Nasal Tamponade Research Articles

Endoscopic Endonasal Surgery at the Yaounde General Hospital-Cameroon: Case Study of 30 Operated Patients

Introduction: Endoscopic endonasal surgery is currently a validated therapeutic modality in most nasal sinus disorders. In developed countries, this practice is common and sees the indications constantly reviewed; In sub-Saharan Africa, this surgical technique is popularized. The external pathways are morbid and not very functional. In our daily practice at the Yaounde General Hospital (YGH), this technique is still in its infancy. Gradually it’s entering our habits and sees its indications increases. Through this study, we are reporting readily available data from our experience. Objectives: The objective was to study the practice of endoscopic endonasal surgery in our setting. Patients and Method: This was a cross-sectional, descriptive, retrospective study. The site of study was the ear-nose and throat service of Yaounde General Hospital. The study was conducted from January 2013 to December 2020, for an 8 years basis. The sampling was consecutive. We included in this study all patients operated on for a nasal sinus disease by the endoscopic endonasal modality. We excluded patients with incomplete files, as well as those who had a complementary transfacial approach during the same operation. The data were collected on prepared questionnaire. Data analysis is done with ssps 23.0 software. Results: We recruited 30 cases, out of a total of 330 interventions carried out in our department. The prevalence of this surgery in our activity was 9%. Male and female had equal ratio of 50%. The most represented age group was 30 - 40 years (33.3%). All the patients had a facial sinus CT scan, we did not note any anatomical variant as risk. Two patients of our sample size had a history of sinus surgery, treated externally. Chronic maxillary sinusitis was the surgical indication in 36.7%, followed by Killian antro-choanal polyps in 13.3%, nasosinus polyposis in 13.3% and all performed under general anesthesia. The most performed procedure was unilateral mean meatotomy with 43.33% followed by bilateral mean meatotomy with 20%, ethmoidectomy 13.3%, bimeatotomy 10%. The admission lasted for 2 days. 100% of patients had a previous nasal tamponade at the end of the intervention. The tamponade was removed on the second postoperative day in 100% of patients. 16.7% of patients presented with complications of low abundance postoperative bleeding. All patients noted clinical improvement over the initial symptoms postoperatively. Conclusion: Endoscopic endonasal surgery is experiencing slow but certain progress in our daily practice. The operated patients are young, chronic maxillary sinusitis is the main indication, the most performed procedure is the unilateral mean meatotomy. The operation goes uneventful with satisfactory prognosis. A study with a larger sample is necessary in order to refine our results. The practice remains limited by the technical platform, which needs to be strengthened, in order to optimize the practice.

Combined method of stopping nasal hemorrage

Topicality: Nasal hemorrhage (NH) is one of the most common reasons for patients to seek emergency otorhinolaryngological care. Due to the significant increase in cardiovascular disease, endovascular interventions, as well as the wide use of anticoagulant and disaggregating therapy (in most cases, long courses or even lifelong), cases of recurrent NH have become more frequent. In reference, there is a problem of modification of local methods of stopping NH in patients who receive the above therapy for a long time, because intervention in the hemostasis system in this group of patients causes certain difficulties. Aim of the study: The development of an anatomical intranasal tampon that allows you to combine several types of effects on the bleeding area is an extremely important task. Materials and methods: We have proposed a combined method of stopping NH, which includes the use of a two-chambered hydraulic tampon of our self design in combination with gel “Nosochem” and thermal exposure. Results: The proposed method of stopping NH was used in 24 patients, the average duration of nasal tamponade was 52.4±5.3 hours. In 23 (95.8%) patients, the proposed method provided effective stoppage of NH. Conclusions. The proposed hydrotampon in combination with “Nosochem” gel and local thermal exposure is a simple, effective and convenient to use combined method of stopping NH, which can be used as a method of choice for NH in patients who take anticoagulants and disaggregants for a long time.

The endonasal patient reference tracker: a novel solution for accurate noninvasive electromagnetic neuronavigation.

