5th International Conference of the Saudi Oto-Rhino-Laryhgolgy Society on 14-16th October 2004 King Fahd Military Medical Complex Dahran, Saudi Arabia

doi:10.4103/1319-8491.289580

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Year : 2004 | Volume : 6 | Issue : 1 | Page : 19-56

5th International Conference of the Saudi Oto-Rhino-Laryhgolgy Society on 14-16th October 2004 King Fahd Military Medical Complex Dahran, Saudi Arabia

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12-Jul-2020

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DOI: 10.4103/1319-8491.289580

How to cite this article:
. 5th International Conference of the Saudi Oto-Rhino-Laryhgolgy Society on 14-16th October 2004 King Fahd Military Medical Complex Dahran, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2004;6:19-56

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. 5th International Conference of the Saudi Oto-Rhino-Laryhgolgy Society on 14-16th October 2004 King Fahd Military Medical Complex Dahran, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2004 [cited 2023 Mar 27];6:19-56. Available from: https://www.sjohns.org/text.asp?2004/6/1/19/289580

Cartilage Palisade Tympanoplasty

Prof. Wolf J. Mann

Underlay technique for repair of defects of the tympanic membrane in patients with chronic otitis media has become the gold standard throughout the world. However recurrent perforations may be seen in a approximately 10 % of the patients depending on the underlying pathology. Patients with Eustachian tube dysfunction, tympanosclerosis and burn injuries of the tympanic membrane seem to be specially prone for failure.

Cartilage palisade tympanoplasty reduces the likelihood for recurrent perforation providing greatest stability of the reconstructed ear drum without impeding sound transmission.

Functional results in patients with tympanoplasty type 1 fi III are presented and disadvantages of the technique are detailed.

Combined Endonasal - Transpalpebral Approach in Endocrine Orbitopathy

Prof. Wolf .J. Mann

Endocrine orbitopathy, refractory to medical treatment, with or without optic neuropathy is a complex disease, which makes surgery for functional or cosmetic reasons necessary. We are presenting long term results over 12 years in over 250 patients. Treatment consists of endonasal posterior eth- moidectomy with removal of the lamina papyracea at the orbital apex and unroofing of the optic canal in case of optic neuropathy. This endonasal micro- scopic/endoscopic approach is combined with transpalpepral fat removal. The amount of fat to be removed is tailored individually and depends on the required degree of Hertel reduction. Long term results are presented.

Intraoperative Navigation in Otolaryngology

Prof. Wolf. J. Mam

For intraoperative navigation in otolaryngology several systems are on the market based on electromagnetic or optica! referencing technology. Preoperative registration is performed using fiducial markers applied before imaging data are acquired or using laser surface registration. Technical advances include picture in picture presentation, microscope-adaptation, look-ahead function, image fusion of CT and MRI data and intraoperative ultrasound update of preoperatively acquired data sets of various imaging modalities. Set-up time and in vitro as well as in vivo accuracy for the various systems varies considerably. The profs and corn’s for different systems will be detailed.

New Strategies in Treatment of Chronic Sinusitis

Prof. Wolf J. Mann

Chronic rhinosinusitis often called chronic eosinophilic sinusitis is related to a non JgE mediated allergic reaction to fungal elements in the mucous of these patients. Molecular biologic examinations of the mucosa reveal, that fungal antigens are also present in the mucosa thereby attracting the eosinophils to migrate into the mucosa and finally into sinus secretions.

Changes in cyclooxygenase activation of the mucosa shift the relationship of prostaglandines and leukotriens towards the latter, this way aggravating inflammatory reactions. This is especially relevant in patients with complete triad of NSAID hypersensitivity but also in patients with an uncomplete triad. A specific desenzitation protocol for these patients will be presented.

Tips and Tricks in Lateral Skull Base Surgery

Prof Wolf J. Mann

Lesions involving the petrous pyramid and the adjacent middle cranial, posterior cranial as well as the infratemporal fossa require the combined expertise of neurosurgeons and neurootologists in order to select functionally silent approaches for tumor removal and preservation of function.

Incision of the temporal muscle, design of craniotomy, selection of retractors and lumbar drainage all have impact on postoperative morbidity.

Partial petrosectomies without rerouting of the facial nerve, preservation of the integrity of the tympanic cavity and ossicular chain and eventually the preservation of jugular bulb patency are today is achievable goals.

Several scenarios are presented.

Environment, New Frontiers For Rhinology

Prof. Wolf. J. Mann

The nose is gatekeeper for inhalant toxins, solvents, indoor and outdoor pollutants, controlling and protecting the body from environmental damage.

Various substances commonly occuring in our surroundings, such as S02, N02, trichlorethylen and formaldehyd are examined and their effect on ciliary beat frequency, mucosal transport time and inflammatory mediators are explained.

Functional and Aesthetic Reconstruction in Head and Neck Surgery

Prof. H. Maier

Basic principle in cancer surgery is not only radical tumor resection but also satisfactory functional and aesthetic reconstruction , which are important requirements for acceptable postoperative quality of life.

In a short overview several techniques including local flaps, pedicled flaps, free flaps and bone anchored epithesis for reconstruction of defects resulting from tumor surgery in the head and neck region are described.

Postlaryngectomy Vocal Rehabilitation Using the Provox Voice Prosthesis: Surgical Technique, Functional Results and Complications

Prof. H. Maier

The loss of the normal voice is the predominant problem after laryngectomy. Within the last 130 years numerous techniques for surgical voice restoration have been developed. In the last years the use voice prostheses ñ non-indwelling and indwelling prostheses - has become widely accepted. Within the last decade there was a switch to indwelling prostheses like the Provox-prosthesis.

In the lecture the technic of voice restoration by use of the Provox-prosthesis as well as functional postoperative results, postoperative quality of life and complications are described.

Hydrodissection, Conchosuction and Some Other New Tools: In ENT-Surgery ñ Nice To Have Or Essential..

Prof. H. Maier

First experiences with the use of some new surgical tools in ENT surgery are reported.

The basic principle of hydrodissection is dissection of tissue by a fine laminar water jet which is rotating at the surface like a drill while nerves and greater vessels remained unharmed. This technique has been successfully used for parotidectomy, oral surgery and especially for tonsillectomy. First results obtained with this tool indicate less blood loss, less trauma and less postoperative pain in comparison to conventional techniques.

Turbinoplasty by shaver technique using a new blade ñ the inferior turbinate blade allows a less invasive volume reduction of the lower turbinate. Preliminary results of a randomized study are demonstrated. Further first experiences with some other new surgical devices are reported

Burning Mouth Syndrome and Xerostomia - Aetiology and Treatment

Prof. H. Maier

Both oral dryness and a disorder known as burning mouth syndrome are fairly common oral conditions. It has been estimated that in the U.S. more than 40 million people suffer from oral dryness and as many as 2.5 million people are afflicted with burning mouth syndrome. Both conditions are not diseases per se but a group of complaints and symptoms wich are caused by a wide variety of different factors.

An overview of the causes and treatment options is given in the following. Special attention is paid to those clinical pictures which are of particular relevance to the field of otolaryngology.

Treatment of Nontumorous Salivary Gland Diseases

Prof. H. Maier

The collective name nontumorous salivary gland diseases describes a great variety of inflammatory and noninflammatory conditions of the major and minor salivary glands.

While the diagnostics have been improved significantly by modern examination techniques , treatment in many cases like chronic recurrent parotitis, myoepithelial parotitis, HIV- associated salivary gland diseases, mycobacterial infections or sialadenosis is still problematic.

In the lecture current surgical and nonsurgical treatment strategies are presented

Dysphagia and Swallowing Disorders -Etiology and Treatment

Prof. H. Maier

Differential diagnosis of dysphagia and swallowing disorders is complex. For example central nervous problems, cranial nerve deficits, muscle and connective tissue disorders, inflammatory conditions, structural problems and tumor surgery may play an etiological role. In the lecture an overview about the etiology of dysphagia and swallowing disorders is presented. Further treatment strategies for those conditions which mainly are related to the field of otorhinolaryngology will be described.

Concepts To Treat Cholesteatoma

Prof. Henning Hildmann

Cholesteatoma is a potentially life threatening disease. Growth patterns of cholesteatoma are shown. Surgery is absolutely necessary. Epitympanic retractions can be observed as long as no debris accumulates. The aim of surgery should be a safe self-cleansing ear. Hearing improvement should be tried in a one-stage procedure, but is second to safety. Intracranial complications do not necessarily need an open cavity. Attic, sinus and tensa cholesteatomas are to be approached differently. Mainly attic cholesteatomas expand into the epi- tympanon and the mastoid. They are followed by drilling from the ear canal. The defect is reconstructed with cartilage whenever possible to avoid an open cavity. For reconstruction of the tympanic membrane fascia, perichondrium or cartilage is used. Depending on the extent of destruction. The chain is reconstructed with the patientis own ossicles if not affected by the disease or titanium implants. As our studies show childrenis cholesteatomas or cholesteatomas in aged persons show no fundamental difference.

An Update on Chronic Otitis Media

Prof. Henning Hildmann

The paper deals with the problems of chronic suppurative otitis media. Generally accompanied with a central perforation or its sequela, such as atrophic scarring of the tympanic membrane with stapedio ñtympanopexia, interruption of the chain or tympanosclerosis. As in sinus surgery preservation of the middle ear mucosa prevent scarring and adhesions. Silicone is seldom necessary in the middle ear. Rare diseases such as tuberculosis have to be remembered. White granulations with little bleeding always call for a biopsy.

Generally there is no absolute necessity for surgery. Therefore the patientis general condition and his wishes must be considered. For instance a child wishing to swim is a candidate for surgery whereas a 70 year old patient who is not bothered by his dry central perforation is not. Promises for hearing improvement must be given critically for not every surgery succeeds.

In children under the age of ten in our series the results are not as good whereas Tos and coworkers die not see any differences. As a general rule the more extensive the destruction the less chances there is for hearing improvement in a one-stage procedure. Nevertheless in our opinion a one-stage procedure should always be tried. Even in highly inflamed meddle ears the closure of the tympanic membrane often treats the inflammation. Mastoidectomy is not generally necessary in a draining middle ear the indication can be individualized.

A side difference of more than 25 dB is generally not realized by the patient as a hearing improvement in spite the reduction of the air bone gap after surgery. Middle ear fibrosis, complete adhesive otitis and tympanosclerotic fixation of the stapes have a bad prognosis. Indication, selection of grafts and postoperative treatment will be discussed. Cartilage is especially helpful in adhesive otitis, totai or subtotal perforations and revision. It is mandatory if alloplastic material such as titanium is used for chain reconstruction to prevent extrusion of the allograft.

The Mastoid Cavity (Open or Closed Technique)

Prof. Henning Hildmann

An open cavity was the classical way of treating a cholesteatoma, opening the mastoid to the ear canal and thus allowing drainage to the ear canal. The disadvantages of many cavities are well-known, continuous need for care and cleaning. For this reason Jansen developed the intact canal wall technique preserving the natural anatomy of the ear canal. Unfortunately in later follow ups recurrence rates up to 50 % were reported. Safety should be the primary intention of cholesteatoma surgery. Nowadays the aim should be a self-cleansing ear, which needs as little medical attention as possible.

This calls for a more individualized attitude. The general rule especially for attic cholesteatomas is to follow the pathology to the epitympanon and the mastoid and to reconstruct the defect in the canal wall with cartilage if possible. Patients with foreseeable tubal dysfunction need a cavity. Also for patients with a sclerosed mastoid usually the small self-cleansing cavity needing little attention is the better option. Obliteration of a cavity must be considered as a closed technique because areas of possible recurrence are covered with the obliteration material. The presentation describes the different situations and possible solutions.

Failures in Middle Ear Surgery

Prof. Henning Hildmann

Some failures are typical for different types of interventions in the middle ear, some are of general importance. Many problems result from inexact preoperative diagnosis or patient information.

The audiogram should always be checked with the tuning fork to exclude shadow curves or wrong audiometry. The ear has to be controlled by the surgical microscope after careful suction.

Counseling of the patient should include the information, that the first aim in chronic inflammatory ear disease is the healthy ear and not hearing improvement. Second aim is restoration of hearing within the limits of the anatomy and audio logy. The patient has to know preoperatively about the possibility of a failure.

Immediate postoperative problems are inner ear- damage, vertigo, and damage to the facial nerve. While postoperative inner ear loss vertigo and tinnitus are generally treated with antibiotics surgical revision might in some cases be necessary. It is absolutely mandatory in postoperative facial paresis to exclude or repair the damage of the nerve.

Postoperative meatal stenosis can generally be prevented by preventing circular damage to the meatal skin. It is often better to remove skin flaps in danger and replace the as free grafts after surgery. Additional split thickness grafts from the posterior side of the auricle may be used. Widening the ear canal the bony covering of the anterior canal wall should remain intact to prevent a prolaps of the connective tissue surrounding the temporomandibular joint. An average postoperative treatment of a mastoid cavity of 2.5 month is normal. Longer postoperative draining may be due to persistent disease, reperfoation of the drum, persisting secreting cells a high facial ridge or irregular shape of the cavity. On the other hand preserving or reconstructing the posterior wall in cholesteatoma presents other problems, especially not recognized recurrent or persistent disease. Treatment policies are described.

Late problems are the lack of hearing improvement or recurrent disease. Indications and limits for revision surgery will be discussed. Rare cases such as malformations, meatal stenosis or tumors should be left to experienced surgeons. Failures in stapes surgery include inner ear damage with hearing loss, vertigo and tinnitus and late complications such as perilymph fistula, necrosis of the long process of the incus and dislocation of the prosthesis.

Exclusive surgery in the ear canal is not common compared to the inflammatory diseases of the ear and the otosclerosis. The possible solutions and approach for post inflammatory fibrosis, meatal stenosis, fractures of the canal and exostoses will be presented. Finally the dealing with complication of infective ear disease with the intracranial complications are discussed.

Cochlear Implantation (Selection of Patients, Surgery and Postoperative Treatment)

Prof Henning Hildmann

The presentation will be covering 3 parts:

Selection of patients.
Surgical procedure.
Post operative habilitation and rehabilitation.

The cochlea implant is like a hearing aid a tool for communication and does not cure hair cell dysfunction. Preoperative expectations largely shape postoperative satisfaction with any form of auditory rehabilitation (Ross and Lewit) It is therefore necessary to make the patients or the parents realize that up to now we cannot predict the outcome in the individual case. Technical failures with the necessity of reoperation are possible. The indications for adults are; acquired deafness with word discrimination not exceeding 30 % under the best aided conditions, the use of high powered hearing aids for 6 months and the verification of the function of the cochlear nerve by stimulation of the promontory or the ear canal. Prelingual deaf adults are no favorable candidates for implantation

For children early implantation gives better results. Therefore they should be implanted as early as possible as soon as the diagnosis is clear, that a child is not developing speech with hearing aids.

A try and observation with high-powered hearing aids has to precede the implantation. Imaging verifies the existence of the inner ear structures and the cochlear nerve. Prelingual evaluation bv a team ot otologists, speech therapists, pediatric neurologists and audiologists is necessary. Especially in children the operative diagnosis is teamwork, which has to continue after implantation. Intensive care of the patient and the family of the patient should precede the operation. Usually the expectations of the patient and the family are too high and have to be reduced.

Contraindications are central deafness, autoagres- sion, autism .progressive neurological disease, short life expectancy and the impossibility to rehabilitate the child postoperatively. The support of the family and rehabilitation facilities are absolutely necessary. For implantation we use the transmastoid approach. The procedure will be illustrated and variations will be discussed.

Postoperatively the healing is generally without complications and rehabilitation can be started after 3 to 4 weeks. Care hat to be taken to the flap design, to the thickness of the flap and the prevention of hematoma.

The third part covers the postoperative care, which remains multidisciplinary especially in children. After careful fitting, which has to be slow and step- by-step especially in children, prelingually deaf children have to learn to hear before they can learn to speak. In postlingually deaf the patientis speech rehabilitation generally is easier unless there are additional problems.

Handicapped children can also be implanted, however with less favorable results. A higher incidence of meningitis after implantation is reported. The existing literature will be reviewed.

Revision Surgery After Cochlear Implantation

Prof. Henning Hildmann

The intention of the paper is to give an overview of the possible causes for revisions and the possibility of prevention. Based on 21 cases of revisions our personal experience is discussed. Revision surgery was done within a week of the implant failure. In 8 patients the fitting parameters could be left unchanged, one had to be readjusted and one was implanted on the other side due to ossification. The intraoperative findings are illustrated. Further possible factors for failures are presented.

Unfortunately there is no surgery without the chance of failure and the need of revision. Certainly for smaller complications failure is not a problem. Infections of the surgical site are rare and can often be treated with the antibiotics. Extreme infections might require explanation. It seems that larger areas of silicon n or around the favor the persistence once an infection has started. Hematomas can be generally prevented by pressure dressing and might have to be punctured under sterile conditions. Postoperative facial palsies always have to be revised and checked for unintentional surgical damage be it direct or indirect by heat trauma due to contact with the drill or the shaft. The covering of the implant, skin and connective tissue, should not exceed 7 mm. Thicker layers make it difficult to place the speech-processor coil or require stronger magnets. So far no extractions of electrodes due to the growth of the scull after implantation in very small children have been reported.

The electrode can be damaged by and break by constant movement if it is placed on the temporal muscle. It should be therefore always be placed under the periosteum. Stimulation of the facial nerve can be stopped by switching of the electrodes in contact with the nerve. This might be difficult in cases of malformations of the inner ear, for instance Mondini malformations.

Late revisions might be due to fracture of the electrode, external physical damage of the implant or technical brake down. The findings such as ossifications, scar formation, problems of electrode replacement and refitting are in these cases discussed and presented.

New Trends in the Diagnosis Of Otosclerosis

Prof Bernard Fraysse

Otosclerosis (OS) is an osteodystrophy genetic disease which develops from residual cartilaginous ilots of the otic capsule.

