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Furthermore treatment associates generic risperdal 3mg line, the use of intrathecal fluorescein is strongly suggested as a guide during surgery to indicate the sites of the leak and to confirm the effectiveness of the repair medications before surgery order risperdal 4 mg. At present treatment zinc poisoning buy risperdal 2mg amex, the authors prefer to use only autologous material because it allows stable healing with viable material 7mm kidney stone treatment cheap risperdal 4mg with mastercard. Such conservative management is used by the Management of a Skull Base Defect According to the Esposito-Dusik classification,26 the authors believe that the repair should be tailored to the. Typically, pneumocephalus is asymptomatic, but the potential concern is tension pneumocephalus. There are a few reports stating that lumbar drainage may increase the volume of the penetrating air, thus inducing intracranial hypertension and a clinical deterioration of the patient. In this rare condition, it is mandatory to remove the lumbar drainage, evacuate the air, and repair the fistula directly at the site of origin. Multiple factors influence the choice of antibiotic prophylaxis, at the forefront of which are patient demographics and the nature of the surgical procedure. In patients allergic to penicillin, either gentamicin or vancomycin is used at the discretion of the surgeon. In the case of an evident or persistent leak, we recommend carrying out revision duraplastic surgery as soon as possible to reduce the time of exposure involving the sinus flora and the intracranial cavity. All surgical injury of the mucosa reduces mucociliary transport in the nose and sinus cavities. Moreover, if the sinus mucosa is removed, the new epithelium is not ciliated and subsequent mucus clearance may be impaired. If the natural ostial patency of the sinus is not respected, it may possibly lead to acute or, more frequently, chronic sinusitis and, over the long term, a postsurgical mucocele. Therefore, to prevent acute or chronic alterations of the sinuses and nasal cavity functioning and/or infection and/or postsurgical mucocele, it is important to avoid unnecessary stripping of mucosa, to preserve sinus patency, and to correct any tendency toward lateralization of the middle turbinate. In the postoperative period, we suggest frequent nasal cleaning with saline solution and a transnasal endoscopic examination 3 to 4 weeks after the surgical procedure. An earlier examination should be performed in the case of an extended approach or in the case of disturbing sinus symptoms, such as rhinorrhea, a foul smell, and/or nasal obstruction. The former depends on the operative time, the recovery time, and bed rest, and on factors related to the general health conditions of the patient; they are not affected by antibiotic prophylaxis. Conversely, local infection at the surgical site (rhinosinusitis, meningitis) is related to the surgical procedure. Despite the theoretical high risk of intracranial contamination with sinus nasal flora, present experience shows a relatively low incidence of central nervous system infections arising from rhinosinusitis. It helps to prevent infection by reducing the "infectious load" in the presence of the clean contaminated surgery inherent in transnasal skull base surgery. A standardized regimen of antibiotic prophylaxis maintains a low incidence of postoperative infection, decreasing the risk of infection resulting from resistant organisms, allergic Conclusion Endoscopic skull base surgery is the most recent development of endoscopic transsphenoidal surgery and is based on the use of expanded endonasal approaches. The key for its widespread acceptance results from the 714 Rhinology direct extracerebral access to the ventral skull base and the avoidance of brain manipulation and neurovascular dissection. In other respects, endoscopic approaches follow the same rules as for microsurgery. It is a technique that can give great results, but that may pose many pitfalls for the surgeon. Safety may be preserved following some golden rules: (1) perform only operations for which the surgeon is highly trained; (2) prevent complications by strictly following the technical rules; and (3) be prepared to treat complications that unfortunately occur even when the surgery is performed in the best hands using careful and cautious management. The latter statement implies that such procedures have to be performed only by surgeons or in centers where all competencies are present-namely, the possibility of switching to open surgery, having rapid access to endovascular treatment, and having an experienced intensive care unit. Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Acquisition of surgical skills for endonasal skull base surgery: a training program. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. Angiographic follow-up of traumatic carotid cavernous fistulas treated with endovascular stent graft placement. Angiographic balloon test occlusion and therapeutic sacrifice of major arteries to the brain. Endoscopic endonasal approach for the treatment of benign schwannoma of the sinonasal tract and pterygopalatine fossa. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Diagnostic values of beta-2 transferrin and beta-trace protein as markers for cerebrospinal fluid fistula. Surgical occlusion of cerebrospinal fistulas of the anterior skull base using intrathecal sodium fluorescein. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Subdural and intraventricular tension pneumocephalus after transsphenoidal operation. It emphasizes the value of multidisciplinary cooperation in choosing among management options, procedures, and patient follow-up. This includes: (1) using high-resolution skull base imaging to assess the extent of disease; (2) appreciating the efficacy of alternatives or adjuncts of surgery such as chemotherapy and conformal radiotherapy.
