Prevention of nostril laceration in endonasal drilling:
The use of protective ear speculum.
Key Points:
- The use of drills in endoscopic rhinosurgery allows for precise, safe
and rapid removal of solid bone in standard procedures such as
dacryo-cysto-rhinostomia and has become indispensable in complicated
surgical interventions such as median maxillectomy
- Conventional otologic drills are often used as they are readily
available, economical and very robust in use
- Injuries caused by the rotating shaft of the burr are rare yet it can
represent a serious complication following drilling procedures in
extended endonasal surgery
- The use of low-cost, reusable otology speculum eliminated this
complication of nasal entrance lacerations throughout our institution
to this date
- As a simple safety measurement, we can recommend the application of
ear speculum as a reliable protection against drill related nasal
entrance laceration
Introduction
Injuries caused by the rotating shaft of the burr are fortunately
uncommon yet it can represent a serious complication following drilling
procedures in extended endonasal surgeries such as
dacryocystorhinostomia (DCR) and median maxillectomy (MM)1,2. In the worst case, these ulcers of the nasal
vestibular skin not only cause transient post-operative pain but also
anxiety and psychological problems3, nasal obstruction
due stenosis and cosmetic problems by scar formation and retraction4,5,6.
When endonasal drills with guarded shafts are not available, most
surgeons resort to the use of conventional drills with the potential
aforementioned complications. These are readily available in most
institutions due to economic reasons.
In order to prevent potential damage to the nostrils whilst using
conventional otology drills (Fig 1A and Fig 1B), we hereby present a
simple, noninvasive technique which in our institution has helped to
prevent any such complications.
Material and Methods
We successfully use conventional otology drills (BASCH ref. 1700074-001,
PMAM 1122 angled handpiece 70 mm ref. 1600207-001, Bien-Air Surgery SA,
Switzerland in DCR and MM on a regular basis ranging from teaching
operations in our residency program, to advanced revision surgeries by
our senior surgeons.
In order to protect the nasal entrance from laceration by the free
rotating drill shaft we position a otology speculum in the nasal
entrance (Fig 2A). The speculum is held in place by the scrub nurse
during the critical phase of bone drilling. The speculum size is chosen
to tightly fit the nasal vestibule providing slight dilation and free
exposure of the piriform aperture. Using speculum sizes from 8 to 10mm,
adequate endoscopic visualization can regularly be achieved (Fig 2B). In
addition, we apply nasal ointment (Bepanthen™, Bayer, Germany) to
lubricate the inner and outer surface of the nasal speculum (Fig 2C).
Essentially, the surgeon must take precautions to minimize contact to
the metallic speculum with the rotation burr shaft.
Conclusion
The use of powered instruments has revolutionized the management of
simple and complicated conditions in paranasal sinuses, skull base und
orbital pathologies7,8. The use of drills allow
precise, safe and rapid removal of solid bone in standard procedures
such as DCR and has become indispensable in complicated surgical
interventions such as MM.
Drills are either available as specifically designed endonasal drills or
as conventional high-speed otology drills. Special drills for designated
endonasal surgical procedures are equipped with special protective
shields used to protect the nasal soft tissue structures. However, these
drills are delicate and may break if the extended drilling of solid bone
is undertaken.
Conventional drills have the disadvantage of a long rotating shaft but
are extremely robust and readily available. Associated injuries by
endonasal drilling procedures, to the best of our knowledge is not
reported extensively in literature, whereas, there is sufficient
evidence of nostril laceration due to nasogastric
intubation9,10,11 or nasogastric feeding
tubes12.
In our institution, two patients had long term scaring due to nostril
laceration following the application of powered tools for DCR und MM
procedures. The discussion of these complications came to the rational
to develop and use protective measures on a regular basis. Following the
introduction of the ear speculum protection, we successfully treated our
DCR procedures (n=27) and MM procedures (n=6) without any further soft
tissue erosions.
The use of low-cost, reusable otology speculum in endonasal drill
application eliminated the complication of nasal entrance lacerations
throughout our institution to this date. Additionally, the use of the
device did not prolong the duration of the operation. Moreover, we have
not observed delayed wound healing or foreign body reactions because of
potential metal dust accumulation by erosion of the otoscope speculum by
contact to the rotating burr shaft.
In conclusion, we can recommend the application of an otology ear
speculum as reliable protection against drill related nasal entrance
laceration for both, simple DCR procedures as well as extended revision
surgery for beginners and experienced surgeons.
Legends to Figures
Figure 1
A) Example of nostril laceration by burr shaft followed by median
maxillectomy during the treatment of the left sided extended recurrent
inverted papilloma.
B) Example of nasal superficial nostril laceration accompanied by the
left sided dacryocystorhinostomia.
All photos are employed with the consent of the involved patients.
Figure 2
A) Skull model with protective ear speculum for a typical, left-sided
endoscopic dacryocystorhinostomia (DCR) procedure held in position by
the surgeon.
B) Intraoperative situation during left-sided DCR; scrub nurse
stabilizing speculum position during drill process.
C) Endoscopic visualization of burr shaft and bur tip within lubricated
ear speculum during reduction of the lacrimal crests in endoscopic DCR
procedure.
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