex mediated by the noncholinergic parasympathetic nerve may be partially involved in the onset of nasal mucosal swelling after antigen challenge. Considering the long-term side effects of inhibition of lacrimation and possible partial recurrence of hyperreactive nasal symptoms observed after vidian neurectomy, less invasive endoscopic posterior nasal neurectomy is considered the treatment of choice for patients with allergic rhinitis who require surgical intervention.

Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery

The purpose of this study was to describe the technique used to safely identify the petrous carotid artery during expanded endonasal approaches to the skull base. A series of 20 cadaveric studies was undertaken to isolate the vidian artery and nerve and to use them as landmarks to the petrous internal carotid artery (ICA). Twenty-five consecutive paraclival endoscopic cases were also reviewed to determine the consistency of the vidian artery in vivo as an intraoperative landmark to the ICA. These data were then correlated with results from a separate study in which computed tomography scans from 44 patients were evaluated to delineate the course of the vidian canal and its relationship to the petrous ICA. In all 20 cadaveric dissections and all 25 surgical cases, the vidian artery was consistently identified and could be reliably used as a landmark to the ICA. The correlation between anatomical and clinical data in this paper supports the consistent use of the vidian artery as an important landmark to the petrous ICA.

Vidian canal: analysis and relationship to the internal carotid artery

OBJECTIVES

The purpose of this study is to describe the anatomy and relationships of the vidian canal to known endonasal and skull base landmarks. This will allow the endoscopic skull base surgeon to safely approach the anterior genu of the petrous carotid artery during expanded endonasal approaches to the skull base.

STUDY DESIGN

The study is a prospective cohort study.

METHODS

Axial, coronal, and sagittal computed tomography scans of the paranasal sinuses and skull base of 44 patients were examined. Individuals with known skull base pathology were excluded. Measurements included the length of the vidian canal, the relationship of the vidian canal to the anterior genu of the petrous carotid artery, and the type of pneumatization of the sphenoid sinus as it pertains to foramen rotundum and the vidian canal. In addition, we will focus on the relationship of the vidian canal to the sphenopalatine foramen and base of the medial pterygoid plate.

RESULTS

The degree of pneumatization of the sphenoid sinus is highly variable. The mean length of the vidian canal is 18 mm (10-23 mm). The vidian canal is found entirely within bone in 27% to 30% of scans reviewed. The anterior genu of the petrous internal carotid artery is found superior-medial to the vidian canal in 44 of 44 of the CT scans reviewed. The vidian canal runs medial to lateral in 93% to 98% of patients studied.

CONCLUSIONS

As a result of this study the endoscopic skull base surgeon has a number of anatomical landmarks and measurements that may be helpful in safely localizing the anterior genu of the petrous internal carotid artery during expanded endonasal approaches to the skull base.

Functional inferior turbinosurgery (FITS) for the treatment of resistant chronic rhinitis

CONCLUSIONS

Modified vidian neurectomy combined with inferior turbinoplasty provided an optimal surgical outcome as a treatment for intractable chronic rhinitis as evidenced by a relatively long-term follow-up.

OBJECTIVE

The study was designed to determine the efficacy of submucosal reduction of the inferior turbinate and resection of the posterior nasal nerve for the treatment of resistant chronic rhinitis.

PATIENTS AND METHODS

Fifty-six consecutive patients (37 males and 19 females; mean+/-SD age, 26+/-11 years) with resistant allergic rhinitis or nonallergic rhinitis with eosinophilia syndrome despite medical treatment. Symptomatic improvement including nasal obstruction, nasal discharge, sneezing, smell perception, and quality of life and objective evaluation of nasal airway resistance and nasal provocation test before and after surgery were investigated.

RESULTS

The patients showed a remarkable improvement of > or = 80%, with the exception of two patients who had an approximately 50% reduction of the total symptomatic scores. Four of eight patients with anosmia subjectively improved whereas the other four patients felt unchanged. All patients who underwent rhinomanometry (n=15) and nasal provocation testing (n = 15) both before and after surgery showed a significant improvement. There were no intraoperative complications. Postoperative epistaxis occurred in one patient. One patient complained of a transient hypesthesia of the soft palate and dry eye. Nasal mucosal tears were observed in approximately 30% of the patients who otherwise showed no severe synechia or persistent crusting.

