External nasal deformity

External nasal deformity

Surgeons have become increasingly aware of the impact of endoscopic endonasal surgery (EES) of the skull base on sinonasal-related quality of life. The prior retrospective investigation described a correlation between nasoseptal flap (NSF) reconstruction in EES with postoperative nasal deformities, such as nasal dorsum collapse.

Transsphenoidal surgery for sellar lesions may affect patency and function of the nasopharyngeal airways, smell and sinonasal quality of life.

In a prospective study, 68 patients scheduled for transsphenoidal operations (32 female, 36 male, age 17-72 years) underwent otorhinolaryngological evaluation of their nasal morphology, a standardized smell test (Sniffin’ Sticks test) and rhinomanometry to analyze nasal breathing function preoperatively, 3-5 days postoperatively (without rhinomanometry), after 3-4 months and after 9 months.

Immediately after surgery, a reduction in smell sensation was detected in almost all patients. Within 3 months, this impairment resolved in all cases except one. In 2 patients (3%) with preoperative anosmia, improvement of smell function to > 6 out of 12 sniffin’ sticks was observed. At the final visit, no patient was noted to have new anosmia. Within 3 months, the results of the rhinomanometry revealed that all patients except one regained their preoperative nasal breathing function. In 6 patients (8.8%) improvement in their nose breathing abilities compared to the preoperative state was found. Three patients (4.4%) underwent a LASER transection of mucosal synechiae. In one case with persistent nasal obstruction (1.5%), secondary septoplasty had to be performed. There was no case in which perforation of the nasal septumnasal tip deflection, or external nasal deformity was observed.

Microsurgical resection of pituitary tumors via the endonasal transsphenoidal approach poses an acceptable risk with regards to sinonasal complications. The incidence of secondary rhinosurgical interventions is low. Standardized comparative studies between endoscopic and microsurgical transsphenoidal operations should be undertaken 1).

The primary objective of Rowan et al. was to prospectively evaluate the incidence of, and contributing factors to, postoperative changes in nasal structure following EES. Secondary goals included assessing subjective changes in nasal appearance as well as objective nasal analysis.

Clinical demographics and detailed perioperative information was prospectively collected for patients undergoing transsellar/suprasellar EES for skull-base tumors. Preoperatively, 1-month and 6-month photographs were completed for objective photographic nasal analysis and blinded assessment by surgeons. Subjective patient feedback was also solicited.

Overall, 14.7% (5/34) of patients subjectively reported postoperative nasal deformities, whereas both blinded-surgeon and objective nasal measurements identified deformities in 12.9% (4/31) of patients. Patients with postoperative deformities were more likely to have skull-base reconstruction with an NSF (p = 0.01) and trended toward an increased incidence in patients with nonpituitary neoplasms (p = 0.07). There were no other associations between clinical or operative characteristics and external deformities. No patients planned to undergo corrective repair.

External nasal deformities following EES are more frequent than previously acknowledged. Postoperative deformities appear to be associated with NSF reconstruction and may be associated with surgery for nonpituitary neoplasms. Patients should be counseled on this potential outcome, and future studies should investigate how to minimize postoperative sequela 2).

see also: Saddle nose deformity



Hondronikos N, Alomari A, Schrader M, Knappe UJ. Rhinological Consequences of Microsurgical Endonasal-Transsphenoidal Surgery for Pituitary Tumors. Exp Clin Endocrinol Diabetes. 2020 May 7. doi: 10.1055/a-1155-6269. [Epub ahead of print] PubMed PMID: 32380562.

Rowan NR, Valappil B, Chen J, Wang EW, Gardner PA, Snyderman CH. Prospective characterization of postoperative nasal deformities in patients undergoing endoscopic endonasal skull-base surgery. Int Forum Allergy Rhinol. 2019 Oct 30. doi: 10.1002/alr.22466. [Epub ahead of print] PubMed PMID: 31665569.

External ventricular drainage complications

External ventricular drainage complications

Acutely increased intracranial pressure (ICP) is frequently managed by external ventricular drainage (EVD). This procedure is life-saving but marred by a high incidence of complications. It has recently been indicated that bolt-connected external ventricular drainage (BC-EVD) compared to the standard technique of tunnelled EVD (T-EVD) may result in less complications 1).

