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OBJECTIVE Olfactory neuroblastoma (ONB) is a rare malignant tumor arising in the upper nasal cleft. Rarely, ONB may originate in ectopic sites and the impact of this on prognosis and treatment strategies continues to be debated. METHODS Retrospective analysis of patients with ectopic ONB treated between 2000 and 2020 in a tertiary-care referral center for skull base tumors. Three patients were included in this analysis: a 37-year-old female with ONB arising from the bulla ethmoidalis; a 28-year-old male with inappropriate secretion of antidiuretic hormone due to a maxillary sinus ONB; and a 41-year-old male with lacrimal sac ONB. Preoperative workup, surgical approach, adjuvant treatments and post-operative surveillance have been analyzed. Relevant literature published between 2000 and January 2021 was fully reviewed in order to investigate oncological outcomes and delineate the standard of care for such rare tumors. RESULTS All patients were treated via endoscopic endonasal resection with radical intent, followed by adjuvant treatments when required. No recurrences of disease were observed after a mean follow-up time of 32 months (range, 12-60 months). Data emerging from current literature suggests that a multidisciplinary treatment approach, including free-margins surgical resection followed by adjuvant radiotherapy or radiochemotherapy is recommended. Olfactory bulb and dura preservation should be attempted whenever feasible. CONCLUSIONS Endoscopic endonasal surgery should be preferred, where possible, to achieve complete excision in order to minimize patients’ morbidity. The ectopic site of origin impacts on prognosis and should be considered when selecting the appropriate multimodal treatment strategy.

Background Cavernous sinus (CS) invasion is found in 15–20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. Method prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. Results Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14 Gy), and one patient had remission after the procedure. Conclusions We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.

Introduction Pituitary surgery has shifted in recent years from microscopic surgery(MS) to endoscopic endonasal surgery (EES). However, the comparative long-term outcome of these surgical approaches, including the need for subsequent re-operation has never been reported. We present our experience in a high-volume referral center experienced in both endoscopic and microscopic approaches to compare the need for re-operation after initial resection of non-functioning pituitary macroadenomas using these surgical approaches. Methods 684 patients (398 with NF adenomas) underwent trans-sphenoidal pituitary surgery in our institution between 2006 and 2017. Complete follow-up (mean 72 months, minimum two years) was available in 87 newly diagnosed patients with non-functioning pituitary macroadenomas (NFPMA; 48-microscopic and 39-endoscopic). The EES approach has been used almost exclusively since 2012. The need for repeat operation for tumor resection during the follow-up period was assessed as the primary end-point of the study. Extracted data included various demographic and clinical parameters, radiographic findings as well as the extent of resection (EOR). Results The EOR was similar for both groups, with a trend towards better EOR in the EES group. The rate of surgical complications was also similar for both groups. There was a strong trend towards lower need for re-operation in the EES group compared to the MS group (12.8% vs. 29.2%, p = 0.056). In a multivariate analysis, only EOR and Knosp grade were independently associated with the need for re-operation surgery. Conclusion Our data indicate that EES in NFPMA tends to be associated with a lower need for re-operation compared to the MS approach, with a similar rate of EOR and complications.

Objective In the present study, we investigated the role of intraoperative neuromonitoring (IONM) in internal carotid artery (ICA) injury during endoscopic endonasal skull base surgery (EESBS). Methods The study group included all 13 patients who had experienced an ICA injury during EESBS with IONM from 2004 to 2017. The medical records were reviewed for the perioperative data. The IONM reports were reviewed to evaluate the baseline somatosensory evoked potentials (SSEP), electroencephalography (EEG), and brainstem auditory evoked potentials (BAEP) and their significant changes related to ICA injury and/or the subsequent surgical/endovascular interventions. Results All 13 patients had undergone SSEP and 7 patients had BAEP monitoring during surgery. EEG was added during emergent angiography following the surgery for 5 patients. Two patients showed significant SSEP changes, and one showed significant SSEP and EEG changes, indicating cerebral hypoperfusion. Of these 3 patients, patient 1 had experienced irreversible SSEP loss with postoperative stroke. Patients 2 and 3 had SSEP and/or EEG changes that had recovered to baseline after interventions without postoperative deficits. Despite ICA injury, 10 patients showed no significant SSEP and/or EEG changes, and all 7 patients with BAEP monitoring showed no significant BAEP changes, indicating adequate cerebral and brainstem perfusion, respectively. The injured ICA was sacrificed in 4 patients, of whom 3 showed stable SSEP and 1 had experienced irreversible SSEP loss. IONM correlated with the postoperative neurologic examination findings in all cases, adequately predicting the neurologic outcomes after ICA injury. Conclusion SSEP and EEG monitoring can accurately detect cerebral hypoperfusion and provide real-time feedback during surgery. SSEP and EEG changes predicted for neurologic outcomes and guide surgical decisions regarding the preservation or sacrifice of the ICA. Comprehensive multimodality monitoring according to the surgical risks can serve to detect and guide the management of ICA injury in EESBS.

Introduction Organised hematoma (OH) in the para-nasal sinus and nasal cavity is a rare, non-neoplastic, benign disease which can be locally aggressive. In clinical practice, OH is easily misdiagnosed as malignancy and over-treated. Case summary These patients with OH had a common history of malignant neoplasms post-radiotherapy, including two cases of nasopharyngeal carcinoma and one case of tonsil cancer with jaw osteosarcoma. All of the patients presented with symptoms of epistaxis and blood-tinged rhinorrhea. All of the patients received endoscopic endonasal surgery under navigation. Discussion All of the patients had a good recovery after surgery. There's no recurrence after follow-up at 6 months. We therefore hypothesised that radiotherapy could be a cause of the OH. Although OH is uncommon and difficult to diagnose, a history of malignancy and imaging features with appropriate treatment are key.

Purpose Endoscopic endonasal surgery requires many skills: a learning program was developed with progressive steps, on a surgical simulator (Cyrano) designed to train junior surgeons in the acquisition of basic endoscopic surgery skills and to assess their progress. The main objective of this study was to establish the construct validity of these exercises and to refine objective criteria to establish students’ level. Material and methods Thirty volunteers with varying experience in endoscopic endonasal surgery were blindly evaluated on 4 modules according to objective and subjective criteria. Results Ten beginner, 11 intermediate and 9 expert level participants were included. For each exercise, at least one criterion was discriminant for level of expertise. Weighted scores succeeded in discriminating groups. Interpretation of a single criterion must remain cautious and evaluation should rather rely on composite scores, which better reflect the participants’ level. Useful criteria and their reference values are specific of each exercise. Face and content validity were rated at 3.92/5 and 4.59/5 respectively (5-level Likert scale). Conclusion The construct/face/content validity of the proposed modules have been verified. Most of the modules tested here were physically not realistic, but they were all rated as highly relevant for surgical training by the participants.

