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vidian_neurectomy

vidian_neurectomy

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This e book discusses the topic vidian neurectomy
This e book discusses the topic vidian neurectomy

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Published by: Dr. T. Balasubramanian on Mar 25, 2011
Copyright:Attribution Non-commercial

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07/10/2013

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Vidian Neurectomy
Dr T Balasubramanian
 
Introduction:Vidius in 1509 identified the vidian nerve in the floor of the sphenoid sinus whileperforming dissection in that area. This nerve is thought to play a role in thepathophysiology of rhinitis, epiphora, crocodile tears, Sluder syndrome, crainal /cluster headaches.In 1943 Fowler reported a rather unusual unilateral vasomotor rhinitis followingipsilateral stellate ganglion destruction. He also went to the extent of suggesting thatexperimental surgeries involving the stellate ganglion could throw light on thefundamental mechanism of vasomotor rhinitis. This was promptly taken up by PhilipHenry Golding – Wood who suggested that chronic vasomotor rhinitis should beconsidered as simple secretomotor hyperactivity of the nasal cavity mucosa. Heconcluded that emotional stress played a role in the initiation and perpetuation ofvasomotor rhinitis.Wolff in 1950 classified emotional effects on target organs as:Stomach reactors – Who manifested with gastrointestinal disturbances followingemotional stressPulse reactors – These patients showed changes in pulse rate in response to emotionalstressNose reactors – These patients manifested with nasal congestion and dischargefollowing emotional stress.Wolff also managed to record changes in the nasal mucosa when he interviewedpsychiatric patients with chronic rhintis. Turbinate biopsies from these patientsrevealed hyperplasia of mucosal glands which was filled with secretions. Lymphchannels were found to be dilated with predominant eosinophilia.Sectioning of greater superficial petrosal nerve as a treatement for vasomotor rhinitiswas first proposed by Zeilgelmann in 1934. This suggestion was followed by MurrayFalconer in 1954.Murray FalconerMurray Falconer's petrosal neurectomy:
 
He performed this surgery under Local anesthesia. The whole procedure wasperformed while the patient is seated up.Incision: Vertical incision is made above the zygoma one inch in front of the externalauditory meatus. The temporalis muscle was split and the squamous portion of thetemporal bone was exposed. A burr hole was performed in the squamous portion ofthe temporal bone and the opening is enlarged till the floor of the middle cranial fossais exposed. The middle cranial fossa dura is gently stripped from the floor andretracted with the help of retractors. While stripping the dura from the middle cranialfossa it could be found attached firmly to the formane spinosum. This area couldbleed during the dissection. The middle meningeal artery which traverses thisforamen was coagulated and cut. The foramen is plugged. From now on the durastrips easily and the mandibular division of trigeminal nerve is identified entering theforamen ovale which lies medial and slightly anterior to foramen spinosum. Onstripping the dura from the anteromedial face of petrous bone the greater superficialpetrosal nerve can be clearly seen. Without causing any traction the nerve is divided.Malcomson in 1957 suggested that the vidian nerve had a predominantlyparasympathetic effect. He also suggested that vidian neurectomy could offer releifin patients with vasomotor rhinitis.Malcomson's approach to vidian nerve: This is a rather blind approach. As a firststep a submucosal resection of nasal septum was performed. The rostrum of sphenoidis identified. In this area the mucoperiosteum is elevated off the anterior and inferiorfaces of the body of sphenoid. The mobilization of the mucoperiosteum is continuedlaterally over to the medial surface of the medial pterygoid plate. The mobilization ofmucoperichondrium extends forwards over the perpendicular plate of palatine bone.The sphenopalatine foramen comes into view and is identified and the vidian nerve isblindly cauterized as it exits from the foramen.Golding – Wood's transantral approach: Inspired by the work of MalcomsonGolding wood started to work on the various approaches to vidian nerve. Hepopularized the transantral vidian neurectomy. He considered it to be a rather safeprocedure in comparison to intracranial approach to the nerve popularized byMalcomson.

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