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Physics of Time in Philosophy of Physical Science. Action at a Distance in Philosophy of Physical Science.
Entanglement in Philosophy of Physical Science. Quantum Theories in Philosophy of Physical Science. The interpretations of measurements in Bohm's and Everett's quantum theories are compared.
Since both theories are based on the assumption of a universally valid Schrödinger equation, they face the common problem of how to explain that arrow of time, which in conventional quantum theory is represented by the collapse of the wave function.
Its solution requires, in a statistical sense, a very improbable initial condition for thetotal wave function of the universe.
The historical importance of Bohm's quantum theory is pointed Compendium of Quantum Physics, ed.
Space and Time in Philosophy of Physical Science. Science, Logic, and Mathematics. Quantum Information in Philosophy of Physical Science.
It is argued by means of analogy with certain irreversible processes that a symmetry-violating vacuum need not necessarily be explained by a special cosmic initial condition.
Symmetry in Physics in Philosophy of Physical Science. Direct download 2 more. Ancient Greek and Roman Philosophy.
Michel Foucault in Continental Philosophy. Poststructuralism in Continental Philosophy. Feminist Ethics in Normative Ethics.
Time travel is one of mankind's most ancient dreams. It inspires our imagination and provides material for bizarre stories.
Wells' novel, "The Time Machine" , marks the beginning of a long history of science fiction literature devoted to the subject of time travel.
The complexity and the contradictory nature this subject makes it difficult to be more precise about "time". But it is also a physical parameter.
The "problem of time travel", a subject that Wells wrote about just ten years before as mere fiction, was now a discussion worthy of physics.
Einstein's Special Theory of Relativity , by predicting the effects of time dilation, allowed for "travels into the future" and Einstein's Theory of Gravity used closed time-like lines for solutions to calculations about time travel for example, the Gödel Universe and the Anti-de Sitter Universe.
However, a trip to a time warp would immediately involve a whole set of paradoxes for example, the grandfather paradox and the information paradox and semantic inconsistencies.
Some of the discussions that will be presented are the tachyon hypothesis, Tipler's rotating cylinder, the Gödel Universe, the Anti-de Sitter Universe and so-called "wormholes".
At the same time, approaches will be presented for example, Eternalism, the Many-Worlds Interpretation and the Consistent Histories Approach that will provide attempts to find a solution for paradoxes regarding time travel to the past.
Yet, in nature, there still seems to be a fundamental prohibition against time travel to the past. Physicist Dieter Zeh, whose position is more closely presented in the final chapter of this work, supports the view that science fiction literature on the subject of "time travel" is overwhelmingly based on simple conceptual errors.
The processes used in this literature, which are based on the General Theory of Relativity, at best, are just as "theoretically possible" as a gas which gathers itself into the corner of a container.
The answer is always, "In principle yes, but…" But the fascination about time travel will continue to provide material for "fiction". Zeit tritt uns entgegen als Form der Wahrnehmung in ihrer zutiefst subjektiven Seite, als biologischer Rhythmus, als soziales Phänomen im Sinne einer kollektiven Zeitbestimmung, aber eben auch als physikalischer Parameter.
The calculated risk of side effects was estimated to be 0. Targets of an injection into the mucous membrane are the area of the uncinate process, the attachment of the middle turbinate and the supposed sphenopalatine foramen [ ], [ ].
Subjectively, after such an injection epinephrine 1: However, this advantage could not be proven clearly, compared to a sodium-chlorine injection or to the application of additional topical decongestion [ ], [ ], [ ].
Nevertheless, a positive effect is said to exist objectively for shorter surgical procedures [ ].
The injection of adrenaline into the nasal mucous membranes quickly leads to a noticeable increase in plasma concentration of adrenaline, an effect lasting for a few minutes.
In other cases, a temporary drop in blood pressure as well as transient arrhythmias have been observed. In several cases following bilateral injection, a distinct cardiovascular response was noticed 1: Relevant side effects, however, are extremely rare [ ], [ ], [ ], [ ], [ ].
For the use of injections, the risk of confusing the diluted solution of adrenaline for example, 1: Regarding the discussion of optimizing anesthesia protocols, often a controlled hypotension is recommended.
The aim is a mean arterial blood pressure of 50—60 mmHg or 80 mmHg for elderly people, and, in general, a reduction of the systolic blood pressure to less than mmHg [ 98 ], [ ], [ ].
Severe complications including organ ischemia have been observed in 0. However, there should be no risk for healthy patients ASA I in general, if the mentioned rules are respected [ ], [ ], [ ].
The mean arterial blood pressure does not correlate with blood loss. This can be attributed to — amongst other things — the pharmaceuticals used to induce hypotension, as they may eventually exert unfavorable effects on various circulatory parameters of the patient: A relationship between heart frequency and blood loss has been confirmed.
As a consequence, the recommendation is to inhibit each reflex tachycardia and to aim for a pulse rate of 60 per minute.
The administration of beta inhibitors metoprolol , only led to a short positive effect regarding bleeding. It has to be kept in mind that the applied pharmaceuticals can principally, and eventually in a time-sensitive manner, disturb the platelet function.
In accordance with this information, visibility in the surgical area tends to drop as the operation time gets extended [ ], [ ], [ ], [ ], [ ], [ ], [ ].
The analysis of influencing factors of anesthesia techniques upon intraoperative bleeding led to contradicting results: According to other sources, this is mostly a subjective effect [ ].
Propofol reduces cardiac output and might contribute to a better objective local anemia eventually via an alpha-adrenergic mediated vasoconstriction.
However, if the operation lasts longer than 45 minutes, adverse effects on the platelet function become apparent. If circulatory parameters are kept mostly constant in otherwise healthy patients, then there is no longer any significant difference between propofol TIVA and sevoflurane in the intraoperative anemia.
