The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
5. Stromme Koppang H, Boman H, Hoel PS. Oral abnormalities in the Saldino-Noonan syndrome. Virchows Arch A Pathol Anat Histopathol 1983;398:247–262 6. De Felice C, Toti P, Di Maggio G, et al. Absence of the inferior labial and lingual frenula in Ehlers-Danlos syndrome. Lancet 2001;357:1500–1502 7. De Felice C, Di Maggio G, Zagordo L, et al. Hypoplastic or absent mandibular frenulum: a new predictive sign of infantile hypertrophic pyloric stenosis. J Pediatr 2000;136:408–410
Navigation-Aided Endoscopic Sinus Surgery To the Editor: Endoscopic sinus surgery is a treatment of choice for chronic sinusitis, with an expanding role in the management of other sinus, orbit, and skull base diseases. Because of the anatomic complexity and intraoperative bleeding, major intraoperative complications still occur.1 Of late, intraoperative navigation has permitted a direct comparison of the intraoperative anatomy with preoperative imaging information.2 Before surgery, a computed tomographic (CT) scan (0.6-mm cuts) was loaded into the navigation computer. To calibrate the system, it is necessary to define a starting position so that the virtual patient on the monitor corresponds anatomically to the real patient on the operating table. The process of correlating the patient's images to the patient's actual anatomy is called registration. It is based on at least 5 noncoplanar reference points that can be uniquely identified in the image data and on the skull of the patient. When the registration is complete, the surgeon can move a pointer instrument during surgery while watching the corresponding movements of the instrument tip on the monitor. Any rigid instrument could be tracked with this technology.3 We report on a patient with chronic sinusitis who underwent endoscopic sinus surgery with the use of the navigation system (Brainlab, Germany). The patient had previous surgery for maxillofacial trauma, and the sinusitis could be related to internal fixation material (Figs. 1A, B). “Screw markers” placed in the maxilla and 2 sphere markers were used for registration. Before surgery, a standardized CT scan was obtained and transferred to the workstation where coronal and sagittal images, in addition to 3-dimensional model reconstructions and software-based CT review, were completed. Under general anesthesia, a headset that permitted attachment of a reference frame, with light-emitting diodes for optical tracking, was placed securely on the patient's head, and registration and calibration were performed. The patient underwent endoscopic ethmoidectomy, endoscopic maxillary antrostomy, endoscopic sphenoidectomy, and frontal recess exposure with frontal sinus suction clearance. Transconjuctival approach with lateral canthotomy was used to remove internal fixation material that was already in place. The surgical navigation system was frequently used for confirmation of the surgical tool position (Fig. 2). To check the precision of the system, the endoscopic images in which a fiducial
FIGURE 1. Preoperative CT scans, axial (A) and coronal (B) views.
326
FIGURE 2. Intraoperative screenshot from the navigation system showing a triplanar view of the image with the current position of the tip of the surgeon's pointer.