The posterior end of the vidian canal delimits the genu between the petrous carotid artery and the paraclival artery medications made from plasma order risperdal 2mg online. The glossopharyngeal treatment 6th feb order risperdal once a day, vagus medications ranitidine buy risperdal discount, and the hypoglossal nerves are also distant from the surgical corridors normally used in the endoscopic endonasal approach nioxin scalp treatment buy discount risperdal 3 mg online. The surgeon should keep them in mind when carrying out an approach to the jugular foramen or to the foramen magnum. The sphenopalatine ganglion or pterygoid ganglion, which receives otho/parasympathetic bundles from vidian nerve and sensitive somatic fibers from maxillary nerve, is also shown. The infraorbital nerve is well visualized, which is the terminal branch of maxillary nerve. The features favoring such a complication are mostly uncontrollable expiratory reflexes, such as sneezing, coughing, or vomiting. A smooth emergence from anesthesia as well as preoperative instructions regarding activity restrictions are useful expedients in preventing such events. Surgical approaches to the anterior skull base have evolved since an initial paper in 1954 by Smith1 described resection of a frontal sinus tumor. Between 1963 and 1973, Ketcham4,5 demonstrated clearly that surgery in this area, although associated with significant morbidity, improved the likelihood of cure of malignant tumors. Since that time, numerous surgical techniques have been introduced to extend or improve anatomic access for resection or reconstruction, and/or to reduce functional or aesthetic morbidity. Small transfacial incisions that supplement a bicoronal craniotomy incision are widely used6 and, increasingly, endoscopic and endoscopic-assisted approaches are being perfected for selected cases, as reviewed by Har-El. Compared with a generation ago, improved local control and survival rates have been documented, and the incidence of severe morbidity and mortality has been reduced to much lower than 5%. Thus, a purely rhinal and often endoscopic approach is preferred unless this would significantly limit the extent of tumor resection or preclude adequate repair of the anterior skull base. Identification of such limitations of a rhinal approach requires familiarity with surgical anatomy, the natural history of neoplastic diseases of the area, and the efficacy of adjuvant therapies. Indications Although extensive bacterial or fungal infections of the anterior or lateral skull base occasionally require combined transcranial and rhinal approaches, tumors far more frequently require these combined approaches and are the focus of this review. Tumors that may require anterior skull base resection include selected malignant tumors of the paranasal sinuses that extend superiorly through the cribriform plate, ethmoid roof, and planum sphenoidale or posteriorly through the posterior wall of the frontal sinus; benign and malignant meningiomas that involve the same areas; and selected benign tumors or tumorlike lesions such as orbital apex schwannomas, large nasal tumors such as juvenile angiofibromas and inverted papillomas, and occasional encephaloceles and mucoceles. The goals of anterior skull base surgery for tumors have remained constant throughout the continuing evolution of surgical and radiation oncology techniques. Segregation of intracranial contents from the contaminated paranasal sinuses, reducing the incidence of meningitis 4. Improved aesthetic outcome Contraindications to aggressive surgical resection include tumor extension that precludes resection of tumor with negative margins. Additional contraindications include distant metastatic disease unlikely to respond to chemotherapy and patient medical fragility. Specific indications for craniotomy or a combined procedure over a rhinal approach alone include the following: 1. Tumor involvement superior to the orbit (and lateral to the ethmoid roof) in cases in which preservation of the orbit is anticipated. Dural enhancement extends laterally (small white arrows), beyond the reach of an endoscopic approach. Inaddition, bilateral left-greater-than-right extension of tumor into the orbit is seen (white arrows). Some might have resected this lesion endoscopically, butthesiteoftumorprecludedtheuseofarobustregionalmucosal B flap. Resectable tumor attached to the dorsal or lateral aspects of the optic nerve, optic chiasm, or the intracranial internal carotid artery and its branches 3. Tumor widely involving subfrontal dura, especially over the orbital roofs, such that watertight closure is precluded. In our experience, when the patient has full extraocular motility on preoperative clinical examination, one can usually preserve the orbit. If there is diplopia solely because of mass effect leading to proptosis and interference with extraocular muscle function but without radiologically evident extension of tumor into orbital fat, then the orbit also is likely to be able to be preserved. Extension of tumor superiorly through the