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Background: Surgical approaches to the cavernous sinus (CS) and middle cranial fossa (MCF) can be challenging, particularly for young neurosurgeons. The anteromedial (Mullan's) triangle is a triangle by the side of the CS and constitutes part of the floor of the MCF. The contents include the sphenoid sinus, superior ophthalmic vein, and sixth cranial nerve. The literature contains very little research that has precisely defined and measured the anteromedial triangle while considering anatomical variances minimally. Methodology: The present study was conducted on the skulls of 25 adult human cadavers which were dissected to expose the anteromedial (Mullan's) triangle on both sides. After precisely defining the triangle on each side, measurements of the three borders were taken, and using Heron's formula, the area of each triangle was calculated. Results: On average, the length of the medial border was 12.5 (+ 3.1 mm); the length of the lateral border was 9.9 (+ 3.1 mm); the length of the base was 10.75 (+ 2.4 mm) and the area of the anteromedial triangle was 43.9 (+ 15.06 mm2). Conclusion: Precise anatomical knowledge of the Mullan's triangle enables the treatment of disorders in often deformed anatomy or difficult-to-access structures. That is the reason it is important to gain a thorough understanding of the surgical anatomy and to adopt a safe procedure. [ABSTRACT FROM AUTHOR]

Internal carotid artery injury is one of the most feared intraoperative complications of endoscopic sinus surgery and endoscopic skull base surgery. Vidian canal is used as a landmark to identify laceral genu of ICA. But, this structure leads to the lateral aspect of the genu and so, there is still a possibility of injuring the genu, if we blindly follow this landmark. So, to find out a more reliable landmark to locate ICA, we conducted a computed tomography-based study in our institution. The aim was to evaluate the anatomical variations in position of palatovaginal canal in relation to laceral genu of ICA. The primary objective was to know the anatomical relation of medial opening of PVC to laceral genu of ICA, and the secondary objective was to measure the distance between these two structures. CT paranasal sinus images of 105 patients were collected and axial cuts evaluated to find out the anatomical relation between PVC and ICA. In 97.1% of the scans, laceral genu of ICA was found lateral to medial opening of PVC, and in the rest 2.9%, both structures were found to lie in the same line. In 62.9% of the patients, the distance between the two structures was found to be between 3.1 and 6 mm. The inter-palatovaginal canal corridor can possibly be considered as a safe corridor to clival region of sphenoid sinus. This corridor can be easily identified intraoperatively during endoscopic skull base surgeries So, if the surgeon limits the instrumentation to the inter-palatovaginal canal corridor, iatrogenic injury to ICA, one of the most dreaded complications, can be avoided, while working in the clival region of sphenoid sinus. [ABSTRACT FROM AUTHOR]

Background: The posterior ethmoid sinuses have a complex anatomy and a highly variable normal structure. The posterior ethmoid Onodi cell needs careful assessment because of its proximity to the optic nerve and the internal carotid artery canal. Recognising the distinctions is essential for optimal pre-op preparation. Sphenoid sinus surgery can now be performed without worrying about compromising vital structures like the internal carotid artery or optic nerve. Preoperative radiological assessment is a quick and easy way to check for ethmoid cell pneumatisation differences. Aim and objectives: To determine the pneumatisation patterns of Onodi cells among the North-East Indian population using 16-slice multidetector computed tomography (MDCT). Results: Nine-hundred MDCT paranasal sinuses were analysed over a period of 0–2 years, out of which 220 cases showed the presence of Onodi cell. Type I were 89 cases (40.45%, CI 32.00–48.90), Type II were 128 cases (58.18%, CI 49.72–66.63), and 3 cases with Type III cell (1.36%, CI 0.18–2.54). Conclusion: The most prevalent pneumatisation pattern is Type II. The pneumatisation patterns of Onodi cells can be best detected and evaluated by multiplanar MDCT imaging. Sinus surgeons need a firm grasp of pneumatisation patterns to avoid damaging the optic nerve and internal carotid artery canal during operations. [ABSTRACT FROM AUTHOR]

Cerebrospinal fluid (CSF) leakage is a common complication associated with endoscopic endonasal skull-base surgery (EESBS). Postoperative mobilization-associated postural changes are considered to cause CSF leakage. However, no study has demonstrated a robust relationship between postural changes and CSF leakage. We used upright computed tomography (CT) to clarify the effects of postural changes on the reconstructed skull base (RSB) after EESBS. Thirty patients who underwent EESBS at our institution were prospectively included, and their upright and supine CTs were compared to measure morphological changes in the RSB. Patient clinical data were also collected from medical charts and surgical videos, and their relationships with morphological changes were assessed. In upright CTs, the RSB shifted intracranially by 0.94 (0.0–2.9) mm on average. This shift was larger in cases with lesions extending to the sphenoid sinus, dural defects, intraoperative pulsation of the RSB, and large bone windows. The direction of the change was opposite to intuitive movement driven by gravity because of reduced intracranial pressure in the sitting position. Thus, these shifts can be directly associated with postoperative CSF leakage caused by reconstruction material displacement. Skull-base reconstruction and postoperative postural management accounting for these morphological changes may be necessary for preventing CSF leakage. [ABSTRACT FROM AUTHOR]

Adenoid cystic carcinoma (AdCC) is a salivary gland neoplasm that infrequently appears in the sinonasal region. The aim of this study was to evaluate the outcome and clinicopathological parameters of sinonasal AdCC. A retrospective analysis was conducted on all cases of AdCC affecting the nasal cavity or paranasal sinuses between 2000 and 2018 at the University Hospital Zurich. Tumor material was examined for morphological features and analyzed for molecular alterations. A total of 14 patients were included. Mean age at presentation was 57.7 years. Sequencing revealed MYB::NFIB gene fusion in 11/12 analyzable cases. Poor prognostic factors were solid variant (p < 0.001), histopathological high-grade transformation (p < 0.001), and tumor involvement of the sphenoid sinus (p = 0.02). The median recurrence-free survival (RFS) and OS were 5.2 years and 11.3 years. The RFS rates at 1-, 5-, and 10-year were 100%, 53.8%, and 23.1%. The OS rates at 1-, 5-, and 10- years were 100%, 91.7%, and 62.9%, respectively. In Conclusion, the solid variant (solid portion > 30%), high-grade transformation, and sphenoid sinus involvement are negative prognostic factors for sinonasal AdCC. A high prevalence of MYB::NFIB gene fusion may help to correctly classify diagnostically challenging (e.g. metatypical) cases. [ABSTRACT FROM AUTHOR]

Background: The sphenoid wing dural arteriovenous fistula (AVF) is rare, and can manifest with severe symptoms, particularly in cases classified as greater sphenoid wing type. Endovascular therapy is generally employed, however, open surgical intervention could be warranted in cases with complex fistula. Method: We present a case with ruptured greater sphenoid wing dural AVF (Cognard type IV), in which endovascular embolization using liquid material was performed, followed by open surgery to concurrently disconnect the fistula and evacuate the hematoma. Conclusion: The sphenoid wing dural AVFs may be effectively cured by open surgery for fistula disconnection in conjunction with endovascular embolization. [ABSTRACT FROM AUTHOR]

Primary cranial meningioma is extremely rare and only rarely described in clinical practice, as is primary sinus ectopic meningioma. We detailed the surgical management of a female patient, aged 83, who had a primary meningioma of the sphenoid sinus. This uncommon clinical entity was the subject of a study of the literature, and its prognosis was summarized. [ABSTRACT FROM AUTHOR]

Fungal rhinosinusitis accounts for a significant portion of paranasal sinus diseases, with fungus ball being the most frequently observed form, constituting 27% of cases. While commonly affecting the maxillary sinus, sphenoid sinus localization occurred in 24.78% of cases. Managing fungal balls in the sphenoid sinus poses challenges because of their proximity to critical structures, necessitating a careful and effective approach. A retrospective analysis was conducted on patients diagnosed with a paranasal sinus fungal ball, specifically isolated sphenoidal localization. Trans-nasal sphenoidotomy was performed, and the patients were followed up postoperatively for recurrence or residual disease. Among four identified cases, headache was the predominant symptom, and all patients underwent successful endoscopic surgery without complications. The follow-up revealed no recurrence or residual disease. Fungal ball in the sphenoid sinus, although uncommon, present diagnostic challenges with symptoms that often mimic other conditions. CT scans play a crucial role in diagnosis and reveal dense masses with characteristic features. Surgical intervention, particularly endoscopic sphenoidotomy, remains the primary and successful treatment, emphasizing the importance of early detection. This study emphasizes the effectiveness of endoscopic sphenoidotomy for managing isolated sphenoid sinus fungal ball. This also highlights the importance of early detection and treatment to prevent complications. Headache, a primary symptom, was successfully resolved after surgery, reinforcing the role of surgery as the primary treatment. [ABSTRACT FROM AUTHOR]

