ObjectiveThe value of endoscopic versus microsurgical approach has not yet been defined in transsphenoidal pituitary adenoma surgery. In this study, we compare both methods and analyze the long-term surgical, radiological, endocrinological, ophthalmological, and rhinological results as well as the patients’ quality of life.MethodsA total of 33 individuals with elective transsphenoidal pituitary adenoma surgery were randomized (pure endoscopic approach or endoscope-assisted microscopic approach) and prospectively underwent investigations with a focus on patient-related subjective outcome measurements.ResultsThe mean follow-up period was 6.3 years. In the microsurgical group, endoscopic inspection revealed residual tumor in seven of 15 patients (46.7%) not seen by the microscope. Endoscopic resection provided long-term tumor-free state in all of them. Compared to pure microsurgical treatment, endoscopy was associated with a lower probability of tumor recurrence (OR = 0.24) and appeared advantageous in the long-term achievement of any surgical goal (OR = 3.80) as well as in anterior pituitary lobe function improvement (OR = 1.60). Where gross total tumor resection was the stated preoperative goal, there was no long-term tumor recurrence in 81.8% (endoscopy group) and 83.3% (endoscope-assisted microsurgical group). Most aspects showed no significant difference between the techniques, such as length of hospital stay, complication rate (endoscopy: 16.7%, endoscope-assisted microsurgery: 20.0%), long-term maintenance of any preoperatively stated extent of resection, pituitary and olfactory function, rates of DI and SIADH, ophthalmological improvement, and SNOT scores.ConclusionsBoth techniques provide good long-term surgical, radiological, endocrinological, rhinological, and ophthalmological results. Endoscopy clearly improved the rate of long-term achievement of the initial surgical goal and the anterior pituitary lobe function.

BACKGROUND AND OBJECTIVES:This paper presents an overview on nasal packing materials which are available in Germany. The current literature is analyzed whether there are robust criteria regarding use nasal packing after sinonasal surgery, whether there are fundamental and proven advantages or disadvantages of products, and what this means in clinical practice.MATERIALS AND METHODS:Selective literature analysis using the PubMed database (key words "nasal packing", "nasal tamponade", "nasal surgery", "sinonasal surgery", or "sinus surgery"), corresponding text books and resulting secondary literature.RESULTS AND CONCLUSIONS:Because of systematic methodological shortcomings, the literature does not help in the decision-making about which nasal packing should be used after which kind of sinonasal surgery. In fact, individual approaches for the many different clinical scenarios are recommended. In principle, nasal packing aims in hemostasis, should promote wound healing, and should not result in secondary morbidity. Nasal packing materials should be smooth (non-absorbable materials), inert (absorbable materials), and should not exert excessive pressure. Using non-absorbable packing entails the risk of potentially lethal aspiration and ingestion. For safety reasons inpatient control is recommended as long as this packing is in situ. With other, uncritical packing materials and in patients with special conditions, outpatient control could be justified.

Zusammenfassung Hintergrund Die Ambulantisierung rhinochirurgischer Eingriffe wird derzeit intensiv diskutiert und insbesondere von politischer Seite stark propagiert. Viele Fragen zur Stratifizierung in ambulante oder stationäre Durchführung sind unklar. Insbesondere ist das Vorgehen bei Anwendung von Nasentamponaden bisher nicht ausreichend diskutiert. Material und Methoden Deutschlandweite Umfrage unter niedergelassenen und in Kliniken tätigen Hals-, Nasen-, Ohrenärzten zur Verwendung von Nasentamponaden in der Rhinochirurgie und zum Auftreten von Komplikationen in Zusammenhang mit einer Tamponade. Ergebnisse 85,6% der Antwortenden verwenden eine Nasentamponade zumindest manchmal bei der Chirurgie von Septum und Nasenmuscheln/lateraler Nasenwand, 44,2% grundsätzlich. Bei der Nasennebenhöhlenchirurgie sind dies 94,1% bzw. 49% der Antwortenden. Überwiegend wurde die Anwendung von sich nicht auflösenden Tamponaden angegeben. Die am häufigsten beobachteten Komplikationen waren eine Blutung unter liegender Nasentamponade (>50% der Antwortenden) und eine Dislokation nach dorsal (24% der Antwortenden), die ein notfallmäßiges Eingreifen erforderte. Eine Todesfolge wurde bei 5 Patienten beschrieben. Ein Patient erlitt eine dauerhafte Hirnschädigung nach Hypoxie. Schlussfolgerungen Die Anwendung einer sich nicht auflösenden Nasentamponade mit Okklusion der Nasenhaupthöhle kann zu einer relevanten Gefährdung der Patienten führen, die ein notfallmäßiges Eingreifen erforderlich macht und deshalb die stationäre Überwachung erfordert.