orbital roof limits tumor resection from below, mandating craniotomy. The exception to mandated craniotomy is tumor involvement of the orbit sufficiently extensive to warrant exenteration, in which case tumor that is superior to the orbit can be removed transorbitally. Many feel, as do we, that the orbit can be functionally preserved in an oncologically sound fashion if there is no significant involvement of the orbital fat, even if the orbital periosteum is involved with the tumor. The thin fascial layer that surrounds the orbital fat just inside the orbital periosteum9 A. Thetumorrestsontheuninvolvedhardpalate(P)inferiorly and extends superiorly into the sphenoid sinus (S), eroding its floor. Foramenrotundum(long white arrow)andthevidiancanal(short white arrow)arenormalontheright,butareinvolvedbytumorandpoorly B definedontheleft. Tumor was removed D largely through the orbital exenteration cavity, including resection of the anterior cranial fossa and nasopharynx, maxillectomy, ethmoidectomy, sphenoidectomy, and a craniectomyfor tumor within thefrontalbone(notshown). Tumor and tumor-infiltrated bone can be removed transsphenoidally from these structures unless tumor invades the optic nerve sheath or the arterial adventitia, in which case tumor should be left behind lest the artery or nerve be injured. It typically runs on the lateral surface of the nerve in the anterior optic canal. Thus, dissection of the anterior optic chiasm and the medial optic canal is generally safe. When tumor is attached to the dorsal or lateral surfaces of the optic nerve, optic chiasm, or the intracranial internal carotid artery and its branches, and particularly when it surrounds these structures, then the risk of dissection from below is substantial and a craniotomy is indicated if it is the judgment of the team that tumor resection is appropriate at all. Tumor within the cavernous sinus, particularly if it surrounds the internal carotid artery, usually cannot be removed safely by even a transcranial approach. Lateral Dural Extension and Preservation of Smell Although areas of dura infiltrated or penetrated by tumor can be resected and the resultant defect repaired 720 Rhinology A B C.
Rare mesenchymal neoplasms medicine vs nursing discount 4 mg risperdal visa, such as solitary fibrous tumor treatment diabetic neuropathy order risperdal 2 mg fast delivery, may be difficult to diagnose both clinically and histologically symptoms zithromax buy cheapest risperdal and risperdal. Metastases to the skull base from remote primary tumors are uncommon medicine 122 risperdal 4mg with mastercard, but must be considered, especially when the lesion is predominantly within the bony structures in a patient with a prior known malignancy. Meningiomas and tumors of neural origin, such as schwannomas, also are encountered frequently, as are chordomas, which originate from notochordal remnants. In addition, several benign proliferations, such as angiofibroma, inverted papilloma, fibrous dysplasia, and pituitary adenomas, warrant discussion. They invariably begin at the lateral basisphenoid at the junction of the sphenoid sinus and pterygopalatine fossa near the sphenopalatine artery, from which they can expand in all directions to disrupt adjacent structures. Extension laterally bows the posterior maxillary 42 Pathology of the Sinonasal Region and Anterior and Central Skull Base 549 Inverted Papilloma and Other Papillomas the histopathologic review of papillomas by Hyams remains fully valid today,4 as discussed anew by Batsakis. Microscopically, islands of thickened epithelial cells are surrounded by edematous and inflamed stroma. The invaginated nests are composed of mature nonkeratinized squamous cells admixed with mucinous cells and mucous cysts and enveloped by a thin basement membrane. Typical histopathologic findings include a polypoid mass with smooth or bosselated edges, and characteristically irregular delicate, thin-walled "staghorn" blood vessels embedded in a variably hyalinized collagenous stroma containing plump, stellate, or spindled fibroblasts. Pleomorphism, mitotic activity, and necrosis are uncommon, except in cases of infarction following preoperative embolization. The stromal cells and endothelial cells are immunoreactive with antibodies for androgen, estrogen, and progesterone receptors. Although some advocate surgery without embolization in selected cases, preoperative embolization significantly reduces intraoperative bleeding to the point that transfusion is rarely required. Even for the 10 to 20% that extend to the cranial base, endoscopic resection is usually indicated. Thus, if the patient is near adulthood and the tumor is asymptomatic and slow growing, observation may be preferable to irradiation. Theroundednests are enveloped by basement membranes and lack a desmoplastic hostresponse(H&E320). Note the preservation of cellular polarity, lack of cytologicatypia,andabsenceofdivisionfigures. Although histopathologic features associated with the risk for malignant transformation have been sought, none have been found