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Endoscopic transnasal hypophysectomy through the sphenoid ostium
Scientific Session—Tuesday
subarachnoid fluid in the herniated sac. Iatrogenic pseudomeningoceles following spinal surgery have been described, but reports following neuro-otologic procedures have been scant. The present study evaluates the incidence of pseudomeningocele following neuro-otologic procedures and delineates an algorithm for the management of this postoperative complication. Methods: A retrospective review of 375 consecutive patients undergoing neuro-otologic procedures at a single institution identified 11 patients with the postoperative complication of pseudomeningocele. The patients’ signs and symptoms, method of management, and ultimate outcome were obtained from patient records and office visits. Results: The incidence of pseudomeningocele formation was 2.9% in the present study. The median time to development of pseudomeningocele was 12 days postoperatively. 8 pseudomeningoceles resolved with nonoperative management including pressure dressing, bed rest, and lumbar spinal drainage. 4 patients failed nonoperative management and required surgical procedures for resolution. All patients ultimately had resolution of their pseudomeningocele, and there were no recurrences during the follow-up period. Conclusions: Skull-base pseudomeningocele does occur as a complication following neuro-otologic procedures. It is associated with chronic irritation of the subarachnoid space and chronic headaches. The majority of these cases can be dealt with in a nonoperative manner, but those failing to respond mandate surgical intervention.
Room OCCC 109A •
Scientific Sessions: Rhinology Serge A Martinez MD; William R LaMear MD (moderators)
9:30
AM
Endoscopic Transnasal Hypophysectomy through the Sphenoid Ostium Vere Carlin MD (presenter); Elgan Davies FRCS; Konstantina T Tzifa Stone United Kingdom; Church Minshull United Kingdom; Birmingham United Kingdom
Objectives: Following the introduction of nasal endoscopes in 1985, otorhinolaryngologists attempted to access the pituitary gland under endoscopic guidance using mainly the sublabial transseptal approach, the transseptal transphenoidal, the transsethmoidal, and sporadically, the route via the sphenoid ostium. The purpose of this paper is to present our experience, over the last 5 years, at North Staffordshire Hospital, one of the largest general hospitals in the United Kingdom, using the technique of endoscopic transnasal hypophysectomy through the sphenoid ostium and to discuss the advantages. Methods: The technique was performed using the rigid
Hopkins rod telescope and telemonitoring. The cases were reviewed retrospectively for surgical outcome and endocrine control. Results: We have used this technique on 46 patients, of which 3 were revisions. This approach provides the advantages of midline exposure and access to both the sphenoid cavities, combined with the detailed and panoramic sphenoidal and intrasellar endoscopic view. The technique is faster to perform, the postoperative care is easy, and the length of recovery and stay in the ward is significantly shorter. The outcome was successful in 77% of cases on decompression and biochemical control. Morbidity was minimal. Conclusions: We believe that otorhinolaryngologists can practice this technique safely, providing they are well trained in endoscopic nasal surgery and are familiar with the anatomy of the sphenoid sinus and sella. The wide exposure and precise anatomical view provide significant advantages for safe primary and revision excision of pituitary tumors. 9:38
AM
The Effect of Maxillary Sinus Antrostomy Size on Xenon Ventilation in the Sheep Model Kevin T Brumund MD (presenter); Geoffrey McLennan MD; Scott M Graham MD Iowa City IA; Iowa City IA; Iowa City IA
Objectives: A major goal of maxillary antrostomy is to increase sinus ventilation. Few data exist regarding the effect of maxillary antrostomy size on sinus ventilation. We sought to quantify the effect of uncinectomy, small antrostomy, and large antrostomy on maxillary sinus ventilation using xenonenhanced computed tomography in the sheep model. Methods: A xenon-oxygen-air mixture was delivered through the nares of 8 fresh cadaveric sheep heads while repeated CT scans were performed through the maxillary sinuses. Baseline and postoperative studies were performed after an endoscopic uncinectomy, small antrostomy (2-4 mm in size), or large antrostomy (6-9 mm in size) was created. Images were obtained every 30 to 60 seconds and analyzed to measure the density of the xenon gas in the maxillary sinus as a function of time. Analysis of density-time curves generated a time constant, tau, equal to the specific ventilation of a region within the maxillary sinus. Results: The time constants for both small antrostomy and large antrostomy were significantly different compared to baseline (P ⫽ 0.003 for both). The change in xenon ventilation between uncinectomy and baseline was not significant (P ⫽ 0.274). The time constant comparison between small antrostomy and large antrostomy was not significant (P ⫽ 0.948). Conclusions: A small antrostomy produces a statistically significant increase in maxillary sinus ventilation over baseline. No significant further ventilation increase is obtained by
TUESDAY
P138
Otolaryngology– Head and Neck Surgery August 2003
subarachnoid fluid in the herniated sac. Iatrogenic pseudomeningoceles following spinal surgery have been described, but reports following neuro-otologic procedures have been scant. The present study evaluates the incidence of pseudomeningocele following neuro-otologic procedures and delineates an algorithm for the management of this postoperative complication. Methods: A retrospective review of 375 consecutive patients undergoing neuro-otologic procedures at a single institution identified 11 patients with the postoperative complication of pseudomeningocele. The patients’ signs and symptoms, method of management, and ultimate outcome were obtained from patient records and office visits. Results: The incidence of pseudomeningocele formation was 2.9% in the present study. The median time to development of pseudomeningocele was 12 days postoperatively. 8 pseudomeningoceles resolved with nonoperative management including pressure dressing, bed rest, and lumbar spinal drainage. 4 patients failed nonoperative management and required surgical procedures for resolution. All patients ultimately had resolution of their pseudomeningocele, and there were no recurrences during the follow-up period. Conclusions: Skull-base pseudomeningocele does occur as a complication following neuro-otologic procedures. It is associated with chronic irritation of the subarachnoid space and chronic headaches. The majority of these cases can be dealt with in a nonoperative manner, but those failing to respond mandate surgical intervention.