Electromagnetic (EM) navigation provides the advantages of continuous guidance and tip-tracking of instruments. The current solutions for patient reference trackers are suboptimal, as they are either invasively screwed to the bone or less accurate if attached to the skin. The authors present a novel EM reference method with the tracker rigidly but not invasively positioned inside the nasal cavity. The nasal tracker (NT) consists of the EM coil array of the AxiEM tracker plugged into a nasal tamponade, which is then inserted into the inferior nasal meatus. Initially, a proof-of-concept study was performed on two cadaveric skull bases. The stability of the NT was assessed in simulated surgical situations, for example, prone, supine, and lateral patient positioning and skin traction. A deviation ≤ 2 mm was judged sufficiently accurate for clinical trial. Thus, a feasibility study was performed in the clinical setting. Positional changes of the NT and a standard skin-adhesive tracker (ST) relative to a ground-truth reference tracker were recorded throughout routine surgical procedures. The accuracy of the NT and ST was compared at different stages of surgery. Ex vivo, the NT proved to be highly stable in all simulated surgical situations (median deviation 0.4 mm, range 0.0-2.0 mm). In 13 routine clinical cases, the NT was significantly more stable than the ST (median deviation at procedure end 1.3 mm, range 0.5-3.0 mm vs 4.0 mm, range 1.2-11.2 mm, p = 0.002). The loss of accuracy of the ST was highest during draping and flap fixation. Application of the EM endonasal patient tracker was found to be feasible with high procedural stability ex vivo as well as in the clinical setting. This innovation combines the advantages of high precision and noninvasiveness and may, in the future, enhance EM navigation for neurosurgery.

ЭТИОЛОГИЧЕСКИЕ АСПЕКТЫ НОСОВЫХ КРОВОТЕЧЕНИЙ И АЛЬТЕРНАТИВНЫЕ СПОСОБЫ ИХ ОСТАНОВКИ

Objective: To study the etiology of epistaxis and to improve the mechanical ways to stop it. Methods: 354 patients with nose bleeding aged 6 months to 78 years were examined from 2,360 people who applied to the urgent ENT Department of the National Medical Center of the Republic Tajikistan, which was 15%. They conducted an otorhinolaryngological examination, evaluation of the general state, finding out the causes of nasal bleeding and all necessary measures to stop it. Results: Out of 354 patients, 339 (95.6%) provided the first emergency care in the urgent ENT Outpatient Department, and 15 (4.2%) hospitalized in ENT Department. Among general and local causes, cardiovascular disease, respiratory infections, chronic atrophic and subatrophic processes of nose mucous were identified. In 297 (83.4%) had a combination of those and other causes. The majority of patients (n=209; 58.5%) suffered from cardiovascular pathology, in particular hypertension and atherosclerosis, in 19 (5.5%) patients the nasal bleeding occurred during the period or after recently suffered acute respiratory infections. Only in 51 (14.4%) patients identified local causes of nasal bleeding, of which 15 patients were hospitalized in the ENT Department. Bleeding was stopped by the anterior nasal tamponade in 6 cases, the anterior and posterior tamponade – in 8 observations, and in one patient, with inefficiency of the posterior and anterior tamponade, ligation of external carotid artery was performed. An alternative method has been used as a rear tamponade for the first time using a device made from a conventional endotracheal tube with an inflatable cuff on the distal end. The method has proven to be more gentle and less traumatic, allowing keeping nasal breathing through the tube. This provides the best quality of postoperative management, and at times accelerates the rehabilitation process. Conclusions: The results show that the causes of nasal bleeding are most often caused by general somatic pathology and only in 14.4% of cases are associated with pathology of nasal cavity. The proposed alternative method of posterior tamponade has shown good results and the possibility of its wide practical application, especially in terms of first aid. Keywords: Epistaxis (nasal bleeding, nosebleed), posterior tamponade, endotracheal tube, hypertension, alternative method