consistently. When the tumor is confined to the nasal cavity, ethmoid sinus, and medial maxillary wall, endoscopic surgical resection of inverted papilloma has a low recurrence rate (less than 5%). Whether this increase reflects underlying tumor biologic predisposition or the technical difficulty of completely resecting the attachment site is difficult to discern. The recurrence rate is,35% for the few cases (10%) that extend beyond the paranasal sinuses, such as through the anterior skull base. Surgical resection of these, especially when recurrent, can be challenging, even with supplemental external approaches. As the anterior lobe migrates posteriorly to fuse with the infundibulum, small islands may remain along the path. These ectopic foci may give rise to ectopic adenomas adjacent to the gland or within the sphenoid bone. They become symptomatic by causing either overproduction or underproduction of pituitary hormones or by compressing nearby structures. Hence, without hormonally associated symptoms, these usually present instead with symptoms that occur secondary to compression of adjacent structures, such as the remaining pituitary gland (hypopituitarism), dura (headache), optic nerve or chiasm (visual field loss), oculomotor nerves (diplopia), and trigeminal divisions (facial numbness). Its cells are organized in a multilayered columnar fashion with abundant granular eosinophilic cytoplasm. Septal Papilloma Septal papilloma occurs as an exophytic mass on the anterior nasal septum. The papillary fronds are composed of up to 20 cell layers and display normal squamous maturation toward the surface epithelium. Variable areas of ciliated columnar cells, mucocytes, and inflammatory cells are present. With practically no malignant potential, it is less aggressive than the other types. It is distinguishable from a nasal vestibular squamous papilloma, which is derived from adjacent epidermal skin. Inset:Formalin-fixedparaffin embedded immunohistochemistry is routinely performed for definitive classification. One often sees elongated small cells forming pseudorosettes around dilated capillaries. The cytoplasm of the cells ranges from acidophilic, amphophilic, basophilic, to clear (chromophobic). Small endocrinologically inactive tumors found incidentally may be observed with serial scans; 10% will regress, 40% will remain stable, but 50% will progress over 5 years. The extent of resection achieved varies with tumor type, size, invasiveness, direction of extension, and adjacent structures involved. Recurrence rates vary between 6 and 46% among these almost exclusively benign tumors, reflecting these same factors. They require surgical intervention if they produce pain and sinusitis associated with blocked drainage of a sinus, typically the frontal sinus or the ethmoid sinus.
In the vector the recognition sites for the restriction enzymes are located close to each other treatment yellow jacket sting order risperdal 2mg without a prescription. Treating the vector with a phosphatase enzyme after it has been cut with the restriction enzymes medications covered by medicare purchase genuine risperdal on-line, however medicine for depression order cheap risperdal on line, can prevent this medicine 4h2 pill cheap risperdal 3 mg without prescription. Phosphatases catalyse the removal of 5 phosphate groups from nucleic acids and nucleotide triphosphates. The basics of cloning into a plasmid vector containing a single unique restriction enzyme recognition site. The ligation of a compatible insert into this vector will result in the ligation of only the 5 -ends of the insert with the vector. The 3 -end of the insert (a hydroxyl group) and the 5 -end of the vector (also a hydroxyl group) will be unable to ligate. Other sites can be made blunt by either cleaving off the overhanging ends with a nuclease. Additionally, as we have already seen, bacteriophages can efficiently infect various strains of E. The different plasmids and bacteriophages that are used as vectors are described detail in Chapter 3. These markers, usually antibiotic resistance genes, will be discussed in more detail in Chapter 3. This chemical transformation treatment was also subsequently shown to allow plasmids to enter bacterial cells, at varying levels of efficiency. Increased transformation efficiencies have been observed using high voltage electric pulses in a process called electroporation, and using a gene gun. This single molecule may be amplified many times within the host, but all of the resulting molecules are identical. Essentially, the cells are grown to mid-log phase, harvested by centrifugation and resuspended in a solution of calcium chloride. Nutrient medium is then added to the cells and they are allowed to grow for a single generation to allow the phenotypic properties conferred by the plasmid. Cells are treated with an electrical pulse, which mediates the formation of pores. The efficiency of transformation is governed by a number of host-specific and other factors, but the molecular processes by which transformation occurs are not