Zusammenfassung Hintergrund Die Ambulantisierung rhinochirurgischer Eingriffe wird derzeit intensiv diskutiert und insbesondere von politischer Seite stark propagiert. Viele Fragen zur Stratifizierung in ambulante oder stationäre Durchführung sind unklar. Insbesondere das Vorgehen bei Anwendung von Nasentamponaden ist bisher nicht ausreichend diskutiert. Material und Methoden Entwicklung einer Checkliste zur ambulanten Durchführung rhinochirurgischer Operationen unter Berücksichtigung der aktuellen Literatur. Ergebnisse und Schlussfolgerungen Nach umfassender Auswertung der Literatur und Analyse von Risikofaktoren wird eine Liste von stationär durchzuführenden rhinochirurgischen Operationen definiert. Es wird eine Checkliste für die ambulante oder stationäre Durchführung rhinochirurgischer Operationen vorgelegt, die soziale, allgemeine medizinische und spezifische operationsbedingte Gründe berücksichtigt und hierbei die Anwendung von Nasentamponaden einschließt. Sie wird ergänzt durch eine Checkliste, anhand derer Kriterien die Entlassungsfähigkeit von Patienten nach einer ambulant geplanten rhinochirurgischen Operation bewertet wird.

Objective Currently, there is an intensive discussion on advancing and expanding outpatient rhinosurgical procedures. Many questions about how to stratify into out- and inpatient procedures are still not sufficiently clarified. Particularly, the use of nasal packing materials is not adequately discussed. Material and Methods Development of a checklist to stratify sinunasal procedures into in- or outpatient procedures with consideration of current scientific literature and risk factors. Results and conclusions After comprehensive assessment of the literature and analysis of specific risk factors, a list of sinunasal procedures is presented, which should be performed as inpatient procedures. We present a checklist for in- and outpatient sinunasal procedures, which considers social, medical and surgical factors as well as the use of nasal packing materials. Furthermore, a checklist is added to assess, whether patients are ready for discharge after a planned outpatient procedure.

Objective Currently, there is an intensive discussion about enhancing and expanding outpatient rhinosurgical procedures. Many questions about how to stratify into out- and inpatient procedures are still not sufficiently clarified. Particularly, the use of nasal packing materials is not adequately discussed. Material and Methods We performed a Germany-wide survey among otorhinolaryngologists regarding the use of nasal packing materials in sinonasal surgery. Additionally, we asked for any complication in relation to nasal packing. Results In 85,6% nasal packing was used for septal and turbinate surgery at least occasionally, in 44,2% always. In sinus surgery these numbers are 94,1% and 49%, respectively. Non-resorbable nasal packing materials were predominantly used. Most frequent complications were bleeding with nasal packing in situ (> 50% of respondents) and posterior dislocation (24% of respondents), requiring emergency treatment. Death was listed in 5 patients. One patient suffered from permanent brain damage due to hypoxia. Conclusions Application of non-resorbable nasal packing materials with occlusion of the nasal cavity carry a substantial risk of complications, which necessitate emergency treatment, thus requiring inpatient care.

