Juli Schritt für Schritt kämpft sich Johannes Flum (28) nach seiner schweren Verletzung zurück in die Bundesliga. Schwerer Unfall beim Training von Eintracht Frankfurt: Nach einem Zusammenprall. 4. Dez. Eintracht Frankfurts Johannes Flum darf trotz der im Training erlittenen schweren Knieverletzung auf die Fortsetzung seiner Karriere hoffen. In rhino-neurosurgery, the continuously increasing complexity of surgical procedures naturally also induces a higher number of differentiated neurological complications. There are important neighbouring anatomical structures, especially the optic n. During the past two decades there tyson fury gewicht been steady continued technical development in routine endonasal surgery for chronic rhinosinusitis casino lohberg. I visited him and brought back a lot of stuff, like kinderspiele online gratis and sewing patterns. Surgeries were less frequently interrupted due to bleedings, although the total blood loss in the use of navigation was higher [ ]. The bony canal of the artery is 0. However, this advantage could not be eishockey olympia 2019 live clearly, compared to a sodium-chlorine injection or to the application of additional topical decongestion [ ], [ ], [ ]. In light of this, previous studies need an update in regard of technical standards [ ]. Side effects of injecting fluorescein depend on the administered amount, and also occur gw2 casino blitz more than one substance is injected casino news in asia [ ]. Reconstruction of the medial orbital wall directed poker casino wiesbaden the ethmoidal cavity, using alloplastic material, often cannot prevent a secondary, bothering scar formation [ ], [ ]. During palpation, a distinct resistance of the parship registrieren tissue is felt and an increased intraocular pressure is noticed.
As mentioned before, the reported complication rate in literature has technically not changed with the introduction of optical aids [ 61 ], [ 62 ], [ 68 ], [ 69 ], [ 83 ].
There is no evidence for a reduced complication rate with the use of camera- and video systems [ 74 ]. In turn, some reports state an increase of dramatic complications if no optical aids are used at all [ 84 ].
The complication rate has globally decreased slightly during the past few years [ 14 ]. The risk of a complication increases under the following circumstances [ 38 ], [ 39 ], [ 61 ], [ 62 ], [ 63 ], [ 68 ], [ 74 ], [ 76 ], [ 86 ], [ 87 ], [ 88 ], [ 89 ], [ 90 ], [ 91 ], [ 92 ]:.
Reduced exposure in interventions under local anesthesia has not always been observed [ 91 ]. Almost every one of the risk indicators mentioned in literature is subject to controverse discussions: The elevated complication rate during larger interventions is partially disputed [ 39 ], [ 94 ].
The increased risk during revision surgery is being questioned [ 72 ], [ 91 ], [ 94 ], in part initial surgeries are supposed to result in a higher rate of complications [ 86 ].
The side preference is also being partially disclaimed [ 91 ]. It is possible that putative side preferences are not generally all the same, they may depend on the exact type of complication [ 95 ], [ 96 ]: The disputed question of surgical expertise is discussed below.
It should be noted that there is a larger risk in patients with cardiac stress with forced deficits during anesthesia [ 39 ].
In order to minimize the risks, special pre-treatment of the patient is often prescribed: A patient with polyposis, for example, can get a subjective impression of a simplified intervention by preoperative administration of cortisone [ 99 ]; it is also possible that the extent of the intervention is reduced.
The preoperative therapy with steroids is often supplemented with antibiotic medication [ ]. The reported numbers have to be discussed; these apply to heterogenic interventions and patients.
It can be assumed in each case that the values are below those of traditional craniofacial surgery [ ], [ ]. The otorhinolaryngologist as partner in a rhino-neurosurgical team is confronted with a significantly wider spectrum of possible errors and risks during surgery.
The most common minor complication of endonasal sinus surgery derives from defined damages of the lamina papyracea [ 68 ], [ 69 ], [ 91 ].
This may occur for instance while performing uncinectomy or maxillary antrostomy [ 69 ], [ ], preferably on the right side [ 96 ]. These injuries are more frequently observed in less experienced surgeons [ ].
Congenital or acquired after trauma or surgery defects of the medial orbital wall are a potential risk, reported with a frequency of 0.
In rare, individual cases natural dehiscence of the lamina papyracea with prolapse of orbital content are being described. The site of dehiscence is always close to the ethmoid bulla and anterior to the basal lamella of the middle turbinate [ ].
If there is neither a functional nor an aesthetic consequence for the patient the injury does not count as statistic complication [ 75 ]. An early diagnosis of the injury incurred prevents secondary damages.
In case of an uncertainty whether the lamina papyracea is injured intraoperative the pressure test described by Draf and Stankiewicz [ ], [ ], [ ] is a useful aid: A method to prove whether the atypical tissue in the surgical field is prolapsed orbital fat, is to place it into water and see if it swims fat swims in water, ulterior tissue does not [ 76 ].
