Revisión del tratamiento quirúrgico de la rinosinusitis

The aim of this revision paper is to provide an update of available resources to achieve the best endoscopic sinus surgery outcomes of adult rhinosinusitis.The cause and mechanisms of rhinosinusitis remain unknown, and curative treatment does not exist. Recent new insights into paranasal sinus pathophysiology, along with technical advances in imaging and endoscopy, have revolutionised surgical treatment of rhinosinusitis.Since an increasing number of patients undergo functional endoscopic sinus surgery as a therapeutic regimen for their disease, appropriate use of computed tomography is critical in providing a “roadmap” for the surgeon to delimit the surgical procedure, as well as to ensure safety and accuracy. With proper training and technique, endoscopic surgery is quite safe, but prevention and management of complications must be known.     

Resultados de cirugía endoscópica nasal en el tratamiento de sinusitis fúngica invasiva en niños con cáncer e inmunosupresión

Background and objectiveto describe the results of the treatment of invasive fungal sinusitis with nasal endoscopic surgery in an immunocompromised paediatric oncological population.Methodsretrospective study of all patients diagnosed with invasive fungal sinusitis operated in the National Paediatric Oncology Unit between 2012 and 2016. Data taken from their medical history included: epidemiological characteristics, oncological diagnosis, haematological data, symptoms, tomographic studies, surgical interventions, results of pathology and cultures, medications received, complications, evolution and survival.Results18 patients were identified, 7 male and 11 female. The average age was 12 years, 13 had a diagnosis of acute lymphocytic leukemia and 5 of acute myeloid leukemia. Seventeen patients presented severe neutropenia at the time of diagnosis. The most frequently identified aetiological agent was Aspergillus in 13 patients. In 16 patients (89%) the disease was controlled with nasal endoscopic surgery. Ten patients died due to unrelated causes throughout the study.Discussion and conclusionsInvasive fungal sinusitis should be considered a medical emergency due to its high mortality. The diagnosis is based on a high index of suspicion in patients with predisposing factors (leukaemia, neutropenia, persistent fever, nasogastric tube) and endoscopic nasal evaluation. Antifungal medical treatment and aggressive nasal endoscopic surgery is indicated regardless of the patient's condition to reduce the fungal burden and associated high mortality. The treatment must be provided by a multidisciplinary team that includes paediatrics, haemato-oncology, infectology and otorhinolaryngology.     

Tratamiento quirúrgico del síndrome de apneas obstructivas durante el sueño: de la cirugía palatofaríngea a la reconstrucción quirúrgica multinivel de la faringe. bases,resultados y perspectivas futuras

In this paper is evaluated the effectiveness, as a function of the morphologic structure of the Upper Airways (UA) -evaluated by vigil ENT exploration plus cephalometrics- in the treatment of Obstructive Sleep Apnea Syndrome (OSAS) of the UPPP with or without Nasal Surgery (NS), performed on 33 OSAS patients, and the Multilevel UA Reconstruction (MUAR), performed on 13 patients with multilevel UA obstruction. 10 patients of this group were also evaluated by UA Pressure Measurements during Sleep (PMS). UPPP shows an effectiveness of 60% in cases of favourable UA topography: Predominant palatal obstruction (Type I: euthopic palate with no hypopharyngeal obstruction and Type IIa: palate of low implantation with no hypopharyngeal obstruction, either N+ (nasal obstruction present) or N- (nasal obstruction obsent) and 0% in cases of unfavourable UA structure: Extrapalatal obstruction (Type IIb: palatal and hypopharyngeal obstruction and Type III: hypopharyngel obstruction, either N+ or N-). The maximum UPPP effectiveness is achieved in UA topography IN+ (80%), followed by IIaN- (60%), IIaN+ (57%) and IN- (47%). MUAR, applied on failures of UPPP and patients with UA topography unfavourable to UPPP (Types IIb and III) that rejected CPAP therapy, shows a success rate of 50% in IIaN+ UA type (allowing the recuperation of the 50% of the UPPP failures having this UA topography), 80% in type IIbN+ (where UPPP is contraindicated) and 0% in types IIaNand IIbN-. PMS shows UA multilevel obstruction during sleep. The role of UPPP, NS and MUAR in the treatment of SAOS is are discussed.     