Intracranial hemorrhage




Ventricular catheter obstruction.

The purpose of this study was to investigate whether a surgeon’s experience affects the associated complication rate. Methods This retrospective study included all adult patients undergoing EVD insertion at a single centre between July 2013 and June 2015. Medical records were retrieved to obtain details on patient demographics, surgical indication, risk factors for infection and use of anticoagulants or antiplatelets. Surgeon experience, operative time, intraoperative antibiotic prophylaxis, need for revision surgery and EVD associated infection were examined. Information on catheter tip position and radiological evidence of intracranial haemorrhage was obtained from postoperative imaging. Results A total of 89 patients were included in the study. The overall infection, haemorrhage and revision rates were 4.8%, 7.8% and 13.0% respectively, with no significant difference among surgeons of different experience. The mean operating time for patients who developed an infection was 22 minutes while for those without an infection, it was 33 minutes (p=0.474). Anticoagulation/antiplatelet use did not appear to increase the rate of haemorrhage. The infection rate did not correlate with known risk factors (eg diabetes and steroids), operation start time (daytime vs out of hours) or duration of surgery although intraoperative (single dose) antibiotic prophylaxis seemed to reduce the infection rate. There was also a correlation between longer duration of catheterisation and increased risk of infection. Conclusions This is the first study demonstrating there is no significant difference in complication rates between surgeons of different experience. EVD insertion is a core neurosurgical skill and junior trainees should be trained to perform it 2).

Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software.

Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis.

Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites 3).



Jensen TS, Carlsen JG, Sørensen JC, Poulsen FR. Fewer complications with bolt-connected than tunneled external ventricular drainage. Acta Neurochir (Wien). 2016 Aug;158(8):1491-4. doi: 10.1007/s00701-016-2863-8. Epub 2016 Jun 21. PubMed PMID: 27324657.

Yuen J, Selbi W, Muquit S, Berei T. Complication rates of external ventricular drain insertion by surgeons of different experience. Ann R Coll Surg Engl. 2018 Mar;100(3):221-225. doi: 10.1308/rcsann.2017.0221. Epub 2018 Jan 24. PubMed PMID: 29364007; PubMed Central PMCID: PMC5930101.

Dey M, Stadnik A, Riad F, Zhang L, McBee N, Kase C, Carhuapoma JR, Ram M, Lane K, Ostapkovich N, Aldrich F, Aldrich C, Jallo J, Butcher K, Snider R, Hanley D, Ziai W, Awad IA; CLEAR III Trial Investigators. Bleeding and Infection With External Ventricular Drainage: A Systematic Review in Comparison With Adjudicated Adverse Events in the Ongoing Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-III IHV) Trial. Neurosurgery. 2015 Mar;76(3):291-301. doi: 10.1227/NEU.0000000000000624. PubMed PMID: 25635887; PubMed Central PMCID: PMC4333009.


Convocatoria para la subvención de proyectos de investigación transnacionales sobre External Insults to the Nervous System, en el marco de la red europea de investigación ERA-NET Cofund NEURON.

Los proyectos deberán cubrir, al menos, una de las siguientes áreas:

  • Fundamental research investigating consequences of external insults to the central nervous system on a biological and functional level.
  • Clinical research, including the exploitation of novel and/or existing clinical data sets, to de-velop new strategies for diagnosis, therapy, and technology-driven neurorehabilitation (e.g. brain computer interfaces, EEG and neuroimaging approaches) for diseases after external insults to the central nervous system.

Los solicitantes pueden pertenecer al sector académico (universidades, institutos de investigación…), clínico (hospitales, centros de atención primaria, CIBER/CIBERNED…) o empresarial. Para la participación española dependiendo del tipo de entidad deberá realizarse la solicitud a través del: Instituto de Salud Carlos III o Ministerio de Economía y Competitividad.
Dotación económica: Depende del rol en el consorcio y de la entidad mediante la cual se realice la solicitud. Entre 100.000 y 200.000€
Presentación de solicitudes: Hasta el 14 de marzo de 2016 a las 14:00h
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