There is no unanimous view whether a beta sympatholytic drug esmolol is an advantage [ ], [ ], [ ]. The change in anesthesia regarding the balance between hypnosis and analgesia resulted in no substantial benefit [ ].
In various regimes, tranexamic acid is applied: Thromboembolic complications could not be observed in the comparatively small cohort study [ ].
Irrigating the surgical field with tranexamic acid also had positive effects. In contrast, the application of epsilon aminocaproic acid had no effect [ ].
Rinsing the surgical field using 40 degree hot water is also described as helpful [ ]. Sinus surgery generally ends with the insertion of nasal packing.
Many surgeons think that nasal packing is not mandatory in isolated sinus surgery and after a careful intraoperative hemostasis [ ], [ ].
When necessary, different kinds of nasal packing is used. Ointment strips are no longer indicated in sinus surgery. The effectiveness of absorbable material for postoperative bleeding prophylaxis remains debatable [ ], [ ].
The administration of antibiotics in patients with nasal packing depends on duration and underlying disease [ ]. In rhino-neurosurgery , the otorhinolaryngologist is confronted with less frequent forms of bleeding and with specific therapeutic algorithms.
As a prophylaxis, e. In case another arterial bleeding occurs, at first one will try to identify the source of the bleeding tissue substrate by means of optimizing the position of the suction.
Afterwards, selected coagulation is performed. In case these measures fail, nasal packing is applied, protecting the surrounding structures [ ].
In general, localized injuries of the cavernous sinus can be reliably controlled e. Alternatively, other hemostyptica e.
Bone density increases at the ethmoid roof from anterior to posterior and is also distinctly higher in the area of the posterior wall of the frontal sinus compared to the anterior part of the roof of the ethmoid.
Women have a lower bone density than men [ ]. As a consequence, the force needed to injure the dorsal or the anterior-lateral ethmoid roof is significantly greater than the force needed to perforate the anterior-medial rhinobasis or rather to remove ethmoidal cells [ ].
The weakest part of the anterior skullbase is located in the area of the lateral lamella of the olfactory fossa [ ]. Here, the bone is often only 0.
Deep position of the cribriform plate, i. Larger angle between the skull base and the horizontal line through the sagittal plane. The incidence of variants a.
In routine surgery cerebrospinal fluid fistulas CSF fistulas are mostly the result of misjudging the anatomy, lack of surgical experience or even distorted anatomy e.
The most common site of erosion is where the middle turbinate passes into the skull base near the ant. In addition the roof of the ethmoid, in case of a relatively high located maxillary sinus, is a predisposed site [ ].
According to other authors especially injuries in the central or anterior area of the ethmoidal roof, 0. The cribriform plate is rarely damaged primarily [ 68 ], [ ].
The rate of unexpected dura exposure is reported with a percentage of 0. The number of minimal, temporary and occult leakage of cerebrospinal fluid ceasing spontaneously without clinical relevance, is significantly higher [ ].
According to literature the rate of manifest, clinical relevant CSF fistulas, is around 0. There are even reports of CSF leaks which were diagnosed postoperatively after the patient had developed meningitis [ ].
When suspecting a fistula postoperatively a standard rhinological examination is indicated. Every patient that complains of severe headaches needs to be examined thoroughly [ 76 ].
Primarily nasal endoscopy is performed. Obvious nasal secretion is tested for beta 2 transferrin or beta-trace protein prostaglandin H2 Delta isomerase which is used as marker to diagnose liquorrhea [ ], [ ].
High resolution computed tomography using thin sections in axial sphenoid sinus, posterior wall of the frontal sinus and coronal plane rhinobasis may detect bony defects and possibly air bubbles trapped intracranially or even accumulated fluid [ ], [ ], [ ].
Intrathecal fluorescein may be used both to confirm the presence and to attempt to localize CSF leaks and consequently enables surgical management [ ], [ ].
Further procedures such as radionuclide cisternograms, CT cisternograms and MRI as MR cisternography may be used in exceptional cases [ ], [ ], [ ], [ ], [ ], [ ].
If a meningocele or a meningoencephalocele is suspected an MRI is indicated [ ], [ ], [ ]. Regarding CT scans the quality of the image is crucial, reconstructed coronal planes frequently lead to misinterpretations [ ], [ ].
Recently beta trace protein has been preferably used as marker — techniques for isolating this marker are less demanding, hence take less time and are less expensive.
Moreover the detection of beta trace protein is more sensitive and specific, a serum control is not needed [ ], [ ], [ ], [ ], [ ], [ ].
It is essential to define valid reference values [ ]. In patients with reduced glomerular filtration false-positive or patients with meningitis false-negative this method cannot be reliably used.
PVA — sponge nasal packing is not appropriate for beta2 transferrin testing, due to the protein absorbing material of the nasal packing [ ].
In individual cases subclinical fistulas were detected with fluorescein, neither with beta trace nor with beta 2 transferrin [ ].
False-negative samples may occur, among others, due to a temporary blockage of the fistula through blood clot, edematous mucosa, brain prolapsed or functional insufficient scars of mucosa.
In case of suspecting a false-negative result after injection, nasal packing is to remain for a certain amount of time, which later is checked for fluorescein [ ].
Intrathecal fluorescein is not approved i. Several authors advise a fundus examination performed by an ophthalmologist, if necessary a neurological consultation before the injection [ ].
There are various regimes to administer fluorescein. The current recommended dilution is 0. Alternatively an increased amount or concentration of fluorescein [ ], [ ], [ ], weight adapted dose [ ], [ ], [ ] or additional intravenous fluorescein injection to dye recent produced cerebrospinal fluid was introduced.
In general, fluorescein is neurotoxic [ ]. Hence a couple of authors suggest injecting 50 mg diphenhydramine and 10 mg dexamethasone intravenously as preliminary [ ], [ ], [ ].