Clinically, the disease has been described as far as 1914, This is the classical form of Lermoyez. Most often, the patient is a 30-40 year-old woman who complains for a hearing loss most often bilateral, tinnitus, or vertigo, or most often for a hearing loss associated to tinnitus. This patient presents a familial history of otosclerosis and/or undiagnosed deafness in the family.

Acoumetry, pure-tone audiometry (PTA) and impedancemetry confirm this diagnosis.

However, the classical form is not the most frequent presentation-†: unilateral deafness, absence of familial history, mixed hearing loss, absence of a Carhart notch at 2000 Hz at PTA can be encountered. The differential diagnosis, that is, minor malformation of the ossicles, tympanosclerosis of the stapes, malformation of the annular ligament etcO, for which the surgical results are inferior compared to OS, may be difficult to deter clinically.

In these cases, computed tomography (CT) may help to the positive diagnosis of OS. In 84,2% of patients reffered with a conductive deafness and normal eardrum, CT confirmed the diagnosis OS. This exam, if it is realized in good circumstances, shows an hypodensity of the otic capsule, with unclear boundaries. Topography of the focus is the anterior margin of the oval window (84%), peric- ochlear most often associated with an anterior focus. A thickening of the footplate, although not specific, may also confirm OS.

In this course, we show that an endostal extension of a pericochlear focus or an obliteration of the round window explains the elevation of bony hearing thresholds and leads to inferioir results. We introduce a form of OS called infra-radiologic OS which is a genuine OS confirmed during surgery without radiological signs. In these latter cases, which corresponds to a beginning focus, there is a statistically a higher percentage of footplate mobilization or fracture during surgery. We also focus on the interest of CT for the differential diagnosis and in revision of OS surgery. Finally, as OS is a genetic disease, we will present the results of a genetic study based on CT-scan of OS patients. We have shown that OS have different radiological presentations according to the familial history of the patient. We concluded that a positive familial history is a very important element in the decisionmaking.

In conclusion, this course emphasizes the interest of CT in the management of all the patients presenting with a conductive hearing loss associated with normal eardrums.

Classification of Cholesteatoma: Surgical Strategy

Prof. Bernard Fraysse

The objective is to analyse the particularities of different Cholesteatomas depending on clinical exams, history, otoscopy, radiological and audio- metrical datas leading to classify these cholesteatomas in many types: cholesteatoma, post retraction, post perforation, papillary cholesteatoma and metaplastic cholesteatoma.

The cholesteatoma extension depends on several factors as the presence of differents compartiments in the middle ear and differents aeration pathways. So we have epitympanic cholesteatoma divided into posterior, anterior and lateral epitympanic cholesteatoma, mesotympanic cholesteatoma and holotympanic cholesteatoma.

The surgical strategy that will results is divided into:

large anterior epitympany for the epitympanic cholesteatoma
transmeatal atticotomy for the isolated lateral epitympanic cholesteatoma
large posterior tympanotomy for the mesotym panic cholesteatoma
for the holotympanic cholesteatoma, we realize a mixed technique or canal wall down technique depending on the pneumatization of the mastoïd.

Cochlear Implant: Our Experience About 267 Cases

Prof. Bernard Fraysse

The authors report a series of 267 patients of cochlear implant. Of these, 27 are monochannels and 240 are multichannels. The proportion of the adults and the children is 52,43 % and 47,57 % respectively.

In this presentation, the audiometric, electrophysiological, speech therapist and neuroradiological assessment will be discussed as well as the critical indications such as implantation : 1) in the young children, 2) in malformations and 3) in severe deafness.

Concerning the operative technique, the minimal invasive incision will be considered as well as the principles of hearing preservation cochleostomy.

Results of implantation will be detailed in the case of children, the old subjects and in severe deafness.

Management of Acoustic Neuroma: Our Algorithm

Prof. Bernard Fraysse

Summary

The aim of this study is to report the management of 469 cases of patients with acoustic neuromas taking charge in our departement. 304 patients were operated, most of them through a translabyrinthine approach. 114 patients were fol- lowed-up during an average period of 48 months. 24 patients were managed by fractionated stereotactic irradiation. This study helps the autors to specify the follow-up as well as the algorithm for the management of acoustic tumors.

Objectives

The therapeutic decision in front of a patient with acoustic neuroma is difficult. This difficulty has mainly two reasons. First, there is not predictive factors of the evolution of this benign tumor which is often asymptomatic. Second, this tumor is diagnosed more and more early that implies a new management of the patients. The management can be a treatment by surgery or radiotherapy or a conservative approach with a follow -up of the patients. This study makes an analyse of this management in our departement and helps in deducting the best one for every case.

Study design

The autors report their experiences of 469 cases of acoustic neuromas between 1985 and 2002. Every patient has been manage by a multidisciplinary team formed by a otologist surgeon, a neuro surgeon and a radiotherapist. Every patient has a clear information on the modalities of treatment after the diagnosis has been made. This information is done by every members of the team in a specialized visit. The final decision is made during a meeting according to the patientis preference in all the cases. Several factors have been taken into consideration!: the patientis age, the tumoris size, the symptoms and the presence of surgical contraindication.

In case of a surgery decision, we used 3 approaches: trans-labyrinthine, retrosigmoOd and midle fossa-approach. Most of the patients were operated through a translabyrinthine approach. Conservative approach is being reserved to the grade 1 and II acording to the classification of Koss and in useful hearing patients (PTA<30 dB, speech discrimination>80 dB).

In case of radiotherapy, there is two modalities of irradiationf: gammaknife or fractionated stereotactic irradiation. Only fractionated stereotactic irradiation is used by our team. Weive made this choice because of the physic bases of this type of radiotherapy and of the knowelge of the side effects.

It consists in a daily irradiation of 2 grays, 5 days a week for 5 weeks (whole irradiation of 50 grays). The follow up consists of a clinical monitoring every 6 month and a radiological mon itoring every year.

In case of conservative management, the patient is follow-up clinically on a 6 months basis and radio- logically by an MRl of of the cerebello-pontine angle every year.

Results: 304 patients (65%) were operated. Most of patients were operated through a translabyrinthine approach. 114 (31 %) patient were follow up by ‘twait and scan during an average period of 48 months. To date 73% still in observation, 11% necessitated a therapeutic management, 11 % are lost of view, 4% refused the observation and 1 % are dead.

24 patients (5%) were managed by fractionated stereotactic irradiation.

Conclusion: The mainly determining factors of the management of a patient with an acoustic neuroma are the patientis age, the tumoris size and the patientis symptoms. According to these 3 factors we tried to made an algorithm of our management (Figure 1).

For young patients, we operate all the cases of grade III or IV, for the grades I and II the decision depends on the presence of symptoms.

For elderly patients, the trend is to follow -up. If the tumor increase in size (grade III or IV) or if the symptoms are invalidating we discuss radiotherapy or surgery according to the health status of the patients and their preference.

For a middle age patient without surgical contraindications, we operated all the tumors of grade III or IV and the symptomatic tumors.

Every patient is a particular case and the therapeutic decision must be made after discussing all the alternatives in order to find the best management.

Is Fess Safe

Dr. Kevin J. Kane

The advent of nasal endoscopes has given rhino- logic surgeons an unprecedented view of the nasal cavity together with the intricate anatomy of the ethmoidal air cell system and its associated major sinuses. However nasal endoscopes and faulty surgical technique can also disorientate the surgeon with the possibility of severe complications such as intracranial penetration or damage to the adjacent orbit.

When endoscopic sinus surgery was introduced to the English-speaking world in 1984, dire prognostications of such eventual complications was predicted.

Have these eventuated? This surgeonis experience with the technique since 1985 with a personal series of approximately 5000 cases will be outlined. What difficulties and complications the author has experienced in this period will be discussed.

Posterior Ethmoid and its Variations

Dr. Kevin J. Kane

In 1995, the International Rhinological Society Committee on Anatomic Terminology and Classification published their report on new descriptions and definitions of sinus anatomy that had come to light with the advent of nasal endoscopy, CT scanning and endoscopic surgical dissection. (Annals of Otology, Rhinology and Laryngology, Suppl. 167, Vol. 104, No. 10, Part 2. Pgs. 7-16 Oct. 1995).

The Committee has decided to update and revalidate this document with new understanding and highlight some remaining controversies and new information that have been published subsequently. A metaanalysis of publications has been undertaken of the last decade of relevant material. Attention has been focused on the definition, frequency and importance of the sphenoethmoidal ccll (Onodi cell) and the anatomy of the superior turbinate and how this structure can be used as a guide and landmark for surgical entry into the sphenoid sinus. The great variation of posterior ethmoid cell size and number is also highlighted and how this arrangement is dependant on the configuration of the basal lamella of the middle turbinate.

Recirculation of Mucus as a Cause of Persistent Sinusitis

Dr. Kevin J. Kane

Recirculation of mucus between adjacent openings in the maxillary antrum is a relatively common cause of persistent sinusitis in either the pre or post surgical patient. Although eluded to by other authors, the condition is inadequately described and poorly understood. It is particularly common after Functional Endoscopic Sinus Surgery when the new middle meatal antrostomy has been sited too far posteriorly Behind an existing natural maxillary ostium. Other recirculation pathways include between the natural ostium and an accessory ostium; between a middle meatal antrostomy and an inferior meatal antrostomy and through a perforated uncinate process. It may be a factor in the persistent infection of the other major sinuses also. The condition is easily diagnosed with the nasal endoscope and the surgical remedy of joining the separate openings into one larger antrostomy is readily carried out under local anaesthesia in the rhinologistfs office.

The phenomenon will be illustrated with numerous slides and short video.

Pacdiatric Fess in Australia

Dr. Kevin J. Kane

Idea: One of the most controversial subjects in the field of chronic rhinosinusitis is the role of endoscopic sinus surgery in the paediatric age group, particularly in children under 10 years of age.

Method: To gauge a national perspective of the controversy, a questionnaire was circulated to 50 Otolaryngologists practising in Australia with a particular interest in FESS and paediatric otolaryngology.

The questionnaire addressed the following issues of paediatric rhinosinusitis:

How practitioners made the diagnosis;
What were the indications for CT scanning;
What practitioners considered failed maximal medical therapy to be;
What were the indications for FESS;
What extent of endoscopic surgical resection was performed; and
What numbers and complications they had experienced.

Results: The results of the census suggested that there was very little support to perform endoscopic sinus surgery in children with symptoms suggesting uncomplicated chronic rhinosinusitis particularly those less than seven years of age.

Conclusion: It was perceived that the condition was mainly a mucosal and immunological problem rather than osteomeatal obstruction which might be amenable to surgical treatment.

Modern Trends in Rhinomanometry

Dr. Kevin J. Kane

Rhinomanometry In Clinical Practice

Since the turn of the century, clinicians have recognised the need for an objective measure of nasal function. Early workers used a variety of ingenious devices including the frosting on mirrors held under the nose which had marked calibrations to give an indication of air flow.

Early Rhinomanometers were dogged with the problem of inaccuracy, reproducability and the requirement of continual calibration. The new generation of digitalised computerised Rhinomanometers mainly developed by the Europeans are accurate, easy to use and give much information on the state of the airway resistance as well as the likely causes.

Most clinicians use active anterior

Rhinomanometry to measure nasal function.

Other types available are active posterior

Rhinomanometry, passive anterior

Rhinomanometry and head out body

Plethysmography.

All utilise a pneumotachometer to measure air flow and pressure transducers to measure pressures in front and at the back of the nose. By utilising Ohmis Law for current flow (l=PD/R ie: R=PD/l=( P/V() the equipment is able to instantly calculate the rcsistancc within the nose at any given pressure and flow. Different graph results before and after nasal decongestion can also give a clue as to the likely pathology.

A recent extension is to combine acoustic Rhinometry with Rhinomanometry. Modern equipment is able to utilise the same computerised soft ware to drive both modalities.

For 15 years, the author has used Rhinomanometry to help differentiate those patients complaining of nasal obstruction from underlying chronic rhinosi- nusitis vvho require a Septoplasty or valve surgery as well as FESS from those who merely require FESS alone. Data will be presented to support this concept.

Fess and the Sphenoid

Dr. Kevin J. Kane

A safe reliable method of surgical entry to the sphenoid sinus is described using the superior turbinate and its insertion onto the anterior face of the sphenoid as a landmark. Such an exposure using a nasal endoscope lias proved to be an invaluable method of entry of a structure that is notorious for its difficulty.

The Crooked Nose

Dr. Peter Allan Adamson

The crooked nose is one of the most challenging deformities in rhinoplasty. This presentation defines and classifies the various deformities seen and establishes essential concepts for correction. A surgical approach which identifies the specific deformities related to the septum, nasal tip, nasal dorsum and the skin soft tissue envelope are discussed. Special attention is paid to scoring and incisional maneuvers to improve the crooked septum. The crooked tip is corrected utilizing a variety of suturing techniques, vertical lobular division and grafting techniques. The nasal dorsum is approached with medial, lateral, intermediate or transverse root osteotomies. Augmentation and/or reduction of the dorsum may also improve curvature. The middle third of the nose, i.e. the cartilaginous pyramid, often requires incisional, exci- sional, suturing and grafting techniques to improve curvatures in this region. These grafts include spreader and oniay grafts. The skin-soft tissue envelope can also be modified in certain cases. All of these techniques are described and illustrated with case presentations.

Advanced Nasal Tip Surgery

Dr. Peter Allan Adamson

It has been said that iHe who masters the tip masters rhinoplasty!. This presentation will review basic nasal tip anatomy and dynamics, stressing the importance of length, projection and rotation of the nose and their manipulation, applying the graduated tripod arch concept. Graduated approaches, which can be applied from simple to more severe deformities, will be outlined to manage problems of nasal tip over and under projection, over and under rotation, and changes in nasal length. The various techniques to improve the nasal lobule, including excisional, incisional, scoring and suturing techniques are presented. Special attention is paid to vertical lobular division which can be used to alter projection, rotation, lobule symmetries, the hanging infratip and the broad domal arch. Numerous examples of tip grafting, including the columellar strut and batten, various lobular grafts, alar batten and strut grafts will also be presented. Case studies which include dynamic diagrams indicating the procedures carried out will illustrate all of these techniques.

Cosmetic Otoplasty

Dr. Peter Allan Adamson

Protruding ears is a relatively common deformity in Caucasians. There is a definite psychological impact of this condition which has a genetic basis. The surgical anatomy of cosmetic otoplasty, including cadeveric dissection model is presented. A graduated surgical approach to correction, emphasizing the conchal soft tissue excision and modified Mustard sutures of the antihealical fold is illustrated with a videotape. Management of lobe protrusion and reduction of the scaphae and lobe are discussed. Surgical results illustrate the outcome of these maneuvers.

Management of the Alar Base and Hanging Columella

Dr. Peter Allan Adamson

Soft tissue techniques to improve alar base proportions and the hanging columella are essential tools for advanced rhinoplasty to achieve final refinement.

The indications for alar base reduction and the surgical technique are described in detail. This is illustrated with a videotape and specific case examples outlining the various applications of this technique. In particular, emphasis is placed on accurate diagnosis of the width of the alar base, the circumference of the nostril, and the degree of flare of the alar wall. The technique presented outlines a stepwise, graduated approach to effect an appropriate degree of refinement with consistent and reliable results.

The hanging columella can present a challenging problem in the primary or secondary rhinoplasty, and is an unfortunate sequlae of certain rhinoplasty maneuvers. The hanging columella and pseudo- hanging columella are defined. Surgical strategies to correct the anatomic deformities are outlined and illustrated. The etiologies include excessive caudal length of septal cartilage, redundant membranous septum, excessive width of the medial crura, ptosis of the medial crura, inadequate placement of columellar struts or battens, and the broad vestibular vault. Etiologies of the pseudo-hanging columella include cephalic insertion of the lateral ala and ala rim retraction. Case studies illustrate the correction of these deformities.

Patient Selection and Management in Cosmetic Surgery

Dr. Peter Allan Adamson

Patient selection is one of the most important aspects of achieving a satisfactory rhinoplasty result. In reality, patients select us as much as we select them. The goals of rhinoplasty, as well as the surgeonsi and the patientsi roles in patient selection, are discussed. The psychology of patient selection is reviewed, emphasizing characteristics which make a person a good or poor candidate. The risk factors associated with rhinoplasty are considered. Current concepts of beauty are reviewed, emphasizing their importance in patient selection. The importance of appropriate data collection is stressed. Surgical factors affecting patient selection are reviewed. These include differences in men and women, young versus older patients, race factors, primary versus secondary patients, functional versus cosmetic and skin thickness factors. Methods to improve patient selection are outlined. The ultimate goal is to achieve the most satisfactory rhinoplasty result for both the patient and the surgeon. Nevertheless, all rhinoplasty surgeons must occasionally deal with unsatisfied patients. The incidence of patient satisfaction is presented and the unique situation of dealing with patient selection for revision rhinoplasty is examined. Special challenges in revision cases and criteria to proceed with elective surgery are reviewed. Warning signs to avoid the potentially dissatisfied patient and causative factors are outlined. The principles and specifics of patient management in addition to specific syndromes such as the chronic pain, exhausted surgeon and loss of identity syndromes are studied. Case presentations illustrate the lecture.

