Georgios Giourgos

Removal of a Fronto‐Ethmoidal Osteoma Using the Sonopet Omni Ultrasonic Bone Curette: First Impressions

Endoscopic exeresis of sinonasal osteomas usually implicates the use of surgical drills with some disadvantages, as underlined by many authors. A new device that performs an ultrasound bone emulsification has been proposed in recent years for bone removal in various surgical disciplines. In this case report, we present the first clinical ENT experience with this device in removing a fronto‐ethmoidal osteoma, and we briefly discuss our impressions.

How we do it: A combined method of traditional curette and power-assisted endoscopic adenoidectomy

Conclusion. After conventional curette adenoidectomy, a significant mass of residual adenoid tissue is observed in about 50% of the cases. The combined approach of conventional curette and endoscopic adenoidectomy with microdebrider assures a complete and accurate removal of the mass. It is an effective and safe method without significantly prolonging the operative time. Objectives. To describe the surgical technique of conventional curette adenoidectomy completed with the microdebrider under endoscopic vision in case of residual adenoid tissue. Patients and methods. This was a retrospective review of 143 consecutive patients (age range 2–16 years, mean 6.2) who underwent endoscopic adenoidectomy for adenoid hypertrophy at an academic hospital-based institution. A classic transoral curette adenoidectomy was performed initially. Then a rigid fibre-optic endoscope was used transnasally to assess the completeness of surgery. Residual adenoid tissue was removed using a microdebrider under endoscopic vision. Results. After conventional curette adenoidectomy 70 children (48.9%) underwent residual adenoid tissue transnasal removal. Mean curette adenoidectomy time with endoscopic visualization of the nasopharynx was 9.1 min and, in the case of completion with the microdebrider, 14.6 min. No significant intraoperative bleeding, postoperative haemorrhage or other complications have occurred. After a mean follow-up of 24.4 months, no patients have been readmitted for symptoms of adenoid regrowth.

Sphenoid sinus fungus ball: our experience

Background Fungal rhinosinusitis is a common disease of the paranasal sinuses. The fungus ball (FB) is defined as an extramucosal mycotic proliferation that fills one or more paranasal sinuses. Sphenoid sinus is an uncommon localization of this disease, as reported in the literature. This study describes our experience in the diagnosis and treatment of sphenoid sinus FB (SSFB), with a particular focus on the surgical approach to the sphenoid sinus. Methods We retrospectively analyzed the clinical records of patients affected by FB of the sphenoid sinus, who underwent endoscopic sinus surgery (ESS) in our institutions between 1995 and 2009. We described the surgical technique, the methods of mycological and histopathological evaluation, as well as the perioperative and postoperative management. Results From 1995 to 2009, 226 patients affected by sinonasal FB underwent ESS in our institutions. A sphenoid localization was found in 56 patients (24.78%; mean age, 62 years). Cephalea was the most common symptom, and 14.3% of patients complained of ocular symptoms. We performed a direct paraseptal sphenoidotomy in 31 patients (55.4%) and a transethmoidal sphenoidotomy in 25 patients (44.6%). Histology unveiled fungal hyphae with absent mucosal invasion in all cases. Cultural results revealed positivity for mycotic colonization in 26 cases (46.4%, most commonly Aspergillus fumigatus). Follow-up ranged from 12 to 181 months with a mean of 70.7 months. Conclusion The description of our experience in the diagnosis and treatment of SSFB underlines the importance of a precise diagnostic pathway in case of sphenoidal disease. Nowadays, in our opinion, the paraseptal direct sphenoidotomy represents the less invasive, fastest and most anatomically conservative approach to the sphenoid sinus in case of SSFB.

Evolution in the treatment of sinonasal inverted papilloma: pedicle-oriented endoscopic surgery.