Background Congenital intranasal encephaloceles (ECs) are rare malformations of the pediatric age, complex to diagnose and treat, above all if associated with genetic syndromes or concomitant dysmorphisms. The aims of the study were to report our experience in managing nasal ECS in children, to evaluate the efficacy and safety of the transnasal endoscopic repair, and to analyze in an overall way the surgical long-term outcomes. Moreover, we sought to contribute to the debate on pathogenesis of ECs, investigating possible related risk factors described in the literature. Methods A retrospective analysis was performed of pediatric nasal ECs managed with a transnasal endoscopic approach at a tertiary referral center through clinical follow-up and telephone survey. Results Twenty-three patients with nasal ECs fitted the criteria of the study. Mean age at surgery was 5 years (69 months) and the mean follow-up was 59 months. The clinical presentation is described in detail, with particular emphasis on syndromic cases. Of 23 patients, 17 had an isolated EC, and in 4 patients, a malformation syndrome was associated. EC recurred in 2/23 patients (8.7%) after surgical correction, necessitating a revision procedure. No perioperative complications or long-term sequelae were noted in the entire population. Conclusions Endonasal endoscopic management of congenital ECs is feasible in children, although regular long-term follow-up is essential. Furthermore, the surgical approach does not seem to affect patients' development and quality of life, although more studies and validated questionnaires are needed. No recurrent risk factors were observed able to justify a certain etiologic relation.

Background and Objective Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting. Methods We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018. Results There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients. Conclusions EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.

Background An aneurysm embedded in a pituitary adenoma is rare, and treatment for both the aneurysm and pituitary adenoma is complex and controversial. Case Description A 53-year-old woman presented with a visual field defect. Magnetic resonance imaging showed a pituitary adenoma and coexistence of an aneurysm located at the orifice of the superior hypophyseal artery (SHA) from the internal carotid artery (ICA). The aneurysm was embedded in the pituitary adenoma; therefore, obliteration of the aneurysm was needed prior to tumor removal to prevent intraoperative rupture of the aneurysm. Although endovascular coil embolization was tried first, it was not successful. A combined endoscopic endonasal approach and transcranial approach was performed for simultaneous tumor removal and aneurysm clipping. A bilateral subfrontal approach was selected for aneurysm clipping because, using this approach, the parent artery was safely controlled from the ipsilateral trajectory, whereas exposure and clipping of the aneurysm were easily done from the contralateral trajectory. Additionally, the supine head position without rotation is comfortable for endoscopic endonasal surgery. The tumor was totally removed, and the aneurysm was safely and completely obliterated with a clip. The patient's postoperative course was uneventful, and her visual disturbance improved. Conclusions A combined endoscopic endonasal and bilateral subfrontal approach is effective for a pituitary adenoma associated with an ICA-SHA aneurysm.

Prediction of visual outcome after endoscopic endonasal tumor resection still remains a challenge. We investigated the prognostic value of the preoperative peripapillary retinal nerve fiber layer (pRNFL) using optical coherence tomography for visual outcome after endoscopic endonasal surgery (EES) for suprasellar tumors.We retrospectively analyzed 122 patients who underwent EES for sellar and suprasellar tumors between January 2016 and January 2018. We retrospectively analyzed the pre- and postoperative relationship between pRNFL thickness and visual outcome based on visual acuity (visual acuity score) and visual field (mean deviation [MD]).Preoperatively, 216 eyes (mean global pRNFL thickness, 94.3 ± 12.4 μm; 88.5%) were included in the normal pRNFL group (≥70 μm) and 28 eyes (mean global pRNFL thickness, 54.3 ± 11.0 μm; 11.5%) were included in the thin pRNFL group (70 μm). There was a very strong correlation between pre- and postoperative pRNFL thickness (r = 0.930). The thin pRNFL group showed a stronger correlation between pre- and postoperative MDs than the normal pRNFL group (r = 0.619 and r = 0.420, respectively; P0.01). Multivariate analyses identified pRNFL thickness as the only significant predictor of postoperative visual acuity (odds ratio [OR], 25.02; 95% confidence interval [CI], 7.68-81.50; P0.01) and visual field (OR, 39.46; 95% CI, 10.39-149.83; P0.01).Preoperative pRNFL thickness plays a prognostic value in postoperative visual outcome after EES for sellar and suprasellar tumors. Patients with pRNFL thickness ≥70 μm before surgery are more likely to improve visual outcome than those with thickness70 μm.

Background Rathke cleft cysts (RCCs) are benign cysts arising from the pars intermedia as a result of incomplete obliteration of the Rathke pouch during development of the pituitary gland. The most common presenting symptoms are headaches, visual disturbances, and endocrinopathies. Recurrence of RCCs after surgical treatment is a well-known phenomenon after surgery with reported recurrence rates as high as 30%. Various methods have been employed to reduce the rate of recurrence. Complete cyst wall resection has been associated with increased rates of perioperative cerebrospinal fluid leak, diabetes insipidus, and carotid injury, while inconsistently demonstrating reduced recurrence rates. Marsupialization, in which the cyst cavity is widely exposed and left open with or without a fat graft suspension, has similarly shown increased morbidity without clear improvement in outcomes. We report here the use of a steroid-eluting sinus stent to maintain patency of the cyst opening. Case Description A 39-year-old female presented with a symptomatic RCC. She underwent 4 different surgeries including cyst wall resection, marsupialization, and fat graft placement. She developed short-term symptomatic and radiographic recurrence within 3 months of each surgery. She then underwent placement of a steroid-eluting sinus stent. At 3 months, the patient remained symptom free, without radiographic recurrence and with patent cyst fenestration on nasal endoscopy. Conclusions Recurrent RCCs are challenging to manage. Strategies to reduce recurrence are typically associated with higher risk and varying success. Stent placement represents a simple, low-risk method of potentially maintaining patency of cyst fenestration.

Background Clinical examination, including pre- and postoperative assessment of olfaction function, should be included in evaluating surgical outcomes in patients with pituitary adenomas. Most of the studies are lacking assessment of olfactory function. Methods A prospective study of 143 patients who underwent surgical resection of pituitary adenomas from January 2014 to December 2017 was performed. Data on clinical presentation, pre- and postoperative neurologic, endocrinologic, and ophthalmologic examinations, complications, and follow-up outpatient examinations were recorded. Olfactory function was assessed using the Sniffin' Sticks odor identification test preoperatively, postoperatively (3 months), and 1 year after surgery. Results Normosmia was present preoperatively in 93.7% of patients, postoperatively in 95.8% of patients, and in 95.1% 1 year postsurgery. Hyposmia was present preoperatively in 4.2% of patients, postoperatively in 2.1% of patients, and in 1.4% 1 year after surgery. Anosmia was present preoperatively in 2.1% of patients, postoperatively in 2.1% of patients, and in 3.5% 1 year after surgery. In patients with preoperative normosmia, postoperative hyposmia and anosmia were present in 1.5% of patients. There were no differences according to age, sex, size, or type of pituitary adenoma. Conclusions Assessment of olfactory function should be included in the analysis of pituitary adenoma surgery results. This prospective study showed low risk of olfaction deterioration if an endoscopic endonasal approach is used without any mucosal flaps for skull base reconstruction. Further studies that include objective olfaction assessment are warranted.

Objective Little is known about the effectiveness of lumbar drainage (LD) in the treatment of delayed or recurrent cerebrospinal fluid (CSF) leaks. We report our institutional experience and the effectiveness of LD in the management of delayed or recurrent CSF leaks. Methods Between January 2014 and December 2018, a total 21 patients with delayed or recurrent CSF leaks were enrolled in the research. All patients were treated conservatively for 48 hours, and LD was prescribed if CSF leaks still existed after 48 hours. If LD failed, endoscopic endonasal surgery (EES) was performed as soon as possible. Medical records were collected to analyze the effectiveness of LD. Results Among 21 patients, 4 patients experienced resolution with conservative treatment, and 17 patients were treated by CSF diversion by LD. The total cure rate of LD was 9/17 (52.9%). The cure rate was not statistically significantly different (relative risk = 3.33; Fisher exact test P = 0.131) between the traumatic group (8/12, 66.7%) and the transsphenoidal surgery group (1/5, 20.0%). During the follow-up time, no recurrence of CSF leaks was observed. Conclusions The cure rate of LD in delayed or recurrent CSF leaks was lower than that of initial treatment with LD. The cure rate in the traumatic group tended to be higher than that in the transsphenoidal surgery group. EES can be used as a remedial treatment for patients in whom LD has failed.

