Bilateral transnasal cauterization of the vidian nerve in vasomotor rhinitis By K. H.
PATEL
and G. A.
GAIKWAD
(Bombay, India)
Introduction neurectomy and cauterization of the vidian nerve in its canal is one of the surgical treatments in non-atopic chronic Vasomotor Rhinitis. Golding Wood described his Trans-Antral Vidian neurectomy, and since then various other approaches to the Vidian Nerve Canal have been described, namely TransPalatine, and Trans-Septal. The main object of this paper is to introduce yet another surgical approach to the Vidian Nerve Canal, which we have found much simpler, with several advantages over the other techniques. We would like to call it the Direct Transnasal Approach, to differentiate it from the Trans-Septal Approach, where extensive elevation of the mucoperichondrium and mucoperiosteum of the nasal septum is a preliminary. We have been able to use this technique very satisfactorily in twenty successive operations to date. A preliminary analytical follow-up report of twenty cases operated by this technique is given.
VIDIAN
Anatomy On looking through the nasal opening in a skull in which the inferior and middle turbinates have been removed, the opening of the Vidian Nerve Canal can be easily visualized through each nasal passage at the upper and lateral region of the posterior choana—approximately f to i cm. from its margin, corresponding to the i o'clock position on the left side and the n o'clock on the right. (Fig. i) Anatomically speaking, and looking at it from before backwards, the Vidian Nerve Canal occupies the root of the pterygoid processes at the junction of the internal pterygoid plate and the body on each side. Its anterior opening appears on the posterior wall of the pterygopalatine fossa, below and internal to the anterior openings of the foramen rotundum; and posteriorly it opens on the anterior wall of the foramen lacerum medium. Figure 2. shows the anterior view of the sphenoid bone. Figure 3. shows X-rays of a cadaveric skull with probes passing through the nasal cavities into the Vidian Nerve Canals of both sides. Studying the cadaveric skull, one can appreciate that this is the only large funnel-shaped well-defined opening in this area surrounded by solid bone and that no other important structures are around this opening. Thus it is not difficult to reach this opening directly through the nasal cavities and thoroughly to cauterize the Vidian Nerve Canal. Operative technique Instruments: As the canal openings are situated almost at the depth of the posterior choanae, extra long instruments are required to reach the canal 1291
K. H. Patel and G. A. Gaikwad openings. A pair of extra long bladed Killian-type nasal specula, extra long nasal forceps, angled elevators, a long handled bistoury and a long, angled and insulated cautery point with a suitably shaped ball tip are essential, to prevent deep penetration of the Vidian Nerve Canal. Anaesthesia: The operation is performed in the supine position with the head slightly elevated. Local anaesthesia is preferable, as local oozing is minimized, but the patient must be well
FIG. I
sedated pre-operatively. The nasal mucosa on both sides is thoroughly decongested and topically anaesthetized by using packs of 4 per cent Lignocaine to which is added 1:1000 adrenaline hydrochloride solution in the proportion of 15 drops to an ounce of the Lignocaine solution. Four to five c.cm. of 2 per cent Lignocaine with adrenaline is injected submucosally in the inferior and middle turbinates and the upper lateral wall of the posterior choana, in each nostril, to make the operation painless. Decongestion of the nasal mucosa is also desirable when operating under general anaesthesia, by local use of diluted adrenaline packs. After adequate shrinkage of the nasal mucosa is achieved, the inferior turbinate is fractured laterally and the middle turbinate is fractured and displaced medially. A large middle turbinate may have to be crushed with Luc's forceps to increase the working space. Rarely it may be necessary to excise partially the posterior end of the middle turbinate if oedematous or hypertrophied. Enough 1292
Opening of Sphenoidal Sinus Superior Orbital Fissure Temp. Div. of Ext. For Ext. Ang. [ Surf, of Greater Wing Proc. of Frontal i
Ethmoidal Spice ,
, Optic Foramen Orbital Surface of Greater Wing
Pterygoid Canal Zygom. Div. of Ext. s' Surf, of Greater Wing
