Yasushi Komatsuzaki

Tonsillectomy Using an Ultrasonically Activated Scalpel

INTRODUCTION Tonsillectomy is one of the most popular surgeries in otorhinolaryngology. Although the progress of antibiotics enhances improvement of treatment for tonsillitis, there are still many indications for tonsillectomy. It is performed in adults and children and sometimes brings about lethal complications. Bleeding is an important, dangerous complication that limits operative indications. The establishment of a safe, bloodless operative procedure will increase the number of cases with operative indication. In 1992 an ultrasonically activated scalpel that achieves effective coagulation and safe cutting of tissue was introduced. 1 The ultrasonic activated scalpel is an instrument that potentially causes minimal tissue injury and provides good hemostasis. Ultrasonically activated vibrations (55,500 cycles per second) can cut the tissue. The ultrasonically activated scalpel is composed of a generator, handpiece, and blade (Fig. 1). The handpiece houses the acoustic system, which is composed of the transducer and the mount. There is no vibration in the handpiece when the system is activated. The three components of the acoustic system vibrate harmonically at 55,500 cycles per second. 2 In this report we introduce a method of tonsillectomy with the aid of an ultrasonically activated scalpel, especially stressing the effectiveness of this device.

Video-assisted submandibular sialadenectomy using an ultrasonic scalpel

OBJECTIVE To evaluate the benefits in video-assisted submandibular sialadenectomy by using an ultrasonically activated scalpel (HS: Harmonic Scalpel(R), Ethicon, Somerville, NJ) and a special handmade lifting device. METHODS The study cohort consisted of four male patients. We considered that the intraglandular part sialolithiasis of the submandibular glands was the main indicator for this technique. Under general anesthesia, a 15-20 mm skin incision was performed just above the inferior margin of the submandibular gland lying parallel to the mandible. We used a 4 mm diameter endoscope that we normally use for paranasal sinus surgery. Appropriate working space was created using a special handmade lifting device that was constructed from a wooden tongue depressor. By using HS, we dissected between the capsule and the circumferential tissue in order to minimize the possibility of damage to the facial nerve and lingual nerve. The submandibular gland was pulled out through the surgical wound, and Whartons duct was then suture-ligated and resected. RESULTS Endoscopic operation without recourse to conventional open surgery was achieved in all patients. No patients suffered any complications, such as functional disorder of the marginal mandibular, hypoglossal and lingual nerves, or wound hematoma formation. Excellent cosmesis was obtained in all patients. The amount of intraoperative bleeding ranged from 10 to 60 ml (mean: 38.0 ml). The operating time ranged from 175 to 250 min (mean: 232.5 min). CONCLUSIONS We applied two useful devices to achieve the endoscopic submandibular surgery: an HS and a special handmade lifting device. Excellent cosmesis was obtained in all patients without complications. The disadvantage of this method is that the surgery is more time-consuming than conventional open methods.

Blanket removal of the sublingual gland for treatment of plunging ranula.

INTRODUCTION The term ranula generally applies to a bluish, translucent cystic mass in the floor of the mouth, which is either a mucus retention cyst or more commonly a mucus extravasation pseudocyst arising from the sublingual gland (SLG). However, clinically, there are two types of ranula: a simple (oral) ranula and a plunging (cervical) ranula. The plunging ranula is uncommon and presents as a swelling in the neck. It may appear as a soft cystic mass in the lateral neck without visible intraoral involvement, in which case the diagnosis is more difficult. These lesions should be differentially diagnosed from other types of cystic masses, such as dermoid cysts, thyroglossal duct cysts, teratoid cysts, and cystic hygromas. The effectiveness of magnetic resonance imaging for differential diagnosis of the ranula has been reported. The ranulas were all well-defined, homogeneous masses appearing as lowand high-intensity signals on T1and T2-weighted images, respectively. Analysis of the cyst fluid may assist in the diagnosis of a ranula since yellow, mucinous, transparent fluid with high levels of protein and salivary amylase are specific to it. Resection of the entire cystic wall, preferably with the excision of the total SLG, is recommended for the surgical management of a simple ranula. In contrast, the definitive surgical management of the plunging ranula has not yet been determined. There is a general agreement to excise the ipsilateral SLG, but using a cervical approach remains controversial. The cervical approach requires a cervical skin incision and is accompanied by the risk of impairment of the marginal mandibular branch of the facial nerve. We propose an intraoral method for surgical management of a plunging ranula utilizing an endoscope to confirm complete resection of the SLG. We have treated six cases of plunging ranulas without recurrence at St. Marianna University Toyoko Hospital. All patients underwent an oral approach using our technique, rather than a cervical approach. In this article, we present the results of our method and stress the importance of endoscopic observation after excision of the SLG.

