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Objective To delineate the steps of exoscopic en bloc carotid artery–sparing total temporal bone resection for malignancies involving the temporal bone in a cadaveric model. Methods Dissections were performed on 3 right-sided (3 sides) formalin-fixed, latex-injected cadaveric specimens. An exoscopic en bloc carotid artery–sparing total temporal bone resection was performed on each cadaver. In the past 4 years, 8 patients have undergone exoscope-assisted internal carotid artery–sparing total temporal bone resection with the technique described in this report. As an example, we present a representative case of a patient in whom this technique was used. Results Exoscope-assisted en bloc total temporal bone resections were performed on 3 right-sided cadaveric specimens. The following steps were described to circumferentially expose the petrous temporal bone: infratemporal fossa exposure, temporal craniotomy for subtemporal middle fossa approach to the petrous bone, retrosigmoid craniotomy, and transjugular approach. Finally, 3 skull base osteotomies were performed to liberate anterior, medial, posterior attachments of the petrous bone for en bloc removal. Possible extensions of these dissections as indicated by tumor pathology were described. A case illustration and operative video utilizing these techniques is presented. Conclusions Exoscope-assisted en bloc carotid artery-sparing total temporal bone resection is a feasible technique for management of malignancies with temporal bone invasion.

Objectives The three-dimensional (3D) exoscope has several advantages over the operative microscope (OM) but has not been extensively reported for its use in malignant temporal bone resections (TBR). We sought to demonstrate the feasibility of performing TBR, both lateral (LTBR) and subtotal (STBR), using the 3D exoscope for head and neck cancers. Design present study is a retrospective chart review from August 2016 until August 2019. Setting The study was conducted at a tertiary care center. Participants Patients were undergoing TBR with the Karl Storz VITOM 3D exoscope. Main Outcome Measures Demographics, tumor and surgical characteristics, patient outcomes were the primary measurements of this study. Results Fifty-five patients underwent 3D exoscopic TBR from 2016 through 2019 of which 18% (n = 10) underwent STBR. The 3D exoscope was used uninterruptedly in all procedures with no intraoperative complications. Most tumors were primarily T3 (42%, n = 23) or T4 (55%, n = 30) and of cutaneous (62%, n = 34) and parotid (27%, n = 15) origin. These TBR were often accompanied by infratemporal fossa resections (87%, n = 48), auriculectomies (47%, n = 26), mandibulectomies (53%, n = 29), and parotidectomies (96%, n = 53). On final pathology, 24% (n = 13) had microscopically positive margins. Over the study period, 20% (n = 11) of patients had recurrences with a median recurrence time of 5 months (range: 2–30 months). Conclusion In the largest case series of LTBR and STBR under exclusive 3D exoscopic visualization to date, we demonstrate the 3D exoscope is a feasible alternative to the operative microscope for LTBR and STBR. While oncologic outcomes remain to be clarified, it carries significant potential for use in complex oncologic procedures.

Recurrent respiratory papillomatosis (RRP) consist of benign tumours along the airway caused by human papillomavirus infection. Papillomas may cause changes in phonation and obstruct the airway. The purpose of this study was to evaluate the different surgical and adjuvant therapies available for the treatment of this condition reported between 2014-2018. A PubMed search was performed for RRP treatment articles published between 2014 -2018. Forty articles that encompassed 1425 patients with RRP met the criteria. Of these, 24 articles evaluate the use of adjuvant therapies such as bevacizumab, human papillomavirus vaccine and cidofovir. There has been an increase in adjuvant therapy options for RRP in the literature in recent years. An awareness of these options highlights gaps and opportunities in the care of these patients, opens the door to new protocols to control disease and increase intersurgical intervals, and guides us towards new management paradigms in the future.

