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Introduction: Surgical techniques for sellar reconstruction include no reconstruction, use of synthetic materials, autologous grafts, and/or vascularized flaps. The aim of this study was to conduct a multi-center study comparing the efficacy and postoperative morbidity associated with different sellar reconstruction techniques., Methods: A retrospective chart review of patients who underwent endoscopic transsphenoidal surgery for pituitary tumors from five participating sites between January 2021 and March 2023 was performed. The variables included demographics, tumor characteristics, reconstruction technique, postoperative cerebrospinal fluid leak (CSF) leak, and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Comparisons of postoperative complications, SNOT-22 scores, and duration of surgery by type of onlay reconstruction were evaluated using Fisher's exact test, analysis of variance, and Kruskal‒Wallis test., Results: Five hundred and one patients were identified. The median tumor size was 2.1 cm, and 64% were non-functioning. Intraoperative CSF leak was identified in 38% of patients. A total of 89% of patients underwent onlay reconstruction: 49% were reconstructed with mucosal grafts, 35% with nasoseptal flaps, and 5% with other onlay techniques. Nasoseptal flaps were utilized more frequently in the setting of giant pituitary adenomas (>3 cm), medial cavernous sinus wall resection, and high-flow intraoperative CSF leaks. Cases who utilized mucosal grafts had an overall shorter operating time (median: 183 min vs. 240 min; p < 0.001). Five postoperative CSF leaks were identified, and therefore, statistical analysis could not be performed for this complication., Conclusion: The effectiveness and morbidity of different sellar reconstruction techniques are comparable. Vascularized flaps were utilized more frequently in the setting of larger tumors and high-flow intraoperative CSF leaks., (© 2024 ARS‐AAOA, LLC.)

Background: Sinonasal malignancies with orbital invasion have dismal prognosis even when treated with orbital exenteration (OE). Sugawara et al. developed a surgical strategy called "extended-OE (EOE)," showing encouraging outcomes. We hypothesized that a similar resection is achievable under endoscopic guidance through the exenterated orbit (endoscopic-EOE)., Methods: The study was conducted in three institutions: University of Vienna; Mayo Clinic; University of Insubria; 48 orbital dissections were performed. A questionnaire was developed to evaluate feasibility and safety of each step, scoring from 1 to 10, ("impossible" to "easy," and "high risk" to "low risk," respectively), most likely complication(s) were hypothesized., Results: The step-by-step technique is thoroughly described. The questionnaire was answered by 25 anterior skull base surgeons from six countries. Mean, median, range, and interquartile range of both feasibility and safety scores are reported., Conclusions: Endoscopic-EOE is a challenging but feasible procedure. Clinical validation is required to assess real-life outcomes., (© 2024 Wiley Periodicals LLC.)

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Background: For aggressive maxillary sinus and pterygopalatine fossa (PPF) tumors, an en-bloc pterygomaxillectomy may be indicated., Methods: Five head specimens were used to study the feasibility of an en-bloc pterygomaxillectomy. Eighty-five non-pathological CT scans were used to compare the superior edge of the inferior turbinate (IT) and the middle turbinate tail (MT) as landmarks for the pterygoid osteotomy., Results: Through a combined sublabial-subperiosteal incision and transoral route, a mid-sagittal osteotomy through the hard palate and an axial osteotomy below the infraorbital foramen were performed. For the endoscopic pterygoid osteotomy, an infra-vidian transpterygoid approach was performed, subsequently removing the pterygomaxillectomy en-bloc. As landmarks, the osteotomies at the level of the MT tail and IT resected the pterygoid plates completely, but the IT osteotomy was further away from the vidian canal (7.5 vs. 6 mm)., Conclusions: The endoscopic-assisted en-bloc pterygomaxillectomy is feasible. The IT landmark is safe and ensures complete resection of the pterygoid plates., (© 2023 Wiley Periodicals LLC.)

