[Postoperative treatment following paranasal sinus surgery]

Postoperative care is a crucial aspect for the success of paranasal sinus interventions. Basic procedures include saline nasal wash, which should be started on the first postoperative day, topical steroids, and antibiotics in cases of infection. Medical treatment involves aspiration of secretion in the inferior meatus during the first week. Removal of scabs in the surgical field should be carried out under endoscopic control beginning at the second week. Intervals are scheduled individually. Occlusion of the nose for the time of epithelium regeneration provides a moist space in the ethmoid, which improves wound healing.

Endoscopic Surgery for Frontal Sinusitis and Its Complications

Endoscopic surgery of the paranasal sinuses has become popular during recent years, but the endonasal approach into the frontal sinus was only rarely recommended. Using a surgical endoscope with 70° optical deflection, the fenestration of the frontal sinus from below has proved a valuable and safe procedure in more than 500 procedures. The control of complications like osteitis and mucopyoceles, and of foreign bodies and benign tumors has become practical with endoscopic exposure.

European position paper on the anatomical terminology of the internal nose and paranasal sinuses

The advent of endoscopic sinus surgery led to a resurgence of interest in the detailed anatomy of the internal nose and paranasal sinuses. However, the official Terminologica Anatomica used by basic anatomists omits many of the structures of surgical importance. This led to numerous clinical anatomy papers and much discussion about the exact names and definitions for the structures of surgical relevance. This European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses was conceived to re-evaluate the anatomical terms in common usage by endoscopic sinus surgeons and to compare this with the official Terminologica Anatomica. The text is a concise summary of all the structures encountered during routine endoscopic surgery in the nasal cavity, paranasal sinuses and at the interface with the orbit and skull base but does not provide a comprehensive text for advanced skull base surgery. It draws on a detailed review of the literature and provides a consensus where several options are available, defining the anatomical structure in simple terms and in English. It is recognised that this is an area of great variation and some indication of the frequency with which these variants are encountered is given in the text and table. All major anatomical points are illustrated, drawing on the expertise of the multi-national and multi-disciplinary contributors to this project.

[The diameter of the Stenon and Wharton ducts. Significance for diagnosis and therapy]

In assessing new minimally invasive diagnostic techniques (duct endoscopy) and therapy (lithotripsy) of salivary gland disease, it is of importance to know the true dimensions of the secretory ducts. Twenty-five ducts of the parotid gland and 20 ducts of the sub-mandibular gland were examined histologically at different points of their anatomic course and their in vivo diameters were evaluated using a previously determined formalin-induced shrinking factor. The mean diameter of Stensen's duct at four different points along its length ranged between 0.5 mm and 1.4 mm, depending on the site. A narrowing at the middle of the duct was striking. In all preparations examined, the minimum width of the secretory duct was located at the ostium. In Wharton's duct the narrowest duct diameter was also identified at the ostium. The mean values for the duct diameters ranged between 0.5 mm and 1.5 mm. For diagnostic and therapeutic purposes, endoscopes, balloon catheters and stone-extraction baskets should conform as much as possible to physiological duct widths. A diameter of 1.2 mm should be considered the upper limit for duct instruments. Our findings also suggest that in the case of salivary stone lithotripsy the best results will be achieved when the maximum size of a stone fragment does not exceed 1.2 mm.

Diameters of the main excretory ducts of the adult human submandibular and parotid gland: a histologic study

In assessing new minimally invasive diagnostic techniques (duct endoscopy) and therapy (lithotripsy), it is of importance to know the true dimensions of the excretory ducts. Twenty-five ducts of the parotid gland and 20 ducts of the submandibular gland were examined histologically at different points of their anatomic course, and their in vivo diameters were evaluated with the use of a previously determined formalin-induced shrinking-factor. The mean diameter of Stensen's duct at four different points along its length ranged between 1.4 mm and 0.5 mm, with a maximum of 2.3 mm and a minimum of 0.1 mm, depending on the site. A narrowing at the middle of the duct was striking. In all preparations examined, the minimum width of the excretory duct was located at the ostium. In Wharton's duct the narrowest duct diameter was also identified at the ostium. The mean values for the duct diameters ranged between 1.5 mm and 0.5 mm. The largest duct diameter reached 2.2 mm; the smallest one, 0.2 mm. For diagnostic and therapeutic purposes, endoscopes, balloon catheters, and stone-extraction-baskets probably should, despite the extensibility of the duct, conform as much as possible to the physiologic duct widths. A diameter of 1.2 mm should be aimed at as an upper limit for these instruments. Our findings also suggest that, in the case of salivary stone lithotripsy, the best results will be achieved when the maximum size of stone fragments does not exceed 1.2 mm.