Fess: Routine Post-Operative Care and Topical Treatment With Yamik Sinus Catheter

Prof. Andrey Lopatin

Any surgical intervention in the nasal cavity and paranasal sinuses initiates a sophisticated process of wound healing involving different tissues: mucosa, bone, and/or cartilage. This process consists of several histomorphological phases, namely clot formation, inflammatory and immune reaction, and finally, tissue remodeling and scar maturation. In contrast to skin, bone, cartilage etc., not much is known about healing of the sinonasal mucosa. It is assumed that the course the nasal mucosa regeneration depends on a complex interaction between epithelium and extracellular matrix regulated by numerous cytokines and growth factors. Several endoscopically defined clinical stages of the nasal mucosa healing have been described (Hosemann, 1990, Shilenkov, 1999) but they purely correlate with the above histomorphological phases. As a matter of fact, postoperative care after FESS should start in the end of the surgery with a careful cleaning and packing of the opened ethmoidal cavities. Self-made elastic tampons or commercially available dressings must not strongly press wound surface. Problems of the early post-operative period (up to 10th day after surgery) are: fibrin clots formation, crusting, and collection of retained muco-purulent secretion in the operated sinuses. There is also a risk of bleeding when fibrin clots or crusts are removed from the wound surface, either spontaneously, or during douching or aspiration. By the end of this period, patient must be under careful medical control. Daily procedures should include decongestion, douching with an antiseptic solution, cautious aspiration of obstructive crusts under endoscopic control, and application of corticosteroid ointments. Systemic corticosteroid therapy should be continued in asthmatic patients. Exhaustive written instructions regarding further post-operative care must be given upon discharge from the hospital.

At the second period (outpatient follow-up), patients continue saline nasal irrigations or douches up to 1.5-2 months, and topical corticosteroid aerosols. Regular use of isotonic seawater sprays significantly improves healing and mucociliary transport and provides faster relief of post-operative nasal obstruction (Akulich, Lopatin, 2002). To prevent synechia formation, endoscopic inspection of the nasal cavity should be performed weekly.

The major problem of the distant follow-up period is recurrent purulent sinusitis that occurs not infrequently, particularly after upper respiratory infections. Because of obstruction of the surgical ostia, these episodes of sinusitis are often resistant to antibiotic therapy. The YAM IK. sinus catheter was developed some 20 years ago in Russia to evacuate secretion from all paranasal sinuses of one side and to introduce antiseptic and other medical solutions through the sinusesi natural ostia (Kozlov, Markov, 1993). Recently, efficacy of this method was studied in cases of recurrent purulent rhinosinusitis in patients who underwent endonasal sinus surgery (Shilenkov, 2001; Gosepath et al., 2002). These studies showed that YAM1K method appears helpful in treatment of post-surgical sinusitis and it can replace revision surgery in most of the patients.

Endonasal Surgical Repair of CSF Leaks

Prof. Andrey Lopatin

CSF rhinorrhea is usually considered primary (spontaneous) and secondary. The latter may have traumatic (including iartogenic) origin or may be caused by intracranial and skull base tumors. Head trauma is the most common cause for CSF leaks and majority of trauma-related CSF leaks resolve without surgical intervention. Persistent CSF rhinorrhea is potentially lethal. As it may lead to meningitis or brain abscess, surgical treatment is often required. The earliest attempts of CSF fistula closure via intracranial approach are dated back to the third decade of the XX century (Grant, 1923; Dandy, 1926; Cushing, 1927). Dohlman (1948) was the first to successfully repair a CSF fistula using extracranial approach.

Developments in endonasal endoscopic surgery have made surgical procedures less invasive and CSF rhinorrhea is now one of its well-established extended indications. In most cases, endoscopic endonasal technique of CSF leak repair has almost completely replaced more traumatic transcranial and extracranial procedures. Different methods, namely onlay, underlay, and combined onlay/underlay placement of bone, cartilage, or mucosal free grafts, rotation of middle turbinate or septum flaps, as well as obliteration and the so- called itobacco porch? technique have been used for endonasal closure of small and large CSF fistulas.

Our personal experience of endonasal CSF leaks closure is based on a series of 55 cases. There were 7 post-traumatic, 21 iatrogenic, and 27 spontaneous teaks. Maximum size of the skull base defect was 18 mm. Preoperative examination included CT, nasal endoscopy, quantitative evaluation of glucose in the nasal discharge, and in some cases, CT cisternography and/or MRI cisternography. Telescopes, conventional endoscopic sinus surgery instruments, and a microdebrider were used in all patients who underwent endonasal surgery. A combination of different plastic materials, i.e., abdominal fat, facia lata, septal cartilage, rotated middle turbinate flaps, and fibrin glue were used for fistula repair.

Post-operative follow-up lasted from 6 to 56 months, and 50 patients were considered cured. Thus, the overall success rate was 90.9%. There were no postoperative complications.

In our series, patients with spontaneous CSF leaks represented a specific clinical entity warranted a separate designation. This cohort of 27 patients presented maximal diagnostic and therapeutic challenge. Possible etiological factors of spontaneous CSF rhinorrhea included obesity, innate skull base malformations, and overpneumatized sphenoid sinus (particularly in its lateral extensions). Spontaneous CSF leaks were often associated with meningocele formation and empty sella syndrome. In contrast to the others, dura defects located in a deep lateral recess of the sphenoid sinus were extremely difficult to visualize and manage with the endoscopic endonasal approach. Two patients with fistulas of this particular location developed recurrent CSF rhinorrhea in the distant follow-up. However, the overall success rate in the isponta- neousi group was 92.6%.

FESS: Minimally Invasive vs Extended Technique

Prof. Andrey Lopatin

To treat patients with chronic rhinosinusitis, functional endoscopic endonasal surgery (FESS) has been established in many centers throughout the world. Nowadays, we have got a huge number of different surgical options ranging from radical sphenoethmoidectomy with amputation of the middle turbinates (the so called inasalisationi) to imini- FESST procedure. Effectiveness of FESS in the treatment of chronic inflammatory sinus disease has been well proved in general, but there is a lack of evidence-based studies comparing effectiveness and outcomes of more radical and less invasive techniques of sinus surgery. There is an ongoing debate whether diseased or polypoid sinus mucosa should be removed thoroughly or if simply providing for ventilation and drainage of the ostiomeatal unit, is sufficient for recovery of the diseased sinuses. There is a feeling that minimally invasive techniques can provide better outcome than more extended {classical! surgery, but more evidence- based studies are needed to confirm this opinion. In a prospective randomized multicenter study immediate and distant resutts of minimally invasive and extended approaches were compared in 65 patients operated with either techniques (M.Kuehnemund et al„ 2002). The patients were examined pre-operatively and reassessed after 6 month and during distant follow-up visits using symptom-, CT- and endoscopic findings score as weli as saccharine transport time. Surgical outcome and post-operative symptomatology were similar in both groups of patients indicating that conservative approach is sufficient and obtains at least same results as more radical surgery.

In our series of 134 consecutive patients with maxillary sinus cysts (152 sinuses) endonasal approach through the natural ostium was sufficient in the majority (73.7%) of cases, additional external approach through the fossa canina was necessary only in the rest 26.3% cases (A.S.Lopatin, V.S.Nefedov, 2000).

Another study evaluated effectiveness of minimally invasive endoscopic shaver-assisted technique in 70 patients with chronic maxillary sinusitis of dental origin and oral antral fistula (A.S.Lopatin et al., 2002). The ooverall recovery rate after primary surgery was 94.7%. This showed that minimally invasive endoscopic approach, even in cases of oral antral fistula, was a reliable method associated with less morbidity and lower incidence of complications than classical Caldwell-Luc technique.

These few examples show a tendency of step-by- step shift from radical extended techniques to limited minimally invasive modalities, which allow for at least the same or even better outcome in treatment of chronic rhinosinusitis and nasal polyposis. Careful attitude to the natural sinus ostia and preservation of the sinonasal mucosa and anatomical structures of the nasal cavity are the clues, which should provide further perfectioning of the FESS outcomes.

Modern Trends in Endoscopic Endonasal Surgery

Prof. Andrey Lopatin

Endoscopic endonasal surgery (EES) has undergone considerable evolution during the two past decades. The greatest advantage of the endoscopic technique developed by W.Messerklinger is that radical procedures like total sphenoethmoidectomy can be avoided in the vast majority of patients with inflammatory sinus diseases. The Messerklinger concept and later technical innovations, especially new generation of endoscopes, high resolution video equipment, and soft tissue shavers have made endonasal surgery much more precise and less traumatic.

Image-guided navigation over the last years has developed into a helpful and reliable tool in ESS and anterior skull base surgery. Navigation devices offer significant advantages for specialized procedures including endonasal frontal sinus surgery, severe recurrent polyposis, foreign bodies and tumors of the sinuses.

Based on the excellent anatomical orientation provided by the new endoscopic equipment and intraoperative navigation, the limits of EES have considerably been pushed further. Both basic and extended indications for EES are now well established.

Basic techniques of EES cover:

chronic sinusitis, nasal polyposis, sinuses’ cysts, and non-invasive fungal diseases of the sinuses,
endoscopic surgical procedures for nasal septum, turbinates, and for anatomic variations of endonasal structures,
endoscopic adenoidectomy.

Extended indications of EES now include:

benign and some malignant neoplasms of the nasal cavity and paranasal sinuses,
nasopharyngeal angiofibromas,
pituitary tumors,
nasolacrimal duct stenosis,
cerebrospinal fluid fistulas and meningo (encephalo)celes,
foreign bodies,
certain forms of orbital and intracranial complications of sinusitis,
orbital and optic nerve decompression,
choanal atresia, etc.

One could object that there is no new surgical procedure on this list, and this would be quite true. As a matter of fact, endoscopes, shavers, and navigation systems are used to perfonn same surgical interventions but more effectively and with a less damage to anatomical and functional integrity of the nose and paranasal sinuses. The evolution of ESS will be presented with several examples.

International Consensus on Nasal Polyposis Update on Pathogenesis, Medical and Surgical Therapy

Prof Andrey Lopatin

Nasal polyposis is a global health problem affecting approximately 1 to 4% of population worldwide. This is a confusing disease for ENT practitioner. Correct definition of the disease has not been given yet. As it is often mixed with other concomitant conditions like asthma, allergic rhinitis, aspirin intolerance, cystic fibrosis etc., nasal polyposis does not present a specific clinical entity. Even large solitaiy choanal polyps may have different sites of origin, i.e., different pathogenesis.

During the last two decades a great number of histopathological, immunohistochemicai, and immunological studies has been carried out. Up to date, two international consensus meetings on nasal polyposis have been held in Siena (2000) and Zagreb (2002), and the first version of consensus document has been obtained and is being published. This book is summing up contemporary knowledge on the pathogenesis, diagnosis, and treatment of the disease.

Etiopathogenesis of nasal polyposis is still largely unknown. From the histological point of view, polyps consist essentially of edematous tissue covered by damaged or metaplastic epithelium and infiltrated by inflammatory cells, mostly eosinophils. How this eosinophilic inflammation leads to polyp formation and growth remains unclear. One of the theories (Bachert et al., 1999) suggests that high concentrations of interleukin-5, eotaxin, and eosinophil cationic protein upregulate eosinophils recruitment into the nasal mucosa and inhibit their apoptosis.

The role of fungi in the pathogenesis of nasal polyps has been much discussed of late. Ponikau et al. (2002) hypothesize that nasal polyposis is a systemic disease caused by hypersensitive T-lympho- cytes, which recruit and activate eosinophils when they meet a fungal allergen. The exact relevance of fungi in the etiology of nasal polyposis and the implications for antifungal therapy have yet to be determined.

Studies by Gosepath et al (1999) revealed in vitro NSA1D intolerance, i.e., incomplete aspirin triad in up to 80% of patients with chronic sinusitis/nasal polyposis. This means that non-IgE-mediated hypersensitivity, which affects the eicosanoid pathway by inhibition of cyclooxygenase may be another pathogenetic factor of nasal polyposis. Genetic etiology is suspected in the development of nasal polyps on the basis of familiar aggregation. It has been shown that people carrying HLA- A74 allele had higher risk of nasal polyposis development (Luxenberger et al., 2000).

Therapy of nasal polyposis revolves around medical and surgical treatment, or a combination of the two. The only conservative method with evidence based proven effectiveness is corticosteroid therapy. There are some other options, which are in progress and need further controlled studies:

topical and systemic antifungal therapy
topical and systemic aspirin desensitization
antibiotics
anti-leucotrienes
furocemidc inhalations

The spectrum of surgical methods encompasses a variety of procedures ranging from simple snare polypectomy to total sphenoethmoidectomy.

Endoscopic endonasal shaver-assisted sinus surgery with preservation of nasal turbinates appears to be the method of choice.

Allergic Rhinitis Current Who Guidelines and the Role of Surgical Treatment

Prof. Andrey Lopatin

Allergic rhinitis, one of the most common form of rhinitis, affects hundreds million people all over the world, including 10% to 30% of adults and up to 40% of children. It is an important cause of widespread morbidity. Although sometimes mistakenly viewed as a trivial disease, symptoms of rhinitis may significantly impact the patient’s quality of life causing fatigue, headache, cognitive impairment, and complicating conditions, such as asthma, sinusitis, or otitis media. The cost of treating rhinitis as well as indirect costs related to loss of workplace productivity resulting from the disease are substantial.

Allergic rhinitis is defined as a complex inflammation of nasal mucosa caused by exposure of inhaled allergens, and characterized by nasal obstruction, rhinorrhea, sneezing, itching of the nose and nasal discharge. The latest WHO guidelines (Allergic Rhinitis and Its Impact on Asthma n ARIA, 2001) proposed a new terminology and classification of the disease. Instead of habitual division in seasonal and perennial forms, ARIA suggested intermittent and persistent forms of allergic rhinitis. Importance of appropriate diagnosis and therapy of co-existent asthma and bronchial hyperreactivity has been also stressed in this document.

There are three major options in treatment of allergic rhinitis: avoidance of inciting factors (allergens, irritants, medications), medical therapy, and allergen immunotherapy. Efficacy of these methods has been well proven and every method has a specific position in the therapeutic protocols designed for management of mild, moderate, and severe forms of rhinitis. In contrast, indications for surgical treatment are not that clear. There is no doubt that nasal turbinate surgery has never been a first line therapy for allergic rhinitis. However, there are some typical situations when allergic rhinitis patients definitely benefit from surgical treatment. There are:

anatomic variations, i.e. nasal septum spurs and ridges, which contact lateral nasal wall;
true irreversible diffuse or local hypertrophy of the inferior turbinates;
sinus cysts and concomitant chronic sinusitis refractory to medical therapy.

If a complete course of relevant conservative treatment fails, thorough examination is necessary and indications for endonasal surgery must be considered. This examination is essential before making a decision, and it must:

detect occult reasons casing persistent nasal obstruction and inefficacy of the therapy,
check reversibility of the turbinates hypertrophy;
reveal bronchial hyperreactivity, and if present, elucidate its severity.

At the time of manifestation of rhinitis and asthmatic symptoms, surgery is temporary contraindi- cated and an adequate course of prophylactic treatment is necessary. The course usually consists of careful environmental control, hypoallergenic diet for 1 month in combination with 2nd generation antihistamines and/or topical corticosteroids for 2 or 3 weeks. In the case of pollen allergy, surgery should not be performed at the time of the pollen season.

Surgery itself must be minimally invasive and may utilize techniques of endoscopic or non-endoscop- ic correction of septum deformities, submucous resection or cauterisation of the inferior turbinates in combination with amputation of their tails, and in some cases, endoscopic sinus surgery. Only a combination of correctly selected endonasal operation and adequate course of pre-operative and postoperative therapy provides significant relief of nasal obstruction and prevents exacerbation and further development of the disease.

Systematic Computed Tomography Study for Safe and Effective Endoscopic Sinus Surgery

Prof. Reda Kamel, Tarek Kandil, Ashraf Khaled, Hany Elgamal

Computed tomography has become the gold standard in the radiological study of the nose, Paranasal sinuses and nasophatynx. It helps achieve proper mapping of the area and identify most of the anatomical variations and pathological abnormalities. Moreover, it helps properly plan medical and/or surgical treatment.

The aim of this presentation is to demonstrate how to interpret CT in the office systematically and how to utilize it in surgical planning when indicated. This helps achieve both effective and safe surgery.

Transnasal Endoscopic Surgery in Choanal Atresia

Prof. Reda Kamel

Congenital choanal atresi is an uncommon disease.

Surgery is the treatment of choice. While bilateral choanal atresia is an indication for immediate interference, unilateral cases can be postponed to age of three.

Conventional approaches include the transpalatal and transnasal. The transpalatal approach which is most popular offers good exposure, easy creation and suturing of mucosal flaps, short term stenting, good results and lack of significant complications. On the other hand, it interferes with oral intake, and is associated with longer operative time, more blood loss, and longer recovery period, possibility of palatal fistula and affection of palatal growth and development affection.

Endoscopy and CT, which are essential before endoscopic surgery, help define the position, composition [bony or membranous] and thickness of the atretic plate.

The steps of endoscopic surgery in choanal atresia are composed of penetration and widening of the atretic plate, removal of the posterior part of the nasal septum and tubing. Its advantages are being most direct, mucosal spare, less complications, one day surgery, immediate feeding, possible revision surgery, easy postoperative care and follow up and good results. However it needs experience, special and expensive tool and may be associated with complication and/or recurrence.

Endoscopic Surgery in Inverted Papilloma

Prof Reda Kamel, Ashraf Khaled, Tarek Kandiel

Inverted papilloma is characterized by local aggressiveness, high rate of recurrence, associated malignancy and tendency to multicentricity. Surgery is the best treatment modality, however the approach and extent of surgery is still a subject of great controversy. Recent studies showed that, endoscopic sinonasal surgery, guided by computed tomography, could achieve good results in papilloma surgery. The aim of this study was to address the indications of endoscopic conservative surgery and transnasal medial maxillectomy in inverted Papilloma.

This study comprised 59 cases of inverted papilloma operated upon transnasal ly under endoscopic control. Follow up for periods ranging between two and eleven years showed no recurrence except in two cases. The author realized that inverted papilloma can be divided into two groups from the anatomical and behavioral points of view and accordingly should be managed differently. For those lesions without involvement of the maxillary sinus, intranasal endoscopic resection is effective, for those lesions with maxillary sinus involvement, transnasal medial maxillectomy, which could be performed safely under endoscopic control, is recommended.

