Effectiveness of Vidian Neurectomy in Chronic Rhinosinusitis with Nasal Polyps: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the clinical efficacy of vidian neurectomy (VN) or posterior nasal neurectomy (PNN) combined with endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

DATA SOURCES

A systematic search of six databases (PubMed, SCOPUS, Embase, Web of Science, Google Scholar, and Cochrane) was conducted to identify relevant studies up to May 2024.

REVIEW METHODS

The effects of combining VN or PNN with ESS were evaluated in comparison to ESS alone. Outcomes were assessed by evaluating changes in Lund-Kennedy score, patient-reported symptom scores (VAS), quality of life, as well as adverse effects and recurrence rate of CRSwNP.

RESULTS

A total of 6 studies, comprising 407 patients, were included in the analysis. The neurectomy group showed significant improvements in Lund-Kennedy score (SMD = 0.7276 [0.5695; 0.8857]), with statistically significant improvements maintained at 6, 12, and 24 months postoperatively. The treatment group maintained better improvements in sinusitis-related quality of life (SMD = 0.4540 [0.1784; 0.7297]) and VAS (SMD = 0.7096 [0.4356; 0.9837]) until 12 months postoperatively, but not at 24 months. Regarding adverse effects, additional neurectomy did not significantly induce epistaxis (odds ratio [OR] = 0.9806 [0.2348; 4.0960]) or dry eye (OR = 2.4194 [0.1114; 52.5255]) compared to the control group. On the other hand, there was no difference in the recurrence rate of CRSwNP between the 2 groups during the follow-up periods.

CONCLUSION

Additional neurectomy shows better efficacy in improving endoscopic findings and symptoms in patients with CRSwNP and appears to be a safe and effective treatment.

Sixty cases of refractory allergic rhinitis treated by vidian trunk or branch neurectomy: A single-center observational study

To investigate the effect of vidian trunk neurectomy and selective vidian branch neurectomy on treating moderate-to-severe persistent allergic rhinitis. Sixty patients with moderate-to-severe persistent allergic rhinitis treated at Zhejiang Hospital of Integrative Medicine participated in this study from June 2018 to June 2020. The patients in the observation group (n = 40) underwent a vidian trunk neurectomy. The patients in the control group (n = 20) underwent a vidian branch neurectomy. The patients in both groups were followed up after 6 months, 1 year, and 2 years of surgery. The efficacy was evaluated based on the AR diagnostic and the efficacy assessment criteria. The 4 symptoms of sneezing, runny nose, nasal congestion, and nasal itch were scored as efficacy indices before and 6 months, 1 year, and 2 years after surgery. Nasal endoscopy or sinus CT was performed to assess the postoperative inferior turbinate swelling. The postoperative tear secretion was followed up in both groups, and patients with dry eyes were counted in combination with ocular symptoms. The data recorded before and after surgery and between the 2 groups were analyzed statistically. The observation group had signs of 2.73 ± 0.452 before surgery, 1.20 ± 0.405 6 months after surgery, 1.25 ± 0.494 1 year after surgery, and 1.30 ± 0.564 2 years after surgery. The control group had signs of 2.75 ± 0.444 before surgery, 1.45 ± 0.686 6 months after surgery, 1.75 ± 0.716 1 year after surgery, and 1.90 ± 0.852 2 years after surgery. The between-subjects effect test between the groups showed an overall significant difference (P < .05). The overall effective rate 2 years postoperatively was 38/40 (95.0%) in the observation group and 10/20 (50%) in the control group. Fisher's exact test showed a significant difference between the groups. No patient in either group had dry eyes 1.5 years after surgery. Both vidian trunk neurectomy and selective vidian branch neurectomy have good immediate therapeutic effects, and vidian trunk neurectomy has higher long-term efficacy than selective vidian branch neurectomy.

Effect of pterygopalatine blockade on perioperative stress and inflammatory outcomes following paediatric cataract surgery

BACKGROUND

General anesthesia is required to perform pediatric cataract surgery. To reduce severity of surgical intervention and postoperative complications, regional techniques have been concomitantly used. The traditional regional ophthalmic techniques are retrobulbar, peribulbar and sub-Tenon blocks, which present some technical difficulties and associated complication risks. The pterygopalatine blockade has been exempt of many of these concerns as it is performed out of the orbit. The purpose of this study was to compare the analgesic and anti-inflammatory effects of the pterygopalatine blockade with retrobulbar block in children undergoing elective congenital cataract surgery.

METHODS

After approval of ethics committee and informed consents, patients were enrolled to the study to have either ultrasound-guided pterygopalatine block (group P) or retrobulbar block (group R), with 2 mL lidocaine 2% and 1 mL ropivacaine 0.5%. Hemodynamic monitoring was recorded throughout the perioperative period. Cortisol level and oxidation-reduction status were assessed before and after surgery. Pain and inflammatory response (Tyndall effect, corneal syndrome and edema) were assessed on the first postoperative day.