Background In the literature, the global endoscopic sinus surgery (ESS) success in the treatment of sinonasal inverted papilloma (IP) is 95%. This study was designed to describe a conservative endoscopic approach, based on research of the tumors pedicle and treatment concentrated on its site of attachment, and to compare the results of this technique with the outcome of standard endoscopic treatment. Methods Retrospective analysis of the patients treated in our institution for paranasal inverted papilloma (IP), between 2002 and 2011 with a minimum of 18 months follow-up was performed. Group A received a standard ESS including whole sinus demucosization (maxillary, ethmoid, frontal, or sphenoid sinus) and bony wall drilling. Group B patients instead underwent pedicle-oriented endoscopic surgery (POES); in this group, bony demucosization and drilling were selectively conducted around the site of pedicle attachment of the tumor. Results The cohort included 73 patients (median age, 60.5 years; median follow-up, 58 months). Group A/group B consisted of 37/36 patients. IP persistence—recurrence for group A/group B was 0/1 cases. Oncological success for global endoscopic/group A/group B was 98.6% (72/73)/100% (37/37)/97.2% (35/36). We noticed a significant difference in surgical operative time and postoperative complication rate among the groups, in favor of POES technique. Conclusion Our data confirm the efficacy of the endonasal endoscopic treatment for sinonasal IP. Moreover, the even more conservative endoscopic treatment proposed (POES) seems to offer good control of the disease, shorter operating times, avoidance of unnecessary surgery with respect to uninvolved structures, and permits a follow-up aimed at the site of the pedicle attachment.

Correlation of severity of epistaxis with nasal telangiectasias in hereditary hemorrhagic telangiectasia (HHT) patients.

Background Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disease that leads to multiregional angiodysplasia. The presence of telangiectasias in nasal mucosa leads to recurrent epistaxis that affects up to 96% of patients but with unpredictable severity. Some authors have previously explained that endonasal morphology and distribution of telangiectasias can be variable too. The purpose of this study was to evaluate any possible relationship between the severity of epistaxis and the different morphology and distribution of nasal telangiectasias in HHT patients. Methods A review was performed of nasal endoscopy records of 76 consecutive HHT patients treated for epistaxis between 2003 and 2007 at our institution. An evaluation was performed of severity of epistaxis in the same patient group using a questionnaire and considering frequency, intensity, duration of nosebleeds, and need for blood transfusions. Comparison of data collected on morphology and distribution of nasal telangiectasias with data collected on severity of epistaxis was performed. Results Morphology and distribution of nasal telangiectasias showed a statistically significant correlation with frequency and intensity of epistaxis. Presence of telangiectasias endoscopically appearing as large and prominent correlates with higher frequency of epistaxis. An increase in number of nasal subsites involved correlates with higher intensity of nosebleeds. Conclusion Our data suggest that to reduce frequency and intensity of epistaxis in HHT patients, treatments should be directed also at lesions located in the posterior part of nasal fossae and especially on telangiectasias endoscopically appearing as large and prominent.

Endoscopic treatment of maxillary inverted papilloma

OBJECTIVES Evaluate the efficacy of endoscopic treatment in maxillary inverted papilloma (IP). METHODOLOGY Between July 2002 - April 2008, 20 patients affected by maxillary localization of IP were treated in our Clinic. All patients underwent endoscopic treatment consisting of an endoscopic medial maxillectomy (simple or extended), or attachment-site endoscopic tumour surgery. RESULTS The cohort was composed of 20 patients (male: 15, female: 5), mean age 58 years, and included 21 endoscopic resections of maxillary IP. Minimum follow-up: 24 months, mean follow-up: 50 months. We registered only 1 case of tumour persistence/recurrence after 15 months, which underwent a second endoscopic treatment. No association with malignant lesions was noted. The efficacy of the endoscopic treatment was 95% (19/20 cases) after primary surgery, and 100% after endoscopic revision. CONCLUSIONS Our experience demonstrates the efficacy of endoscopic treatment in maxillary IP. Based On its reduced morbidity in comparison to external approaches and its good control of the disease, we consider it our standard treatment for maxillary-originated inverted papilloma.