Endoscopic Surgery in Nasopharyngeal Angiofibroma

Prof. Reda Kamel, Ashraf Khaled, Tarek Kandiel

Juvenile nasopharyngeal angiofibroma is a highly vascular and locally invasive tumor with a high incidence of persistence and recurrence.

This work comprised 14 cases of limited juvenile nasopharyngeal angiofibroma operated upon transnasally under endoscopic control. All these lesions were localized to the posterior nasal cavity, nasopharynx, sphenoid sinus and/or pterygopalatine fossa. The tumors were completely excised without complications. A wide middle meatal antrostomy, removal of the anterior wall of the pterygopalatine fossa and the anterior lip of the sphenopalatine foramen were basic steps in the procedure. Endoscopic follow-up for periods ranging between one and ten years and contrast computed tomography excluded any residual or recurrence. It was concluded that, in limited lesions of angiofibroma, experienced endoscopic surgeons could cautiously consider the option of a transnasal endoscopic approach. The transnasal endoscopic approach is the most direct and avoids any external, palatal and/ or sublabial incisions, However, it is feasible only in limited lesions and the surgeon should be ready for an open approach in case of inability to achieve good exposure and/or complete removal.

Pediatric Endoscopic Sinonasal Surgery

Prof. Reda Kamel

Recent advances in the fields of endoscopy and radiology paved the way for better chance of early and precise diagnosis and treatment of sinonasal diseases in children.

This paper presents the experience of the author in Pediatric Endoscopic Siunonasal surgery at Cairo University, Egypt during the last 13 years. Choanal atresia, chronic sinusitis, adenoids, foreign bodies, antrochoanal polyps, allergic fungal sinusitis, mucoceles, angiofibroma, dacryocystitis, O are addressed. It was concluded that transnasdal endo- scopoic sinus surgery is safe and effective but needs good justification and experience.

The Dilemma of Fungal Rhinosinusitis The State of the Art in Diagnosis and Management

Prof. Reda H. Kamel Tarek Kandiel Ashraf Khaled

Fungal sinusitis has become more common. It constitutes one of the most challenging situations in Otorhinolaryngology.

Invasive forms indicate debridement, and intravenous anti-fungal therapy. Allergic fungal sinusitis [AFS] has its peculiarities in both diagnosis and treatment. Treatment is based on aeration and corticosteroid therapy. Recently computed tomography and endoscopic sinus surgery helped achieve better results. However, recurrence constitutes one of the most frustrating outcomes in some cases.

The aim of this presentation is to demonstrate the state of the art in the classification, diagnosis and treatment of different forms of fungal rhinosinusitis.

Endonasal DCR

Dr. V. H.Oswal

The operation of Endonasal DCR involves making a surgical opening between the lachrymal sac and the nasal fossa, at the nasolachrymal ridge, just anterior to the middle turbinate. This new opening is proximal to the site of obstruction, so as to allow free drainage of lachrymal fluid. We have undertaken the endonasal procedure with Hof; YAG laser for past five years. The procedure is fairly routine as practiced in a number of centres. A retrospective analysis showed success rate in the region of 75%. Our initial routine method was modified in the two respects: Firstly, we think insertion of stent at the conclusion is not necessary. Our results without insertion of stents compared well with those with stents. Secondly, we think the success rate can be improved further by modifying the technique. We make an opening of four to five mm diameter in every case, measured by a simple probe which has a metal ball at each end, one with a diameter of four mm and the other with a diameter of five mm. The opening made by the laser will have a thermal damage zone around the periphery. This zone may encourage fibrosis with closure of the opening and lead to failure of the procedure, at lease in some cases. In the past nine months, we have started to remove the thermal damage zone of one to two mm around the rim with cold instruments. Special punch forceps was designed for this purpose. We also use micro drill to create bony opening. The initial results indicate that the success rate has risen to 89%. A prospective study is underway and will form the basis of further report in scientific journal.

Holmium: YAG Laser to Control Epistaxis in Patients With Hereditary Haemorrhagic Telangiectasia

Dr. V. H. Oswal

Hereditary haemorrhagic telangectasia (HHT), also known as Osleris or Rendu-Osler-Weberis disease, is transmitted in an autosomal dominant manner with a high degree of penetrance. HHT can affect any part of the body including the nose, eyes, skin, lungs, tongue, brain, gastrointestinal (GI) and genitourinary (GU) tracts. Manifestations of the disease are generally secondary to bleeding, and, since 90% of cases present with recurrent epistaxis (Guttmacher et al., 1995), the Otolaryngologist is often the first to encounter, diagnose and treat these patients (Proteous et al., 1992). The classic nasal mucosal lesions are the macular telangiectasia measuring one to three mm in diameter (Jahnke, 1970). They consist of vascular channels lined by a single endothelial cell layer originating from capillaries and postcapillary venules and, as such, are extremely susceptible to trauma leading to frequent and sometimes severe epistaxis.

The management of HHT is manifold. Acute management consists of control of bleeding with nasal packing, cautery etc. Long term management is both medical and surgical. The medical management consists of iron and folate supplementation and in some cases blood transfusions. The surgical management of telangiectatic vessels is variously aimed at reducing susceptibility to trauma by der- moseptoplasty, obliteration by embolisation (Vekery and Kuhn, 1996), and destruction by chemical or thermal methods.

During the last decade the thermal effects of various lasers have been used to destroy the HHT lesions by vaporising them - CO2 (Ben-Bassat et al., 1978), Nd:YAG laser (Parkin and Dixon, 1981 and Shapshay and Oliver, 1984) and Argon lasers (Parkin and Dixon, 1981). We report our experience of using Holmium YAG (Ho:YAG) laser for the HHT lesions in the nose, on the face and the tongue.

Hereditary haemorrhagic telangiectasia remains a challenging clinical problem. Although this technique does not represent a cure and does not prevent development of new lesions, we have fond that Ho: YAG laser to be a useful tool in controlling epistaxis in cases of HHT.

Ho: YAG Laser in Turbinate Surgery

Dr. V. H. Oswal

This paper aims at assessing the suitability of the Ho: YAG laser for reduction of hypertrophied inferior turbinate. The laser performs well for both vaporisation and intra operative haemostasis. However, it is associated with much spattering of tissues, thus soiling the endoscope Jens and blocking the view of the operating site. Hot flying debris is a potential hazard for septal perforation. A dedicated suction fibre cannula was designed to carry the fibre to the operating site and also suck the tissue debris by providing the channel in the close proximity of the operating site. The septum was protected with silicon splint. The turbinate reduction was carried out without any decongestant. There were no cases of intra or post operative bleeding.

The Ho:YAG laser consists of lasing crystal YAG ( yittrium-aluminium-garnet) doped with holmium element, emitting an invisible, near infra red (IR) wavelength of 2,120 nm (2.1 um). Since wavelength absorption in water reaches peak at 1.98 um, the 2.1 um Ho:YAG laser energy is well absorbed by water containing tissues such as mucosa. The ablative effect and the limited collateral thermal damage of the Ho:YAG thus compares favourably with the CO2 laser. Additionally, since the energy is transmissible through a small diameter silica fibre, the Ho:YAG laser can be used in conjunction with minimally invasive endoscopic procedures. The Ho:YAG laser energy is also transmissible both in gaseous (air, CO2) as well as liquid (blood, saline) media. The transmission through liquids is due to ‘Moses effect’ - part of the energy divides the liquid and produces a vapour cavity through which the remaining energy is transmitted to the target tissue (1). Therefore, unlike the CO2 laser, it is not necessary to have a totally bloodless field for tissue effects. Even though the wavelength emission at 2.1 um is very near the water absorption peak at 1.98 um, the Ho:YAG laser absorption in water is about two magnitude less than that of the CO2 laser (1). The Ho: YAG thus has a somewhat greater collateral spread of its energy, which also means that it is a superior haemostat when compared with the CO2 laser.

Some fifty five procedures were undertaken for evaluation of the technique, as follows:

An outpatient video-endoscopic assessment and VCR recording is carried out, preferably without the use of topical anaesthesia, or decongestant. The patency of the airway is assessed at the nasal valve, along the medial and inferior surfaces of the inferior turbinate and in the choana. Similarly, any hypertrophy of the middle turbinate is also noted and its contribution to nasal obstruction is judged, with view to undertaking reduction. Apart from hypertrophy of the turbinates, there may be other contributory factors present : collapse of the ala nasi, small sessile polypi in the middle meatus, deviation of the septum, presence of posterior spur etc. The postnasal space is examined and assessed. Patient is advised reduction of turbinectes as appropriate and any other subsequent surgery for the contributory factors. An informed consent is obtained and recorded.

The turbinate reduction with Ho:YAG laser is undertaken under general anaesthetic and without the use of topical decongestant. The surgical site is viewed with an operating microscope and Killian speculum. This combined access and visualisation provides magnification and allows video recording to be carried out. The septum was protected with silicon splint. The laser is set at 0.6 J energy per pulse and 12 pps. Following further assessment, a strip of mucosa some 2-3 mm wide is vaporised, at the valve, or at the first site of the hypertrophy, using a short Killian speculum. The upper and lower limits of the strip are judged according to the extent of the obstruction. The tissue surrounding the strip blanches and collapses due to thermal coagulation. A normal looking strip next to the blanched tissue is left intact to aid epithelial regeneration of the vaporised strip. The Killian speculum is advanced further to cover both the vaporised strip and the normal strip. The strip vaporisation of the next hypertrophied section is undertaken, followed by normal strip which is left intact. The procedure is repeated as required.

Results showed that the Oswal suction fibre provided accurate delivery of energy, keeping target- tip distance relatively constant. The removal of smoke, debris and tissue fragments was instantaneous. The successive strikes were seen clearly, and it was possible to continue vaporisation continuously. The splattering of surrounding non target tissue was absent or minimally present. The intraoperative haemostasis of the operative site was total. Any bleeding in the form of oozing was only from instrumentation trauma either of the nasal mucosa, or the operative site. The oozing had stopped by the end of the procedure. None of the patients required packing.

In the immediate postoperative period, most patients reported improvement in breathing. This was obviously due to reduction of turbinate bulk through vaporisation, and lack of packing. There was no pain or any discomfort in the nose. If operated during the morning session, patients were able to go home the same day. Inpatient stay was necessary only for logistic reasons, and not related to surgical procedure.

Postoperative assessment was carried out four weeks later. Some patients reported blood stained watery discharge for a few days, but there was no bleeding. Crusting was formed on second or third day, this caused nasal obstruction to return. Crusting continued for up to 10 days to two weeks. By the end of second week, crusting was minimum and all patients were satisfied with the improvement in nasal obstruction.

These results indicate that Ho:YAG laser is capable of effective, bloodless ablation of nasal turbinate tissue, with minimum postoperative crusting and oedema. Leunig et al{2) reported similar findngs in prospective study of eighty five patients, at one year follow up. Ho: YAG laser treatment of hyperplastic inferior nasal turbinate showed comparable results to conventional and other laser techniques. Immediate advantages of this technique are apparent: a minimally invasive procedure, a feasibility of day surgery, bloodless surgery without any need for packing, minimum postoperative crusting and a good postoperative result. In contrast with KTP/532 or Argon laser, the Ho:YAG wavelength is well absorbed by water containing nasal mucosa, and therefore, the deep tissue thermal penetration is minimum. This reduces the inflammatory oedema and crusting. The deep thermal tissue damage, although less than KTP/532 and Argon lasers, is adequate for intraoperative haemostasis, in contrast with the CO2 laser. The Ho:YAG is capable of layer by layer ablation of soft tissue of the nasal turbinate with concurrent haemostasis.

The 2.1 Ho:YAG laser is a high energy, fibre transmissible, pulsed laser with high degree of absorption by water. It is thus suitable for vaporisation of water containing soft tissues such as the nasal turbinates, in conjunction with endoscopic and minimally invasive techniques. It also causes adequate thermal coagulation of the deeper tissue to effect concurrent haemostasis, obviating any need for packing. The deep thermal energy spread however is less than that of KTP/532 and Argon laser. The inflammatory response and the crusting is therefore much less, but this conclusion would need a supportive randomised controlled trial. The specially designed Oswal suction fibre cannula(3) removes splattered debris instantly and keeps the operating site unimpaired.

Overview of Lasers in Otolaryngology

Dr. V. H. Oswal

Clinical applications of Laser technology in ENT started in the late seventies; the most commonly used laser was the CO2 laser. Some workers also used Argon laser for turbinate surgery and for stapedotomy. The eighties and the nineties saw the introduction of the KTP and the Ho: YAG lasers, particularly for endonasal nasal surgery. The CO2 laser was further refined with scanning devices; and a small spot size with high average energy made it suitable for phonosurgery. Although the CO2 laser wavelength remains non-transmissible down the true optical fibre, hollow wave-guides with limited flexibility allow delivery of the energy directly to surgical site under endoscopic control. Alongside the clinical applications, safety rules were drawn and professional organisations established to promote and oversee the development of this new technology. Dedicated educational courses provided hands on instructions to those new to technology. Some centres also ran courses for laser workers other than clinicians.

Photodynamic therapy (PDT) was an exciting development in oncological applications. By initially photosensitising the target tissue, it was possible to raise its absorption co-efficient for a particular wavelength such as the Argon, thereby selectively ablating it. The development of a suitable short acting photosensitiser may result in a wider use of this technology in future.

Optimum clinical effect of various lasers calls for a thorough understanding of three factors: the inherent property of various lasers, the user controllable parameters, and their effects on target tissue. Added to this is the all important safety aspect, particularly for the Otolaryngologist, since endotracheal tube ignition is the most severe of all laser hazards.

The CO2 laser operates in the far infra red, invisible region, at 10600 um. This laser has consistently proved to be the workhorse for the ORL surgery. It has a high water absorption coefficient. The thermal damage zone is shallow, less than 500 um. It is therefore, comparatively, a poor haemostat, not being effective in controlling bleeding from vessels greater than 0.5 mm in diameter.

It is non-fibre transmissible, although flexible guides are available with a limited flexibility for delivery. The beam delivery can be via a Micromanipulator mounted on to the microscope. In particular, in the laryngeal surgery, it produces very little thermal damage. Its use on the cords has the advantage of producing minimum scarring with preservation of vocal function. It causes minimum inflammatory oedema, and the glottic competency is rarely jeopardised after its, even extensive, application. A bronchoscope coupler is available to extend its applications to subglottic and tracheobronchial region.

Its use has been further refined by the development of the Acu-spot, which reduces the spot size to 200um, resulting in much precision and minimum scarring due to low levels of laser energy used to ablate the tissues.

The KTP: YAG laser

It operates in the visible spectrum at 532 um, delivering green beam. The beam is fibre-transmissible. The thermal damage zone is greater than the CO2 laser (600-800 um). It is therefore a superior haemostat as compared to the CO2 laser. Its main use has been in the nasal surgery.

The Ho: YAG laser

It operates in the invisible near infra red zone, at 2.1 um. It is a pulsed laser, with high energy. It is fibre-transmissible. Its thermal damage zone is around lOOOum. This makes it a useful laser for nasal surgery where it provides excellent haemostasis. It is also useful for bone removal in such procedures as DCR (Dacro-cysto-rhinosto- my).

The Argon laser

It operates in the visible blue green spectrum at 488-515 um. It is preferentially absorbed by strongly pigmented tissue, and its use is limited mainly in the ophthalmological procedures.

The Nd: YAG laser

It operates at 1064 um, just outside the visible spectrum. It is fibre transmissible. It has a much greater scatter within the tissue, and thus has a deeper thermal damage zone (3 -4 mm) than most lasers. It has no particular application in the ORL on account of the depth of thermal damage zone.

The Diode laser

It is commercially available at 810, 940 and 980 um and is fibre transmissible. The ORL application is increasing on accounts of its relatively low cost, low maintenance and portability.

Systematic assessment of Laser Safety in Otolaryngology

Dr. V. H. Oswal

Agencies Responsible For Risk Management Of Lasers Within The National Health Service In The United Kingdom

Risk management of lasers can be broadly defined as a process of identification of the risk, assessment of the risk and steps taken to avert the risk. The risk management may be divided into:

Risk inherent to the technology and risk in clinical use. Within the National Health Service in the United Kingdom, a useful document, which provides hospital laser users with advice on safety, is the ^Guidance on the Safe Use of Lasers in Medical and Dental Practicei issued by the Medical Devices Agency for the Department of Health in the UK ^[9]. It recommends the appointment of a Laser Protection Adviser (LPA) who is knowledgeable in the evaluation of laser hazards. One of the duties LPA is to ensure that Local Rules are drawn up for each specific application of a laser. A Laser Protection Supervisor (LPS) should also be appointed with responsibility to ensure that the Local Rules are observed. It is a sensible precaution that laser users should be those approved by the Laser Protection Supervisor in consultation with the Laser Protection Advisor. All laser users should sign a statement that they have read and understood the Local Rules.

Apart from laser specific regulations, the employees also have redress in the event of laser injury, by evoking the legal requirement, which stipulates the statutory responsibility on the employers to provide safe and healthy work environment.

Risk assessment in clinical use is a broad subject and has an implication on patient and staff injury; law suits for compensations and so on. Department of Clinical risk management in individual hospital can provide further general guidance in clinical situation, e.g. operating Theatre.

Risk Inherent To The Laser Technology

In the laser beam, there is a very high concentration light energy in a very small focused laser spot. Most of this energy can be absorbed by biological tissue in varying proportion and converted into heat energy. Since human (and not robot) operators use the energy for operations to ablate human tissue, it is not possible to isolate either the patient or the surgeon from the laser energy emerging from the equipment.

Poor Performing Lasers And Delivery Systems

Not all energy emitted from the aperture is available for tissue ablation. There are loses due to reflection of energy in the articulated delivery system or during fibre transmission. The etherapeutic energy! at the point of delivery to the tissue must be adequate to obtain desired effect. A loss of up to 30% of energy will still result in sufficient available energy level for practical purposed.

