Endoscopically controlled sinus floor augmentation. A preliminary report

Sinus augmentation has been advocated to be a surgical technique with predictable results in peri-implant surgery. Endoscopic surgery of the maxillary sinus so far has been used as diagnostic procedure. In this paper, the use of endoscopy is described as a low invasive adjunctive technique in sinus floor augmentation. After preparation of the mucoperiosteum, bone grafts can be placed under endoscopic control between sinus floor and mucoperiosteum. A laterobasal approach via a small osteotomy and a transalveolar approach are possible for mucosal elevation and graft placement. First clinical results are reported. Endoscopic sinus lift may contribute to a reduction of perioperative morbidity, reduction of oroantral fistulae and control of graft position. The less invasive technique may allow to extend the indication for sinus augmentation.     

The radiology of transsphenoidal hypophysectomy: a review of 100 cases

This report describing the radiology of transsphenoidal hypophysectomy based on a review of 100 consecutive surgical procedures. Preoperative laminographic evaluation of the sphenoid sinus is an important aid in planning the most direct surgical approach to the pituitary. It is also useful in defining the many anatomic structures that may be injured inadvertently at the time of surgery. Intraoperative radiography or fluoroscopy is helpful in identifying the sella floor and as an aid in preventing loss of orientation within a capacious sinus. Various changes occur within the sphenoid sinus following surgery, some transient and others persistent. The surgical defect is usually difficult to identify on routine roentgenograms but is clearly visible on lateral laminography. A persistent soft tissue mass within the sinus is usually a manifestation of fascia and fat placed as a seal within the sinus.     

Regenerative periodontal therapy in mucogingival surgery for root coverage

This article illustrates the potential benefits of regenerative periodontal therapy in mucogingival surgery and esthetic dental treatment. Cases are described in which the treatment of soft-tissue recessions and root exposures are treated with surgical procedures where both clinical soft-tissue augmentation and the regeneration of periodontal attachment are obtained. Cases are also presented to illustrate the clinical application of guided tissue regeneration. Resorbable and nonresorbable barriers are placed over the root surface and bone and covered by the overlying flap, which allows the selective repopulation of the lesion by progenitor cells and the inhibition of a long junctional epithelium. Emphasis is placed on regenerative procedures in soft-tissue augmentation, particularly with respect to rationales, techniques, and indications.     

The use of osteotomes for sinus augmentation at the time of implant placement

The placement of endosseous dental implants is often hampered by the loss of alveolar bone. In the posterior maxilla, the presence of the maxillary sinus and less-dense bone present additional obstacles to successful implant placement. Existing methods of subantral augmentation require extensive surgical manipulation, often including a second surgical site for harvesting autogenous bone. The development of surgical osteotomes has facilitated the placement of implants in areas of minimal alveolar bone height in the posterior maxilla. This article describes the osteotome technique for sinus augmentation at the time of implant placement and presents a short-term evaluation of 34 implants placed in 18 patients.     

Ovarian surgery in premenarchal girls

OBJECTIVES: Evaluate causes of surgical failure at time of revision endoscopic sinus surgery. STUDY DESIGN: Prospective review of 682 cases that had endoscopic sinus surgery performed between 1991 and 1995. METHODS: In all cases, variables of age, sex, asthma, allergy, computed tomography stage, associated procedures, complications, and operative findings were collected. Those cases that had a failure after a previous endoscopic sinus procedure and not an intranasal procedure or an external procedure were evaluated. RESULTS: Fifty-two patients (7.6%) were identified. The age range was 24 to 70 years. The most common cause of failure was residual air cells and adhesions in the ethmoid area (30.7%), followed by maxillary sinus ostium stenosis in 27%, frontal sinus ostium stenosis in 25%, and a separate maxillary sinus ostium stenosis in 15% of the cases. CONCLUSION: Review of surgical causes of failure in endoscopic sinus surgery patients revealed that residual air cells and stenotic maxillary or frontal sinus ostium were the most common causes of failures.     

The use of small intestine in bladder reconstruction

OBJECTIVE: This study was conducted to determine the efficacy of FESS (functional endoscopic sinus surgery) on sinus and asthma symptoms. METHOD: Seventy-nine patients with asthma and medically unresponsive sinusitis were evaluated. Maximal medical therapy was attempted to relieve both sinus and asthma symptoms. The surgical procedures involved standard FESS techniques. Fifty-six percent of patients had undergone a sinus procedure prior to the FESS. Nasal polyposis was noted in 73% of the group. The majority of patients had pansinusitis. RESULTS: Eighty-six percent of patients stated that FESS improved their sinusitis. Nine of 11 sinus symptoms recorded preoperatively diminished significantly (p < .05) following surgery. Eighty percent of patients noted improvement of their asthma following FESS. The factors associated with treatment failure and the unique characteristics of this disease process were evaluated. CONCLUSIONS: FESS is a viable option in the treatment of asthma when medical therapy fails.     