The density of fluorescein is generally higher as in CSF, which is why patients are instructed to lie with the head tilted low for 2 hours after injection.
Bed rest is prescribed for 12 hours, the patient is supervised for 24 hours. The yellowish color of the fluorescein is mostly visible with an endoscope, even without light adaptations or filter [ ].
In some cases blue light — nm and blue-filter — nm were installed [ ]. Up to 20 hours after injection the dye remains visible in the CSF [ ].
Side effects of injecting fluorescein depend on the administered amount, and also occur when more than one substance is injected simultaneously [ ].
In general the administration of fluorescein is prohibited in patients with intolerance towards fluorescein as well as in patients with contraindications for lumbar puncture: Seizure disorders which are effectively treated and are without EEG abnormalities do not count as contraindication [ ].
In literature an alternative method of topical application of fluorescein without lumbar puncture is introduced. Iatrogenic cerebrospinal fluid fistulas are usually below 3mm in size, in some cases 2—20 mm [ ], [ ], [ ].
Once a small cerebrospinal fluid leak is confirmed, references recommend conservative treatment to begin with [ ], [ ], [ ], [ ].
In a few cases lumbar drainage was solely carried out [ ]. However, in case of a persisting leak encountered during routine sinus surgeries or e. Closure of cerebrospinal fluid leaks via endoscopic endonasal approach belongs to the standard repertoire of sinus surgery.
There are various approved techniques for repairing defects [ ], [ ], [ ]. The choice of approach does not necessarily influence whether the rhinorrhea ceases when applying the usual diligence [ ].
In general, free and pedicle flaps as well as autogenous, allogenous or xenogenous grafts may be used. Autogenous transplants include mucosa, bone, cartilage, fat, fascia or mucoperichondrium.
For matter of stabilization gelatin, cellulose or fibrin glue may be prepared in different ways [ ]. The initial exposition of the defect is important.
The correct orientation and position of the free mucosa graft has to be carefully taken into account — otherwise an intracranial mucocele may develop [ ].
Generally, larger defects above 5 mm in diameter are closed in several layers, partly with cartilage or bone [ 12 ], [ ], [ ], [ ], [ ], [ ].
Fibrin glue does not have to be applied in every case [ ], [ ]. Regarding certain allogenous material acellular dermis a prolonged healing and crusting phase has to be expected [ ].
Usually routine sinus surgery may be continued after an isolated CSF fistula has occurred [ ]. The further anesthetic management needs to consider the circumstance, hence avoid an increase in CSF pressure or pressure of the upper airways no positive pressure ventilation, deep extubation technique, avoiding coughing and straining.
Most surgeons use nasal packing for 3—7 days [ ], [ ]. In individual cases nasal packing was removed and the patient was discharged on the first day after surgery [ ], [ ], [ ].
As a rule patients are restricted to 1—5 days bed rest [ 76 ], [ ], [ ], and they are released after 3—7 days [ ], [ ], [ ].
Postoperatively the patient has to be closely monitored. Especially the state of consciousness needs to be mediated closely — in case of loss of consciousness a neurosurgical consult has to take place immediately.
The patient is supposed to elevate the upper part of his bed 40 to 70 degree ; is advised not to lift heavy objects and not to blow his nose for some time.
The same applies to coughing, pressing as well as sneezing; possibly antiallergics, laxatives and antacids are prescribed. When sneezing cannot be prevented, the patient is advised to sneeze with open mouth [ ], [ ], [ ], [ ], [ ], [ ].
After the complication-prone procedure, a postoperative CT scan [ 76 ], [ ] is appropriate. If an instrumental penetration into the intracranial space as part of the genesis of the CSF fistula could not be clearly excluded, a CT scan is performed emergently and mandatory.
An MRI 6 months postoperative is not generally recommended [ ]. Other authors suggest a fluorescein test 6 weeks after successful defect closure [ ].
This also applies for antibiotic prophylaxis regarding active CSF fistulas in traumatology — in case of intracranial air or concurrent intracranial hematoma, antibiotics are strongly recommended [ ], [ ], [ ].
Even if the data in literature is not consistent, administration of an antibiotic as a prophylaxis of an ascending infection is approved by the majority [ 12 ], [ ], [ ], [ ], [ ], [ ].
Usually, a cephalosporin is preferred, at least initially in parenteral administration [ 12 ], [ ]. The duration depends on how long nasal packing remains, generally approx.
Irrespective of several positive recommendations [ ], [ ] literature generally points out that a lumbar drainage is not indicated for relevant fistulas [ 12 ], [ 76 ], [ ], [ ].
The rate of relapses after the treatment of iatrogenic fistulas with and without drainage does not differ [ ]. In particular, drainage is useful in case of increased intracerebral pressure, in the broadest sense also following the closure of large defects or following revisions.
Regarding literature the same holds true in the event of clearly increased body weight BMI [ ], [ ], [ ], [ ], [ ], [ ].
Recurrence of fistulas is frequently observed in patients with an increased CSF pressure [ ]. Certain guidelines should be followed see above , even flights etc.
Active CSF fistulas may result in meningitis. In a few cases 0. If an iatrogenic fistula is treated immediately and adequately without any of the above mentioned complications, medico-legal consequences occur merely as an exception [ 76 ].
In rhino-neurosurgery, the often extensively reconstructed dura represents a weak spot in the therapeutic concept.
This fact led, amongst others, to the introduction of the vascular pedicle intranasal mucoperiosteal flaps and to a consistently multilayered defect closure.
A number of special factors determine the particular risk associated with a large dura deficiency: In the majority of cases, especially for postoperative persisting heavy flow of cerebrospinal fluid, revision surgery is advisable [ ].