"*• Foramen Rotunduin NSplien.-maxill. Surf. of Great Wing N -Sphenoidal Crest
ft
Spine of Sphenoid
Lateral Pterygoid Plate Pterygoid Hamulus / Pterygoid Fissure Medial Pterygoid Plate / Pterygo-palatine Groove Sphenoidal Concha Rostrum Vaginal Process FlG. 2
FIG. 3
K. H. Patel and G. A. Gaikwad space is now available to insert a long flat-bladed self-retaining Killian nasal speculum right up to the posterior end of middle turbinate and opened up to the maximum possible extent. This exposes the mucoperiosteum of the upper and lateral border of the posterior choana. The exposed mucoperiosteum in this area is incised and elevated upwards and downwards till the opening of the Vidian Nerve Canal is identified. With a little manipulation the tip of the nasal dressing forceps can be made to seek and identify the opening of the Vidian Nerve Canal. The tip of the forceps can be felt passing into the canal for about \ cm. and is usually felt to be fairly fixed in the bony canal. After controlling bleeding wliich usually occurs from the Vidian artery coming out through this canal, the opening and a short distance of the canal itself are thoroughly cauterized with an electrosurgical cautery, using the special ball-point electrode, long enough to reach the opening of the canal. The mucoperiosteal flaps are reflected back and the same procedure is carried out through the other nasal cavity. The nose is packed with petroleum jelly gauze for 48 to 72 hours. Post operative management is in as a routine septal operation. If there is a markedly deviated nasal septum, a conventional submucous resection of the septum is performed as a preliminary, the flaps approximated and the above described procedure of exposing the Vidian Nerve Canal through the nasal cavity is subsequently carried out. Bleeding from the small artery of the Vidian Canal can be controlled by using saline adrenaline packs during'the operation and by petroleum jelly packs after the operation. No other complications, immediate or delayed, have been encountered in this series. While attempting to locate the Vidian Nerve Canal one may enter either the posterior group of ethmoid cells laterally, or the sphenoid sinus medially. This false passage should at once be recognized by the feel of an egg-shell crackling if either of these air-cells or sinus wall are opened. In such an event the nasal forceps seems to easily find its way in for a considerable distance and the feeling of entering a cavity can be easily recognized as the instrument can be moved freely within the lumen. The sinus cavities appear pale white and lined with mucous membrane. Occassionally the forceps may on the other hand create a false passage between the mucoperiosteum and the bone of the upper lateral margin of the posterior choana. The forceps in this situation bulges through the mucoperiosteum and its movement can be seen through the mucoperiosteum. It is advisable that one should become thoroughly conversant with the anatomy of this region by studying the skull and practising on fresh cadavers. Advantages of Trans-Nasal over Trans-Antral Approach: (1) A relatively safe and simple piocedure because the deep surgical dissection is minimized. (2) No necessity of exposing the maxillary antrum and the pterygopalatine fossa behind it, in the Trans-Nasal approach, and hence the maxillary artery, branches of the trigeminal nerve and dental nerves are not encountered as in the antral approach. Inadvertant damage to these structures and consequent complications like bleeding from the maxillary artery which can be quite profuse; post-operative anaesthesia or paraesthesia of cheek and upper teeth which can be very annoying to the patient are avoided. 1294
Clinical records (3) Post operative swelling of the cheek and a chance of maxillary sinus infection are absent in the Trans-Nasal approach. (4) Since the operating time is reduced in the Trans-Nasal approach, as compared to the Trans-Antral approach, bilateral Vidian Nerve cauterization can be done at the same sitting even under local anaesthesia without undue discomfort to the patient. Advantages of the Trans-Nasal over Trans-Septal Approach: (1) The elevation of the septal mucoperiosteal flaps and the tedious deep dissection of these flaps from the medial to the lateral margin of the posterior choana is eliminated in the Trans-Nasal route. (2) The elevation of these flaps to locate the Vidian Nerve Canal requires excessive dilatation with a nasal speculum which is painful to the patient when being operated under local anaesthesia. (3) The Trans-Septal route is necessarily a very narrow and slightly oblique approach to the Vidian Nerve Canal, hence the Vidian Nerve Canal exposure is inadequate. (4) Septal haematoma, tears of the mucopeiiosteal flaps and also other complications incidental to septal surgery, are avoided by the Trans-Nasal approach. (5) The opeiative procedure and time are much reduced. Report on twenty operated cases