1H and 15N resonance assignment of neural cell adhesion molecule module-2

This article presents a simple, inexpensive method for precisely locating the floor of the maxillary sinus, as well as the presence of any septa, at the time of sinus augmentation surgery. Using an anesthesia light wand placed transnasally to illuminate the sinus, the surgeon can reliably elevate the lateral maxillary wall overlying the sinus with relative ease without fear of placing the osteotomy cuts too far from the sinus floor. The same procedure can be used postoperatively to evaluate the density of the bone graft placed into the sinus prior to closure.     

Complications of endonasal paranasal sinus surgery--diagnostic and therapeutic consequences

BACKGROUND: Functional endoscopic sinus surgery has been proven the therapeutic method of choice in surgical therapy of chronic sinusitis. On the other hand, endonasal sinus surgery may cause severe complications even when performed by a skilled surgeon. This is easily explained by the close vicinity of many functionally important structures to the operative site. CASE REPORTS: Three histories are reported that involve possible complications even in apparently simple cases. Diagnostic and therapeutic consequences are discussed. In a case previously diagnosed histologically as chronic unspecific sinusitis, an endonasal biopsy resulted in endocranial bleeding requiring neurosurgical intervention. Midline granuloma was found to be the correct diagnosis. Another patient was seen with a normal X-ray of the sinuses and solitary polypoid structure in his left nose. Polypectomy was planned and a CT scan was performed, which demonstrated a meningocele. Transfacial surgery was then performed to remove the meningocele. Another patient presented with a traumatic impression of the frontal sinus, and open reposition by transfacial surgery of the frontal and ethmoid sinus was planned. When CT scans revealed an uncovered optic nerve in the sphenoid sinus of the fractured side, we abandoned ethmodectomy and performed reposition of the frontal sinus as the only surgical procedure. RESULTS AND CONCLUSIONS: In this paper, we show typical complications of endonasal sinus surgery and strategies for avoiding them. If any complication occur, prompt treatment is required. Three groups of complications can be defined: perforation of frontobasal dura resulting in cerebrospinal fluid (CSF) fistula, severe bleeding, and orbital or optic nerve injury. When the surgeon discovers an intraoperative complication, possible consequences must be considered immediately to minimize side effects for the patient. A CSF fistula should be closed in the same procedure, and transfacial surgery may be necessary. Hemorrhage resulting from an ethmoidal artery may require frontoorbital surgery and ligation of this vessel. If retrobulbar hemorrhage caused by retraction of an ethmoid artery occurs, immediate intervention is necessary. Usually a transfacial approach, resection of the medial orbital wall and retrobulbar decompression are performed. In some cases lateral canthotomy may be the best way to drain haematoma and decompress the optic nerve. Subsequently, orbital revision and ligation of the retracted artery must be performed. Any delay can result in persistent visual loss. We conclude that the extranasal frontoorbital approach should be part of the residency training program in ENT departments. Any surgeon performing endonasal sinus surgery must be trained in transfacial emergency procedures, which should be part of anatomic preparations in teaching courses, thus avoiding severe damage in case of intraoperative complication.     

Environmental Protection Agency risk assessment--process and toxicologic pathology

Although rare, orbital osteomyelitis secondary to sinusitis can be devastating. Early, aggressive ophthalmologic surgical intervention, as well as otorhinolaryngologic co-management, is necessary to obtain the best outcomes. We present two cases of orbital osteomyelitis. One patient remained infected with Pseudomonas meningitis even after extensive sinus and orbital surgery, rapidly declined, and is now deceased. The other patient, after multiple sinus procedures and a medial orbitotomy, was placed on hyperbaric oxygen and is still undergoing treatment.     

Advances in equine arthroscopy

Surgical procedures completed under arthroscopic guidance have become commonplace in many equine practices and have largely replaced surgery using arthrotomy incisions. With a limited amount of equipment, numerous diagnostic and surgical procedures can be completed. Surgeons need to become familiar with regional and intraarticular (intrasynovial) anatomy to ensure that proper surgical approaches are used, access to the lesion will be realized, and potential complications will be minimized. Specialized motorized instruments and surgical lasers are now available and may be useful in the treatment of selected clinical cases.     

Telesurgical consultation

PURPOSE: We evaluated the feasibility of "telesurgical" consultation during laparoscopic surgery. Telesurgical consultation is a distinct application of telemedicine in which a surgeon at a primary operating site can consult another experienced surgeon or colleague for complex and/or unexpected problems encountered during surgery. MATERIALS AND METHODS: Telesurgical consultation was used in 6 complex laparoscopic cases, including upper pole nephrectomy, diagnostic laparoscopy with inguinal hernia repair, orchiectomy, gastric augmentation with bladder suspension, bladder reconstruction and ureteral lithotomy. RESULTS: In each case an experienced laparoscopic surgeon at the primary operative site consulted a surgical specialist at the remote site who had expertise in the particular procedure being performed. All procedures were accomplished successfully without intraoperative or post-operative complications. CONCLUSIONS: Complex laparoscopic procedures that normally require a surgical specialist can be performed successfully by an experienced laparoscopic surgeon consulting a remote specialist via the tele-operative system.     

