Kazuhiro Omura

A modified Lund-Mackay system for radiological evaluation of chronic rhinosinusitis

OBJECTIVE The Lund-Mackay system (L-M system) is widely used for computed tomography (CT) evaluation of chronic rhinosinusitis (CRS). However, a major drawback of the L-M system is its insufficiency of gradation. To avoid this deficiency, a new staging system proposed by American societies and the Zinreich system were reported as modifications of the L-M system. The aim of this study was to investigate the efficiency of gradation and the accuracy of the visual quantification of these modified staging systems. METHODS Preoperative CT scanning was performed on 20 adult patients with CRS. A computer workstation was used to measure the volume of each sinus and the volume of inflammatory disease in each sinus. Then the soft tissue density rate (STDR) and objective scores, which were adapted to each system, were calculated. Visual evaluation of the CT images was performed using these systems. The visual score with each staging system and STDR value were evaluated for a correlation, and the rate of agreement was determined between the visual and objective scores obtained with each staging system. RESULTS The correlation between the visual scores and the STDR values was shown with all staging system including L-M system. The coefficients of correlation between the visual scores and the STDR values with these modified systems were higher than with the L-M system. While the agreement rates with these modified systems were significantly lower than with the L-M system, differences of 2 or greater between the subjective and objective scores were rare. CONCLUSION We cannot conclude that one of these three staging systems is superior to the other. With this study, the simple grading system such L-M staging score was considered easy and accurate method to use the clinical level. The modified staging systems showed more efficient ability to gradate in evaluating rhinosinusitis inflammation compared with the L-M system and also showed acceptable accuracy.

Role of intraoperative CT-updates during image-guided endoscopic sinus surgery for sinonasal fibro-osseous lesions

Fibrous dysplasia, ossifying fibroma and osteomas are collectively known as fibro-osseous lesions. Occurrence in the sinonasal region is rare, and its management can be technically challenging. We report a case of an 8-year-old female with cemento-ossifying fibroma of the ethmoid sinus who underwent a two-staged, endoscopically assisted, transfacial resection of the lesion and a 31-year-old male with fibrous dysplasia of the ethmoid sinus who underwent endoscopic removal of the tumor. Both cases utilized intraoperative computed tomography (CT)-updated image-guided systems (IGS) to improve surgical precision. In the second patient, further resection was undertaken after CT-update in the same surgery. The postoperative courses were uneventful, and at 1-year follow-up no tumor recurrence was observed in either patient. Our experience suggested that the use of intraoperative CT-updated IGS in endoscopic or endoscopically assisted surgeries for sinonasal fibro-osseous lesions will lead to more optimal tumor control, which can translate into greater patient safety.

Transseptal Access with Crossing Multiple Incisions for Improved Pedicle Control and Septum Preservation: “How I do it”

Introduction Recently, the surgical management of nasal tumors has been greatly influenced by advanced endoscopic techniques. To achieve complete endoscopic resection of large obstructing nasal tumors, a sufficient corridor for adequate exposure is also required. In the Japanese language, TACMI means “master expert,” and herein we describe an endoscopic technique with novel elements that we term transseptal access with crossing multiple incisions (TACMI). This approach enables a direct transseptal approach to the pedicle through tumor transposition while allowing complete septal reconstruction and stability. Methods We prospectively collected data from eight patients who underwent the TACMI approach for sinonasal tumors. Results When using TACMI, complete en bloc neoplasm resection was achieved in all but one patient, who underwent piecemeal tumor removal. The follow-up duration ranged from 10 to 28 months (mean, 19 months). None of the patients experienced septal perforation, nasal valve incompetence, or tumor recurrence. Conclusion We presented evidence that TACMI was a simple, efficient, and effective technique for tumor transposition, and for pedicle visualization and access of challenging unilateral sinonasal lesions. These advantages contributed to limited blood loss, improved pedicle control, and complete nasal valve and septum preservation without functional deficits.

Lacrimal sac exposure and a superior lateral anterior pedicle flap to improve outcomes of Draf type II and III procedures: SLAP flap for Draf III

Although the efficacy of Draf type II and III procedures for frontal sinus diseases is well recognized, a certain amount of postoperative stenosis of the frontal neo‐ostium occurs. Exposed bone induces inflammation and leads to osteoneogenesis. To prevent stenosis, we developed a surgical technique designed to minimize bone exposure while maximizing the frontal neo‐ostium area created with Draf type II and III procedures. We fully exposed the lacrimal sac and used a superior lateral anterior pedicle flap to cover the exposed bone during the Draf procedure. We aimed to describe our technique.

Male with watery rhinorrhoea and disturbed consciousness after trauma

A 74-year-old man presented to the emergency department with slightly impaired consciousness (Glasgow Coma Scale (GCS): E3V5M6) after a fight while drinking alcohol. The next day, he developed a strong headache and gradually deteriorating consciousness (GCS: E3V4M6) with watery rhinorrhoea (see online supplementary video 1). CT showed air between the tips of the frontal lobes, the so-called ‘Mount Fuji sign’, with fractured bone within the anterior skull base 2 days after the trauma (figure 1A,B). The patient was admitted to the operating room …

Endoscopic Transnasal Approach for Orbital Floor Fracture

Objective: In recent years, we developed a more minimally invasive technique of endoscopic transnasal approach to repair orbital floor fractures (OFF) with preserving and repositioning the fractured bones. This study reviews our technique of endoscopic transnasal approach to OFF patients. Method: OFF patients treated with endoscopic transnasal approach were reviewed in a retrospective fashion. Type of fracture, locations, period from injury to surgery, surgical outcomes including patient’s subjective symptom and objective examinations, and complications were collected from patient charts. Preoperative and postoperative (>6 months) CT scans were also evaluated. Results: A total of 5 patients were treated with endoscopic transnasal approach. The subjective symptoms were recovered in all patients. Hess screen test showed no limitation of eye movement after surgery. Postoperative CT scan also showed that the fractured bone of the orbital floor was identified in the almost original anatomic location 6 months after surgery. No complications or bone absorption were found after surgery. Conclusion: The novel technique of endoscopic transnasal approach to OFF patients resulted in excellent outcomes. It allows more minimally invasive surgery for the patients without any incisions and graft placement. We still have to watch for late complications and the presence/absence of the fractured bone absorption.

Nasal Packing of Calcium Alginate after Endoscopic Sinus Surgery

Objective: Sorbsan (calcium alginate) is an absorbent packing that shows a potent hemostatic effect and can maintain moist wound surfaces. The aim of this study was to evaluate the early symptoms and QOL with Sorbsan versus Beschitin-F (chitin-coated gauze) for middle meatus packing after endoscopic sinus surgery (ESS). Method: We performed a cohort study of 40 patients who underwent ESS. The patients were randomly allocated into 2 groups who underwent insertion of either Sorbsan or Beschitin-F into the middle meatus. A daily diary was used to record the symptoms and QOL, measured using visual analogue scales. Results: The scores for each of the symptoms of nasal pain, headache, nasal bleeding, and postnasal drip were statistically significantly lower in the Sorbsan group. The scores for each of the QOL parameters, including the effect on their stay in the hospital and sleep disturbance, were also significantly lower in the Sorbsan group. There were no findings of postoperative hemorrhage or local infection in either group. Conclusion: Sorbsan packing did not cause any major complications and has the potential to reduce nasal pain and suffering in post-ESS patients compared with gauze packing.