Endoscopic vidian neurectomy assisted by power instrumentation

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Journal of the Chinese Medical Association 76 (2013) 517e520
www.jcma-online.com
Brief Communication
Endoscopic vidian neurectomy assisted by power instrumentation and
coblation
Chao-Yuan Hsu a, Ping-Hung Shen a,b,*, Erik Kent Weitzel c
a
Department of Otolaryngology, Kuang-Tien General Hospital, Taichung, Taiwan, ROC
b
Department of Biotechnology, Hung-Kuang University, Taichung, Taiwan, ROC
c
Department of Otolaryngology, Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, TX, USA
Received August 15, 2012; accepted January 16, 2013
Abstract
Vidian neurectomy has been used to manage intractable vasomotor rhinitis for decades. After the introduction of endoscopic sinus surgery in
the 1980s, transnasal endoscopic vidian neurectomy (EVN) was subsequently reported. The most common problem in performing EVN was
excessive bleeding from the pterygopalatine fossa. The complexity and vascularity of the pterygopalatine fossa can cause bloody surgical fields
and prevent complete neurectomy. In response to this surgical problem, a procedure was developed to use powered instrumentation and coblation
during EVN. There were eight cases of EVNs (16 neurectomies) assisted by power instrumentation and coblation from December 2011 to May
2012. The average blood loss of these cases was 37.5 mL (range, 25e50 mL). The average surgical time of each neurectomy was 27.4 minutes
(range, 20e35 minutes). No complications occurred in any of the eight cases. Very limited bleeding and less thermal damage were noted while
achieving a complete neurectomy.
Copyright Ó 2013 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
Keywords: endoscopic surgical procedure; pterygopalatine fossa; vasomotor rhinitis
1. Introduction
The vidian nerve is composed of the union of postsynaptic
parasympathetic fibers and presynaptic sympathetic fibers.
The theory behind vidian neurectomy is that inhibits excessive
activity of the parasympathetic system by interrupting
cholinergic innervation to the nasal mucosa. As endoscopic
instrumentation and techniques have advanced, vidian neurectomy can be performed more safely and easily via either a
pterygopalatine fossa (PPF)1 or transsphenoidal approach,2
resulting in fewer complications. However, since the PPF
benefits from extensive hemocirculation, dissection is apt to be
obscured by poor surgical fields. Therefore we modified the
* Corresponding author. Dr. Ping-Hung Shen, Department of Otolaryngology, Kuang-Tien General Hospital, 117, Shatian Road, Shalu, Taichung
433, Taiwan, ROC.
E-mail address: [email protected] (P.-H. Shen).
accepted current technique of EVN and added power instrumentation and coblation to reduce PPF bleeding.
2. Methods
EVN was provided as a treatment option for patients
suffering intractable rhinitis. Possible surgical complications,
including permanent dry eyes, were explained to patients prior
to surgery. EVN was performed under general anesthesia, with
patients lying in reverse Trendelenburg position. Preoperative
packing included Cottonoid swabs soaked in a 3-mL solution
consisting of 1 mL of 10% cocaine, 1 mL of 1:1000 adrenaline,
and 1 mL of saline 10 minutes prior to surgery. A continuous
esmolol infusion was used during the surgery to improve surgical fields.3 The esmolol (100 mg/10 mL) infusion was started
2 minutes prior to initiation of surgery with 0.5 mg/kg for a
loading dose and a maintenance infusion of 50 mg/kg/minute. A
nominal minimal alveolar concentration of inhaled anesthetic
was titrated to achieve a mean arterial blood pressure of
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C.-Y. Hsu et al. / Journal of the Chinese Medical Association 76 (2013) 517e520
50e75 mmHg. The lateral nasal wall over the region of the
posterior fontanelle was infiltrated with 2% xylocaine with
1:80,000 adrenaline. A U-shaped mucosal incision was made
with the base centered over the sphenopalatine foramen. A
lateral wall periosteal mucosal flap was elevated by suction
freer dissector to expose the ethmoid process of the palatine
bone. The sphenopalatine artery was identified and cauterized
by suction bipolar. The mucosal flap was then elevated toward
the sphenoid until the posterior nasal artery was identified and
then cauterized. The flap was then advanced posteriorly and
inferiorly to the level of choana, to expose the perpendicular
plate and sphenoid process of the palatine bone (Fig. 1), which
were then drilled to allow better exposure of the PPF (Figs. 2
and 3). A coblator was then used to defat the fully exposed
PPF, allowing the vidian nerve to be transected without
bleeding (Fig. 2). The navigation system was also utilized to
confirm the precise location of vidian nerve or canal (Fig. 4).
The flap was then repositioned and no packing was required.
Fig. 2. Pterygopalatine fossa is widely exposed and the coblator is ready to cut
the nerve. Sph ¼ sphenoid sinus; SPA ¼ sphenopalatine artery (cauterized);
PPF ¼ pterygopalatine fossa; Co ¼ Coblator; PL ¼ palatine bone.