Comparison of complications between in-hospital patients and out patients for aesthetic surgical procedures: a ten-year study

On the basis of the clinical evidence and the statistical analysis of the 10-year survey, this study would confirm our hypothesis that in the surgical procedures performed-rhytidectomy and augmentation mammaplasty-there is no significant difference in the rate of serious complications between the inpatient group and the outpatient group. It would seem appropriate that further studies should be undertaken to evaluate other procedures and other ;complications. If we are to embark further on the course of out patient aesthetic surgery, we must strive for greater statistical knowledge in the area of complications and risk factors to evaluate our results better, keeping in mind our ultimate goal of continually improving our art.     

Frontal sinus surgery in children

Surgery for frontal sinusitis in children is unusual. When required, surgery for ostiomeatal disease or, in certain circumstances, frontal sinus trephination is usually all that is required. Nevertheless, for a few children, surgery of the nasofrontal recess and frontal sinus is required and can be very beneficial. A variety of surgical approaches to the frontal sinus are discussed. Functional endoscopic surgery based upon physiologic principles and the concept of reversible disease is emphasized.     

Phonosurgical treatment of vocal cord cysts

INTRODUCTION: Functional-traumatic lesions of the vocal folds include mucous stranding, "nodular" lesions, polyps, cysts, contact hyperplasia and haematoma [1]. They all appear at the predilection sites of the vocal fold, at the junction between the anterior and middle thirds, slightly below the free edge. Vocal fold cysts are also located at the predilection site. They interfere with the glottic closure and vibration process. The treatment consists of surgical enucleation. This paper is aimed to present our results with direct and indirect surgical procedures. MATERIAL AND METHOD: A series of 63 vocal fold cysts was operated by the use of direct microlaryngoscopy (DML), indirect microlaryngoscopy (IMS) and videostroboscopy (IVCS). RESULTS: Over a 10-year period 1550 surgical procedures were performed for benign lesions of the vocal folds, including 63 cases of vocal fold cysts (4.1%). A very satisfactory phonusurgical result was obtained. Recovery of the vibration pattern was after DML procedures within 3 weeks in 66.6% of patients, while it was apparently faster after indirect operations. The latter were performed only for minor cystic lesions, and therefore direct and indirect procedures cannot be compared to vibration recovery. DISCUSSION: A careful surgical manipulation is required for the enucleation of vocal fold cysts, sparing the local tissue. DML is used in the majority of cases, while indirect procedures can be used only in minor lesions, where enucleation is not possible.     

Benign solid and papillary epithelial tumors of the pancreas

The exact incidence of orbital complications due to sinusitis in children is unknown. However, a medial subperiosteal orbital abscess is the most common serious complication to occur. Surgical intervention is mandatory whenever antibiotic treatment fails. Most authors prefer open surgical procedures such as external ethmoidectomy, while others recommend transnasal endoscopic drainage as the first attempt at sinus decompression. Five out of 12 children with proven subperiosteal orbital abscess and sinusitis on computed tomographic scans failed antibiotic treatment and required surgical drainage. Transnasal endoscopic drainage of the abscess was performed on four patients, while one child underwent external ethmoidectomy. Our experience with endoscopic surgery in these four cases is discussed, along with a brief review of the advantage of this procedure over external surgery.     

Indirect microsurgery of the vocal folds--videostroboscopy vs. microstroboscopy

In spite of the great significance of direct microlaryngeal surgery (DML), the inadequacies of this technique are evident. In order to avoid surgical trauma and introduce functional control during surgery, indirect microstroboscopic (IMS) and indirect videostroboscopic surgery (IVS) of the vocal folds are advocated. Both of these meet most criteria for surgical work in this field. The aim of this work was to make a comparative study of these techniques. The study is based on 603 operations conducted for benign lesions of the vocal folds. We are of the opinion that indirect vocal fold surgery for small benign lesions has significant advantages when compared with the conventional microlaryngoscopy, including laser surgery, which was proven elsewhere. When comparing these two indirect surgical approaches, the principal advantages of IVS surgery over the IMS method are easier surgical manipulation and better view. With respect to other areas of comparison, these techniques are quite similar. As complementary methods to conventional microlaryngoscopy, we believe that both IVS and IMS surgery should be used in practice.     