Regarding inevitably larger defects after extended skull base surgery, local vascular pedicled flaps nasoseptal flaps [ ], flaps from the middle or inferior turbinate [ ], [ ] or, in special cases, also local flaps pericranial flap [ ], temporoparietal flap [ ], palatal flap [ ] are available [ ].
These flaps are superior to free grafts. The dorsal pedicled nasoseptal mucosal flap is most frequently used — postoperatively, however, due to the loss of large area of septal mucosa, un-negligible, long-term modification of the nasal physiology has to be taken into consideration [ ].
Mucoceles rarely develop in the sphenoid sinus after reconstruction with the nasoseptal flaps, even if the original mucous membrane has not been cleared out extensively before [ ], [ ].
The following factors are associated with an increased rate of unsuccessful reconstructions: The lowest rate of postoperative cerebrospinal fluid fistulas was observed in individual case series with a transcribriform approach, whilst the highest rate was observed in a transplanum-transtuberculum approach.
This is caused by a relatively high flow rate of cerebrospinal fluid due to open suprasellar or chiasmatic cisterns.
Additionally the dense anatomy prevents the inserted grafts from adapting naturally [ ]. Other authors report a less favorable prognosis for large-area defects of the anterior base of the skull [ ].
Opinions differ as to whether, even after rhino-neurosurgical operations, there is any indication to provide a lumbar drain after reconstruction of the skull base.
In most cases this is decided individually, supporting a drainage in cases of large defects, heavy cerebrospinal fluid flow or increased cerebrospinal fluid pressure, history of radiotherapy or already preoperatively existing liquorrhea [ ], [ ].
An early drainage can help to relieve pressure variations within the area of transplantation during extubation [ ]. In a medico-legal respect , when cerebrospinal fluid fistulas are found in close proximity to radiologically normative ethmoidal cells, discussions often arise on whether an extended surgery is necessary, i.
As a matter of principle, in each individual case, the extent of the surgery has to be justified from a medical perspective and carefully documented and discussed with the patient.
In case the whole range of manipulations is used up within the boundaries of what had been discussed with the patient before, it is recommended to include an explanatory statement in the operative report.
The findings in preoperative imaging and preoperative endoscopic examination can be different [ ], [ ]. Hence, preoperative imaging does not determine the scope of the surgical procedure restrictively.
The surgeon should in fact remove diseased tissue according to intraoperative findings. In general, localized cerebrospinal fluid fistulas cannot always be avoided, even when the procedure is carried out very carefully [ ].
Functional endoscopic sinus surgery is always tailored to the anatomy of the individual and is not strictly standardized. This issue makes it difficult to analyze surgical results as well as define deficiencies in surgical technique — e.
Postoperatively the individualized anatomy is distorted in the process of healing — intranasal wounds generally undergo secondary healing.
The respective prospects of healing are less favorable for certain patient groups e. After complete ethmoidectomy, the ethmoid shaft scars and shrinks, which is proven radiologically.
In experiments with young animals, midfacial growth had changed postoperatively see 5. For the purpose of prevention, placing mucosal grafts onto the exposed bone in order to avoid a reactive ostitis with secondary thickening of the bone, is recommended [ ], [ ], [ ], [ ].
In principle, the size of an enlarged primary maxillary ostium is not decisive for the condition of the maxillary sinus mucosa; at a diameter of more than 2 mm these ostia are generally function normative [ ].
Synechiae represent a more complex problem. Hence, they are often not mentioned in statistics regarding complications [ 63 ], [ 76 ].
The benefit of special postoperative follow- up in order to optimize healing is partially questioned [ ], [ ], [ ]. On the contrary, the benefit of this treatment for prophylaxis of adhesions and synechiae is stressed by other sources [ 98 ], [ ], [ ], [ ], [ ].
Especially in differentiated and extended surgeries, e. A routine administration of antibiotics does not improve the result [ ]. Non absorbable nasal packing can help to avoid synechiae or adhesions [ ].
Specific placeholders have been developed with the same intention [ ]. Despite of a well-intended fenestration in the middle or, in rare cases, also the inferior nasal meatus, persistent symptoms arise in the corresponding maxillary sinus [ ], [ ] Figure 2 Fig.
Treatment comprises the microsurgical unification of the two ostia with excision of the uncinate process. The treatment again, consists in a surgical unification of the ostia see above.
Preserved, intact uncinate process and persistent obstruction of the natural maxillary sinus ostium due to mucosal edema of the neighbouring mucosa.
The use of a shaver prevents this development [ ]. CT-scan of a patient having been subjected to anterior ethmoidectomy. Lateralization of the right sided vertical lamella of the middle turbinate causing inflammatory retentions in the ethmoidal cavity.
The lateralization of the vertical lamella of the turbinate with its possible adverse effects, e. This may be performed especially in case of an evidently fractured or destabilized vertical lamella during surgery.
Nevertheless, many authors approve of conserving the turbinate [ ], [ ], [ ]. The rate of recurrent nasal polyposis was lower [ ] and there was a tendency of improved olfactory function [ ].
The number of lateral synechiae also decreased, although the synechiae developing during therapy in spite of partial resection were more challenging [ ], [ ], [ ].
In human anatomy the exact dimension of the olfactory region is unknown. In general, postoperative smell deficits may occur after direct mechanical trauma, after removal of olfactory mucosa accompanied by scarification of the latter, caused by a progressive inflammation of the mucosa or even by a postoperative modification of the nasal air passage.
A partial resection of the lower third of the anterior middle nasal turbinate does not affect the ability to smell - in routine resections, there was no evidence of olfactory mucosa in the surgical specimens [ ].
On the other hand, a complete postoperative anosmia was reported, following a resection of the superior nasal turbinate that was done by mistake [ ].
