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A patient in his 20s presented with a change in the appearance of his left eye with evidence of relative afferent pupillary defect. Imaging revealed a giant frontoethmoidal osteoma, a benign sinonasal tumour, invading three-quarters of the orbit. Multidisciplinary discussion involving opthalmology, maxillofacial surgery, neurosurgery and otolaryngology resulted in the decision to attempt entirely endoscopic excision of this lesion, which was performed with successful outcomes. This case demonstrates how a sinonasal osteoma should be considered in the differential diagnosis for a patient presenting with proptosis or other eye signs suggestive of compression of the orbital compartment. This case report and literature review highlights the possibility of managing giant sinonasal osteomas with orbital extension through a completely endoscopic approach., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The purpose of this study was to describe the pathology of the different compartments in endoscopic resection of nasal intestinal-type adenocarcinomas (ITACs) and its relationships with oncologic outcomes., Methods: This retrospective study included all patients endoscopically operated for nasal ITACs, followed by radiotherapy in the majority of cases, between 2004 and 2014. The surgery systematically separated 3 compartments: ethmoid lateral mass, olfactory cleft, and anterior cranial fossa (in cases with skull-base invasion) to analyze their pathological "focal" or "massive" invasion by the tumor., Results: Sixty-seven patients (aged 69.2 ± 9.8 years) were included. Twenty-nine patients (43.3%) had only pathological focal invasion. At 61.0 ± 41.7 months of mean follow-up, the recurrence rates were 34.2% in the group with massive invasion and 10.3% in the group with focal invasion (P = .023). The disease-specific death rate had a tendency to be higher in the group with massive invasion (23.7% vs 6.9% for the group with focal invasion; P = .097). By Kaplan-Meier analysis, the 5-year disease-specific survival rate was better in the group with focal invasion than the group with massive invasion (P = .01). The 5-year overall survival was not different between the 2 groups (47.4% and 65.5% for focal invasion and massive invasion respectively; P = .14)., Conclusion: Compartmentalized endoscopic resection, combined with postoperative radiotherapy, is one way to operate on nasal ITACs with good oncologic outcomes., (© 2018 Wiley Periodicals, Inc.)

Background: Traditional endoscopic anterior cranial base resection involves the total removal of the ethmoidal cells, including the middle and superior turbinates. This is associated with increased volume of the nasal cavity postoperatively, with increased crusting and permanent change of the nasal airflow. Here we provide a step-by-step description of the technique and evaluate the feasibility of the superior ethmoidal approach for anterior cranial base resection with maximum exposure of the anterior cranial base while keeping the middle turbinates, uncinate processes, and ostiomeatal complexes intact., Methods: Three fresh cadaveric heads were used for dissections. This technique was successfully performed in 2 consecutive cases of large olfactory groove meningiomas., Results: In all anatomic dissections, satisfactory exposure of the cranial base was achieved while keeping the middle turbinate, uncinate process, ethmoid bulla, and middle meatus intact bilaterally. Successful resection of 2 consecutive cases of olfactory groove meningioma was performed using this approach., Conclusions: The endoscopic superior ethmoidal approach for anterior cranial base resection is a feasible and safe approach that maximizes preservation of the nasal structures while providing optimal access to the anterior skull base. It can be used in pathologies that involve the anterior cranial base and do not involve the nasal structures., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Retromaxillary air cells (RMC) are posterior ethmoid cells that separate the maxillary and ethmoid sinuses. The clinical significance of these cells in contributing to revision functional endoscopic sinus surgery (FESS) is unknown., Objectives: To investigate the prevalence, anatomic dimensions, and radiographic characteristics of RMC in patients with recalcitrant chronic rhinosinusitis after previous FESS., Methods: A retrospective review of patients who underwent revision FESS at a tertiary medical center between January 1, 2012, and December 31, 2014. Computed tomographies of patients who underwent revision FESS, including posterior ethmoidectomies, were reviewed. Each side of the scan was assessed for residual RMCs. The radiographic dimensions and Lund-Mackay (LM) scores of these cells were recorded., Results: Sixty-nine patients who underwent revision FESS were identified. The median age of the patient population was 51 years (range, 21-79 years). Forty-two percent of the patients had nasal polyps. The mean number of previous FESS was 2 (range, 1-10). Incompletely dissected RMCs were identified in 101 of 138 analyzed sides (73%), despite documented previous posterior ethmoidectomies. Sixty-five percent of RMCs had an LM score of ≥1; RMCs of patients with polyps were more likely to have an LM score of 2 (p = 0.049). There was a significant correlation between the number of previous FESS procedures and whether the RMCs had been dissected (p = 0.010). There also was a significant correlation between RMC height and the number of previous FESS procedures (p = 0.015)., Conclusion: RMCs seemed to often be undissected during primary FESS and, thus, were commonly encountered in revision FESS. The majority of analyzed cells in this cohort demonstrated an LM score of ≥1, which indicated that these cells frequently harbor residual diseased mucosa that may contribute to the need for revision surgery.

