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Objectives: Endoscopic imaging techniques and endoscopic endonasal surgery (EES) expertise have evolved rapidly. Only few studies have assessed the effect of three-dimensional (3D) endoscopy on endoscopic sinus surgery (ESS). The present study aimed to objectively and subjectively assess the additional value of 3D high-definition (HD) endoscopy in ESS. Design: A randomized crossover study of endoscopic surgery performance, using five ESS tasks of varying complexity, performed on Thiel embalmed human specimens. Setting: Simulated surgical environment. Participants: Thirty participants, inexperienced in ESS. Main outcome measures: Performance was assessed using video imaging, surgical navigation and questionnaires. Main outcome measures were as follows: efficiency (defined by time to task completion), distance covered inside the nose, average velocity towards target, accuracy (measured by error rate), and subjective assessment of endoscope characteristics. Results: During ESS tasks, both efficiency and accuracy did not differ significantly between 2D HD and 3D HD endoscopy. Subjectively, imaging characteristics of the 3D HD endoscope were rated significantly better. Conclusions: ESS performance of inexperienced participants was not significantly improved by the use of 3D HD endoscopy during ESS tasks, although imaging characteristics of the 3D HD endoscope were rated significantly better. Surgical field characteristics and surgical techniques are likely to influence any additional value of 3D HD endoscopy.

IntroductionAchieving gross total resection and endocrine remission in pituitary neuroendocrine tumours (PitNET) can be challenging, especially in PitNETs with cavernous sinus (CS) invasion, defined as a Knosp grade of 3 or 4. A potential target to identify PitNET tissue is vascular endothelial growth factor A (VEGF-A), which expression is known to be significantly higher in PitNETs with CS invasion.Methods and analysisThe aim of this non-randomised, non-blinded, single centre, feasibility and dose-finding phase 1 trial is to determine the feasibility of intraoperative fluorescence imaging detection of PitNET tissue during endoscopic transsphenoidal surgery using the VEGF-A targeting optical agent bevacizumab-800CW (4, 5, 10 or 25 mg). Nine to fifteen patients with a PitNET with a Knosp grade of 3 or 4 will be included. Secondary objectives are: (1) To identify the optimal tracer dose for imaging of PitNET tissue during transsphenoidal surgery for further development in a phase 2 fluorescence molecular endoscopy trial. (2) To quantify fluorescence intensity in vivo and ex vivo with multidiameter single-fibre reflectance, single-fibre fluorescence (MDSFR/SFF) spectroscopy. (3) To correlate and validate both the in vivo and ex vivo measured fluorescence signals with histopathological analysis and immunohistochemical staining. (4) To assess the (sub)cellular location of bevacizumab-800CW by ex vivo fluorescence microscopy. Intraoperative, three imaging moments are defined to detect the fluorescent signal. The tumour-to-background ratios are defined by intraoperative fluorescence in vivo measurements including MDSFR/SFF spectroscopy data and by ex vivo back-table fluorescence imaging. After inclusion of three patients in each dose group, an interim analysis will be performed to define the optimal dose.Ethics and disseminationApproval was obtained from the Medical Ethics Review Board of the University Medical Centre Groningen. Results will be disseminated through national and international journals. The participants and relevant patient support groups will be informed about the results.Trial registration numberNCT04212793