Pituitary tumors are a heterogeneous group of lesions (usually benign) and proper understanding of the anatomy, physiology, and pathology of the hypothalamic/pituitary region is essential to make an accurate diagnosis and define the essential treatment options (i.e., surgery, medical therapies, and radiotherapy, alone or in combination). Surgery is the primary treatment for acromegaly, Cushing disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing mass effect. Medical and radiation therapy are reserved in cases in which surgery is not possible or does not provide a complete cure. In the last decades, tremendous innovations (i.e., targeted drugs and refined surgical tools and techniques) have expanded the treatment strategies for pituitary adenomas. We herein report the current indications for and depiction of the surgical techniques in pituitary surgery, review current medical treatments, and provide a glimpse of future possibilities.

In the study and practice of neurosurgery at the “Federico II” University of Naples, a central role has always been reserved for anatomy. Based on worldwide cooperation, the meaning of anatomical research has evolved from methodological investigation to an educational and communication tool. The contribution of our school to the anatomical data on the sellar region has been chronologically reviewed in the present report. The path that brought us to focus on the endoscopic endonasal anatomy has been presented, together with the evolution of anatomical investigation. The confidence achieved with decades of cadaveric laboratory studies has changed the profile of our anatomical investigations. The quantification and comparison became essential in these studies owing to their effect on surgical application and advanced imaging techniques entered the field of anatomical dissection. Anatomy at our school is an evolving science. Our efforts in anatomical scientific publications and organization of participatory courses have made us a center of reference for endoscopic endonasal surgery and have allowed us to share our knowledge with other specialists in this field.

Juvenile nasopharyngeal angiofibroma (JNA) is a hypervascular tumor and uncontrolled hemorrhage makes its removal very difficult. Although preoperative intravascular embolization of a feeding artery is recommended, serious complications such as iatrogenic thrombosis in the brain and insufficient decrease in blood flow to the tumor are concerns. Recently, coblation plasma technology has been reported to be useful for tumor removal with minimum hemorrhage under a clear surgical field. Here we report successful removal of advanced JNA without preoperative embolization, using intraoperative ligation of the maxillary artery and coblation plasma technology. The left nasal cavity of a 23-years-old man was closed by a JNA tumor at Radkowski stage IIC, which was 65mm in size and extended from the nasal cavity to the infratemporal fossa. MRA imaging showed the maxillary artery running along the posterior wall of the maxillary sinus. Therefore, the maxillary artery was first clipped using an endoscopic modified medial maxillectomy (EMMM) approach and endoscopic endonasal en bloc resection of the tumor was then completed using coblation technology with no need for blood transfusion. This case illustrates that preoperative embolization is dispensable in JNA surgery even at Stage IIC if the maxillary artery can be ligated during surgery and a coblation device can be utilized.

Background Intracranial pseudoaneurysm is a rare complication of endoscopic endonasal surgery. Herein, we describe 2-staged stent-assisted coil embolization for posterior communicating artery pseudoaneurysm after endoscopic endonasal surgery for pituitary adenoma. Case Description A 68-year-old man had a history of severe adult growth hormone secretion deficiency, requiring growth hormone replacement therapy; secondary adrenocortical hypofunction; hyperthyroidism; hypertension; constipation; glaucoma; and hyperuricemia. Five years ago, after initial endoscopic transsphenoidal surgery for pituitary adenoma, he was hospitalized for reoperation. Posterior communicating artery injury was observed during second endoscopic transsphenoidal surgery, and pressure hemostasis was performed using a hemostatic preparation. Immediately post surgery, a localized subarachnoid hemorrhage was observed. Sudden-onset impaired consciousness and respiratory disturbances ensued on postoperative day 7, and computed tomography of the head was performed. Recurrent subarachnoid hemorrhage was confirmed, and acute hydrocephalus secondary to third ventricular blockage was identified. Cerebral angiography was performed after urgent bilateral cerebral ventricular drainage under general anesthesia. A pseudoaneurysm was identified in the left posterior communicating artery, and coil embolization was performed. Six weeks post surgery, a low-profile visualized intraluminal stent called an LVIS Jr. stent was placed in the posterior communicating artery. Recurrence of the aneurysm was not detected 6 months post surgery. He underwent lumboperitoneal shunting for secondary normal pressure hydrocephalus after dual antiplatelet therapy discontinuation and is being followed up as an outpatient with a modified Rankin scale score of 2 ten months post surgery. Conclusions Two-staged stent-assisted coil embolization using a low-profile visualized intraluminal stent was effective for a posterior communicating artery pseudoaneurysm occurring after posterior communicating artery injury following endoscopic transsphenoidal surgery for follicle-stimulating hormone-producing pituitary adenoma.

Objective: Describe the surgical management of clival chordomas in the pediatric population, with an emphasis on techniques of endoscopic endonasal surgery. Finding: Endoscopic endonasal approaches to the clivus provide access from posterior clinoids to foramen magnum. The clivus is divided into thirds (superior, middle, and inferior), each with corresponding vascular and neural structures. The abducens nerve is at greatest risk for injury due to spread of tumor within the interdural space to Dorello's canal. Despite decreased pneumatization of the sinuses in pediatric patients, the same techniques can be applied to this population. The contralateral transmaxillary approach enhances the ability to achieve a gross total resection when tumor extends laterally into the petrous apex. A multi-layer reconstruction with vascularized tissue minimizes the risk of cerebrospinal fluid leak. Conclusion: Endoscopic endonasal surgery can be safely applied to the pediatric population and provides the best opportunity for complete surgical excision for most tumors.

Highlights • Purastat is a novel haemostatic agent used effectively in nasal procedures in the prevention of epistaxis and adhesions. • This study describes the use of PuraStat following division of nasopharyngeal stenosis to reduce the risk of restenosis. • On last follow-up the patient experienced excellent resolution of symptoms with no evidence of readhesion. • The authors propose that PuraStat may be used in other surgical interventions to prevent mucosal adhesion formation., Introduction Purastat is a novel haemostatic agent that has recently been used effectively in nasal procedures, specifically in functional endoscopic endonasal surgery in the prevention of post-operative epistaxis while minimising adhesion formation. This study presents a case of successful application of Purastat following division of a nasopharyngeal/palatal stenosis following radiotherapy. Presentation of case A 49-year-old male developed severe nasopharyngeal stenosis following concurrent chemoradiotherapy with curative intent a HPV positive base of tongue squamous cell carcinoma. Following treatment, while the patient experienced excellent metabolic response, he began to progressive nasal obstruction which he reported to be significantly affecting his quality of life. Following multidisciplinary team discussion, division of the stenosis was considered appropriate. Under general anaesthesia, the patient was positioned lying supine with the neck extended. A Boyle-Davis gag with lip and teeth protection was placed and a Y-suction catheter inserted to lift the palate from the posterior pharyngeal wall. Coblation using a PDW wand was used to divide the area of fibrosis bilaterally toward the superior tonsillar pillar until palatopharyngeus musculature was visible. Injection of 4 mg of Dexamethasone with a hypodermic needle was then performed followed by application of 4 ml of topical Purastat onto the raw surfaces after haemostasis was confirmed. The patient was discharged the same day on simple analgesia and instructions to avoid exertion for two weeks. He attended follow-up in the outpatient department two months later and reported persisting resolution of his nasal obstructive symptoms. No evidence of recurrence or residual adhesion tissue was noted.

