Alexander Asanau

Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis.

Objectives: We describe the surgical treatment of severe epistaxis and evaluate the recurrence of bleeding in a nonrandomized retrospective trial. Methods: We performed a retrospective study comparing bilateral endoscopic ligation of the sphenopalatine artery alone (ELSPA) and bilateral endoscopic ligation of the sphenopalatine artery with concomitant bilateral external ligation of the anterior ethmoidal artery (ELSPEA) in the management of persistent epistaxis. Clinical and hematologic information, preoperative and surgical care, and short- and long-term outcomes were analyzed. The main outcome measure was recurrence of epistaxis in the short- and long-term follow-up periods. Results: Forty-five patients were enrolled in the study. There were 20 patients in group A (ELSPA) and 25 in group B (ELSPEA). Three patients in group A and no patients in group B had long-term (more than 2 weeks after surgery) re-bleeding. The difference between the two groups was not statistically significant (p > 0.05). Conclusions: We conclude that ELSPA and ELSPEA are effective, well-tolerated, reliable procedures if performed by an experienced surgeon. Their failure can be explained by anatomic lateral nasal wall variations and perioperative technical difficulties. They can be appropriate methods to treat severe recurrent epistaxis refractory to repeated nasal packing.

Preauricular Transmandibular and Transzygomatic Approach for Tumors of the Infratemporal Fossa Revisited

Aim: To demonstrate the surgical technique and results in patients operated on with a preauricular transmandibular transzygomatic approach. Methods: This surgical technique was used in 21 patients with benign and malignant tumors of the infratemporal fossa (ITF), operated on between 1999 and 2011. Results: Twenty-one patients were enrolled in the study. There were 6 patients with benign tumors and 15 with malignant ones. No patients with benign lesions show any disease recurrence 5 years after surgery and present excellent functional and cosmetic results. Postoperatively, a reduction of pain was noted in all patients with malignant lesions. Four patients in this group, who are alive 5 years after surgery, do not demonstrate any disease progression. Conclusion: The described approach provides an excellent exposure of the ITF and could be the procedure of choice in the management of ITF tumors.

Posterior Cricoarytenoid Bellies: Relationship Between Their Function and Histology

OBJECTIVES/HYPOTHESIS Complete physiological information about human posterior cricoarytenoid muscle (PCA) is essential and is not only of basic science interest but also could lead directly to understanding phonation and many clinical issues in neurolaryngology. The purpose of the study was to investigate and compare the histochemical and morphological properties to know contractile muscle fiber characteristics of two bellies of the PCA. STUDY DESIGN Cross-sectional experimental study. METHODS The PCAs were harvested from the total laryngectomy simples. Serial transverse sections of the two PCA bellies were performed and studied by immunohistochemical analysis. RESULTS Two separate muscle bellies were always identified within 15 PCA. The following muscle fiber types were observed: I, I-IIA, and IIA. Comparisons of the vertical and horizontal bellies of the PCA reveled differences in the fiber-type composition. CONCLUSION In our experience, the PCA should be considered as a combination of two functional subunits, which significantly differ in their muscle fiber-type composition.

Strategy of modern epistaxis management.