OBJECTIVES: The patients' perspective on health has become increasingly important when assessing treatment outcomes. Recently, the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q) was developed to determine the impact of endoscopic endonasal surgery on health-related quality of life (HRQoL). The aim of this study was to evaluate the test-retest reliability, construct validity, and responsiveness of the EES-Q.DESIGN: Prospective cohort study.SETTING: University Medical Center Groningen, tertiary referral hospital, the Netherlands.PARTICIPANTS: One hundred patients who underwent endoscopic endonasal surgery because of sinus or anterior skull base pathology.MAIN OUTCOME MEASURES: Test-retest reliability, construct validity and responsiveness.RESULTS: The EES-Q domains exhibited good test-retest reliability (ICC > 0.90). Construct validity was corroborated by significant positive and negative correlations between the EES-Q and the SNOT-22 and postoperative health status (p < 0.01) respectively. The correlation between the social EES-Q domain and the ability to move and perform usual activities (EQ-5D-3L) was significant positive (p < 0.01). In patients with paranasal sinus pathology, the EES-Q was responsive to clinical change (Cohen's d = 0.6).CONCLUSION: The EES-Q is a reliable and acceptable responsive disease-specific HRQoL instrument. The expected construct validity of the EES-Q is supported by the results in this study. Inconveniences in social functioning had the greatest negative impact on postoperative health status rating. This reflects the importance of a multidimensional HRQoL assessment after EES. The results indicate that the EES-Q is a promising disease-specific tool for the HRQoL assessment after endoscopic endonasal sinus or anterior skull base surgery. This article is protected by copyright. All rights reserved.

Background The patients’ perspective of health outcomes has become important input for assessing treatment effects. However, existing endoscopic endonasal surgery (EES) instruments are not fully aligned with the concept of health-related quality of life (HRQoL). A prospective cohort study was therefore conducted to develop a suitable quality-of-life tool to assess nasal morbidity after EES: the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q). Methods The study included 300 patients: 207 with sinus pathology and 93 with anterior skull base pathology. The EES-Q was administered prior to surgery and postoperatively (2 weeks, 3 months, and 1 year). Psychometric instrument properties were tested and relevant health domains were formulated. Seventy-two items were generated by the conventional psychometric approach. An exploratory factor analysis was used to test construct validity. The optimal number of factors to retain was determined by using the eigenvalues-greater-than-1 rule and scree plot. Orthogonal varimax rotation was used to enhance interpretability. Internal consistency was assessed using the Cronbach α. Results The factor analysis yielded a 3-factor solution, representing physical, psychological, and social functioning. The final version of the instrument consisted of 30 items with a high internal consistency (>0.80) for all 3 HRQoL domains. Conclusions The EES-Q is a comprehensive, multidimensional, disease-specific instrument. A distinguishing characteristic is that, apart from the physical and psychological domains, the EES-Q also encompasses a social domain. Understanding different HRQoL aspects in patients undergoing EES may help caregivers restore, improve, or preserve the patient's health through individualized care, which depends on identifying their specific needs.

We hypothesize that three-dimensional imaging using cone beam computed tomography (CBCT) is suitable for calculating nasoseptal flap (NSF) dimensions. To evaluate our hypothesis, we compared CBCT NSF dimensions with anatomical dissections. The NSF reach and vascularity were studied. In an anatomical study (n = 10), CBCT NSF length and surface were calculated and compared with anatomical dissections. The NSF position was evaluated by placing the NSF from the anterior sphenoid sinus wall and from the sella along the skull base towards the frontal sinus. To visualize the NSF vascularity in CBCT, the external carotic arteries were perfused with colored Iomeron. Correlations between CBCT NSFs and anatomical dissections were strongly positive (r > 0.70). The CBCT NSF surface was 19.8 cm(2) [16.6-22.3] and the left and right CBCT NSF lengths were 78.3 mm [73.2-89.5] and 77.7 mm [72.2-88.4] respectively. Covering of the anterior skull base was possible by positioning the NSF anterior to the sphenoid sinus. If the NSF was positioned from the sella along the skull base towards the frontal sinus, the NSF reached partially into the anterior ethmoidal sinuses. CBCT is a valuable technique for calculating NSF dimensions. CBCT to demonstrate septum vascularity in cadavers proved to be less suitable. The NSF reach for covering the anterior skull base depends on positioning. This study encourages preoperative planning of a customized NSF, in an attempt to spare septal mucosa. In the concept of minimal invasive surgery, accompanied by providing customized care, this can benefit the patients' postoperative complaints.