Transoral endonasal-controlled combined adenoidectomy (TECCA)†

INTRODUCTION Adenoidectomy with or without tonsillectomy is one of the most commonly performed surgical procedures in the pediatric population. The standard surgical technique with adenoid curette or LaForce adenotome has evolved in the lasts years with the introduction of the endoscopic sinus surgery instrumentary, with an improved patients’ outcome, and a better satisfaction for the surgeon itself. However, in up to one-third of children with clinically significant adenoid hypertrophy a classical surgical technique canot completely remove the obstructive adenoid tissue, especially in the upper portion of the nasopharynx, the peritubaric region, and in the case of an intranasal extension. With the introduction of microdebriders in the otolaryngologist’s armamentarium, adenoidectomy (partial or total) has been one of the most interesting applications of this instrument, but for most surgeons the approach still remained transoral with a laryngeal mirror control. The advent of endoscopic sinus surgery in the 1990s popularized the use of intranasal scopes, and so the endoscopic adenoidectomy became the natural evolution of the conventional one. The endoscopic control permitted a complete removal of the adenoid tissue also in areas such as the eustachian tube, the upper part of nasopharynx, and the choanae. Parson, in 1996, and Yanagisawa and Weaver, in 1997, introduced for the first time the use of a transnasal microdebrider under endoscopic transnasal control to perform an adenoidectomy. In a recent publication, similar to that published by Havas and Lowinger in 2002, we described the surgical procedure used in our institution: a combined method of traditional curette and power-assisted transnasal adenoidectomy under endoscopic transnasal control. The purpose of this article is to report our experience in the evolution of such surgical approach: a combined use of a traditional curette adenoidectomy, completed, when necessary, by a transoral curved microdebrider revision under endoscopic transnasal control (TECCA).

Is canine fossa access necessary for successful maxillary fungus ball treatment

BACKGROUND Sinus fungus ball (FB) is a non-invasive mycosis that affects immunocompetent hosts, most frequently localized in the maxillary sinus. The current golden standard treatment is surgical removal. OBJECTIVE To evaluate the effectiveness of an endonasal endoscopically assisted approach to remove a maxillary FB combined or not with a transoral approach (sinusoscopy via canine fossa). METHODS A retrospective evaluation of paranasal FB treated by functional endoscopic sinus surgery (FESS) + transoral approach, compared to those treated by a sole FESS procedure. RESULTS In total, 65 out of 90 patients presented with a maxillary localization and were treated by FESS. Thirthy-three patients received a combined FESS + transoral approach and 32 received solely a FESS procedure. Antimycotic medical therapy was not used in any case. With a mean follow-up of 93 months, the treatment was successful in 62 patients (95,4%) without significant differences between the two groups. CONCLUSIONS Our data confirm the efficacy of FESS in the treatment of maxillary FB. A similarity in long-term results in both groups demonstrated that transoral sinusoscopy can be avoided. With the assistance of lateral-view and flexible endoscopes, angled surgical equipment and maxillary saline solution irrigations, complete removal of the diseased material and sinus clearance can be achieved by a sole middle meatotomy, reducing both morbidity and operating time.

“Hook-scope” technique for endoscopic extraction of nasal foreign bodies†

INTRODUCTION Management of nasal foreign bodies (FBs) is a common problem in the ear, nose, and throat (ENT) practice. Pediatric nasal FBs are usually treated in the emergency department, but, in many institutions, directly by the ENT specialist on call. However, the management of the extraction of nasal FBs sometimes can be frustrating and distressing for the physician, the patient, and the patient’s parents. If removal is not feasible in the emergency setting, then hospitalization is mandatory, and a general anesthesia or sedation is required for the extraction. Although endoscopes are part of the ENT’s diagnostic and therapeutic armamentarium, data in the literature on extraction of nasal FBs in awake children encompass, mostly, the use of rigid scopes; however, this procedure is not free from accidental injuries and complications, particularly in children. We describe a simple new technique for selected nasal FB removal in awake children, using the flexible endoscope both as a camera and an extractor.

Endoscopic removal of a nasal foreign body with the "hook-scope" technique

We present a case of a pediatric nasal foreign body removal with a new technique, the “hook-scope” technique, in which the flexible scope is used both as an endoscope and as a hook and permits a safe and rapid extraction of the object. This is the first report where such technique is presented with an image-documentation of a real case.