Laser Plume

A laser strike on tissue results in formation of vapour and smoke. The result is a laser plume, which contains contaminants fi Laser generated air contaminants (LGAC). The contaminants are metallic fumes, toxic gases such as benzene, hydrogen cyanide, formaldehyde, carbonised tissue and bacteria and viruses, which are DNA strands. Studies in the rat have revealed pathological changes in the lung caused by smoke produced by laser or electrosurgery ^[3]. The HIV DNA was detected in culture of the plume on the 14th day. Garden ET. al. (19S8) studied the content of the plume produced during vaporisation of infected verrucae and concluded that intact viral deoxyribonucleic acid (DNA) was present in the plume. The papillomavirus DNA was demonstrated to be infectious. There is the possibility that active viruses may be present in the CO2 laser plume but studies have shown that the use of appropriate smoke evacuators virtually eliminates any risk to the operator ^[4], A study performed during laser treatment of laryngeal papillomas was unable to find HPV DNA ^[5]. In laboratory experiments, viable bacteria have been found in the plume ^[6],[7]. Apart from biological hazard, the plume can evoke allergic rhinitis in susceptible individuals. It has an unpleasant odour, not unlike burning flesh.

Fire Hazard

The surgical laser is primarily used to ablate tissue, which is to be considered its legitimate target. The laser can do this very efficiently indeed, with added advantage of bloodless field and so on. However, targets, of necessity are surrounded by non-targets and pose potential hazard. Unlike any other surgical field, surgery on larynx poses a unique hazard as the airway is also used to deliver anaesthetic gases and oxygen via endotracheal tube. Universally used PVC tubing poses a particular and serious hazard. Even if the laser is not being used in the close proximity of the tube, the tube is still at risk to ignition from reflected beam. We designed a stainless steel flexible anaesthetic tube in the early eighties. Later years saw introduction of laser safe tubes (Lasershield, Zomed). These tubes are coated with silica and do resist self-sus- tained ignition. Nevertheless, the do ignite and may cause minor tracheal burns. The cuff still remains vulnerable. These tubes are expensive and marketed for single use. There is a temptation to continue to use rubber or PVC tubes, which are protected with aluminium foil. Wet swabs must be used to protect this further and extreme care taken to wrap the aluminium foil with a good overlap so that no part of the tube remains vulnerable. Tubeless anaesthesia is another alternative. Laser surgery on the larynx requires a team effort; a competent anaesthetist with experience in a variety of anaesthetic techniques has a tremendous contribution to make to laser safety.

Eye Hazard

An accidental strike of a laser beam to the finger does not have a catastrophic effect. But the same cannot be true for an eye exposed to accidental laser strike. Laser radiation from short wavelength UV lasers, such as the excimer laser, and long wavelength infrared lasers, including the Ho: YAG and CO2, is absorbed by the cornea. Though painful, this is not usually sight threatening since the cornea has a very high capacity for repair. Aversion reflex whereby a sharp movement of the head away from the beam will protect the eye to a certain extent but cannot be relied upon. Suitable glasses or goggles must be worn to avert any possibility of accidental exposure, however remote.

Anyone within the vicinity of a laser must ensure that his or her eyes are adequately protected. This generally means wearing the appropriate type of laser safety eyewear. It is important to realise that goggles intended for one type of laser will usually not be suitable for any other.

Non-Target Strike

Apart from the obvious non-biological targets, it must be remembered that tissue surrounding the target tissue remains vulnerable to laser damage, either by direct strike, or indirectly due to conduction or scatter of thermal energy. These tissues should be suitably protected with wet gauze, suction cannula, or any other instrument being used for retraction etc. The indirect thermal damage may not be immediately apparent. It, however, can take place in a variety of ways:

High Energy Setting With Prolonged Exposure Time

The deeper tissue is heated by conduction of heat from the point of laser strike. Likewise, there may be a lateral spread of energy from the point of strike.

Excessive Charring

Excess accumulation of char absorbs energy and impedes surgical progress. It may flare due to excessive heating and cause secondary burns. Heated char transmits energy in all directions (scatter) and contributes to non-target damage.

Malaligned Beam

Another problem can arise when the aiming beam and therapeutic beam are mal-aligned with the result that the main beam is directed to an adjacent area. Before use, a simple beam alignment and power check should be carried out, using heat-sen- sitive paper or wooden spatula placed on wet towel, with the laser set on low power. The spatulas should be filed away and brought out for comparison with current results. In case of fibre deliv- eiy, it is worthwhile to check the integrity of the fibre before use. This may be done simply with the aiming beam only. If there is a fibre break at any point, the beam will leak from the damaged site, and also the emerging beam will be very weak.

Fibre Contamination

The optical quartz fibres sold for the use with the laser technology are usually specified for single use. The fibres are expensive and cost prohibitive for extensive laser surgery. It is therefore not surprising that the fibre is cleaved and re-used, particularly where the rules are not stringent or not properly enforced. In the event, one must ensure that adequate sterilising procedure, particularly in consultation with a microbiologist or theatre sister, be undertaken. The clcaving must be sharp and at right angle so that the emergent beam is perfectly circular, sharp and bright. Fibres which are sculpted should not be cleaved, as, used this way, the laser parameters are completely altered and substantial non-target tissue damage will take place.

Untrained Medical. Technical And Nursinp

Staff Laser is not just eanotheri tool or a refinement on the existing tools such as a pair of scissors or diathermy. The main difference is in the concentration of vast amount of energy over a tiny area with potential to deep tissue damage, fire hazard and a substandard surgical outcome. The optimum energy level for a particular tissue ablation is dependent upon a number of parameters. However, no amount of reading can replace peer supervised practical experience. An well-organised and approved course can provide both theoretical and practical experience to all those involved in the laser surgery, the surgeons, the nursing staff and the technicians alike.

Legal Requirement For Safe Operation of the Laser

In national healthcare systems, such as the National Health Service (NHS) the employing authorities have a common law duty to ensure that the employees have adequate skill to undertake their work. However, in the private sector there is no such control, particularly for office based laser procedures. In the final analysis, therefore, the onus must be on the individuals to obtain suitable training and maintain their competence through attendance at courses and conferences.

Role of Lasers in Laryngeal Cancer

Dr. V. H. Oswal, Prof. M. Remacle

History of Laser Usage in Laryngeal Cancer

During the early part of the 1970s, Strong (Strong 1974, 1975) introduced transoral carbon dioxide laser (CO2 laser) for the excision of premalignant glottic lesions and T1 glottic carcinomas. The work of Ossoff et al. (Ossoff 1985), Koufman (Koufman 1986), Mc Guirt & Koufman (Mc Guirt and Koufman 1987), and Wetmore (Wetmore et al 1986) in the United States established the role of the CO2 laser for endoscopic treatment of early malignancy and for reducing the bulk of obstructive laryngeal tumours. Similar work followed from Europe by Annyas et al (Annyas et al 1984). Motta et al. (Motta et al 1997), Rudert et al. (Rudert et al 1991), and Steiner et al (Steiner et al 1991), who extended the laser application to more advanced cases.

Endoscopic Excision of Laryngeal Cancer: Current Status

Cancer of larynx affects a number of anatomical sites within the larynx. The natural history, the access to the lesion and incidence of secondary metastasis is vastly different for each location, and no one single management strategy can be correct.

Glottic cancer

An increasing number of reports in the literature suggest that the laser management of TIS, T1 and some early T2 lesions is now a viable option. The comparison with established conventional methods is inevitable and necessary. A valid comparison is only possible if some form of standardisation is introduced. The Nomenclature Committee of the European Laryngological Society (Remacle et al 2000) has recently proposed a new classification for endoscopic management of cancer of larynx, described later. It has received acceptance from several European teams. However, the basis for comparison of voice quality following each treatment modality remains a matter for debate.

While there is some unanimity for T1 and T2 lesions, a great deal of controversy exists for laser usage for more advanced T3 and T4. glottic lesions. Similarly, endoscopic laser management of supraglottic and hypolaryngeal cancer is also not universally accepted as a preferred option.

Supraglottic Cancer

The first report of laser treatment for supraglottic cancer appeared in 1978 (Vaughan 1978) This work was followed by Davis et al (Davis et al 1991) and Zeitels (Zeitels et al 1994,1995,1997) in the United States and by Eckel (Eckel 1997), Rudert et al. (Rudert and Werner 1995b), and Steiner (Steiner 1993) in Europe.

Hypopharyngeal Cancer

Steiner (Steiner 1994, 1996) advocates management of hypopharyngeal cancer with laser-assisted endoscopy. Zeitels (Zeitels et al 1994) and Rudert (Rudert 1991) also include hypopharyngeal cancer in their indications of laser-assisted endoscopic treatment in carefully selected cases, provided the cancer is ësmalli.

The most important single factor for a successful endoscopic laser excision is the size of the lesion (Blakeslee et al 1984). The anatomical sites are also important since access may not be easy, or the natural history, unfavourable. Subglottic lesions are most difficult for endoscopic laser surgery.

Two different methods are followed for endoscopic removal of the tumour. The first method calls for the conventional en block removal and submission for the histological examination. The second method involves layered excision by slicing through the tumour.

The authors believe that the surgeons who remove large T3 or T4 tumours endoscopically are obligated to follow the elayer methodi because en block removal has physical limitations. The whole of the tumour just could not fit into the lumen of the laryngoscope for its en block removal. On the other hand, surgeons who limit endoscopic removal for T1 and T2 tumours can remove the whole of the tumour, which easily appears in the lumen with normal anatomical structures.

The CO2 laser-assisted endoscopic excision does not call for a great deal of expertise on the part of a trained pathologist (Lawson et al 1997). The thermal energy in the laser surgery eshrivelsi the tissue. The norma! tissue may thus appear much closer to the pathological tissue, in spite of a good clear margin apparent during the excision. The histology of the laser-excised tissue has certain peculiarities, which are not seen in cold surgical excision. The layer immediately deep to the pathological tissue shows thermal damage and charring. This layer is then followed by normal histology of the anatomical structure from which the tumour has been excised. In order to help determine the clearance, particularly with the excision of T1 tumour in the anterior third of the cord where the specimen is very small, it is necessary to minimise the thermal damage zone. The latest micromanipulators and the recent refinement in the CO2 beam such as the Pulser, ensure that the coagulation along the margin of the excised specimen usually does not exceed 100(. The thermal damage zone can be further minimised to about 50( by using the Superpulse mode. Clearance is confirmed when tumour-free tissue is identifiable in the areas not affected with the laser.

The Scope of Endoscopic Cordectomy

Surgery for malignant lesion involves complete removal of the tumour, confirmed by intraoperative frozen section assessment. By relating the extent of surgery to anatomical structures of the larynx, the TNM classification of the disease process is undertaken at the conclusion of the operation.

Prior to the introduction of laser, the endoscopic removal of tumour was mostly confined to the removal of vocal cord fi Endoscopic cordectomy. The term did not take into account the anatomical or histological extent of surgery, it encompassed a wide range of surgical removal, from just a few millimetres of superficial layers to the whole thickness involving muscles and even the perichondrium. Introduction of laser added further confusion. It allowed even wider endoscopic excision and the term eExtended cordectomyi was used to differentiate it from esimplei cordectomy. Lack of standardised terminology meant that the results from one centre could not be matched and compared to the results from another centre.

The Nomenclature Committee of the European Laryngological Society has taken this issue aboard. The personal classification used by various members was analysed, and integrated in to a common format. Thus, a new classification (Remade et al accepted for publication) was proposed and accepted by the members. The nomenclature takes into account both histological and anatomical extent of the surgery and groups it into several categorises. The sections below describe the various types of cordectomy. Documentation of cases along the lines approved by the Nomenclature Committee of the European Laryngological Society will allow comparison of results obtained by endoscopic and external surgery and also by radiotherapy. Only then it will be possible to rationalise the endoscopic use of the laser for selected lesions, with dependable outcome.

The Transvestibular Approach: A New Horizon in Rhinoplasty

Prof. Nabil Fuleihan

A good exposure of the lower lateral cartilages is an essential step in rhinoplasty. Different endonasal techniques have limitations in visualizing the lateral and intermediate crura predisposing to asymmetries in reduction and rearrangement. The author presents a new endonasal rhinoplasty technique. Using a marginal incision, the vestibular skin is elevated and the endonasal surface of the lower lateral cartilage is exposed permitting reduction, rearrangement as well as placement or interdomal sutures. The author discusses the surgical steps and results of his experience using this approach in more than 750 rhinoplasties. This transvestibular approach is a new dependable and simple approach that should permit the rhinoplastic surgeon to achieve more predictable results.

Dynamics in Rhinoplasty

Prof. Nabil Fuleihan

The aesthetic nasal appearance is the result of multiple anatomic complexes and units. Rhinoplasty is the science and art of changing different aesthetic complexes into a more pleasing and natural shape. The nasal framework is a three dimensional structure made of anatomical elements that have different shapes, angulations, consistency and elasticity. They respond differently to reduction or rearrangement. Maneuvers of tip rotation, projection, narrowing, dorsal reduction or augmentation have different surgical requirements. In certain cases minor enhancements can produce illusions of narrowing and rotation.

Otoplasty and Auricular Reconstruction

Prof. Nabil Fuleihan

The auricular framework is characterized by multiple angulations, curvatures and projections making its reconstruction a unique surgical experience. Congenital deformities like artresias require a comprehensive approach. Rib cartilage graft or Porex implants have different benefits and risks. Surgical steps used for reconstruction using implants will be discussed. Lop ear deformities are mostly due to hypertrophy of the eminenciae, a simplified technique of remodeling along with suspension sutures will be discussed with illustrative cases.

Rehabilitation of the Paralyzed Face

Prof Nabil Fuleihan

Facial rehabilitation is designed to restore facial symmetry, facial movement and to regain facial emotional expression. The type of reanimation depends on the status of the nerve, duration of paralysis, and the status of the muscle. Different static and dynamic procedures are available, rationales for such methods will be presented along with illustrative cases. Special emphasis will be put on varaitions in Hypoglossal facial anastomosis.

Principles of Reconstruction of Facial Defects

Prof Nabil Fuleihan

Reconstruction of facial defects is based on principles of maintaining equilibrium between function and cosmetics. The choice of flap or method of reconstruction requires a good understanding of skin tension lines, aesthetic units, framework requirements, relation to different facial orifices, and blood supply. This course stresses basic dynamics of different facial flaps and choice of flaps for different defects. Analysis of methods that can give the most natural results will be presented.

Management of Anterior Skull Base Lesions

Prof. Nabil Fuleihan

Approaching lesions affecting the anterior skull base requires significant preoperative analysis and experience. The basic goal is to design the simplest procedure that has the least morbidity, provides a good access of the elements that needs to be removed and reconstructed, provide a good seal isolating the intracerebral structures from the external environment.

Different approaches have been used to access lesions involving the anterior skull base:

The Transfacial Approach
The degloving Approach
Extended Maxillectomy Approach
The Subcranial Approach
The Craniorbital Approach
The Transmandibular approach
Facial Translocation
The Endoscopic Approach

Indications and illustrative cases using these approaches will be presented along with reconstructive options for the anterior skull base.

Challenges in Endoscopic Sinus Surgery: Round Table Discussion.

Dr. Muaaz Tarabichi

Multiple case presentation of challenging encounters in endoscopic sinus surgery. Radiographic and endoscopic findings will be presented. Cases were selected to demonstrate clear educational objectives. Our round table experts will demonstrate to us their expert thought process when approaching these problems.

Characteristics of Sinus Related Pain

Dr. Muaaz Tarabichi

Objectives:

To determine possible distinctive features of facial pain when caused by chronic sinusitis and to validate the pain characteristics previously described in the literature.

Methods:

82 patients with radiographic and endoscopic evidence of chronic sinusitis and significant facial pain who underwent functional endoscopic sinus surgery and were available for one year follow up were included. A modified McGill Pain Questionnaire was filled out preoperatively and follow-up at one year was obtained.

Results:

38% of patients had persistent facial pain at one year despite the lack of any evidence of persistent sinusitis. A consistent use of pain adjectives and other distinctive features were noted in patients reporting improvement of headache. There was no correlation between the severity of pain and the extent or location of mucosal disease. The site of pain did not correlate with the site of disease.

Conclusions:

Sinusitis related pain has distinctive features setting it apart from primary headache disorders and other causes of facial pain. Non-sinus etiologies account for the headache in one in three patients undergoing sinus surgery.

Chronic Rhinosinusitis: The Inflammatory Side.

Dr. Muaaz Tarabichi

CRS has long been considered and treated as an infectious and/or obstructive process. An emerging body of evidence is slowly eroding this understanding. Associated lower airway disease is an important marker of this inflammatory process and much of the work being done on the lower airways will contribute to our understanding of the pathophysiology of CRS. This shift will have wide implications for our day-to-day management of sinus disease and the role of surgery and or medications in the management of these patients.

Endoscopic Limited Attic Cholesteatoma

Dr. Muaaz Tarabichi

Objectives:

Microscopic postauricular tympanomastoidectomy provides a limited exposure to the attic, especially anteriorly. In contrast, the endoscope offers wide transcanal access to the attic, allowing for complete removal of limited attic disease, possibly without interrupting the ossicular chain. This report evaluates 8 years experience with transcanal endoscopic management of limited attic Cholesteatoma.

Methods:

73 ears with limited attic Cholesteatoma underwent endoscopic transcanal tympanotomy and extended atticotomy to access and completely remove the sac. Disease was dissected off the tegmen, medial and lateral attic walls, as well as the ossicles. Appropriate ossicular reconstruction was performed. The defect was reconstructed with composite tragal graft.

Results:

Transcanal endoscopic approach was adequate for removal of disease in all cases. There were no iatrogenic facial nerve injuries. Bone thresholds were stable. Disease was dissected off the head of malleus and the body of incus with preservation of both in 24 ears. Mean follow-up was 43 months.

Five ears required revision for recurrent disease, and 8 were revised for failed ossicular reconstruction or persistent perforation. Moderate to severe retraction in other areas of the tympanic membrane were evident in 28 cases, none of these required further intervention.

