Atsushi Hatano

Traumatic perilymphatic fistula with the luxation of the stapes into the vestibule.

Traumatic perilymphatic fistula due to luxation of the stapes into the vestibule caused by an earpick is an extremely rare situation. In order to treat such an injury, it is necessary to evaluate the extent of the damage and the actual condition of the middle and inner ear. However, it is difficult to obtain such precise information about the condition of the stapes prior to performing surgery. We report on a case of a traumatic perilymphatic fistula with luxation of the stapes into the vestibule that was diagnosed using multislice CT (MSCT). MSCT clearly demonstrated the presence of air in the vestibule (pneumolabyrinth), which indicated the presence of a perilymphatic fistula and the deep depression of the stapes into the vestibule. In order to seal the perilymphatic fistula and prevent middle and inner ear infection, surgery was performed on the portion of the stapes that remained in the vestibule. The patient has been free from vertigo and has exhibited some recovery of his hearing. We discuss the diagnosis along with other therapeutic problems that have been presented in the literature for traumatic perilymphatic fistula.

Craniofacial resection for malignant nasal and paranasal sinus tumors assisted with the endoscope

BACKGROUND Craniofacial resection is regarded as the treatment of choice for paranasal malignant tumors invading the skull base. Even with this approach, the surgical view remains obscured when tumors in the deep nasal and paranasal sinuses are resected. Endoscopy provides a wide and clear surgical view in the deep and narrow nasal cavity. We report two patients who underwent craniofacial resection assisted with endoscope. METHODS Two patients with malignant paranasal sinus tumor invading the anterior skull base underwent endoscope-assisted craniofacial resection. RESULTS To avoid a limited surgical view in the sinonasal cavity, we performed craniofacial resection with endoscopic osteotomy and several procedures in the nasal cavity. The neurosurgeon performed anterior skull base osteotomy at an appropriate site from above, while the otolaryngologist provided illumination with the endoscope from below and preserved the adjacent structures. The patients recovered uneventfully and the endoscopic examinations of both patients 18 months after the surgery showed no recurrence. CONCLUSIONS Endoscopes were useful for the craniofacial resection at osteotomy, providing illumination from below and at the several procedures in the deep part of the nasal cavity. If a lateral rhinotomy incision is made, the combined transfacial and transnasal approaches avoid the limited working angle associated with the transnasal approach alone. Although an endoscopic approach is useful for treating sinonasal tumors, we should recognize its advantages and limitations.

Risk factors for recurrent epistaxis: Importance of initial treatment

OBJECTIVE A retrospective study of risk factors for recurrent epistaxis and initial treatment for refractory posterior bleeding was performed. Based on the results, proposals for appropriate initial treatment for epistaxis by otolaryngologists are presented. METHODS The data of 299 patients with idiopathic epistaxis treated during 2008-2009 were analyzed by multivariate logistic regression analysis. Treatment data for 101 cases of posterior bleeding were analyzed using the chi-square test. RESULTS Recurrent epistaxis occurred in 32 cases (10.7%). Unidentified bleeding point (adjusted odds ratio (OR) 5.67, 95% confidence interval (CI) 1.83-17.55, p=0.003) was predictive of an increased risk of recurrent epistaxis, and electrocautery (adjusted odds ratio (OR) 0.07, 95% confidence interval (CI) 0.03-0.17, p=0.000) was predictive of a decreased risk of recurrent epistaxis. In terms of initial treatment for posterior bleeding, the rate of recurrent epistaxis was significantly lower for patients who underwent electrocautery as initial treatment compared with those who did not (6.4% vs. 40.7%, p<0.01), and it was significantly higher for those who underwent endoscopic gauze packing compared with those who did not (39.5% vs. 15.9%, p<0.01). CONCLUSION In the present study, the risk factors for recurrent epistaxis were unidentified bleeding point. Thus, it is important to identify and cauterize a bleeding point to prevent recurrent epistaxis. The present results also suggest the effectiveness of electrocautery and the higher rate of recurrent epistaxis for patients who underwent gauze packing as initial treatment for posterior bleeding. Electrocautery should be the first-choice treatment of otolaryngologists for all bleeding points of epistaxis, and painful gauze packing may be inadvisable for posterior bleeding. More cases of posterior bleeding are needed for future studies involving multivariate analyses and appropriate analyses of factors related to hospitalization, surgery, and embolization.