Olfactory fibers in the turbinate bone can also be damaged without any resection, e. After surgery, many of these patients can expect an improvement or a normalization.
For medico-legal reasons, these circumstances suggest that a preoperative measure of olfactory ability should always be performed.
After extensive nasal surgery, secondary atrophic rhinitis may develop Figure 4a Fig. Literature focuses on consecutive states of excessive surgical procedures performed on the inferior nasal turbinate [ ].
However, such an iatrogenic, secondary atrophic rhinitis can also develop after extensive and usually recurrent sinus surgeries, with removal of larger areas of mucous membrane and resection of the middle or superior nasal turbinate.
Right nasal cavity of a patient having been subjected to a rhino-neurosurgical intervention for craniopharyngeoma with application of a naso-septal flap.
Patients complain about a paradox nasal obstruction, in the presence of an objective wide inner nose. Further symptoms are dyspnea, a dry feeling in nose and pharynx, hyposmia and depression.
If the sphenopalatine ganglion is intensively exposed towards nasal airflow after extensive tissue resection, additional pain may be caused.
For unknown reasons, only very few patients develop an ENS after generous resection of turbinate tissue apart from the inferior turbinate - possibly due to the fact that due to the underlying chronic rhinosinusitis, hyperplastic mucous membrane often forms postoperatively.
ENS often develops with a latency period of several years postoperative [ ], [ ], [ ], [ ], [ ], [ ]. In oncological surgeries of the maxillary sinus, the only precaution which can be taken consists in a temporary displacement of the inferior turbinate [ ], [ ].
In routine surgery of chronic rhinosinusitis, the rate of postoperative atrophic rhinitis is roughly between 0.
Therapy is mainly conservative, based upon intensive moistening, local care with the administration of ointments or oils [ ], [ ].
Rhino-neurosurgical procedures often lead to a serious, long-term and substantial restriction of postoperative nasal physiology [ ], [ ]. As a matter of principle, an irritating crust formation, accompanied by a restricted nasal physiology, occurs in up to one third of all cases [ 42 ], [ ].
Attaching laminar, pedicled mucous membrane flaps to the nasal septum adjusts this dysfunction [ ]. The extremely irritating crust formation lasts for at least days [ ].
Further possible consequences are synechiae, septum perforations, burns or mechanical skin damage at the nasal vestibulum caused by drills and other instruments [ 42 ], [ ].
In a rather aggressive mode of preparation or when electrosurgical measures are applied in the maxillary sinus, an injury of the infraorbital n.
Bony dehiscences in the channel of the infraorbital nerve increase the risk of such a complication. As a consequence, facial sensibility is affected postoperative [ 76 ], [ ] Figure 5 Fig.
The same applies to the alveolar nerves. In justified individual cases of endonasal procedures, a complementary, localized transoral puncture of the maxillary sinus is recommended in order to remove hyperplastic mucosa in hidden anatomical areas, e.
In an adverse case, a branch of the infraorbital n. A relatively safe location for a complementary puncture is the intersection of two reference lines, i.
In transpterygoid rhino-neurosurgical approach, amongst others, the maxillary or the vidian n. Past references depict single cases of severe orbital complications of vidian neurectomy.
Recent literature only reports occasional cases of e. Concerning the orbital haematoma, the slowly developing, venous hematoma is distinguished from the comparatively fast evolving arterial hematoma [ ].
The incidence of orbital hematomas is around 0. With right handed surgeons, orbital complications are supposed to occur more often on the right side, whilst other authors report a preference of the opposite side [ ], [ ].
A threatening venous bleeding is mostly observed with a delay, i. It is safe to assume that an accumulation of 5 ml of blood can already lead to a dangerous intraorbital increase in pressure, causing a loss of vision.
Therefore, even in case of seemingly slightly developed orbital hematomas, vision must be controlled repeatedly.
A simultaneous control of color vision is recommended — here, restrictions occur in a relatively early stage [ 76 ], [ ].
As a basic principle, cooling compresses are applied and the top end of the bed is raised [ ]. In case of threatening development, an emergency ophthalmic consultation is recommended.
Nasal packing is removed and the intraocular pressure is measured. The digital ocular massage is recommended various times in literature; it is, however, contraindicated in patients with illnesses of the bulbus and is debatable even in patients without a special ophthalmological anamnesis see below.
Further conservative treatment and possibly surgery as therapy of threatening venous hematoma is identical to the therapy for arterial bleeding [ ], [ ].
The retrobulbar hematoma as an arterial bleeding with a swift increase in intraorbital pressure is dreaded Figure 6b Fig.
It appears intraoperatively and often even with delay, e. Literature points out rare cases of a hematoma occurring hours later — for outpatient surgery, this has to be taken into consideration [ ].
Patient revealing major right-sided intraorbital hematoma in the course of ethmoidectomy. Lateral canthotomy and also inferior canthoysis have been performed.
Consequently a progressive proptosis with chemosis, pain, congestion of the conjunctival vessels and, eventually, ecchymoses or subconjunctival bleeding develops.
During palpation, a distinct resistance of the orbital tissue is felt and an increased intraocular pressure is noticed. Ocular motility is disturbed and the pupil reaction is pathological in side comparison, reduced or absent pupil reaction , resulting in visual field loss and loss of vision.
The orbital hematoma is a clinical diagnosis. It is not necessary to wait for a radiological confirmation [ ]. The most frequent cause is an injury of the anterior ethmoidal a.
Alternatively, the blood vessel is pulled out of its bed at the base of the skull, together with the onset of the vessel inside the orbit [ 82 ].
A similar event rarely occurs in the posterior ethmoidal a. There is a risk of blindness, though the pathogenesis is not completely clear: A pressure-related occlusion or a spasm of the ophthalmic or the central retinal a.