Paraganglioma of the nasal cavity. case report

Paraganglioma is one of the tumors that is rarely found in the practice of an otorhinolaryngologist. Approximately 90% of tumors from nonchromaffin paraganglia occur in the adrenal glands. Nevertheless, 5 – 10 % of paragangliomas have different localization: 85 % - in the abdominal cavity, 12 % - in the chest, 3 % - on the head and neck. Paraganglioma grows slowly, but there is a risk of its degeneration into a malignant neoplasm. Diagnosis of paraganglioma includes CT, MRI; Ultrasound scintigraphy, arteriography, biopsy, histological examination. The main treatment for this education is surgical. As this tumor occurs rather rarely, we present a clinical observation of a paraganglioma of the nasal cavity. Purposes. The purpose of this article is to describe a rare clinical case of paraganglioma of the nasal cavity to determine diagnostic measures and treatment tactics to help a practical doctor. Materials and methods. On 01/18/2019 patient M., 52 years old, with complaints of recurrent nosebleeds, difficulty breathing in the right half of the nose was received at the ENT Center «V. T. Lisovets Dynasty». Bleeding from the nasal cavity has been disturbing the patient twice a week for 6 months, for no apparent reason. An increase in the frequency of bleeding up to 4–5 times a week has been noticed for the last month. On a series of MRI tomograms dated 12.24.2019, in the front sections of the nasal concha, on the right, a volumetric pathological formation with dimensions of about 10 × 12 mm, with tuberous contours, an inhomogeneous MR structure was determined. Bone structures were not affected. The neoplasm narrowed the lumen of the nasal cavity on the right. Conclusion: MR-picture of the pathological volumetric formation (of blastomatous nature) of the nasal cavity on the right. Results. On 01/21/2019 the patient underwent surgical removal of the neoplasm within healthy tissues using a radioknife. An anterior nasal tamponade with a hemostatic preparation was performed. The postoperative period was without complications. A morphological examination of surgical material N 330/2019 yielded the following results: a microscopic examination determined a tumor with the same histological picture in the form of alveolar and solid areas, a branched network of blood vessels of capillary type, fibrous tissue of various thicknesses. Tumor parenchyma was represented by epithelioid morphology cells with pronounced eosinophilic cytoplasm, a large nucleus with granular chromatin. Cells with a weakly expressed eosinophilic cytoplasm, with small monomorphic nuclei were also found. Conclusions. The patient was diagnosed with a rare tumor of neuroectodermal nature, which in most cases has a benign nature, slow growth and develops from nonchromaffin ganglia, which are scattered throughout the body. As the formation grows, the arterial and venous network of vessels develops. The clinical picture of a neoplasm of the nasal cavity is often masked by the symptoms of chronic polypousrhinosinusitis, vasomotor and chronic hypertrophic rhinitis. Based on the foregoing, this clinical cases valuable for the practitioner in terms of the features of localization, diagnosis and these lection of the correct therapy for this category of patients.

Transnasal endoscopic treatment of equine sinus disease in 14 clinical cases

SummaryTransnasal endoscopic sinus treatment was used in four horses diagnosed with primary sinusitis and 10 horses with dental sinusitis. Pre‐existing (n = 5) or surgically created (n = 9) sinonasal fistulae were used as portals for transnasal endoscopic exploration, debridement and lavage of the inflamed sinus cavities. Endoscopic sinonasal fistulation was performed using either trans‐endoscopic diode laser fibre (four cases) or an electrocautery instrument under endoscopic control (five cases). All procedures were performed on standing sedated horses with the use of local anaesthesia. In six cases, the ventral concha was fenestrated in order to gain a portal into the ventral conchal and rostral maxillary sinus. In two cases the dorsal concha was fenestrated to access the caudal group of the paranasal sinuses. One case required fenestration of the ventral conchal bulla due to its empyema. Post‐operative bleeding was controlled with a nasal cavity tamponade for 24 h. Endoscopic lavage and debridement of the inflamed sinuses were performed every 2–3 days. Medical treatment consisted of antibiotic and anti‐inflammatory drugs. In the cases of dental sinusitis, the underlying dental pathology was addressed. Median hospitalisation time was 10 days (range 5–25 days) and the median number of endoscopic procedures (including the initial procedure) was 4 (range 3–7). Cases were followed‐up by telephone consultations with their owners. Intervals between discharge and last follow‐up ranged from 4 to 22 months (median 9.5 months). Complete recovery was reported in 10 cases, clinical improvement (occasional nonpurulent discharge) in two cases. Two cases were readmitted due to recurrence of the purulent nasal discharge; both subsequently underwent trephination of the affected sinuses and made a full recovery after removal of the remaining pathological sinus content.