Purpose: To describe the relation of the sphenoid ridge (SR) with the surrounding anatomical structures in healthy children when approaching the anterior and middle fossae. Methods: Computed tomography of 180 pediatric patients (90 males / 90 females), aged 1–18 years were included the study. The size of the lesser wing (LW) and the distances of the LW to certain landmarks were measured. Results: The LW length was 28.48 ± 8.15 mm. The LW widths at the midline and the midpoint and lateral point of the SR were 7.78 ± 1.74 mm, 2.84 ± 0.81 mm, and 1.91 ± 0.64 mm, respectively. The distance between the midpoint of the SR and the crista galli was 28.22 ± 5.56 mm, and the distance between the crista alaris and internal auditory meatus was 51.73 ± 5.79 mm. The linear function was calculated as y = 18.748 + 1.024 × age for SR length, y = 6.046 + 0.182 × age for the midline width of SR, y = 2.367 + 0.050 × age for the midpoint width of SR, y = 1.249 + 0.069 × age for the crista alaris width, y = 21.727 + 0.683 × age for the distance between the SR midpoint and the crista galli, and y = 43.614 + 0.855 × age for the distance between the crista alaris and internal auditory meatus. Conclusion: All measured parameters increased irregularly with advancing age. Furthermore, our regression equations representing the growth dynamics of SR may be used to estimate these parameters. [ABSTRACT FROM AUTHOR]

Background: Recent literature highlights anomalous cranial nerves in the sinonasal region, notably in the sphenoid and maxillary sinuses, linked to anatomical factors. However, data on the suspended infraorbital canal (IOC) variant is scarce in cross-sectional imaging. Anatomical variations in the sphenoid sinuses, including optic, maxillary, and vidian nerves, raise interest among specialists involved in advanced sinonasal procedures. The infraorbital nerve's (ION) course along the orbital floor and its abnormal positioning within the orbital and maxillary sinus region pose risks of iatrogenic complications. A comprehensive radiological assessment is crucial before sinonasal surgeries. Cone-beam computed tomography (CBCT) is preferred for its spatial resolution and reduced radiation exposure. Objective: The aim of this study was to describe the prevalence of anatomical variants of the infraorbital canal (IOC) and report its association with clinical condition or surgical implication. Methods: We searched Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception up to June 2023. Two authors independently performed the search, study selection, data extraction, and assessed the methodological quality with assurance tool for anatomical studies (AQUA). Finally, the pooled prevalence was estimated using a random effects model. Results: Preliminary results show that three types are prevalent, type 1: the IOC does not bulge into the maxillary sinus (MS); therefore, the infraorbital foramen through the anterior wall of MS could be used for identification of the ION. Type 2: the IOC divided the orbital floor into medial and lateral aspects. Type 3: the IOC hangs in the MS and the entire orbital floor lying above the IOC. From which the clinical implications where mainly surgical, in type 1 the infraorbital foramen through the anterior wall of MS could be used for identification of the ION, while in type 2, since the lateral orbital floor could not be directly accessed an inferiorly transposition of ION is helpful to expose the lateral orbital wall directly with a 0 scope; or using angled endoscopes and instruments, however, the authors opinion is that direct exposure potentially facilitates the visualization and management in complex situations such as residual or recurrent mass, foreign body, and fracture located at the lateral aspect of the canal. Lastly, in type 3, the ION it's easily exposed with a 0° scope. Conclusions: This systematic review identified four IOC variants: Type 1, within or below the MS roof; Type 2, partially protruding into the sinus; Type 3, fully protruding into the sinus or suspended from the roof; and Type 4, in the orbital floor. Clinical recommendations aim to prevent nerve injuries and enhance preoperative assessments. However, the lack of consistent statistical methods limits robust associations between IOC variants and clinical outcomes. Data heterogeneity and the absence of standardized reporting impede meta-analysis. Future research should prioritize detailed reporting, objective measurements, and statistical approaches for a comprehensive understanding of IOC variants and their clinical implications. Open Science Framework (OSF): https://doi.org/10.17605/OSF.IO/UGYFZ. [ABSTRACT FROM AUTHOR]

Purpose: This examination aimed to display the size and topographic position of the Vidian canal (VC) in normal children. Methods: 180 pediatric subjects aged 1–18 years were included this computed tomography examination. The distances of VC to certain landmarks, and VC length were measured. The locations of VC according to the sphenoid sinus, and the medial plate of pterygoid process were classified as three types, separately. Results: The distances of VC to the vomerine crest, midsagittal plane, round foramen, and the superior wall of sphenoid sinus were measured as 12.68 ± 3.17 mm, 10.76 ± 2.52 mm, 8.62 ± 2.35 mm, and 14.16 ± 5.00 mm, respectively. The length and angle of VC were measured as 12.00 ± 2.52 mm, and 16.60 ± 9.76°, respectively. According to the sphenoid bone, VC location was identified as Type 1 in 113 sides (47.5%), as Type 2 in 70 sides (29.4%), and as Type 3 in 55 sides (23.1%). According to the medial plate of pterygoid process, VC location was identified as Type A in 274 sides (76.1%), as Type B in 55 sides (15.3%), and as Type C in 31 sides (8.6%). VC location types correlated with pediatric ages, but not sex or side. Conclusion: With advancing pediatric age, the protrusion of VC into the sphenoid sinus increases, and VC shifts from medial to lateral side of the medial plate of pterygoid process. [ABSTRACT FROM AUTHOR]

Isolated sphenoid sinus disease is a rare paranasal sinus (PNS) problem, comprising only 2–3% of cases of sinonasal diseases. It is caused mainly by inflammation, and neoplastic causes are exceedingly rare. Due to the nonspecific nature of the symptoms and possible complications, the proper diagnosis and treatment has paramount importance. A 53-year-old woman with a history of diabetes experienced sudden paralysis of the right side of her body and face. A diagnostic workup revealed an acute infarction in her left medial pons and the left midbrain. However, an abnormal finding in her sphenoid sinus caught the neurologist's attention, which led to a consultation with the otorhinolaryngology service. During the sinonasal endoscopy, the surgeon detected the presence of secretions and fungal debris in the nasopharynx and sphenoid sinus. Following the surgery, antifungal treatment began. The pathology report revealed that the fungal ball was most likely caused by aspergillosis. According to the neurologist's opinion and the imaging results, the inflammation and infectious activity in the patient's sphenoid sinus may have damaged the basilar artery and caused the observed symptoms. This finding underlines the vital significance of the accurate diagnosis and treatment of sphenoid sinus disease, as it can prevent further complications. [ABSTRACT FROM AUTHOR]

Solitary fibrous tumors (SFTs) belonging to a distinct group of mesenchymal tumors, was originally described by Klemper and Rabin in the pleura in year 1931. However, it can also be extra-pleural in origin. With tongue being the most common site involved in this region, epiglottis, larynx, thyroid, external auditory canal, lacrimal sac, hypoglossal nerve, parotid gland, sublingual gland, Para pharyngeal space, nasopharynx, scalp, gingiva, orbit and infratemporal fossa as well as paranasal sinuses and nasal cavities can also get involved. But SFTs involving nasal cavities and nasopharynx are quite uncommon, accounting for < 0.1% of all Sino-nasal neoplasms. Until now there have only been 40 cases of nasal SFT reported in literature. We report the case of an extraserosa solitary fibrous tumor arising from the nasal cavity with extension to the sphenoid sinus, a much rarer presentation of its type. Our case report is one of its type, emphasizing the need conducting further studies on the nature and management of the disease. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to investigate that complicated mucoceles of paranasal sinuses and their clinical presentation, complications of relations with size, destructions areas, extension limits in affected patients. Materials and methods: A retrospective review was performed on patients who were diagnosed and treated as paranasal sinus mucoceles at ENT department from 2002 to 2013 years. Patients' demographic data, mucoceles location, symptoms, surgical approach and complications were evaluated. Results: The study group included 9 male and 10 female patients with a mean age of 45,0 years (range, 12–76 years). This case series include fronto-ethmoidal complex (52,6%), followed by frontal (26,3%), maxillary (15,7%) and sphenoid sinus mucoceles (5,2%). Endoscopic sinus surgery (ESS) was performed on 11 patients (57.8%); endoscopic procedures included marsupialization through an infundibulotomy, associated with an anterior ethmoidectomy and maxillary sinus antrostomy. Four patients (21%) underwent an external surgical procedure. 8 patients (42%) were treated by a combination of both endoscopic and external approaches such as trephination of the anterior wall of the frontal sinus, osteoplastic flap approach, Caldwell-Luc operation, anterior craniotomy and Lynch procedure. Complications occurred only in 2 cases (10.5%). Conclusion: The majority of patients with extensive paranasal sinus mucoceles exhibited ophthalmologic and intracranial symptoms. A satisfactory outcome can be achieved after surgical treatment of both endoscopic and external approaches. [ABSTRACT FROM AUTHOR]

