Microscopic Assistance Research Articles

Microscopic Assistance in Cold Dissection Tonsillectomy – Does it Improve Surgical Outcome?

Background: Tonsillectomy is one of the commonest surgical procedure carried out by ENT surgeon. In the post-operative period, rate of life-threatening post-operative bleeding varies between 0 and 20 % of the patients. The use of magnifying devices like microscopes or magnifying glasses is still in the focus of clinical investigation as it is hypothesized that precise vision of vessels during surgery allows precise coagulation and therefore reduces post-operative bleeding. Furthermore, precise coagulation should reduce post-operative pain too. The study aims to compare the surgical outcome between microscopic assisted tonsillectomy and traditional cold dissection tonsillectomy. Methods: This prospective study was conducted on 32 patients who had undergone tonsillectomy from March 2020 to December 2021. The patients included in the study underwent cold dissection tonsillectomy where one tonsil was removed with Microscopic assistance and other with traditional cold dissection method with unsupported vision. Intraoperative blood loss was calculated. Post-operative pain score was measured with Wong- Baker FACES® Pain rating scale till 7th post-operative day. Post-operative complications if present were noted. Results: Total of 32 patients were enrolled in the study with age ranging from 16-42 years. There were total 18 male (56.3%) and 14 females (43.8%) in the study. Intraoperative time for Microscopic assisted cold dissection (16.44 ± 3.46 minutes) was longer than Conventional dissection technique (13.94 ± 2.86 minutes) (p=0.04). Amount of blood loss during MCD technique was 16.47 ± 4.58 ml whereas in CD group it was 18.22 ± 4.54 ml (p=0.02). Pain score in both methods were higher during early post-operative period and gradually decreased with time. During rest, there was no statistically significant difference in pain between the two methods during first three post-operative days, after which pain was significantly reduced in MCD through day 4-7 (p <0.05). None of the patient had post- operative hemorrhage requiring intervention in operation room. Conclusions: Microscopic assisted cold dissection showed statistically significant results for reduced intraoperative blood loss and post-operative pain score than Conventional dissection method.

ENDOSCOPIC EAR SURGERY: A SCOPING REVIEW / CIRURGIA ENDOSCÓPICA DE OUVIDO: UMA REVISÃO DO ESCOPO

INTRODUCTION: Endoscopic surgery has gained notoriety among otologists in recent decades thanks to the enhancement of potential surgical methods and to the significant volume of scientific publications on the subject. AIM: The present literature review was carried out in order to assess endoscopic ear surgery research available in the literature, its main surgical indications, as well as advantages and disadvantages. METHODS: The present literature review was based on the term Endoscopic Ear Surgery; 385 articles were selected as its basis. RESULTS: 326 (84.6%) of the 385 selected articles were published in 2011, 37 (9.6%) of them were published between 2001 and 2010, and 22 (5.8%) up to 2000. According to these articles, 17664 endoscopic ear surgeries have already been performed, either as entire surgical procedures or just for microscopic assistance purposes. Tympanoplasty accounts for the largest number of ear surgeries, it is followed by cholesteatoma surgeries (either via transcanal tympanoplasty or mastoidectomy). Endoscopic surgery advantages include reduced cholesteatoma recurrence, less mastoidectomy procedures, shorter operating room time and costs, less postoperative pain, better visualization of middle ear structures, minimally invasive procedures and less second-look surgeries. Its disadvantages include required healthy external auditory canal, single-handed surgical procedures and thermal effects of endoscopy. CONCLUSIONS: Endoscopic ear surgery has been acknowledged as a promising surgical method by otolaryngologists. Although it has faced some resistance from surgeons who have previously mastered micro-ear surgery, this surgical method has already been regarded as a point of no return.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Emerging Therapies for the Treatment of Patients With Vestibular Schwannomas.