3. Results
There were eight cases of EVNs (16 neurectomies) assisted
by power instrumentation and coblation from December 2011
to May 2012. Another 24 cases underwent EVNs using traditional electrocauterization from May 2010 to November 2011
as a control group. The average blood loss of these eight cases
was 37.5 mL (range, 25e50 mL), and of the control group was
91.7 mL (range, 50e150 mL). The average operation time of
each neurectomy was 27.4 minutes (range, 20e35 minutes),
and of the control group was 44.4 minutes (range, 30e60 minutes). No complications occurred in any of the eight cases.
4. Discussion
cluster headaches, and corneal ulceration.4 The vidian nerve
exits the lateral part of the anterior end of the carotid canal,
passes along the upper part of the anterolateral edge of the
foramen lacerum, courses through the vidian canal, and ends
in the pterygopalatine ganglion at the posterior part of the
PPF.4e6 It passes forward through the pterygoid canal with its
corresponding artery (artery of the pterygoid canal) and is
joined by a small ascending sphenoidal branch from the otic
ganglion. It then enters the PPF and joins the posterior angle of
the pterygopalatine ganglion.
The vidian neurectomy procedure was introduced by
Golding-Wood to manage intractable vasomotor rhinitis as
well as allergic rhinitis and nasal polyposis in the early 1960s.7
In the past, various techniques have been described as a means
It is believed that the vidian nerve plays a role in rhinitis,
epiphora, crocodile tears, Sluder’s neuralgia, cranial and
Fig. 1. The vidian nerve has been cut completely by coblator. Sph ¼ sphenoid
sinus; S ¼ septum; PPP ¼ perpendicular plate of palatine bone; black circle ¼
vidian nerve stump in vidian canal.
Fig. 3. Hand drawing of anatomy of PPF and vidian nerve (canal). VC ¼
vidian canal; Sph ¼ sphenoid sinus; VN ¼ vidian nerve; PPG ¼ pterygopalatine ganglion; V2 ¼ maxillary branch of trigeminal nerve; GPN ¼
greater palatine nerve; MA ¼ maxillary artery; DPA ¼ descending palatine
artery; SPA ¼ sphenopalatine artery; PNA ¼ posterior nasal artery; MS ¼
maxillary sinus.
C.-Y. Hsu et al. / Journal of the Chinese Medical Association 76 (2013) 517e520
519
Fig. 4. Image-guided system (Navigation) showed the exact location of the vidian nerve.
to approach the vidian nerve prior to the development of
endoscopic sinus surgery.7e10 However, these approaches
carried the risk of significant postoperative morbidity such as
loss of vision,11 oronasal or oroantral fistula,9 and catastrophic
hemorrhage. Most recently, endoscopic sinus surgery and
computed tomography have led to a better understanding of
the anatomy of the vidan nerve.1,12e14 Robinson and Wormald1 described an endoscopic approach for vidian neurectomy utilizing a series of predefined anatomical landmarks
that allow reliable identification of the nerve. Lee et al2 also
reported a novel way to perform vidian neurectomy via an
endoscopic intrasphenoidal or transsphenoidal approach.
However, this approach is not consistently feasible due to the
variable course of the vidian canal through the sphenoid sinus.
We performed vidian neurectomy via the PPF approach
assisted by power instrumentation, in order to get better
exposure of the PPF, after which the true neurectomy could be
performed with greater confidence. The posterior pharyngeal
nerve is very close to the vidian canal and the vidian neurectomy was often done incorrectly in conjunction with a
pharyngeal neurectomy prior to the clear identification of the
vidian canal.15 A blind cauterization of this area will often just
result in pharyngeal neurectomy. Coblation then used in the
management of bleeding issues from PPF dissection. Within
the very tight confines of the PPF, surgical bleeding tends to
readily obscure the endoscopic view, but the coblation overcame this problem due to its unique combination of
modalities.
Coblation technology is The U.S. Food and Drug Administration (FDA) approved for use in sinus surgery (ArthroCare,
Austin, TX, USA). It was first introduced for adenotonsillectomy and turbinate reduction surgery and has been rapidly
evolving in indications. In rhinology, the coblator has since been
used for sinonasal polyposis16 and more recently nasopharyngeal angiofibromas.17 One of the major advantages of the
coblator device is the ability of the wand to be used to retract the
lesion while simultaneously dissecting, coagulating, irrigating,
and suctioning. There is only one other case series that recently
reported the use of radiofrequency coblation endoscopic resection of intranasal and sinus tumors in 10 patients.18 One of the
main advantages for its use in the nose is the coblator’s unique
balance between hemostasis and limited thermal damage.
Whereas electrocautery operates at temperatures between 400 C
and 600 C, the coblator operates at between 40 C and 70 C.19
EVNs will be completed in a smooth manner using coblation,
without the disadvantages of repeated electrocauterization.
Although coblator has its unique advantages, some disadvantages still present. Patients have to pay the extra cost
arising from use of the coblator, and the tip of the present
model is a little large for neurectomy procedure; however, a
smaller neurectomy tip will be available soon.
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