Background The endoscopic endonasal approach has recently become an acceptable option for resection of all pituitary adenomas. We assessed biochemical outcome of endoscopic endonasal surgery in growth hormone (GH)–secreting adenomas, including remission rate, predictors of remission, and associated complications. Methods Sixty-eight consecutive patients with acromegaly who underwent endoscopic endonasal surgery were analyzed prospectively. Tumors were classified according to size, Knosp grade, and Hardy-Wilson classification. Biochemical remission was defined as normal serum insulin-like growth factor 1 level and either a suppressed GH serum level less than 0.4 μg/L during an oral glucose tolerance test or a random GH level less than 1.0 μg/L at least 3 months after surgery. Results Total biochemical remission rate was 64.7%. Gross total resection was achieved in 61 of the 68 patients (89.7%). Remission was achieved in 12 of 16 microadenomas (75%) and 32 of 52 macroadenomas (61.5%). Based on univariate logistic regression analysis, preoperative variables predictive of remission were age (P = 0.004), Knosp grade (P = 0.023), and preoperative GH levels (P = 0.042). Three patients (4.4%) experienced postoperative panhypopituitarism, and permanent diabetes insipidus was seen in 4 patients (5.9%). Two patients (2.9%) developed cerebrospinal fluid leaks, which were treated by lumbar puncture in one case and early surgical repair in the other case. Conclusions Endoscopic endonasal adenoma resection leads to a high rate of endocrinologic remission in GH-secreting adenomas with a low complication rate. Patients with older age, higher preoperative GH levels, and higher Knosp grades are less likely to achieve remission.

To explore the surgical methods and clinical effect of endoscopic endonasal approaches for the treatment of invasive pituitary adenomas (IPAs).A retrospective analysis was made of the clinical data of 74 patients (75 procedures) with IPAs treated by different endoscopic endonasal approaches at the Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University from May 2014 to August 2017. The data include clinical manifestation, imaging features, surgical methods and complications, resection rate, cure rate, prognosis, and complications in different Knosp classifications and Hardy stages. The transcavernous approach was used in 47 patients, the lateral-cavernous approach was used in 14 patients, the tuberculum sella planum approach was used in 8 patients, and the diaphragma sellae open or dorsum sellae cut approach was used in 6 patients.The gross total resection (GTR) rate was 70.7% (53 patients) and tumor residue rate was 29.3% (22 patients). GTR rate for pituitary adenoma according to Knosp classification was 89.3% in grade 3 and 28.6% in grade 4. The biology cure rate was 75.0% and 23.8%, respectively. There was significance between them (P 0.05). In addition, the GTR rate of Hardy stage was 90.5% in stage C, 90.0% in stage D, 26.1% in stage E, and the biology cure rate was 80.1%, 75.0%, and 13.0%, respectively. There was significance among them (P 0.05) Postoperative severe complications included 9 patients (12.0%) with cerebrospinal fluid leaks, 26 patients (34.7%)with electrolyte imbalance, 36 patients (48.0%) with transient diabetes insipidus, 22 patients (29.3%) with hypopituitarism, 2 patients (2.7%) with permanent hypopituitarism, and 2 patients (2.7%)with epistaxis. The follow-up lasted 2-41 months (average, 19.3 months). No patient experienced recurrence after GTR, 1 patient undergoing subtotal experienced recurrence and underwent reoperation, 3 patients underwent postoperative Gamma Knife treatment, and 2 patients with refractory IPA were given temozolomide and metformin chemotherapy.According to the invasiveness of IPA, choosing the appropriate endoscopic surgical approach is helpful in removing tumors and reducing complications.

Background Xanthomatous pituitary diseases rarely occur in childhood. We report a rare pediatric case of a xanthogranuloma that developed in the sellar region, resulting in a visual disturbance that was treated successfully with endoscopic endonasal surgery. Case Description A 13-year-old boy came to us with a headache and visual disturbance that occurred 1 month prior. Clinical examination findings showed that he was alert with signs of bitemporal hemianopsia. An endocrinologic examination showed partial hypopituitarism, and brain magnetic resonance imaging revealed a cystic mass in the sellar turcica compressing the optic apparatus. Endoscopic endonasal surgery was performed to decompress the optic apparatus, and the mass was removed. Histopathologic analysis of the tumor demonstrated granulomatous tissue with cholesterol clefts, foamy macrophages, and multinucleated giant cells, with no epithelial component. The diagnosis was xanthogranuloma of the sellar region. The patient gradually recovered from the visual disturbance and was free from any neurologic signs or symptoms 6 months after surgery. Conclusions Xanthogranuloma, although rare, should be considered as a differential diagnosis of a sellar or suprasellar lesion, even in children.

Background Isolated sphenoid mucoceles are rare, but because of their close proximity to important vasculonervous structures, local extension may result in serious consequences. Case Description A 47-year-old patient presented with headaches, meningismus, and a left homonymous lateral hemianopia. We report the atypical evolution of a posttraumatic sphenoid mucocele invading the sellar region and extending into the subarachnoid space with compression of the right optic tract, and we describe its surgical management. Further, with the aid of cadaveric specimens, we aim to analyze the precise pathway followed by the expanding collection from an anatomic perspective. Conclusions Anatomic knowledge of the sellar and parasellar regions is the key to understand the process of how sphenoid mucoceles may extend intracranially. Early endoscopic drainage with a large sphenoidotomy allows favorable outcomes and prevents serious consequences.

The olfactory cleft is the specific site of development of many tumours (respiratory epithelial adenomatoid hamartoma, intestinal-type adenocarcinoma, neuroblastoma, inverted papilloma, glomangiopericytoma, etc.) and is also the site of CSF rhinorrhoea via the cribriform plate (cribri-rhinorrhoea). Olfactory cleft surgery must therefore be considered to be a specific type of surgery, complementary to ethmoidal labyrinth surgery and anterior skull base surgery. Olfactory cleft tumours can be resected according to five different surgical procedures: olfactory cleft mucosal resection, partial resection of the olfactory cleft, total resection of the olfactory cleft, unilateral endoscopic anterior skull base resection, and bilateral endoscopic anterior skull base resection. The diagnosis and closure of cribri-rhinorrhoea (i.e. documented CSF rhinorrhoea, demonstrated to arise from the cribriform plate during endoscopic examination of the olfactory cleft under general anaesthesia in a patient with no localizing signs on imaging) completes this range of treatment options.

Background We report a rare case of hemorrhagic cavernous sinus hemangioma with sudden onset of abducens palsy. Case Descriptions Sudden onset of diplopia occurred in a 49-year-old female. Head computed tomography findings revealed a high-density mass in the right cavernous sinus with protrusion to the sphenoid sinus. Endoscopic endonasal surgery was performed, though early recurrence was noted. A Gamma Knife surgical procedure was then performed to prevent early recurrence after histopathologic confirmation of cavernous sinus hemangioma. Thereafter, the tumor was controlled and abducens palsy disappeared. Conclusions For treatment of cavernous sinus hemangioma, stereotactic radiosurgery should be considered as primary or adjuvant treatment in the very early phase after removal, to avoid early recurrence.