We present a case of a 60-year-old woman with a 2-year history of nasal obstruction and unilateral recurrent epistaxis. Anterior rhinoscopy identified a unilateral hypervascular lobular mass occupying the entire left nasal cavity. Imaging studies documented an extensive soft tissue density lesion in the left nasal cavity with complete infiltration of the anterior ethmoid, limited indentation of the medial wall of the orbit, bone demineralisation of the cribriform plate and involvement of the anterior cranial fossa. The diagnosis of locally invasive glomangiopericytoma was obtained preoperatively through biopsy of the lesion, which resulted in a self-limited epistaxis that was easily controlled by nasal packing, confirming the vascular nature of the lesion. We discuss the diagnostic work up, imaging and surgical approach of this tumour, and review the recent literature on endoscopic treatment of these lesions., (2016 BMJ Publishing Group Ltd.)

Background: The Draf III (modified endoscopic Lothrop) procedure has been proposed to extend the endonasal transethmoidal, transfovea ethmoidalis, and transcribriform approach through the back wall of the frontal sinus. The exposure is time-consuming and increases the risk of cerebrospinal fluid leak, and the indications for use are not well described. There are few data quantifying the advantage it conveys over the approach without the Draf III procedure., Methods: An endoscopic, endonasal transfovea, transcribriform approach was performed in 5 fresh, injected cadaveric heads. Anatomic boundaries and measurements of the exposure were compared before and after addition of a Draf III procedure. Computed tomography scans were performed before and after dissection, and additional radiographic measurements were made to quantify the additional exposure provided by the Draf III procedure. Also, 2 clinical cases are presented in which a Draf III procedure was used., Results: The mean anterior to posterior boundary from the frontal sinus to the planum sphenoidale before the Draf III procedure was 3.0 cm and after the Draf III procedure was 3.8 cm with an average change of 0.8 cm. After the Draf III procedure, the mean anterior to posterior boundary from the posterior wall of frontal sinus to the planum sphenoidale increased from 3.0 cm to 4.3 cm. There was an average increase of 1.3 cm with an average increased area of view of 1.79 cm(2)., Conclusions: This study quantifies the increased field of view provided by the Draf III procedure during anterior skull base dissection. Recommendations for preoperative examination of radiographic evidence are provided to help identify which individuals would benefit from the additional exposure., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: We report the first report of an expansile crista galli (CG) mucocele treated surgically by an endoscopic endonasal approach. Only 1 other case of a CG mucocele has been previously reported in the literature. This was treated by a craniotomy approach., Case Report: We describe the technique employed in endoscopic marsupialization. We also discuss relevant CG anatomy, pneumatization patterns, surgical approaches, and its potential to cause disease, including CG sinusitis and mucocele formation., Conclusion: We present this case to highlight that the growing experience with endoscopic techniques offer us less morbid and more functional alternatives to a variety of lesions that were once tackled by neurosurgical or external approaches. In the contemporary era, the indications for open approaches and craniotomy for frontal sinus and CG lesions is likely limited. We recommend these patients undergo careful evaluation by a surgeon experienced in advanced endoscopic techniques before being advised to undergo open or craniotomy techniques., (© 2014 ARS-AAOA, LLC.)

ENT navigation has given new opportunities in performing Endoscopic Sinus Surgery (ESS) and improving surgical outcome of the patients` treatment. ESS assisted by a navigation system could be called Navigated Endoscopic Sinus Surgery (NESS). As it is generally accepted that the NESS should be performed only in cases of complex anatomy and pathology, it has not yet been established as a state-of-the-art procedure and thus not used on a daily basis. This paper presents an algorithm for use of a navigation system for basic ESS in the treatment of chronic rhinosinusitis (CRS). The algorithm includes five units that should be highlighted using a navigation system. They are as follows: 1) nasal vestibule unit, 2) OMC unit, 3) anterior ethmoid unit, 4) posterior ethmoid unit, and 5) sphenoid unit. Each unit has a shape of a triangular pyramid and consists of at least four reference points or landmarks. As many landmarks as possible should be marked when determining one of the five units. Navigated orientation in each unit should always precede any surgical intervention. The algorithm should improve the learning curve of trainees and enable surgeons to use the navigation system routinely and systematically.