Other mechanisms are a blockage in the blood flow of the posterior ciliary arteries, caused by pressure or tension. The increased intraorbital pressure is most likely to produce an effect upon the venous system [ 76 ], [ ], [ ].
According to literature, in case of imminent loss of vision, a maximum duration of about 90 minutes remains until definite amaurosis.
This basically depends on the ischemic tolerance of the retina [ 68 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ].
A pressure-related interruption of the axonal transport in the optic n. In animal testing, slightly longer durations — about minutes were determined for the retina [ ], [ ].
Individual factors among others, a preexisting subclinical vasculopathy and anatomical factors can generally strongly modify the tolerance of the organism in regard to an increase in orbital pressure [ ].
The dynamics of the increase in pressure may also play a role [ 76 ]. As animal testing for orbital hematoma cannot be easily standardized, it is sometimes problematic to transfer the scientific findings to humans [ ].
Sinus surgeons should have a clear action-algorithm in the case of an orbital hematoma. In principle, there is no solid proof of effectiveness regarding conservative treatment.
Analogies from traumatology form the basis for the recommendations, partly any effect is denied [ 71 ], [ 82 ], [ ], [ ], [ ].
The regimes are variable, e. Partly acetazolamide is prescribed in a lower dose or administered for longer periods — mg i.
In individual cases, the therapy with cortisone is based on other substances e. The indication for a surgical approach is often discussed in literature on the basis of an objective measurement of the intra-ocular pressure IOP [ ], [ ].
However, in daily routine the indication mainly takes place clinically, the pressure conditions can be estimated via comparative bilateral palpation [ ], [ ], [ ].
With individual differences, the orbital pressure is approx. Generally surgery of the paranasal sinuses has no effect on the intra-ocular pressure [ ].
Emergency indication for canthotomy and cantholysis is assumed for an IOP above 40 mmHg [ ], [ ], [ ], [ ], [ ].
In different references, surgery is necessary if the intra-ocular pressure IOP is higher than the mean arterial pressure minus 20 mmHg [ ].
Lateral canthotomy results in a reduction of the intra-ocular pressure by approx. An orbital decompression may cause an additional pressure reduction of 10 mmHg [ ].
With complementary measures e. Lateral canthotomy with cantholysis is an emergency procedure. It is simple and every sinus surgeon should be able to handle it.
The surgery can take place almost everywhere e. At first a straight, small vascular clamp is placed from the lateral canthus towards the border of the bony orbit between the upper and lower eyelid and is compressed.
To restrict surgery merely to this horizontal incisure is not recommended by the majority [ ], [ ] — the inferior and, if necessary, the superior cantholysis should complement canthotomy.
The lateral inferior palpebral ligament between conjunctiva and external skin of the eyelid is identified during the inferior cantholysis.
The palpebral ligament is completely dissected in caudal direction — during this process, it is repeatedly identified by palpation. The immediate release of the inferior eyelid is noticed when the forceps is held into place with a certain tension at the lower eyelid [ ], [ ], [ ], [ ], [ ], [ ].
Many authors suggest to perform the canthotomy [ ], [ ], [ ] followed by inferior cantholysis only. Others recommend an additional incisure of the upper palpebral ligament if the canthotomy with inferior lysis is not effective [ ], [ ], [ ], [ ].
It is important to consider that the effects of this procedure are limited in time [ ]. If the angle of this protrusion is less than degree, the eye is definitively at risk [ ] Figure 7 Fig.
As a rule, however, the wound is sutured with a delay of 2 to 5 days, e. For secondary reconstruction of the lateral palpebral ligament, the special anatomy of the anchorage of the lateral canthus must be considered [ ], [ ], [ ].
Regarding prognosis it is known from traumatological literature that the risk of permanent blindness with manifest retrobulbar hematoma with accompanied loss of vision is approx.
Vision recovery takes place within a time frame of approx. Prognosis for younger patients is better [ ]. As a consequence the intra-ocular pressure was raised up to a pressure level of 54 mmHg IOP.
Canthotomy and inferior cantholysis reduced the pressure to 32 mmHg and there were no relevant permanent damages [ ]. In other cases, a paraffinoma may develop especially within the region of the eyelids after a sinus operation.
In the event of a often minimal injury of the lamina papyracea with a often mild orbital haemorrhage and if a paraffinic nasal packing ointment strip or ointment is inserted into the nose the paraffin can be absorbed via the mucosal wound in individual cases and transported via blood into the soft tissue of the orbit, respectively eyelids.
In rare cases, the inflammation continues as sclerosing lipogranulamatosis or as orbital pseudotumour, in a rare case this may lead to the development of a sinogen orbital phlegmon.
Spontaneous, partial regressions are rare. Classic paraffinomas should not occur any longer due to modern types of nasal packing in use and due to tendencies to disclaim packing at all.
Despite this fact, appropriate casuistic case reports still exist [ ], [ ], [ ], [ ], [ ], [ ].
If the history of the patient does not include a sinus operation, differential diagnoses are, among others: Two special cases of a lipogranulomatous tissue reaction were reported 2 to 14 days following an endonasal sinus operation, where no oily material was inserted.
There was a palpable tumour of the eyelid, eye movement disorder and proptosis. The granulomas were externally removed by surgery and oral corticoids and also an antibiotic were administered.
Concerning pathogenesis, an intraoperative injury of the orbit with focal fat necrosis and a consecutive tissue reaction on extracellular fat were assumed [ ].
The treatment of paraffinomas is surgical excision. A complete resection is usually impossible because of the diffuse tissue infiltration [ ].
Myospherulosis is related to the paraffinoma. It corresponds to a foreign body reaction of the mucosa to ointments containing lipids.
Typical aggregates of erythrocyte residuals are histologically found in the vacuoles. Factors that predispose the development of myospherulosis are not yet clarified.
