Avoiding and dealing with bleeding during endoscopic sinus surgery

Endoscopic sinus surgery is one of the most frequent surgical ENT-procedures. Bleeding during surgery may increase complications and may have negative effects on surgery and outcome. The present paper describes strategies to prevent and deal with bleeding during sinus surgery. Preoperative conservative treatment of mucosal inflammation as well the use of adrenalin for decongestion may reduce intraoperative bleeding and hence complications.     

鼻-翼腭窝神经鞘瘤

目的通过对鼻一翼腭窝区域神经鞘瘤的临床病例回顾,探讨该部位神经鞘瘤的临床诊断及治疗策略。方法回顾性分析5个鼻一翼腭窝区域神经鞘瘤的临床病例资料,并列举其主要的临床表现、辅助检查、治疗方法和预后情况。结果5例神经鞘瘤分别位于上领窦（1例）、蝶窦（1例）,鼻腔（1例）、鼻中隔（1例）及翼腭窝（1例）。临床表现多由肿物的局部压迫所引起,包括眼眶深部隐痛、鼻塞、清水涕、嗅觉减退、额顶部头昏和头痛等。查体可见鼻腔神经鞘瘤呈灰白色,质软,表面光滑。神经鞘瘤在C1上主要表现为软组织密度影,并且伴有不同程度的周围骨质破坏,在MR此的的特点主要是T1wI呈等信号,T2wI呈不均匀稍高信号。5个病例均行手术切除治疗。5个病例的术后病理中HE染色的特点主要为梭形细胞肿瘤。术后随访中无1例患者出现复发,总体预后良好。结论鼻一翼腭窝神经鞘瘤临床表现较为隐蔽,影像学表现与其他类型肿瘤不易区分,因此直接诊断困难,需结合术后病理。手术为其主要治疗方式,并且总体预后良好。     

Pre- and postoperative evaluation of patients with nasal obstruction undergoing endoscopic sinus surgery

Functional endoscopic endonasal sinus surgery (FESS) is at present the surgical method of choice for many clinicians treating chronic sinusitis and nasal polyposis. Postoperatively, patients have felt that patency of the nasal airway is improved, although all previous studies have failed to objectively measure changes produced. By using anterior active rhinomanometry, decreased unilateral and total nasal resistance was measured. Although improvement in total resistance was not statistically significant, reduction in unilateral resistance was. All patients demonstrated subjective improvements in unilateral and total nasal patencies. The reduction in nasal resistance was more pronounced in baseline resistance values than after decongestion, indicating that FESS had a positive effect on mucosal edema but did not alter the structural anatomy of the main nasal passages.     

Ultrasonography in a nasal cavity filled with water during endoscopic sinus surgery

We developed a new ultrasonographic imaging technique to be used in a water-filled nasal cavity during endoscopic sinus surgery, and estimated how well surgically dangerous sites were depicted. Our newly developed balloon can completely fill the choana, preventing water from leaking into the pharynx. The balloon enables endoscopic sinus surgery to be relatively safely performed in "flowing water." Fifteen patients with chronic sinusitis underwent endoscopic sinus surgery under local anesthesia, and a MicroTip Radial probe was inserted into the water-filled nasal cavity. The orbital contents, skull base, and maxillary sinuses were visualized in all cases. Even in cases with a thin lamina papyracea, the boundary of the orbit could be judged from the motion of the orbital contents. Ultrasound information obtained in real time will be useful for improving the safety of endoscopic sinus surgery. Our ultrasonographic imaging technique can provide an early warning to the surgeon and thereby prevent severe complications.     