Image-guided endoscopic surgery: results of accuracy and performance in a multicenter clinical study using an electromagnetic tracking system

Image-guided surgery has recently been described in the literature as a useful technology for improved functional endoscopic sinus surgery localization. Image-guided surgery yields accurate knowledge of the surgical field boundaries, allowing safer and more thorough sinus surgery. We have previously reviewed our initial experience with The InstaTrak System. This article presents a multicenter clinical study (n=55) that assesses the system's capability for localizing structures in critical surgical sites. The purpose of this paper is to present quantitative data on accuracy and performance. We describe several new advances including an automated registration technique that eliminates the redundant computed tomography scan, compensation for head movement, and the ability to use interchangeable instruments.     

The sinus lift graft: basic technique and variations

Following an early controversy concerning its efficacy, the sinus lift and graft technique is now considered to be a state-of-the-art surgery. In 1975, Tatum introduced the technique that increased maxillary bone height by placing graft material under the maxillary sinus and Schneiderian membrane; by the early 1990s, a modification of Tatum's original technique had become a standard procedure. This article describes and illustrates three variations of the basic sinus lift surgery and graft operation--the hinge osteotomy, the elevated osteotomy, and the complete osteotomy. Additional considerations affecting the surgical outcome are also discussed as is the management of possible complications. The learning objective of this article is to obtain up-to-date information regarding the basic technique and variations of the sinus lift procedure to the general practitioner as well as the specialist.     

Orbital rhinocerebral mucormycosis associated with diabetic ketoacidosis: report of survival of a 10-year-old boy

Cerebral mucormycosis is a rare fungal infection that occurs mostly in association with diabetic ketoacidosis. This central nervous system infection is characterized by a rapid decline in clinical status, and has been recognized as a uniformly fatal event if aggressive therapy is not instituted. We report a diabetic child who presented with blurred vision, chemosis, and pain in the left periorbital region noted for about 1 week during an episode of ketocidosis. Neurologic examinations revealed that there was a decreased range of motion in the upward and lateral gaze, along with incomplete pupillary dilatation and papilledema of the left eye. Imaging studies demonstrated left-side orbital cellulitis, paranasal sinusitis, and a large lobulated abscess in the left frontal lobe. Two surgical procedures, including functional endoscopic sinus surgery for sinus debridement and a subsequent open craniotomy for abscess resection were performed. Pathologic specimens obtained from the abscess wall revealed necrotic inflammation and wide, nonseptate hyphae with right angle branching, which are typical characteristics of the family Mucoraceae. Postoperatively, the patient was treated with 1.5 g of amphotericin B over a 7-week period, and aggressive diabetic control for 2 months. Through the combination of medical and surgical treatment the child made an uneventful recovery.     

Hereditary angio-oedema: new clinical observations and autoimmune screening, complement and kallikrein-kinin analyses

Sinus cavities are often a major obstacle to the placement of dental implants in the posterior maxilla, especially when early tooth loss has occurred. Several grafting procedures aimed at reducing the expanded volume of these pneumatic cavities have been routinely utilized since 1979. Essentially, these techniques have consisted of recreating the necessary viable bone volume at the floor of sinus cavities by placing different bone substitute materials to allow for the insertion of endosseous implant devices. The progress achieved in the refinement of the surgical procedures and the knowledge acquired in the field of patient screening and selection, choice of biomaterials, management of complications, etc., have made sinus graft surgery highly codified and predictable. A comprehensive statistical study by multifactorial procedures was carried out to establish a Burt Contingency Chart. This chart visualizes the frequencies of all the "modality combinations" among the selected "qualitative parameters" and, by a " factorial analysis", the "multiple correlations", so that the "statistical affinities" that may exist among the same variables can be determined. This critical study endeavors to search for and reveal the favorable clinical, biologic and scientific parameters necessary for the success of sinus graft surgery on short-, medium-, and long-term bases (more than nine years). It is a particularly homogenous study, since all the operative procedures have been carried out exclusively by the author under standardized conditions. The wide variety of biomaterials utilized by the author since 1979 shows the development of bone substitute biomaterials as they have been introduced into the market during the past 15 years. The large number of patients treated, the variety of grafting materials, the important success rate obtained, and the long duration of patient follow-up have been instrumental in enabling us to establish scientifically significant results. Autogenous bone and its combinations with calcium- and phosphorus-containing biomaterials remain undoubtedly the best all-purpose biomaterials. The synthetic biomaterials have their own specific indications according to their stable (non-resorbable) or unstable (resorbable) nature and their rates of metabolic "turnover". Differently treated bones from the tissue bank (if not contaminated or immunologically questionable) behave in a fashion not unlike autogenous bone. Root-form implants are by far the best implants in the reconstructed sinus sites, while other implant types (subperiosteal implants, etc.) inserted beneath the reinforced osseous sinus floor, buccal wall, and pyramidal process, also have their indications.