Objective Skull base meningiomas carry a nonnegligible risk of recurrence. In particular, those arising from the sphenoid wings or middle cranial fossa penetrate into extracranial regions, uncommonly showing massive expansion into the craniofacial regions on recurrence. The role of endoscopic endonasal surgery for those intractable lesions remains unclear. Methods We performed endoscopic endonasal craniofacial surgery for 8 recurrent meningiomas invading into the pterygopalatine fossa, infratemporal fossa, nasopharynx, paranasal sinus, or orbit, comprising 2 meningothelial and 1 fibrous meningiomas (World Health Organization [WHO] grade I), 3 atypical and 1 clear cell meningiomas (grade II), and 1 anaplastic meningioma (grade III). All were large (15–80 cm3; median, 45 cm3) and highly vascularized. Results All 8 tumors were sufficiently resected. Gross total resection of the craniofacial part of the lesions was achieved in 5 patients (62.5%). In 3 patients with WHO grade I meningiomas and 1 with grade II, tumors were successfully controlled as of the last follow-up. In 4 patients with WHO grade II or III meningiomas, craniofacial lesions were controlled, whereas original intracranial lesions were poorly controlled and became critical. Conclusions We consider the endoscopic endonasal approach as an acceptable, less-invasive alternative for recurrent craniofacial meningioma. Although all these cases were relatively large and highly vascularized, preoperative endovascular embolization of the feeding arteries contributes to significantly reducing vascularity of the tumors, and local control of the craniofacial lesions was successfully achieved in all cases. Endoscopic endonasal craniofacial surgery enabled sufficient mass reduction without disfiguring facial incisions.

Background Although pituitary adenoma (PA) and Rathke cleft cyst (RCC) share a common embryologic origin, concurrent appearances have rarely been reported. We present a case of intractable RCC hidden behind a coexisting giant PA. Case Description A 39-year-old woman presented to an ophthalmologist with visual disturbance. Brain magnetic resonance imaging findings showed a giant mass in the intrasellar and suprasellar portion, with a cystic portion contained in the posterior part. Endoscopic endonasal surgery was performed to remove the tumor, and histopathologic findings revealed a nonfunctioning PA. Further brain magnetic resonance imaging showed the appearance of a residual cyst. A second endonasal endoscopic surgery was performed to relieve compression of the optic chiasm by the growing cyst, followed by cyst drainage and irrigation, and portions of the cyst walls were obtained. The histopathologic diagnosis was RCC with inflammation. Over the course of 1 year, 3 separate recurrences of the growing cyst were noted, with cyst drainage and irrigation performed each time. Finally, ethanol cauterization was performed, which stopped the symptomatic RCC recurrence. Eight years after the final procedure, there was no cyst recurrence, and the patient's condition was good with improved visual acuity and normal pituitary function. Conclusions The presence of a nonenhanced cyst with a PA on magnetic resonance imaging suggests the possibility of coexisting RCC and PA.

Purpose To demonstrate the utility of virtual reality (VR) for preoperative surgical planning of endoscopic endonasal craniovertebral junction (CVJ) surgery. Materials and methods Five patients who had undergone endoscopic endonasal surgery of the craniovertebral junction with preoperative virtual reality surgical planning were identified and described. Results The anterior approach to the CVJ has been traditionally accomplished transorally. However, recently the transnasal endoscopic approach to this location has been described. Multiple anatomical studies have been conducted using the nasopalatine, nasoaxial, and rhinopalatine lines (NPL, NAxL, RPL) in an attempt to preoperatively delineate the inferior limits of endoscopic dissection. The use of advanced surgical simulation using immersive virtual reality is an innovative approach for analyzing CVJ anatomy and developing a surgical plan. VR simulation through the use of interactive and highly accurate patient specific models allows for the creation of three-dimensional (3D) digital reconstructions via the fusion of CT and MRI studies. Incorporation of simulation technology has been shown to increase surgeon proficiency while simultaneously decreasing complication rates. The described case series demonstrates the novel utility of VR planning for designing the endoscopic surgical approach to the CVJ. Conclusions VR technology allows for the creation of anatomically accurate 3D models that can be used for preoperative planning of endoscopic endonasal surgery. Such models help in the development of safe surgical plans by predicting inferior and lateral planes of dissection and assisting in the identification of critical structures.

Purpose Paranasal mucocele (PM) is reported as a complication in children with cystic fibrosis (CF) in up to 4% of patients. The objective of this study was to identify PMs in the personal large series of children with CF and to assess their diagnosis and treatment. Material and methods Medical records of children with CF and PM who were admitted and treated by means of endoscopic nasal surgery between 2004 and 2020 were retrospectively reviewed. Results Thirty-four patients were included in the study (mean age 7.7 years). CT scan of sinuses showed a total of 53 PMs. Nasal endoscopic findings suggestive for PM were present in almost 80% of patients. PMs were located in the maxillary, ethmoid, and sphenoid sinuses in 29/34 (85.3%, bilateral in 17 cases), 4/34 (11.8%) and 1/34 (2.9%) patients, respectively. Marsupialization of PMs was performed in all patients using an endoscopic transnasal approach. No complications were observed. Resolution of symptoms and normalization of the endoscopic nasal picture was evident in all patients. After a mean follow-up of 85 months, no recurrences were observed. Conclusions To the best of our knowledge, this is the largest series of CF patients with PMs. Even if not frequently reported in the literature, PMs should not be considered an uncommon finding in patients affected by CF. Routine nasal endoscopy is mandatory to favor early diagnosis. Endoscopic transnasal marsupialization represents the gold standard of care for patients with CF and PM(s).

Purpose Skull base defects in children may be the result of congenital anomalies or trauma. They often present as cerebrospinal fluid (CSF) rhinorrhea, meningitis, brain abscess or nasal obstruction. Surgical intervention is predominantly the treatment of choice. Our goal is to assess the efficacy of endoscopic endonasal approach in treating skull base defects in pediatric patients. Material and methods In this retrospective study we identified 38 patients (mean age 8.7 ± 5.6 years old, ranging 2 months-18 years) who underwent endoscopic endonasal repair of skull base defects, between March 2010 and February 2020. Patients who had skull base reconstruction after tumor resection, those who were lost to follow-up or did not sign the consent forms were excluded from the study. Results The clinical indications for endoscopic endonasal repair were trauma (n = 24, 63.1%) and congenital defects (n = 14, 36.9%). Congenital skull base defects included basal meningoencephalocele (n = 5, 35.7%) and frontoethmoidal defects (n = 9, 64.3%). Mean follow up time was 32 ± 29.04 months, ranging 2–103 months. Fat graft (alone or in combination) was the most commonly used material to repair the skull base defects. Thirty-seven patients (97%) showed successful results after endoscopic endonasal surgery and were symptom free. Conclusion The endoscopic endonasal repair of CSF leak and skull base defects proved to be safe and feasible with 97% success rate.