well understood, and conditions by which efficient transformation can take place are determined empirically. If a suitable electric field pulse is applied, then the electroporated cells can recover, with the electropores resealing spontaneously, and the cells can continue to grow. The use of electroporation to transform both bacterial and higher cells became very popular throughout the 1980s. The mechanism by which electroporation occurs is not well understood and hence, like chemical transformation, the development of protocols for particular applications has usually been achieved empirically by adjusting electric pulse parameters (amplitude, duration, number and inter-pulse interval) (Ho and Mittal, 1996; Canatella et al. The pulse amplitude and duration are critical if electropores are to be induced in a particular cell. The product of the pulse amplitude and duration has to be above a lower limit threshold before pores will form, beyond which the number of pores and the pore diameter increase with the product of amplitude and duration. An upper limit threshold is eventually reached, at high amplitudes and durations, when the pore diameter and total pore area are too large for the cell to repair. During the electroporation pulse, the electric field causes electrical current to flow through the cells that are to be transformed. These currents can lead to dramatic heating of the cells that can result in cell death. Heating effects are consequently minimized by using a relatively high-amplitude, short-duration pulse or by using two very short-duration pulses (Sukharev et al. The coated beads are then attached to the end of a plastic bullet and loaded into the firing chamber of the gene gun. An explosive force fires the bullet down the barrel of the gun towards the target cells that lie just beyond the end of the barrel. Some of the beads pass through the cell wall and into the cytoplasm of the target cells. The gene gun is particularly useful for transforming cells that are difficult to transform by other methods. For example, a vaccine has been developed against foot and mouth disease, a highly virulent viral infection of farm animals. The vaccine is composed of several viral genes that when expressed in the pig will give the animal resistance to infection by the natural virus (Benvenisti et al. Separation techniques that needed less material and gave a high degree of separation were required to effectively monitor genetic engineering experiments. The pore size of this kind of gel may be varied, by altering the percentage polyacrylamide used to construct the gel (from 3 to 30 per cent), for separating molecules of different sizes. It is a linear polysaccharide made up of the basic repeat unit agarobiose, which comprises alternating units of galactose and 3,6-anhydrogalactose. This is poured into a suitable gel former containing a comb to form wells, and allowed to cool to room temperature to form a rigid gel (Figure 2. The bands formed in an agarose gels are relatively fuzzy because the pore size cannot be accurately controlled.
However medicine 5277 purchase risperdal 4mg line, the anterior projection of the anterior skull base in the midline usually requires some very careful drilling after identification of the first olfactory nerve treatment ringworm buy risperdal on line amex, to produce the maximal anteroposterior diameter symptoms questionnaire generic 2mg risperdal. The drilling is continued superiorly medications kidney failure buy risperdal 2 mg overnight delivery, removing the intersinus septum as high as possible, and anteriorly, up to the skin, aiming for the largest possible, smooth-edged, common outflow pathway, as defined by the lacrimal bones laterally, the anterior skull base posteriorly, and the nasal skin anteriorly. Alternatively, the frontal beak is removed outside-in with a 15-degree 5-mm diamond drill, as described by Harvey. We aim to preserve a thin (1 mm) bone layer at the skin side to prevent skin collapsing in the neo-ostium. The opening proceeds until the drill can be felt under the skin, both anteriorly on the nasal bridge and laterally on the frontal process of the maxilla, removing as much of the beak as possible, aiming for a neo-ostium where the anterior frontal wall can be easily visualized with a 30-degree scope. Osteoplastic Flap (With or Without Obliteration) 5 2 1 3 We routinely use the coronal (and not bicoronal) incision, although for patients with male pattern baldness and forehead rhytids, another option is a midforehead browlift incision, which can be hidden within an existing forehead wrinkle. On the other hand, we never use the gull wing incision, which is associated with unpredictable and often unsightly scarring, as well as supratrochlear and supraorbital nerve damage. We start from a point anterior to the ear near the attachment of the helix in a coronal fashion, going 1 to 2 cm posterior to the hair margin to the opposite ear. We use a sawtooth incision, 1 to 2 cm in length, to prevent contracture and to improve cosmesis, as interrupted lines are more