Adults with histologically proven or suspected vestibular schwannomas with neurofibromatosis type 2 (NF2). What is the role of bevacizumab in the treatment of patients with vestibular schwannomas? Level 3: It is recommended that bevacizumab be administered in order to radiographically reduce the size or prolong tumor stability in patients with NF2 without surgical options. Level 3: It is recommended that bevacizumab be administered to improve hearing or prolong time to hearing loss in patients with NF2 without surgical options. Is there a role for lapatinib, erlotinib, or everolimus in the treatment of patients with vestibular schwannomas? Level 3: Lapatinib may be considered for use in reducing vestibular schwannoma size and improvement in hearing in NF2. Level 3: Erlotinib is not recommended for use in reducing vestibular schwannoma size or improvement in hearing in patients with NF2. Level 3: Everolimus is not recommended for use in reducing vestibular schwannoma size or improvement in hearing in NF2. What is the role of aspirin, to augment inflammatory response, in the treatment of patients with vestibular schwannomas? Any patient with a vestibular schwannoma undergoing observation. Level 3: It is recommended that aspirin administration may be considered for use in patients undergoing observation of their vestibular schwannomas. Is there a role for treatment of vasospasm, ie, nimodipine or hydroxyethyl starch, perioperatively to improve facial nerve outcomes in patients with vestibular schwannomas? Adults with histologically proven or suspected vestibular schwannomas. Level 3: Perioperative treatment with nimodipine (or with the addition of hydroxyethyl starch) should be considered to improve postoperative facial nerve outcomes and may improve hearing outcomes. Is there a role for preoperative vestibular rehab or vestibular ablation with gentamicin for patients surgically treated for vestibular schwannomas? Adults with histologically proven or suspected vestibular schwannomas. Level 3: Preoperative vestibular rehabilitation is recommended to aid in postoperative mobility after vestibular schwannoma surgery. Level 3: Preoperative gentamicin ablation of the vestibular apparatus should be considered to improve postoperative mobility after vestibular schwannoma surgery. Does endoscopic assistance make a difference in resection or outcomes in patients with vestibular schwannomas? Vestibular schwannoma patients, who are surgical candidates. Inclusion in this analysis required resection utilizing the endoscope, either as the primary operative visualization or microscopic assistance with more than 20 patients treated. Level 3: Endoscopic assistance is a surgical technique that the surgeon may choose to use in order to aid in visualization. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_9.

Transforaminal Resection of Cervical Dumbbell Schwannomas in Patients with Additional Tumors

It is rare for 2 primary tumors to occur simultaneously in a patient. Management of cervical dumbbell schwannomas (CDSs) with concurrent tumors (CTs) requires a specific neurosurgical strategy. The primary objective of this study is to investigate surgical strategies for CDSs with CTs while preserving as much of the mechanically relevant bone structures as possible. Twelve patients with concurrent CTs and CDSs were identified from 3 medical centers. Surgical strategies for CDSs were based on accurate preoperative images and subsequent treatment considerations for CTs. All patients received surgical treatment for CDSs and CTs. Clinical features, surgical considerations for a transforaminal approach (TA), and ultimate outcome were studied retrospectively. Gross total resection of CDSs was achieved with endoscopic and microscopic assistance in 9 cases, and subtotal resection was achieved in 3 cases after the head and neck surgeons exposed and removed the extraforaminal anatomy. One patient required an additional hemilaminectomy for the resection of the intraspinal segment. After wound healing, patients were transferred to the appropriate surgical department for surgery on CTs with cervical spine stabilization after a transforaminal approach. In most patients, the stability of the cervical spine can be preserved with low invasive microsurgical or endoscopic transforaminal resection. CTs could be surgically treated sequentially after microscopic- and endoscopic-assisted resection of CDSs.

Lingual Thyroidectomy

We report the clinical findings, surgical management, and outcomes for lingual thyroidectomy. We performed a retrospective case review of lingual thyroidectomy performed at 3 tertiary-care academic referral centers between 1994 and 2012. Nine patients underwent lingual thyroidectomy for symptoms including globus sensation (6 patients), dysphagia (5 patients), and airway obstruction (5 patients). Before surgery, 3 patients had attempted medical suppressive therapy. Lingual thyroidectomy was performed by transoral laser microsurgery in 4 patients, transoral robotic surgery in 3 patients, transoral surgery without microscopic assistance in 1 patient, and an open approach with a modified Sistrunk procedure in 1 patient. Total thyroidectomy was attained in 7 patients, and subtotal resection in 2. The follow-up averaged 8 months, and all patients reported significant improvement in their symptoms. One patient had a recurrence. Complications included postoperative bleeding and epiglottic perforation in 1 patient and airway obstruction secondary to angioedema in another patient. There was no significant difference in operative times between transoral laser microsurgery (91 ± 16 minutes) and transoral robotic surgery (109 ± 35 minutes). Transoral surgery without microscopic assistance and open resection had longer operative times (206 and 246 minutes, respectively). Surgical resection of lingual thyroid glands achieves significant improvement in patient symptoms, with low rates of recurrence. We favor a total lingual thyroidectomy approach with use of either a microscope or a robotic endoscope for optical assistance.