The purpose of this study was to analyze the volume and area of sphenoid sinuses of Brazilian individuals' cone-beam computed tomography (CBCT) images using the beta version of the DDS-Pro™ 2.14.2_2022 software (DPP Systems, Czestochowa, Poland), to assess a potential correlation to sex, age, skin color, and nutritional status, and to evaluate differences between the right and left sides. Three-dimensional volume and area measurements were made with the software using CBCT images of 113 living Brazilian individuals of both sexes (67 females and 46 males). TEM, rTEM, and R were used to assess the reproducibility of inter- and intra-examiner measurements. The measurement means were estimated with 95% confidence intervals according to sex and age group. There were no significant differences between the left and right sides for both volume and area and between the sexes and black and white individuals. Volume and area were significantly higher in 18 years or older (p < 0.05) and in individuals with normal body mass index (BMI) (p < 0.05). The obtained results do not allow indicating the use of sphenoid sinuses volume and area measurements to estimate sexual dimorphism, and the same occurred for skin color. However, such measures can help to estimate age. Further studies are suggested with a larger sample, especially for the nutritional status variable. [ABSTRACT FROM AUTHOR]

Background: In human anatomy, there are well-known the foramina of the greater sphenoidal wing, the foramen rotundum, the foramen ovale, the foramen spinosum, as well as the inconstant sphenoidal emissary foramen of Vesalius and the foramen of Arnold. Different canals are found in several species of rodents, such as the alisphenoid and sphenopterygoid (SPC) canals. Method: It was re-explored an archived computed tomography angiogram of a 60 y.o. female case. Results: Bilateral superior recesses of the pterygoid fossae (SRPF) and a right SPC were found. The SRPF on each side penetrated the non-lamellar pterygoid root and superiorly reached the sphenoidal sinus wall. Upper fibres of medial pterygoid muscles were inserted into each SRPF. An unexpected SPC was found on the right side. It opened superiorly on the lateral side of the foramen rotundum and inferiorly at a pterygoid foramen in the superior end of the posterior margin of the lateral pterygoid plate. A sphenoidal emissary vein traversed that SPC to drain into the pterygoid plexus. Conclusion: The SRPF and SPC could also be found in humans. As the sphenoidal emissary veins are surgically relevant, they should not be further regarded as exclusively crossing the foramen of Vesalius but also the SPC. [ABSTRACT FROM AUTHOR]

Purpose: To measure the volume of the sphenoid and ethmoid sinuses and to analyse the asymmetry index values by age/gender. Methods: Three-dimensional (3D) Computed Tomography (CT) images of 150 individuals (75 females, 75 males) of both sexes between the ages of 18–75 were included in our study. Sphenoid and ethmoid sinus volumes were measured using the 3D Slicer software package on these images, and the asymmetry index was calculated. Results: In our study, mean sphenoid sinus volume (female right: 4264.4 mm3, left: 3787.1 mm3; male right: 5201.1 mm3, left: 4818.2 mm3) and ethmoid sinus volume (female right: 3365.1 mm3, left: 3321.2 mm3; male right: 3440.9 mm3, left: 3459.5 mm3) were measured in males and females. Left sphenoid sinus values of males were statistically higher than females (p = 0.036). No statistically significant relationship existed between age, sinus volumes, and asymmetry index (p > 0.05). A statistically weak positive correlation existed between males' left sphenoid and ethmoid sinus volume (rho = 0.288; p = 0.012). There was no statistical relationship between asymmetry index in the whole group (p > 0.05). A statistically weak negative correlation was found between sphenoid and ethmoid sinus asymmetry index in males (rho=-0.352; p = 0.002). There was no statistical relationship between asymmetry index in females (p > 0.05). Conclusion: Knowing paranasal sinus morphology, morphometry, and asymmetry index value will be significant for preoperative and postoperative periods. [ABSTRACT FROM AUTHOR]

Inverted papilloma is a tumor found involving the nasal cavity and paranasal sinuses. They are not cancerous but can be locally aggressive. They are most commonly seen involving the lateral wall of nose and maxillary sinus. When the tumor involves the frontal sinus and sphenoid sinus or the post ethmoid cells it presents a surgical challenge. Inverted papilloma almost always occur unilateraly and affect mainly the maxillary sinus. Inverted papilloma arising from the sphenoid and frontal sinuses are rare. Here we present two cases; one involving a 60 year man, with inverted papilloma originating from the frontal sinus and another case where it originated from the sphenoid sinus anterior wall and posterior ethmoidalcell (Onodi cell) and was resected endoscopically. [ABSTRACT FROM AUTHOR]

Spontaneous cerebrospinal fluid (CSF) leaks are an uncommon clinical entity, often challenging to diagnose accurately. We present a unique case of a patient with symptoms suggestive of an ethmoidal CSF leak, initially supported by radiological findings, but ultimately revealed to be a mid-clival CSF leak (from the posterior wall of the sphenoid sinus). This case underscores the complexities of diagnosing CSF leaks and highlights the importance of surgical exploration in cases where radiological evidence appears contradictory. The patient's Computed Tomography scan indicated a CSF leak in the cribriform plate, prompting a surgical approach to address this region. However, intraoperative findings surprisingly revealed no evidence of leak in the cribriform plate but instead a posterior wall of the sphenoid defect as the culprit. This report emphasizes the critical role of interdisciplinary collaboration, meticulous preoperative and intraoperative assessment, and adaptability in managing challenging cases of CSF leaks, ultimately leading to successful surgical repair and improved patient outcomes. It serves as a valuable reminder for clinicians to consider the possibility of a masquerading CSF leak when clinical and radiological findings do not align, thereby facilitating more precise diagnosis and targeted treatment. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study is to investigate the effect of sphenoid sinus pneumatization types, Onodi cell (OC), internal carotid artery (ICA), optic nerve (ON) on sinus volume and area on computed tomography (CT) images. Methods: The CT images of 150 patients were evaluated. Sphenoid sinus pneumatization types, OC prevalence, protrusion and dehiscence of ICA and ON, the volume and area were evaluated. Results: The sinus volume and area were statistically higher in patients with bilateral protrusion of ICA and ON then patients without protrusion of ICA and ON. The mean volume and area of sinus were 9949.4 ± 351.0 mm3 and 4570.9 ± 1604.9 mm2, respectively. The volume and area of sphenoid sinus did not differ significantly between groups with and without OC. The postsellar b type sphenoid sinus had the highest volume, while conchal type has the least volume. Conclusions: Bilateral protrusion and dehiscence of ICA and bilateral protrusion of ON caused a significant increase in the sphenoid sinus volume and area. The presence of ICA and ON, the pneumatization of the sinus is an anatomical structure that can affect the sinus volume and area. Before the operation, three-dimensional evaluation should be performed to determine whether these structures are bilateral/unilateral and it should be remembered that the sinus volume and area can change. [ABSTRACT FROM AUTHOR]

Introduction- Endoscopic minimally invasive pituitary surgery (MIPS) is advantageous over microscopic technique, as it provides superior close up, wide angle view of surgical target area. Image guided navigation system (IGNS) guides the surgeon to localize the lesion. In the present study we analyzed the Image Guided Surgical procedure and outcome of Endoscopic minimally invasive pituitary surgery and shared our experiences regarding disease clearance. Materials and methods: During the period of April 2015 to August 2022 a total 104 patients, diagnosed with pituitary adenoma underwent surgery and further followed up in a multidisciplinary team approach in a tertiary care hospital of Kolkata, India. The data obtained were reviewed statistically to satisfy the study objectives. Results: Total 104 operations were done on 98 patients and total cases taken for calculation and analysis was 98, which consist of 11 microadenomas, 81 macroadenomas. Among 35 patients with normal preoperative hormonal assay, one patient developed postoperative hypopituitarism. Among 6 patients with preoperative hypopituitarism 4 patients (66.6%) recovered after surgery. Overall, 85 cases had total disease clearance as detected on post-operative MRI. In functioning pituitary adenoma (FPA) clinical and endocrinological improvement occurred after primary surgery in 85.36% (n = 35) and after revision surgery it was 84.44% (n = 38). Macroadenomas, giant adenomas were found to have statistically significant higher risk of incomplete disease clearance but large adenomas do not have statistically higher risk of incomplete clearance. Conclusion: IGNS requires extra time for setup, but with proper registration of tracker instruments it adds precision to the surgery. IGNS supplements endoscopic visualization with localization of target lesion by real time stereotactic feedback using preset preoperative imaging data, thus increasing accuracy, safety and effectiveness of minimally invasive surgery. [ABSTRACT FROM AUTHOR]