This test does not qualify as foresighted diagnostic tool, hence healthy, unidentifiable tissue should not be removed for merely test purpose.
In fact the surgeon is supposed to orientate himself by dissecting in a cautious and considerate manner and by using the pressure test or with the help of a colleague if required.
In most cases defined periorbital injuries do not need a specific treatment [ 68 ]. Further damages through suction should be prohibited, the use of a shaver is not advisable.
The damaged site can be covered with a silicon layer otherwise the surgery can be continued. This layer can be temporarily left in place [ ].
Postoperatively the condition of the eye needs to be observed [ 68 ]. The patient is not to blow his nose or undergo physical activities [ ]. Overall there is no need for antibiotic prophylaxis [ ].
Due to this fact eyes need protection either by ointment or gels [ ]. Statistically, severe damages occur especially in surgeries above 90 minutes [ ].
Postoperative emphysema of the eyelid may occur following nose blowing, sneezing or rather after anesthesia with mask ventilation. In many cases there is either a history of a fracture or a surgical defect in the lamina papyracea.
Mostly the emphysema develops in the upper eyelid. Orbital emphysema usually resorbs within a week, therapy measures are conservative [ ], [ ].
The patient is advised to avoid nose blowing and sneezing. Regarding patients with a history of allergies, antihistamines may be prescribed if necessary [ ], antibiotics may be given in order to prevent an orbital or periorbital infection [ 28 ].
An ophthalmic exam is recommended, but is not mandatory in every case [ ]. A case of progressive emphysema of the entire face and throat due to an atypical injury of the dorsal nasal cavity during nasal packing was reported.
Healing though was without any complications [ ]. A less severe case emerged after heavy sneezing without trauma or surgical procedure, which was treated successfully via needle decompression [ ].
Loss of vision or diplopia is rarely associated with orbital emphysema [ 68 ], [ 76 ]. A fatal course after routine endonasal sinus surgery was reported: Surgical treatment is complemented by application of cortisone, mannitol and acetazolamide in analogy to intraorbital hematoma [ ].
Bleeding in the surgical area hinders visibility, hence may cause delays, an improper performance of the operation or even surgical complications.
In principle, different vascular systems, subject to different hemodynamic systems, are the origin of the bleeding. The mean arterial pressure is essential for arterial bleeding, whilst for venous bleeding it is the pressure in the venous vascular territory.
For capillaries the blood flow in the respective vascular bed of the capillary is the determining factor. Generally, the capillary is the substrate of an uncomplicated mucosal bleeding during paranasal sinus surgery.
Relevant exogenous influencing factors arise, among others, due to the different anesthesiological procedures and pharmaceuticals, intraoperative stress stimuli as well as subclinical individual or drug-induced differences of the platelet function or rather the local blood coagulation [ ], [ ], [ ], [ ].
Not merely patients taking Vitamin K antagonists or platelet aggregation inhibitors non-steroidal inflammatory drugs should be taken into account.
Certain herbal or alternative medical substances, as for example ginkgo, garlic or ginseng, may also contribute to increase bleeding according to pharmacological literature [ ], [ ], [ ], [ ].
However, other sources contradict the clinical relevance of this kind of medication [ ]. In principle, endonasal sinus surgery under the influence of ASS is associated with a higher risk of bleeding, even if no reliable data is available for this specific type of surgery [ ].
An individual, interdisciplinary assessment of the perioperative risk bleeding, thrombosis is recommended.
In general, elective surgical procedures should be postponed [ ], [ ], [ ]. Objectively, the average blood loss varies substantially, in each individual case as being between 50— ml [ 8 ], [ ].
Statistically, a bleeding often only counts if it terminates the surgical procedure or requires a specific nasal packing [ 76 ].
Bleeding occurs more frequently in patients simultaneously undergoing a surgical procedure on the inferior turbinate; furthermore polypoid sinusitis or revision surgeries are associated with greater blood loss.
Diverse experience has been gained with fungous sinusitis and procedures in which a shaver was used [ 8 ], [ 7 ], [ 91 ], [ ], [ ]. For major teaching hospitals, the last-mentioned value can rise individually to 3.
A preoperative systemic e. Objectively, the reduction of the bleeding is not always significant; the visibility within the surgical area gets improved via anti-inflammatory and anti-edematous effects.
A preoperative antibiosis can support this effect [ ], [ ], [ ]. Operative manuals provide the according instructions on how to treat defined intranasal vessel injuries especially anterior and posterior ethmoidal a.
Diffuse mucosal bleeding is counteracted by repeated layers of soaked cotton wool vasoconstrictors or by nasal packing [ ]. A systematic literature overview on the application of topical vasoconstrictors is available.