Laser treatment of hyperplastic inferior nasal turbinates: a review

BACKGROUND AND OBJECTIVE

Since the early 80s various types of lasers have been used for the reduction of hyperplastic inferior nasal turbinates. Up to now many studies have revealed a variety of important information. To summarize these findings and to determine the value of laser treatment of hyperplastic inferior nasal turbinates, a comparative review of the literature was performed.

STUDY DESIGN/MATERIALS AND METHODS

The study of the literature revealed that hyperplastic inferior turbinates of more than 2,000 patients have been treated and followed up. Treatment was performed with the CO2 (10,600 nm), diode (805/810/940 nm), Argon-ion (488/514 nm), KTP (532 nm), Nd:YAG (1,064 nm), and Ho:YAG (2,080 nm) laser in more than 20 studies so far. Generally, the authors of the trials used different laser parameters (power, energy) and application modalities (contact, non-contact, interstitial, superficial). To determine the long-term results objective (active anterior rhinomanometry, acoustic rhinometry, mucociliary function tests, allergy tests) as well as subjective parameters (questionnaire) were recorded and evaluated. In some cases morphological changes of the turbinate tissue were studied by light and scanning electron microscopy (SEM).

RESULTS

Laser surgery of inferior turbinates can be performed as an outpatient procedure under local anesthesia. Due to a minimally invasive and controllable coagulation and ablation of soft tissue, almost no complications or bleedings were observed during the operation or postoperatively. Depending on the chosen parameters (power, energy) and the application modalities (contact, non-contact, superficial, interstitial) laser treatment of hyperplastic inferior nasal turbinates achieved comparable or better results than most of the conventional techniques for turbinate surgery like conchotomy, electrocautery, cryotherapy, chemical cauterization, and vidian neurectomy. More invasive (radical) operative methods, such as inferior turbinoplasty, submucous turbinectomy, lateral outfracture, partial and total turbinectomy, seemed to be more effective than laser surgery in the long-term.

CONCLUSIONS

Laser treatment of hyperplastic inferior nasal turbinates can be considered as a useful, cost-effective, and time-saving procedure for the reduction of hyperplastic inferior nasal turbinates. Short operation time, good results, and minor side effects compared to other surgical methods provide an excellent clinical response of the patients.

Secretomotor rhinopathy after Le Fort I maxillary osteotomy. Case report

Severe secretomotor (vasomotor) rhinopathy is a very uncommon nasal condition which is believed to result from marked autonomic neural imbalance to the nasal and lacrimal glands. It has not, to our knowledge, been reported after trauma or elective surgery. A patient is described who developed this condition after a Le Fort maxillary osteotomy. The clinical difficulties of establishing this diagnosis are highlighted, and contemporary management options are discussed.

Endoscopic surgery of the vidian nerve. Preliminary report

The anatomy, surgical technique, and difficulties of endoscopic vidian neurectomy are described. The procedure was carried out on 12 patients: 8 had resistant secretomotor rhinopathy and 4 had recurrent nasal polyposis. This technique is a minor surgical procedure with symptomatic relief and minimal postoperative morbidity.

Stimulation and resection of Vidian nerve in patients with chronic hypertrophic non-allergic rhinitis: effect on histamine content in nasal mucosa

Parasympathetic innervation of nasal mucosa plays an important role in the pathogenesis of chronic hypertrophic non-allergic rhinitis (C.H.N.A.R.). The present study investigated the effect of Vidian nerve stimulation and resection on the histamine contents and on the morphological pattern in mucosal samples of patients with C.H.N.A.R. Vidian nerve stimulation determines a significant decrease in histamine content in the samples examined; microscopical observations showed significant variations in the glandular, stromal and vascular components. The changes indicate an enhanced secretory activity, intensive vasodilatation and active degranulation of mast cells, which were significantly decreased in number in the samples obtained after 90 sec of stimulation. The neurectomy of the Vidian nerve resolves quite completely the clinical symptomatology and in parallel decreases the mucosal histamine contents, which are increased in patients with C.H.N.A.R. before the operation in comparison with the normal controls.

Transnasal preganglionic vidian nerve section

Vidian neurectomy is a useful procedure in relieving the symptoms of vasomotor rhinitis. However, the nerve is difficult to approach because of its deep location in the pterygopalatine fossa. A direct transnasal approach to the pterygopalatine fossa, passing through the sphenopalatine foramen in the lateral wall of the nose, is described and its merits are discussed. We have operated upon 247 cases by this approach over the past four years without any significant complications.