The effect of functional endoscopic sinus surgery on nasal resonance

Background and objectiveFunctional endoscopic sinus surgery (FESS) increases the nasal volume, and thereby it can alter the nasal resonance. The objectives were to measure the percentage of nasal resonance following FESS and compare it with healthy individuals with normal nasal findings.MethodsThe nasometric analysis of voice was done using n/p/m consonant sounds in 72 individuals with healthy post FESS cavities (group 1) and 72 healthy individuals with normal nasal findings without any nasal pathology (group 2). The scores of nasal resonances were expressed in percentages and were compared between the two groups. Both in group 1 and group 2, 32 (44.4%) were females, and 40(55.6%) were males. In group 1, 51 participants had bilateral FESS cavities, and 21 had unilateral FESS cavities. Kannada was the mother tongue in 30 (41.7%) participants in group 1 and 36 (50.0%) in group 2. Malayalam was the mother tongue in 42(58.3%) participants in group 1 and 36 (50.0%) in group 2.ResultsIn both cases and control groups, more than 80% of the participants were showing less than 20% of nasal resonance. In group 1, the mean values of/n/p/m sounds were 11.23%, 10.23% and 11.42% respectively, and in group 2 the mean values were 8.27%, 8.58% and 8.58% respectively. But the P value was not statistically significant. Individuals with unilateral FESS cavities had more nasal resonance values compared to bilateral FESS cavities. Similarly, Kannada speaking people had more values compared to Malayam speaking individua.ConclusionChanges in nasal resonance after FESS is minimal, and it is unnoticed. But it may affect the speech quality in professional voice users, depending on their language. Though the nasometer is considered as the most validated instrument to record nasal resonance, we feel that further standardization is needed to evaluate the nasalance.     

不同内镜手术入路对翼腭窝及颞下窝的显露程度比较及其临床应用价值探讨

目的应用不同的内镜手术入路解剖翼腭窝及颞下窝,比较内镜下各手术入路的显露范围,为恰当选择内镜手术入路处理翼腭窝及颞下窝病变提供解剖学方面的依据。方法 4具8侧成人尸头标本,0°内镜引导下分别采取上颌窦后壁入路、扩大上颌窦后壁入路、鼻腔外侧壁入路、揭翻经上颌窦入路进行解剖学研究,观测各手术入路的有效显露范围。结果上颌窦后壁入路能显露翼腭窝上部和颞下窝内侧区深部;扩大上颌窦后壁入路在以上手术入路的基础上进一步显露翼腭窝下部;鼻腔外侧壁入路再进一步显露整个上颌窦和上颌窦底壁平面以上的颞下窝内外侧区;揭翻经上颌窦入路则能更进一步显露整个颞下窝。结论不同的内镜手术入路对翼腭窝及颞下窝的显露程度各不相同,以此为基础选择相应的手术入路处理不同范围的翼腭窝及颞下窝病变将有利于充分显露和有效切除病变,并尽可能避免不必要的手术损伤和并发症。     

鼻内镜手术颌内动脉翼腭段的应用解剖

目的：研究颌内动脉翼腭段的走行及分支规律,为经鼻内镜手术过程中合理处理颌内动脉提供解剖学依据。方法：10具去脑颅底骨正中裂开,显微镜下解剖蝶腭动脉,经鼻内镜上颌窦入路开放翼腭窝,暴露颌内动脉翼腭段所有分支,将上颌窦后、内壁交界的凹陷定义为A点,通过眶下孔的水平线与上颌窦前壁、后外侧壁交线相交于B点,上颌窦前壁、后外侧壁和底壁的交点为D点,BD连线的中点为C点,颌内动脉翼腭段发出的第一分支点为C′点,观察其分支及走行规律。结果：蝶窦口下缘到鼻后中隔上动脉的距离为（5．88±2．21）mm;C′点位于AC上13侧,占65%（13／20）;位于AB上5侧,占25％（5／20）;位于AD上1侧,占5％（1／20）;高于AB1侧,占5％（1／20）。结论：熟悉颌内动脉的分支及走行对于治疗顽固性鼻出血和翼腭窝手术有重要意义;本实验中利用A、B、C、D点为参照点确定颌内动脉走行的方法,有助于内镜经鼻（上颌窦）手术中颌内动脉的定位及结扎处理。     

鼻内镜手术疗效综合评价

目的 探讨鼻内镜手术对慢性鼻窦炎及鼻息肉疗效的综合评价方法.方法 采用声反射鼻腔测量系统、前鼻测压计、T＆T嗅觉计定量检查法和术区黏膜评分法,对46例慢性鼻窦炎及鼻息肉患者鼻气道阻力、嗅觉、鼻腔术区黏膜形态进行测试.结果 鼻内镜手术后患者的鼻气道通气、嗅觉有明显好转;术后鼻腔、黏膜状况与功能恢复有显著相关性.结论 鼻气道阻力、嗅觉功能测试、鼻声反射检查、术区黏膜评分检测作为手术前后鼻功能的检测手段,可对术后疗效进行客观的综合评价.     