Patients tend to present a higher rate of postoperative synechia leading to a high number of revision surgeries [ ]. Myospherulosis granulomas also may form within the area of the eyelid following sinus surgeries with intraoperative haemorrhage of the eyelids and perioperative use of nasal packing with ointment [ ].
The microanatomy of the pterygopalatine fossa and the sphenopalatine foramen plays an important role in sinus surgery [ ]. Further terminal branches of the maxillary a.
If the routine opening of the maxillary sinus in the middle nasal meatus is systematically enlarged in dorsal direction, up to the level of the posterior wall of the maxillary sinus, then, in individual cases, it will be necessary, for anatomical reasons, to cut through a branch of the sphenopalatine a.
Bleeding from the root of the sphenopalatine a. During extended surgical procedures in the area of the infratemporal fossa severe bleeding from the maxillary a.
Instructions to identify the sphenopalatine a. In rare cases, a pseudoaneurysm may form as a result of an injured sphenopalatine artery.
It was discovered 13 days after sinus surgery took place, which is quite early. The authors prefer embolization rather than targeted endoscopic treatment clipping of the maxillary a.
When entering the sphenoid sinus, the surgeon encounters the septal branch of the sphenopalatine a. In the area of the anterior wall of the sphenoid sinus, it is mostly divided into three branches which supply the nasal mucous membrane [ ].
Within the scope of ENT routine surgery, an electrosurgical handling of this vessel is possible without any complication. In case or repeated perioperative bleeding, angiography with selective embolization will only be performed in extremely rare cases [ ], [ ], [ ], [ ].
This applies especially for embolization in case of a treatment-resistant nose bleeding after routine sinus surgery when the source of bleeding does not evolve the internal carotid artery.
The exposure of radiation during embolization is relevant around 18 minutes in single series. The pharyngeal ramus of the sphenopalatine a. It is a rare source of bleeding, e.
The anterior ethmoidal a. In some of the cases the artery is located directly in the area of the osseous skull base, and more frequently ca.
According to anatomical studies, the anterior ethmoidal a. Arteries at risk are those with a larger distance to the skull base, arteries with bony dehiscences or those running within a ground lamella [ ].
Lateral injuries in the area of a funnel-shaped, medial-directed protrusion of the orbital wall can result in a threatening orbital hematoma, after retraction of the vessel stump see above.
It is situated in the level below the superior oblique m. If the artery has been injured and is bleeding into the ethmoidal cavity, a bipolar or monopolar coagulation is generally used to stop the bleeding [ ].
Many authors avoid the monopolar coagulation at the skull base due to possible secondary damage to the meninges [ ], [ ], [ ].
Alternatively, clips are suggested, which, however, are not always effective, due to anatomical reasons [ ], [ ], [ ].
With a diameter of ca. The distance between the anterior and the posterior ethmoidal artery is approximately 10—14 mm and the distance from the latter to the optic nerve as well as to the anterior wall of the sphenoid is about 8—9 mm [ 12 ], [ ], [ ], [ ].
In a coronal CT, a tip-like protrusion of the medial orbital wall at the location of the posterior ethmoidal a. As a general rule, the posterior ethmoidal a.
A case report depicts a secondary orbital hematoma without significant proptosis, but with blindness [ ].
A subperiosteal orbital hematoma with visual impairment should be equally rare — symptoms were reversible after an emergency hematoma decompression [ ].
Uncomplicated hemorrhages in the posterior shaft of the ethmoid bone are treated with electrocoagulation [ ].
There are important neighbouring anatomical structures, especially the optic n. The distance between the internal carotid a.
Surgery performed in the sphenoid sinus requires sufficient preoperative diagnostic measures based on cross-sectional imaging [ 95 ], [ 97 ].
Particularly in the axial CT, significant anatomical details or variants are displayed: In principle, the carotid a.
Dorsally, another prominence of the artery can occur in the lateral wall of the sphenoid sinus. The bony canal of the artery is 0.
The exact incidence rate of carotid injuries in paranasal sinus surgery is unknown. According to literature, carotid artery injuries occur with a rate of 0.
In the last mentioned operations, the risk increases considerably in revision surgery, after radiation therapy or if there is a tumor infiltration of the carotid [ ].
In routine paranasal sinus surgery, the most frequent defect site of the carotid a. In the scope of extensive rhino-neurosurgical procedures, further sources of bleeding, also from smaller branches of the carotid a.
As a matter of principle, every ENT surgeon and every clinic should therefore have clear action plan at hand for the emergency of an internal carotid a.
For paranasal sinus surgery, the following measures are recommended in case of an injury of the cavernous internal carotid a Revision surgery of the respective sphenoid sinus revealing a partly exposed coil green arrow: Additionally, the arterial injury can no longer be identified in the angiographic image, so that the otolaryngologist has to loosen the nasal packing and the angiography is repeated [ 95 ], [ ], [ ], [ ].
Due to the former reason the otolaryngologist should be present during neuroradiological diagnostics and intervention [ ].
In case of a very small lesion in the carotid vessel — provided appropriate local conditions, sufficient medical status of the patient and capabilities to pack the nose repeatedly — the surgeon should at first create an optimum access to the sphenoid sinus.
The placement of an autologous muscle graft or allogenic material is recommended. This construction is fixed with fibrin glue and is tightened with packing.
Alternatively, under favorable conditions, a specific vessel clip may be used [ 97 ], [ ]. Occasional reports point out that such a supply was permanently successful preserving the arterial circulation [ 96 ].
For this reason an angiography is indicated postoperatively [ 95 ], [ 97 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ]. In case of an aneurysm secondary neuroradiological treatment is performed.
During a primary neuroradiological intervention after an accidental lesion of the carotid a. Here, specific complications, such as a vessel dissection, thrombosis, embolism or a vessel perforation have to be kept in mind.