To the Editor We have read with great interest the article by Strach et al. [1] published recently in Cardio Vascular and Interventional Radiology and would like to give some comments on this study. The authors have reported their experience of endovascular treatment of life-threatening epistaxis and have mentioned that cases of severe intractable epistaxis are rare. We wish to emphasize that the issue of ‘‘modern’’ epistaxis is changing. The episodes occurring in the older population, especially in patients who are receiving antiplatelet and/or anticoagulant medication, tend to be more severe and frequent, whereas those in children more often are minor and self-limited [2]. According to this statement, a severe epistaxis in elderly frail persons remains almost an every day challenge faced by otolaryngologists, particularly in tertiary care centers. Often, to be controlled properly, it necessitates a regional hemostasis. In addition, embolization-rated complications were compared with complication rates for surgical ligation of the internal maxillary artery. Today, more sophisticated technologies, such as endoscopic surgery, give us possibility to resolve the problem of nasal hemorrhage definitively; therefore, ligation of the internal maxillary artery has already been forgotten [3]. The sited surgery also helps to avoid accidents that could be a result of embolization. Nevertheless, in some institutions and in cases of conservative treatment failure, angiographic embolization remains the procedure of first choice. At the same time, it was stated that the region above the middle turbinate is supplied only by the anterior and posterior ethmoidal arteries. In reality, the superior turbinate artery, which is a branch of the sphenopalatine artery, also supplies this region [3]. As far as identification of primary bleeding site is concerned, it is a difficult task. Traditionally, before otolaryngological examination, both sides of the nose are already packed. This packing can lead to intranasal injuries and to rebleeding on its removal. Additionally, if there is a septal deviation, an inexperienced emergency physician may traumatize the nasal (septal and/or turbinate) mucosa and create even more bleeding [4]. Furthermore, some areas of the nose have rich bilateral vascular anastomosis [5]. To achieve the best result and to avoid reoperation after the failure, we always propose to our patients a bilateral regional hemostasis [3]. In cases of posttraumatic epistaxis, a CT scan with contrast-injection protocol is systematically performed before intervention. It checks possible cranial base fractures and determines further hemostasis strategy. Equally important, the treatment of nose bleeding in case of hereditary hemorrhagic telangiectasia is very complicated. The best management of this lesion is unclear, with its failure rate remaining high [6]. Severe epistaxis is a frequently encountered emergency. Needless to say, it should be controlled safely and quickly. For this reason, the collaboration between radiologists and otolaryngologists is very important. We hope that in the near future we will learn to prevent severe epistaxis instead of treating it. Still, a lot of work must be done to achieve this goal. A. Asanau (&) A. P. Timoshenko J.-M. Prades Department of Otolaryngology-Head and Neck Surgery, North Hospital, Saint-Etienne University Hospital Centre, 42055 Saint-Etienne Cedex 2, France e-mail: alexander.asanau@chu-st-etienne.fr

Epistaxis and its complex origin

Dear Editor With interest we read the article by Yang ZD et al. The authors of the article hypothesized that ‘‘the location and gravity of heart and aorta may determine the trend of lateral flexion and axial rotation of the normal spine, which may be the reason of both left– right handedness and left–right convex curve pattern of AIS’’. We would like to comment on their hypothesis. In our previous studies, we systematically analyzed vertebral rotation of the normal, nonscoliotic spine and demonstrated the existence of a consistent pattern of physiological vertebral rotation, unrelated to the pathogenesis of AIS [1–3]. We postulated that, once the spine starts to decompensate into scoliosis, the direction of the developing curve is determined by this preexistent rotational pattern. The asymmetrically positioned organs of the body and the existence of right and left-handedness are also typical examples of normal human body asymmetry. We would like to refer to our study in 2007, in which we investigated pre-existent vertebral rotation in the normal, nonscoliotic spine of persons with a situs inversus totalis (SIT) [4]. This study showed a pattern of vertebral rotation opposite to what was found in persons with normal organ anatomy. We also determined rightand left-handedness in our SIT group, which showed a similar distribution as in the general population. Since rotation of the thoracic vertebrae in the SIT group was to the opposite side as compared to normals and handedness was distributed in a similar manner, these data suggest that handedness is not involved in the direction of vertebral rotation in the normal spine. In conclusion, we do agree with the authors’ hypothesis that the asymmetrical anatomy of the thoracic organs plays an important role in determining the direction of a physiological axial rotation of the normal spine, which may be the reason of the characteristic right convex thoracic curve pattern of AIS. However, there appears to be no relationship with handedness.

Epistaxis management: which strategy to choose?

Dear Sirs, We read with great interest Supriya and colleagues’ article ‘Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome’, published recently in The Journal of Laryngology & Otology. Despite the our belief that management of the epistaxis depends on the departmental policy and experience of the clinician, Supriya and colleagues’ article generated some questions. The authors report successful nasal examination with a rigid nasal endoscope and identification of the bleeding site in 91 per cent of cases, even within 24 hours of Merocel nasal pack removal. However, in our experience such packing can lead to intranasal injuries and recurrent bleeding upon removal, especially when placed by a physician inexperienced in ENT emergency management. If there is a septal deviation, any packing may traumatise the nasal mucosa (septal and turbinate) and create more sites of bleeding. Traditionally, both sides of the nose are packed, and identification of the side of bleeding after packing removal is frequently a difficult problem. Septal deformation and hypertrophic turbinates often prevent visualisation of the bleeding regions. The article in question did not discuss these issues, nor the substantial number of patients with these common anatomical variations. In addition, Supriya et al. did not make clear whether their patients had continuous epistaxis at the moment of cauterisation. In our experience, we prefer to refer to severe and nonsevere epistaxis, rather than anterior and posterior epistaxis, in order to indicate the procedure most likely to result in successful management.