The aim of this study was to analyse the relationship between frontal sinus pneumatization and its effect on various variations of paranasal sinuses on paranasal sinus CT scan. A total number of 100 patients (51 males, 49 females) were included in this study. Patients were divided into three groups on the basis of their frontal sinus pneumatization extent on paranasal sinus CT as Type 1 pneumatization (aplasia and hypoplasia), Type 2 pneumatization (medium) and Type 3 pneumatization (hyperplasia). The prevalence of various variations like pneumatization of upper and middle turbinate, presence of agger nasi, Haller and Onodi cell, maxillary sinus hypoplasia, extent of sphenoid sinus pneumatization, pneumatization of anterior clinoid process, pterygoid process and greater wing of sphenoid sinus, dehiscence and protrusion of internal carotid artery and optic nerve types were ascertained and compared within each group. The prevalence of Onodi cell, anterior clinoid process and greater wing of sphenoid pneumatization and optic nerves type 3 and 4 were higher in Type 3 frontal sinus pneumatization group as compared with other groups. Excessive pneumatization of frontal sinus has various effects on paranasal sinus variations. Surgeons dealing with endoscopic sinus surgery, maxillofacial and skull base surgery must be vigilant of association between these variations preoperatively for avoiding complications. [ABSTRACT FROM AUTHOR]

Background: Cystic fibrosis (CF) is a severe systemic disease that affects many aspects of patients' lives. It is known that the progression of the disease adversely affects lower and upper airways including the paranasal sinuses. However, its impact on sinus development in the pediatric population is not fully examined. The purpose of this study was to evaluate the development of the paranasal sinuses in a pediatric population with CF and compare it to a control group consisting of healthy children. Methods: The results of computed tomography (CT) scans of children with the disease and the control group were evaluated. The study included 114 CT images of children in the study group and 126 images of healthy children aged 0–18 years. The volumes of maxillary, frontal, and sphenoid sinuses were analyzed. The obtained results were compared with those of the control group and analyzed statistically. Results: The volume and the development of the paranasal sinuses in both groups increased with age, but statistically significant differences were found between the study and the control group. Conclusions: The obtained results provide valuable knowledge regarding the impact of the CF on sinuses development. Also, they may be important in understanding the progression of the disease and its influence on the quality and length of life of patients. The results may contribute to enhanced diagnostics and have implications for improving therapy for patients with chronic sinusitis associated with CF. [ABSTRACT FROM AUTHOR]

Background: Sphenoid sinus (SS) is an important landmark for endoscopic sinus surgery (ESC) and endoscopic skull base surgery. This study examines the relation of the extent of pneumatization of the sphenoid sinus with adjacent vital structures such as the internal carotid artery, optic canal, and Vidian nerve by using paranasal sinus computed tomography (PNSCT). Methods: The study was designed retrospectively. PNSCT images in axial, coronal, and sagittal planes on both sides (right, R; left, L) were examined for sphenoid sinus, Vidian canal (VC), optic canal (OC), and carotid canal (CC) bilaterally. Results: The carotid canal did not show identification on the SS wall in females compared to males bilaterally (right, p= 0.002 and left, p= 0.002). The mean age was significantly higher in patients with a presellar type of sphenoid sinus (p=0.003). The mean age was significantly lower on the right side with a VC completely within the sphenoid sinus (p=0.005). The mean age of patients with an optic canal protrudation to the SS wall was significantly higher than patients with an optic canal indentation to the SS wall (p= 0.007). On the left side, cases with an optic canal protruding to the SS wall were older than cases with an optic canal indentation to the SS wall (p= 0.008). SS variations on the sagittal plane were significantly correlated with RVC, RCC, LVC, and LCC variations. Also, SS variations on the coronal plane were significantly related to types of LVC and RVC. Conclusions: Pneumatization of SS significantly affects the development of surrounding vital structures, especially with increasing age. [ABSTRACT FROM AUTHOR]

Purpose: Endoscopic endonasal approaches in the pediatric population pose specific challenges. Management of postoperative cerebrospinal fluid [CSF] leak is probably the major concern. The purpose of the present investigation is to describe and analyze the incidence of postoperative CSF leaks in our pediatric series of endoscopic endonasal approaches. Methods: This is a retrospective analysis, case review of our institutional series. Descriptive statistical parameters and bivariate correlations are analyzed. Results: Twenty-one patients have been operated through endoscopic approaches in our series. Four patients showed a postoperative CSF leak needing a revision surgery; these cases are described in further detail. Approaches expanded beyond the sellar area and non-sellar pneumatization of the sphenoid sinus were significantly associated with a higher risk of postoperative CSF leak. Conclusions: CSF leak incidence after endoscopic endonasal approaches is higher in pediatric patients than in adult series. Anatomic and pathologic factors add complexity to these approaches in children. Multilayer closure is advisable to prevent and treat this complication. [ABSTRACT FROM AUTHOR]

Background: The standard endoscopic endonasal approach gives access to the median sphenoid sinus, but not to its lateral part. We propose an endoscopic technique for lesions in the lateral sphenoid sinus. Method: Based on our experience with 28 patients, we have developed a less invasive approach to the lateral recess of the sphenoid sinus, limiting the opening of the maxillary sinus while avoiding resection of the inferior turbinate and ethmoidal cells. The technique is described. Conclusion: The proposed endoscopic approach is reliable and safe to treat CSF leak or tumours located within the lateral recess of the sphenoid sinus. [ABSTRACT FROM AUTHOR]

The purpose of our study was to assess the prevalence of variations and type of sphenoid sinus and its adjacent structures pneumatization and its significance. This prospective study included 114 patients who underwent CT of the paranasal sinuses. The CT scan in axial, coronal and mid sagital section were analysed to assess the type of pneumatization of the sphenoid sinus and its adjacent structures like; anterior clinoid process, greater wing of sphenoid and pterygoid process. The sphenoid sinus pneumatization was classified into Conchal, Presellar, and Sellar types, later comprised of sellar and post-sellar types. Out of 114 cases of pneumatized sphenoid sinus, 5.2% cases were conchal type, 26.3% cases Presellar type and 68.4% cases sellar type. The one or more adjacent structures was pneumatized in 71 (62.2%) of cases. The adjacent structures which found to be pneumatized are anterior clinoid process in 26.3%, Pterygoid process in 23.6%, and greater wing of sphenoid in 12.3% cases. The pneumatization of adjacent structures was more prevalent in sellar type of sphenoid sinus, followed by pre-sellar type and no pneumatization in conchal type. The anterior clinoid process pneumatization was present in 26.1% of cases, in which 3 (2.6%) cases in pre-sellar type and 27 (23.5%) cases in sellar type. It was unilaterally pneumatized in 13 (11.4%) and bilaterally in (17 (14.9%) cases. The pterygoid process pneumatization was present in 27 (23.6%) of cases, unilateral in 16 (14%) cases and bilateral in 11 (9.6%) cases. The Greater wing of sphenoid pneumatization was found in 14 (12.3%) cases, no cases in conchal types, 2 (1.8%) in pre-sellar type, and 12 (10.4%) in sellar type There was no statistically difference found in between right and left side of sphenoid sinus and its structure pneumatization. The extent of pneumatization of the sphenoid sinus has clinical and surgical implications in sinus diseases, sellar and central skull base lesions. [ABSTRACT FROM AUTHOR]

Aims: To determine the best technique to repair anterior skull base defects using various grafts. Materials & Methods: This Ambi-directional cohort study was carried out at a tertiary care hospital from May 2019 to October 2021. A total of 17 patients who underwent Endoscopic Repair of Anterior Skull Base Defects using various grafts were included in the study. Detailed history and clinical evaluation followed by Diagnostic Nasal Endoscopy, Biochemical and Radiological investigations were done for all patients with postoperative follow-up for at least 6 months. Results: Most common site of anterior skull base defect in our study group was the posterior wall of the sphenoid sinus. Various graft materials used in our study were fascia lata, thigh fat, Hadad flap, Septal cartilage, nasal septal bone chip, septal mucosal free flap, surgicel and fibrin glue. The most commonly used sequence of graft materials used is the fat(underlay) - fascia lata - fat(overlay). Various complications that occurred were nasal bleeding, residual CSF leak, localized collection of pus in the Septal region, cerebral oedema and Alar trauma. Conclusions: The success of Anterior skull base defect repair depends on watertight Dural closure with multiple layers of grafts to prevent postoperative CSF leak. Although dependent on the Surgeon's preference, usually the sequence of an underlay fat - fascia lata - overlay fat followed by glue/gel foam/Hadad flap works well. Even after discharging the patient, regular follow-up and evaluation ensure that the graft is in situ and there is no CSF leak or other complication. [ABSTRACT FROM AUTHOR]

