Paolo Lozza

Sphenopalatine Endoscopic Ganglion Block: A Revision of a Traditional Technique for Cluster Headache

The diagnosis of chronic cluster headache (CH), the most painful form of headache, is based on typical clinical features characterized by strictly unilateral pain with no side shift and ipsilateral oculofacial autonomic phenomena. The attacks occur several times a day for periods of 1 to 2 months in the episodic form of the disease or less frequently on a daily basis in the chronic form. The pathogenesis of CH involves the activation of parasympathetic nerve structures located within the sphenopalatine ganglion (SPG), which explains many of the associated symptoms, whereas the activation of the ipsilateral hypothalamic gray matter may explain its typical circadian and circannual periodicity. A number of surgical approaches have been tried in cases of chronic CH resistant to pharmacologic therapy, of which SPG blockade has been shown to have certain efficacy. We have adopted a new technique based on endoscopic ganglion blockade that approaches the pterigo‐palatine fossa by way of the lateral nasal wall and consists of the injection of a mixture of local anesthetics and corticosteroids, which was performed in 20 selected patients with chronic CH, according to the International Headache Society criteria (18 male, 2 female; mean age 40 yr), who were selected for SPG blockade because they were totally drug resistant. The symptoms improved significantly, but always only temporarily, in 11 cases. These results should be considered rather good because, unlike other frequently used techniques, SPG blockade is not invasive and should therefore always be attempted before submitting patients to more invasive surgical approaches.

Sinonasal complications resulting from dental treatment: outcome-oriented proposal of classification and surgical protocol.

Background Odontogenic sinusitis is a relevant infectious condition of the paranasal sinuses. The widespread use of dental implants and reconstructive procedures for dental implant placement has led to new types of complication. To the authors’ knowledge, no publication has extensively examined sinonasal complications resulting from dental treatment, and no classification system allowing standardization and comparison of results is currently available. This study was designed to (a) analyze the results obtained from surgical treatment of complications resulting from dental procedures combining functional endoscopic sinus surgery (FESS) and an intraoral approach and (b) propose a new classification system and standardized treatment protocols for sinonasal complications resulting from dental procedures. Methods A total of 257 patients consecutively treated with FESS (136 in conjunction with oral surgery) were included in the study. Different clinical situations were integrated into a new classification system based on the pathogenesis and clinical aspects of each case, with the aim of identifying homogenous treatment groups. Results were evaluated for each class. Results Of the 257 patients, 254 were successfully treated with surgery performed according to the proposed protocols. Three of 257 patients required a second surgery, after which they completely recovered. Complications of implant and preimplant surgery (maxillary sinus floor elevation) showed longer recovery times. Conclusion The results obtained are very encouraging. The majority of patients (254/257; 98.8%) were successfully treated with the proposed protocols. These results seem to indicate that the rationalization of surgical treatment protocols according to the initial clinical situation may significantly improve the clinical outcome.

Sphenopalatine endoscopic ganglion block in cluster headache: a reevaluation of the procedure after 5 years

Cluster headache (CH) is considered the most painful form of primary headaches. It is characterized by severe unilateral pain, typically associated with autonomic manifestations and may be divided into an episodic and a chronic form. The latter is often resistant to a multitude of medication and is, therefore, very hard to treat. In 2002, our group developed a technique for the endoscopic sphenopalatine ganglion block that was able to ameliorate the symptoms in 55% of drug-resistant chronic CH patients. This paper is intended as an update on the technique as well as a comparison in effectiveness to our prior approach.

Redefining boundaries in odontogenic sinusitis: a retrospective evaluation of extramaxillary involvement in 315 patients

Odontogenic sinusitis and “sinonasal complications of dental disease or dental treatment” (SCDDT) have been assumed to be limited to the maxillary sinus. Nevertheless, many patients also show more extensive sinonasal involvement and, occasionally, also have associated bilateral disease. We evaluated the incidence of extramaxillary extension over an 11‐year period in our clinic.

The role of the ear, nose and throat specialist in diagnosing headaches

The revised International Headache Society classification (2004) represents a very good reference also for ear, nose and throat (ENT) specialists and can be largely shared. The authors follow the classification outline and comment on the chapters of ENT interest. The classification leaves unsolved problems and most of them are of ENT competence, such as mucosal contact point headache. It will be a task for ENT specialists to clarify the real role of very hypothetical primary forms frequently assigned to diagnosis without a correct rationale.

Orbital medial wall fractures: purely endoscopic endonasal repair with polyethylene implants.