We report a case of a left fronto-temporo-parietal subdural haematoma that emerged as a complication of an endonasal endoscopic resection of a sinonasal adenocarcinoma of the left ethmoidal region. During the first surgical intervention, following oncological principles, the dura mater above the ethmoidal plate was removed and a skull base plasty was performed. In the post-operative phase a massive cerebrospinal fluid leak was observed and a revision duraplasty was performed the following day. Subsequently the patient was discharged on day 8 with no signs of CSF leakage. At the three month follow-up MR examination a subdural haematoma was observed and then treated by the neurosurgeon in a standard fashion. The collection was quite asymptomatic and discovered accidentally. We strongly advise the role of early post-op neuroimaging in every patient undergoing skull base procedures. We maintain that a massive CSF leak, that causes a significant reduction of intracranial pressure, should be managed as a surgical emergency, in order to reduce the risk of subdural haematoma., (Copyright © 2011 Elsevier B.V. All rights reserved.)

The management of medically intractable epilepsy is frequently assisted by the identification of structural abnormalities made possible by modern imaging techniques. The association between meningoencephaloceles and epileptic seizures is well reported in the literature. We report a patient with refractory right frontal lobe epilepsy caused by a right nasal meningoencephalocele who was rendered seizure free by endoscopic nasal excision and skull base repair, obviating the need for resective epilepsy surgery. Epilepsy patterns associated with encephalocele and their management are reviewed.

Craniofacial resection has been adopted worldwide as the standard therapy for tumors of the paranasal sinuses involving the anterior skull base. Recent refinements in endoscopic techniques together with the development of related surgical instruments allow complete radical resection of complex anatomic structures through combined transcranial and endonasal approaches without compromising any oncological principles. We use a transcranial nasoendoscopic approach for ethmoid malignant tumors in stage I and II according to the Instituto Nazionale Tumori, Milano staging. With this technique, no cutaneous incisions and no approaching osteotomies of the facial skeleton were performed. This approach reduces the period of hospitalization and speeds recovery. Furthermore, intraoperative endoscopy facilitates placement of the osteotomies in the optimal position and improves the likelihood of achieving a complete en bloc resection with removal of all disease hitherto obscured from vision. It represents the choice indication to increase precocious postsurgery radiotherapy possibilities.

Background: The surgical management of anterior skull base cerebrospinal fluid (CSF) fistulas has evolved throughout the last decade. Endonasal endoscopic surgery of the anterior skull base has become the standard procedure for the repair of most these fistulas., Objectives: To describe the presenting symptoms, etiology, treatment, and long-term outcomes of patients with anterior skull base CSF fistulas treated endoscopically at our institution. MATERIAL/ METHODS: Retrospective analysis of 25 patients with CSF fistulas treated endoscopically at the University of Puerto Rico Hospital from November 2004 to August 2008., Result: The etiology was spontaneous leak in 10 patients, menigoencephalocele in 7 patients, previous sinus surgery in one patient, and trauma in one patient. The most common location of leak was the cribiform plate, followed by the ethmoid roof. An overlay technique was used for repair in 61% of the procedures versus 39% for the underlay technique. The mean follow up was 23 months. Our overall initial rate of closure was 94% with 100% after a second procedure., Conclusions: Endoscopic repair of anterior skull base CSF fistulas has a high success rate and lower morbidity and mortality when compared with open approaches.

The frontal sinus, because of its proper anatomic features, has a particular relation with nasal cavities. Indeed, its anatomic opening (ostium) is strictly related to a complex ethmoidal structure prechamber mainly composed of the frontal recess.This constitutional feature makes the endoscopic approach more complex in comparison with other major sinuses treatment.In the following work, we present a systematization of surgical approach in relation to different pathologies, analyzing differences and results throughout the comparison of 2 groups: one treated with the endoscopic approach, and the other with open surgery.From these observations, we can assess that surgical approach choice must consider several parameters such as neoplasm localization, extension, dimension, and frontal recess anatomic features.

