Endoscopic Vidian Neurectomy: The Anatomy Consideration and Preoperative Images Analysis

Abstract

Although surgery is not a primary treatment for manaing rhinitis, it can have some adjuvant benefit in patients with significant nasal congestion or poor pharmacologic response. It is usually performed by surgical approaches to the inferior turbinate, and the more aggressive procedures such as the vidian neurectomy have not been widely applied. Traditional approaches to the vidian canal necessitate larger incisions, including transseptal, transpalatal and transantral methods. These approaches are often not reliable and at the risk of injury to the abutting neurovascular structures. Pioneers in endoscopic surgery are exploring alternatives to these traditional techniques in an attempt to minimize morbidity and the lack of irrelevant incisions. The main difficulties encountered during endoscopic approach are anatomic variations such as canal wall dehiscence, intra-sphenoid septa, pneumatization degree of pterygoid process and the relationship between vidian canal and middle turbinate. Those variations will have effect in determining the surgical success rate and the related complications. Therefore, a powerful tool, in the purpose of identifying the canal location and its surrounding anatomy, is very important to guide the surgeon in preoperative assessment and intraoperative approach. Computed tomography (CT) scanning is superior for the evaluation of the bony confines of the sinonasal tract and skull base. The most minimal recesses of the sinonasal region are easily assessed and it is possible to evaluate the position and configuration of the vidian canal. That valuable information provided by imaging studies enhances the surgical feasibility and offers an alternative for treating the rhinitis. This chapter describes the use of CT images in this capacity. Growing surgical experience and evolving technology will help to advance the feasibility of endoscopic vidian neurectomy and elucidate their indications by using preoperative images.