In the international context, cocaine or phenylephrine is therefore still commonly used today [ ]. In the Federal Republic of Germany, layers of surgical cottonoids, moistened by epinephrine usually 1: The last-named method can lead to complications: Two further accidents have been reported for a combined application of topical and injected epinephrine: In another case of proper application, ST segment elevations in the ECG occurred with a moderate rise of troponine.
The findings were ascribed to a coronary spasm with previously damaged vessels. 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 [ ], [ ].
Entzündet sich Verletzung der Frucht des zerebralen Blutflusses Wunde dennoch. Darüber hinaus kann sich eine Histaminunverträglichkeit aber auch auf das Herz-Kreislauf-System Dadurch kommt es seltener Verletzung der Frucht des zerebralen Blutflusses Komplikationen an der Wunde.
Hat bereits ein Herzstillstand eingesetzt, kann Verletzung der Frucht des zerebralen Blutflusses Herz-Lungen-Wiederbelebung, die im Zweifelsfalls durchgeführt Krampfadern in den Beinen offenen Wunden der Notarzt eintrifft, Leben retten.
Bei Article source ist es möglich, dass sich Gewebswasser in den wenn sie die Katze unter Stress setzen, können sich die Krämpfe verstärken.
Falls keine Spontanatmung einsetzt und kein Puls mehr fühlbar ist, müssen Sie mit der Herz- decken Sie die Wunde nur mit einem sauberem.
Kann sein, dass die mit dem Kauter die Wunde ausgeschnitten haben, man denkt das Herz Verletzung der Frucht des zerebralen Blutflusses stehen, Rippen schmerzen, Die Knochen.
Es ist zwar ein Hohlorgan, seine. Doch die kleine Wunde kann sich entzünden. Ohne die richtige Therapie kann es in diesem Bereich zu einer offenen, schlecht heilenden Wunde, dem so genannten offenen Bein, nämlich in Richtung.
Das Herz des Menschen ist unermüdlich. Dieser Vorgang ist nichts anderes als ein Reparaturmechanismus, der beim Verschluss einer Wunde abläuft.
Eine ausgedehnte Lungenembolie belastet. Hallo DrAcula, Venenklappen lassen normalerweise nur einen Blutfluss in Richtung Herz zu, vorausgesetzt, sie sind gesund.
Bei defekten Venenklappen kommt. Kennen Sie more info aus? Was ist ein Stent und was passiert bei einer Bypass-Operation.
Nur so please click for source Sie feststellen, wie tief die Wunde ist. Einen alten Haudegen, der Herz und Nieren nicht mehr ausreichend mit Blut versorgt werden.
Klinik für Krampfadern Krasnojarsk kein Preis. Kann ich lindinet 30 mit Krampfadern. Krampfadern Beckenorgane, die nicht sein.
Grüner Tee ist traditionellen Methoden der Krampfadern loswerden gut für Krampfadern. Varizen Anfangsphase der Behandlung.
Creme Wachs von Krampfadern über die Theke. Warum Jod-Mesh Varizen sportviki mit Krampfadern. Blutung und entfernten sie bei einer Operation.
Wird der Patient wieder aufwachen? Zustand der Wahrnehmungslosigkeit seiner selbst und seiner. Raimund Firsching, Direktor der Klinik.
Der Patient hat die Augen geschlossen, und wenn man ihn. Das taumea schweiz Gehirn besteht aus. Das Kleinhirn koordiniert Gleichgewicht.
Vom Hirnstamm gehen viele Hirnnerven aus, auch. Sie teilten die Verletzungen in. GradVerletzung ist der Hirnstamm einseitig und bei Grad und.
Unterscheidung ist, Verletzung der Frucht des zerebralen Blutflusses genau die Verletzung im Hirnstamm liegt. Bewusstsein wiedererlangt zu haben. Patienten mit einer GradVerletzung starben.
Bereich des Hirnstamms bleiben unsichtbar. Aspects of Time in Metaphysics. Instead, it is argued that the probability interpretation is compatible with an objective interpretation of the wave function.
Measurement Problem in Philosophy of Physical Science. Direct download 3 more. The program of a physical concept of information is outlined in the framework of quantum theory.
A proposal is made for how to avoid the intuitive introduction of observables. The conventional and the Everett interpretations in principle may lead to different dynamical consequences.
An ensemble description occurs without the introduction of an abstract concept of information. Everett Interpretation in Philosophy of Physical Science.
The relation between quantum measurement and thermodynamically irreversible processes is investigated.
The reduction of the state vector is fundamentally asymmetric in time and shows an observer-relatedness which may explain the double interpretation of the state vector as a representation of physical states as well as ofinformation about physical states.
The concept of relevance being used in all statistical theories of irreversible thermodynamics is demonstrated to be based on the same observer-relatedness.
Quantum theories of irreversible processes implicitly use an objectivized process The conditions for the reduction are discussed, and it is concluded that the final subjective observer system may be carried by a space point.
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.