Complications and number of follow-up visits after using septal stapler in septoplasty.

Septoplasties have traditionally been closed with transseptal sutures, silicone splints, or packing with nasal tamponade. In 2015, our clinic began to employ a septal stapler. The stapler adheres the mucosa to the septal cartilage with bioresorbable staples, replacing both sutures and silicone splints and limiting the use of nasal tamponade for bleeding cases. The complications of stapler versus other methods have not been reported on previously. Thus, the aim of this study was to investigate whether the use of stapler in septoplasties makes a difference in complication rates, operation time, or number of follow-up visits when compared to the traditional closure or filling methods. Patient records from 101 septoplasties in which the stapler had been used, and a reference group of 356 septoplasties in which the stapler had not been used, were retrospectively reviewed and analysed. No significant difference was seen in the complication rate between the stapler and the control group. Overall follow-up visits were fewer in the stapler group when compared to the control group, however there was no significant difference in the number of unplanned follow-up visits between the groups. By using the stapler in septoplasty, the number of postoperative follow-up visits might be reduced. Neither complication rate, nor operation time differed when using the stapler as compared to the traditional methods of closure.

Clinical management of epistaxis

Epistaxis is asymptom with many causes, often multifactorial and afrequent cause of consultation in acute medicine. The goal of this study is to analyse the diagnostics used for and therapy of epistaxis, complications and the predictive benefit of laboratory tests. In this retrospective clinical analysis reports of 720patients with epistaxis in the period from January 2005 to December 2015 were evaluated. The causes and the therapy of the epistaxis relapses were analysed. Male patients were predominant. Patients with relapses of epistaxis were significantly more likely to be older than 70 years, with higher multimorbidity and more often had used acombination of blood thinning medications. Posterior bleeding was the most found location and was associated with alonger hospitalization. In laboratory tests most patients with coumarins were shown to have inadequate INR (international normalized ratio) control. The prevalence of nicotine consumption was clearly increased compared to the total population. The most used therapy was nasal tamponade. The most complication was anemia with need of blood transfusion. High age and posterior bleeding source seem to raise the necessity of inpatient therapy. In most cases tamponade is sufficient for treatment. Initial laboratory tests are of limited use to estimate risk of recurrence, but is necessary for patients taking coumarins to determine INR control.

Trigemino-Cardiac Reflex and High-Degree Atrioventricular Block in Recurrent Epistaxis

We present a case of a 55-year-old male who presented to emergency department with recurrent epistaxis. After placement of a 16-French Foley catheter in his right nare to tamponade the bleeding, the patient subsequently developed two episodes of syncope. Review of the telemetry rhythm strips showed that he had developed PR interval prolongation followed by complete atrioventricular block. Our case was likely secondary to stimulation of the trigemino-cardiac reflex, a neuro-cardiogenic reflex, that can occur after stimulation of the trigeminal nerve, whether centrally or peripherally. Patients can develop severe bradycardia, hypotension, asystole, and even death. The relatively common occurrence of epistaxis and its treatment with direct nasal tamponade require an increased awareness and possibly a requirement for telemetry monitoring to prevent complications from stimulation of this reflex. J Med Cases. 2018;9(1):16-18 doi: https://doi.org/10.14740/jmc2957w