Twenty patients suffering from chronic vasomotor rhinitis were operated by this Direct Trans-Nasal approach, under local anaesthesia. Both the Vidian Nerve Canals cauterized at the same sitting. The patients selected were those having symptoms of excessive sneezing, profuse watery discharge from the nose and perpetual nasal blocking, the duration of symptoms varying from three years to thirteen years. Clinically all these patients had pale boggy nasal mucous membrane, with watery discharge, and two cases had marked septal deviation which required submucous resection before the Vidian Nerve Canal could be directly approached trans-nasally. None of the cases had polypi in the nose, or in the paranasal sinuses as ascertained radiologically. All the cases had tried varied treatments like oral antihistamines, corticosteroids, intraturbinal injections of autoblood and cortisone, and cauterization of the inferior turbinates, without any relief. The excessive sneezing and watering from the nose were the first symptoms from which the patients were relieved after the operation. The pale boggy nasal mucous membrane becomes pinkish and devoid of oedema later on, but not excessively dry. The nasal airway is re-established gradually in a few days after the initial operative oedema has subsided. Some of the patients do get occassional attacks of cold with a few sneezes and mild watering from the nose but in no way suggestive of a relapse. None of the operated patients were prescribed antihistamine drugs or corticosteroids as a routine after the operation. This approach to the Vidian Nerve Canal has given satisfactory results as compared to the trans-antral approach. The longest follow-up being i£ years, long term results are hopefully awaited. 1295
K. H. Patel and G. A. Gaikwad Summary A brief report of twenty cases of bilateral cauterization of the Vidian Nerve Canals in intractable non-atopic chronic Vasomotor Rhinitis by a Trans-Nasal approach not previously described is given. The authors find this approach to be a much safer and simpler procedure than either the Trans-Septal or the Trans-Antral routes. The advantages of this approach to the Vidian Nerve Canal over the Trans-Septal and Trans-Antral routes are discussed. Acknowledgement We wish to thank the authorities of the Municipal E.N.T. Hospital, Bombay, India for allowing us to present the case reports. REFERENCES CHANDRA, R. (1969) Archives of Otolaryngology, 89, 542. GOLDING WOOD, P. H. (1961) Journal of Laryngology and Otology, 75, 232. (1962) Journal of Laryngology and Otology, 76, 969. (1970) The Laryngoscope, 80, 1179. HIRANANDANI, N. L. (1966) Journal of Laryngology and Otology, 80, 902. MINNIS, N. L., and MORRISON, A. W. (1971) Journal of Laryngology and Otology, 85, 255. PATEL, K. H., and JAIN, J. C. (1972) Indian Journal of Otolaryngology, 25, 103. Municipal E.N.T. Hospital 7 Napier Road Bombay-i, India
1296
PATEL
and G. A.
GAIKWAD
(Bombay, India)
Introduction neurectomy and cauterization of the vidian nerve in its canal is one of the surgical treatments in non-atopic chronic Vasomotor Rhinitis. Golding Wood described his Trans-Antral Vidian neurectomy, and since then various other approaches to the Vidian Nerve Canal have been described, namely TransPalatine, and Trans-Septal. The main object of this paper is to introduce yet another surgical approach to the Vidian Nerve Canal, which we have found much simpler, with several advantages over the other techniques. We would like to call it the Direct Transnasal Approach, to differentiate it from the Trans-Septal Approach, where extensive elevation of the mucoperichondrium and mucoperiosteum of the nasal septum is a preliminary. We have been able to use this technique very satisfactorily in twenty successive operations to date. A preliminary analytical follow-up report of twenty cases operated by this technique is given.