acceptable esthetically than straight. Dissection usually proceeds rather easily and quickly, although it is important anteriorly to stay deep to the corrugator muscle to protect the supraorbital and supratrochlear nerves. The temporal branch of the facial nerve passes superficial to the zygoma between 0. When reaching the level of the temporalis muscle, it is important to incise its fascia and continue elevation between the muscle and this fascial layer. Staying in the subgaleal plane and deep to the temporalis fascia laterally protects the facial nerve. We incise the periosteum 1 cm outside the markings, then elevate it to just inside the margin of the frontal sinus. The periosteum is left undisturbed inferiorly to provide blood supply to the flap and to aid its reapproximation. We use a 4-mm otologic bur to make the initial holes in the anterior table of the frontal bone to avoid inadvertent dura laceration in case of high entry. After the first bur hole, we confirm our position with aspiration followed by gentle probing. Multiple holes along the marked perimeter are made, then brought together with a saw, angled at 45 degrees. This is to produce a beveled edge and aid reapproximation of the flap and also avoid inadvertent damage of the posterior wall. By easing the anterior plate forward, we get a complete view of the frontal sinus. If the frontal recess is not compromised and the mucosa of the frontal sinus is not irreversibly diseased, we do not obliterate the sinus. In such cases, and after the initial pathology has been dealt with, the bony flap is replaced and secured in place with titanium miniplates. We try to ensure that the miniplates are not palpable under the skin, as they can be Corrugator muscle Supraorbital nerve Temporal branch of facial nerve Supratrochlear nerve Temporoparietal fascia Temporalis muscle Deep temporal fascia. The supratrochlear and supraorbital nerves are preserved by going deep into the galea and corrugator muscle anteriorly. Particularly in cases of tumors when the follow-up is important, we find that obliteration is better avoided. When obliteration is performed, complete removal of mucosa is crucial, as postoperative mucoceles have been reported in up to 10% of patients. We have found that the best material for obliteration is autologous fat, which has been shown to generate fibrosis, while we use bone chips to isolate the frontal sinus from the nasal cavity. Narrow Anteroposterior Diameter of the Frontal Recess (Usually with Underdeveloped Agger Nasi) Specific Anatomical Considerations Anteroposterior distance of the frontal ostium 1 cm can complicate the drainage of the frontal sinus and has been considered an absolute contraindication for type 3 median drainage. Type 3/4 Cell Supraorbital Cell Chronic frontal sinusitis in the presence of Kuhn type 3 or 4 cells represents a challenge. If the anteroposterior or lateral diameter of the frontal ostium is large enough, the cell may be removed via a wide frontal sinusotomy. If, however, the dimensions of the the presence of a lateral supraorbital cell is not an indication for an external approach. Narrow Lateral Diameter of the Frontal Recess/Small Intercanthal Distance eroded but the dura is still intact, there is usually no need for reconstruction, and an endonasal approach provides adequate access. We believe that interorbital distance is an important factor in determining the extent of lateral access one can get via median drainage. Following the removal of the superior septum and the drilling of the nasal beak, lateral access to the frontal sinus is restricted primarily by the medial orbital walls. Specific Pathological Considerations Revision Type 3 Drainage Orbital Extension Tumors and mucoceles extending into the orbit with erosion of the orbital wall are usually best managed endoscopically. The wide access provided by a type 3 procedure is usually adequate, unless the tumor extends anterior to the nasolacrimal duct, in which case an inferior transconjunctival incision can provide access to the most anterior medial orbit wall with no esthetic consequences. It has been shown that, after median drainage, the neoostium tends to stenose by 33% over the first year. Although our experience does not meet the quality standards of a randomized, controlled study, we think that its use can prevent restenosis and scarring in recurrent cases. Revision after Osteoplastic Flap Cranial Extension Similarly, we do not feel that erosion of the posterior frontal plate is an indication for an external approach. In mucoceles or tumors where the posterior plate has been Previous external (osteoplastic flap or Lynch-Howarth) procedures are not contraindications for an endonasal approach. Indeed, complete removal of the mucosa of the frontal sinus during an obliteration procedure can be challenging, a fact reflected in the incidence of postoperative mucoceles. In such cases, we have found that a median drainage procedure can both drain the mucocele and facilitate subsequent follow-up.
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