point was detected were matched with the images on the monitor (Figs. 3A, B). Postoperative course was uneventful. Neither dehiscences nor signs of infections were observed. An appropriate restoration of the facial morphology was clinically observed. Postoperative CT scans showed a correct restoration of the sinus. Endoscopic surgery in the region near the skull base must be safe. Most complications occur if the surgeon is not aware of the exact position of his instrument.4 On account of that, interest in the use of navigation systems in maxillofacial surgery increased. Navigation-aided surgery is most helpful in specific anatomic areas, especially in the frontal sinus, the sphenoid, and the sphenoethmoid regions, the residual ethmoid partition and disease, in skull base identification, and in orbital dehiscence or orbital surgery for optic nerve or orbital decompression.5 Our clinical report confirms literature findings. We found that navigation-aided endoscopic surgery was valuable in confirming
FIGURE 3. A, The surgeon touched a screw placed during previous surgery with the tip of the pointer to check the precision of the system on the monitor. B, Intraoperative screenshot showing the tip of the pointer on the head of the screw.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
the surgeon's understanding of the paranasal sinus anatomy and helpful in performing a more complete anatomic dissection. This helped to reduce intraoperative complications and provide better outcomes.6 Moreover, we found the navigation platform a valuable teaching tool in the residency training program in our institute.7 To conclude, the use of intraoperative navigation system is firmly established as a valuable technology in the management of paranasal sinus disease. It may improve the confidence of the surgeon by confirming the position within the challenging anatomic fields. This increases surgical effectiveness and improves surgical safety. The effect of navigation-aided endoscopic surgery on the clinical outcomes is to date not demonstrated. Emanuele Zavattero, MD Stefano Viterbo, MD Giovanni Gerbino, MD Guglielmo Ramieri, MD, DDS Division of Maxillofacial Surgery Surgical Science Department Città della Salute e della Scienza Hospital University of Torino Torino, Italy [email protected]
REFERENCES 1. Anon JB. Computer-aided endoscopic sinus surgery. Laryngoscope 1998;108:949–961 2. Olson G, Citardi MJ. Image-guided functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 2000;123:188–194 3. Uddin FJ, Sama A, Jones NS. Three-dimensional computer-aided endoscopic sinus surgery. J Laryngol Otol 2003;117:333–339 4. Hepworth EJ, Bucknor M, Patel A, et al. Nationwide survey on the use of image-guided functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 2006;135:68–73 5. Chiu AG, Vaughan WC. Revision endoscopic frontal sinus surgery with surgical navigation. Otolaryngol Head Neck Surg 2004;130:312–318 6. Irugu DV, Stammberger HR. A note on the technical aspects and evaluation of the role of navigation system in endoscopic endonasal surgeries. Indian J Otolaryngol Head Neck Surg 2014;66(suppl 1):307–313 7. Gerbino G, Zavattero E, Berrone M, et al. Management of needle breakage using intraoperative navigation following inferior alveolar nerve block. J Oral Maxillofac Surg 2013;71:1819–1824
FIGURE 1. A, Initial examination. B, Magnetic resonance image showing the left frontotemporal lesion. C, In the sixth month of the treatment, there was improvement both in the lesion and in the ptosis with the aid of a plaster. D, Increase in size due to intralesional hemorrhage in the seventh month.
A 1-month-old male infant (term, 3850 g, delivered via cesarean delivery) was admitted with a swelling on the left side of the scalp. Informed consent was taken from the mother. On physical examination of the infant, a big mass on the left frontotemporal region also totally covering the left eye was palpated. The lesion was nontender as well as soft and was extending to the left upper eyelid. Total ptosis of the left eye by the mechanical effect of the lesion was observed (Fig. 1A). Magnetic resonance imaging (MRI) of the head revealed a 9 3 7-cm lesion containing irregular cystic dilatations, considerably with regular borders, and that had no invasion to the adjacent bones, which can be consistent with a hemangioma (Fig. 1B). The diagnosis of the lesion was accepted as hemangioma. Systemic examinations and laboratory investigations were within reference limits. The treatment was started with systemic steroid (2 8 mg) and β-blocker, propranolol (2 10 mg). To prevent amblyopia, the mother was advised to elevate the lump with the aid of sticking a
A Propranolol Nonresponsive Mass: Lymphangioma-Mimicking Hemangioma To the Editor: Lymphangiomas are benign congenital malformations of the lymphatic system that occur most commonly in the head and neck region with the involvement of skin and subcutaneous tissue. The most involved site of lymphangiomas is the head and neck region, primarily affecting the tongue and mouth.1,2 Treatment of lymphangioma is difficult because of difficulty in choosing the treatment modality, close relationship with vital structures, potential visual and cosmetic problems, and possibility of recurrences.3 We report a case of a big mass on the scalp, which was initially misdiagnosed as hemangioma and finally diagnosed as lymphangioma.