The authors aimed to develop an extensive preoperative checklist of CT scan findings during endoscopic access to the ventral skull base and implement it in clinical practice. A comprehensive literature review was conducted to identify the radiological landmarks crucial to endoscopic skull base surgery. Four electronic databases were searched: PubMed, MEDLINE, EMBASE, and Google Scholar using search terms/keywords such as "radiological landmarks," "endoscopic skull base surgery," "CT scan," "pituitary surgery," "anatomical variations," "internal carotid," "optic nerve," "sphenoid sinus," "pneumatization," "dehiscence," and "protrusion". Inclusion criteria were limited to original articles and systematic reviews published in English, between the years 2000 and 2021, which pertained to the radiological landmarks to be identified during endoscopic skull base surgery. Full-text articles were retrieved and collated into a narrative review focused on a 12-item checklist the authors agreed upon. The mnemonic "O ROAD TO SELLA" was used to represent the checklist and include the following landmarks: Sphenoid Ostium, Sphenoid Rostrum, Onodi cells, Anatomic variations of the sphenoid sinus, Distance between the carotids, Tumor characteristics, Optic nerve dehiscence/protrusion, Septation/insertion of the sphenoid sinus, Entrance to the sellar floor, Lateral recess of the sphenoid sinus, cLinoid process pneumatization, and internal carotid Artery dehiscence/protrusion. The checklist is designed to be used by attending physicians, fellows, and residents and the authors intend to implement it into electronic medical records at the institution's medical center to monitor the outcomes of EEPS after implementation. [ABSTRACT FROM AUTHOR]

Purpose: Inverted papilloma of the sphenoid sinus (IPSS) is a rare tumor with debated surgical management due to its proximity to vital structures. The aim of this manuscript is to highlight the role of a transpterygoid approach (TPA) and pedicle-orientated strategy in case of involvement of critical structures in IPSS and compare it with data from the literature. Methods: Patients with primary IPSS between January 2000 and June 2021 were included. Pre-operative CT/MRI were analyzed to classify the pneumatization of the SS and predict the insertion point of the inverted papilloma. All patients were treated with a trans-sphenoidal approach which was combined with a TPA in case of lateral insertion point. A systematic search was also performed to summarize the available literature. Results: Twenty-two patients were treated for IPSS. By CT, the SS was categorized with type III pneumatization in 72.8% of cases. Eleven patients (50%) were treated with a TPA with a statistical association with the insertion point on the SS lateral wall (p = 0.01), rather than a SS pneumatization (p = 0.63). The overall success was 95.5% after a mean follow-up of 35.9 months. For the literature, 26 publications were included on 97 patients and described a trans-sphenoidal approach with a success rate of 84.6% after a mean follow-up of 24.5 months. Conclusion: IPSS is generally treated with a sphenoidotomy approach, although in selected cases, a TPA should be preferred to expose the whole SS lateral wall though allowing a complete pedicled oriented resection of the tumor. [ABSTRACT FROM AUTHOR]

Background: Osteosarcoma usually arises from primitive bone-forming mesenchymal cells. Metaphyseal growth plates of long bones are the usually affected site. Though it is the most common primary bone malignancy, only 6–10% of osteosarcomas are craniofacial. In the sinonasal region, the commonly involved sites reported in the literature are maxillary and ethmoid sinus. Sphenoid sinus has been the least commonly involved site among the paranasal sinuses and only a handful of cases have been reported. Methods: A rare case of osteosarcoma involving the sphenoid and ethmoid sinus was presented to our institute and he was managed surgically and with postoperative chemotherapy. Further, an internet-based literature search was conducted to detect cases of osteosarcoma involving sphenoid sinus only as well as combined sphenoid and ethmoid sinus. Results: About 13 articles (13 patients), which fulfilled our inclusion and exclusion criteria were included in our study. Out of the 14 patients (including the present case), 5 patients (100%) who underwent both modes of adjuvant therapy were alive during the final follow-up. On the other hand, among those who received single adjuvant therapy, only one patient was alive (33.3%) and two patients died (66.6%). Conclusion: Osteosarcomas are highly malignant primary bone neoplasms with rare occurrence in the head and neck region. It constitutes a therapeutic challenge because of its anatomical location and the known side effects of chemotherapy. Timely intervention with a multidisciplinary approach is necessary to avoid death in these patients. [ABSTRACT FROM AUTHOR]

Purpose: Worldwide, the incidence of chronic fungal rhinosinusitis (CFRS) has increased. Although ageing leads to weakening of the immune system, which increases susceptibility to CFRS, the CFRS characteristics in geriatric patients are unclear. Therefore, we comparatively analysed the clinical characteristics of CFRS in geriatric and non-geriatric patients. Methods: This retrospective analysis compared the demographics, rhinologic symptoms, multiple allergen simultaneous tests, olfactory function tests, paranasal sinus computed tomography findings, and outcomes of 131 patients with CFRS who underwent functional endoscopic sinus surgery and 131 enrolled patients were divided in geriatric (> 65 years) and non-geriatric (≤ 65 years) groups. Results: Among the geriatric and non-geriatric participants (n = 65, 49.6% and n = 66, 50.4%, respectively), hypertension and diabetes mellitus were more common in the geriatric group. Demographics, including symptoms, showed no significant intergroup differences. Normosmia and hyposmia were significantly less prevalent, whereas phantosmia and parosmia were more prevalent in the geriatric group than in the non-geriatric group (p = 0.03 and p = 0.01, respectively). Sphenoidal sinus involvement was significantly higher in geriatric patients than in non-geriatric patients (p = 0.02). Conclusion: Based on greater sphenoidal sinus involvement, a deeper anatomical area is more vulnerable to fungal infection in the geriatric group than in the non-geriatric group. Increasing clinicians' awareness of CFRS in geriatric patients with olfactory dysfunction, including phantosmia and parosmia, is important for early intervention. [ABSTRACT FROM AUTHOR]

Objective: Neurosurgical indications for the superior eyelid transorbital endoscopic approach (SETOA) are rapidly expanding over the last years. Nevertheless, as any new technique, a detailed knowledge of the anatomy of the surgical target area, the operative corridor, and the specific surgical landmark from this different perspective is required for a safest and successful surgery. Therefore, the aim of this study is to provide, through anatomical dissections, a detailed investigation of the surgical anatomy revealed by SETOA via anterolateral triangle of the middle cranial fossa. We also sought to define the relevant surgical landmarks of this operative corridor. Methods: Eight embalmed and injected adult cadaveric specimens (16 sides) underwent dissection and exposure of the cavernous sinus and middle cranial fossa via superior eyelid endoscopic transorbital approach. The anterolateral triangle was opened and its content exposed. An extended endoscopic endonasal trans-clival approach (EEEA) with exposure of the cavernous sinus content and skeletonization of the paraclival and parasellar segments of the internal carotid artery (ICA) was also performed, and the anterolateral triangle was exposed. Measurements of the surface area of this triangle from both surgical corridors were calculated in three head specimens using coordinates of its borders under image-guide navigation. Results: The drilling of the anterolateral triangle via SETOA unfolds a space that can be divided by the course of the vidian nerve into two windows, a wider "supravidian" and a narrower "infravidian," which reveal different anatomical corridors: a "medial supravidian" and a "lateral supravidian," divided by the lacerum segment of the ICA, leading to the lower clivus, and to the medial aspect of the Meckel's cave and terminal part of the horizontal petrous ICA, respectively. The infravidian corridor leads medially into the sphenoid sinus. The arithmetic means of the accessible surface area of the anterolateral triangle were 45.48 ± 3.31 and 42.32 ± 2.17 mm2 through transorbital approach and endonasal approach, respectively. Conclusion: SETOA can be considered a minimally invasive route complementary to the extended endoscopic endonasal approach to the anteromedial aspect of the Meckel's cave and the foramen lacerum. The lateral loop of the trigeminal nerve represents a reliable surgical landmark to localize the lacerum segment of the ICA from this corridor. Nevertheless, as any new technique, a learning curve is needed, and the clinical feasibility should be proven. [ABSTRACT FROM AUTHOR]