Conclusion:

Endoscopic technique allows transcanal, minimally invasive, eradication of limited attic Cholesteatoma. Preservation of the ossicles coupled with complete removal of disease is more likely with the endoscope.

Endoscopic Transcanal “Open Cavity” Management of Cholesteatoma

Dr. Muaaz Tarabichi

Objective:

Large problematic cavities, unpredictable healing pattern, fibrosis, and closing of the meatus are commonly associated with postauricu- lar canal wall down procedures and often prevent further ossicular reconstruction. Endoscopic technique allows transacanal exploration of the attic and antrum and provides a iwhat you see is what you getT open cavity; this in turn allows a better framework for ossicular and partial tympanic membrane reconstruction.

Methods: 51 ears with acquired cholesteatoma underwent endoscopic transcanal tympanotomy and extended atticotomy to access and remove the sac. Partial reconstruction of the TM up to the level of the horizontal segment of the facial nerve was performed along with ossicular reconstruction. The extended atticotomy was packed open. Office based endoscopic surveillance and follow up was performed.

Results: 49 procedures were performed on an outpatient basis. There were no iatrogenic facial nerve injuries. Bone thresholds were stable, except in one patient with perilymphatic fistula. Mean follow-up was 42 months. Closure of air bone-gap to within 20dB (avg. of 500, 1000, 2000 Hz) was accomplished in 23 ears. 2 ears required revision surgery. 9 required office based minor procedures.

Conclusions:

Transcanal endoscopic iopen cavity! approach allows minimally invasive management and surveillance of cholesteatoma with results that compare well to postauricular methods. This technique produces a predictable, safe, easily manageable cavities; and it provides for a better framework for ossicular reconstruction

Endoscopic Tympanoplasty.

Dr. Muaaz Tarabichi

Surgical management of chronic ear disease is an all-around difficult task. The most challenging aspect is patient selection and a realistic appraisal of our limited degree of understanding of the pathology. Determinants of successful outcome go well beyond the type of surgical technique being used. Minimally invasive endoscopic approach has a distinct application that better fits our limitations. 64 medial graft transcanal procedures and 18 transcanal endoscopic lateral graft procedures were performed. The results were compared to 50 consecutive microscopic procedures. While the success rates were similar, postauricular approach was needed in 21/50 of the microscopic procedures.

Benefits of Image Guided Technologies in Endoscopic Sinus Surgery

Dr. Spyros E. Davris

The goal of Endoscopic Sinus Surgery is to offer maximum efficacy with the minimum complication rate. Disorientation during Sinus Surgery can lead to serious complications. Image guidance systems, initially developed for neurosurgical procedures, have been developed to assist the surgeon with anatomical localization. Two different devices use either an electromagnetic or optical-based tracking system to monitor the position of surgical instruments relative to the patient’s anatomical landmarks, A real time intraoperative video displays the location of these instruments on the pre- op CT scan. The best candidates are patients with poor anatomical landmarks from previous surgery or extensive disease. Our goal is to avoid and protect the orbit, optic nerve, dura of anterior skull base and ICA. The technological improvements permit accuracy better than 2mm and set-up time less than 10 minutes. The experience of the OR staff is mandatory to achieve these prior values. The aim of this topic is to present the personal experience, during the last 2 years, using an optical IGS in a variety of patients. The several presented cases confirm the benefits of additional safety, better orientation in case of distorted anatomy, more complete tumor removal and teaching facilities in specialty training.

Endoscopic Surgery of Benign Nasal and Paranasal Ttimors

Dr. Spyros E. Davris

The main indication of endoscopic sinus surgery is the management of inflammatory diseases. During the recent years, the indications have expanded in the management of tumors. The endoscopic removal is very effective in a great variety of benign tumors and in extremely selected malignant cases. The choice of an endoscopic approach depends on the tumoris pathology, the experience in endoscopic techniques and the facilities of the ENT department. The aim of the topic is to present the results and experience of the following 32 benign nasal and paranasal tumors, treated exclusively with endoscopic techniques.

15 inverted papilloma
4 papilloma
6 osteomas
1 hamartoma
1 pleomorphic adenoma
1 hemangeioendothilioma
1 capillary hemangioma
1 fibrous dysplasia
1 clivus chordoma
1 cavernous clivus hemangioma

In no case we had any major intra or post-op complication. The duration of hospitalization for all patients didnit exceed 3 days. In patients with total tumor removal we hadnit till now any recurrence. The endoscopic surgery doesnit exclude external approaches and the patient is always aware of the possibility for a change of an endoscopic to an external approach.

Management of Primary Cerebrospinal Fluid Rhinorrhea

Dr. Khalid Al-Sebeih, Miloslav Valvoda, Kostadin Karagiozov

Although the majority of the Cerebrospinal (CSF) fistulas in the anterior skull base are traumatic in nature, the minority of cases are primary or spontaneous. Primaiy CSF leak can raise difficulty and chailenge in terms of diagnosis or treatment. We present a series of patient that were managed between July 2000 and October 2002. Diagnosis, methods of Localization and surgical repair are discussed for each patient. Resolution of CSF rhinorrhea was achieved in 8 out of 9 patient with one a single procedure and one patient had a successful repair at 2 procedures.

Causes of Epistaxis in Bahrain

Dr. LubnaJanahi, Dr. M.AL Sindi

Epistaxis is a common symptom for patients to present with to the emergency & routine ENT clinic, actually it is well known in the old literature from the fifth century BC, described by hippocrats.

This paper describes the cases of Epistaxis presented to Salmaniya Medical Complex from 1997- 2001 & review the age of patients, mode of presentation, associated symptoms, causes of Epistaxis & modality of treatment.

It is a retrospective study, 96 inpatients were reviewed during this period, the main causes of Epistaxis were found to be idiopathic in 23 patients (23.9%), hypertension in 23 patients (23.9%), other causes like deviated nasal septum (DNS) in 14 patients (14.6), 9patients (9.3%) in nasal trauma, 17 patients (17.7%) in inflammatory, vascular causes in 6 patients (6.2%), & other causes in 4 patients (4.1%).

Most of the cases (79%) presented as emergency, & most of the cases had Epistaxis for one day. Cases due to hypertension are not known hypertensive, almost half of them discovered to have hypertension & needed regular anti hypertensive treatment. From this study, the different causes of Epistaxis in Bahrain were identified out of which a significant number of patients were found to have hypertension for the first time, so screening patients for hypertension may help to detect hypertensive patients & treat them before they get attacks of sever Epistaxis which may need blood transfusion.

Allergic Rhinitis as a Risk Factor For Childhood Hearing Impairment

Prof. Siraj Zakzouk, Dr Fatma Homood Al Anazy

Objective: To study the prevalence of allergic rhinitis (A.R.) in relation to hearing impairment (H.I.) due to otisis media, and to identify the common allergens found.

Design: An epidemiological Survey, where questionnaires were prepared (WHO/PDHI) (1) for hearing impairment and a modified ISAAC (2). A field study for the prevalence of H.I. and the various risk factors was carried out. Those children with allergic history were subjected to allercy work up.

Material: 9540 children were surveyed, and their parents were interviewed. ENT and audiological assessment were performed. Only 374 were able to attend for allergy work up consisting of Prick skin test and IgE estimation.

Results: 2529 children (26.51%) were found with allergic rhinitis and 649 of them with asthma as well. Nasal allergy was found to be higher in children whose parents were cousins or, relatives, and males were found with higher prevalence as compared to female. Prevalence of H.I. is higher in children exposed to nasal allergy, with Otitis media. Positive skin test was found among 61.8% and 38.2% were negative, a positive family history was found among 73.9% and IgE >200 l.U./L in 48%.

Conclusion-.Nasal allergy and consanguinity were found as risk factors for Hearing Impairment. Bermuda grass, mesquite, chenopodaceas, cockroach and cat fur were common allergens found. There is an association between allergy and otitis media as a cause of hearing impairment in this study.

Key words: Allergic rhinitis (A.R.), otitis media, hearing impairment, consanguinity.

Otogenic Brain Abcess a Total Management

Prof. Abdul Aziz Ashoor

Objective : To present our experience with the management of Otogenic Brain Abcess and compare it with the current concept.

Material And Merhod: Over the last years 6 patients with Otogenic Brain Abcess as a complication of chronic otitis media (cholesteatoma) have been admitted to our ENT and Neurosurgery ward for management. Each patient underwent thoroughly ENT, Audiological and Radiological Examination, Ear culture, Neurological and Opthalmological consultation. In addition to antibiotic, treatment abcess was drained either through burr hole, craniotomy or through a transmastoid approach. Later on, infection source have been satiated through a radical mastoid surgery.

Results: Main complains at time of admission were; severe headachc, vomiting, somnolens, disbalance and deafness. Main findings were bilateral or unilateral tempanic membrane perforation, foul smelly discharge, granulation tissue, retraction pocket, hearing loss, nystagmus, and hemipareses. Four had temporal lobe abscess, one cerebellar and one parietal. For draining these abscesses four had burr hole, craniotomy plus radical mastoidectomy (RM) and antibiotic treatment. Two had only R.M. plus transmastoid drainage and antibiotic. All of them recovered without deficit. Their stay in hospital ranged from 7-32 days and their follow up from 3-6months.

Conclusion: Otogenic brain abscess is a very common complications of ear cholesteatoma. It is a life treatening infection associated with high morbidity and mortality rate. Radical mastoidectomy (RM) with trans mastoid drainage in addition to the proper antimicrobial is the first line of treatment before attempting craniotomy or burr hole for evacuation.

Do we Know an Effective Monitoring System for the Treatment of Necrotizing External Otitis

Prof. A bdul Aziz Ashoor

Objective : It is a retrospective clinical study aiming to come up with an effective and practical monitoring system for the treatment of Necrotizing External Otitis.

Methodology: During the last 6 years (I997. 2003), 9 patients with the diagnosis of Necrotizing externa Otitis (NEO) were admitted to the ENT- ward at King Falid Teaching Hospital for investigation and treatment. After admission a detailed history were taken followed by a thoroughly ENT examination and relevant investigations such as : Diabetes Mellitus profile (DM), Erythrocytes Sedimentation Rate (ESR), Ear Swab for culture and sensitivity (C/S), computed Tomography (CT) and scintigraphy using technicium 99 and / or Gallium 67. After diagnosis were achieved, treatment of the infection and controlling of D.M. was started and after discharge a long term follow up was initiated. Their treatment were monitored using effective subjective and objective assessment measurements.

Results: All the cases (apart from 30 responded very well to the antibiotic treatment. Before discharge (7-32 days) patient were put on oral treatment. Patient with cranial nerve involment (3) showed good to poor improvement. One of these was expired due to carotid artery hemorrhage. Under treatment the clinical symptoms such as ear pain, discharges and granulations disappeared. Also the ear swab; DM and ESR went back to normal or were controlled. Radiological changes showed remarkable improvement.

Conclusion: The clinical and laboratory assessment measurements are practical and reliable in monitoring patientis therapy in particular the ESR. The radiological modalities are useful in detecting soft tissue and bony involvement but are not reliable enough in monitoring therapy.

Common Complications Following Ventilation Tubes Insertion

Prof. Mohammed Attallah Dr. A. Essa

Purpose: To report the incidence of complication following grommet insertion.

Method: 215 children with otitis media with elusion who underwent grommet insertion were found suitable for inclusion in this study.

Results: Otorrhoea was found to be the commonest complication, 31.16% of the children suffer from otorrhoea. 20.46% of the patients were found to have tympanosclerosis as the second commonest complication. Permanent perforation comprise 5.11%, retraction of tympanic membrane 2.79%, aural polyp 1.86%, retraction pocket 1.39%, and atelectasis & granulation tissue represent 0.93% and 0.46% respectively.

Conclusion: Otorrhoea, tympanosclerosis, and perforation of tympanic membrane are the commonest complications following grommet insertion. Complications such as profound sensorineural hearing loss, dislocation of the middle ear ossicles and cholesteatoma were found to be relatively ' uncommon and were not encountered in this study.

Ostiomeatal Complex in Normal Semitic Adults

Prof. Hamad Al Muhaimeed, Dr. Yasser Hashash, Prof. A. Shafy, Prof. Mustafa Hashash

This is a ciinico-radiological study of six components in the ostiomeatal complex (OMC) of normal adult Saudis of both sexes. It presents them through the mean values of the osseous components of the Computed Tomographic coronal cuts of the nose and paranasal sinuses. The maximum mean value of the maxillary ostium in males and females was 0.22 cm and 0.21 cm respectively. The maximum height of the uncinate process was 1.27 cm and 1.26 cm, the largest surface area of bulla ethn- moidalis was 0.69 and 0.52 cm2, the maximum width of the infundibulum was 0.22 cm and 0.21 cm, the largest width of the middle turbinate was 1.47 cm and 1.44 cm and the maximum width of the middle meatus was 0.83 cm and 0.79 cm. Their standard deviation (SD) and P value were calculated. The measured units of OMC did not show any significant variation between the two sexes as well as between the different age groups except for the bulla ethmoidalis where there was significant variation between males and females in the age group of 15 n 31 years. This study was done to provide endoscopic rhinologist a set of reference distances of OMC.

Open Rhinoplasty: Effectiveness of Different Tipplasty Techniques to Increase Nasal Tip Projection.

Prof. Sameer Bafaqeeh

Purpose: To study the effectiveness of 3 different tipplasty techniques to increase nasal tip projection (NTP).

Materials and Methods: NTP of 61 patients who underwent open rhinoplasty were retrospectively studied in 3 different tipplasty techniques used to increase NTP. Using a standard measurement technique, the preoperative and least 1 year after surgery. The study population of 61 patients was divided into 3 groups. Groups 1 (n=32) underwent the authorfs routine nasal tip procedure (coiumellar strut, conservative cephalic trim of the lateral crura, and transdomal mattress sutures). Group 2 (n=10)underwent the foutine procedure and, in addition, has further medical recruitment of the lateral crura. (Group 3 (n=19) underwent routine procedure and, in addition, has a tip cartilage graft.

Results and Conclusion: The mean gain NTP postoperatively was highest in group 3 and lowest in group I, and this was statistically significant. Causes of these differences in the NTP gain are discussed

Simultaneous Open Rhinoplasty and Alar Base Excision: Is There a Problem With the Blood Supply of the Nasal Tip and the Coiumellar Skin

Prof Sameer Bafaqeeh, Prof Mohammad M. Al-Qattan

In a prospective study, 15 consecutive patients who underwent simultaneous open rhinoplasty and alar base excsion were included to investigate whether there is a problem with the blood supply of the nasal tip and coiumellar skin. During the surgical procedure in these patients, there was transection of the coiumellar arteries and external nasal arteries, and frequently of the alar braches of the angular artery. Yet, none of the patients had any evidence of ischemia of the nasal tip or coiumellar skin, and there was primary wound healing with a thin-line transcolumellar scar in all patients. Techniques to avoid injury to the lateral nasal artery and nasal tip plexus are discussed. It was concluded that simultaneous open rhinoplasty and alar base excision is safe as long as certain surgical principles are applied.

A Comparative Study of Staphylococcus Species Nasal Carriers in Sudanese

Prof. Hashim Yagi, Dr. Nagat Elawad, Prof. S.M. El Sanosi, Dr. K. M. Shamboul

Objective: To determine the prevalence of different Staphylococcus species nasal carriers and compare the identified species in selected groups of Sudanese population and hence note the significance.

Methods: Two groups twenty-five each of adult Sudanese were studied. The first group was hospital staff and the second were subjects w ho work in contact with animals. Nasal swabs were collected for culture from all subjects. Morphology and culture characteristics, determination of growth characteristics under aerobic and anaerobic conditions as well as determination of biological and biochemical characteristics of staphylococci were studied.

Results: The Staphylococcal carrier rate was 58.6% and 30.4% in the first and second group respectively. Of the bacteria isolated in the first group 96.7% were Staphylococci and 3.3% were Neisseria cataralis. In the second group 92% were Staphylococci 4% were Alfa flHaemolytic streptococci and 4% Neisseria haemolysans. Nineteen Staphylococcal species were isolated from the different groups. This included Human as well as Animal species. In the first group 55.1% were Human and 44.9% were Animal species, while in the second group 60.9% were Human and 39.1 were Animal species.

Conclusion: Staphylococci are the main bacteria in nasal carriers in this study. Human subjects could be unknowingly nasal carriers of Animal species of Staphylococci. Cross infections caused by such organisms would be missed in routine Hospital cultures, which are done for Human species. Hence response for treatment could be protracted with significant morbidity in the resistant forms treated without a sensitivity result.

Incidence of Postoperative Outcomes of Tympanoplasty Type I a Three years Retrospective Study

Dr. Abdulmonem Al-Shaikh, Dr. Peer Moh’d Syed Ahmed

The aim of tympanoplasty as a whole include prevention of ear infection, improvement in hearing either by audiological assessment or by subjective feeling and elimination of the need for water precaution. In our center, it is one of the day to day common procedure. We reviewed retrospectively 3 years follow up of tympanoplasty type I from June 1999 to May 2002 which were 735 procedures. With male to female distribution of 365:369 and left to right distribution are 401:334 with success rate of 72% in terms of intact graft 6 months postoperative and 76.2% success in terms of hearing (both audiological & subjective feeling). We present this paper with various statistics in order to compare our results with other similar studies and found to have slightly higher than that of other published papers.

Key words: tympanoplasty, perforatum*, conductive and sensorineural hearing losses.

Radiofrequenries Related Headache and Facial Pain

Dr. Suraiye Al Dowsary

This paper describes the possible adverse health effects arising ftvwn the use of mobile phone especially concentrating on symptoms of headache and facial pain. A clinical setting was made available in the ORL Dept. of KAUH every Tuesday morning for mobile phone users: this clinic is till ongoing having been started in 1996.

