1

Introduction

Bone has always been cut using either manual or motorized instruments. Manual instruments are difficult to control, especially when a precise cut is required (close to nerves and arteries). Motorized instruments offer less control in the cortical bone and generate a significant amount of heat that can alter the healing response. Reduced rotational velocity limits heat production, but it causes an increase in manual pressure, with the consequent augmentation of macrovibrations and the reduction of surgical sensitivity.

These limits have stimulated the development of a new instrument that can cut the bone without causing necrosis and nonmineralized tissue damage: the Piezosurgery device .

Piezoelectric bone surgery, also known simply as Piezosurgery, is a new technique for osteotomy and osteoplasty: the equipment consists of 2 hand pieces and 2 inserts that are connected to a main unit. This unit supplies power and has holders for the hand piece and irrigation fluids. It contains 2 peristaltic pumps for cooling during surgery with a jet of physiologic solution that discharges from the inserts ( Fig. 1 ).

Piezosurgery medical device.

The piezoelectric device uses low-frequency ultrasonic waves (25–30 kHz), which are created by the piezoelectric effect. (Certain ceramics and crystals are modified when an electric current is passed across them, which causes an oscillation that has an ultrasonic frequency.) The instrument’s power can be modulated, between 2.8 and 16 W, in accordance to the density of the bone. The microvibrations that are created in the piezoelectric hand piece cause the inserts to vibrate linearly between 60 and 210 μ m .

In our department, Piezosurgery has been used successfully in otologic surgery. Appropriate hand pieces and inserts have been created; the width, thickness, and angle depend on the applied power, bone density, and surgical technique ( Fig. 2 ).

The inserts.

The objective of this study was to evaluate the applicability and safety of Piezosurgery in the resection of nasal malignant tumors through a paralateronasal approach and to consider the effects on soft tissues such as nerves, vessels, and mucoperiosteum.

2

Materials and methods

For the first time, we have used Piezosurgery in the excision of nasal malignant tumors through a paralateronasal approach on 10 patients, 7 males and 3 females, aged between 46 and 71 years. All the patients presented history of nasal obstruction and epistaxis of 6 months’ duration. The preoperative computed tomography scan in a coronal plane and fibroscopy showed a large nasal tumor extending from the nasal cavity (6 left, 4 right) into the ethmoid sinus and monolateral chronic maxillary sinusitis. A preoperative biopsy was taken from the periphery of the tumor to exclude malignancy; the result revealed an adenocarcinoma.

In all the patients, under general anesthesia with orotracheal intubation, we used a lateral rhinotomy approach by a paranasal and an infraorbital incision extended in the caudal direction by an alatomy and a Z-shaped vertical incision at the midline of the upper lip.

Piezosurgery was used in many intraoperative steps with specific insert. Among the different available inserts, we used a bony saw insert (OT7); after a lateral bony rhinotomy, performed with OT7 (bony saw), a cranially situated transverse piezosurgical osteotomy and a ventral intermediate piezosurgical osteotomy were carried out with OT7 ( Figs. 3 and 4 ).

Particular of OT7 insert.

Nasal osteotomy carried with OT7 insert.

The insert OT7 is slightly curved at the base and becomes rectilinear, wider and thinner, at the extremity. With a light pressure, it is linearly moved along the cut line, achieving complete section of the external and internal cortex of the bone ( Fig. 3 ).

The frontal process of the maxilla, together with a part of the nasal bone, was removed from the underlying mucoperiosteum. A bony specimen (of the cut surface of the nasal bone) was taken for histologic examination.

After having medially folded the mucoperiosteum of the nasal roof, the mass was isolated and removed.

The bone defect was repaired by replant of bone material removed previously. The diagnosis of adenocarcinoma was confirmed by the histopathologic analysis of the surgical piece.

Nasal bleeding was controlled with monolateral packing and electrocoagulation; the nasal packing was removed in 2 to 3 days.

One month after surgery, all the patients were treated with external beam radiation to 5040 cGy.