Postoperative pain in tonsillectomy: comparison of ultrasonic tonsillectomy versus blunt dissection tonsillectomy.

Intraoperative blood loss, postoperative pain, and postoperative appetite were compared between 15 adult patients who underwent tonsillectomy using an ultrasonically activated scalpel (UT) and 15 adult patients who underwent blunt dissection tonsillectomy with cold steel instruments (BT). The average intraoperative blood loss of the UT group was 4.6 ± 1.9 ml (mean ± standard deviation), while that of BT group was 41.9 ± 12.9 ml. This difference was highly statistically significant (p < 0.0001). In contrast, there were no significant differences in the VAS pain and appetite scores between patients who underwent UT and those who underwent BT on any day in the 6-day postoperative period. Our current results show that UT is a safe technique, and we believe that it should be considered a useful alternative for tonsil surgery.

Patency of inferior meatal antrostomy

OBJECTIVE To evaluate the patency and effectiveness of inferior meatal antrostomy for the treatment of maxillary lesions. METHODS Patients suffering from moderate-to-severe chronic sinusitis who underwent inferior meatal antrostomies at St. Marianna University Toyoko Hospital and followed up for at least 1 year after surgery were selected. Thirty sides of 27 patients were analyzed. Postoperative mucociliary function was examined in seven sides of seven patients. RESULTS No closure was observed in all 30 procedures. Out of 30 antra, 26 (86.7%) had normal antral mucosa. Recurrent mucosal lesions inside the maxillary sinus were successfully treated through the inferior meatal window. No cases showed circular flow on the india ink test. All sinuses exhibited a discharge from the middle meatal window and three out of seven sinuses exhibited a discharge from the inferior meatal window. CONCLUSIONS Although long-term follow-up is required to determine the patency of inferior meatal antrostomy, initial results are encouraging. The inferior meatal window provides both intra- and postoperative benefits.

Vestibular-evoked myogenic potentials in two patients with Ramsay Hunt syndrome

We report on the function of the inferior vestibular nerve, as monitored by the vestibular-evoked myogenic potentials (VEMP), in two patients suffering from Ramsay Hunt syndrome. Both the patients presented canal paresis (CP) and hearing loss, but in one patient normal VEMP was recorded while the other presented vagus nerve paralysis plus no VEMP response at the highest stimulus intensity used in our institute (i.e., 105 dB nHL).

Powered endoscopic marsupialization for recurrent sphenoid sinus mucocele: a case report.

We report a case of recurrent sphenoid mucocele successfully treated by using a powered instrument under endoscopic control. A 59-year-old male came to our clinic complaining of severe headache, right-side facial numbness (in the areas of the first and second branches of the trigeminal nerve), diplopia, and right blepharoptosis. Computed tomography (CT) imaging revealed opacification and expansion of the sphenoid sinus lesion. The lesion was diagnosed as right-side sphenoid mucocele affecting the functions of the trigeminal (first and second branches), oculomotor, and abducent nerves. Endoscopic drainage of the right-side sphenoid mucocele leads to gradual improvement of these symptoms. Approximately 1 year after the drainage procedure, the size of the enlarged sphenoid sinus ostium had decreased. The patient underwent endoscopic right-side total marsupialization of the sphenoid sinus using a powered instrument. Subsequently, the patient has presented no evidence of recurrent disease after 1 year of follow-up.

Approach to Maxillary Lesions.

First, we evaluated the patency of inferior meatal antrostomy for the treatment of maxillary lesions. Patients were followed for at least one year, with a mean follow-up duration of 23.3 months. There was no closure observed in 22 procedures. Secondly, we reported three cases of maxillary lesions. Recurrent mucosal lesions of antrochoanal polyps were successfully treated using a micro-debrider through the trocar at the canine fossa, while monitoring via the middle meatal window. A dental foreign body in the maxillary sinus was removed through the inferior meatal window, while monitoring via the trocar at the canine fossa. Blow-out fracture was successfully treated using canine fossa and inferior meatal approaches. An inferior meatal approach is useful postoperatively as well as intraoperatively. It is also useful when recurrent maxillary lesion is expected. A canine fossa approach is useful for improving intraoperative procedure without necessitating the use of special instruments. A canine fossa approach using the trocar is useful because it is minimally invasive for the patient. It can be safely concluded from the present results that the surgeon should choose the appropriate approach (or combine two or three approaches) for each maxillary lesion after considering several factors, including the general condition and bone structure of the patient, patient age, the location of the lesion and the treatment required, anesthesia, instrumentation availability at the institute, the skill of the surgeon, and the expected postoperative status.