The lamina papyracea of the ethmoid bone owes its name to its paper-thin papyrus-like thickness, which makes fractures extremely common. According to some case series, medial wall fracture is the most frequent among orbital fractures. Small, isolated blow-out medial wall fractures generally may not require treatment, but early or late enophthalmos might become an aesthetic concern for patients. This complication is very likely to occur with fractures exceeding 1 cm or 50% of the wall. Furthermore, patients may also suffer from late functional problems, due to fracture site scarring which impairs eye movement. Transfacial approaches still retain their value today, while several anecdotal transnasal microscopic and endoscopic approaches have been proposed since the early 90. These approaches not only differ in terms of approach, but also for the materials employed for the reconstruction. Recently, some small case series shed a new light on the soundness of endoscopic approaches. Most authors rely on the use of Silastic sheets and nasal packing to maintain the orbital content in place, with obvious drawbacks. Use of resorbable panels or autologous materials (bony fragments or septal cartilage) has been proposed in case reports only. Non-resorbable materials, such as titanium meshes, have been traditionally limited to transfacial approaches, implementing also computer-aided design for better aesthetic results. Given the superior stability given by non-resorbable implants and the chances provided by modern biocompatible materials, we introduced a new purely endoscopic technique employing a porous polyethylene implant (Medpor, Stryker, Kalamazoo, MI, USA). Our technique couples the stronger support granted by non-resorbable materials and the minimal invasiveness of the endoscopic approach without the need for long-term nasal packing.

Unusual case of bilateral maxillary fungus ball

An otherwise healthy 34-year-old man was referred to our ear, nose and throat (ENT) clinic for a bilateral maxillary radiologic opacity. This condition was accidentally discovered with a panoramic radiography performed during a follow-up visit after a bilateral endodontic treatment. The patient did not report any specific sinonasal symptom such as purulent nasal discharge, loss of smell and cough, apart from an unspecific sinus pressure. The CT scans showed a bilateral inflammatory process into the maxillary-ethmoidal sinuses and an iron-like density within the maxillary sinuses, while nasal endoscopy showed purulent discharge in the ostiomeatal complex. The patient underwent functional endoscopic sinus surgery under general anaesthesia and the inflammatory material collected was histologically diagnosed as a rare case of bilateral fungus ball. The patient was dismissed the following day with no complications; there were not any sign of recurrence or symptoms during a 4 month follow-up.

Endoscopic endonasal repair with polyethylene implants in medial orbital wall fractures: A prospective study on 25 cases

The aim of the study was to assess the mid-term effectiveness and safety of an original technique consisting of reconstructing fractures of the medial wall of the orbit with porous polyethylene implants with an exclusive transnasal approach. Twenty-five patients were treated. Each patient underwent a pre-operative ophthalmologic evaluation and a CT scan. The surgery started with an anteroposterior ethmoidectomy of the fractured side; all the fractured bone fragments were removed and all usual landmarks of healthy bony margins were identified. A Medpor sheet was placed endoscopically to reconstruct the fractured wall. Each patient received an immediate postoperative CT scan, and was evaluated at day 1, 7, 30 and 6 months after surgery clinically and with an endoscopic examination. In all patients, preoperative enophthalmos and/or diplopia were corrected. The CT scans showed excellent reconstruction of the fractured bony walls. The immediate postoperative period was characterized by a very high degree of subjective comfort. No perioperative complications were detected. At the 6 months follow up, all meshes appeared covered by epithelialized mucosa at the endoscopic inspection, and clinical results were stable. Scars or lid complications are always prevented. The technique described has become the standard to treat medial wall fractures in our department.

One-Step Maxillary Sinus Augmentation in Association With Endoscopic Sinus Surgery: Case Series and Review of the Literature.

Introduction:Sinonasal anatomical anomalies and inflammatory conditions may reduce success rates of maxillary sinus elevation (MSE) procedures used to allow implant placement in the atrophic posterior maxilla. Approaches combining endoscopic sinus surgery (ESS) and MSE were firstly proposed by our group and have already been described in the literature. This article aims to re-evaluate the procedure in a larger sample of patients comparing results and indications with the pertaining literature. Materials and Methods:Thirty-three patients (19 men and 14 women, mean age 52.79 ± 11.95 years) underwent combined ESS/MSE with 48 MSE procedures performed. Results:No intraoperative complications were reported. An uneventful and complete graft integration was obtained after 6 months in all but one patient. All patients completed prosthetic rehabilitation within 9 to 12 months. Conclusion:Combined ESS and MSE has proven to be a safe and reliable procedure, which can be proposed to selected patients presenting with reversible sinonasal contraindications to MSE and should be no more considered an experimental procedure.