In 6 patients with endocrine ophthalmopathy, indications, surgical technique and results of the endoscopic controlled endonasal orbital decompression are described in comparison to the common surgical procedures. When medical and radiation therapy fail, indications for decompression are a) loss of visual acuity or visual field defects, b) increasing strabismus, c) severe keratopathy due to eyelid retraction. The endoscopic-controlled endonasal surgical decompression technique is proceeded in three steps. First, an endonasal ethmoidectomy with resection of the middle turbinate is performed and the medial wall of the maxillary sinus is widely opened. Second, the medial and inferior wall of the orbital walls are removed, preserving the infraorbital nerve. In the last step, the periorbital area is incised and the orbital fat herniates. The advantages of this procedure consist in the absence of exterior scars and the known morbidity of a Caldwell-Luc antrotomy. The results were documented by computed tomographic scans (CT), magnetic resonance imaging (MRI), Hertel measurements, evaluation of ocular motility and ophthalmoscopy. An average of 3-4 mm improvement in Hertel-measurements could be reached. All patients had a postoperative improvement of visual acuity. 2 patients developed more significant diplopia postoperatively, whereas in all other patients ocular motility either improved or rested unaffected. Therefore, the endoscopic controlled endonasal procedure allows to obtain comparable results to the common extranasal and transantral procedures without the disadvantages of the latter.

Zoom endoscopic electromyography of the larynx, as introduced in 1979, has contributed greatly to the diagnosis of lower cranial nerve palsies, but in the early stage of a vagus nerve disorder one cannot investigate the nerve conduction from the brain stem to the laryngeal muscles with electrical stimulation. As with the early diagnosis of facial nerve palsies, up to now the intracranial part of the motoric brain nerves could not be stimulated directly. With a new magnetic coil device (Novametrix, Magstim 200) this intracranial stimulation is easily possible in the awake patient with painless magnetic stimuli that induce a muscle action potential into the laryngeal muscles. Hence, an immediate diagnosis is possible. Two coils with mean diameters of 8.5 or 3 cm were used. The stimulator delivered current pulses of peak amplitude up to 5,000 A with rise times of 140 microseconds and 65 microseconds, respectively, that generated peak fields of up to 2 T. In a healthy population, cisternal stimulation of the vagus nerve leads to a muscular response in the vocal muscle after 4 to 6.6 milliseconds (mean 5 milliseconds). Cortical stimulation leads to such a response after 9.5 to 12 milliseconds. Potentials in healthy individuals have been shown to be very uniform. Stimulation in recurrent nerve palsies may show prolongation of these latencies up to 30 milliseconds. The method is limited by the fact that complete neural blocks cannot be overcome by proximal stimulation. We have applied magnetic stimulation to 190 patients with different disorders of the vagus nerve.(ABSTRACT TRUNCATED AT 250 WORDS)

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Management of laryngeal carcinoma located at the anterior commissure remains controversial. Local control rates with radiotherapy or surgery are not as good as those seen after treatment of midcord lesions. The vertical partial laryngectomy with epiglottic reconstruction (VPLER) may be a more successful approach to such lesions. The charts of all patients treated for larynx carcinoma between 1991 and 1996 at the authors' institutions were reviewed to identify those patients treated with VPLER as described by Sedlacek in 1965, Kambic in 1976 and Tucker in 1979. Indications for performing surgery and outcome data of patients were collected and analyzed according to the indications for surgery, surgical technique, perioperative complications, oncological outcomes and functional results. Twelve patients were identified that had been treated with VPLER. Indications for surgery included five patients with local recurrences following endoscopic laser partial laryngectomies, four cases with previously untreated primary tumors at the anterior commissure (T2 N0-2 M0), two with local recurrences following radiotherapy, and one with recurrence following frontolateral partial laryngectomy. There were no postoperative complications except for one laryngocutaneous fistula that required secondary repair. All patients were able to swallow at the tenth postoperative day. All had their tracheostomies closed after completion of wound healing, (a mean of 17 days after surgery). Phonatory results were usually poor. Two local recurrences occurred during the follow-up period. However, both patients were salvaged with total laryngectomies and have since been free from disease. All other patients are alive and well. Our findings show that VPLER is an effective surgical approach for carcinoma at the anterior commissure of the larynx that cannot be adequately managed with transoral laser surgery or simple frontolateral partial laryngectomy. This study demonstrates that the procedure can be successfully applied to the treatment of local recurrences following initial radiotherapy or surgery. No major complications occurred in our study.

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SYSTEMIC A N D OTHER COMPLICATIONSSerious complications after rhinoplasty are rare but various. Much is written about cosmetic failures, but less has been written about life-threatening complications of nasal surgery. The incidence of all these complications are rarely reported in plastic surgery literature and ranges anywhere between 1.7% andThey are either local problems, depending on special nasal surgery techniques and implanted material; or systemic complications, like hemorrhage, infection, bacteremia and allergy, and complications of structures adjacent to the nose like traumatic, ophthalmic, and other problems. Most systemic complications arise from intraoperative and early problems from bleeding, general or local anesthesia, and infection.An excessive hemorrhage during or after rhinoplasty can cause cardiopulmonal problems with hypotension and circulation shock reaction. If electrocoagulation and intranasal packing is unsuccessful, specific vessel ligation is indicated. The ethmoid vessels are exposed through an incision midway through the medial canthus or by an endonasal approach. The internal maxillary artery should be reached endonasally at the dorsal wall of the maxillary cavity. Performed by intraartery angioigraphy or computerized subtraction angiography, a selective embolization to bleeding disorders and vascular abnormalities may be possible. Allergic reactions to local or systemic anesthetic drugs can cause serious effects like cardiopulmonary collapse, malignant hyperthermia, or anaphylactic shock.Reports of intracranial infection after septa1 surgery are frequently found in the preantibiotic era. They include meningitis, sinus cavernous thrombosis (CST), brain abscesses, endocarditis, and pulmonary embolism after bacteriemia. A further serious reaction, toxic shock syndrome, is relatively short noted. Iatrogenic traumatic injuries penetrating the cribiform plate with the olfactory nerves can also cause serious complications. A cerebrospinal fluid (CSF) leak will occur with rhinoliquorrhoe, anosmia, and following meningitis or frontal abscess if the leak is not recognized and repaired immediately by the surgeon.Other traumatic lesions are injuries of the bony wall of the orbita like the processus trochlearis, the nasolacrimal apparatus, or the infraorbital nerve and other intraorbital structures. Ocular complications to nasal surgery are attributed to two basic causes: vascular disturbances and direct mechanical trauma of the borders of the orbit and to the optic nerve. Finally, a few cases of asphyxiation as a result of aspiration of the nasal packing have been reported.Knowing these complications, it is essential for the surgeon doing septo-rhinoplasty as an elective intervention in plastic surgery to get further patient information to calculate the risk of the operation and