THE TRANSNASAL APPROACH TO SELLAR LESIONS. A NEUROSURGICAL EXPERIENCE AND PERSPECTIVE

The transnasal approach for pituitary lesions has been adopted increasingly by neurosurgeons for removing sellar lesions. It has made surgery in this region safer with fewer complications in experienced hands. However, the approach requires good knowledge of nasal anatomy and formal training to achieve good results since the territory is unfamiliar to most neurosurgeons. The approach has a somewhat steep learning curve. In our experience of 41 cases, we have presented here. We have discussed the history of this approach, technique and relevant complications and their avoidance.

Narrowing the Wide Tip via Endonasal Approach

Rhinoplasty is arguably the most complex and intricate surgery performed by facial plastic surgeons. Nasal tip refinement of a broad nasal tip has remained the most challenging part of rhinoplasty as sophisticated techniques are critical to achieve aesthetically pleasing and structurally sound nasal tips that can withstand the contractile forces of healing. Successful tip refinement relies on an in-depth preoperative and intraoperative understanding of the patient's nasal anatomy, well developed arsenal of techniques, the experience of the surgeon, and the aesthetic desires of the patient. Although the approach to gain access to the nasal tip so as to successfully reshape the tip has been a topic of debate over many years, the aim of this article is to outline and demonstrate how the broad nasal tip can be successfully recontoured through an endonasal approach using nondestructive techniques that have been effectively used in open rhinoplasty. We believe that there continues to be a place for endonasal tip rhinoplasty especially in this era in which patients desire less invasive procedures with shorter healing time.

The effect of decongestion on nasal airway patency and airflow

Nasal decongestant reduces blood flow to the nasal turbinates, reducing tissue volume and increasing nasal airway patency. This study maps the changes in nasal anatomy and measures how these changes affect nasal resistance, flow partitioning between superior and inferior cavity, flow patterns and wall shear stress. High-resolution MRI was applied to capture nasal anatomy in 10 healthy subjects before and after application of a topical decongestant. Computational fluid dynamics simulated nasal airflow at steady inspiratory flow rates of 15 L.min$$^{-1}$$ - 1 and 30 L.min$$^{-1}$$ - 1 . The results show decongestion mainly increases the cross-sectional area in the turbinate region and SAVR is reduced (median approximately 40$$\%$$ % reduction) in middle and lower parts of the cavity. Decongestion reduces nasal resistance by 50$$\%$$ % on average, while in the posterior cavity, nasal resistance decreases by a median factor of approximately 3 after decongestion. We also find decongestant regularises nasal airflow and alters the partitioning of flow, significantly decreasing flow through the superior portions of the nasal cavity. By comparing nasal anatomies and airflow in their normal state with that when pharmacologically decongested, this study provides data for a broad range of anatomy and airflow conditions, which may help characterize the extent of nasal variability.

An Unusual Retained Choanal Foreign Body: A Possible Complication of COVID-19 Testing With Nasopharyngeal Swab

Testing for coronavirus disease 2019 is critical in controlling the pandemic all over the world. Diagnosis of severe acute respiratory syndrome coronavirus-2 infection is based on real-time polymerase chain reaction performed on nasopharyngeal swab. If not adequately performed, the viral specimen collection can be painful and lead to complications. We present a complication occurred during a nasopharyngeal swab collection performed in a noncooperative patient where the plastic shaft of the swab fractured during the procedure, resulting in swab tip retention deep into the nasal cavity. The foreign body was found endoscopically, stuck between the nasal septum and the superior turbinate tail at the upper level of the left choana and removed under general anesthesia in a negative pressure operating room with the health care personnel wearing personal protective equipment. Unpleasant complications like the one described can happen when the swab is collected without the necessary knowledge of nasal anatomy or conducted inappropriately, especially in noncooperative patients. Moreover, the design of currently used viral swabs may expose to accidental rupture, with risk of foreign body retention in the nasal cavities. In such cases, diagnosis and treatment are endoscopy-guided procedures performed in an adequate setting to minimize the risk of spreading of the pandemic.

Guidelines for Dorsum Preservation in Primary Rhinoplasty

The multiplication of scientific articles related to the fast-growing interest in preservation rhinoplasty (PR) may lead to confusion in the decision-making process, thus requiring a need for guidelines through a focus on benefit–risk ratio and revisions. This study analyzes a 352 consecutive primary rhinoplasties series during a 3 year (2016 to 2019) period with 1-year follow-up. The evaluation of the most appropriate procedure to the patient's nasal anatomy and expectations requires to correlate (1) a convenient classification of nasal profile lines; (2) a review of the dorsum preservation techniques (DP) classified as: full DP, DP + resurfacing, bony cartilaginous disarticulation, and finally traditional rhinoplasty; (3) the role of septoplasties, subdividing this series in two main groups; (4) analyzing the revisions in the different subgroups and to the literature. Thirty-five revisions (9.94%) were done. Correlations between profile lines, surgical procedures, and revisions show (1) 129 straight noses underwent full DP in 88 cases with 5.68% revisions; however, DP+ hump resurfacing in 32 patients with no revision. (2) Among 71 tension noses, 33 underwent full DP with 6 revisions (18.18%), while 32 patients had bony cap resurfacing, 1 revision (3.13%). (3) Among 109 kyphotic noses, 64 patients underwent DP + resurfacing with 10 revisions (15.63%); 27 patients had cartilage-only DP with two revisions (7.41%). (4) In the 43 difficult noses group, revisions were done equally in DP + resurfacing and cartilage-only subgroups. Septum stability modifies the correlations, introducing Cottle's septorhinoplasty in the paradigm. The revision rate is jumping ×2.50% when a septoplasty is associated with the rhinoplasty. Correlated to the benefit–risk ratio and the revisions, the following guidelines may be suggested in primary rhinoplasty: (1) Straight noses: full DP, (2) tension noses: DP + dorsum resurfacing and/or Cottle's variations, (3) kyphotic noses: cartilage-only DP, and (4) difficult noses: traditional rhinoplasties.

Biomechanical Nasal Anatomy Applied to Open Preservation Rhinoplasty

Preservation rhinoplasty is a new way to reshape the nose by preserving the dorsum, nasal ligaments, soft tissue envelope, and muscles. This new concept provides the opportunity to achieve a more natural aesthetic and functional result. To achieve a good aesthetic and functional outcome while maintaining surgical safety, knowledge of the relevant anatomy is key. This is especially true for the preservation rhinoplasty technique, where a firm grasp of the anatomy of the nasal soft tissue and bony–cartilaginous framework is critical. The preservation technique is made more accessible by the open approach, which provides an opportunity for the deformity to be clearly visualized from the tip of the nose and the dorsum. Furthermore, tip plasty is easier to perform under direct vision, which is an advantage of the open approach. The goal of this article is therefore to make clear all the important anatomical structures and their relevance to the surgical steps taken when performing the open preservation rhinoplasty technique.