A standard questionnaire was filled about the users demographic data, t>pe and model of the mobile telephone, the duration of calls and the side used most frequently. Alteration was paid to the auditory. vestibular and Head and Neck symptoms. Noise-exposure and smoking habits aw well as past medical or surgical histories were considered. Clinical assessment of the auditor, and vestibular apparatus, and of the head and neck was performed. 93 users felt ear discomfort or pressure and blockage sensation. Headache was noticed by 83 users on the same side. Sharp facial pain was noticed by 72 patients. Other complaints mentioned were: hearing loss, fatigue, warmth over the car, ner\ous- ness, hot sensation on the same side of the face. Adverse health effects like headache, facial pain, sleep disruption, impairment of short term memory associated with mobile phone use while not life threatening complaints, do have a debilitating, effect that undoubtedly alTect general well-being of an individual. We can safely conclude from our study and a review of contemporary literature that there is a statistically significant increase in the complaints of headache and facial pain amon£ users of mobile phones.

Cochlear Implant: Success and Challenges in Developing Countries

Dn Khalid Taibah

Aim: To review our preliminary results in pre-lin- gual profoundly deaf children and their achievement post implant surgery.

Methods: Sixty-seven (67) patients had cochlear implants surgery at King Faisal Specialist Hospital and Research Centre (KFSH&RC) between years 1994 and 2001, There were 30 congenital, pre-lin- gual and post-lingual children and 37 post-lingual and pre-lingual adult patients. In our services, there were 8 patients who developed profound hearing loss after neurobrucellosis, with excellent outcome and considered to be the first to be reported in the literature. Ossification of the Cochlea following meningitis presents a surgical and audio- logical challenge. In 18 implanted cases of meningitis, there were different degrees of ossification with variable radiological interesting findings.

Results: 30 pre-lingual children showed that 95% wears the devise all the time and 76% had spontaneously attends to environmental sound. On responding to her/his name, 62% showed encouraging result, especially for their parents. Because of lack of special school in different region in the Kingdom, only 19% uses speech to communicate in full/long sentences and 24% uses speech to communicate in small sentences.

Conclusion: Absence of auroverbal school supported by the government in the developing countries had unfortunately discouraging result in post implanted children as compared to the result in developed countries. From the above results, the program decided to develop a special educational and rehabilitation center in the hospital to achieve better result in the pre-lingual implanted children.

CSF Rhinorhea. Endoscopic Repair

Dr. Saleh Al-Abdulwahed

Spontaneous CSF rhinorhea is a rare condition. Three patients presented with this condition and CT scan was positive in identifying the site of leak. Collecting the fluid was the first step in identifying the condition.

The use of nasal septum cartilage was sufficient for closing the defect. We did not need tissue glue, nor the use of Image guided system.

Repair of CSF Rhinorhea could be very simple once the defect is identified and the right instrument is available.

Acoustic Neuroma. Translabyrinthine Approach the Experience of King Faisal Specialist Hospital & RC ñ Jeddah

Dr. Saleh Al-Abdulwahed, Dr. Saleh Baessa

Acoustic Neuroma has been managed surgically over the last century. Translabyrinthine approach started by William House around 45 years ago. This is now the method of choice for all CPA tumors. For small intracanalicular tumors, the middle fossa approach is the route of choice while CPA tumors smaller than 2 CM with a good hearing, a retrosgmoid; posterior fossa approach could be utilized. Hearing preservation is not possible for any tumors larger than 2 cm, no matter what would the surgical approach might be. We see a very limited indication for radiotherapy as an option for the management of benign CPA. We are presenting our 3 years experience with a 17 cases. Complete resection was achieved in 95% of patients. One patient had facial nerve injury. 2 patients developed CSF leak that required surgical intervention.

Transsphenoid Endoscopic Management of Petrous Apex Cholesterol Granuloma

Dr. Saleh Al-Abdulwahed, Dr. Saleh Baessa

The goals of surgery for cholesterol granuloma are relief of symptoms and obtaining tissue for histopathologic confirmation of the diagnosis. These objectives are best accomplished by surgical drainage of the lesion and creation of a well-aerat- ed cavity to prevent obstruction and reaccumula- tion of the cyst contents, surgical approaches varies from infralabyrinthine, subcochlear, translabyrinthine, transcochlear, transethmoid- transsphenoid, suboccipital, and middle fossa approaches. Each approach has its benefits and complications, but all share the common problem of postoperative stenosis of the tract used to exteriorize the cyst. High rate of recurrence of this lesion is associated with all routs of drainage. Endoscopic sphenoidotomy and cyst drainage were performed with the aid of image guided surgery.

Spontaneous Tonsillar Haemorrhage in Saudi Arabia

Dr. Ezzat E Dawlatly

Spontaneous Tonsillar Haemorrhage (STH) in the post-antibiotic era has only been reported in association with Infectious Mononucleosis until 2 cases were reported in 1987 that were not associated with Infectious Mononucleosis.

Until 1998 when 4 females with STH were reported from Saudi Arabia, there were 19 males and 3 females reported with STH in the world literature. There were 2 adults and 2 children. Two further cases of STH in adult females have since been diagnosed and managed in KFHU.

The 6 cases are briefly presented. The probable causes ofthe exclusively female patients with STH in Saudi Arabia, and the seasonal distribution ofthe patients are discussed.

Treatment of Children with Large Adenoid and MEE: A Comparative Study

Dr. Laila Telmesani, Dr. Yasser Nufaily

Objective: To see if Adenoidectomy alone is an effective modality of treatment of secretory otitis media in children with large adenoid.

Setting: This study was conducted at King Fahad Hospital, ofthe University in Al Khobar:

Material and Method: A prospective study of 49 cases of secretetory otitis media was carried out between October 1998 and March 2000. All children with secretory otitis media not responding to medical treatment for minimum three months and has large adenoid were included. They were divided into two groups.

Group A : Patients had adenoidectomy alone.

Group B : Patients had adenoidectomy and Myringotomy with ventilation tube insertion if needed patients allocation to a group was done by patients parents. Tympanometric findings to type C or A were the criteria for improvement.

Results: fifteen patients had Adenoidectomy alone. While thirty-four patients had Adenoidectomy and Myringotomy with ventilation tube insertion if needed. In group A 85% ofthe earis improved while 15%of them showed recorrance.

In group B 81% of ears improved while 19% of them had recurrance of secretory otitis media.

The number of cases with recurrance secretory otitis media in group A is not significantly lower than the number of patients with recurrance secretary otitis media in group B.

Conclusion: Adenoidectomy alone is a effective treatment as adenoidectomy and myringology in children with secretory otitis media and large adenoid.

Key words: Adenoidectomy, Secretory Otitis media, large adenoid.

F.E.S.S. Risk and Complications and How To Avoid Them

Dr. Tariq Ashoor

FESS aim to maintain physiological function and anatomical structure. The aim of the presentation is not only to avoid major complications but also minors like eye swelling, bruising, injury of lacrimal duct and nasal turbinate, post-operative sinusitis and polyps, hemorrhage, scar formation, synechea, closure of antrostomy, diplopia.

We should go in 3 directions: pre-operative, operative and post-operative.

Pre-operative: Indication for F E S S.

Anatomy and anomalies ofthe nose and paranasal sinuses.

Hoe to prepare patient for F E S S, blood work, CT scan and MRI.

Medications not to be used before the surgery and medications should be used.

Operative: What surgeonis do during surgery.

How to deal with the major draining area the anterior osteomeatal complex, anceneate process, bulla, maxillary & frontal ostea. Hematosis, prevention of lateralization middle turbinate, the use of add technology like CT guide surgery, laser, flexible forceps, debridor.

Post-operative: How to achieve long lasting relief from sinusitis and polyps.

How to prevent early stenosis of ostea.

Specific post-operative instructions.

Post-operative antibiotics.

Post-operative visits from the 1st day until 3 months.

Signs to be reported post-operative.

Obstructive Sleep-Disordered Breathing and Stroke Cause or Consequence?

Dr. Ahmed BaHammam

Does obstructive sleep-disordered breathing (OSDB) cause stroke or does stroke cause SDB? Is OSDB an independent risk factor for stroke in the presence of many confounding overlapping risk factors, or is the association with stroke mediated by other independent predictors like age, body mass index, diabetes, and arterial hypertension in patients with OSDB? The relationship between OSDB and stroke is still under discussion, but increasing evidence demonstrates that OSDB is an independent risk factor for stroke. Does OSDB in patients with stroke influence the outcome? Does treatment of OSDB reduce the risk of stroke or improve outcome? Should OSDB be checked systematically in all patients with acute stroke? Finally, should OSDB be treated in the acute phase of stroke or should treatment be deferred until the acute stage is over?

In this lecture, we will try to explore the above concerns by critically reviewing the current literature. The following points will covered:

Snoring and stroke
Obstructive sleep apnea (OSA) and stroke
OSA as a consequence of stroke
OSA as a risk factor for stroke
Predictors of upper airway obstruction in stroke
CPAP treatment trials
Circadian variation in ischemic events
Possible mechanisms for the association
Outcome

Comparison of Nasal Prong Pressure and Thermistor Measurements for Detecting Respiratory Events During Sleep

Dr. Ahmed BaHammam

Background: Thermistor (TH) measurements have been traditionally used to determine airflow during polysomnographic studies (PSG). However, low accuracy in detecting hypopneas is a major drawback. Nasal prong pressure (NPP) measurements are becoming increasingly popular for quantifying respiratory events during sleep. However, few concerns were raised recently regarding the practicability of NPP. We hypothesized that most concerns regarding NPP do not have significant clinical implications and do not preclude routine use of NPP measurements in overnight sleep studies.

Objectives: To compare NPP and TH measurements with respect to their ability to detect respiratory events during routine PSG and to assess the practicability of routine use of NPP.

Methods: Forty consecutive patients (26 male, 14 female) with clinically suspected sleep disordered breathing (SDB) underwent routine diagnostic PSG. Airflow was measured using NPP and TH devices simultaneously. PSG was scored manually according to R and K criteria. Respiratory events were scored in two passes. During the first pass, the TH signal was disabled and NPP signal was scored. During the second pass, the NPP signal was disabled and TH signal was scored. Scorers for one method were blinded from the results of the other method. To assess respiratory events, we used the respiratory arousal index (RAI), which was defined as the number of apneas and/or hypopneas followed by an arousal per hour of sleep, as detected by TH (RAI-TH) or NPP (RAI-NPP). Agreement analysis of the results obtained using the two different techniques was performed using the methodology of Bland-AItman.

Results: Twenty-six patients had obstructive sleep apnea (OSA), 10 had respiratory effort-related arousals (RERAs) and 5 had habitual snoring (HS). The failure time of the flow signal on the raw data was not different between the two methods (NPP: 6 ± 13 minutes, TH: 4 ± 7 minutes). Bland-AItman analysis of RAIis demonstrated that more events were nearly always detected using NPP compared to TH devices (44.4 ±37 vs. 35.4 ±31, p <0.001). No difference in the index of central apneas between the two methods could be detected. Sleep position had no effect on either measurement method.

Conclusions: NPP measurements are superior to TH measurements for detecting obstructive respiratory events during sleep. NPP measurement is a simple, practical, sensitive and reliable method for detecting the whole spectrum of SDB. We recommend incorporating nasal prongs in routine polysomnographic monitoring.

Cemento-Ossifying Fibroma in the Right Ethmoid Sinus: Case Report and Review of Literature

Dr. Mona Ashoor

Cemento-ossifying fibroma is a rare tumor in the head and neck region. Itis characterized by being aggressive, locally destructive and has a high recurrence rate. The mandible region is the most common site where it is found but can also be seen in the maxilla and paranasal sinuses which is very rare. We describe a case of ethmoidal cemento- ossifying fibroma in a young patient stressing the rarity of the location, the difficulties related to differential diagnosis, and the main clinical features.

Foreign Body Aspiration in Children the Effect of Delayed Bronchoscopies

Dr. Nasser Jazan, Dr. Laila Telemesani

Introduction: Foreign body aspiration (FBA) is one of the common emergencies in pediatric age population, yet it might be difficult to diagnose. Delay in the diagnosis will render the management even more difficult, and it left untreated can lead to considerable morbidity and in some instances may cause death.

Objective: To see if duration period from FBA till broncoscopy has direct influence on clinical picture difficulties in broncoscopy and complications.

Setting: ENT Department King Fahd Hospital of the University in Al-Khobar.

Material and Method: From January 2000 till December 2002 all children. diagnosed as FBA were included. Duration between FBA and bronchoscopy, clinico-radiological findings, difficulties during bronchoscopy and complications were analyzed.

Results: 71 children were diagnosed as FBA, seventy bronchoscopies were carried out. Duration between FBA and bronchoscopy ranged from 2 hours to 18 months with a median period of 19.4 days. Twenty three children presented with marked respiratory symptoms (bad cough, stridor, respiratory distress) due to delay in diagnosis, 11 of them were due to delay in diagnosis, 11 of them were due to late presentation by the family and 12 were due to late referral. Cough was the commonest presenting symptom in 53 patients, followed by chocking in 45 and cyanosis in 39. 7 patients were found to have foreign bodies (FB) out of 9 with Bronchial asthma not responding to medical therapy, radiological findings were negative in 34 patients. Out of 70 broncoscopies: 27 were difficult due to edema, granulation, excessive secretions (23) or distallv placed FB (4patients). Post bronchoscopy 2 patients had chest infections, 1 patient had subgluticfidema and 1 patient needed thoracotomy.

Bronchoscopy was performed one patient since patients expired before procedure.

Conclusion: FBA should be suspected in any child with persistent or recurrent repiratory problem. If foreign body aspiration is suspected broncohoscopy should be done as early possible and should be performed by an experience ENT surgeon

Pediatric and Neonatal Surgical Interventions I Distraction in Neonatal for OSA

Dr. Abdullah Faidhi

Purpose: Develop a novel method for mandibular distraction with

Rapid distraction rates
Reduced hardware failure rates
Elimination of open bite
Ability to assess pin strain
Planned callus re-osteotomies

Materials And Methods: Patient Population 33 consecutive patients Two and 1/2 years Indications

Micrognathia w/ obstructive sleep apnea (OSA) by polysomnography
Tracheostomy for micrognathia
Facial scoliosis

Results:

Mean distance 24mm (18-66mm)

Mean duration 13 days (9ñ35d)

No distraction failures

Autocorrection of all open bites

Decannulation of tracheotomies

Sleep apnea resolved in 21/24

No early terminations of distraction

Detection of pin strain avoided failure ñ planned re-osteotomies

All patients required re-osteotomy beyond 20mm

Three Pruzansky III hemifacial microsomia ñ successful

Conclusions:

Simple and reliable technique

Detects early consolidation

Serial osteotomies permit aggressive distraction

No vector planning

No open bite

Minimal scars

Pediatric and Neonatal Surgical Interventions II “Stairstep” Midfacial Distractioin Crouzon Syndrome

Dr. Abdullah Faidhi

Purpose:To present a simple and staged applicable technique for midfacial distraction with multiple advantages over current methods including:

Stable result with less relapse

Stage correction of Open bite

Different levels of advancement

Materials And Methods: 4 adolescents w / Crouzon sx 18 months collection Indications

Midface deficiency w/ obstructive sleep apnea (OSA) by polysomnography
Severe class III malocclusion
Need for differential facial advancement

Results: Mean LeFort III distance 16mm (11-21 mm)

Mean duration 21 days

No distraction failures

Sleep apnea resolved in 4/4

Four Crouzon patients treated with IStairstep’ procedure Permits solid distraction callus at LeFort III level, without regard for interval occlusion

Can be integrated with monobloc

No early terminations of distraction

Conclusions:

Simple and reliable technique Allows more aesthetic plan without regard for interim occlusion

Excellent callus at LeFort III

Minimal relapse at 6 months

Corrects sleep apnea.

Cervical Paragangliomas: Diagnosis, Management and Complications (Personal Experience)

Dr Hossam Thabet

Sixteen patients were diagnosed to have cervical paragangliomas. Eleven patients (68.75%) had twelve carotid paragangliomas (C.P), and five patients (31.25%) had six vagal paragangliomas (V.P). Only one C.P (8.33%) originated from paraganglia around the C.C.A. Three case reports of multiple paragangliomas were presented (18.75% ). In 80 % (4/5) oft V.P patients, there was widening of the carotid bifurcation similar to that of C.P. Transcervical approach with cutting the digastric muscles and the styloid process with the attached ligaments and muscles, and dislocation of the mandible was sufficient for excision of most V.P.† Vascular injuries occurred in 12.5 % (2/16) of patients.† Superior laryngeal nerve paralysis occured in 18.18% (2/11) of patients with C.P, hypoglossal nerve paralysis occured in 9.09% (1/11) of patients with C.P., and vagal paralysis occurred in all patients with V.P.† Cerebrovascular accidents occurred in one patient (6.26 %). Postoperative mortality occurred in one patient (6.26%)

Hyoid Bone Syndrome Role of Ultrasound in Diagnosis & Understanding The Pathogenesis

Dr. Hossam Thabet

Hyoid bone syndrome (H.B.S) involves pain in the anterolateral part of the upper neck radiating to the ear. In this study, 74 patients were presented with H.B.S. This syndromes occurred in a recurrent acute and chronic persistent forms. The key for clinical diagnosis of this syndrome was the palpating finger for a tender tip of the greater cornu of the hyoid bone.Plain X-ray had a limited role in diagnosis of H.B.S. Ultrasonographic examination of the digastric muscle and tendon at the hyoid region confirmed the clinical diagnosis and showed the underlying pathology (tenosynovitis and tendinitis) in both acute and chronic forms of the disease.Conservative management was the treatment of choice in H.B.S. Clinical presentation, pathogenesis, and management plans of this syn- dromef were discussed.

