Severe Posterior Epistaxis-Endoscopic Surgical Anatomy

Objective: To describe the anatomy of the sphenopalatine foramen (SPF) region and possible anatomical variations. Study Design: Prospective study accomplished from September, 2006, to January, 2007. Methods: The sphenopalatine foramen (SPF) of 61 cadavers were carefully dissected. Presence of the ethmoidal crest, location of sphenopalatine and accessory foramens, and the number of arterial branches emerging through foramens were observed. Data were analyzed in relation to gender, racial group, and symmetry of the cadaver. Prediction of the presence of accessory foramen was evaluated. Results: Mixed race cadavers prevailed in 122 nasal fossae dissected (75% males). Ethmoidal crest was present in 100% of the cadavers, being anterior to the SPF in 98.4% of the cases. The most frequent SPF location was the transition of the middle and superior meatus (86.9%). Mean distance from the SPF and accessory foramen to anterior nasal spine was 6.6 cm and 6.7 cm, respectively. Accessory foramen was present in 9.83% of the cases. A single arterial stem emerged through the SPF in 67.2% of the cases, and 100% through accessory foramens. The prevalence analyses showed no differences that were statistically significant (P > 0.05) between gender and racial group. The symmetry analyses showed a strong conformity (P < 0.01) between nasal fossae in relation to the SPF location. There was no statistically significant conformity between nasal fossae and accessory foramen (P = 0.53). None of the variables of interest presents any statistically significant (P > 0.05) association with the presence of the accessory foramen. Conclusions: There are anatomical variations in the lateral nose wall that should be considered for successful endoscopic surgical treatment of severe epistaxis.

Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients

The authors investigate the complications of transnasal transsphenoidal endoscopic surgery in the treatment of 301 patients with pituitary adenomas. A retrospective analysis of complications in 301 patients submitted to transsphenoidal transnasal endoscopic surgery at the General Hospital of Fortaleza, Brazil between January 1998 and December 2009. The complications were divided in two groups: anatomical (oronasofacial, sphenoid sinus, intrasellar, suprasellar and parasellar) and endocrinological complications (anterior and posterior pituitary dysfunctions). We observed a total of 81 complications (26.9%) in our series. Anatomical complications occurred in 8.97% (27 cases): 8 CSF postoperative leaks (2.6%), 6 cases (1.9%) of delayed nasal bleeding, 5 cases (1.6%) of sphenoidal sinusitis, 3 cases (0.9%) of carotid artery lesion, 2 cases of meningitis (0.6%) and one case (0.3%) of each of the uncommon following complications: intrasella-suprasella hematoma, pontine hematoma and chiasmaplexy. Endocrinological complications occurred in 17.9% (54 cases): additional postoperative anterior lobe insufficiency in 35 cases (11.6%), and postoperative diabetes insipidus in 19 cases (6.3%). In our series, 3 cases of deaths (not directly related to the procedure) were also observed. Endoscopic transsphenoidal surgery represents an effective option for the treatment of patients with pituitary tumor. Complications still occur and must be reduced as much as possible. Successful endoscopic pituitary surgery requires extensive training in the use of an endoscope and careful planning of the surgery. Additional improvement can be expected with greater experience and new technical developments.

Cephalometric And Anthropometric Data Of Obstructive Apnea In Different Age Groups.

Patients with obstructive sleep apnea syndrome usually present with changes in upper airway morphology and/or body fat distribution, which may occur throughout life and increase the severity of obstructive sleep apnea syndrome with age. To correlate cephalometric and anthropometric measures with obstructive sleep apnea syndrome severity in different age groups. A retrospective study of cephalometric and anthropometric measures of 102 patients with obstructive sleep apnea syndrome was analyzed. Patients were divided into three age groups (≥20 and <40 years, ≥40 and <60 years, and ≥60 years). Pearson's correlation was performed for these measures with the apnea-hypopnea index in the full sample, and subsequently by age group. The cephalometric measures MP-H (distance between the mandibular plane and the hyoid bone) and PNS-P (distance between the posterior nasal spine and the tip of the soft palate) and the neck and waist circumferences showed a statistically significant correlation with apnea-hypopnea index in both the full sample and in the ≥40 and <60 years age group. These variables did not show any significant correlation with the other two age groups (<40 and ≥60 years). Cephalometric measurements MP-H and PNS-P and cervical and waist circumferences correlated with obstructive sleep apnea syndrome severity in patients in the ≥40 and <60 age group.

