Canine fossa puncture in endoscopic sinus surgery: report of two cases

Neurovascular territories of the canine fossa: Analysis of a South African population

BACKGROUND

The canine fossa, a depression on the surface of the maxillary bone, is important clinically due to the nexus of the neurovascular elements which occur in this region and supply the superficial and deep structures of the face. While it is known that there is much variation in the neurovascular structures of this region, little is known about sex differences. The aim of this study was to investigate and map the neurovascular branching within the region of the canine fossa of a South African population, with particular reference to any sex differences.

METHODS

Sixty hemifaces (n=30 female; n=30 male) of individuals between the ages of 40 and 100years were dissected. The origin, number of branches, connections between branches, origin of connecting branches and the distribution of the neurovascular structures associated with the mid-facial and canine fossa regions were documented. The data obtained was qualitative and was statistically analysed with SPSS v26 statistical analysis software. Frequency and contingency tables, along with Chi-squared analysis and Fischer's Exact test, were used for quantitative data analysis.

RESULTS

While high levels of variation in the neurovascular elements were documented, there was no statistically significant variation between the sexes. A sex variation was only observed for the terminal branches of CN VII with females displaying a lower number of buccal nerve terminal branches than males.

CONCLUSION

While only one sex difference of significance was found in the highly variable neurovascular structures resident in the region of the canine fossa, the variability of the neurovascular elements is of importance to surgeons.

Imaging After Sinonasal Surgery

Posttreatment imaging evaluation of sinuses encompasses a wide gamut of procedures, ranging from endoscopic procedures for sinonasal inflammatory diseases to markedly radical surgeries for malignant neoplasms (with or without reconstructions), as well as providing access for surgeries involving the anterior and central skull base. Advances in both techniques and devices have expanded the use of endoscopic approaches in managing both benign and malignant lesions, in addition to being the primary surgical method for treating all medically refractive sinonasal inflammatory disorders. Familiarity with the complex anatomy in the sinonasal region and knowledge of the various procedures is indispensable in interpreting these imaging studies.

Supernumerary tooth in nasopalatine canal: a rare cause of septal cartilage collapse

Mesiodens is the most common type of supernumerary tooth, located between the maxillary central incisors in close relation to the nasopalatine canal. A 20-year-old man presented with right-sided nasal blockage, nasal discharge and collapsed nose without history of trauma. Imaging revealed a calcified mass in the inferior meatus extending into dilated nasopalatine canal. Endoscopic removal of the mass revealed tuberculate appearance of an incompletely developed tooth, consistent with mesiodens. Based on the history of septal cartilage collapse with right-sided mucopurulent discharge, endoscopic findings of the right inferior turbinate being adherent to the septal cartilage and the underlying mesiodens, we believe that the patient developed a septal abscess secondary to infection in nasal mucosa surrounding the mesiodens causing collapse of septal cartilage. While a tooth or tooth-like mass causing nasal passage air-flow obstruction is uncommon, we believe that this is the first reported case of mesiodens presenting with septal cartilage collapse.

A comparison of two endoscopic techniques for the treatment of antrochoanal polyps

An antrochoanal polyp (ACP) is a benign sinonasal lesion that originates from the mucosa of the maxillary sinus. In order to avoid any recurrence of disease, it is important to choose the best surgical approach for removal of ACP with respect to the site of attachment within the maxillary sinus walls. A retrospective cohort study was carried out by analysing a database of 82 patients who were operated on for ACPs in the Ear, Nose and Throat (ENT) clinics of both Sant’Orsola-Malpighi Polyclinic Hospital and Bellaria Hospital in Bologna, Italy from January 2001 to November 2017 to compare the rate of recurrence of ACPs after surgical removal using two different approaches. The first technique was endoscopic antrochoanal polypectomy with middle meatal antrostomy and the second was endoscopic antrochoanal polypectomy combined with both middle meatal antrostomy and a minimal access through the inferior meatus. A total of 49 patients were operated on with an endoscopic polypectomy with middle meatal antrostomy and 18.4% experienced a recurrence. The remaining 33 patients underwent endoscopic polypectomy with combined middle meatal antrostomy and access through the inferior meatus with a recurrence rate of 3%. The difference between the two groups was statistically significant (p = 0.0441). The strategy of the authors, namely combining medial antrostomy with a small inferior meatus access, was associated with a lower rate of recurrence and no increased morbidity in the short- or long-term.

An Unusual Maxillary Sinus Foreign Body: A Case Report

BACKGROUND Paranasal sinus foreign bodies are rarely encountered in otolaryngology practice. CASE REPORT We present the case of a 32-year-old man who presented to our Emergency Department with his left eye bleeding after a nail gun injury. The initial physical examination revealed the presence of a left eye ruptured globe, which led to left eye blindness. An urgent plain X-ray scan was done, in which the presence of a metallic object impacted in the left maxillary sinus was demonstrated. The patient was managed surgically by an external approach using the Caldwell-Luc procedure, with no intra- or postoperative complications. CONCLUSIONS Paranasal sinus foreign bodies, if improperly treated, can cause serious morbidity. Surgical removal, either endoscopically or through an external approach, is required.

