drium of the perpendicular plate of the ethmoid and vomer. An inferior tunnel is then made along the floor of the nose by elevating the mucosa of the floor of the nose. The anterior and inferior tunnels are con¬ nected by sharp dissection. The left side of the sphenoid rostrum is identified, and the transsphenoidal speculum is introduced be¬ tween the flap and septum on the left side, such that its tip reaches the sphenoid ros¬ trum. The speculum is gradually opened and the thin bony septum fractures to the right, exposing the anterior and inferior walls of the sphenoid sinuses. If there is any question regarding location, a lateral roentgenogram is taken. The surgical microscope is positioned and the mucosa over the ante¬ rior and inferior walls of the sphenoid sinuses is elevated. The sphenoid crest and rostrum are removed with a forwardgrasping forceps, thus entering one or both of the sphenoid sinuses. The opening is en¬ larged using Kerrison's rongeurs and the neurosurgical procedure is performed, af¬ ter which the transsphenoidal speculum is removed. The mucosal incision is sutured with absorbable sutures, the bony septum is repositioned with Ashe's septal forceps, and the nasal cavities are packed with medicated ribbon gauze.
Comment—From November 1989 until May 1990, endonasal transseptal
procedures were performed on 14 pa¬ tients requiring surgery of the pitu¬ itary gland. On follow-up, none of the patients developed septal perforation. One patient developed vestibulitis postoperatively, which healed with lo¬ cal application of neosporin ointment, because of the trauma of applying the transsphenoidal speculum. Since no part of the bony or carti¬ laginous septum is removed and a flap is elevated only on one side of the nasal septum, septal perforation is avoided. The procedure is technically simple, reduces operating time, and provides good visualization of the pituitary gland. ANAND JOB, MS, DLO SIDDARTHA GOSH, MS THOMAS JOSEPH, MS Vellore, South India
1. Kern EB. Transnasal pituitary surgery. Arch Otolaryngol. 1981;107:183-190.
2. Koltai PJ, Goldstein JC, Parnes SM, Price JC. External rhinoplasty approach to transsphenoidal hypophysectomy. Arch Otolaryngol. 1985; 111:456-458. 3. Escajadillo JR, de Gortari E. Transseptal approach for the treatment of pituitary lesions. Arch Otolaryngol. 1983;109:326-328. 4. Peters GE, Birmingham AL, Zitsch RP. Columellar flap for transseptal transsphenoidal hy-
pophysectomy. Laryngoscope. 1988;98:897-899.
Facial Palsy Following Local Anesthetic Infiltration for Middle Ear
Surgery To the Editor.\p=m-\Facial palsy following tympanomastoid surgery has recently been reported1 due to local anesthetic
effect. This has been attributed to the possible dehiscent facial canal in the middle ear. We have also seen patients with facial palsy following local anesthetic infiltration during middle ear surgery. We were, however, quite convinced of the integrity of the facial canal during surgery. The possible explanation is the effect of local anesthetic on the facial nerve at the level of the stylomastoid foramen. During parotid gland surgery, the facial nerve is identified as following the posterior belly of the digastric muscle and the external ear cartilage pointer. Hence, it is postulated that whenever local anesthetic is infiltrated near the mastoid tip for postaural or at the inferior osseocartilaginous junction for permeatal surgery, the local anesthetic seeps out to affect the facial nerve. Interestingly, in two patients there was a history of Bell's palsy that had recovered spontaneously. Hence, as a policy, it may be advisable to use adrenalin infiltration alone to raise the flap and achieve hemostasis in patients where the surgery is done under gen¬ eral anesthesia. In patients where sur¬ gery is done under local anesthesia, it is useful to check for facial palsy after infiltration, before performing the sur¬ gery.
R. RAMAN, MS, DLO ANAND JOB, MS, DLO Vellore, South India
1. Madden G. Facial palsy following tympanomastoid surgery. Arch Otolaryngol Head Neck
Surg. 1989;115:635.
Pseudocyst of the Auricle To the Editor.\p=m-\Thearticle by Cohen and Grossman1 on the "Pseudocyst of the Auricle" was very good. However, their conclusion that "corticosteroids do not play a role in the management of pseudocyst of the auricle" based on two cases,
one
by systemic
treatment
and another by intralesional injection, seems to be contrary to my experience with the latter. The technique used is to first cleanse the area with an antiseptic, then inject a local anesthetic with epinephrine into the skin overlying the swelling. A 22-gauge needle is then inserted into the pseudocyst and the fluid is aspirated. The first syringe is removed and a second syringe with the steroid is attached. The cavity is then flushed with triamcinolone acetonide suspension (10 mg/mL) (Kenalog 10) through the same needle that was left in place. The cavity is then aspirated once more to remove the excess steroid. Occasionally, pressure may have to be applied to the needle site after its withdrawal because of bleed¬ ing. This condition usually clears
promptly.
In the past 20 years, I have seen over half dozen of these patients and treated most of them with injection of steroid into the pseudocyst, with good results in all but one patient; that case having resulted in a thickened carti¬ a
lage. Another patient did require a second injection, with resolution. This technique met the following
outcome criteria of Cohen and Gross¬
"(1) resolution of the lesion with¬ and (2) structural and cosmetic preservation of the architec¬ man
out
recurrence
ture of the external ear."