Balloons can get displaced and then may increase the risk of new bleeding. Postoperatively, patients with vessel stents receive anticoagulant drugs Clopidogrel, ASS mg [ 95 ], [ ], [ ], [ ], [ ], [ ], [ ].
Within the first 24 hours after the neuroradiological intervention, a CCT control should be performed. Later on a control angiography should take place [ ], [ ].
The defect site in the sphenoid sinus should be covered secondarily, for example with fascia [ 95 ] Figure 9 Fig.
Hemorrhages from the cavernous sinus are mostly much less demanding. Bleeding is interrupted by placing hemostatic material directly and applying smooth pressure.
The material is inserted, covered with neuro-cotton wool and lightly pressed [ ]. In principle, hemostasis during rhino-neurosurgical procedures as well as during sinus surgery is based upon bipolar coagulation, compression, nasal packing or ligature as well as upon the application of clips.
However, in case of an exposed dura, a sufficient compression is not always possible and an external nasal packing additionally creates the risk of bleeding in intracranial direction.
Immediately after the incidence, a second suction is introduced into the operating field and the endoscope is directed to a protected place; if applicable, equipped with a rinsing and suction device.
In favorable individual cases, it might be possible to direct the jet of blood into the suction, to display small lacerations of the artery and to fuse and glue them by means of bipolar coagulation [ ], [ ], [ ].
The use of an intraoperative Doppler is recommended as a measure of prevention [ ], [ ]. If an ordinary hemostasis is not successful, further nasal packing is applied and an emergency transfer of the patient to the neuroradiological ward is carried out [ ].
The prognosis of an injury of the carotid a. An injury of the carotid a. This condition is treated through neuroradiological intervention [ 89 ], [ ], [ ].
Even after a successful occlusion-test complications following the definitive occlusion cannot be excluded [ 95 ], [ 97 ], [ ], [ ]. In this regard, very different frequencies are found in literature: The average bone thickness in the direction of the sphenoid sinus is 0.
Hence it is even more important to look out for a history of previous eye defects preoperatively. Perioperatively, this damage might only appear to deteriorate, e.
As a consequence, unnecessary emergency measures might be taken, even medico-legal problems might arise [ ]. Perioperative blindness in paranasal sinus surgery occurs in case of a direct injury of the nerve, a drug-induced interruption of local blood supply or a hematoma in extremely rare cases also by an emphysema, see above or in case of damaging the central nervous system, as, for instance through meningitis [ 76 ].
Direct mechanical damage to the optic nerve is only reported in exceptional individual cases [ ], [ ]. Here, during removal of the covering bone, the nerve can be damaged or destroyed in the cranial, lateral wall of the sphenoid sinus [ ] or within the orbit [ ].
In other cases, injuries of the optic n. A case report of a severe, direct injury of the eyeball across the lamina papyracea caused by an electrosurgical tube without direct nerve damage seems to be exceptional [ ].
In case of an injury of the optic n. Compared with direct lesions, indirect injuries of the optic nerve caused by a retrobulbar hematoma occur more frequently [ 83 ], [ ].
Loss of vision as a complication of adrenaline-soaked e. Adrenaline resorption with consecutive spasm of the vessel network around the optic n.
After every postoperatively noticed or supposed visual reduction, an ophthalmological emergency consultation should occur. MRI is strongly recommended [ ].
After mechanical injury of the nerve, collateral damage has to be searched for, e. If the optic n. Even if nerve continuity is preserved, the immediate treatment of the perioperative visual reduction is problematic.
The regimen is individualized and is under ophthalmological guidance. If neurapraxia or a hematoma is suspected, a high dose corticosteroid treatment is followed out e.
The concept is aligned to the treatment of traumatic optic neuropathy — evidence of which, however, still remains a subject of debate [ 71 ].
Traumatology and neurology provide some experimental evidence to suggest that corticosteroids may also hinder the restitution of an optic nerve [ ], [ ], [ ], [ ], [ ].
In specific cases, decompression of the nerve may be discussed — however, its benefit has not been proven yet [ 12 ], [ 76 ].
Under certain, adverse conditions, the symptoms of an ischemic optic-neuropathy may appear within the scope of sinus surgery, a disease of which little is known.
In these rare cases, neither mechanical injury of the nerve has occurred nor has the lamina papyracea been damaged. The exact pathogenesis is not yet known.
The resulting loss of vision or visual field reduction emerges immediately or with a delay of several hours to days.
MRI displays a vaguely defined and swollen optic n. A decompression of the optic nerve does not always seem appropriate. Administration of cortisone e.
An immediate normalization of blood pressure and hemoglobin by means of transfusions seems essential [ ]. A case report described residual ethmoidal cells revealing opacification.
An emergency revision surgery was performed with decompression of the orbit and periorbital incisure. Additionally, high dose corticosteroid treatment Prednisolone mg intravenously and calculated antibiotic treatment was initiated.
Within a period of 4 weeks the condition of the patient improved. In another case, the optic n. These two cases were interpreted as a consequence of an infectious impairment of the optic n.
In endonasal surgery of the paranasal sinuses, an impairment of the medial rectus m. In general, these injuries result of a fracture of the inferior lamina papyracea with perforation, destruction or incarceration of the muscle.
The middle or posterior ethmoid is most at risk — as hardly any fat is situated between the muscle and the bony orbital wall [ 76 ], [ ], [ ], [ ].
In rare cases, there is a particular risk due to a congenital or posttraumatic bulge of the lamina papyracea with or without direct embedding of parts of the muscle [ ], [ ].
Other eye muscles are distinctly less often injured intraoperatively: The inferior rectus muscle may be damaged in surgeries involving the maxillary sinus and the superior oblique trochlea muscle may be lacerated in extended endonasal frontal sinus surgery with a drill for instance.