导航鼻内镜下治疗鼻窦囊肿

目的 探讨应用影像导航系统在鼻内镜下治疗鼻窦囊肿的方法及优势。方法 在导航鼻内镜下对121例鼻窦囊肿施行手术,其中上颌窦黏液囊肿12例,上颌窦黏膜囊肿5例,筛窦黏液囊肿43例,额窦黏液囊肿29例,蝶窦黏液囊肿32例。均采用气管插管全麻,根据手术中的需要标定探针或吸引器作为术中的定位设备,在鼻内镜下使用导航定位设备以判断囊肿的准确位置,根据术中探针的指引通过最短的距离到达囊肿,完整或部分切除囊壁,通畅引流。结果 121例手术均准确定位了囊肿的位置,完成手术, 无术中、术后并发症发生。结论 影像导航系统结合鼻内镜治疗鼻窦囊肿具有定位准确、手术创伤小的优点,可以有效地提高手术疗效和避免并发症的发生。     

鼻内镜术后中药"五黄液"鼻腔冲洗疗效观察

目的 观察术后"五黄液"术腔冲洗对功能性鼻内镜手术疗效的影响.方法 三个研究中心慢性鼻窦炎、鼻息肉患者131例,随机分为实验组69例和对照组62例.功能性鼻内镜手术后,实验组以"五黄液"冲洗术腔,对照组以生理盐水冲洗术腔,观察比较患者症状和体征评分改善情况及总体疗效.结果 治疗前两组症状体征总评分差异无统计学意义(P>0.05),治疗后"五黄液"治疗组总体疗效优于生理盐水组(P<0.05),主要症状体征消失或改善程度明显(P<0.05),单侧鼻腔积脓和窦口阻塞性变化组间差异无统计学意义(P>0.05).结论 功能性鼻内镜术后应用"五黄液"冲洗鼻腔,可明显提高手术疗效而且安全性好.     

内镜下减血手术治疗鼻科疾病的可行性探讨

目的：探讨内镜下减血手术治疗鼻科疾病的可行性。方法：对53例(86侧)鼻科疾病患者，以双极射频探头凝固消融病变组织和所需切除部位组织边缘，以减少术中出血，对渗、出血部位凝固止血。结果：37例(69.8％)患者术后鼻腔无需填塞止血，术中出血量平均为39．67ml。结论：内镜下减血手术治疗鼻科疾病，术中平均出血量较常规内镜下手术出血量明显减少。     

鼻内镜下经前囟钩突切除术治疗慢性鼻-鼻窦炎疗效观察

目的 观察经前囟钩突切除术治疗慢性鼻-鼻窦炎的疗效及术后上颌窦黏液纤毛传输功能的恢复情况。方法 收集2012年5月至9月行手术治疗的慢性鼻-鼻窦炎不伴鼻息肉患者60例的临床资料, 其中研究组31例(52侧), 对照组29例(50侧)。采用功能性鼻内镜的常规术式, 在切除钩突开放上颌窦口时, 研究组采用经前囟钩突切除术, 对照组采用Messerklinger术式。根据术后1年时的VAS评分、Lund-Kennedy评分、黏液纤毛传输时间(MTT)评价两组疗效。结果 术后1年研究组VAS评分为 0.93±0.69, 对照组为1.91±0.99(t=-3.21, P<0.01);研究组Lund-Kennedy评分为0.89±0.67, 对照组为2.03±0.91(t=-3.76, P<0.01); 两组窦口开放良好率差异无统计学意义(研究组为100%, 对照组为94%, P>0.05)。研究组52侧(100%)的活性炭均从上颌窦口下缘流出;对照组47侧中, 有8侧(17.02%)活性炭颗粒滞留于窦腔, 不能从窦口排出, 15侧(38.46%)从窦口下缘排出, 20侧 (51.28%) 从后缘和(或)上缘排出, 4侧(10.25%)从前缘排出。研究组平均黏液纤毛传输时间为 (21.87±4.76)min, 对照组为 (34.21±3.96)min(P<0.01)。结论 采用经前囟钩突切除术治疗慢性鼻-鼻窦炎有利于上颌窦纤毛传输功能的恢复, 较传统的Messerklinger术式效果更好。     

