Rhinoplasty – indications and techniques

Rhinoplasty is considered to be one of the most challenging procedures in otolaryngology head and neck surgery. Meticulous planning and excellent surgical skills are pre-requisites for reproducible good outcomes. More than 100 years after the first rhinoplasty, many controversies regarding indication and techniques remain unresolved. The aim of this article is to review current concepts and arguments

Reasonability of implementation of the endoscopic technique for sellar lesions in a low volume center

AbstractWe evaluated the implementation of the endoscopic (E) technique by an interdisciplinary ENT/neurosurgeon team as compared to the established classical microscopic technique (M) performed by one experienced neurosurgeon for pituitary adenomas in a single center. A retrospective analysis of patients operated for newly diagnosed pituitary adenomas was performed between November 2004 and August 2012. Outcome and complications are presented. A total of 116 patients were operated, 64 microscopically (M) and 52 endoscopically (E). Mean follow up was 35months (range 1.4–95), 1 patient was lost to follow-up. Most frequent pathology was hormone inactive adenoma (60% E, 51% M). Operating time was stable in the M-group (±94min). The E-group showed a learning curve in mean operating time (2004–2007: 154min, 2008–2012: 93min). Postoperative CSF leaks were seen in 9.6% (E) vs. 3.1% (M) of cases. More E-cases were re-operated (5 vs. 1) and more M-cases received a lumbar drainage (8 vs. 19). Transient postoperative diabetes insipidus occurred more often after E-operations (17 vs. 5%, p=0.03) without significant long term difference. Improved visual outcome showed a more favorable trend in E-cases. The implementation of the endoscopic technique was associated with more surgical complications in the learning phase, however with more improved visual outcome. Our observations should be of value for the more average neurosurgical department dealing with pituitary adenomas and aiming to switch from the microscopic to the endoscopic technique

Benefits of a short, practical questionnaire to measure subjective perception of nasal appearance after aesthetic rhinoplasty

Background: The authors tested a short, practically designed questionnaire to assess changes in subjective perception of nasal appearance in patients before and after aesthetic rhinoplasty. Methods: A prospective cohort study was conducted in a group of 121 patients who desired aesthetic rhinoplasty and were operated on by one surgeon. The questionnaire contained five questions (E1-E5) based on a five-point Likert scale and a visual analogue scale (range, 0 to 10). Two questions were designed as trick questions to help the surgeon screen for signs of body dysmorphic disorder. Results: All patients rated the appearance of their nose as improved after surgery. The visual analogue scale revealed a Gaussian curve of normal distribution (range, 0.5 to 10) around a significant improvement (mean, 4.36 points, p = 0.018). Also, question E1, question E2, and the sum of questions E1 through E5 showed a statistically significant improvement after surgery (p = 1.74 x 10(-36), p = 4.29 x 10(-33), and p = 9.23 x 10(-31), respectively). The authors found a linear relationship between preoperative score on the trick questions and postoperative increase in visual analogue scale score. Test-retest reliability could be investigated in 74 of 121 patients (61 percent) and showed a positive correlation between postoperative (1 year after surgery) and repostoperative response (2 to 4 years after surgery). Conclusions: The authors concluded that a surgeon performing aesthetic rhinoplasty can benefit from using this questionnaire. It is simple, takes no more than 2 minutes to complete, and provides helpful subjective information regarding patients' preoperative nasal appearance and postoperative surgical outcome

Nasolacrimal Duct Obstruction Caused by Lymphoproliferative Infiltration in the Course of Chronic Lymphocytic Leukemia

Background Endoscopic dacryocystorhinostomy (DCR) is the standard treatment of nasolacrimal duct obstruction. Only in rare cases, blockage may be caused by malignant tumors and even more exceptionally by lymphatic neoplasms so that biopsies are not routinely taken for diagnostic purposes. Methods A computerized retrieval system was used for this retrospective study to identify all patients with histologically documented lymphoproliferative infiltration in the lacrimal drainage system from 2001 to 2009. Results In four of 191 patients (2.1%), infiltration of the nasolacrimal sac mucosa with a small lymphocytic lymphoma (SLL)/chronic lymphatic leukemia (CLL) was found. Patients who develop symptoms like epiphora within the course of known CLL are highly suspicious for lymphoproliferative infiltration of the lacrimal drainage associated lymphoid tissue. Conclusion A proactive approach with ophthalmologic consultation and DCR should be followed in these patients to avoid dacryocystitis

Sound localization measured by eye-tracking

OBJECTIVE: To introduce a new method of measuring sound localization ability based on eye-tracking and to test this method by analysing the influence of mild induced conductive hearing loss on sound localization. DESIGN: Sound signals were presented from different angles, and the participant's responses were measured using an eye-tracking device. For validation, a comparison of responses to visual stimuli was performed. To test the clinical application of this method, a mild conductive hearing loss was simulated, and the impact of this change on sound localization was measured. STUDY SAMPLE: Fifteen participants. RESULTS: The system provided repeatable measurements, and there was a good correlation of sound and visual signals. A large number of trials could be completed fairly rapidly. Following the induced conductive hearing loss, a decline of 5.5° in the accuracy of sound localization in the horizontal plane was found towards the side of the non-impaired ear for frontal presentations. CONCLUSIONS: Quantifying sound localization by eye-tracking was found to be feasible, fast and accurate. A mild conductive hearing loss caused a slight degradation of sound localization accuracy within the 30° frontal sector, which is in good agreement with results found using methods requiring more extensive instrumentation

