Use of Foley catheter in control of internal carotid hemorrhage during endoscopic endonasal surgery

Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are rare life-threatening events. We describe a technique to manage ICA injuries based on the use of Foley catheters.A 26-year-old female underwent endoscopic transnasal trans-sphenoidal removal of pituitary adenoma. Cerebrospinal fluid leak occurred 4 days postoperatively. During repair procedure, accidental injury of ICA occurred. Emergency nasal packing through positioning of four Foley urologic catheters was successfully performed to stop bleeding. The patient did not report neurologic deficits.In author's opinion, Foley catheters are suitable to obtain immediate bleeding control since they are rapidly available and easily usable

The Exclusive Endoscopic Traspromontorial Approach and Its Pilot Clinical Experiences

Objectives: Describe a minimally invasive transcanal endoscopic approach, starting from the external auditory canal and reaching the internal auditory canal, used to treat inner ear pathology. Methods: Three patients, affected respectively by cochlear schwannoma, acoustic neuroma, and temporal bone cholesteatoma, were treated by an exclusive endoscopic approach without external incisions. Surgical steps and useful landmarks were reviewed and described. Results: The operation provided a direct transcochlear intradural approach from lateral to medial and from external to internal auditory canal, without any external incision. The pathology was totally removed in all patients. Results regarding facial nerve were very satisfying. Hospital stay was markedly reduced compared to traditional approaches. Conclusions: The transcanal exclusive endoscopic approach proved successful for pathology removal involving the fundus, internal auditory canal, and cochlea. Potential future application of this kind of approach in lateral skull base surgery will depend on the development of technology and surgical and anatomical refinements

The endoscopic anatomy of the cochlear hook region and fustis: Surgical implications

The cochlear hook region can be considered as the interface between the middle and inner ear. The identification of surgically-relevant endoscopic landmarks of this anatomical entity and assessment of their clinical value is still lacking in the literature. Procedures like cholesteatoma surgery and minimal invasive endoscopic approaches to the lateral skull base may particularly benefit from these considerations. We hypothesize that the spatial orientation of anatomical landmarks in the cochlear hook can be expressed in angles and are reproducibly identifiable by transcanal otoendoscopy. Therefore, endoscopic dissection of the cochlear hook region was performed in 32 temporal bone specimens. Topographic anatomy was documented and analysed. We performed computed tomography of 28 specimens to assess the region in three-dimensional reconstructions. The mean angle between the round window and the basal scala tympani was assessed 25.9\ub0 in endoscopic and 28.2\ub0 in three-dimensionally reconstructed models. The fustis was recognised as a reliable landmark for the basal turn. A mean angle of 155.4\ub0 to the basal scala tympani was assessed. A slight bulging without obstruction of the basal turn was observed in 5 cases. The utility of the revealed anatomical details was assessed in minimal invasive endoscopic lateral skull base approaches. In conclusion, we described the angles between anatomical landmarks of the cochlear hook region. Moreover, the angle as recorded through an endoscope was found to be reliable compared to three-dimensional reconstructions from computed tomography

Value of Endoscopy in Surgical Procedures to Stapedial Region

Objectives: Evaluate the role of endoscopic approaches during exclusive or combined (microscopic and endoscopic) procedures to stapedial region, particularly in difficult cases or in anatomic abnormalities. Methods: From 2009 to 2014, 56 endoscopic exclusive or combined (microscopic and endoscopic) approaches to the stapedial region were performed at the otolaryngology department, University Hospital of Modena. Operations performed were stapedoplasties or explorative tympanotomies for conductive hearing loss. Video, patient charts, and operative reports from surgeries were reviewed in February 2014. Cases in which stapedial abnormalities were identified were included and analyzed in the present study. Results: In 8 cases a malformed stapes was identified. Of those, 6 were eventually treated, while in 2 cases, after a diagnosis was made, a conservative attitude was chosen. Under endoscopic view, precise procedures under direct view were made possible, even in very delicate and hidden regions. Conclusions: Whether chosen as a pure explorative tool, or as the main operatory visualization modality, endoscopy can guarantee very good visualization of the stapedial region, and may help in diagnosing and fixing altered stapedial conditions

Surgical multidisciplinary approach of orbital complications of sinonasal inflammatory disorders