FIGURE 2. A, Magnetic resonance image showing intralesional hemorrhage in the seventh month. B, Surgical procedure. C, Totally excised lesion. D, First-week appearance of the patient with improvement in the ptosis.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
327
Correspondence
5. Stromme Koppang H, Boman H, Hoel PS. Oral abnormalities in the Saldino-Noonan syndrome. Virchows Arch A Pathol Anat Histopathol 1983;398:247–262 6. De Felice C, Toti P, Di Maggio G, et al. Absence of the inferior labial and lingual frenula in Ehlers-Danlos syndrome. Lancet 2001;357:1500–1502 7. De Felice C, Di Maggio G, Zagordo L, et al. Hypoplastic or absent mandibular frenulum: a new predictive sign of infantile hypertrophic pyloric stenosis. J Pediatr 2000;136:408–410
Navigation-Aided Endoscopic Sinus Surgery To the Editor: Endoscopic sinus surgery is a treatment of choice for chronic sinusitis, with an expanding role in the management of other sinus, orbit, and skull base diseases. Because of the anatomic complexity and intraoperative bleeding, major intraoperative complications still occur.1 Of late, intraoperative navigation has permitted a direct comparison of the intraoperative anatomy with preoperative imaging information.2 Before surgery, a computed tomographic (CT) scan (0.6-mm cuts) was loaded into the navigation computer. To calibrate the system, it is necessary to define a starting position so that the virtual patient on the monitor corresponds anatomically to the real patient on the operating table. The process of correlating the patient's images to the patient's actual anatomy is called registration. It is based on at least 5 noncoplanar reference points that can be uniquely identified in the image data and on the skull of the patient. When the registration is complete, the surgeon can move a pointer instrument during surgery while watching the corresponding movements of the instrument tip on the monitor. Any rigid instrument could be tracked with this technology.3 We report on a patient with chronic sinusitis who underwent endoscopic sinus surgery with the use of the navigation system (Brainlab, Germany). The patient had previous surgery for maxillofacial trauma, and the sinusitis could be related to internal fixation material (Figs. 1A, B). “Screw markers” placed in the maxilla and 2 sphere markers were used for registration. Before surgery, a standardized CT scan was obtained and transferred to the workstation where coronal and sagittal images, in addition to 3-dimensional model reconstructions and software-based CT review, were completed. Under general anesthesia, a headset that permitted attachment of a reference frame, with light-emitting diodes for optical tracking, was placed securely on the patient's head, and registration and calibration were performed. The patient underwent endoscopic ethmoidectomy, endoscopic maxillary antrostomy, endoscopic sphenoidectomy, and frontal recess exposure with frontal sinus suction clearance. Transconjuctival approach with lateral canthotomy was used to remove internal fixation material that was already in place. The surgical navigation system was frequently used for confirmation of the surgical tool position (Fig. 2). To check the precision of the system, the endoscopic images in which a fiducial
FIGURE 1. Preoperative CT scans, axial (A) and coronal (B) views.
326
FIGURE 2. Intraoperative screenshot from the navigation system showing a triplanar view of the image with the current position of the tip of the surgeon's pointer.