WALTER K. W. YOUNG, MD Honolulu, Hawaii 1. Cohen PR, Grossman ME. Pseudocyst of the auricle: case report and world literature review. Arch Otolaryngol Head Neck Surg. 1990;116:1202\x=req-\ 1204.
Downloaded From: http://archotol.jamanetwork.com/ by a Michigan State University User on 06/16/2015
Comment—From November 1989 until May 1990, endonasal transseptal
procedures were performed on 14 pa¬ tients requiring surgery of the pitu¬ itary gland. On follow-up, none of the patients developed septal perforation. One patient developed vestibulitis postoperatively, which healed with lo¬ cal application of neosporin ointment, because of the trauma of applying the transsphenoidal speculum. Since no part of the bony or carti¬ laginous septum is removed and a flap is elevated only on one side of the nasal septum, septal perforation is avoided. The procedure is technically simple, reduces operating time, and provides good visualization of the pituitary gland. ANAND JOB, MS, DLO SIDDARTHA GOSH, MS THOMAS JOSEPH, MS Vellore, South India
1. Kern EB. Transnasal pituitary surgery. Arch Otolaryngol. 1981;107:183-190.
2. Koltai PJ, Goldstein JC, Parnes SM, Price JC. External rhinoplasty approach to transsphenoidal hypophysectomy. Arch Otolaryngol. 1985; 111:456-458. 3. Escajadillo JR, de Gortari E. Transseptal approach for the treatment of pituitary lesions. Arch Otolaryngol. 1983;109:326-328. 4. Peters GE, Birmingham AL, Zitsch RP. Columellar flap for transseptal transsphenoidal hy-
pophysectomy. Laryngoscope. 1988;98:897-899.
Facial Palsy Following Local Anesthetic Infiltration for Middle Ear
Surgery To the Editor.\p=m-\Facial palsy following tympanomastoid surgery has recently been reported1 due to local anesthetic
effect. This has been attributed to the possible dehiscent facial canal in the middle ear. We have also seen patients with facial palsy following local anesthetic infiltration during middle ear surgery. We were, however, quite convinced of the integrity of the facial canal during surgery. The possible explanation is the effect of local anesthetic on the facial nerve at the level of the stylomastoid foramen. During parotid gland surgery, the facial nerve is identified as following the posterior belly of the digastric muscle and the external ear cartilage pointer. Hence, it is postulated that whenever local anesthetic is infiltrated near the mastoid tip for postaural or at the inferior osseocartilaginous junction for permeatal surgery, the local anesthetic seeps out to affect the facial nerve. Interestingly, in two patients there was a history of Bell's palsy that had recovered spontaneously. Hence, as a policy, it may be advisable to use adrenalin infiltration alone to raise the flap and achieve hemostasis in patients where the surgery is done under gen¬ eral anesthesia. In patients where sur¬ gery is done under local anesthesia, it is useful to check for facial palsy after infiltration, before performing the sur¬ gery.
R. RAMAN, MS, DLO ANAND JOB, MS, DLO Vellore, South India
1. Madden G. Facial palsy following tympanomastoid surgery. Arch Otolaryngol Head Neck
Surg. 1989;115:635.
Pseudocyst of the Auricle To the Editor.\p=m-\Thearticle by Cohen and Grossman1 on the "Pseudocyst of the Auricle" was very good. However, their conclusion that "corticosteroids do not play a role in the management of pseudocyst of the auricle" based on two cases,
one
by systemic
treatment
and another by intralesional injection, seems to be contrary to my experience with the latter. The technique used is to first cleanse the area with an antiseptic, then inject a local anesthetic with epinephrine into the skin overlying the swelling. A 22-gauge needle is then inserted into the pseudocyst and the fluid is aspirated. The first syringe is removed and a second syringe with the steroid is attached. The cavity is then flushed with triamcinolone acetonide suspension (10 mg/mL) (Kenalog 10) through the same needle that was left in place. The cavity is then aspirated once more to remove the excess steroid. Occasionally, pressure may have to be applied to the needle site after its withdrawal because of bleed¬ ing. This condition usually clears
promptly.
In the past 20 years, I have seen over half dozen of these patients and treated most of them with injection of steroid into the pseudocyst, with good results in all but one patient; that case having resulted in a thickened carti¬ a
lage. Another patient did require a second injection, with resolution. This technique met the following
outcome criteria of Cohen and Gross¬
"(1) resolution of the lesion with¬ and (2) structural and cosmetic preservation of the architec¬ man
out
recurrence
ture of the external ear."
WALTER K. W. YOUNG, MD Honolulu, Hawaii 1. Cohen PR, Grossman ME. Pseudocyst of the auricle: case report and world literature review. Arch Otolaryngol Head Neck Surg. 1990;116:1202\x=req-\ 1204.
Downloaded From: http://archotol.jamanetwork.com/ by a Michigan State University User on 06/16/2015
