A 4 year-old boy presented to our tertiary center with acute left ethmoiditis and a subperiosteal orbital abscess. He presented with exophtalmia but had no visual impairment or limitation of ocular mobility.
CT-scan found a 8 mm large subperiosteal orbital abscess with no further complications.
Surgery was decided using a combined approach to drain the abscess and to obtain a bacterial sample: first external (incision in the inner canthus area) and then endonasal (functional endoscopic sinus surgery – FESS) to open the middle meatus and ethmoid.
External approach: 10 mm incision in the inner canthus region, elevation of the lamina papyracea periosteum until the abscess was reached. Rubber drain was put in place for irrigation.
Endonasal approach: after careful CT-scan examination, endonasal surgery was performed with a 30° rigid endoscope. The middle turbinate was medialised to expose the middle meatus, uncinectomy and antrostomy followed by anterior and posterior ethmoidectomy was performed.
Antibiotics were given intravenously for 5 days and saline irrigation on the drain was performed during 2 days. Patient was discharged after 5 days.
- External drainage: 10 mm cutaneous incision in the inner canthus area. The lamina papyracea periosteum is elevated to reach the abscess. A rubber Delbet corrugated drain (Peters Surgical, Bobigny, France) is left in the abscess during two days for irrigation (saline irrigation).
- Endonasal drainage: Opening of the ipsilateral ethmoidal cells by transnasal endoscopic approach, using a 30° rigid endoscope. The extent of the ethmoidectomy can vary from one surgeon to the other. In this video anterior and posterior ethmoid was opened. The surgery may be limited to the opening of the anterior ethmoidal cells and of the bulla, until a flow of pus appears. Also, direct exposure of the abscess through a small opening of the lamina papyracea can be achieved.
- Surgeons may choose either an external or endonasal approach, or a combined technique as in this video can be preferred.
The literature has not shown any significant difference of failure rates between endoscopic, external or combined approaches.
The indications for surgical drainage in our department are the following:
- abscess width > 5 mm;
- absence of improvement in signs and symptoms after 48–72 h of intravenous antibiotics;
- severe clinical complications such as epidural empyema, loss of visual acuity or cavernous sinus thrombophlebitis
None.
- Standard instruments for the external approach and rubber Delbet corrugated drain (Peters Surgical, Bobigny, France).
- Standard functional endoscopic sinus surgery (FESS) instruments and 30° rigid endoscope for endonasal approach.
- Clinical examination of the patient especially concerning the eye (exophtalmia, visual acuity, ocular mobility, pupillary reflex)
- Study of CT-scan:
. measurement of abscess width (drainage if > 5 mm)
. Other ethmoiditis complications (subdural abscess, etc.)
. FESS anatomical landmarks (see here-after)
As in any FESS, endonasal anatomical landmarks must be noted on the CT-scan.
This pathology mostly concerns young children, therefore the development of the different sinuses must be explored.
Insertion of the uncinate process and inferior turbinate must be noted.
Position of the orbit and anterior skull base in relation to the maxillary and ethmoid sinus must be examined.
- Advantages:
Drainage of the abscess is necessary for healing.
- Disadvantages:
External approach: scar
Endonasal approach: risks due to FESS (anterior skull base, orbit) in an inflammatory environnement, requires experience.
- External approach: Risks and complications are rare if the elevator is correctly positioned against the bone.
- Endonasal approach: Risks are those of any FESS: anterior skull base breach, orbit and bleeding. In inexperienced hands, the drainage can be insufficient requiring a second procedure.
Overall, the main risk is failure which is why a combined approach may be preferred.
None to declare.
N/A
- Rubin F., Pierrot S., Lebreton M., Contencin P. et Couloigner V. (2013) Drainage of subperiosteal orbital abscesses complicating pediatric ethmoiditis: Comparison between external and transnasal approaches. International Journal of Pediatric Otorhinolaryngology 77:796-802.
- Coudert A., Ayari-Khalfallah S., Suy P. et Truy E. (2018) Microbiology and antibiotic therapy of subperiosteal orbital abscess in children with acute ethmoiditis. Int J Pediatr Otorhinolaryngol 106:91-95.
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Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
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