In dieser Arbeit soll ein Überblick über die aktuell in Deutschland verfügbaren Nasentamponaden gegeben und die aktuelle Literatur dahingehend analysiert werden, ob sich Kriterien für die Anwendung von Nasentamponaden nach endonasaler Chirurgie ableiten lassen und ob einzelne Produkte oder Produktgruppen grundsätzliche und nachprüfbare Vorteile gegenüber anderen besitzen und welche Schlussfolgerungen sich hieraus für die praktische Anwendung ergeben. Hierzu erfolgte eine selektive Literaturrecherche in der Datenbank PubMed mit den Stichworten „nasal packing“, „nasal tamponade“, „nasal surgery“, „sinonasal surgery“ oder „sinus surgery“, in themenbezogenen Textbüchern bzw. in hieraus sich ergebender Sekundärliteratur Insgesamt gibt es aufgrund systematischer methodischer Defizite keine ausreichende Hilfestellung in der Literatur, welche Nasentamponaden bei welcher Art der endonasalen Chirurgie wie zu verwenden sind. Innerhalb der vielen klinischen Szenarien ist für den Patienten eine individuelle Lösung zu definieren. Grundsätzlich sollte die Anwendung von Nasentamponaden dazu führen, dass ggf. eine ausreichende Blutstillung erfolgt, die Wundheilung begünstigt wird und keine sekundäre Morbidität entsteht. Die Anwendung glatter Materialien zur Nasentamponade mit Formkörpertamponaden, die Vermeidung eines übermäßigen Drucks auf die Schleimhaut, der Einsatz inerter Materialien bei Verwendung sich auflösender Materialien sowie die Vermeidung obsoleter Materialien sind geboten. Die Verwendung nichtauflösender Nasentamponaden birgt das Risiko der potenziell tödlichen Aspiration und Ingestion sowie eines fortlaufenden Blutverlusts und obstruktiver Atmungsstörungen in sich, sodass aus Sicherheitsgründen während der Liegedauer eine stationäre Überwachung lege artis ist. Andere unkritische Tamponaden und ggf. fehlende sonstige Risikofaktoren können nach individueller Beurteilung des behandelnden Arztes unter Umständen eine ambulante Betreuung rechtfertigen.

Wir trauern um unseren Lehrer, einen weltweit geschätzten und verehrten Kollegen, der Entwicklungen und Fortschritte in der HNO-Heilkunde ganz wesentlich mitgeprägt hat.

Background:Reconstruction of the bony socket after orbital exenteration is a matter of much debate. Prompt defect closure with a microvascular flap is desirable but involves a major surgical procedure and hence, places considerable burden on the patient. The new surgical technique presented here permits a technically simpler wound closure with fewer complications after orbital exenteration. Methods:Between May 2014 and June 2022 in the ENT department of Regensburg University, nine patients underwent exenteration and reconstruction with a pericranial flap. The flap was raised via a broken line incision in the forehead or endoscopically, incised in a roughly croissant-like shape, then introduced into the orbit through a tunnel in the eyebrow. A retrospective analysis of the patients and considerations about determining the size, shape, and vascular supply of the flap are presented. Results:Flap healing was uncomplicated in all cases. Only 6 weeks after surgery, the flap was stable, making it possible to start adjuvant therapy and prosthetic rehabilitation swiftly. The flap is adapted to the near cone-shape of the orbit. The mean (& PLUSMN; standard deviation) surface area of the measured orbits is (39.58 & PLUSMN; 3.32) cm(2). The territory of the angular artery provides the periosteal flap arterial blood supply. Venous drainage is via venous networks surrounding the artery. Conclusions:Use of the pericranial flap makes it possible to close the orbital cavity promptly with minimal donor site defect and a short operating time, thereby minimizing the surgical risk and speeding up physical and psychological recovery.

BACKGROUND:Eosinophilic granuloma (EG) belongs to the family of Langerhans cell histiocytosis (LCH) and is considered to be a benign disease typically found in children younger than 15 years of age. Here, the authors describe an EG of unusual localization and clinical presentation.OBSERVATIONS:The authors report a 9-year-old girl with an EG presenting as an osteolytic lesion of the clivus. After transsphenoidal resection and histological confirmation, adjuvant chemotherapy was initiated. Presenting signs and symptoms were weight loss, episodic grimacing, and moderate ballism-like movements. After a follow-up-period of 32 months, the patient presented with a total resolution of initial symptoms and no further tumor growth.LESSONS:Although these lesions are rare, one should consider EG as a differential diagnosis when confronted with osteolytic lesions of the clivus.