Purpose: A detailed understanding of the neurovascular relationships between the optic nerve (ON) and the ophthalmic artery (OA) in the optic canal (OC) is paramount for safe surgery. We focused on the neurovascular anatomy of this area from both an endoscopic endonasal and transcranial trajectories to compare the surgical exposures and perspectives offered by these different views and provide recommendations to increase the intraoperative safety., Methods: Twenty sides of ten formalin-fixed, latex-injected head specimens were utilized. The surgical anatomy and anatomical relationships of the OA in relationship to the ON along their intracranial and intracanalicular segments was studied from endoscopic endonasal and transcranial perspectives., Results: Three types of OA-ON relationships at the origin of the OA were identified: inferomedial (type 1, 35%), inferior (type 2, 55%), and inferolateral (type 3, 10%). The endoscopic endonasal trajectory offers an inferomedial perspective of the ON-OA neurovascular complex, in which the OA, especially when located inferomedially, is first encountered. When comparing with the transcranial view, all OA were covered by the nerve, type 1 was located below the medial third, type 2 below the middle third, and type 3 below the lateral third of the OC. The mean extension of the intracanalicular portion of both OA and ON was 8.9 mm, while the intracranial portion of the OA and ON were 9.3 mm and 12.4 mm, respectively. The OA, endoscopically, is located within the inferior half of the OC, and occupies 39%, 43%, and 42% of the OC height at its origin, mid, and end points, respectively. The mean distance between the superior margin of the OC at its origin and superior margin of the OA is 1.4 mm., Conclusions: Detailed anatomical understanding of the OC, and the ON and OA at their intracranial and intracanalicular segments is paramount to safe surgery. When opening the OC dura endoscopically, our results suggest that a medial incision along the superior third of the OC with a proximal to distal direction is recommended to avoid injury of the OA., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Objective: At our institution, skull base reconstruction using a free mucosal graft from the nasal cavity floor has been the standardized technique after pituitary adenoma resection via transsellar approach. In this study, the expected appearance of the reconstruction on postoperative magnetic resonance imaging (MRI) scans is described and its integrity and impact on the sinonasal cavity are assessed., Methods: Fifty patients were selected, and their electronic medical records were reviewed for postoperative course, Sino-Nasal Outcome Test-22 (SNOT-22) scores, and nasal endoscopy reports. A total of 116 postoperative MRI scans were available to evaluate 1) the appearance and thickness of the graft, 2) the enhancement of the graft, and 3) the T2 signal in sphenoid sinus as a potential indication for inflammatory disease., Results: There was no significant change in the thickness of the graft over time. Except for the 7 scans that were obtained without intravenous contrast, all scans showed enhancement of the graft. About half of the patients showed persistent T2 hyperintense signal at 12 and 24 months. However, this finding was not clinically significant, because postoperative SNOT-22 scores showed minimal sinonasal impact., Conclusions: Postoperative MRI surveillance scans showed a stable appearance of the graft that mimics the native mucosa, with enhancement through time, reflecting its robust vascularization and integration to the skull base. Although persistent T2 hyperintense signal was detected in the sphenoid sinus, clinical evidence based on nasal endoscopy reports and SNOT-22 scores indicated minimal sinonasal morbidity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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.)

Objectives/hypothesis: To conceive and critically evaluate an adaptation of the split calvarial osteopericranial flap for reconstruction following endoscopic endonasal resection of the anterior skull base., Study Design: Cadaveric anatomic study., Methods: Five cadavers were embalmed with methanol, and vasculature was injected with latex. Endoscopic endonasal resection of the anterior skull base was performed, followed by reconstruction with a unilateral osteopericranial flap and a contralateral conventional pericranial flap., Results: Rigid reconstruction was achieved in all specimens. Osteoplastic flap harvest was made more reliable by drilling the diploe below the graft with a curved bur. Dimensions of the bony flap were ideally shorter and wider than the defect, allowing for flap inset and rigid support by the orbits without compromise of the flap vascular supply. Endoscopic inset of the flap is feasible via nasion-frontal osteotomy and inlay technique., Conclusion: Rigid anterior skull base reconstruction via split calvarial osteopericranial flap is adaptable to current endoscopic techniques. This provides more anatomic reconstruction than current methods and may lead to decreased complication rates following anterior skull base resection., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The aim of this study was to investigate and compare the surgical anatomy of two different routes to access and drain petrous apex (PA) cholesterol granulomas: the expanded endonasal approach (EEA) and the transcanal infracochlear approach (TICA)., Study Design: Anatomic and radiologic study., Methods: The EEA and TICA to the PA were performed in 11 anatomic specimens with the assistance of imaging guidance. The PA was categorized into three zones: superior PA, anterior-inferior PA, and posterior-inferior PA. The maximum drainage window achieved by each approach was calculated using the imaging studies of each anatomic specimen., Results: The EEA was able to reach superior PA and anterior-inferior PA in all specimens and posterior-inferior PA in 90%. The TICA did not provide access to superior PA in any case. The TICA was suitable to reach anterior-inferior PA in 80% of specimens and posterior-inferior PA in 60%. Based on the radiologic study, the EEA provided a drainage window three times larger than the TICA., Conclusions: The transnasal approach provides reliable access to the PA when combined with internal carotid artery exposure and allows for large drainage window. The transcanal approach is less versatile and more limited than the transnasal approach but provides access to the most posterior and inferior portion of the PA without Eustachian tube transection. Here we propose a new surgical classification that may help to decide the most suitable approach to the PA according to the location and extension of the lesion., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: Measure the dimensions of the nasoseptal (NS) flap and the anterior skull base (ASB) defect. Verify whether the flap is sufficient to cover the defect. Study the anatomy of the septal artery (SA)., Study Design: Anatomical and radiological study., Methods: After endoscopic craniofacial resection, sufficiency of the flap to cover the ASB defect was assessed. The SA was dissected. The number of branches in the pedicle and the distance between the artery and the sphenoid ostium were noted. Radiologic study analyzing CT scans of 30 patients for comparison among measurements of the NS flap and the ASB defect was performed., Results: In all cases the flap was sufficient to cover the ASB. Two branches of the SA were found in the pedicle in 71.4%. The distance between the SA and the sphenoid ostium was 9.3 mm. The reconstruction area of the flap (17.12 cm(2) ) was larger than the defect area (8.64 cm(2) ) (P < .001). The difference between the superior length of the flap and the anterior-posterior distance of the defect was ≤ 5 mm in 26.7%. Comparison between the anterior flap width and the anterior defect width revealed that in 33% the difference was ≤ 5 mm., Conclusions: The dimensions of NS flap are sufficient to cover completely the ASB defect. The anterior edge of the defect presents increased risk for failure in coverage. Additional width adding the nasal floor mucosa to the flap is important to decrease the risk of gap in the anterior orbit-orbit defect. It is more common to find two branches of the SA in the pedicle., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)