Comportamento da sutura palatina mediana em crianças submetidas à expansão rápida da maxila: avaliação mediante imagem de tomografia computadorizada

OBJETIVO: o presente estudo, de caráter prospectivo, objetivou avaliar a imagem da sutura palatina mediana em crianças submetidas à expansão rápida da maxila por meio de tomografia computadorizada, após a fase de contenção. METODOLOGIA: a amostra constou de 17 crianças de ambos os gêneros, na faixa etária compreendida entre 5 anos e 2 meses e 10 anos e 5 meses no início do tratamento, provenientes da Clínica de Ortodontia Interceptiva da Sociedade de Promoção Social do Fissurado Lábio-Palatal da Universidade de São Paulo (PROFIS-USP), Bauru/SP. Tomografias computadorizadas foram implementadas para avaliar o comportamento da sutura palatina mediana em diferentes momentos do tratamento. RESULTADOS E CONCLUSÕES: constatou-se que, após um período médio de 8 a 9 meses de contenção com o aparelho expansor, a sutura palatina mediana mostrou-se completamente ossificada, desde a região da espinha nasal anterior até a espinha nasal posterior. Tal informação esclarece o comportamento da sutura palatina mediana frente à expansão rápida da maxila e reitera o senso comum quanto ao caráter biológico do procedimento.

Avaliação cefalométrica da posição do osso hióide em crianças respiradoras bucais

MATERIAL E MÉTODOS: em função das relações anatomofuncionais do osso hióide com o complexo craniofacial, realizou-se avaliação cefalométrica da posição do osso hióide em relação ao padrão respiratório. A amostra consistiu de 53 crianças, gênero feminino, com idades médias de 10 anos, sendo 28 respiradoras nasais e 25, bucais. As medidas cefalométricas horizontais, verticais e angulares foram utilizadas com a finalidade de determinar a posição do osso hióide. Estabeleceu-se uma comparação entre os grupos por meio do teste t de student, bem como correlação de Pearson entre as variáveis. RESULTADOS: Observou-se que não ocorreram diferenças estatísticas significativas para a posição mandibular e posição do osso hióide e o tipo do padrão respiratório. No Triângulo Hióideo, o coeficiente de correlação de 0,40 foi significativo entre AA-ENP (distância entre vértebra atlas e espinha nasal posterior) e C3-H (distância entre a terceira vértebra cervical e osso hióide) demonstrando uma relação positiva entre os limites ósseos do espaço aéreo superior e inferior. Para as medidas cranianas sugeriu-se uma relação entre a posição do osso hióide com a morfologia mandibular. CONCLUSÃO: Os resultados permitiram concluir que o osso hióide mantém uma posição estável, provavelmente, para garantir as proporções corretas das vias aéreas e não depende do padrão respiratório predominante.

A comparison of nasopharyngeal endoscopy and lateral cephalometric radiography in the diagnosis of nasopharyngeal airway obstruction

Two auxiliary methods of diagnosing nasopharyngeal airway obstruction were compared. Cephalometric radiography and nasopharyngeal videoendoscopy were evaluated for efficacy in terms of reproducibility and validity. Thirty orthodontic patients (7 to 12 years of age) seeking otorhinolaryngologic treatment for mouth breathing, or mouth and nose breathing, had nasopharyngeal endoscopy and radiographic examinations performed on the same day. Two otorhinolaryngologists analyzed the results. Nasopharyngeal endoscopy was more reliable in identifying all the obstructive nasopharyngeal processes. Endoscopy obtained kappa index scores of almost perfect agreement for diagnosis of posterior nasal septum deviation, of substantial agreement for anterior nasal septum deviation and lower turbinate hypertrophy, and of moderate agreement for middle turbinate hypertrophy. Lateral cephalometric radiography obtained scores of perfect agreement for imaging hypertrophy of the middle turbinate, of almost perfect agreement for imaging hypertrophy of the posterior portion of the inferior turbinate, and of substantial agreement for imaging hypertrophy of the inferior turbinate. Radiographic diagnoses of hypertrophy of the middle and lower turbinates exhibited high sensitivity and low specificity when compared with diagnoses by nasopharyngeal endoscopy.