Introduction: Foreign bodies in the paranasal sinuses are rare and can result from high velocity trauma. Here, we report a case of a 12 year old child, who sustained a penetrating injury to the left eye with a tree branch while playing. On CT scan, the wooden foreign body was found to extend into sphenoid sinus. Patient was posted for removal of foreign body in emergency OT under antibiotic coverage. The foreign body was mobilised from surrounding structures and was removed by giving strong traction. Primary closure of the wound was done and patient recovered with a stable post-op course. Discussion: Prompt and complete removal of wooden foreign body in the paranasal sinus is important due to their close proximity to vital structures. Their location and nature can be difficult to diagnose as they can have diverse appearances on imaging. Conclusion: Foreign bodies in close proximity to the sphenoid sinus should be removed by a multi-specialist team with good knowledge of head and neck anatomy in a tertiary care centre to avoid complications. [ABSTRACT FROM AUTHOR]

There are several variations in the anatomical relations of the optic nerve with the sphenoid sinus. Proper understanding of these variations is clinically important to minimize injuries associated with surgical procedures that involve the sphenoid sinus. CT scans of paranasal sinuses obtained prior to any endoscopic surgery in the sphenoid sinus area is useful for designing operative strategies. Ethnic variations in sinonasal anatomy have been documented. The objective was to study the pattern of relationship between optic nerve and the sphenoid sinus using computerized tomographic imaging in a north Indian population, to compare our findings with previous studies in different ethnic groups and find out if ethnic variations in such a relationship matter. A prospective study was conducted on 300 patients who underwent computed tomography of the paranasal sinuses from Sept 2020 to June 2021. Relationship of optic nerves to the sphenoid sinuses was categorized according to DeLano classification. Pneumatization of the anterior clinoid process and bony dehiscence of optic nerve was also observed. Type 1 position of optic nerve was seen in 69.3%, Type 2 in 20.9%, Type 3 in 3% and Type 4 in 6.8% of sinuses. The pneumatization of anterior clinoid process (ACP) was observed in 10.5% and the bony dehiscence of optic nerve was noted in 6.5% sinuses. Bony dehiscence of optic canal had associated ACP pneumatization in 64.1% sinuses.The variability of the relation of optic nerve to the sphenoid sinus even in the persons of same ethnicity precludes a definite role of ethnicity in these variations. Other factors possibly contributing to such a relationship have been discussed. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to assess the sphenoid sinus pneumatization types and their correlation with adjacent neurovascular structures using cone-beam computed tomography (CBCT). Materials and methods: This cross-sectional study was conducted on 97 CBCT scans of patients over 18 years of age that were retrieved from the archives of the Oral & Maxillofacial Radiology Department of School of Dentistry. Type of sphenoid sinus pneumatization based on its relationship with sella turcica (conchal, presellar, sellar, and postsellar), the correlation of internal carotid artery (ICA) and optic nerve (ON) with the sinus cavity in the axial and coronal planes (smooth or prolonged type), and presence of Onodi cells and their correlation with the sphenoid sinus (lateral, superior, and superolateral) were all evaluated on CBCT sections. Data were analyzed by the Chi-square and Fisher's exact tests (alpha = 0.05). Results: Postsellar type was the most common sphenoid sinus pneumatization type (82.5%). The Smooth type was the most common form of correlation of ON and ICA with the sphenoid sinus. Onodi cells were noted in 28.9% of the cases; among which, the lateral type had the highest prevalence. Conclusion: Considering the high prevalence of sphenoid sinus pneumatization, Onodi cells, and ON and ICA protrusion in our study population, CBCT should be requested prior to trans-sphenoidal surgical procedures to prevent perioperative and postoperative complications. [ABSTRACT FROM AUTHOR]

This systematic review aims to determine whether linear or morphometric analysis of paranasal sinuses can be used for accurate determination of gender and to appraise which sinus can be evaluated for accurate gender determination. A comprehensive search of the specialized databases (PubMed/MEDLINE, Science Direct, Clinical Key, ProQuest, Google Scholar, Epistomonikos, LILACS, OpenGrey) and other institutional repositories was performed for including the studies which assessed paranasal sinuses for gender determination. Quality assessment was carried out with the AQUA tool. The meta-analysis was performed with the eligible study data at 95% CI and p ≤ 0.05 in the random-effects model. Forty-six studies evaluating frontal sinus (13), maxillary sinus (26), frontal and maxillary sinus (5), or three paranasal sinuses (2) were included. All the included studies assessed height, length, width, and volume, respectively, and other additional parameters (area, perimeter) if wherever applicable. Frontal sinus had significantly higher values for males compared to females except for left height (LH) and left volume (LV). Maxillary sinus measurements were significantly higher in males contrasted to females except for LH. Sub-group analyses revealed that analyses involving the population had statistically significant results for all the measured parameters for both the sinuses (p < 0.05 and p = 0.00, respectively). Measurements obtained from assessing sinuses reveal that there are variations in size, among populations in different geographic regions. Hence, more studies with improved sample sizes and standardized measurement protocols should be carried out on different populations to see the diversity and their reliability. [ABSTRACT FROM AUTHOR]

Background Frontal sinus carcinoma is commonly seen as an extension of the ethmoid sinus, overlying skin, or lacrimal gland. The existence of this disease has been unclear. We aimed to describe the occurrence of primary frontal sinus carcinoma. Methods We conducted a systematic literature review and a retrospective review of the medical records at our institution in the past 10 years. Results Sixty-four articles were included in the literature review. Most frontal sinus carcinomas involved surrounding structures as the sphenoid or ethmoid sinus, and a primary origin in the frontal sinus could not be confirmed. No cases of primary frontal sinus carcinoma were identified at our hospital. Conclusion Isolated primary frontal sinus carcinoma, if exists, is very rare. There is uncertainty regarding the primary origin of frontal sinus carcinoma in most studies. The frontal sinus seems to be immune from primary carcinoma. Further studies are needed to explain such immunity. [ABSTRACT FROM AUTHOR]

The sphenoid sinus (SS) is one of the four paired paranasal sinuses (PNSs) within the sphenoid bone body. Isolated pathologies of sphenoid sinus are uncommon. The patient may have various presentations like headache, nasal discharge, post nasal drip, or non-specific symptoms. Although rare, potential complications of sphenoidal sinusitis can range from mucocele to skull base or cavernous sinus involvement, or cranial neuropathy. Primary tumors are rare and adjoining tumors secondarily invading the sphenoid sinus is seen. Multidetector computed tomography (CT) scan and magnetic resonance imaging (MRI) are the primary imaging modalities used to diagnose various forms of sphenoid sinus lesions and complications. We have compiled anatomic variants and various pathologies affecting sphenoid sinus lesions in this article. [ABSTRACT FROM AUTHOR]

Objective: The most common surgical technique for the management of pituitary adenomas is the endoscopic endonasal transsphenoidal approach (EEA). preoperative neuroimaging along with detecting surgical landmarks of the sphenoid sinus during surgery is important for making a successful operation. Method: This study includes 1009 patients with pituitary adenomas who underwent EEA between 2013 and 2020. We evaluated the anatomical features of the sphenoid sinus through a panel of items obtained from imaging and intra-operative findings. Results: Our result includes 57.38% nonfunctional, 8.42% cushing, 12.39% prolactinoma, and 21.8% acromegaly patients who had undergone endoscopic endonasal transsphenoidal surgery. The mean age of the patients was 45 with a male to female ratio of 1.2:1. Sellar sphenoid type was the most common (91.8%) with only 12% symmetrical inter sphenoid septa, Internal carotid artery dehiscence was found in 1.7% of the cases. Apoplexy was present in 6.3% of patients, which was found more prevalent in nonfunctional adenomas (9.67%, Odds ratio: 4.85, 95% CI 2.24–11.79) and further investigation revealed a significant association between apoplexy and sphenoid mucosal edema and hemorrhage (Odds ratio: 43.0, 95% CI 22.50–84.26), and between apoplexy and cystic lesions (OR = 4.14, 95% CI 1.87–8.45, P-value < 0.0001). Acromegaly is associated with the increased number of lateral recces (Odds ratio: 11.41, 95% CI 7.54–17.52), septation of the sphenoid sinus (Marginal mean: 3.92, 95% CI 3.69–4.14), edematous sinonasal mucosa (Odds ratio: 6.7; 95% CI 4.46–10.08), and higher bony (OR: 4.81, 95% CI 2.60–8.97, P-value < 0.001) and cavernous (OR: 1.7, 95% CI 1.13–2.46, P-value < 0.01) invasion. Conclusion: The present study provides anatomical data about the sphenoid sinus and its adjacent vital structures with adenomal specific changes that are necessary to prevent complications during endoscopic advanced transsphenoidal surgery. [ABSTRACT FROM AUTHOR]