VIDIAN
Anatomy On looking through the nasal opening in a skull in which the inferior and middle turbinates have been removed, the opening of the Vidian Nerve Canal can be easily visualized through each nasal passage at the upper and lateral region of the posterior choana—approximately f to i cm. from its margin, corresponding to the i o'clock position on the left side and the n o'clock on the right. (Fig. i) Anatomically speaking, and looking at it from before backwards, the Vidian Nerve Canal occupies the root of the pterygoid processes at the junction of the internal pterygoid plate and the body on each side. Its anterior opening appears on the posterior wall of the pterygopalatine fossa, below and internal to the anterior openings of the foramen rotundum; and posteriorly it opens on the anterior wall of the foramen lacerum medium. Figure 2. shows the anterior view of the sphenoid bone. Figure 3. shows X-rays of a cadaveric skull with probes passing through the nasal cavities into the Vidian Nerve Canals of both sides. Studying the cadaveric skull, one can appreciate that this is the only large funnel-shaped well-defined opening in this area surrounded by solid bone and that no other important structures are around this opening. Thus it is not difficult to reach this opening directly through the nasal cavities and thoroughly to cauterize the Vidian Nerve Canal. Operative technique Instruments: As the canal openings are situated almost at the depth of the posterior choanae, extra long instruments are required to reach the canal 1291
K. H. Patel and G. A. Gaikwad openings. A pair of extra long bladed Killian-type nasal specula, extra long nasal forceps, angled elevators, a long handled bistoury and a long, angled and insulated cautery point with a suitably shaped ball tip are essential, to prevent deep penetration of the Vidian Nerve Canal. Anaesthesia: The operation is performed in the supine position with the head slightly elevated. Local anaesthesia is preferable, as local oozing is minimized, but the patient must be well
FIG. I
sedated pre-operatively. The nasal mucosa on both sides is thoroughly decongested and topically anaesthetized by using packs of 4 per cent Lignocaine to which is added 1:1000 adrenaline hydrochloride solution in the proportion of 15 drops to an ounce of the Lignocaine solution. Four to five c.cm. of 2 per cent Lignocaine with adrenaline is injected submucosally in the inferior and middle turbinates and the upper lateral wall of the posterior choana, in each nostril, to make the operation painless. Decongestion of the nasal mucosa is also desirable when operating under general anaesthesia, by local use of diluted adrenaline packs. After adequate shrinkage of the nasal mucosa is achieved, the inferior turbinate is fractured laterally and the middle turbinate is fractured and displaced medially. A large middle turbinate may have to be crushed with Luc's forceps to increase the working space. Rarely it may be necessary to excise partially the posterior end of the middle turbinate if oedematous or hypertrophied. Enough 1292
Opening of Sphenoidal Sinus Superior Orbital Fissure Temp. Div. of Ext. For Ext. Ang. [ Surf, of Greater Wing Proc. of Frontal i
Ethmoidal Spice ,
, Optic Foramen Orbital Surface of Greater Wing
Pterygoid Canal Zygom. Div. of Ext. s' Surf, of Greater Wing
"*• Foramen Rotunduin NSplien.-maxill. Surf. of Great Wing N -Sphenoidal Crest
ft
Spine of Sphenoid
Lateral Pterygoid Plate Pterygoid Hamulus / Pterygoid Fissure Medial Pterygoid Plate / Pterygo-palatine Groove Sphenoidal Concha Rostrum Vaginal Process FlG. 2
FIG. 3
K. H. Patel and G. A. Gaikwad space is now available to insert a long flat-bladed self-retaining Killian nasal speculum right up to the posterior end of middle turbinate and opened up to the maximum possible extent. This exposes the mucoperiosteum of the upper and lateral border of the posterior choana. The exposed mucoperiosteum in this area is incised and elevated upwards and downwards till the opening of the Vidian Nerve Canal is identified. With a little manipulation the tip of the nasal dressing forceps can be made to seek and identify the opening of the Vidian Nerve Canal. The tip of the forceps can be felt passing into the canal for about \ cm. and is usually felt to be fairly fixed in the bony canal. After controlling bleeding wliich usually occurs from the Vidian artery coming out through this canal, the opening and a short distance of the canal itself are thoroughly cauterized with an electrosurgical cautery, using the special ball-point electrode, long enough to reach the opening of the canal. The mucoperiosteal flaps are reflected back and the same procedure is carried out through the other nasal cavity. The nose is packed with petroleum jelly gauze for 48 to 72 hours. Post operative management is in as a routine septal operation. If there is a markedly deviated nasal septum, a conventional submucous resection of the septum is performed as a preliminary, the flaps approximated and the above described procedure of exposing the Vidian Nerve Canal through the nasal cavity is subsequently carried out. Bleeding from the small artery of the Vidian Canal can be controlled by using saline adrenaline packs during'the operation and by petroleum jelly packs after the operation. No other complications, immediate or delayed, have been encountered in this series. While attempting to locate the Vidian Nerve Canal one may enter either the posterior group of ethmoid cells laterally, or the sphenoid sinus medially. This false passage should at once be recognized by the feel