Tension pneumocephalus is a rare form of pneumocephalus in which the air is under pressure; it is generally due to communication between the atmosphere and the intracranial cavity, and is an infrequent (0.88%) complication of cranial trauma. Tension pneumocephalus causes an increase in intracranial pressure with deterioration of the neurological situation and requires emergency treatment. Endoscopic surgery of the paranasal sinuses, which is generally applied in the diagnosis and treatment of fistulas with cerebrospinal fluid leakage, was here used to treat a case of pneumocephalus due to cranio-ethmoidal communication, in a patient we had treated previously for severe cranio-facial trauma.

Objective: To describe the anatomy of the sphenopalatine foramen (SPF) region and possible anatomical variations., Study Design: Prospective study accomplished from September, 2006, to January, 2007., Methods: The sphenopalatine foramen (SPF) of 61 cadavers were carefully dissected. Presence of the ethmoidal crest, location of sphenopalatine and accessory foramens, and the number of arterial branches emerging through foramens were observed. Data were analyzed in relation to gender, racial group, and symmetry of the cadaver. Prediction of the presence of accessory foramen was evaluated., Results: Mixed race cadavers prevailed in 122 nasal fossae dissected (75% males). Ethmoidal crest was present in 100% of the cadavers, being anterior to the SPF in 98.4% of the cases. The most frequent SPF location was the transition of the middle and superior meatus (86.9%). Mean distance from the SPF and accessory foramen to anterior nasal spine was 6.6 cm and 6.7 cm, respectively. Accessory foramen was present in 9.83% of the cases. A single arterial stem emerged through the SPF in 67.2% of the cases, and 100% through accessory foramens. The prevalence analyses showed no differences that were statistically significant (P > 0.05) between gender and racial group. The symmetry analyses showed a strong conformity (P < 0.01) between nasal fossae in relation to the SPF location. There was no statistically significant conformity between nasal fossae and accessory foramen (P = 0.53). None of the variables of interest presents any statistically significant (P > 0.05) association with the presence of the accessory foramen., Conclusions: There are anatomical variations in the lateral nose wall that should be considered for successful endoscopic surgical treatment of severe epistaxis.

Dermoid and epidermoid cysts are congenital, slowly growing tumours that usually become symptomatic when patients reach the middle of their third decade. An otherwise healthy 20-year-old man presented with an epileptic attack. Imaging studies including computed tomography and magnetic resonance imaging revealed an intradural cystic lesion located in the anterior subfrontal region. Choices of traditional approaches for such a lesion are a bicoronal craniotomy or a transfacial procedure. Taking the advantage of the endoscope, the authors decided to remove the lesion via an endonasal route. After a fully endoscopic endonasal operation, gross total resection of the dermoid tumour was achieved. We have not observed cerebrospinal fluid leakage or any infectious complication after the operation. In this report the technique of operation and reconstruction method are described. The endoscopic endonasal approach offers a good option for lesions located in the anterior skull base. Carefully piecemeal resection of the tumour while preserving the underlying neural and vascular structures should be the main strategy of the operation. Reconstruction is very important after the surgery and a carefully planned pedicled graft technique may help in the prevention of cerebrospinal fluid leakage.

A 39-year old female was referred with a 2 year history of slowly progressive headache, exophthalmos, diplopia and restricted eye movements with exotropia of the right eye. Orthoptic examination revealed restricted elevation and mildly restricted adduction of the right eye. CT and MRI demonstrated a large (35 x 20 x 23 mm) calcified infraorbital lesion extending into the ethmoidal sinus. Because the visual field defects were progressive and the acuity OD dropped to 20/80 surgical intervention was necessary. The osteoma was successfully removed using an inferior and medial orbitotomy with swinging eyelid combined with an endoscopic approach. In a second procedure the orbital floor was reconstructed with a porous polyethylene (Medpor) implant. A final procedure consisted of a 3 mm recession of the left superior rectus muscle and infundibulotomy by the sinus surgeon to open the blocked maxillary sinus. After 6 months visual acuity OD had returned to 20/20. Orthoptic examination showed normal binocular function.

Objectives: The aim of this study is to look at the incidence of supraorbital ethmoid cells (SOEC) in normal Chinese subjects by using spiral computed tomography (CT) scanning. In addition, subjects with chronic rhinosinusitis with SOEC were reviewed for endoscopic analysis., Methods: A total of 202 normal Chinese subjects underwent spiral CT. Meanwhile, a retrospective review of patients who had undergone endoscopic sinus surgery over a 1-year period was conducted., Results: SOEC showed an incidence of 5.4% (22 sides), and all of them arose from the anterior ethmoid cells. On coronal CT, an SOEC might give the appearance of multiple frontal sinuses, type III frontal cells, suprabullar cells, frontal bullar cells, interfrontal septal cells, or that there was a septation present within the frontal sinus. Meanwhile, 11 chronic rhinosinusitis patients with 12 SOEC were identified., Conclusion: A thorough knowledge of endoscopic anatomy and CT of the frontal recess and various fronto-ethmoid cells were required for safe dissection of the SOEC and frontal ostium.