Introduction The objective of this study was to determine whether postoperative additive systemic steroid administration in chronic rhinosinusitis with nasal polyps (CRSwNP) impacted selected endoscopic, subjective and objective outcome measures. Methods This was a prospective, randomized, double-blind, placebo-controlled, noninferiority multicenter trial of n=106 patients with CRSwNP. All patients underwent primary functional endoscopic sinus surgery (FESS) followed by topical nasal steroids. Patients were randomized to a systemic steroid or placebo for 1 month. Patients were followed up for 2 years over 9 time points. The primary outcome measures were the differences between groups with respect to the nasal polyp score (NPS) and sinonasal quality of life (SNQoL). Secondary outcome measures included interactions with respect to the Lund-Kennedy score (LKS), sinonasal symptoms, general quality of life (GQoL), 16-item odor identification test scores, recurrence rates, need for revision surgery and mucus biomarker levels. Results 106 patients were randomized to either the placebo or the systemic steroid group (n=53 per group). Postoperative systemic steroids were not superior to placebo with respect to all primary (p= 0.077) and secondary outcome measures (p>0.05 for all). Reported adverse events were similar between the two groups. Conclusion In conclusion, the addition of postoperative systemic steroids after primary FESS did not confer a benefit over topical steroid nasal spray alone with respect to NPS, SNQOL, LKS, GQOL, sinonasal symptoms, smell scores, recurrence rates, the need for revision surgery or biomarkers over a short-term follow-up of up to 9 months and a long-term follow-up of up to 24 months in CRSwNP patients. Functional endoscopic surgery did, however, show a strong effect on all outcome measures, which remained relatively stable up to the endpoint at 2 years.

Die postoperative Behandlung stellt einen entscheidenden Aspekt für den Erfolg von Nasennebenhöhleneingriffen dar. Zu den grundlegenden Maßnahmen gehören Nasenspülungen mit Salzlösung, mit denen bereits am ersten postoperativen Tag begonnen werden sollte, die topische Steroidapplikation und die Gabe von Antibiotika im Fall einer Infektion. Zur ärztlichen Versorgung gehört das Absaugen des unteren Nasengangs in der ersten Woche. Die Krustenentfernung im Op.-Bereich sollte unter endoskopischer Kontrolle in der zweiten Woche beginnen. Dabei werden die Intervalle individuell festgelegt. Die Okklusion der Nase für die Zeit der Epithelregeneration hält den ethmoidalen Raum feucht, was zu einer besseren Wundheilung führt.

The middle turbinate’s basal lamella (3BL) is a variable landmark which needs to be understood in endoscopic transnasal skull base surgery. It comprises an anterior frontal and a posterior horizontal part and appears in its simplest depiction to be “L”-shaped, when viewed laterally. In this study we analyzed its 3D morphology and variations focusing on a precise and systematic description of the anatomy. CBCTs of 25 adults, 19 cadavers and 6 skulls (total: 100 sides) were investigated with the 3DSlicer software, creating 3D models of the 3BL. We introduced a novel geometrical classification of the 3BL’s shape, based on segments. We analyzed their parameters and relationship to neighboring structures. When viewed laterally, there was no consistent “L”-shaped appearance of the 3BL, as it is frequently quoted. A classification of 9 segment types was used to describe the 3BL. The 3BLs had in average of 2.95 ± 0.70 segments (median: 3), the most frequent was the horizontal plate (23.05% of all segments), next a concave/convex plate (22.71%), then a sigma plate (22.37%). Further types were rare. We identified a horizontal plate in 68% of all lateral views whilst 32% of the 3BLs were vertical. A sigma–concave/convex–horizontal trisegmental 3BL was the most common phenotype (27%). Globally, the sigma–concave/convex pattern was present in 42%. The 3BL adhered the ethmoidal bulla in 87%. The segmenting method is eligible to describe the 3BL’s sophisticated morphology.