This study aimed to quantify 24 h body core temperature (BcT°) and sleep-wake cycle rhythm alterations in craniopharyngioma (CP) patients and to identify markers related to the postsurgical outcomes. Ten consecutive CP patients underwent neuroradiological, endocrinological and ophthalmological evaluations, 24 h BcT° and sleep-wake cycle recordings before and after endoscopic endonasal surgery. The sample included four women and six men. Nocturnal sleep efficiency was pathologically reduced in eight patients before surgery. Seven out of ten patients presented one to three daytime naps. 24 h BcT° rhythm was pathological in six out of ten cases. Post-surgery sleep efficiency normalized in four out of eight patients, whereas nine out of ten patients presented with two to six longer daytime naps. Diurnal naps were mainly present in patients showing pre-operative involvement of the third ventricle floor. 24 h BcT° remained pathological in only one out of six cases, returned to normal in two and improved in three. 24 h BcT° rhythm improved more in papillary CPs than in adamantomatous CPs. Our data confirmed that both CP and surgery frequently disrupt the sleep-wake cycle and BcT° rhythms. Tumour location and histotype may be related to a worse postsurgical outcome. Therefore, in-depth investigation including circadian monitoring is crucial for surgical outcome.

Background Successful endoscopic endonasal surgery for the resection of skull base tumors is reliant on preoperative imaging to delineate pathology from the surrounding anatomy. The increased signal-to-noise ratio afforded by 7-T MRI can be used to increase spatial and contrast resolution, which may lend itself to improved imaging of the skull base. In this study, we apply a 7-T imaging protocol to patients with skull base tumors and compare the images with clinical standard of care. Methods Images were acquired at 7 T on 11 patients with skull base lesions. Two neuroradiologists evaluated clinical 1.5-, 3-, and 7-T scans for detection of intracavernous cranial nerves and internal carotid artery (ICA) branches. Detection rates were compared. Images were used for surgical planning and uploaded to a neuronavigation platform and used to guide surgery. Results Image analysis yielded improved detection rates of cranial nerves and ICA branches at 7 T. The 7-T images were successfully incorporated into preoperative planning and intraoperative neuronavigation. Conclusions Our study represents the first application of 7-T MRI to the full neurosurgical workflow for endoscopic endonasal surgery. We detected higher rates of cranial nerves and ICA branches at 7-T MRI compared with 3- and 1.5-T MRI, and found that integration of 7 T into surgical planning and guidance was feasible. These results suggest a potential for 7-T MRI to reduce surgical complications. Future studies comparing standardized 7-, 3-, and 1.5-T MRI protocols in a larger number of patients are warranted to determine the relative benefit of 7-T MRI for endonasal endoscopic surgical efficacy.

A new and low cost multitask training box created to develop some skills needed for endoscopic skull base surgery is presented.

Combined transcranial and endoscopic endonasal approaches remain useful in the treatment of ventral skull base malignancies. The extended bifrontal transbasal approach provides wide access to the anterior ventral skull base and paranasal sinuses without transfacial incisions. In more extensive lesions, the bifrontal transbasal approach can then be combined with an endoscopic endonasal approach (EEA) from below. This article reviews the indications, surgical technique, and operative nuances of combined transbasal and EEA (cranionasal) approaches for the surgical management of ventral skull base malignancies.

The endoscopic resection of pterygopalatine and infratemporal fossa malignancies allows excellent visualization and manipulation of tissues in an anatomically complex area compared with open approaches. With less approach morbidity, endoscopic endonasal surgery allows an easier recovery and earlier transition to adjuvant radiotherapy. The endoscopic approach is minimal access but rarely minimally invasive. Surgeons should not hesitate to gain wide surgical exposure of the pterygopalatine, infratemporal fossa, and petrocavernous carotid artery to ensure comfortable maneuverability and easy visualization of the tumor and its normal tissue margins. This method maximizes the chances of complete resection and effective postoperative surveillance.

Objectives To determine the risk factors associated with cerebrospinal fluid (CSF) leak following endoscopic endonasal surgery (EES) for pediatric skull base lesions. Methods Retrospective chart review of pediatric patients (ages 1 month to 18 years) treated for skull base lesions with EES from 1999 to 2014. Five pathologies were reviewed: craniopharyngioma, clival chordoma, pituitary adenoma, pituitary carcinoma, and Rathke's cleft cyst. Fisher's exact tests were used to evaluate the different factors to determine which had a statistically higher risk of leading to a post-operative CSF leak. Results 55 pediatric patients were identified who underwent 70 EES's for tumor resection. Of the 70 surgeries, 47 surgeries had intraoperative CSF leaks that were repaired at the time of surgery. 11 of 47 (23%) surgeries had post-operative CSF leaks that required secondary operative repair. Clival chordomas had the highest CSF leak rate at 36%. There was no statistical difference in leak rate based on the type of reconstruction, although 28% of cases that used a vascularized flap had a post-operative leak, whereas only 9% of those cases not using a vascularized flap had a leak. Post-operative hydrocephalus and perioperative use of a lumbar drain were not significant risk factors. Conclusions Pediatric patients with an intra-operative CSF leak during EES of the skull base have a high rate of post-operative CSF leaks. Clival chordomas appear to be a particularly high-risk group. The use of vascularized flaps and perioperative lumbar drains did not statistically decrease the rate of post-operative CSF leak.

The pterygopalatine fossa (PPF) is an inverted, pyramid-shaped space immediately behind the posterior wall of the maxillary sinus, and lesions arising here include juvenile angiofibromas, schwannomas, and, in exceptionally rare cases, malignant peripheral nerve sheath tumors.1,2 Surgical access to the PPF is challenging and has been historically achieved via an open transmaxillary approach associated with facial scaring/deformity as well as potential injury to facial and infraorbital nerve branches.3 We present the case of a 67-year-old woman with facial numbness secondary to a presumed trigeminal schwannoma in the right PPF on magnetic resonance imaging. This surgical video highlights the key stages in performing an endoscopic endonasal excision of a PPF tumor. We start with a wide medial maxillary antrostomy, mobilization of the inferior turbinate, ethmoidectomy, and sphenoidotomy. The posterior wall of the maxillary sinus is then lifted off the anterior aspect of the tumor. The soft tissue attachment medial to the tumor containing the sphenopalatine artery is then cauterized and divided. This is followed by circumferential blunt dissection of the tumor until it is sufficiently mobile to remove in a piecemeal fashion. The PPF is then examined for any residual tumor and any bleeding from the maxillary artery within the fat pad. Hemostasis and reattachment of the inferior turbinate into the lateral nasal wall is demonstrated. The patient did not have any new deficits postoperatively, but histology indicated a malignant peripheral nerve sheath tumor and she underwent postoperative proton beam therapy. Postoperative surveillance magnetic resonance imaging at 14 months showed no tumor recurrence. The patient consented to the procedure in a standard fashion (Video 1).

Sinonasal malignancies are rare and histologically heterogeneous. Treatment is complicated by tumor aggressiveness and location near critical anatomic structures (orbita, skull base, etc.). This low incidence and histologic diversity make prospective studies unfeasible, and thus therapeutic guidelines difficult to establish. The gold standard for surgery is a transfacial approach, with craniofacial resection in case of skull-base involvement. However, these techniques are associated with non-negligible perioperative morbidity. In the past two decades, endoscopic surgery has made major progress, extending its indications: initially developed for functional sinus surgery, it is now applied in benign skull-base pathologies (CSF leakage, meningocele, etc.) and, more recently, in sinonasal malignancy. Literature analysis shows a significant decrease in morbidity and improved quality of life associated with endoscopic endonasal surgery, with oncologic safety and efficacy in well-selected cases, although dependent on operator experience. Additional studies with longer follow-up and comparison between histologic subtypes will be needed.