Endoscopic endonasal extended transsphenoidal removal of tuberculum sellae meningioma (TSM): an experience of six cases

Aims. Tuberculum sellae meningiomas (TSMs) are usually removed through a transcranial approach. Recently, the sublabial transsphenoidal microscopic approach has been used to remove such tumours. More recently, endonasal extended transsphenoidal approach is getting popular for removal of tuberculum sellae meningioma. Here, we describe our initial experience of endonasal extended transsphenoidal approach for removal of suprasellar meningiomas in six consecutive cases. Materials and method. Six patients (four female and two male) who presented for headache and visual loss were investigated with MRI of brain that showed tuberculum sellae meningioma compressing visual apparatus. Average size was 3 × 3 cm in three cases and 4 × 4 cm in rest of the three. All patients underwent endoscopic endonasal extended transsphenoidal tumour removal, but in two patients with large tumour, microscopic assistance was needed. Complete tumour removal was done in all cases except one case where perforators seemed to be encased by the tumour and resulted in incomplete removal. The surgical dural and bony defects were repaired in all patients with thigh fat graft. Nasal packing was not used, but inflated balloon of Foley's catheter was used to keep fat in position. Result. There was mild postoperative cerebrospinal fluid (CSF) leakage in one patient on the fourth postoperative day after removal of lumbar CSF drain and stopped spontaneously on the seventh postoperative day. There were no postoperative CSF leaks or meningitis in the rest of the cases. In one patient, there was visual deterioration due to pressure on optic nerve by grafted fat and improved within 4 weeks. At 4 months after surgery, three patients had normal vision, two patients improved vision comparing with that of preoperative state but with some persisting deficit; one patient had static vision, no new endocrinopathy and no residual tumour on MRI in five cases but residual tumour in remaining case was static at the end of the ninth month. Conclusion. The endoscopic endonasal extended transsphenoidal approach appears to be an effective minimally invasive method for removing relatively small to medium tuberculum sellae meningiomas. With more experience of the surgeon, larger tuberculum sellae meningioma may be removed by purely endoscopic techniques in near future.

O-16-231 - Epidural buprenorphine for relieving postoperative pain in patients undergoing lumbar laminectomy: A preliminary study

It is rare for 2 primary tumors to occur simultaneously in a patient. Management of cervical dumbbell schwannomas (CDSs) with concurrent tumors (CTs) requires a specific neurosurgical strategy. The primary objective of this study is to investigate surgical strategies for CDSs with CTs while preserving as much of the mechanically relevant bone structures as possible.Twelve patients with concurrent CTs and CDSs were identified from 3 medical centers. Surgical strategies for CDSs were based on accurate preoperative images and subsequent treatment considerations for CTs. All patients received surgical treatment for CDSs and CTs. Clinical features, surgical considerations for a transforaminal approach (TA), and ultimate outcome were studied retrospectively.Gross total resection of CDSs was achieved with endoscopic and microscopic assistance in 9 cases, and subtotal resection was achieved in 3 cases after the head and neck surgeons exposed and removed the extraforaminal anatomy. One patient required an additional hemilaminectomy for the resection of the intraspinal segment. After wound healing, patients were transferred to the appropriate surgical department for surgery on CTs with cervical spine stabilization after a transforaminal approach.In most patients, the stability of the cervical spine can be preserved with low invasive microsurgical or endoscopic transforaminal resection. CTs could be surgically treated sequentially after microscopic- and endoscopic-assisted resection of CDSs.