Recomendaciones sobre el uso de la neuromonitorización en cirugía de tiroides y paratiroides

Introduction

Thyroid and parathyroid surgery (TPTS) is associated with risk of injury to the recurrent laryngeal nerve, superior laryngeal nerve and voice changes. Intraoperative neuromonitoring (IONM), intermittent or continuous, evaluates the functional state of the laryngeal nerves and is being increasingly used. This means that points of consensus on the most controversial aspects are necessary.

Implicación clínica de la lesión iatrogénica de la cuerda del tímpano en la cirugía de la otosclerosis

Introduction: Damage to the chorda tympani nerve is frequent during otologic surgery. This article studies the clinical outcomes of the nerve's section versus its conservation in otosclerosis surgery.Material and method: Retrospective observational study using our department's otosclerosis database and a validated questionnaire on symptoms associated with the chorda tympani nerve. The sample was divided into two groups: section and conservation (patients whose nerve was anatomically conserved). We studied the presence and duration of symptoms, the surgical technique and the audiometric results.Results: 78 patients (88 ears): section group (18 ears; 20 %) and conservation group (70 ears; 80 %). Overall, gustatory symptoms appear in 35 % (39 % section group; 34 % conservation group). Differences between groups are not statistically significant in relation to presence and duration of symptoms, surgical technique or audiometric results. Only 1 patient in each group reports long-term symptoms. Our results suggest there are no major clinical differences following section versus conservation of the chorda tympani nerve. A wide range of factors such as age, presence of previous middle ear pathology, cross innervation and gastronomic culture may play a role in the appearance of symptoms.Conclusions: Symptoms appearing after iatrogenic damage to the chorda tympani nerve have, in general, little clinical relevance, especially in the long term, regardless of whether the nerve is dissected or manipulated to various degrees.     

Monitorización intraoperatoria del nervio facial durante la cirugía de la glándula parótida en servicios de otorrinolaringología - cirugía de cabeza y cuello

IntroductionFacial nerve injury remains the most severe complication of parotid gland surgery. Due to the increasing evidence about the advantage of the use of intraoperative facial nerve monitoring, a survey was distributed among members of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery with the objective of determining patterns of its use.Material and methodsA questionnaire which included 12 separate questions in 3 sections was distributed via email through the official email of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery. The first section of questions was in relation to demographic characteristics, the second section was related to the pattern of monitoring use and the third section referred to litigation related to facial palsy.Results1544 anonymous questionnaires were emailed. 255 surveys were returned, giving an overall response rate of 16.5%. From these, 233 (91.3%) respondents perform parotid gland surgery. Two-hundred nineteen (94%) respondents use intraoperative facial nerve monitoring. Of the respondents,94% used intraoperative facial nerve monitoring if in their current practice they performed fewer than 10 parotidectomies per year and 93.8% if they performed more than 10 (OR, 1.02; 95% CI, 0.68-1.45; p = .991). With regard to lawsuits, just 3 (1.2%) of the respondents had a history of a parotid gland surgery–associated lawsuit and in just one case the facial nerve monitor was not used.ConclusionOur data demonstrate that most otolaryngologists in Spain use intraoperative facial nerve monitoring during parotid gland surgery. Almost all of them use it to improve patient safety and consider that facial nerve monitoring should be helpful preventing inadvertent injury.     

Integración de la cirugía endoscópica en una unidad de base de cráneo: experiencia en los primeros 72 casos

IntroductionA multidisciplinary team is essential to develop and expand the indications in endonasal endoscopic skull base surgery.The aim of this study was to present our experience in a group of patients with skull base lesions treated using endonasal endoscopic approach.MethodsFrom January 2008 to January 2012, 72 patients with skull base involvement were diagnosed and treated in our centre.ResultsThe mean patient age was 53 years. The different pathologies included 36 pituitary adenomas, 10 cerebrospinal fluid leaks and 5 inverted papillomas as the most frequent pathologies. We performed a transsphenoidal transellar approach in 45 cases, a transmaxillary transpterygoid approach in 4 cases and a transnasal expanded approach in 6 cases. We performed an ethmoidal/sphenoidal approach in 12 patients and a Draf IIb/III procedure in four cases. Total resection was achieved in 61% of patients with pituitary adenomas, subtotal in 22% and partial in 17%. Successful repair was achieved in 86% of CSF leaks. No recurrences were observed in patients with inverted papilloma. Complications were observed in 21 patients (29%), 6 being major complications.ConclusionsOur centre stresses the importance of multidisciplinary collaboration in endoscopic endonasal skull base surgery.     