RESULTS

Comparative analysis demonstrated a decrease in cortisol of 123.24% (p˂0.05) and an increase in the redox coefficient of 37.7% (p˂0.05) in group P. Pain intensity was significantly higher in group R until the 16th postoperative hour. The corneal syndrome in patients in group P and group R was noted by 7.6% and in 32.1%, respectively (p˂0.05).

CONCLUSION

The use of the pterygopalatine blockade as a component of anesthesia in pediatric cataract surgery allows reduction of the severity of surgical stress during surgical intervention, providing intraoperative hemodynamic stability and prolonged analgesia.

Chronic paroxysmal headache secondary to an orbital metastatic leiomyosarcoma: A case report

Background Intraorbital lesions associated with symptomatic trigeminal autonomic cephalalgias (TACs) are rarely reported. We present a case of orbital metastatic leiomyosarcoma, presenting with chronic paroxysmal hemicrania-like headache. Case report A 43-year-old man presented with a severe paroxysmal headache in his left periocular and frontal area for a year. The attacks occurred 10-12 times per day, lasting 10-15 minutes with ipsilateral lacrimation and conjunctival injection. Neurological examination and brain MRI without contrast were unremarkable. Different medications were tried, without beneficial effects. A follow-up contrast-enhanced brain MRI performed one year after the baseline MRI revealed an enhancing mass in the left superior oblique muscle. Orbital metastatic leiomyosarcoma arising from the thigh was revealed. He received gamma knife surgery, which completely resolved the headache. Discussion Intraorbital lesion should be considered a possibility in patients with headache mimicking TACs. Baseline contrast-enhanced MRI is essential, and repeated MRI scans might be needed if clinically indicated.

Randomized, Double-Blind, Controlled Study to Evaluate the Effect of Vidian Nerve Cauterization on Lacrimation

Background

After vidian neurectomy, low reported rates of dry eye syndrome (DES) seemed incompatible with the high success rate of nerve severance in previous studies. This study aimed at understanding of the pathophysiology of lacrimation and evaluating the effect of thermal injury through the distal stump on the sphenopalatine ganglion (SPG) after vidian neurectomy.

Methods

A randomized, double-blind, controlled study was performed to evaluate the DES. Eighty precise vidian neurectomies were randomized in a 1:1 ratio to groups 1 and 2. Group 1 represented the cauterization and was used in both distal and proximal nerve stumps, whereas only the proximal nerve stump was cauterized in group 2 subjects. The DES was evaluated with Schirmer's test and ocular surface disease index (OSDI) before and after surgery at 7–10 days and 30 days, respectively.

Results

In group 1, the Schirmer's test showed a mean decline of 20 mm (20/30, 66%) at 7–10 days and 15 mm (15/30, 50%) at 30 days. In group 2, the Schirmer's test revealed significantly lesser dry eye problems, with a mean decline of 16 mm (16/30; 52%) at 7–10 days and 2 mm (2/30; 6%) at 30 days. The significantly less postoperative dry eye problems in group 2 can be shown by the OSDI at 7–10 days, but not at 30 days. The mean follow-up period was 24 months. No recurrence of nasal allergy symptoms was noted in the follow up period.

Conclusion

The significant advantage of preservation of the SPG function is justified by Schirmer's test, although the effect did not appear to be comparable with the clinical manifestations evaluated by OSDI at 30 days. Nevertheless, the preservation of distal stump from preventive cauterization can still offer better eye ball moisture in the early evaluation of DES.

Improved depiction of pterygopalatine fossa anatomy using ultrahigh-resolution magnetic resonance imaging at 7 tesla

Purpose. To study the anatomy of the pterygopalatine fossa (PPF) using ultrahigh-resolution magnetic resonance imaging. Methods. A human cadaveric tissue block containing the pterygopalatine fossa was examined on a clinical 7-Tesla magnetic resonance imaging system. Subsequently, cryosections of the tissue block were created in a coronal plane. The cryosections were photographed and collected on adhesive tape. The on-tape sections were stained for Mallory-Cason, in order to detail the anatomic structures within the fossa. Magnetic resonance images were compared with surface photos of the tissue block and on-tape sections. Results. High-resolution magnetic resonance images demonstrated the common macroscopic structures in the PPF. Smaller structures, best viewed at the level of the operation microscope, which have previously been obscured on magnetic resonance imaging, could be depicted. Some of the orbital pterygopalatine ganglion branches and the pharyngeal nerve were clearly viewed. Conclusions. In our experience with one human cadaver specimen, magnetic resonance imaging at 7 Tesla seems effective in depicting pterygopalatine fossa anatomy and provides previously unseen details through its demonstration of the pharyngeal nerve and the orbital pterygopalatine ganglion branches. The true viability of depicting the pterygopalatine fossa with ultrahigh-resolution MR will depend on confirmation of our results in larger studies.