Treatment of Iatrogenic Septal Perforation with Conchal Cartilage

Objectives: Septal perforation is one of the unwanted complications of septal surgery. The effects of perforation may change according to the location of the perforation, but anterior septal perforation may give rise to crusting and bleeding. Sometimes minor perforations may cause a whistling sound while breathing. Methods: We included 9 patients who had septal perforation caused by septal surgery. All perforations were located anteriorly and their diameter was between 2 and 3 cm. In one case, the septum was almost totally perforated, and we closed the perforation with auricular conchal cartilage. This study was done in Canakkale Military Hospital between 2010 and 2013. All subjects were males between the ages of 20 and 23 years. All had previously been operated on for septal deviation. Their main complaint was nasal stuffiness and epistaxis. An open approach rhinoplasty was done. In order to expose both septal perforation flaps, we separated upper lateral cartilages. The cartilage graft harvested from conchal cartilage was trimmed and sutured transseptally that fits perforation dimensions. Results: Nasal tamponade for stabilizing the graft were kept in place for 10 days. The graft stability was examined monthly for 3 months. The main criteria for surgical success was mucosal integrity and postoperative crusting in nasal passages. Eight of 9 cases were fully closed by conchal graft. In 1 case, the partially posterior part of the perforation was left open, but this perforation was asymptomatic. Conclusions: Auricular conchal graft usage in treatment of large septal perforations is an effective method.

Nosocomial infection of Crimean-Congo hemorrhagic fever in Kosovo

Aims: To analyze the clinical manifestations and outcome in four cases with nosocomial infection of Crimean–Congo hemorrhagic fever (CCHF) disease; treated at the Infectious Diseases Clinic in Prishtina (Kosovo). Material and methods: In this retrospective study, the medical data and the history of four health care workers with CCHF were analyzed. The diagnosis was confirmed by real-time polymerase chain reaction (RT-PCR). The health workers were engaged in the management of patients with severe forms of CCHF. Results: In all four cases the infection was caused by not following the protective measures.Three otolaryngology doctors were infected during tamponades of the nasal cavities of the patients with CCHF. Two of them did not wear any of the protective measures (the nasal tamponade was done without gloves and mask). The third doctor was not wearing the face shield and goggles with side shields (infection occurred after coughing blood drops were deposited on the doctor's face. The fourth case was a laboratory hygienist who cleaned test tubes with blood samples from patients with CCHF without the use of protective gloves. The mean incubation period of the disease was 6.2 days. Two of the cases manifested moderately severe disease by fever and other nonspecific symptoms including chills, severe headache, dizziness, neck pain, nausea, vomiting, myalgia, and arthralgia without hemorrhagic syndrome. In two cases the disease had severe clinical manifestations with fever, other nonspecific symptoms and hemorrhagic syndrome which in one case ended with hemorrhagic shock and fatal outcome. Discussion and conclusion: Kosovo is an endemic region, with frequent epidemic outbreaks and sporadic cases occurring with hospitalized case fatality of approximately 30%. CCHF is a very contagious disease which is transmitted among the health workers by blood and other body fluids. Accidental infections are possible if strict universal precautions are not followed. Nosocomial infections can be serious and with possible fatal outcome.

Ciężki uraz okolicy twarzoczaszki i szyi połączony z wniknięciem ciał obcych podczas obróbki drewna

IntroductionThe aim of this work was to describe the patient with severe injury within the splanchnocranium and neck connected with the penetration of large foreign bodies in his wood processing activity, and their impaction in soft tissues and life-threatening localisation. Material and methodsThe authors describe the case of a 37-year-old male patient whose splanchnocranium and neck were injured while he was processing the wood with a mechanical saw. Two enormous wooden strips staved in his face while one was boring towards the nose and paranasal sinuses and the other was penetrating through the soft tissues of the cheek and neck from side of the oral cavity, with a visible prominent ending at the nape. ResultsOn diagnostic tests, the patient underwent tracheotomy media under neuroleptoanalgesia and infiltration anaesthesia, then, under intratracheal anaesthesia, he was intubated through tracheostomy. The two foreign bodies (enormous wooden strips) were removed by a multispecialty team of surgeons. Further, repositioning and osteosynthesis of the fractured ramus of the mandible on the left side were performed. The minititanium plate, 5 holes, 8 holes and 3 holes, was used. The wound within the nasal passages, maxillary sinuses and anterior surface of the maxilla was cleaned from fragments and chips of wood. The reconstruction of the tissues and repositioning of the bony fragments were conducted. The Redon drainage tube was implemented in the postoperative cavity, anterior and posterior nasal tamponade (Bellocq type) was required, the wounds in the left cheek and neck were debrided. The patient was discharged in general good condition 7 days on surgery. ConclusionsThe patients with severe injuries within the splanchnocranium and the neck, connected with the penetration of foreign bodies huge in size, should be treated in specialist centres by a multispecialty team of surgeons according to therapeutic standards.