Post expansion evaluation of the midpalatal suture in children submitted to rapid palatal expansion: A CT study

The aim of this prospective study was to evalute the midpalatal suture in children submitted to rapid palatal expansion, at the end of the retention stage, with CT scans. The sample was comprised of 17 children aged between 5 years 2 months and 10 years 5 months. The tomographic images showed that the midpalatal suture was completely ossified from the anterior nasal spine area to the posterior nasal spine area at the end of the retention phase, that is, 8 to 9 months post-expansion.

Alterações do tecido mole, espaço faríngeo e estabilidade após avanço maxilo-mandibular xom rotação anti-horária e prótese total de ATM

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts (R) total joint prostheses Part I - Skeletal and dental stability

The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total join, prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9 +/- 8.0 degrees. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9 +/- 3.5 mm at the lower incisor tips, 12.4 +/- 5.4 mm at Point B, 17.3 +/- 7.0 mm at menton, 18.4 +/- 8.5 mm at pogonion, and 11.0 +/- 5.3 mm at gonion. Vertically, the lower incisors moved upward -2.9 +/- 4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the rnaxillo-mandibular complex was a stable procedure for these patients at the longest follow-up.

Ocular masquerade syndrome associated with extranodal nasal natural killer/T-cell lymphoma: case report

A 33-year-old woman complained of unilateral eyelid edema and blurred vision. Initial ophthalmic examination disclosed anterior chamber reaction with keratic precipitates on the cornea, without posterior abnormalities. Anterior uveitis was treated. Despite that, patient showed rapidly progressive unilateral vision loss with optic nerve swelling. Systemic workup was inconclusive, as well as cranial magnetic resonance imaging and cerebrospinal fluid examination. Based on the hypothesis of optic neuritis, intravenous methylprednisolone pulse was performed with no success. During the following days, the patient presented pericardial effusion and cardiac tamponade, progressing to death. Necropsy was performed and diagnosis of extranodal natural killers/T-cell lymphoma, nasal type with ocular involvement was confirmed by immunohistochemistry.

Photographic assessment of nasal morphology following rapid maxillary expansion in children

OBJECTIVE: The aim of the present study was to use facial analysis to determine the effects of rapid maxillary expansion (RME) on nasal morphology in children in the stages of primary and mixed dentition, with posterior cross-bite. MATERIAL AND METHODS: Facial photographs (front view and profile) of 60 patients in the pre-expansion period, immediate post-expansion period and one year following rapid maxillary expansion with a Haas appliance were evaluated on 2 occasions by 3 experienced orthodontists independently, with a 2-week interval between evaluations. The examiners were instructed to assess nasal morphology and had no knowledge regarding the content of the study. Intraexaminer and interexaminer agreement (assessed using the Kappa statistic) was acceptable. RESULTS: From the analysis of the mode of the examiners' findings, no alterations in nasal morphology occurred regarding the following aspects: dorsum of nose, alar base, nasal width of middle third and nasal base. Alterations were only detected in the nasolabial angle in 1.64% of the patients between the pre-expansion and immediate post-expansion photographs. In 4.92% of the patients between the immediate post-expansion period and 1 year following expansion; and in 6.56% of the patients between the pre-expansion period and one year following expansion. CONCLUSIONS: RME performed on children in stages of primary and mixed dentition did not have any impact on nasal morphology, as assessed using facial analysis.