Background Despite the rarity of epidermoid cysts in the chiasmatic region, their surgical treatment is particularly complicated because of the tendency toward massive dissemination of the epidermoid masses along cerebrospinal fluid pathways and significant deviation of the tumor from the midline. Objective The purpose of the present work is evaluation of the role of extended transsphenoidal endoscopic endonasal approaches in the surgery of epidermoid cysts. Methods The study included 6 patients with epidermoid cysts in the chiasmatic region who were operated on at the Burdenko Neurosurgery Institute in the last 5 years using an anterior extended transsphenoidal endoscopic endonasal approach. Results The epidermoid masses were totally removed in 5 patients, but in no patient was it possible to completely remove the epidermoid cyst capsule. Visual deterioration was not noted in any patient, nor did new focal neurologic symptoms appear. One of the patients developed hypopituitary disorders in the postoperative period. No recurrence of the epidermoid cysts was observed during the follow-up period. Conclusions Removal of epidermoid cysts in the chiasmatic region using an anterior extended transsphenoidal endoscopic approach may be an alternative to transcranial microsurgery operations. This technique is widely accepted as an approach to this area.

Background The collection of the greatest possible amount of pathologic tissue is of paramount importance in neurosurgery to achieve the most accurate histopathologic diagnosis, to perform all of the necessary biomolecular tests on the pathologic specimen, and to collect biological material for basic or translational science studies. This problem is particularly relevant in pituitary surgery because of the possible small size and soft consistency of tumors, which make them suitable for removal through suction, reducing the amount of available pathologic tissue. To solve this issue, we adopted a filter connected to the suction tube, which allows the surgeon to collect all of the tissue aspirated during surgery. Methods Our experience of 1734 endoscopic endonasal procedures, performed adopting this device since 1998 to December 2015, has been revised to assess its advantages and limitations. Results This system is easy-to-use, does not impair the surgical maneuvers, and does not add any relevant cost to the surgery. The tissue collected through the filter proved useful for diagnostic histologic and biomolecular analyses and for research purposes, without any relevant artifacts as a result of this method of collection. Conclusions The use of a filter has allowed us to obtain the greatest amount possible of pathologic tissue at each surgery. This surgical material has revealed to be helpful both for diagnostic and basic science purposes. The use of the filter has proven to be of particular importance for microadenomas, soft tumors, and supradiaphragmatic or skull base lesions with heterogeneous features, improving the accuracy of histopathologic diagnosis.

Objective The endoscopic extended transsphenoidal approach for suprasellar craniopharyngiomas may be a really alternative to the transcranial approach in many cases. The authors present their experience with this technique in 136 patients with craniopharyngiomas. Methods From the past 7 years 204 patients with different purely supradiaphragmatic tumors underwent removal by extended endoscopic transsphenoidal transtuberculum transplanum approach. Most of the patients (136) had craniopharyngiomas (suprasellar, intra-extraventricular). The patients were analyzed according to age, sex, tumor size, growth and tumor structure, and clinical symptoms. Twenty-five patients had undergone a previous surgery. The mean follow-up was 42 months (range, 4–120 months). The operation is always performed with the bilateral endoscopic endonasal anterior extended transsphenoidal approach. Results A gross-total removal was completed in 72%. Improvement of vision or absence of visual deterioration after operation was observed in 89% of patients; 11% had worsening vision after surgery. Endocrine dysfunction did not improve after surgery, new hypotalamopituitary dysfunction (anterior pituitary dysfunction or diabetes insipidus) or worsening of it was observed in 42.6%. Other main complications included transient new mental disorder in 11%, temporary neurological postoperative deficits in 3.7%, bacterial meningitis in 16%, cerebrospinal fluid leaks in 8.8%. The recurrence rate was 20% and the lethality was 5.8%. Conclusions Resection of suprasellar craniopharyngiomas using the extended endoscopic approach is a more effective and less traumatic technology, able to provide resection of the tumor along with high quality of life after surgery, and relatively rare postoperative complications and mortality.

Background Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives. Methods All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging. Results The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26–73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4–167) each patient is in good clinical condition with no further episodes of leaking or seizures. Conclusions Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure.

Background Tension pneumocephalus (TP), or the presence of intracranial air with additional neurologic decline, is a common complication after sinonasal surgery due to inadvertent iatrogenic damage to the dura and/or surrounding bony structures. Case description We present the case of a 69-year-old man who underwent routine trans-sphenoidal resection of a pituitary macroadenoma with an uncomplicated hospital and discharge course. The patient subsequently developed sepsis and meningitis, and a spontaneous unilateral TP developed amidst the treatment course. Intraoperatively, no active leaks or post-operative injuries were discovered. However, on post-operative imaging, an occult, bony defect was found located in the right posterior table of the frontal sinus. The patient progressively improved to stable CT Brain over 14 days with the use of short term 100% inspired oxygen and bedside subdural port placement. Conclusions This report highlights the impact of remote trauma in development of delayed tension pneumocephalus following endoscopic endonasal surgery. The clinical history, presentation, and management are reviewed.

Biochemical remission of adrenocorticotropic hormone (ACTH)-secreting macroadenomas can be challenging to achieve.1,2 Staying outside the adenoma pseudocapsule is an important technique to achieve gross total resection.1-3 Dural invasion is an important recognized factor that can prevent biochemical remission. In particular, invasion of the medial wall of the cavernous sinus has been implicated as an important determinant in remission and/or recurrence of ACTH-secreting macroadenoma.4,5 A 27-year-old patient presented with severe clinical features and biochemical workup consistent with ACTH-dependent hypercortisolism. Urinary free cortisol was nearly 10 times the upper limit of normal, and prolactin and insulin-like growth factor 1 were moderately elevated at 405 ng/mL and 577 ng/mL, respectively. Magnetic resonance imaging of the brain revealed a 2.4-cm pituitary macroadenoma contacting the left medial wall of the cavernous sinus (CS) and a compressed pituitary gland covering the right medial wall CS. The video demonstrates the technique for resection of the macroadenoma using a pseudocapsular technique with intermittent controlled central debulking to soften the tumor. The tumor had significant adherence to the left medial CS wall, and therefore the left CS was opened from a lateral-to-medial approach. Care must be taken to identify parasellar ligaments and watch for the inferior hypophyseal artery.1-3 The medial wall CS specimen revealed focal invasion of adenoma cells. The tumor stained for ACTH, prolactin, and growth hormone, and Ki-67 index was 1%. The patient went into biochemical remission postoperatively and had significant improvement in preoperative symptoms.