Utilidad de la mucoplastia endonasal en el tratamiento quirúrgico de la rinosinusitis crónica con pólipos nasales. Estudio prospectivo

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease with great impact on health. The surgical option using endoscopic sinus surgery is the therapeutic alternative when control of the disease is not achieved with medical treatment. Extensive endoscopic approaches are being postulated as a possible best surgical treatment option in certain phenotypes of CRSwNP. Endonasal mucoplasty associated with these approaches has been shown to be a complementary technique that improves both healing and mucosal edema in patients with CRSwNP in the short term. The aim of our study was to analyse the results of endonasal mucoplasty associated with a complete ethmoid-sphenoidotomy plus grade III frontal sinusotomy in the treatment of CRSwNP in the medium term. For this purpose, a prospective case-control study (10/10) was carried out on patients with CRSwNP. In the case group, endonasal mucoplasty in the left nostril was associated with surgery, and the control group was not. The assessment of quality of life at one year after surgery, as measured by the mean difference in SNOT-22 (mean [SD]), was significantly better in the case group than in the control group (45.9 [19.6]-26.6 [16.05] P = 0.027). The endoscopic improvement in healing and mucosal edema, measured by the Modified Lund-Kennedy scale, showed relevant improvements, when comparing both nostrils, but without reaching significance (P = 0.29). Endonasal mucoplasty promotes short-term healing, improving the quality of life in the medium term (one year) of patients treated with extensive endoscopic mucosal resections.     

Factores implicados en el éxito y fracaso de la dacriocistorrinostomía endoscópica desde nuestra experiencia

IntroductionChronic dacryocystitis is the condition secondary to permanent lacrimonasal duct stenosis (LNDS) that generates epiphora and recurrent conjunctivitis. Endoscopic dacryocystorhinostomy (EDCR) is a more natural route than the external route and offers higher success rates than the laser technique. We value this centre's experience in this procedure.Patients and methodsA retrospective review was carried out in our centre of the medical records of adult patients undergoing EDCR due to LNDS between 1995 and 2019. The minimum follow-up period required after surgery was 6 months.ResultsOver 297 months, 167 EDCR procedures were performed on 156 patients, with an average age of 65.7±11.6 years and a male/female ratio of 1/1.98. The functional improvement was 86%, with an anatomical success rate of 87%. Lack of clinical improvement statistically significantly correlated with the age of the patient and the time since onset of the LNDS, the presence of concomitant systemic (especially diabetes mellitus) or ophthalmological disease, the intraoperative finding of a thickened tear sac and absence of drainage of the tear sac when marsupialised. Longer-term stent carriers in the rhinostomy had poorer outcomes. There were no postoperative complications of interest.ConclusionsEDCR is an effective and safe technique, based on stable anatomical references. Failure rate seems to be multifactorial and should be considered in older, multipathological patients, with a long duration of the condition.     

Importancia de la cuantificación del desplazamiento hioideo en la valoración del estadio y evolución de la disfagia orofaríngea

Introduction and objectivesThe objective of this paper was to show our experience and considerations when quantifying hyoid bone displacement and to observe its correlation with the qualitative scales that evaluate dysphagia.MethodsHyoid displacement was assessed using the method described by Molfenter and Steele's group in 2014 in a series of 14 patients affected by oropharyngeal dysphagia. The degree of dysphagia was also qualitatively assessed with the Rosenbek Penetration and Aspiration Scale (PAS) of 1996 and with the Functional Oral Intake Scale (FOIS) of Crary of 2005. All assessments were done before and after treatment.ResultsAll patients increased their hyoid bone total displacement after the treatment. These variations were highly correlated with the variations in the PAS scale with aspiration or penetration. However, the variations of hyoid bone displacement did not correlate with the FOIS scale.ConclusionsThe improvement in total hyoid bone displacement is a clinical indicator of improved aspiration of patients suffering dysphagia. However, the improvement of this displacement is not related to the oral intake tolerance of the patients.     

