Branchial Cleft Sinus Tract VS Fistula?

Methylene blue and lacrimal probes assist in the dissection.  Over probing can lead to cyst wall penetration and over dissection.  Often the surgeon needs to combine direct larygoscopy with the external approach to identify the origin of the fistula.  Cauterization of the original mucosa has proven acceptable vs some type of a stitch closure.

Nasal Alar Reconstruction

This was a large defect from a skin cancer.  It was reconstructed with a superiorly based nasolabial flap wrapped around a conchal cartilage graft.  The division and inset was at 3 weeks.

Moisturizing Nasal Measures

shoppingBactroban (Mupirocin) ointment is a water miscible ointment that out performs all others in the anterior nose.

shopping-1Pretz Spray Web smallPonaris Nasal Emmolient is also a staple of our practice.  Pretz, Blairex, Nose Better, Nasal Moist, and Rhinaris are all moisturizing sprays.  Entertainer’s Secret is a special formulation used as a throat spray that some have used as a nasal moisturizer. Some have advocated Conjugated Estrogens dissolved in saline.  Mayo clinic has compounded rose geranium in sesame oil they say works well.

Recognition and management of Orbital Bleeding

Obviously the eyes need to be exposed during the case.  Often what is going on intranasally gives little indication of the problem.  The eye rapidly grows proptotic and tense.  Immediate cantholysis and canthotomy is necessary to allow the globe to release anteriorly.  The next move I made was to decompress the orbit a bit intranasaly.  I also made an immediate Lynch incision and bipolared the offending artery.  Some Arista was also used and the final ethmoid packing was fairly loose.

 

Anterior Ethmoid Artery Hemorrage

It is not unusual for recurrent polyps or papillomatous sinus disease to lead to dehissance of the Lamina Papyrecea.  The Anterior Ethmoid Artery is in close proximitry to this region and injury is possible.  I have probably done as many sinus surgeries as anyone alive and kind of felt that my super human skills left me immune to this complication, until now.  The intranasal surgery showed little sign of any problem, but the exposed eye become immediately proptotic and tense.