Trigeminal schwannomas are benign slow-growing tumors originating from the peripheral nerve sheath. They account for 0.1%–0.4% of all intracranial tumors and 1%–8% of all intracranial schwannomas. 1 , 2 , 3 While most of these tumors develop in the trigeminal ganglion within the middle fossa, trigeminal schwannomas can develop anywhere along the course of the trigeminal nerve. As a result, they can be intradural, interdural, and extradural. 4 , 5 Trigeminal schwannomas from the pterygopalatine fossa (PPF) are extremely rare and very difficult to remove because of limited access to this region and the rich neurovascular contents. Numerous traditional microsurgical approaches to the PPF have been described; however, they are more invasive with increased morbidity. 6 , 7 Therefore, endoscopic endonasal surgery is a feasible solution. This technique allows good visualization of the region with decreased morbidity and a shorter recovery period. A previously healthy, 40-year-old woman presented with right facial pain for 3 weeks. On neurologic examination, the patient had hypoesthesia in the territory of the maxillary (V2) branch of the right trigeminal nerve. She had no other symptoms on physical examination. Cranial computed tomography and magnetic resonance imaging were performed and showed a high signal density mass in the right PPF that exhibited heterogeneous contrast enhancement. She was initially treated with low-dose carbamazepine; however, the dose could not be further increased because of drowsiness and dizziness. Given the size and location of the mass, an endoscopic endonasal approach was performed, and the tumor was successfully resected ( Video 1 ). The postoperative course was uneventful, and the patient had significant improvement of her symptoms and was discharged with no new neurologic deficits. However, she continued to have hypoesthesia of the V2 segment of the trigeminal nerve.

Wanpeng Li,* Quan Liu,* Hanyu Lu, Huan Wang, Huankang Zhang, Li Hu, Xicai Sun, Yurong Gu, Houyong Li, Weidong Zhao, Dehui Wang Department of Otolaryngology-Head and Neck Surgery, Affiliated Eye Ear Nose and Throat Hospital, Fudan University, Shanghai 200031, People’s Republic of China*These authors contributed equally to this workCorrespondence: Weidong Zhao; Dehui Wang Email zhaowda@sina.com; wangdehuient@sina.comPurpose: Tension pneumocephalus (TP) caused by endoscopic endonasal surgery is a serious complication. We report four cases of TP caused by endoscopic surgery and review other cases in the literature, with special attention devoted to symptoms, imaging features, and therapeutic approaches.Methods: A retrospective chart review of patients who experienced TP caused by endoscopic surgery in our institution between 2015 and 2018 was performed. Additionally, the MEDLINE database was searched for all case series or reports of TP caused by endoscopic surgery.Results: Eighteen articles were identified for review, including four cases from the authors’ institution; ultimately, 26 cases were included in the present study. The main symptoms of TP were headache and a change in mental status. Cerebrospinal fluid (CSF) leakage was reported in 21 of the 26 patients (80.8%). Eight of the 26 patients (30.8%) presented with the “Mount Fuji sign” imaging feature. Twenty-four patients were treated with surgical intervention for TP (endoscopic multilayer closure of skull base defect, cranial burr hole, or bifrontal craniotomy). In addition, the present study is the first to report two patients with TP who were successfully treated conservatively.Conclusion: The therapeutic method for treating TP should depend on the degree of the mass effect and clinical symptoms. When patients with TP present with obvious symptoms of CSF leakage and intracranial hypertension, urgent surgical multilayer repair of the skull base defects and/or release of the intracranial pressure are keys to treating these patients. However, conservative treatment under close observation is also feasible when the related symptoms are not overtly obvious.Keywords: tension pneumocephalus, endoscopic surgery, cerebrospinal fluid, skull base

Objective To evaluate a cranial base repair method using the dural suturing technique in combination with a mucosal flap in the endoscopic endonasal approach. Methods We analyzed 190 patients (mean age, 52.3 years; age range, 3–86 years) who underwent 194 endoscopic endonasal approaches. The degree of intraoperative cerebrospinal fluid (CSF) leakage was graded based on previously published criteria: grade 0, absent; grade 1, small; grade 2, moderate; and grade 3, large. Cranial base repair using the dural suturing technique was performed according to the grade of CSF leakage: grades 1 and 2, autologous fat graft anchored by dural suturing covered with a sphenoid sinus mucosal flap, and grade 3, multilayered, inlay sutured and onlay nonsutured fascial grafts covered with a nasoseptal flap. Results Intraoperative CSF leakage was observed in 125 of 194 cases (64.4%). The degree of CSF leakage was grade 0 in 69 cases, grade 1 in 51 cases, grade 2 in 30 cases, and grade 3 in 44 cases. A postoperative CSF leak was encountered in 2 of 125 repaired cases (1.6%). Both cases with CSF leak involved grade 3 CSF leak (4.5%), and both were successfully treated with lumbar drainage. Conclusion Our graded cranial base repair method using the dural suturing technique is simple and reliable.

Background The anterior skull base is an uncommon site for brain metastases. A limited number of cases have been reported where a region of the skull base is accessed through an expanded/extended transsphenoidal route. In addition, reports of overall and progression-free survival rates are lacking. Objective To report progression-free and overall survival rates for skull base metastases treated with aggressive endoscopic endonasal surgery and radiation therapy. Methods We retrospectively review a prospective database of patients at New York Presbyterian Hospital undergoing expanded endoscopic endonasal surgery from 2004 to 2014. From this database, we identified all patients whose final pathology revealed a metastatic lesion in the midline skull base. Results Seven hundred forty-nine patients underwent endonasal endoscopic surgery. Final pathology in 12 patients (1.6%) revealed metastasis to the sellar or parasellar region. Tumors were located in the sella, suprasellar cistern, clivus, ethmoid sinuses, sphenoid sinus, cavernous sinus, and craniovertebral junction. Breast and lung cancers were the most common primary diagnoses. Gross total resection was achieved in 41.6% of patients. There were no postoperative cerebrospinal fluid leaks. Adjuvant radiation therapy was used in 92% of cases. Median follow-up was 14 months (range, 1–55). Median progression-free and overall survival were 18 and 16 months, respectively. Conclusions The range of anterior skull base metastatic lesions that can be managed endonasally has increased with the advent of extended endonasal endoscopic surgical approaches. Favorable results can be obtained with this surgical approach as part of the overall management paradigm for patients with skull base metastases.

Background The endoscopic endonasal approach for pituitary neoplasms has shown similar efficacy compared with the microscopic approach. However, outcomes and complication rates with larger macroadenomas is not as well documented. This study addresses the efficacy and outcome of the fully endoscopic endonasal approach for large and giant pituitary adenomas. Methods Endoscopic endonasal resection was performed in 39 patients with large (>3 cm) or giant (>4 cm) pituitary macroadenomas. Outcomes were assessed using formal visual examinations, endocrine status, and neurologic examinations. Statistical analyses of multiple variables were addressed for correlation to visual, endocrine, and neurologic outcomes. Results Gross total resection of the pituitary macroadenoma was achieved in 22 of 39 (56.4%) patients based on postoperative magnetic resonance imaging. Higher Knosp grade was associated with near-total resection or subtotal resection ( P = 0.0004). All patients had improved or stable visual symptoms. Time to diagnosis, preoperative visual deficit, and tumor size were not significant predictors of visual outcome. Of patients, 34 (87.1%) had a "good" endocrine outcome, whereas 5 did not. Among the 5 patients who did not have a good outcome, 1 had new hypopituitarism, and 4 required increased dosages of pharmacologic therapy. All patients with recurrent tumors had stable visual and good endocrine outcomes. Postoperative cerebrospinal fluid leak occurred in 4 patients; lumbar drainage resolved the leak in 3, and reoperation was performed in 1 patient. There were no new cranial nerve deficits, new neurologic deficits, or mortality. Conclusions Endoscopic endonasal resection of large and giant pituitary macroadenomas is safe and efficient. Postoperative complications, including cerebrospinal fluid leak, are low. Surgical efficacy of the fully endoscopic endonasal approach for large and giant macroadenomas makes the technique a preferable option in this subset of patients.