Orbital infection complicating sinonasal inflammatory disorders may lead to serious sequelae, including blindness and death, if untreated. Communication between the otorhinolaryngologist, neuroradiologist, ophtalmologist, neurosurgeon and maxillo-facial surgeon is critical and time-sensitive for a successful treatment. The large majority of pre-septal cellulitis cases resolves after broad-spectrum antibiotic therapy. Also orbital cellulitis has been found responsive to pharmacological approach in most cases. The management of the subperiosteal abscess (SPA) is more controversial. An aggressive surgical approach is always recommended also in case of cavernous sinus thrombosis. In cases of surgical indication, debate is still open on the timing and the approach (endoscopic or external). The surgeon should be prepared to convert an endoscopic approach to an external one if needed and this should be included in the informed consent. Decompression of one or more orbital walls may be necessary if orbital pressure remains elevated. Immediate surgery is indicated in children with large SPA or orbital abscesses (OA), or in immune-compromised patients. Moreover, any worsening in the ophthalmological function must be carefully considered as a landmark in candidacy to surgery

Treatment of Recurrent Tracheocutaneous Fistulas in the Irradiated Neck with a Two Layers-Two Flaps Combined Technique

The development of a tracheocutaneous fistula (TCF) is a well-documented complication after tracheostomy, especially in chronic morbid patients, in whom tubes or cannulas are left in place over time, or in irradiated patients. Surgical treatments are therefore needed which range from simple curettage and dressings to local skin flaps, muscle flaps and, in the more complex cases, microsurgical free tissue transfers. We present a novel combined technique used to successfully treat recurrent TCFs in irradiated patients, involving a superiorly based turnover fistula flap and a sternocleidomastoid transposition flap

Novel surgical and radiological classification of subtympanic sinus: implications for endoscopic ear surgery

Objective The aim of this study is to describe the endoscopic anatomy of the subtympanic sinus (STS), establish a classification according to its extension regarding the level of the facial nerve (FN), and assess the feasibility of the transcanal endoscopic approach to the STS. Study Design Experimental anatomic research. Setting Temporal bone laboratory. Methods We performed endoscopic dissection of 34 human whole head and ear block specimens. Of those, 29 underwent high-resolution computed tomography. The STS was classified according to its extension regarding the level of the FN: type A, no extension medial to the FN; type B, extension to the medial limit of the FN; type C, extension of the sinus medially and posteriorly from the FN into the mastoid cavity. Results The majority of cases (n = 21, 72%) showed a shallow type A STS. We observed a deep type B configuration in 6 cases (21%) and a type C in 2 cases (7%). The STS was completely exposable with a 0\ub0 endoscope in 44% of the specimens. Using a 45\ub0 endoscope, we gained complete insight in 79%. However, in 21% of the cases, the posteromedial extension of the STS was too deep to be completely explored by an endoscopic transcanal approach. Conclusion The majority of the STS is shallow and does not extend medially from the FN. This morphologic variant allows complete transcanal endoscopic visualization. In more excavated STS, a complete endoscopic exploration is not achievable, and a retrofacial approach may be adopted to completely access the STS

Complications in endoscopic ear surgery

Objective: The aim of this study was to examine the premise that endoscopic ear surgery (EES) is associated with a low rate of complications (intraoperative and postoperative). Study design: Retrospective review at two institutions. Setting: Tertiary referral center. Patients: The study included 825 patients who underwent exclusive EES between 2008 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Modena University Hospital, and between 2014 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Verona University Hospital. Interventions: Exclusive endoscopic ear surgery between 2008 and 2016 (tympanoplasties, second look or revision tympanoplasties, myringoplasties, stapedoplasties, canalplasties, ossiculoplasties, and exploratory tympanotomies). All surgical procedures were performed by two experienced surgeons. Main outcome measure: For each procedure, intraoperative, and early and delayed postoperative complications were evaluated. Results: The most common ear pathologies for which patients were sent for EES were cholesteatoma (33.6%), chronic otitis media (36.3%) and otosclerosis (26.8%). There was no case of major intraoperative complications such as injury to the dura or vascular structures. We observed minor intraoperative complications in 4.1% of the cases. Only 1.3% of patients experienced early postoperative complications. Delayed complications affected less than 1% of the cohort. Conclusions: Data from this study confirm the safety of the endoscopic technique, with very low complication rates, indicating that EES is a reliable therapeutic option, in particular, for tympanoplasties, myringoplasties, and stapedoplasties, as well as second look procedures. We have reported our experience with EES morbidity so that it can be compared with data from other centers using the same surgical technique