Intranasal Microsurgery of All Paranasal Sinuses, the Septum, and the Lacrimal Sac with Hypotensive Anesthesia

Abstract

Since 1958 all intranasal surgery at Krupp Hospital (including 2,986 operations in 1984) have been performed with the Zeiss operating microscope. Anesthesia with hypotension is important to improve the results. To facilitate focusing, a balanced movable position of the microscope directed by head motions of the surgeon and a semi-Fowler's position for the patient have proven best. Large fenestrations above and below the lower turbinates permit maxillary sinus surgery under direct binocular vision with the aid of mirrors or endoscopes. For the last 12 years the Caldwell-Luc approach was used in less than 2% of operations. All ethmoidal, lacrimal sac, and epistaxis surgery is performed intranasally. In 1984 frontal sinus surgery was performed in 59 cases with an intranasal and in 11 cases with an osteoplastic procedure. For a larger defect of the ethmoidal roof in severe injuries, conically trimmed rib cartilage is wedged into the defect from above. Having performed more than 4,000 ethmoidal operations we have never experienced an iatrogenic CSF leakage, or persisting postoperative visual or ocular disturbance. In order to achieve the necessary skill, training on 50 cadavers is required.

Anaesthesia for endoscopic sinus surgery

“…Cocaine, the only local anaesthetic with intrinsic vasoconstrictive properties, is very popular in nasal surgery and is often combined with epinephrine‐containing solutions 3,13,29–32 . Other local anaesthetics may be used in solutions prepared with epinephrine to provide vasoconstriction 3,12,13,29–37 . Injection of a local anaesthetic/epinephrine mixture into the pterygopalatine fossa, rather than at the operative site, has also been shown to improve surgical conditions 38 …”

“…Controlled hypotension has been advocated to reduce blood loss and improve surgical conditions in ESS 12,14,34,43,44 . A reduction in arterial pressure can be achieved through a reduction in systemic vascular resistance (SVR), cardiac output (CO) or both.…”

The wide field multifocal ERG reveals a retinal defect caused by vigabatrin toxicity?

“…10 In 1974, Jokinen and Karja revived the endonasal approach. 11 Heerman and Neues used a microscope for a transnasal approach to the lacrimal sac, 12 whereas McDonough and Meiring were the first to advocate endonasal endoscopic dacryocystorhinostomy (EEDCR), in 1989. 13 Using new instrumentation and techniques for endoscopic sinus surgery in general, many authors have proved that EEDCR can be performed with lower morbidity in adults and with success rates equal to those achieved with the traditional external approach.…”

A Study to Evaluate the Effectiveness of Clonidine vs Atenolol in Providing Optimal Surgical Field in Nasal Surgeries under General Anaesthesia

“…To avoid such complications, nasal surgeries can be performed either with local anaesthesia [3], vasoconstrictors (e.g. epinephrine, cocaine and phenylephrine) [4,5] or under general anaesthesia [6]. But as topical anaesthesia has been associated with discomfort; general anaesthesia is preferred [3].…”