Reasonability of implementation of the endoscopic technique for sellar lesions in a low volume center

We evaluated the implementation of the endoscopic (E) technique by an interdisciplinary ENT/neurosurgeon team as compared to the established classical microscopic technique (M) performed by one experienced neurosurgeon for pituitary adenomas in a single center. A retrospective analysis of patients operated for newly diagnosed pituitary adenomas was performed between November 2004 and August 2012. Outcome and complications are presented. A total of 116 patients were operated, 64 microscopically (M) and 52 endoscopically (E). Mean follow up was 35 months (range 1.4–95), 1 patient was lost to follow-up. Most frequent pathology was hormone inactive adenoma (60% E, 51% M). Operating time was stable in the M-group (± 94 min). The E-group showed a learning curve in mean operating time (2004–2007: 154 min, 2008–2012: 93 min). Postoperative CSF leaks were seen in 9.6% (E) vs. 3.1% (M) of cases. More E-cases were re-operated (5 vs. 1) and more M-cases received a lumbar drainage (8 vs. 19). Transient postoperative diabetes insipidus occurred more often after E-operations (17 vs. 5%, p = 0.03) without significant long term difference. Improved visual outcome showed a more favorable trend in E-cases. The implementation of the endoscopic technique was associated with more surgical complications in the learning phase, however with more improved visual outcome. Our observations should be of value for the more average neurosurgical department dealing with pituitary adenomas and aiming to switch from the microscopic to the endoscopic technique

A basic model for training of microscopic and endoscopic transsphenoidal pituitary surgery: the Egghead

Background: Transsphenoidal endoscopic surgery has gained popularity in the last 2 decades and is becoming a standard technique for resection of pituitary adenomas. In contrast to their ENT colleagues, neurosurgical residents have practically no endoscopic experience when they reach the training stage for transsphenoidal procedures. We have developed an affordable method for repetitive training in endoscopic (and microscopic) work in a narrow channel, allowing training of the basic movements needed for resection of pituitary adenoma. Methods: In collaboration with colleagues in the ENT Department, Cantonal Hospital St. Gall, and the Technical University of Zurich, a three-dimensional model of the nasal cavity was developed and patented. The Egghead model consists of a 3D synthetic reconstruction of the head nasal cavity and sphenoid sinus. A boiled egg represents the sella. For validation, 17 neurosurgical residents from the Department of Neurosurgery, University Hospital of Basel, and Department of Neurosurgery, Cantonal Hospital of St. Gall, St. Gall, Switzerland, and two experts performed a standardized procedure mimicking a transsphenoidal pituitary procedure by dissecting a corridor to the egg yolk and resecting it, respecting the surrounding egg white. This procedure was performed under both microscopic and video-endoscopic visualization. A score for the precision and speed of the surgical performance was developed and used. Results: The model allows repetitive training of the resection of the egg yolk under sparing of the egg white after careful opening of the shell. The validation data showed a steeper learning curve using the endoscopic technique than performing the same task using the microscope. After three repetitions, the quality of resection was better with the endoscopic technique. Conclusions: Our model, the Egghead, is affordable, offers tactile feedback and allows infinite repetitions in basic training for pituitary surgery. It can be used for training of advanced neurosurgical residents, who thus far have very few possibilities of acquiring endoscopic experience

A basic model for training of microscopic and endoscopic transsphenoidal pituitary surgery: the Egghead

Background Transsphenoidal endoscopic surgery has gained popularity in the last 2 decades and is becoming a standard technique for resection of pituitary adenomas. In contrast to their ENT colleagues, neurosurgical residents have practically no endoscopic experience when they reach the training stage for transsphenoidal procedures.We have developed an affordable method for repetitive training in endoscopic (and microscopic) work in a narrow channel, allowing training of the basic movements needed for resection of pituitary adenoma. Methods In collaboration with colleagues in the ENT Department, Cantonal Hospital St. Gall, and the Technical University of Zurich, a three-dimensional model of the nasal cavity was developed and patented. The Egghead model consists of a 3D synthetic reconstruction of the head nasal cavity and sphenoid sinus. A boiled egg represents the sella. For validation, 17 neurosurgical residents from the Department of Neurosurgery, University Hospital of Basel, and Department of Neurosurgery, Cantonal Hospital of St. Gall, St. Gall, Switzerland, and two experts performed a standardized procedure mimicking a transsphenoidal pituitary procedure by dissecting a corridor to the egg yolk and resecting it, respecting the surrounding egg white. This procedure was performed under both microscopic and video-endoscopic visualization. A score for the precision and speed of the surgical performance was developed and used. Results The model allows repetitive training of the resection of the egg yolk under sparing of the egg white after careful opening of the shell. The validation data showed a steeper learning curve using the endoscopic technique than performing the same task using the microscope. After three repetitions, the quality of resection was better with the endoscopic technique. Conclusions Our model, the Egghead, is affordable, offers tactile feedback and allows infinite repetitions in basic training for pituitary surgery. It can be used for training of advanced neurosurgical residents, who thus far have very few possibilities of acquiring endoscopic experience