Papel de la resonancia magnética de difusión en el diagnóstico y seguimiento del colesteatoma. Estudio con la técnica PROPELLER difusión

Introduction and objectivesThe diagnosis of cholesteatoma is based on clinical evaluation and computed tomography. New non-echo-planar diffusion-weighted magnetic resonance imaging (MRI) techniques, without intravenous contrast, are capable of differentiating cholesteatoma from inflammatory tissue, cholesterol granuloma and granulation tissues. The technique is very helpful in differential diagnosis of cholesteatoma, mainly after canal wall-up tympanoplasty surgery, to avoid routine second-look surgery in these patients. Congenital cholesteatoma and difficult cases can be detected and correctly diagnosed as well. The aim of this study was to evaluate sensitivity, specificity, positive predictive value and negative predictive value of the diffusion-weighted PROPELLER MRI in cholesteatoma diagnosis.MethodsA prospective study was performed on 52 patients. Clinical and surgical findings were correlated with diffusion-weighted PROPELLER MRI results.ResultsSensitivity, specificity and positive and negative predictive values were 92.85%, 92.30, 92.85 and 92.30%, respectively.ConclusionsDiffusion-weighted PROPELLER imaging is an effective technique in cholesteatoma diagnosis. It is capable of detecting lesions larger than 2 mm.     

Fístulas de LCR tras la cirugía de tumores del ángulo pontocerebeloso y su relación con el índice de masa corporal

IntroductionThe most frequent complication after vestibular schwannoma surgery is cerebrospinal fluid (CSF) fistula.Material and methodsRetrospective study of 170 patients who had vestibular schwannoma (163) or other tumours in the cerebello pontine angle (CPA) (7). Resection was carried out using different approaches: retrosigmoid (66%), translabyrinthine (24%), middle cranial fossa (5%) and others (5%). We studied the day of onset, location and treatment of the CSF leaks, and the influence of demographic, radiological and clinical variables, including Body Mass Index.Results27 patients developed a CSF fistula (15.9%): 15 were incisional (8.8%), 8 patients developed CSF rhinorrhea (4.7%), 1 CSF otorrhea (0.6%) and 3 a combination of the above (1.8%). We controlled 11 CSF fistulae with bed rest and compressive dressings (6.5%), 7 required lumbar drainage (4.1%), 2 lumbar drainage and wound closure with local anaesthesia (1.2%) and 7 patients required returning to the operating room under general anaesthesia (4.1%). There was not a significant relationship between the apparition of CSF and tumour size, type of approach, age or body mass index (BMI).ConclusionsDespite the great development and new surgical techniques, CSF fistulae are still a frequent complication after VS surgery. There might be other aetiological factors such as intracranial pressure. There was no significant relationship between CSF fistula and BMI. Adequate management and early conservative measures led to reduced reintervention rates of less than 5% in all patients.     

Disección fría y coagulación bipolar versus disección con bisturí armónico en la cirugía de los tumores benignos de la glándula parótida

IntroductionSurgical techniques for extirpation of tumours of the parotid gland have evolved significantly in recent years. Previous data suggest the use of Harmonic Scalpel reduced operative time, intraoperative blood loss, postoperative drain production, and incidence of facial nerve injury, in comparison to cold scalpel dissectionMaterial and methodsretrospective analysis of 2 group of patients operated using harmonic scalpel versus cold knife dissection and bipolar diathermy and compare operative time and post-surgical complication rate:, facial nerve injury, sialocele or salivary fístula formation, after parotidectomy for benign parotid tumours.Results108 patients were included. Regarding surgical time, the mean time to using Harmonic Scalpel was 114 ± 39 (Min: 60/Max: 240), and the mean time using bipolar diathermy was 135 ± 38 (Min: 90/Max: 285) and this was the only significant difference between the 2 techniques (p = .049).ConclusionsHarmonic scalpel is a safe and effective tool to perform parotid surgery in benign tumours. However, a shorter surgical time was the only advantage found over the traditional cold dissection and bipolar dissection method.     

Cirugía endoscópica transoral ultrasónica (TOUSS) en el diagnóstico del carcinoma de primario desconocido en cabeza y cuello

Metastatic carcinoma of unknown primary (CUP) to cervical lymph nodes represents less than 5% of all head and neck malignancies. Recent publications support the use of transoral surgery during the diagnosis work-up, and transoral endoscopic ultrasonic surgery represents a recently described alternative technique in transoral surgery. A pilot study to assess the feasibility of trans-oral ultrasonic base of tongue (BOT) mucosectomy and bilateral tonsillectomy approach in CUP diagnosis work-up was conducted. Ten patients were included consecutively. In two cases (20%) the primary was found, in one case in the right tonsil, and another one in the left BOT. According to our results, the use of trans-oral ultrasonic surgery to perform the base of tongue mucosectomy and bilateral tonsillectomy in CUP patient's during the diagnosis work-up represents an effective option in patients with good anatomical exposure.     