[Electrohydraulic intracorporeal lithotripsy of salivary calculi. In vitro and animal experiment studies]

BACKGROUND

Extracorporeal lithotripsy is now used routinely for the treatment of salivary duct stones. The question arose whether electrohydraulic intracorporeal lithotripsy, which is applied in urology and gastroenterology, might also be useful in the treatment of this disease. Before its possible clinical application the influence of electrohydraulic intracorporeal shock waves on salivary stones in vitro and any influence on the tissue in the head and neck region (in vivo) had to be investigated.

MATERIALS AND METHODS

In vitro experiments. Fifty-eight salivary stones and 11 extirpated human submandibular glands were treated by three different electrohydraulic devices. Animal experiments. Electrohydraulic shock waves were applied to the dilated Stensen's duct and other tissues (muscle, parotid gland, facial nerve) of six rabbits.

RESULTS

Of 58 salivary stones, 53 (91%) were fragmented, 39 (67%) with a remaining size of less than 1.5 mm and 14 (24%) more than 1.5 mm. In 5 cases (9%) no effects were seen at all. Fragmentation occurred independent of the mineralogical components of the stone and independent of the different lithotriptors used. The smaller the probe diameter and the larger the stone, the more shock waves were needed to achieve fragmentation. With the smaller probes the stones could not be fragmented completely. In human submandibular glands, extensive tissue lesions could be evidenced macroscopically and histologically after application of electrohydraulic shock waves in vitro. Application of electrohydraulic shock waves to the dilated parotid gland duct of rabbits led to perforations of the duct after 1-5 single pulses. Lesions of nerves and blood vessels could also be observed within the duct environment. This occurred with all of the different electrohydraulic devices, probe diameters and intensities used. In our opinion the damage produced is probably the result of both the direct effect of the plasma as well as the resultant stress wave.

CONCLUSION

In view of the severe damage caused to different tissues, use of the described method for the treatment of stones in the narrow human salivary ducts should be greatly restricted.

Results of endoscopic surgery of the paranasal sinuses and anterior skull base

Based on the experience with more than one thousand endoscopical interventions at the paranasal sinuses, a concept of the surgical treatment of chronic sinusitis is presented. According to the individual localization and extent of pathologic changes, appropriate operations may be selected. They follow the principles of conservative surgery. Regeneration of the diseased mucosa is enhanced by the reestablishment of ventilation and drainage instead of its radical removal. The endoscopical postoperative care is mandatory. A follow-up of 90 cases has evidenced a difference between subjective evaluation and endoscopic findings. Patients with bronchial asthma had benefits from their sinus surgery. Endoscopic management of foreign bodies, dural fistulas and benign tumors at the anterior skull base has also proven valuable.

ASA-induced release of histamine from nasal mucous membranes in analgesic intolerance and polyposis nasi

Tissue samples from the polypous mucous membrane and the inferior nasal concha were taken from 13 patients with polyposis nasi and from 12 other patients with an additional intolerance to analgesics. The tissue of the inferior nasal concha from patients without polyposis nasi served as a control. The relative histamine content of the samples (in ng/mg dry weight) and the relative histamine release (in %) after addition of acetylsalicylic acid (ASA) were determined. A significantly higher relative histamine content in the tissue samples of polyp patients without an intolerance to analgesics was seen in comparison to the other two groups. The relative histamine release of both patient groups with nasal polyposis was comparable. The control group exhibited both an increased spontaneous release of histamine as well as a higher relative histamine release from the tissue of the inferior nasal concha.