Takehiro Iki

Intra-Operative Pain during Endoscopic Sinus Surgery under Local Anesthesia

Endoscopic sinus surgery (ESS) is a well-documented procedure that has been used worldwide. Patients can undergo surgery under either local or general anesthesia. Under local anesthesia, one of the important issues for patients is the degree of intra-operative pain. We should perform the procedure without causing unbearable pain. This study evaluated the degree of intra-operative pain during ESS under local anesthesia and the ability of patients to cope with unbearable pain. Twenty-one patients were entered into this study (10 men, 11 women) operated by one surgeon between March 2006 and June 2007. During the first 9 months, 11 patients underwent the procedure without the maxillary nerve block. During the next 7 months, 10 patients were managed with the maxillary nerve block. The severity of pain was scored by the patient on a numerical rating scale (NRS). Pain severity was indicated by the number (minimum 0 and maximum 5).Eleven patients without the block reported pain during of the opening maxillary sinus (average of score 2.91). However 10 patients with the block reported that there was little pain (score average 0.95). The difference between the two groups was significant. We confirmed the degree of the intra-operative pain during ESS and that pain could be successfully managed by maxillary nerve block. NRS is a useful tool to evaluate intra-operative pain under local anesthesia, because we can hear a report of the pain score even without visually monitoring the tool (NRS).

A Case of Myopericytoma of the Neck

Myopericytoma is a newly-defined benign soft tissue tumor showing perivascular myoid differentiation. This tumor usually arises from the extremities of the elderly, however its occurrence in head and neck is rare. A 67-year-old woman presented with a gradually growing painless mass of the lateral neck. The tumor, which was well circumscribed, measured 38×35mm. On CT and MRI study, the tumor was well enhanced by contrast medium. Preoperatively, we diagnosed the lesion as a neurogenic tumor like paraganglioma, because of its rich blood supply. The tumor was easiky excised under general anesthesia. The surgical specimen was histopathologically and immunohistochemically diagnosed as myopericytoma. The postoperative clinical course was uneventful, and she was discharged 11 days after surgery. Currently, she is making satisfactory progress without recurrence. We reported a case of myopericytoma of the neck and review the literature.

Retrograde Approach for the Parotid Gland Tumor-from the Zygomatic Branch of the Facial Nerve-

Conventionally, partial parotidectomy has been performed for benign parotid gland tumor. In this procedure, dissection and preservation of the facial nerve plays an important role. The conventional approach starting from the main trunk of the facial nerve has generally been used.However, when we perform partial parotidectomy for tumor in the anterior part of the parotid gland using the conventional approach, it is necessary to dissect the facial nerve long from the gland. In that case, we have been using the retrograde approach starting from the zygomatic branch of the facial nerve. The zygomatic branch can located easily in front of the gland, below the zygomatic arch and the surface of the masseter muscle.In this method, there is no need to ligate vessels, to use a drain or to cut the great auricular nerve and retromandibular vein. Furthermore, exposure of the facical nerve and parenchyma of the gland is more limited, avoiding facial palsy, frey syndrome and salivary fistula.Based on advantages described above, a retrograde approach starting from the zygomatic branch should be used more often for surgery on parotid gland tumor.