Rhabdomyosarcoma of the Lateral Nasal Wall a Case Report

Dr. Mohammed M Zahran

Rhabdomyosarcoma is considered as the most common primary malignant tumor of the head and neck during the first two years of age. In the United States, rhabdomyosarcoma strikes approximately five in every one million children each year. It is a curable disease in the majority of children who receive optimal therapy, with more than 60% five years survival rate. We report a case of lateral nasal wall rhabdomyosarcoma with the management and literature review.

Key Words: Rhabdomyosarcoma, lateral nasal wall, head and neck, paranasal sinus, childhood.

Intratympanic Gentamicin as Treatment For Disabling Unilateral Meniereis Diseases- Longterm Effect

Dr. Abdul Aziz Al-Abidi, Nedzelski, Chen J

Objective: Is intratympanic Gentamicin (Fixed protocol) effective as a longterm method of controlling vertigo associated with disabling unilateral Meniereis Disease?

Method: A retrospective review of ongoing prospective study for 31 patients followed for a minimum of four years (pos treatment) with fixed treatment protocol.

Results: Complete vertigo control continue in 25 patients, recurrence in 6 patients of whom 2 patients with contralateral disease, in 8/31 patients, hearing continue worsening.

Conclusion: Longterm follow-up is necessary to properly evaluate efficacy of treatment for disabling Meniereis Disease.

Cricotracheal Resection in Children: The Cincinnati Experience

Dr. Majdi Karim

Subglottic stenosis (SGS) is currently the biggest challenge for Pediatric if the treatmencheoplasty of S.G.S has changed dramatically over the last 20 years. Traditionally surgical techniques were either splitting the larynx (ACS) in neonates or augmentation of the iarynx (Laryngotracheoplasty (LTR). In Cincinnati series ACS gave an overall extubation rate of 75% but limited to neonates LTRs (single & double stage) with anterior/posterior grafts gave deacanulation rate of 97% for grade If and less than 77% for grade IV SGS. However recently the revolution came with Cricotracheal Resection (CTR) for grade III & IV SGS, and currently CTR is becoming very promising procedure with an overall decanulation rate of 87 %. Multiple factors influencing these results are fully discussed: age, previous surgery, staging, length & type of stent, type of graft, associated conditions (reflux, tracheomalacia & pulmonary pathology).

The Contralateral Ear in Acquired Cholesteatoma (A Clinico-Radiological Study)

Dr.Hamed Khalil, Mahmoud A. Saleh, Ayman A.Sakr

Clinico-audiological assessment of the normal contra lateral ear in patients with unilateral cholesteatoma can be a good predictive method for the fate of these ears. Fifty patients with unilateral cholesteatoma and 25 control subjects with bilateral normal ears were subjected to otomicroscopical and audiological assessment. Axial and coronal sections for the mastoid bone at 1 mm slice thickness were done for all ears. A simplified method was used to find out the surface area (SA) of the air cells at each individual section and automatically calculate the total volume of the mastoid air cells.

Otomicroscopically, 72% of the contra lateral ears showed signs of retraction pockets, granulation tissues, or chronicity. Audiologically, 20% ofthe controlled ears showed moderate to severe conductive hearing loss while 10% showed mixed hearing loss. As regards mastoid pneumatization, the mean air cell volumes were 6.1, 12.68 & 29.92 Cmm in Cholesteatomatous, contra lateral & control ears respectively. This indicates a highly significant difference in the mean air cell volume between the control ears and the other two groups It can be concluded that continuous follow up ofthe contra lateral ear in cholesteatomatous ears is mandatory to detect early pathological changes and manage them early. Systematic preventative measurements ofthe contra lateral ears (including the applied simple method) can lead to a reduction in major surgery and can affect the choice of the surgical approach.

Conclusion: Since cholesteatoma is a chronic insidious destructive disease; meticulous and continuous follow up of the contralateral ear of patients with unilateral cholesteatoma is highly mandatory to detect up any early pathological change and manage them early and effectively. . From the practical point of view, systematic preventative measurements ofthe contralateral ear can lead to a reduction in major surgery and can affect the choice of the surgical approach. Moreover, it may also condition the precision and length of the follow-up.

It is advisable to use the applied simplified measurement method in CT mastoid to define the degree of pnumatization in relative to the values of the control group.

Effects of Peripheral Hearing and Vestibular Loss on Molecular: Correlates of Central Processing

Dr. Hesham M. Samy

There is growing interest in examining the molecular and genetic mechanisms that may underlie inner ear pathologies. These facts have important implications for our understanding ofthe possible therapeutic management of inner ear diseases. An understanding of the central auditory and vestibular system responses to altered peripheral input may influence the clinical management of inner ear pathologies. This study examines how peripheral sensory loss may affect molecular correlates of central auditory and vestibular central processing. We focused on changes of proteins related to calcium binding (parvalbumin) and synaptic activity (GABA-A beta receptor subunit, NMDA-R2A receptor subunit). These were studied with both immunocytochemistry and non-radioactive in situ hybridization techniques in gerbils receiving unilateral inner ear destruction.

A Rare Type of Bacterial Sinusitis Resembling Fungal Sinusitis

Dr. Hatim Y. Shawli

This is a case report of bacterial sinusitis in a 12 years old male child which was having clinically and radiologically as fungal sinusitis, culture ofthe surgical specimen revealed E.coli and Pasteurella Multocida, questioning the family after surgery revealed that the child used to play with street cats. He responded very well to surgical debridement and postoperative antibiotics.

Controversial Issues in the Management Issues in the Managcmnet: Of Benign Paroxysmal Positional Vertigo

Dr. Hatim Y. Shawli

This is a literature review of the controversies in the etiology, pathophysiology, Types of BPPV, Diagnostic maneuvers, treatment maneuvers, the need for post maneuver precautions, etc.

It discusses the different opinions regarding the management of this condition (BPPV) the most common cause of dizziness in Otolaryngology clinics.

Segmental Lower Lobe Collapse of the Left Lung Associated With Mediastinitis Secondary To Parapharyngeal Abscess and Quinsy

Dr. Latifi Asrar

A 36 year old male Indian was referred from a private dispensary with complaints of fever, sorethroat, dysphagia and swelling of the left side of the neck. A diagnosis of quinsy was made. Initial management including incision and drainage, did not resolve his condition. He developed a deep neck space abscess. At this stage he was referred to our hospital.

A diagnosis of parapharyngeal abscess with mcdis- tinitis and segmental lower lobe collapse of the left lung was made. Findings were confirmed by CT scan. Intensive management including drainage of the abscess resulted in resolution of the patient’s condition and he was discharged after 11 days.

We present segmental lung collapse as a rare complication of mediastinitis secondary to cervical and oral infections. Delay in the diagnosis and treatment of quinsy can result in life threatening complications like parapharyngeal abscess, retropharyngeal abscess, necrotising fasciitis and mediastinitis. CT scan is a good diagnostic tool in the management of these complications.

Choanal Atresia: A retrospective study of 31 cases

Dr. Laila Telmesani, Dr. Khalid Abo Shama

Objective: To perform an analytic study of all cases diagnosed as congenital Choanal Atresia in the last 16 years.

Design and setting: A retrospective study at King Fahad hospital of the university at Al khobar Saudi Arabia.

Patients and Methods: The medical records of all patients diagnosed as a congenital choanal atresia (CA)and treated between 1987and 2002 were reviewed .Information collected included sex, age, type, and site of atresia ,presence or absence of other congenital anomalies, method of surgical repair, and postoperative complications.

Results: We had total number of 31 patients, 19 female and 12 male patients (1.6: I). Age range is from two days newborn to 20years. Unilateral choanal atresia (UCA) was seen in 18 patients (58 %). The bilateral choanal atresia (BCA) was founded in 13 patients (42 %).Atretic plate was mixed type in 23 cases (74.3 %). Family history was positive in 9.7 % of cases .16 out of 31 patients (51.6%) had other congenital anomalies which were seen more common with the BCA (69.2%) than in UCA cases (33.3 %).

Twenty five cases were corrected using the transnasal approach; Transpalatal approach was used in 8 cases, and transnasal endoscopic repair was used in last 3 cases.

Conclusion: The present report encompasses on of the largest series of children treated for CA, in Saudi Arabia, Fifty percent of children had other concurrent congenital anomalies, warranting comprehensive evaluations. The transnasal approach was effective in correcting CA. Surgical outcome by using the transnasal endoscopy is promising to reduce the stenting duration as well as the follow up dilatation surgery

Evidence Base Medicine, Challenges Facing The Surgeons.

Dr. Saleh Al-Abdulwahed

The current medical practice requires diligent knowledge not only of the recent publications but also on how to interpret, use and apply this knowledge to answer patientis queries and justify financial coverage from insurance and third parties payers.

This presentation attempts to simplifies the practice of E.B.M and identify the challenges ahead.

Clinical Pathway, Applications in Surgery

Dr. Saleh Al-Abdulwahed

The iclinical pathways! starting to be the standard of practice for many procedures. The surgical applications are tremendous. Surgeons should be very well versed with all aspect of clinical pathway to able to use it for their benefits. While it started to be a must in some hospitals; the clinical pathway practice is spreading among all hospitals in a fast base.

Introduction to Sleep Medicine

Dr. Ahmed BaHammam

Sleep disorders is a known specialty in the field of medicine.

Unfortunately, the importance of this specialty is not fully appreciated by some in the medical and non-medical communities.

Sleep occupies one third of the every day. Sleep or lack of sleep has an effect on the remaining two-thirds of the day.

Understanding the importance of sleep and the effects of sleep deprivation is crucial to public health and safety.

History Of Steep Medicine: Interest in sleep and sleep disorders has existed since the beginning of man and continued to grow over time.

Charles Dickens (the novelist) first described sleep apnea in 1836.

The field of sleep disorders expanded significantly from 1930s to the 1970s where a lot of research was conducted on circadian rhythms on cats and dogs.

The worldis first sleep disorders clinic was established at Stanford University in 1970 by Dr. W. Dement ithe father of sleep medicine.

“Some Must Watch While Some Must Sleep” At the present, iSleep Disorders? is a known specialty in the medical field that has its own fellowship training programs, societies and medical centers.

Importance Of Sleep Disorders: The occurrence of sleep disorders among the general public has increased significantly during the past few years secondary to the changes in life style and the pressures of today’s life as well as the increased awareness of primary health care physicians and improved diagnostic tests.

In USA:

40% of adults report some type of sleep disorders
35% of adults complain of insomnia at some time of their life
2-4% of middle age adults have Obstructive Sleep Apnea Syndrome (OSAS)
1% have narcolepsy

Another measure of the growing interest in sleep disorders is the increasing number of sleep disorders centers. In the year 1977, there were three _ accredited sleep disorders centers in the United States. This number increased to 201 in the year 1991 and 337 in 1996.

Recently, campaigns such as iWake Up Americal and iDrive Alert Arrive Alivei have attempted to bring attention to the pervasive problem of sleepiness in America today

Recent research indicates that lack of sleep is amore critical factor in all type of accidents (from automobile to industrial incidents). Examples:

The risk of having automobile accidents in patients with sleep disorders is three times the risk in normal people

Challenger disaster
Chernobyl
A study of 278 fatal truck driver accidents, concluded that sleep deprivation and fatigue were major causative factors

One estimation in USA set the cost to the society of sleep related problems as 16000 billion dollars annually

Sleep Disorders: Patients with sleep disorders usually present with insomnia, excessive daytime sleepiness or snoring.

However, some patients may present with vague, non-specific complaints such as fatigue, depression and impaired concentration.

The above mentioned presentations can be caused by a long list of disorders which require the assessment by a specialized doctor to be able to diagnose and treat each individual patient appropriately.

Hence, the classification of sleep disorders has been of particular interest to sleep specialists since the rapid expansion of sleep medicine.

In 1990, an International Classification of Sleep Disorders (ICSD) was produced after a lengthy process. This classification lists 84 sleep disorders with their specific diagnostic criteria and differential diagnosis.

Classification Of Sleep Disorders:

Dyssomnias:

Intrinsic sleep disorders

Extrinsic sleep disorders

Circadian rhythm sleep disorders

Parasomnias:

Arousal disorders

Sleep-wake transition disorders

Parasomnias usually associated with REM sleep

Other parasomnias

Sleep disorders associated with medical or psychogenic disorders:

Associated with mental disorders

Associated with neurological disorders

Associated with medical disorders

Proposed sleep disorders

Diagnosis:

History: Usual presentation include: Insomnia, snoring, excessive daytime sleepiness (EDS). Children usually, present with hyperactivity rather than EDS.

Other presentations: early morning and nocturnal headache, fatigue, depression, impaired concentration, perception, and communication as well as impotence.

Ideally, the history should be got from the bed partner

The above symptoms can be caused by a long list of sleep disorders

Therefore, if the diagnosis is not clear, the patients should assessed by a sleep disorders specialist

Foreign Body Aspiration in Children. Who is at Risk? How Can We Prevent It?

Dr. Mona Ashoor, Dr. Laila Telmisani

Foreign body aspiration in children is a common pediatric emergency worldwide. Most otorhino- laryngologists are trained in managing such an emergency. But not much has been done for preventing it. We have conducted a prospective study on 70 children with history of foreign body aspiration whom presented to the King Fahad Hospital of the University in Al-Khobar, Saudi Arabia from January 2000 to January 2002. The socioeconomic status of the patient was evaluated, aiming to find the most prevalent group. The guardians! knowledge regarding foreign body aspiration was also evaluated. Certain recommendations are suggested to prevent and reduce the incidence of foreign body aspiration.

Significance and Radilogical Assessment of the Pre-epiglottic and Paraglottic Space (Pes & Pgs): Invasion In Laryngeal And Hypopharyngeal Tumors

Dr Hossam Thabet

An informed concept of the pre-epiglottic, and paraglottic spaces is essential to understanding the growth and spread of laryngeal cancer and the adequacy of surgical extirpation in conservation surgery for cancer larynx. “Ninety four patients diagnosed and treated for cancer of the larynx or hypopharynx were studied preoperatively endo- scopically and by CT. Lesions were resected by partial or total laryngectomy, partial pharyngecto- my, or total laryngopharyngectomy. Operative specimens were examined by whole organ section. Incidence of PES invasion in supraglottic tumors was 48.5%, while in ventral supraglottic tumors, it was 50.0%, and in ventrolateral tumors, was 71.4%. Incidence of PGS involvement in lateral supraglottic tumors was 75.0t%. CT had an accuracy of 94.2% in showing PES and PGS invasion in laryngeal and hypopharyngeal tumors, however, it has a false positive results in 12.5% of cases, and a false negative results in 5.8% of cases. Medial arytenoid cartilage displacement with or without widening of the posterior cricothyroid space in laryngeal or hypopharyngeal tumors denotes PGS ionvasion in 100% of cases, PGS can be invaded by tumor, meanwhile vocal cords might be still mobile in 33.3% of laryngeal and hypopharyngeal tumors, and in 10% of transglottic tumors.

New Stent in Prevention of Recurrent Stenosis Following Choanal Atresia Repair

Dr Ali Al Qahtani

The incident of restenosis following choanal atresia repair may reach 80%. No standard and ready fimade stent available and all stants are usually fashioned from different soft and hard materials. We describe newly designed stent, which has several advantages. It is composed of two parallel tubes, made of reinforced silicone rubber. The front part of each tube contains a hole on each side, so that the four holes are on the same line. A bridge consists of a hollow tube made of PVC, with piece of sponge attached to it, fixed by a strong thread which passes through the holes and the inside of the PVC tube. This is to stabilize the tube in the postrils, sponge protects columella from undue pressure. The two tubes in the postrils, sponge protects columella from undue pressure. The two tubes are connected posteriorly by a strip of the same material without any metal reinforcement. Two solid-tipped PVC catheters (one for each tube) to be used to position stent in nostrils through the mouth. Stent has several advantages. They are as follows:

Ready made, shortens operative time.
Imbedded metal wire within walls keeps lumen patent and suction easier.
Metal wire expands at body temperature, rather than collapsing in front of attempts of the choanae to close again, it stands pressure of restenosis.
Spiral metal wire adds flexibility to stent easing its insertion.
Presence of attached piece of sponge to the bridge prevents pressure necrosis of columella,

Produced from material previously tested and licensed for use in humans (Z79-IT). This material does not initiate inflammatory toxic tissue reaction, which eventually results in scar tissue formation and possible restenosis.

Issues in Implementing Early Hearing Detections and Intervention Programs

Dr. Mohd Ismaiel Hafiz

Normal hearing is a pre-requisite for the development of optimum aural/oral communication. Speech production and perception are negatively affected by the lack of normal input model and an intact auditory feedback loop. Moreover the age at which the hearing loss is indentified and time at which intervention is initiated appears to impact outcome. To avoid or reduce the negative effects to a minimum. The hearing defect has to be detected early as possible. This could be fulfilled through the so called iUniversal Newborn Hearing Screening Program (UNHSP)i. We will talk about the design of the program. How does it works and its reactivity in Saudi Arabia, what are the pre-req- uisites to be implemented and how good is the outcome.

Conclusions and recommendations will be discussed later.

Feasibility of Transient Evoked Otoacoustic Emissions as a Hearing Screen Folowing Grommet Insertion

Dr Osama Elsayed Badrart

Purpose: To measure transient evoked otoacoustic when the children are ready to be discharged from the ward following grommet insertion & to evaluate its efficacy as a hering assessment method performed before children leave the hospital following grommet insetion.

Method: A Prospective study comprised 40 children who were admitted to King Fahd Teaching hospital n Al Khobar for ventilation tube insertion between April 2001 & May 2002. Transient Evoked Otoacoustic Emissions screening was performed when the children were ready to leave the hospital; this was usually the next day following surgery. An age appropriate hearing was done prior to discharge from the hospital.

Results: The present study obtained normal transient evoked otoacoustic emissions in 69 cars representing 90.8% before hospital discharge. Regarding behavioral hearing assessment only 32 ears representing 48.8% pass the test.

Conclusion: Transient evoked otoacoustic emissions are an effective means of confirming normal hearing when performed the next day following grommet insertion before discharge from the hospital.