Esthesioneuroblastoma is a rare malignant neoplasm arising in the nasal cavity. Huge esthesioneuroblastomas, extending into the ethmoid roof and the cribriform plate, or invading the anterior cranial fossa, have traditionally been treated by craniofacial resection. Because of the invasiveness and potentially disfiguring results of a transfacial approach, a new technique has been proposed, combining endoscopic nasal and anterior craniotomy resection. We describe the case of a young male presenting with a large esthesioneuroblastoma involving the nasal cavity and the anterior cranial fossa, causing a huge skull base destruction. A combined transcranial and endoscopic nasal resection resulted in a macroscopically total removal of the tumor. The operative technique is reviewed in detail, along with the method used for the reconstruction of the anterior skull base defect.

We describe the case of a foreign body lodged into ethmoidal labyrinth and sphenoidal sinus with fracture of the clivus and consequent rhinoliquorrhea removed by an endoscopic technique. We performed a skull base plasty to close the rhino-liquoral fistula with resolution of the rhinoliquorrhea. There were no postoperative complications and there was a good therapeutic result at long-term follow-up.

Fibrous dysplasia (FD) is a non-neoplastic, expansile lesion of unknown origin. In about one-fourth of cases this disorder affects the head and neck area, where the mandible and maxilla are the most frequently involved sites. Its localization to the ethmoid is a rare event. Since the disease slowly progresses, its management is delayed until significant clinical symptoms or non-well-tolerated aesthetic deformities are present. When required, surgery is the treatment of choice. Several external procedures have been used to manage the lesion, but recently, more conservative transnasal approaches have been proposed. We report the history of a 6-year-old boy with fibrous dysplasia of the ethmoid labyrinth that underwent successful transnasal endoscopic removal. Furthermore, an analysis of the literature is presented with particular emphasis on clinical picture, diagnosis, and treatment of this rare illness.

Background: With the introduction and subsequent widespread acceptance of endoscopic surgery, otolaryngologists are increasingly being called on to care for patients with cerebrospinal fluid rhinorrhea and meningoencephaloceles. Patients with large encephaloceles and skull base defects present a special challenge. We present our experience with cranial bone grafts in treating this important entity., Methods: Our clinical experience was reviewed from 1998 to 2001. Review parameters included defect size, cranial bone graft harvest site and size, and graft appearance on postoperative follow-up., Results: Results revealed that 20 patients underwent defect repair with cranial bone graft. The average defect was approximately 0.92 x 0.7 cm; nine defects were located in the ethmoid roof, eight defects were in the sphenoid, and three defects were in the posterior table of the frontal sinus. Donor sites included 2 parietal, 3 frontal, and 15 temporal (mastoid). Grafts healed well and all defects remained closed on endoscopic and computerized tomographic follow-up. All donor sites healed well., Conclusion: Our experience indicates that cranial bone graft is an excellent material for endoscopic reconstruction of skull base defects. It confers special advantages in large defects, in defects with complex three-dimensional characteristics, and in patients with cerebrospinal fluid leaks associated with an elevated intracranial pressure.

Because of its special anatomic features, the roof of the anterior ethmoid is a preferred area for frontobasal fractures as well as an area of hazard during ethmoid surgery. As clinical experience proves, the most critical area for lesions to occur is the vicinity of the anterior ethmoidal artery, especially where this leaves the dome of the ethmoid medially to reach the ethmoidal sulcus in the olfactory fossa. Complete ethmoidal specimen were investigated by the means of serial histological sections in the frontal plane. 40 anterior ethmoidal arteries were anatomically prepared and the special features of their topography like connection with the dura, fixation of the dura to the bone of the skull base and the variations of the thickness of the surrounding bony wall studied with regard to their surgical relevance. Not the dome of the ethmoidal roof proves to be the most critical point for lesions to occur, but the area where the anterior ethmoidal artery leaves the ethmoid medially, to enter the olfactory fossa. Here, the bone is tenfold thinner than at the very roof of the ethmoid.