Room OCCC 109A •
Scientific Sessions: Rhinology Serge A Martinez MD; William R LaMear MD (moderators)
9:30
AM
Endoscopic Transnasal Hypophysectomy through the Sphenoid Ostium Vere Carlin MD (presenter); Elgan Davies FRCS; Konstantina T Tzifa Stone United Kingdom; Church Minshull United Kingdom; Birmingham United Kingdom
Objectives: Following the introduction of nasal endoscopes in 1985, otorhinolaryngologists attempted to access the pituitary gland under endoscopic guidance using mainly the sublabial transseptal approach, the transseptal transphenoidal, the transsethmoidal, and sporadically, the route via the sphenoid ostium. The purpose of this paper is to present our experience, over the last 5 years, at North Staffordshire Hospital, one of the largest general hospitals in the United Kingdom, using the technique of endoscopic transnasal hypophysectomy through the sphenoid ostium and to discuss the advantages. Methods: The technique was performed using the rigid
Hopkins rod telescope and telemonitoring. The cases were reviewed retrospectively for surgical outcome and endocrine control. Results: We have used this technique on 46 patients, of which 3 were revisions. This approach provides the advantages of midline exposure and access to both the sphenoid cavities, combined with the detailed and panoramic sphenoidal and intrasellar endoscopic view. The technique is faster to perform, the postoperative care is easy, and the length of recovery and stay in the ward is significantly shorter. The outcome was successful in 77% of cases on decompression and biochemical control. Morbidity was minimal. Conclusions: We believe that otorhinolaryngologists can practice this technique safely, providing they are well trained in endoscopic nasal surgery and are familiar with the anatomy of the sphenoid sinus and sella. The wide exposure and precise anatomical view provide significant advantages for safe primary and revision excision of pituitary tumors. 9:38
AM
The Effect of Maxillary Sinus Antrostomy Size on Xenon Ventilation in the Sheep Model Kevin T Brumund MD (presenter); Geoffrey McLennan MD; Scott M Graham MD Iowa City IA; Iowa City IA; Iowa City IA
Objectives: A major goal of maxillary antrostomy is to increase sinus ventilation. Few data exist regarding the effect of maxillary antrostomy size on sinus ventilation. We sought to quantify the effect of uncinectomy, small antrostomy, and large antrostomy on maxillary sinus ventilation using xenonenhanced computed tomography in the sheep model. Methods: A xenon-oxygen-air mixture was delivered through the nares of 8 fresh cadaveric sheep heads while repeated CT scans were performed through the maxillary sinuses. Baseline and postoperative studies were performed after an endoscopic uncinectomy, small antrostomy (2-4 mm in size), or large antrostomy (6-9 mm in size) was created. Images were obtained every 30 to 60 seconds and analyzed to measure the density of the xenon gas in the maxillary sinus as a function of time. Analysis of density-time curves generated a time constant, tau, equal to the specific ventilation of a region within the maxillary sinus. Results: The time constants for both small antrostomy and large antrostomy were significantly different compared to baseline (P ⫽ 0.003 for both). The change in xenon ventilation between uncinectomy and baseline was not significant (P ⫽ 0.274). The time constant comparison between small antrostomy and large antrostomy was not significant (P ⫽ 0.948). Conclusions: A small antrostomy produces a statistically significant increase in maxillary sinus ventilation over baseline. No significant further ventilation increase is obtained by
TUESDAY
P138
Otolaryngology– Head and Neck Surgery August 2003