Radiological diagnostic dilemma in a child with small aggressive facial mass, time to increase the differentials: an inflammatory myofibroblastic tumour

A 5-year-old girl with left facial swelling in the medial maxillary region close to the nasal ala was brought by her parents to our head and neck clinic. They have visited other doctors for similar presentation in the last 6 months, which started as redness and swelling, with occasional epiphora. The redness resolved after medical treatment, with slight regression of swelling, although it did not disappear. CT and MRI showed a locally aggressive, small enhancing soft tissue mass involving the left anteromedial maxillary wall, the nasal bone and the orbital floor. The mass involved the bony course of the nasolacrimal duct, which was the aetiology of the epiphora. The head and neck team performed an incisional biopsy through a sublabial approach. Concurrently, a nasolacrimal duct stent was inserted by an ophthalmologist. Histopathology was consistent with inflammatory myofibroblastic tumour with positive stains for CD68, CD163 and anaplastic lymphoma kinase-1. The tumour was excised and presently the patient is on periodic follow-up with head and neck and ophthalmology clinics.

Mini-Invasive Endoscopic Approaches to the Maxillary Sinus Floor: A Comparative Anatomical Study

BACKGROUND

While middle antrostomy (MA) is the most common approach to the maxillary sinus (MS), it is known for not allowing to fully inspect the whole MS, especially in its inferior and anterior portions. To overcome this limitation, alternative approaches have been proposed, such as inferior antrotomy (IA) and canine fossa accesses (CFA).

OBJECTIVE

Given the lack of studies on the MS floor visualization with different accesses, our study aims, in a cadaver lab setting, to systematically compare three different approaches (MA, IA and CFA) in these regards.

METHODS

Eight cadaver heads, previously submitted to CTscan, were prepared inserting fixtures corresponding to teeth 2, 4, 6, 11, 13 and 15 and into the canine fossae. Three approaches were prepared: a wide MA, an IM and a CFA. We endoscopically evaluated, for each specimen, side, access type and scope angle (0°, 30°, 45°, and 70°), which fixtures were visible on the maxillary sinus floor and whether the canine fossa fixture was visible (MA and IA only).

RESULTS

IA allowed to visualize all fixtures in nearly all cases (14/16 with 70° endoscope), while MA showed poor visualization results (3/16 with 70° endoscope); CFA failed to gain full visualization in most specimens (7/16 with 70°endoscope). Such difference was statistically significant. MA proved unable to visualize the canine fossa fixture in most cases while IA showed excellent possibilities. All differences were statistically significant (p < .001, Mcnemar's test).

CONCLUSIONS

Our data show that the IA grants a statistically significant superior surgical field vision when compared to MA and CFA, though in vivo validation of these results is still required.

Cerebrospinal Fluid Leak Following Nasal Packing for Epistaxis

Anterior epistaxis is commonly treated with Merocel nasal packing insertion. A 63-year-old male patient showed a cerebrospinal fluid rhinorrhea and pneumocephalus immediately after insertion of a Merocel tampon used for spontaneous right anterior epistaxis. He later developed fever and headache. This clinical report is to highlight how the nasal merocel should be positioned by specialized personnel and to describe how to manage this type of complication.

Endoscopic sinus surgery with and without computer assisted navigation: A retrospective study

OBJECTIVE

In the last years endoscopic sinus surgery (ESS) is improved with the introduction of computer assisted navigation (CAN). In this retrospective study we evaluated the usefulness of CAN in endoscopic sinus surgery and studied its advantages over conventional endoscopic sinus surgery.

METHODS

We retrospectively reviewed the records of 96 patients with chronic rhinosinusitis (CRS). 48 patients undergoing endoscopic sinus surgery with surgical navigation (A group) and other 48 without navigation (B group). Data about percentage of complications, olfactory function (Visual Analogue Scale), Sino-nasal Outcomes Test (SNOT-22), Rhinosinusitis Quality of Life (RhinoQoL), recurrence (CT Lund-Mackay score), total nasal resistance (rhinomanometry) and duration of the intervention were collected and analyzed.

RESULTS

A group evidenced a decrease of recurrence rate (p=0.009), a reduction of total nasal resistance (p=0.007), of frontal recess stenosis (p=0.04) and of nasal symptomatology (p=0.008). QoL had a better improvement in group A. Rate of other complications and olfactory function did not show statistically significant differences between the two groups. The average calibration time was approximately 11min in the A group. Total time of surgical procedure does not evidenced statistically significant difference between the two groups (p>0.05) but if it is considered only the time of the surgical intervention, the difference of duration is significant reduced statistically (p<0.05) in CAN surgery.

CONCLUSION

Computer assisted navigation in ESS can be useful for the most experienced surgeons, especially in the frontal recess surgery, decreasing the recurrence rate and reducing the total nasal resistance.