Cryosurgery on postganglionic fibers (posterior nasal branches) of the pterygopalatine ganglion for vasomotor rhinitis

Clinical experience with a newly designed device for cryosurgery on autonomic nerves in cases of vasomotor rhinitis is reported. The device consists of a handy spray of liquid nitrogen and a slender probe 2.5 mm in diameter. The posterior nasal branches of the pterygopalatine ganglion were destructed by freezing for 5-8 sec with a jet of supercooled nitrogen gas delivered onto the pterygopalatine foramen under anesthesia with 4% lidocaine. Satisfactory results were obtained by this procedure in 77 of 102 cases of vasomotor rhinitis which had failed to respond to antihistaminics. This original technique of cryosurgery which is not time-consuming and can be performed on an ambulatory basis will prove useful in clinical practice.

Laser vidian neurectomy

Laser vidian neurectomy appears to offer the technical advantages of a less traumatic, more precisely controlled method of operating in an anatomical area which creates, by its location, technical difficulties in accessibility. Results indicate that postoperative patient comfort is greater, affording the opportunity to perform surgery on an outpatient basis. Results of laser vidian neurectomy are no different than those using conventional techniques.

Vidian neurectomy: neuroanatomical considerations and a report on a new surgical approach

If conventional treatment fails, vidian neurectomy is a viable alternative for therapy of chronic rhinitis with recurrent polyposis of the nose and sinuses. From a neuroanatomical point of view beneficial and adverse effects of this surgical procedure are discussed. According to our own investigations and experiences, vidian neurectomy should be performed together with clearing out of the sinuses in every case. Beginning with this precondition a new surgical approach was developed: the vidian nerve is detected through a transethmoidal route in the pterygoid canal at the bottom of the sphenoid sinus and dissected using the operation microscope.

Effects of greater superficial petrosal neurectomy on nasal mucosa in rhesus monkeys (Macaca mulatta)

The effects of greater superficial petrosal neurectomy on normal nasal mucosa was studied in ten rhesus monkeys by light microscopy at four, six, and eight weeks postoperatively. Greater superficial petrosal neurectomy caused no histological alteration in the nasal mucosa of these monkeys. These procedures were accomplished with no complications.

Unilateral blindness following vidian neurectomy

A case with unilateral blindness is being reported, to arouse awareness in surgeons about the possibility of such a serious complication after Vidian neurectomy by the trans-septal route.

Bilateral transnasal cauterization of the vidian nerve in vasomotor rhinitis

A brief report of twenty cases of bilateral cauterization of the Vidian Nerve Canals in intractable non-atopic chronic Vasomotor Rhinitis by a Trans-Nasal approach not previously described is given. The authors find this approach to be a much safer and simpler procedure than either the Trans-Septal or the Trans-Antral routes. The advantages of this approach to the Vidian Nerve Canal over the Trans-Septal and Trans-Antral routes are discussed.

Surgical anatomy of the pterygopalatine fossa

The pterygopalatine fossa is the distribution centre for the main vessels and nerves of the middle third of the face. Its surgical anatomy is discussed, with particular emphasis on the relationship between the medical plate of the pterygoid process of the sphenoid bone and the vertical plate of the palatine bone; the position of the several foramina is reviewed also. It is stressed that the vascular contents of the pterygopalatine fossa lie in a coronal plane, anterior to the neural contents. Finally, a short review is given of the different surgical approaches to the pterygopalatine fossa. It is concluded that the transantral approach to the fossa, as originally described by Carnochan (1858), still seems to be the best way to gain access to this space.

Selective denervation of the autonomic nerve supply of the nasal mucosa

The autonomic innervation of the nasal mucosa has been studied in normal rats and in rats in which the supplying nerves had seen selectively transected; postoperative survival times varied from 2 weeks up to 18 months. The vascular structures appeared to be innervated both by acetylcholinesterase- and noradrenalin-containing fibres. Furthermore a nerve plexus consisting of both types of fibres was observed in the subepithelial region. The nasal glands however showed only a cholinergic innervation. The pattern of the autonomic nerve supply deduced from these selective denervation experiments does not differ fundamentally from the generally accepted scheme of this system in the nose of other mammals. Denervation occurred within 2 weeks after transection of the supplying nerves, but after longer survival times reinnervation was observed.