Evaluation of inverted papilloma and squamous cell carcinoma by nasal contact endoscopy

Background: Contact endoscopy (CE) was initially described as a method used in the analysis of uterine and vocal folds histology. The first nasal cavity CE studies achieved promising results regarding its use for the differentiation between benign and malignant lesions, considering that biopsy might cause some complications, especially bleeding. This study described and compared the findings of CE on inverted papilloma and nasosinusal squamous cell carcinoma (SCC) and tested the effectiveness of this exam as a noninvasive method for in vivo differentiation between these tumors. Methods: The patients included in this study were divided into group A, patients diagnosed with inverted papilloma, and group B, patients diagnosed with SCC. CE results were compared among themselves. CE images were presented to examiners not experienced with the method. Results: Twenty-two patients were examined, 13 in group A and 9 in group B. The main relevant differences in CE findings between those two groups were corkscrew vessels, presence of mitoses, keratinization and nuclear pleomorphism in carcinoma, and vacuolated cells in papilloma. The examiners were capable of defining the diagnosis of these nasal tumors only based on CE images. Conclusion: CE may be a useful noninvasive exam to be used in the in vivo diagnosis of inverted papilloma and nasosinusal SCC, which may enable better preoperative planning. (Am J Rhinol Allergy 24, 210-214, 2010; doi: 10.2500/ajra.2010.24.3467)

Does rapid maxillary expansion increase nasopharyngeal space and improve nasal airway resistance?

Objective: To evaluate the effect of rapid maxillary expansion (RME) on the dimension of the nasopharyngeal space and its relation to nasal airway resistance. Methods: Twenty-five school-age children (from 7 to 10 year-old) with mouth and/or mixed breathing, with mixed dentition and uni- or bilateral posterior crossbite involving the deciduous canines and the first permanent molars, were evaluated. RME was placed and remained during 90 days. Rhinomanometry and orthodontic documentation were performed at four different times, i.e., before (T(1)), immediately after (T(2)), 90 days (T(3)) and 30 months (T(4)) after RME. Results: Differences in nasopharyngeal area and in nasal airway resistance were observed only 30 months after RME, and could be explained by facial growth, and not because of the orthodontic procedure. Conclusion: RME does not influence on nasopharyngeal area or nasal airway resistance in long-term evaluation. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Long-term effects of rapid maxillary expansion on nasal area and nasal airway resistance

Background: Rapid maxillary expansion (RME) may improve the nasal respiratory pattern This study was performed to evaluate the effect of RME on the nasal cavity by acoustic rhinometry and computed rhinomanometry and to determine nasal and maxillary width by posteroanterior cephalometric radiography, up to 30 months after the orthodontic procedure Methods: Twenty-seven children with oral breathing, ranging in age from 7 to 70 years, and with mixed dentition were selected The children had unior bilateral posterior crossbite involving deciduous canines and the first permanent molars All subjects were submitted to nasofibroscopy, acoustic rhinometry, and computed rhinomanometry and posteroanterior cephalometric radiography at four different tunes, i e, before expansion, immediately, 90 days and 30 months after expansion Results: The mean linear left-to-right nasal cavity lateral prominence and left-to-right jugal ponds cephalometric measures increased considerably after expansion and this increase was maintained throughout the period of evaluation There was an immediate significant decrease in nasal resistance, up to 90 days after RME, but the nasal resistance increased 30 months after the procedure The acoustic rhinometry results did not show any difference in values throughout time Conclusion: RME significantly increased nasal and maxillary width as measured by frontal cephalometry, but the nasal mucosal effects were more subtle Also, the influence of RME on nasal resistance was not stable, and nasal resistance values returned to close to the initial ones after 30 months (Am J Rhinol Allergy 24, 161-165, 2010, doi 10.2500/ajra.2010.24.3440)

Endoscopia nasal e a localização do sítio de sangramento na epistaxe: a revolução da última década

A epistaxe continua sendo uma das emergências otorrinolaringológicas mais comuns e preocupantes. Apesar do grande interesse no assunto, ainda não há consenso com relação à sua melhor abordagem inicial. OBJETIVO: Avaliar o sítio de sangramento em pacientes com epistaxe ativa ou recorrente. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Trinta pacientes adultos com epistaxe ativa ou recorrente foram avaliados com rinoscopia anterior clássica e endoscopia para identificação do sítio de sangramento na cavidade nasal. RESULTADO: O uso do endoscópio permitiu o diagnóstico do sítio de sangramento em todos os pacientes. CONCLUSÃO: O exame endoscópico cuidadoso da porção posterior da cavidade nasal permite a identificação do sítio de sangramento na maioria dos casos de epistaxe e deve ser considerado um exame de rotina.