内镜鼻窦手术后局部应用Merogel对促进术腔黏膜上皮化的临床效果观察

目的　观察使用美国Xomed公司生产的Merogel(透明质酸 )作为内镜鼻窦手术后的术腔填塞物对促进术腔上皮化的作用。方法　对 16例 (32侧 )经鼻内镜全鼻窦开放术患者进行同体对照观察 ,左侧为Merogel观察组 ,右侧为空白对照组 ,连续内镜随访 12周 ,观察双侧术腔上皮化过程。结果　Merogel侧治愈 93 75 % ,好转 6 2 5 % ,平均上皮化时间 3 4周 ;对照侧治愈 87 5 0 % ,好转12 5 0 % ,平均上皮化时间 8 3周。表明使用Merogel侧术腔上皮化时间比对照组明显缩短。结论　内镜鼻窦手术后局部使用Merogel ,可以促进术腔上皮化过程     

Hypotensive anaesthesia and bleeding during endoscopic sinus surgery: an observational study

Significant bleeding during functional endoscopic naso-sinusal surgery (FESS) impairs recognition of anatomical references and may negatively affect surgical outcome. Through their hypotensive effect, adjuvant anaesthetic agents may influence intraoperative bleeding. The present study compared intraoperative bleeding in patients undergoing FESS administered a clonidine-based anaesthetic regimen and in patients receiving other an anaesthetic combination with higher acquisition costs. Prospective observational study included 37 subjects undergoing FESS in 2011. Assessment of intraoperative bleeding was according to type of anaesthesia (clonidine vs. opioid derivatives). Patients receiving clonidine (N = 11; 29.7 %) presented significantly lower surgical field bleeding scores than those receiving opioid derivatives (N = 26; 70.3 %) [mean (SD) Boezaart scores 1.91 (0.53) vs. 2.92 (0.79), p < 0.0001]. The multivariate analysis including baseline characteristics and risk factors related to bleeding intensity showed that the type of drug used for controlled hypotensive anaesthesia was the best predictor of bleeding during FESS, with an OR of 0.03 for clonidine based vs. opioid based anaesthesia (p = 0.014). The anaesthetic combination including clonidine for controlled hypotensive anaesthesia produces lower levels of surgical field bleeding during FESS. Compared with other hypotensive anaesthetics, clonidine is inexpensive and associated with better surgical conditions during FESS. If confirmed through randomized clinical trials, the use of clonidine during FESS can reduce surgical time and improve surgical results through a less bloody field, resulting in lower patient morbidity and improvement of operating room resources.     

精神障碍伴有鼻部疾病患者的鼻内镜手术

随着社会竞争日趋激烈，人们的工作和学习的压力越来越大，所面临的问题越来越复杂，精神负担也就越来越重，精神障碍的发生率也随之增多。在临床工作中如何处理伴有精神障碍的鼻部疾病患者对耳鼻咽喉科医师是一个挑战。从1998年12月至2006年12月，我们对5例伴有精神障碍的鼻部疾病患者实行了鼻内镜手术，现总结报告如下。[第一段]     

The incidence of complications after canine fossa puncture performed during endoscopic sinus surgery