Endoscopic endonasal surgery in the management of selected malignant naso-ethmoidal tumors

OBJECTIVE The objective of this study was to report the cases of three patients with sinonasal malignant tumors who underwent en bloc tumor resection using endoscopic endonasal approaches, and to discuss the advantages and limitations of endoscopic endonasal tumor resection. METHODS Three patients with malignant naso-ethmoidal tumors underwent en bloc resection with endoscopic endonasal approach. RESULTS In very carefully selected cases of naso-ethmoidal malignant tumors that were preoperatively evaluated on endoscopic findings and magnetic resonance imaging to be limited to within the nasal cavity and/or ethmoid sinus and to have some safe margins between the tumor and skull base and/or lamina papyracea, tumors were resected en bloc using endoscopic endonasal approaches. A case of cerebrospinal fluid leakage was safely managed with the endoscopic approach. CONCLUSIONS In selected T1-T2 naso-ethmoidal malignant tumors with some safe margins, endoscopic endonasal surgery may offer a satisfactory alternative to external procedures.

Study of hemostasis procedures for posterior epistaxis

OBJECTIVE Hemostasis is difficult in patients with bleeding emanating from the deep regions in the nasal cavity; however, there is no standard treatment method. We studied hemostasis procedures in patients who visited our outpatient department and presented with idiopathic epistaxis extending from the posterior nasal cavity to Kiesselbachs area. METHODS The subjects were patients with epistaxis who visited our hospital between June 2008 and May 2010. We asked specific questions at the time of the hospital visit and examined patients using a nasal speculum, a flexible endoscope, and a rigid endoscope (0 or 70 degree) to identify bleeding sites. Hemostasis using electrocoagulation was selected as the first-line therapy for patients in whom a bleeding point had been identified, whereas hemostasis using a gauze tampon was performed in patients in whom the bleeding point was unknown. The subjects were analyzed by multivariate logistic regression analysis. RESULTS The bleeding point was unknown in most cases of recurrent posterior epistaxis. Electrocoagulation was the best hemostasis procedure. Identifying the bleeding points as much as possible and performing electrocoagulation at these sites was the preferred procedures. CONCLUSION We propose the treatment procedure for refractory epistaxis. When it is difficult to identify a bleeding point in a patient with refractory epistaxis due to a deviated nasal septum, a bleeding point should be identified after septoplasty; for bleeding from the sphenopalatine artery region, electrocoagulation or endoscopic cauterization of the sphenopalatine artery should be performed.

Combined tumor resection with endoscopic endonasal and external approach for sinonasal malignant tumors—A report of four cases

要旨:鼻副鼻腔腫瘍進展例に対する手術では外切開による拡大切除を行うが,その際副鼻腔深部操作時におけ る十分な視野の確保が問題となる。今回われわれは,当科において鼻副鼻腔悪性腫瘍に対して開頭手術または 外切開による腫瘍摘出時に内視鏡下鼻内操作を併用した手術を施行した 4 症例を経験したので,手術時の操作 性および術野の利点と欠点に対する評価を加えて報告する。内視鏡下減量術と放射線施行後に再発した前頭篩 骨洞扁平上皮癌症例,篩骨洞腺癌症例,鼻腔癌肉腫症例の 3 例に対しては前頭蓋底手術を施行し,鼻骨後方に 再発した腺様囊胞癌の 1 例に対しては鼻外側切開術を行った。4 症例に対して外切開を施行し術中内視鏡を用 いて鼻内からのアプローチを併用した手術操作を行った。鼻腔後方深部においても,内視鏡操作により明るく 明瞭な術野を確保でき明視下操作が可能であった。頭蓋底および,鼻腔前方部の骨切り操作では外方からの骨 切りが有用であり,その際に内視鏡を用いて内腔から腫瘍周囲に安全域をつけた部位を明視下に確認しつつ, 鼻内から照明することで外側からの骨切り操作を補助した。この操作により腫瘍に切りこむことなく必要かつ 最小限の確実な切除を行うことができた。さらに,症例によっては頭蓋底手術においても頭皮冠状切開のみ で,顔面皮膚切開を回避することができた。 鼻副鼻腔悪性腫瘍の進展例に対しては外切開による拡大切除も必要となるが,その際に内視鏡を併用して鼻 内からの観察を併用することで,切除範囲を必要かつ最小限なものにすることが可能であった。さらに顔面皮 膚切開を回避した根治切除が可能な症例があることより,鼻内外からのアプローチによる腫瘍切除は有用であ ると考える。 キーワード:鼻副鼻腔,悪性腫瘍,内視鏡,外切開,頭蓋底手術