Учебники / Revision Sinus Surgery Kountakis 2008
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Aldo C. Stamm, João Flávio, and Richard J. Harvey |
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Fig. 33.5 Recurrent cystic craniopharyngioma. 1 Olfactory tract, 2 transplanum opening to cyst, 3 Sella. (Reproduced with permission from Centro de ORL, Sao Paulo, Brazil)
Fig. 33.6 Recurrent chordoma. 1 Basilar artery, 2 vertebral arteries, 3 tumor. (Reproduced with permission from Centro de ORL, Sao Paulo, Brazil)
Table 33.3 Graft materials used in reconstruction of skull-base defects
•Mucosal flaps
–Posterior rotation septal flap (based on the septal branch of the sphenopalatine artery (SPA); Fig. 33.7a)
–Contralateral transposition septal flap (based on ethmoidal arteries; Fig. 33.7b)
–Inferior turbinate flap (based on turbinate branch of the SPA; Fig. 33.7c)
–Nasal floor flap (based on branches of the SPA and Woodruff’s plexus; Fig. 33.7d)
•Free mucosal or mucoperioteal grafts
–Well-described series with closure of anterior skull-base defects with cerebrospinal fluid leaks but not with extensive dural resection [35]
•Tissue glues and substrates – BioGlue [13] Tisseel [27] DuraGen [9] and Duraseal
•Autologus fascia (fascia lata, temporalis fascia)
•Homologus fascia (Alloderm)
•Free fat grafts
•Free flaps [67] (usually requiring conversion to open skull-base surgery)
•Free bone or synthetic materials
Chapter 34
Stenting in Revision Sinus Surgery |
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Seth J. Kanowitz, Joseph B. Jacobs, and Richard A. Lebowitz |
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Contents |
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Core Messages |
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■ Long-term patency rates may be improved by post- |
Introduction . . . . . . . . . . . . . . . . . |
301 |
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Stenting Materials and Design . . . . . . . . . |
. 301 |
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operative stenting of the frontal sinus outflow tract. |
Preoperative Assessment . . . . . . . . . . . . |
303 |
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In cases of previous partial middle-turbinate resec- |
Indications for Stenting . . . . . . . . . . . . |
. 303 |
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tion, stenting of the frontal sinus outflow tract al- |
Duration of Stenting . . . . . . . . . . . . . |
. 304 |
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lows for stabilization of the remnant fragment dur- |
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ing revision frontal sinusotomy. |
Surgical Technique . . . . . . . . . . . . . . |
. 305 |
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In cases of extended frontal sinus drillout proce- |
Postoperative Stent Management . . . . . . . . |
. 306 |
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dures, stenting allows for improved mucosalization |
Conclusion . . . . . . . . . . . . . . . . . |
307 |
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and aids in temporary inhibition of circumferential |
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Acknowledgments . . . . . . . . . . . . . |
. 307 |
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stenosis. |
■Soft (Silicone) sheets or stents, either prefabricated or designed in the operating room, are superior to rigid stents.
■No absolute length of stenting exists and a determi- ing endoscopic visualization, high-resolution triplanar
nation should be made on a case-by-case basis. |
computed tomographic (CT) imaging, through-cutting |
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■ Postoperative stent management includes routine |
frontal sinus instrumentation, and image-guided surgery |
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endoscopy with gentle debridement, culture-direct- |
have occurred since the original external approaches |
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ed antibiotic therapy, and nasal irrigations. Nasal |
were described, prevention of FSOT restenosis after revi- |
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steroid spray is reserved for select cases. |
sion sinus surgery remains a difficult challenge. |
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Intrinsic host factors such as sinonasal polyposis, |
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osteoneogenesis, ciliary dyskinesis, immunodeficiency, |
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vasculitis, and other autoimmune phenomena may pre- |
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dispose the patient to a poor outcome regardless of the |
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surgical technique. Extrinsic factors such as lateralization |
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Introduction |
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of the middle turbinate/middle turbinate remnant, post- |
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Revision frontal sinus surgery is a demanding challenge |
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operative sinus cavity infections, scarring, synechiae, and |
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that incorporates a keen understanding of three-dimen- |
incomplete primary sinus surgery may also compromise |
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sional anatomy, surgical precision, and vigorous post- |
postoperative healing and ultimately lead to FSOT ste- |
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operative medical management aimed at maximizing |
nosis. Historically, failure rates of nearly 30% have been |
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long-term surgical success. Restenosis of the frontal sinus |
reported in the literature – and because of this propensity |
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outflow tract (FSOT) is frustrating and can occur even |
for postoperative stenosis of the FSOT, stenting remains |
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under the best of circumstances. The concept of frontal |
an important component in the surgical and postopera- |
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sinus stenting to minimize postoperative stenosis, im- |
tive management of chronic frontal sinusitis during revi- |
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prove mucosalization, and allow for functional patency |
sion endoscopic surgery. |
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of the of the FSOT following frontal sinus surgery has |
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been reported in the literature for over a century. In the |
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initial description of the external frontoethmoidectomy |
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Stenting Materials and Design |
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that now bears his name, Lynch described postoperative |
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From a historical perspective, the initial descrip- |
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stenting of the nasofrontal communication. Although |
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many technological advances in sinus surgery includ- |
tions of frontal sinus stenting usually involved external |