Purpose: Accessory sphenoidal septum (ASS) is a septal variation that exists in addition to the primary septum of the sphenoid sinus and can be found in or near anatomically essential structures. This study aimed to investigate the relationships between protrusions of vital structures around the sphenoid sinus and the ASSs. Methods: This cross-sectional retrospective study is based on the analysis of CBCT scans of 314 patients in axial, coronal, and sagittal planes with 0.2–0.3 slice thicknesses. Optic nerve (ON), internal carotid artery (ICA), both ON and ICA, maxillary nerve (MN), vidian canal (VN) and ASSs were detected, and the relationship between protrusions of these vital anatomical structures and ASS was evaluated. Results: Statistically significant relationship was observed between the right Type 1 ON protrusion (p < 0.05) and left Type 1 ON protrusion (p = 0.001); left Type 3 ON protrusion (p < 0.05); right Type 4 ON protrusion (p < 0.05) and ASS. Statistically significant relationship was also observed between the right ICA protrusion and ASS (p < 0.05). The right Type 1 VN protrusion (p = 0.001); left Type 2 VN protrusion (p < 0.001); right and left Type 3 VN protrusions (p < 0.001) were found to be significantly associated with the ASS. Conclusions: ASSs have significant associations with some protrusions, and they tend to cause potentially severe complications in endoscopic sinus surgery. This variability requires a comprehensive understanding of regional sphenoid sinus anatomy with detailed three-dimensional tomographic imaging. [ABSTRACT FROM AUTHOR]

Introduction – To study the anatomical variations of sphenoid sinus and its related structures and to know the association of extension of pneumatisation of sphenoid sinus with sphenoid sinusitis. Materials And Methods - This was a prospective study. Analysis of 100 patients CT PNS scans who was attending Otolaryngology clinic OPD with signs/symptoms of chronic sinusitis evaluated between September 2019 to April 2021. The pneumatization of adjacent structures of sphenoid sinuses and its relation with the protrusion of neurovascular structures surrounding the sinus and the association between the extension of pneumatisation of sphenoid sinus and presence of sphenoid sinusitis have been investigated. Chi-square test was used for statistical analysis. The p value < 0.05 was expressed as significant. Result - The association of extension of pneumatisation of sphenoid sinus with sphenoid sinusitis was statistically significant (p < 0.001) i.e. sphenoid sinusitis is seen more in patients having absence of extension of peumatization of sphenoid sinus. We also observed that seller type of pnematization (89%) is most common type. Type 1 variation (76%) is most common for Optic nerve variations, Type 3 is most common type (83%) for variation of Foramen rotendum, and Vidian canal (85%) passing through the sphenoid sinus. Conclusion – In conclusion we observed that seller type of pnematization is most common type. Type 1 variation is most common for Optic nerve variations, Type 3 is most common type for variation of Foramen rotendum, and Vidian canal passing through the sphenoid sinus, we also concluded that sphenoid sinusitis is more common in sphenoid sinus with absence of extension of pneumatisation. [ABSTRACT FROM AUTHOR]

Tension Pneumocephalus and spontaneous CSF rhinorrhea are very rare associations in clinical practice. We report a case of 65 years old male with clear rhinorrhea, severe frontal headache, vomiting and lethargy for a week. MR Cisternography and CT Paranasal sinuses showed significant Tension Pneumocephalus with defect in the posterior wall of sphenoid sinus and CSF pooling in the sphenoid sinus. Endoscopic trans-sphenoidal CSF leak repair was done without any delay followed by complete resolution of Tension Pneumocephalus with in 4 post op days. Prompt precise diagnosis and early intervention of Tension Pneumocephalus is vital to avoid neurological complications. [ABSTRACT FROM AUTHOR]

Acinic cell carcinoma (A.C.C.) is a low-grade malignancy involving salivary glands. A.C.C. accounts for only 1–4% of all sinonasal malignancies. We report the case of a 45-year-old female who presented with A.C.C. of paranasal sinus who developed loss of vision after Endoscopic sinus surgery (E.S.S.). Blindness, though rare, is a devastating complication of E.S.S. In this report, the rare occurrence of a papillary cystic variant of A.C.C. in the sphenoid sinus is reported. The causes that may lead to blindness during E.S.S. are analyzed in the absence of direct neural trauma. [ABSTRACT FROM AUTHOR]

Background: Sphenoid sinus is a type of sinus surrounded by critical structures so that its injury potential to induce complications during surgery. The purpose of this study was to investigate the factors affecting the location of the sphenoid sinus natural ostium (SSO) to provide valuable data for endoscopic sinus surgery. Methods: Ostiomeatal unit (OMU) computerized tomography (CT) was performed on 198 subjects. Across the left and right sides, 396 evaluation results were obtained. The vertical distance to determine the location of the SSO was analyzed based on Lines 1, 2 and 3 on the sagittal image. The horizontal distance was analyzed based on Lines 4 and 5 on the axial image. The upper, lower, medial and non-medial borders were defined according to the location of the SSO. The presellar, sellar and postsellar types were categorized according to the level of sphenoid sinus pneumatization (SSP) on the sagittal image. The presence and absence of Onodi cells were defined on the coronal image. Binary logistic regression analysis was performed to investigate each factor. Results: As the rostrum width of the SSO on the horizontal position increased, the position toward non-medial boarder increased by 4.902 times so that the natural ostium showed a trend of lateralization. For the postsellar type, compared to the presellar type, the position toward the non-medial boarder decreased by 0.223 times, indicating that the postsellar type had the natural ostium showing a trend of medialization. In the presence of Onodi cells, the position toward the lower boarder increased by 2.599 times with a significant association. Conclusions: The results in this study indicated that the presellar type of SSP had the natural ostium exhibiting lateralization with an increase in the rostrum width, whereas the postsellar type had the natural ostium exhibiting medialization with a decrease in the rostrum width. Based on these findings, the methods to widen the natural ostium may be diversified. [ABSTRACT FROM AUTHOR]

Postoperative management after transsphenoidal surgery (TSS) is important; however, the guidelines for resuming daily activities after TSS are insufficient. This study aimed to examine the time to return to activities of daily living (ADL) after TSS for pituitary tumors. A 4-month prospective data collection was completed for 114 of 117 patients who underwent TSS for pituitary tumors from April to July 2021. The time when the patient returned to ADL after surgery was measured using the self-recording sheet. More than 97% and 92% of the patients returned within 1 month (median: within 7 days) for the elements of basic ADL and within 2 months (median: within 15 days) for the elements of instrumental ADL, excluding a few. Notably, 73.3% of patients returned to work within 4 months. The median time for the activities included 64 days for washing hair head down, 44 days for blowing nose, 59 days for lifting heavy objects, and 102 days for sexual activity. For patients who received extended-TSS or had postoperative problems, the time to return was delayed. Based on these results, it will be possible to provide practical information and guidelines on the time to return to ADL after TSS in pituitary tumor patients. [ABSTRACT FROM AUTHOR]

Cushing´s disease is a rare endocrinological disorder which is caused by an adrenocorticotropic hormone secreting pituitary adenoma. The condition is associated with an increased risk for venous thromboembolism. While there exist reports on symptomatic venous thromboses complicating Cushing's disease, the prevalence of incidental leg vein thromboses accompanying pituitary surgery for Cushing's disease is yet unknown. 30 consecutive patients (9 male; age 25–77 years) with histologically confirmed Cushing's disease underwent transsphenoidal adenomectomy between October 2018 and September 2019. All patients received perioperative pharmacological thromboprophylaxis. Whole leg compression ultrasound was performed within one week after surgery (median 2 days) to exclude leg vein thromboses (primary endpoint). Preoperative laboratory values including plasma cortisol and various coagulation parameters were evaluated as secondary outcome measures. A comparison was made between patients with and without thrombotic events (p value ≤ 0.05). A total of 2 out of 30 patients (6.7%; CI 0.8–24.1%) presented with asymptomatic perioperative deep vein thromboses of the lower legs. Thrombosis patients differed not significantly from their counterparts with respect to age, sex, and comorbidities, but preoperative morning plasma cortisol was significantly higher in patients with venous thromboses (421.0 ± 49.5 μg/l vs. 188.1 ± 78.2 μg/l; p = 0.01). Moreover, von Willebrand factor activity was markedly increased in one case (409.0%) compared to the mean value obtained from 28 patients without phlebothromboses (146.9 ± 60.7%; p < 0.01). Perioperative asymptomatic leg vein thrombosis can be found with the aid of compression ultrasound in a considerable proportion of patients undergoing transsphenoidal adenomectomy for Cushing's disease despite the administration of pharmacological thromboprophylaxis. [ABSTRACT FROM AUTHOR]