Evaluación metodológica para detección de malignidad en patología quirúrgica tiroidea

IntroductionWe review a methodology for detection of malignancy in thyroid gland surgery, comparing clinical exploration, ultrasonography, gammagraphy, fine-needle aspiration (FNA) and extemporaneous biopsy with the definitive pathological results.Material and methodsWe carried out a retrospective study on a sample of 433 (N=433) patients who had been intervened due to thyroid gland disease at the same ENT centre between 1999 and 2004. We collected information focusing on the characteristics of cervical exploration, ultrasonography, gammagraphy, FNA, extemporaneous biopsy and definitive pathological results.ResultsWith N=433, the male/female ratio was approximately 1/9 (m/f 1/9), the average age was 45.5 years, with a range between 13 and 87 years, and with 20.3% of referred family history of thyroid gland disease; the cervical exploration, ultrasonography ang gammagraphy were not good tests for the screening of malignancy; FNA and extemporaneous biopsy offered 74% and 81% of sensitivity (Se), and 73% and 92% of specificity (Sp) in the detection of malignancy. The specific sensitivities towards papillary carcinoma of FNA and extemporaneous biopsy were 81% and 88%, whilst for follicular carcinoma they were 66% and 62.5%, respectively.ConclusionsFNA has good sensitivity in clinical suspicion of thyroid papillary carcinoma, although it should be complemented by extemporaneous biopsy due to its better specificity. In the case of follicular carcinoma there is a tendency towards conservative treatment, without carrying out extemporaneous biopsy previously and with reintervention in case of definitive malignancy.     

Determinación de pth i en la cirugía del hiperparatiroidismo. nuestra experiencia

Our service of otolaryngology has performed 90 parathyroidectomies at all since april 1990 to 2000 on 92 patients sent to us with diagnosis of hyperparathyroidism. 67 patients were diagnosed as primary hyperparathyroidism; 22 as secondary and 3 cases corresponded to tertiary hyperparathyroidism. we analysed a string of variables before and after the surgery standing out the recent estimate of rapid pth i levels. the kind of surgery we performed was the removal of adenoma in 63 cases; 23 patients were put to subtotal parathyroidectomy and 4 to a total one. an exploratory neck surgery was performed in two patients without finding a parathyroid pathology. we compare the obtained results with other published series and we think it can be useful to determinate the rapid paratohormone levels (pth i) pre and postsurgery (only used in 3 cases by now) in order to predict the clinic response of the patients with hyperparathyroidism     

Evaluación de la incapacidad en pacientes con acúfenos

ObjectivesTinnitus handicap evaluation through Spanish validation of the Tinnitus Handicap Inventory. Study Design: Spanish validation of the Tinnitus Handicap Inventory.PatientsEighty patients referred to our Tinnitus Unit in University Hospital, between September and December, (1999). Outcome Measures: The Spanish version of the Thi was administered after translation and retrotranslation. Internal consistency and reliability were established.ResultsSpanish adaptation of the THI and its subscales (functional, emotional and catastrophic) showed a high reliability and internal consistency (Cronbach’s alfa: 0.90).ConclusionsSpanish adaptation of the THI is valid, reliable and can be used in a clinical setting to quantify the impact of tinnitus on patient’s quality of life.     

Reconstrucción mediante colgajos basados en el sistema de la arteria facial. Un sistema vascular para múltiples usos en cirugía reconstructiva de cabeza y cuello

Introductionto review the modifications and advances in reconstructive surgery of the soft tissues of the oral cavity exclusively based on flaps that depend on the facial artery system.Methodsreview of the literature regarding oral cavity reconstructions based on main facial artery system flaps.DiscussionThe reconstruction of the soft tissues of the oral cavity, based on facial artery system flaps, offers satisfactory results and allows limited reconstructions avoiding the use of pedicled regional flaps or free flaps.ConclusionsKnowledge of reconstructive options using the facial artery system in oral cavity surgery allows expanding reconstructive options for head and neck surgeons, enabling safe, high quality and effective reconstructions, with limited resources consumption.