Hidden scar or its absence: is it always safe?

We have read with great interest the online published article of Kim et al. [1], and would like to make some comments on this surgical approach, which we find interesting and provocative at the same time. Although the described small series was successful, it is difficult to speak with certainty about perfect results. First, the authors wrote that there was no harm caused to the facial nerve; however, they did not mention anything regarding the great auricular nerve (GAN). In our opinion, potential damage for the GAN and its branches could be caused during the flap raising. This injury is not always noticed, because many surgeons pay not much attention to sequels of such lesion [2]. In addition to that most patients accept superficial explanations that the numbness around the ear is an inevitable consequence of the operation, and a cheap price to pay for the results achieved. However, such injuries could be symptomatic [3]. Secondly, it was reported that five out of six patients presented a pleomorphic adenoma. At the same time, the reported mean follow-up period was only 10 months, which is too short to judge the non-recurrent rate. Even though patients were well informed about possibility to convert this surgical approach to another one, they were not aware of the risk of pleomorphic adenoma recurrence. This risk must be kept in mind by every surgeon and should not be forgotten even many years after the tumor excision [4]. As far as we are concerned, these tumors should be excised by a more simple approach to avoid a recurrence depending on the initial surgical procedure. Our choice in this case is the standard time-tested lateral open transcervical approach. Finally, as for the postoperative scar, another disadvantage of this approach is a risk to destroy hair follicles during incision and dissection of the skin flap. It might make the postoperative scar more visible, especially for people with short hair. Certainly, it is true that many people are more and more preoccupied with the way their body looks: they paint and pierce it, they keep it in shape through exercise and diet, and if they should really undergo a surgical intervention they ask to make it without any visible scar [5]. But surprisingly, they are less aware of the complications like temporary lingual nerve paresis and limitation of tongue movement, than facial marginal mandibular branch palsy, or constant GAN deficiency. That is why since 2009 we have used the transoral submandibulectomy approach, except for the tumor cases and cases with contraindications described by Weber et al. [6]. This approach, well known since 1952, is feasible and could be a procedure of choice in selected patients to avoid postoperative cervical scar [7].

Epistaxis as a challenge faced by otolaryngologist (Re: ANZ J. Surg. 2011; 81: 336–9)

tions after pancreatic surgery. A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann. Surg. 2006; 244: 931–9. 3. Bassi C, Dervenis C, Butturini G et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138: 8–13. 4. Wente MN, Veit JA, Bassi C et al. Postpancreatectomy hemorrhage (PPH)-An International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142: 20–5.

Surgery without scar: Is it always evident and safe?

We have read with great interest the article entitled ‘‘Endoscopic resection of the submandibular gland (SMG) via a hairline incision: a new surgical approach’’ published in The Laryngoscope. In this article the authors provided a comprehensive description of their surgical approach to the SMG resection applied to only one patient. We wish to comment on this surgical approach because it is interesting and provocative at the same time. Regardless of this successful case, one cannot speak of good cosmetic outcome without neurologic or woundrelated complications if no statistically valid studies confirming the same results exist. In our opinion, the potential damage for the great auricular nerve and its branches and marginal mandibular branch of the facial nerve during flap elevation and retraction remains always possible and can lead to postoperative sensitive and motor complications. As for the postoperative scar, there are two minimal but visible scars of the cervical region on the figure Some people are preoccupied with the way their body looks: they paint and pierce it, they keep it in shape through exercise and diet, and if they should really undergo a surgical intervention they demand to make it without any remarkable scar. But surprisingly, they are less aware of the complications like temporally lingual nerve paresis and limitation of tongue movement. That is why we use the transoral submandibulectomy approach except the cases with contraindications described by Weber et al. This approach, well known since 1952, is feasible and could be a procedure of choice in selected patients to avoid postoperative cervical scar. The authors also reported that the histologic examination showed a pleomorphic adenoma originating from the SMG. This diagnostic could be predicted by magnetic resonance tomography or needle aspiration. These tumors should be excised by a more easy approach to avoid the recurrence depending on the initial surgical procedure. Our choice in this case is the standard timetested lateral open transcervical approach.