Intraoperative ingestion of blood, cerebrospinal fluid, and irrigation fluid can lead to an increase in gastric volume, resulting in the potential risk of aspiration in patients after endoscopic endonasal transsphenoidal surgery (EETS). In this prospective observational study, we aimed to assess the volume of gastric contents in patients undergoing this neurosurgical procedure using ultrasound, and to determine the factors associated with volume change. Eighty-two patients diagnosed with pituitary adenoma were recruited consecutively. Semi-quantitative (Perlas scores: 0, 1 and 2) and quantitative (cross-sectional area, CSA) ultrasound assessments of the gastric antrum were performed immediately before and after surgery in the semi-recumbent and semi-recumbent right-lateral positions. Seven (8.5%) patients had antrum scores from preoperative grade 0 to postoperative grade 2; nine (11%) patients had antrum scores from preoperative grade 0 to postoperative grade 1. The mean ± standard deviation (SD) of increased gastric volume was 71.0 ± 33.1 mL and 236.5 ± 32.4 mL in postoperative grade 1 and 2 groups, respectively. Subgroup analysis showed that 11 (13.4%) patients (4 in grade 1 and all in grade 2) had postoperative estimated gastric volume > 1.5 mL kg−1 (mean ± SD 3.08 ± 1.67, range 1.51–5.01 mL kg−1). Logistic regression analysis revealed that older age, diabetes mellitus, and long surgical duration were independent risk factors for significant volume change (all P < 0.05). Our results showed a significant increase in gastric volume in some patients who underwent EETS. Bedside ultrasound measurements of gastric volume can be used to assess the postoperative aspiration risk, particularly in older diabetic patients with a longer surgical duration. [ABSTRACT FROM AUTHOR]

Silent corticotrophic adenomas (SCAs) represent a rare group of non-functioning adenomas with a potentially aggressive clinical course. Cystic component is a very common finding among SCAs, but its clinical relevance has not yet been investigated. The aim of this study was to analyze clinical features of cystic and non-cystic SCAs, perioperative complications after microscopic transsphenoidal surgery, clinical outcome after first and repeat surgery along with risk factors for recurrence. We conducted a retrospective analysis of 62 silent corticotrophic adenomas treated at our university medical center via microscopic transsphenoidal surgery between January 2008 and July 2019. Parameters investigated included histology, invasiveness, intratumoral haemorrhage or cystic component on MRI, perioperative alteration of visual field, tumor size, pre- and postoperative ACTH, FSH, GH, LH, TSH, prolactin, cortisol, free T4, free T3, IGF-1, estrogen and testosterone levels, perioperative complications, neoadjuvant and adjuvant therapy along with clinical outcomes. A total of 62 patients were analyzed. The mean follow up was 28.3 months. Tumors with a cystic component occur statistically significant more often among male than non-cystic (80.6% vs. 44.4%, p = 0.02) and display lower rates of cavernous sinus invasion and sphenoid sinus invasion were significantly lower for cystic lesions comparing to non-cystic tumors (42.3% vs. 69.4%, p = 0.04 and 3.8% vs. 47.2%, p < 0.001). GTR after MTS was not statistically significant higher by cystic SCAs (80% vs. 57.1%, p = 0.09). Cystic lesions were also associated with higher risk of hyperprolactinemia (19.4% vs. 2.8%, p = 0.02) and only densely granulated cystic SCAs presented with preoperative intratumoral hemorrhage (19.2% vs. 0%, p = 0.01). Mean duration of first surgery was significantly shorter for cystic SCAs (71.6(± 18.7) vs. 94.8(± 31.1) minutes, p = 0.01). Preoperative pituitary insufficiency (25% vs. 16.7%, p = 0.49), intraoperative CSF space opening (21.1% vs. 37.5%, p = 0.32), along with postoperative new pituitary insufficiency (15% vs. 10%, p = 0.67) or diabetes insipidus/SIADH (10% vs. 13.3%, p > 0.99) with histological markers such as Ki67 (21.1% vs. 13.8%, p = 0.70) and p53 expression (6.3% vs. 0%, p = 0.39) as well as mitotic rate (5.3% vs. 10.3%, p > 0.99) were comparable between both groups. The presence of cystic component did not affect the tumor recurrence (10% vs. 16%, p = 0.68). Mean duration of surgery was first surgeries was not statistically shorter than repeat surgeries (85.4 ± 29.1 vs. 93.8 ± 28 min, p = 0.15). Patients undergoing first surgery had a higher probability of gross total resection (74.4% vs. 30%, p = 0.01) and lower probability of intraoperative CSF space opening (26% vs. 58.3%, p = 0.04) as well as a lower rate of preoperative anterior pituitary insufficiency (20% vs. 58.3%, p = 0.01). The incidence of new postoperative anterior pituitary insufficiency (10% vs. 0%, p = 0.57) and transient diabetes insipidus/SIADH (12% vs. 8.3%, p > 0.99) between those groups were comparable. No statistical difference was observed between patients with remission and with recurrent tumor regarding cortisol and ACTH levels, incidence of different histological subgroups, invasively growing tumors and lesions with cystic components as well as the percentage of cases with increased Ki67 proliferation index, p53 expression and mitotic indices. Our study presents one of the largest available cohorts of SCAs after microscopic transsphenoidal surgery and first clinical analysis of cystic versus non-cystic SCAs so far. We also performed the first comparison of index and repeat surgeries for this tumor entity. Cystic tumors presented with characteristic clinical aspects like male predominance, higher risk of hyperprolactinemia as well as lower rates of cavernous sinus and sphenoid sinus invasion comparing to non-cystic lesions. Mean duration of first surgery was significantly shorter for cystic SCAs. Moreover preoperative intratumoral hemorrhage had 100% specificity and 60% sensitivity for densely granulated cystic SCAs. All these clinical hallmarks may suggest a novel subgroup of SCAs with distinct clinical and biological features, however further clinical and molecular investigations are required. Second surgeries are associated with a higher incidence of preoperative pituitary insufficiency, and a higher risk of subtotal resection, and a higher probability of CSF space opening intraoperatively compared to first surgeries. On the other hand, the risk of new postoperative pituitary insufficiency was higher after first surgeries. In our cohort of patients, no prognostic factor for recurrence among histological diagnosis, Ki67-proliferation index, p53 expression, number of mitoses, invasive growth or cystic lesions for SCAs could be detected. [ABSTRACT FROM AUTHOR]

Background: Nasal sinus cholesteatomas are uncommon slow-growing lesions that are frequently misdiagnosed preoperatively. They can develop due to embryologic remnants or iatrogenic factors (surgical trauma or nasal sinus trauma). In addition, they can cause bone destruction resulting in intracranial or intraorbital complications as well as malignant change if neglected. Complete surgical removal is a must with strict postoperative follow-up. Materials and methods: Three cases of nasal sinus cholesteatoma are reported. The first case was found inside the ethmoidal sinus, the second in the frontal sinus, and the third was found inside a concha bullosa. In all three cases, a wide endoscopic surgical excision was performed. Due to the lateral extension of the lesion, frontal sinus trephine was also used in the case of frontal sinus nasal cholesteatoma. In addition, a review of the English literature for the reported cases of nasal sinus cholesteatomas was conducted. Results: There were no reported recurrence or residual during strict postoperative follow-up for 2 years (by endoscopic examination and diffusion-weighted MRI with delayed postcontrast T1 images). A review of the English literature revealed 42 cases of nasal sinuses cholesteatomas (including the present three cases) (17 in the frontal sinus, 15 in the maxillary sinus, 5 in the ethmoid sinus, 3 in the sphenoid sinus, and 2 in a concha bullosa). Conclusions: Although nasal sinus cholesteatomas are uncommon, they must be considered in the differential diagnosis of slow-growing nasal sinuses lesions. Preoperative CT scan and diffusion-weighted MRI are essential for proper diagnosis and to exclude other similar lesions, such as nasal sinus mucoceles, cholesterol granuloma, or neoplastic lesions. Wide complete surgical excision is necessary to avoid recurrence and facilitate postoperative follow-up. As with ear cholesteatoma, strict postoperative follow-up is required to detect recurrence or residual early and is performed by endoscopic examination, diffusion-weighted MRI, and delayed post-gadolinium T1 images. [ABSTRACT FROM AUTHOR]