Intranasal balloon catheters: How do they work?

Despite there being a wide range of different epistaxis balloons their mode of action is unknown. Manufacturers' drawings depict balloons neatly filling the nasal cavity or precisely occluding the anterior and posterior nasal apertures. In view of the complexity of nasal internal anatomy these explanations seem unlikely. A better understanding of the configuration of these devices within the human nasal cavity may explain their mode of action and complications. This study aimed to delineate radiographically the configuration of 3 commonly used balloons within the noses of 4 human cadavers and to observe the effects of alterations in inflation volumes. The results showed that devices designed to fill the nasal cavity do not achieve this aim. Balloons do not conform to the contours of the nasal cavity but expand along pathways of least resistance and prolapse into the nasopharynx. The findings may explain the occurrence of complications such as headache and Eustachian tube obstruction. Accurate nasal tamponade is unlikely to be their true mode of action. These devices probably work by a combination of factors rather than as a result of specific design features. The possibility of rational design modifications is discussed.

Neumoencéfalo intraventricular a tensión secundario a cirugía transesfenoidal: presentación de un caso y revisión de la literatura

Tension pneumocephalus is a rare complication of transsphenoidal approaches. The case of a 37 year old woman with a transsphenoidal resection of a pituitary adenoma who presented self-limited rhinoliquorrhea postoperatively is reported. Three days later the patient developed progressive decreased consciousness, amnesia and headache, showing an intraventricular tension pneumocephalus on CT scan. Urgent treatment with bilateral external ventricular drainage and anterior nasal tamponade was performed with good clinical outcome. Later transsphenoidal sealing of the dural defect was achieved without recurrence. Tension pneumocephalus following transsphenoidal surgery usually occurs after the presentation of a cerebrospinal fluid leak due to an incomplete sealing of the sphenoid sinus. The postoperative insertion of a lumbar drainage seems to be a predisposing condition for this complication. The combined approach of tension pneumocephalus with external ventricular drainage and repair of the sphenoid sinus offers optimal results solving the acute neurological deterioration and avoiding recurrence.

Rapid Rhino: A new pneumatic nasal tamponade for posterior epistaxis

Some of these measures to control posterior epistaxis cause loss of nasal respiration and put the patient on those related risks. The efficiency of a new pneumatic nasal tamponade (Rapid Rhino) was compared with a choanal balloon tamponade that has been used in our department for years in a prospective randomized study in patients with posterior epistaxis. The new pneumatic tamponade was used on the affected side only and nasal ventilation of the contralateral side was possible. Because of the successful use of the new pneumatic tamponade in most of the patients, epistaxis could be controlled without bilateral obstruction of nasal respiration. The use of the new pneumatic tamponade was evaluated to be less painful by the patients than choanal balloon tamponade. In an adapted therapeutic regime, the new pneumatic tamponade seems to have its place before using bilateral nasal respiration obstructing measures.

Upper airway obstruction caused by a double-cuffed nasal balloon after extubation

This case report highlights a situation in which a double-cuffed nasal balloon tamponade device can cause an upper airway obstruction. An 89-year-old female required general anesthesia for an emergent embolization for right-sided epistaxis. The patient had no signs of upper airway obstruction when a double-cuffed nasal tamponade balloon was in place prior to general anesthesia. However, upper airway obstruction occurred immediately after extubation and was corrected by cuff deflation. The mechanisms of upper airway obstruction as a result of cuff dysfunction and management are discussed.