BACKGROUND: Patients with extensive disease affecting the maxillary sinus may require a canine fossa approach for complete removal of disease. This study was designed to determine the complications associated with this procedure. METHODS: We performed a retrospective study of 21 patients who had undergone a canine fossa puncture at an academic hospital complex in Adelaide, Australia. RESULTS: A total of 37 canine fossa punctures were made in 21 patients. Twenty-eight of the 37 (75.7%) sides in which a canine fossa puncture was performed experienced a complication. The most common complaint was of cheek swelling in 14 (38%) followed by facial pain in 12 (32%), facial numbness in 11 (30%), cheek pain in 10 (27%), dental numbness in 10 (27%), gingival complications in 9 (24%), and facial tingling in 6 (16%) of sides. Most complications (75.5%) resolved within the 1st month after surgery. Six patients (28.6%) had persistent complications with facial tingling in 3 patients (50%) followed by facial numbness and tingling in 1 patient (11%), facial numbness alone in 1 patient (8.3%), and facial pain in 1 patient (7.1%). CONCLUSION: Canine fossa antrostomy is a technique that provides additional access to the maxillary sinus. Surgeons need to be aware that, although minor, a significant number of patients will experience both transient and long-term complications.     

慢性鼻窦炎鼻内镜围手术前期治疗对术中出血的影响

目的探讨减少慢性鼻窦炎患者鼻内镜术中出血的方法。方法122例双侧慢性鼻窦炎患者,分为治疗组与对照组。治疗组(59例)围手术前期予以综合治疗,对照组(63例)围手术前期未予综合治疗,对比分析两组患者的术中出血量。结果治疗组术中出血量为(92.7±72.02)ml,对照组术中出血量为(145.24±116.29)ml,两组间差异具有显著性意义(P<0.05)。结论术前综合治疗对减少鼻内镜术术中出血量有重要意义。     

Preoperative corticosteroid oral therapy and intraoperative bleeding during functional endoscopic sinus surgery in patients with severe nasal polyposis: a preliminary investigation

OBJECTIVES: The aim of the study was to investigate whether orally administered steroids might improve surgical field conditions during functional endoscopic sinus surgery. METHODS: Total blood loss and visualization of the surgical field during the surgical procedure were compared in 2 groups of 18 patients each with severe nasal polyposis. The groups were similar in respect to age, body mass index, general health status, incidence of allergy, bronchial asthma, aspirin triad, and stage of disease. One group received 30 mg of prednisone daily for 5 consecutive days before the operation. The second group served as a control. RESULTS: Although the total blood loss was only slightly less in the steroid group, the visual conditions of the surgical field improved significantly. CONCLUSIONS: Better surgical field conditions were the results of the powerful anti-inflammatory and antiedematous activity of the drug, which facilitated blood and secretion evacuation from the operated area and prevented the optic system from staining.     

Validation of the Modena bleeding score in endoscopic sinus surgery

IntroductionThe Modena bleeding score is a categorical rating scale that allows the assessment of the surgical field in relation to bleeding during endoscopic surgery. It has recently been presented and validated in the field of endoscopic ear surgery by the present authors. The Modena bleeding score provides five grades for rating the surgical field during endoscopic procedures (from grade 1 ? no bleeding to grade 5 ? bleeding that prevents every surgical procedure except those dedicated to bleeding control).ObjectiveThe aim of this study was to validate the Modena bleeding score in the setting of endoscopic sinus surgery.MethodsFifteen three-minute videos of endoscopic sinus surgery procedures (each containing three bleeding situations) were evaluated by 15 specialists, using the Modena bleeding score. Intra and inter-rater reliability were assessed, and the clinical validity of the Modena bleeding score was calculated using a referent standard.ResultsThe data analysis showed an intra-rater reliability ranging from 0.6336 to 0.861. The inter-rater reliability ranged from 0.676 to 0.844. The clinical validity was α = 0.70; confidence limits: 0.64 ? 0.75, corresponding to substantial agreement.ConclusionThe Modena bleeding score is an effective method to score bleeding during endoscopic sinus surgery. Its application in future research could facilitate the performance and efficacy assessment of surgical techniques, materials or devices aimed to bleeding control during endoscopic sinus surgery.