of an egg-shell crackling if either of these air-cells or sinus wall are opened. In such an event the nasal forceps seems to easily find its way in for a considerable distance and the feeling of entering a cavity can be easily recognized as the instrument can be moved freely within the lumen. The sinus cavities appear pale white and lined with mucous membrane. Occassionally the forceps may on the other hand create a false passage between the mucoperiosteum and the bone of the upper lateral margin of the posterior choana. The forceps in this situation bulges through the mucoperiosteum and its movement can be seen through the mucoperiosteum. It is advisable that one should become thoroughly conversant with the anatomy of this region by studying the skull and practising on fresh cadavers. Advantages of Trans-Nasal over Trans-Antral Approach: (1) A relatively safe and simple piocedure because the deep surgical dissection is minimized. (2) No necessity of exposing the maxillary antrum and the pterygopalatine fossa behind it, in the Trans-Nasal approach, and hence the maxillary artery, branches of the trigeminal nerve and dental nerves are not encountered as in the antral approach. Inadvertant damage to these structures and consequent complications like bleeding from the maxillary artery which can be quite profuse; post-operative anaesthesia or paraesthesia of cheek and upper teeth which can be very annoying to the patient are avoided. 1294
Clinical records (3) Post operative swelling of the cheek and a chance of maxillary sinus infection are absent in the Trans-Nasal approach. (4) Since the operating time is reduced in the Trans-Nasal approach, as compared to the Trans-Antral approach, bilateral Vidian Nerve cauterization can be done at the same sitting even under local anaesthesia without undue discomfort to the patient. Advantages of the Trans-Nasal over Trans-Septal Approach: (1) The elevation of the septal mucoperiosteal flaps and the tedious deep dissection of these flaps from the medial to the lateral margin of the posterior choana is eliminated in the Trans-Nasal route. (2) The elevation of these flaps to locate the Vidian Nerve Canal requires excessive dilatation with a nasal speculum which is painful to the patient when being operated under local anaesthesia. (3) The Trans-Septal route is necessarily a very narrow and slightly oblique approach to the Vidian Nerve Canal, hence the Vidian Nerve Canal exposure is inadequate. (4) Septal haematoma, tears of the mucopeiiosteal flaps and also other complications incidental to septal surgery, are avoided by the Trans-Nasal approach. (5) The opeiative procedure and time are much reduced. Report on twenty operated cases
Twenty patients suffering from chronic vasomotor rhinitis were operated by this Direct Trans-Nasal approach, under local anaesthesia. Both the Vidian Nerve Canals cauterized at the same sitting. The patients selected were those having symptoms of excessive sneezing, profuse watery discharge from the nose and perpetual nasal blocking, the duration of symptoms varying from three years to thirteen years. Clinically all these patients had pale boggy nasal mucous membrane, with watery discharge, and two cases had marked septal deviation which required submucous resection before the Vidian Nerve Canal could be directly approached trans-nasally. None of the cases had polypi in the nose, or in the paranasal sinuses as ascertained radiologically. All the cases had tried varied treatments like oral antihistamines, corticosteroids, intraturbinal injections of autoblood and cortisone, and cauterization of the inferior turbinates, without any relief. The excessive sneezing and watering from the nose were the first symptoms from which the patients were relieved after the operation. The pale boggy nasal mucous membrane becomes pinkish and devoid of oedema later on, but not excessively dry. The nasal airway is re-established gradually in a few days after the initial operative oedema has subsided. Some of the patients do get occassional attacks of cold with a few sneezes and mild watering from the nose but in no way suggestive of a relapse. None of the operated patients were prescribed antihistamine drugs or corticosteroids as a routine after the operation. This approach to the Vidian Nerve Canal has given satisfactory results as compared to the trans-antral approach. The longest follow-up being i£ years, long term results are hopefully awaited. 1295
K. H. Patel and G. A. Gaikwad Summary A brief report of twenty cases of bilateral cauterization of the Vidian Nerve Canals in intractable non-atopic chronic Vasomotor Rhinitis by a Trans-Nasal approach not previously described is given. The authors find this approach to be a much safer and simpler procedure than either the Trans-Septal or the Trans-Antral routes. The advantages of this approach to the Vidian Nerve Canal over the Trans-Septal and Trans-Antral routes are discussed. Acknowledgement We wish to thank the authorities of the Municipal E.N.T. Hospital, Bombay, India for allowing us to present the case reports. REFERENCES CHANDRA, R. (1969) Archives of Otolaryngology, 89, 542. GOLDING WOOD, P. H. (1961) Journal of Laryngology and Otology, 75, 232. (1962) Journal of Laryngology and Otology, 76, 969. (1970) The Laryngoscope, 80, 1179. HIRANANDANI, N. L. (1966) Journal of Laryngology and Otology, 80, 902. MINNIS, N. L., and MORRISON, A. W. (1971) Journal of Laryngology and Otology, 85, 255. PATEL, K. H., and JAIN, J. C. (1972) Indian Journal of Otolaryngology, 25, 103. Municipal E.N.T. Hospital 7 Napier Road Bombay-i, India
1296