最重度精神遅滞者の巨大後鼻孔鼻茸

In patients with severe mental retardation, special surgical treatment should be considered.A giant antrochoanal polyp in a 31-years-old man with severe mental retardation is reported. The polyp discovered accidentally after the patient began exhibiting snore and rhinorrhea, and after a few months observation weight loss due to dysphagia was noted. Surgical treatment without nasal tamponade was planned, since we were concerned that the patient would be unable to cooperate with the necessary postoperative treatment; embolization of a maxillary artery, functional endoscopic sinus surgery (FESS) and Argon Plasma Coagulation. Postoperatively, the patient's symptoms and the radiological findings of his sinuses were improved.

Kombiniert transseptale- transnasale Chirurgie einseitiger Choanalatresien ohne Verwendung von Platzhaltern1

This is a report of a surgical procedure with which stenting after surgery of unilateral choanal atresia can be avoided. We start transseptally with a hemitransfixion incision. The vomer and the bony atresia plate are dissected submucosally and then resected with punches and a diamond burr, whilst the nasal and the pharyngeal mucosa of the atresia is preserved completely. The next step is to cut transnasally a door-like flap out of the nasal blade of the mucosa of the atresia, that is based laterally and with which the lateral raw surface of the new choana will be covered. Now a medially based door-like flap is cut out of the up to now intact pharyngeal blade of the atresia, with which the medial wound surface is to be covered. The flaps are fixed with fibrin glue and with a nasal tamponade for two days, as after septoplasty. It is not necessary to insert stents anymore. Between 1995 until 1998 we treated three female and two male patients using this method. Their ages were 6, 17, 17, 20 and 35 years and the postoperative observation lasted 2, 4, 1, 3 and 3 years. A restenosis was not seen in any of the cases. Because of these results, it is recommended to treat unilateral choanal atresias of adults and children older than five years by using a combined transseptal-transnasal procedure. By using the described surgical technique postoperative stenting can be avoided.

Tornwaldt's disease.

Tornwaldt's disease was first described by Tornwaldt as one of the causes of epipharyngitis, and is an inflammation or abscess of the embryonic remnant cyst of the pharyngeal bursa appearing at the posterior median wall of the nasopharynx. Although many cases are symptom-free, symptoms can often be caused by nasal tamponade, trauma, adenotomy, or other mechanical stimuli. Only a few cases have been reported in Japan between 1929 and 1992. At about the 10th week of embryonic development, the pouch, which forms by adhesion of the pharyngeal ectoderm to the notochord at the most cranial end of the notochord, becomes closed at the orifice (cystic type), or crusts adhere to the orifice without closing (crust type). Symptoms are those of upper respiratory tract infection with obstinate occipital pain, purulent choanal discharge, nasal obstruction, halitosis, feeling of ear fullness, clearing of the throat, etc. Posterior rhinoscopy, simple lateral view X-ray tomography, nasopharyngeal fiberoscopy, CT scan and MRI are useful in showing adhesion to the cervical vertebrae. While complete extirpation via a transpalatal approach is desirable, incision or excision of the cyst can also be performed.

Intranasal balloon catheters: How do they work?

Despite there being a wide range of different epistaxis balloons their mode of action is unknown. Manufacturers' drawings depict balloons neatly filling the nasal cavity or precisely occluding the anterior and posterior nasal apertures. In view of the complexity of nasal internal anatomy these explanations seem unlikely. A better understanding of the configuration of these devices within the human nasal cavity may explain their mode of action and complications. This study aimed to delineate radiographically the configuration of 3 commonly used balloons within the noses of 4 human cadavers and to observe the effects of alterations in inflation volumes. The results showed that devices designed to fill the nasal cavity do not achieve this aim. Balloons do not conform to the contours of the nasal cavity but expand along pathways of least resistance and prolapse into the nasopharynx. The findings may explain the occurrence of complications such as headache and Eustachian tube obstruction. Accurate nasal tamponade is unlikely to be their true mode of action. These devices probably work by a combination of factors rather than as a result of specific design features. The possibility of rational design modifications is discussed.