point was detected were matched with the images on the monitor (Figs. 3A, B). Postoperative course was uneventful. Neither dehiscences nor signs of infections were observed. An appropriate restoration of the facial morphology was clinically observed. Postoperative CT scans showed a correct restoration of the sinus. Endoscopic surgery in the region near the skull base must be safe. Most complications occur if the surgeon is not aware of the exact position of his instrument.4 On account of that, interest in the use of navigation systems in maxillofacial surgery increased. Navigation-aided surgery is most helpful in specific anatomic areas, especially in the frontal sinus, the sphenoid, and the sphenoethmoid regions, the residual ethmoid partition and disease, in skull base identification, and in orbital dehiscence or orbital surgery for optic nerve or orbital decompression.5 Our clinical report confirms literature findings. We found that navigation-aided endoscopic surgery was valuable in confirming
FIGURE 3. A, The surgeon touched a screw placed during previous surgery with the tip of the pointer to check the precision of the system on the monitor. B, Intraoperative screenshot showing the tip of the pointer on the head of the screw.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Correspondence
the surgeon's understanding of the paranasal sinus anatomy and helpful in performing a more complete anatomic dissection. This helped to reduce intraoperative complications and provide better outcomes.6 Moreover, we found the navigation platform a valuable teaching tool in the residency training program in our institute.7 To conclude, the use of intraoperative navigation system is firmly established as a valuable technology in the management of paranasal sinus disease. It may improve the confidence of the surgeon by confirming the position within the challenging anatomic fields. This increases surgical effectiveness and improves surgical safety. The effect of navigation-aided endoscopic surgery on the clinical outcomes is to date not demonstrated. Emanuele Zavattero, MD Stefano Viterbo, MD Giovanni Gerbino, MD Guglielmo Ramieri, MD, DDS Division of Maxillofacial Surgery Surgical Science Department Città della Salute e della Scienza Hospital University of Torino Torino, Italy [email protected]
REFERENCES 1. Anon JB. Computer-aided endoscopic sinus surgery. Laryngoscope 1998;108:949–961 2. Olson G, Citardi MJ. Image-guided functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 2000;123:188–194 3. Uddin FJ, Sama A, Jones NS. Three-dimensional computer-aided endoscopic sinus surgery. J Laryngol Otol 2003;117:333–339 4. Hepworth EJ, Bucknor M, Patel A, et al. Nationwide survey on the use of image-guided functional endoscopic sinus surgery. Otolaryngol Head Neck Surg 2006;135:68–73 5. Chiu AG, Vaughan WC. Revision endoscopic frontal sinus surgery with surgical navigation. Otolaryngol Head Neck Surg 2004;130:312–318 6. Irugu DV, Stammberger HR. A note on the technical aspects and evaluation of the role of navigation system in endoscopic endonasal surgeries. Indian J Otolaryngol Head Neck Surg 2014;66(suppl 1):307–313 7. Gerbino G, Zavattero E, Berrone M, et al. Management of needle breakage using intraoperative navigation following inferior alveolar nerve block. J Oral Maxillofac Surg 2013;71:1819–1824
FIGURE 1. A, Initial examination. B, Magnetic resonance image showing the left frontotemporal lesion. C, In the sixth month of the treatment, there was improvement both in the lesion and in the ptosis with the aid of a plaster. D, Increase in size due to intralesional hemorrhage in the seventh month.
A 1-month-old male infant (term, 3850 g, delivered via cesarean delivery) was admitted with a swelling on the left side of the scalp. Informed consent was taken from the mother. On physical examination of the infant, a big mass on the left frontotemporal region also totally covering the left eye was palpated. The lesion was nontender as well as soft and was extending to the left upper eyelid. Total ptosis of the left eye by the mechanical effect of the lesion was observed (Fig. 1A). Magnetic resonance imaging (MRI) of the head revealed a 9 3 7-cm lesion containing irregular cystic dilatations, considerably with regular borders, and that had no invasion to the adjacent bones, which can be consistent with a hemangioma (Fig. 1B). The diagnosis of the lesion was accepted as hemangioma. Systemic examinations and laboratory investigations were within reference limits. The treatment was started with systemic steroid (2 8 mg) and β-blocker, propranolol (2 10 mg). To prevent amblyopia, the mother was advised to elevate the lump with the aid of sticking a
A Propranolol Nonresponsive Mass: Lymphangioma-Mimicking Hemangioma To the Editor: Lymphangiomas are benign congenital malformations of the lymphatic system that occur most commonly in the head and neck region with the involvement of skin and subcutaneous tissue. The most involved site of lymphangiomas is the head and neck region, primarily affecting the tongue and mouth.1,2 Treatment of lymphangioma is difficult because of difficulty in choosing the treatment modality, close relationship with vital structures, potential visual and cosmetic problems, and possibility of recurrences.3 We report a case of a big mass on the scalp, which was initially misdiagnosed as hemangioma and finally diagnosed as lymphangioma.
FIGURE 2. A, Magnetic resonance image showing intralesional hemorrhage in the seventh month. B, Surgical procedure. C, Totally excised lesion. D, First-week appearance of the patient with improvement in the ptosis.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
327