BACKGROUND A minimal access technique for the management of nasopharyngeal tumors extending below the palatal plane and laterally beyond the pterygoid musculature is yet to be developed. In this study we demonstrate the feasibility of endoscopic transoral nasopharyngectomy (ETON) for resection of large nasopharyngeal lesions as a natural orifice alternative to traditional approaches. METHODS ETON was completed in three latex-injected specimens. Surgical freedom (SF) and angles of attack (AoA) were calculated along the internal carotid artery (ICA). RESULTS An endoscopic transoral approach was successfully used to identify the parapharyngeal ICA and subsequently perform a complete nasopharyngeal resection. SF and AoA (sagittal) were found to be the greatest at the anterior genu of the ICA. CONCLUSIONS ETON is feasible. It provides wide exposure of the skull base and proximal control of the ICA. It may be indicated for the management of nasopharyngeal tumors with inferolateral extension, involving the ICA.

Background: COVID-19 poses a risk to the endoscopic skull base surgeon. Significant efforts to improving safety have beenemployed, including the use of personal protective equipment (PPE), preoperative COVID-19 testing, and recently the useof a modified surgical mask barrier. The objective of our cadaveric study is to reduce the risks of pathogen transmissionwith the use of readily available and innovative equipment as a means of creating a three-dimensional (3D) printed mask inaddition to a trocar system for use during endoscopic skull base surgery. Methods: Our study presents the ventilated upper airway endoscopic procedure mask (VPM), a 3D-printed mask with ananterior aperture fitted with a surgical glove with ports designed to allow for surgical instrumentation and side ports toaccommodate suction ventilation and an endotracheal tube. As an alternative, a modified laparoscopic surgery trocar servedas a port for instruments, and, on the contralateral side, rubber tubing was used over the endoscrub sheath to create anairtight seal. On cadaveric models, various surgical approaches were performed which each device to assess for surgicalmaneuverability including septoplasty, maxillary antrostomy, total ethmoidectomy, frontal sinusotomy, and sphenoidotomy.Surgical freedom (SF) and aerosolization were tested in both modalities. Results: The VPM allowed the unimpeded performance of the above-mentioned surgical approaches, using both two- andfour-handed techniques, with excellent surgical maneuverability and access, while maintaining a continuous facial seal.Debris and smoke were ventilated with a size 8-Frazier tip suction, and ambient gas was additionally suctioned by thenegative-pressure VPM. SF with the VPM was equivalent (1.0 cm2 ) to the SF with no mask. With the presence of a posterior septectomy, the endoscopic endonasal trocar (EET) system was effective for posteriorsurgical procedures, allowing access to critical paramedian structures (clivus, sella, and tuberculum), and afforded asuperior surgical seal, but was limited in terms of visualization and maneuverability during anterior approaches. For thisreason, aerosolization studies were only performed in the posterior nasal cavity with the EET. SF was found to be reducedby 55% (SF = 0.45 cm2 ), and surgery anterior to the sphenoid rostrum was limited when using the trocar system. Aerosolization was reduced using both the VPM and EET. During anterior surgery, the VPM reduced particle spillage by 86%.During posterior surgery, the VPM reduced overall particle spillage by 71%, while the EET reduced spillage by 97%.Conclusion: The VPM mask allows for a sealed surgical barrier during endoscopic skull base surgery and may play a criticalrole in advancing skull base surgery in the COVID-19 era. The EET may be a useful alternative for binarial procedures in theposterior nasal cavity and in instances where 3D printing is not available. Additionally, considering the ongoing pandemic,PPE shortage is a serious concern. The VPM may serve as a renewable alternative with various applications. In the future,our team will be performing studies to validate these preliminary findings.

Patients frequently access online resources for medical information. The National Institutes of Health and the American Medical Association recommend that to be understood by the average American, patient information should be presented at or below the sixth to seventh academic grade level. The popularity of rhytidectomy (facelift) is rising, and providers are frequently using the Internet to attract patients. All rhytidectomy information provided by 100 private practice Web sites in New York City, Los Angeles, Chicago, Houston, and Phoenix was analyzed using Readable.io software. The information was also assessed using the Flesch-Kincaid Grade Level, Gunning-Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook, Automated Readability Index, Flesch Reading Ease Score, and Fry Reading Graph tools. Analyzed material was written at a higher academic grade level than recommended for the average American. The overall average grade level was 10.99 ± 1.39. Online patient education materials about rhytidectomy provided by private practice clinics in 5 major cities of the United States were written at academic grade levels above the National Institutes of Health and American Medical Association recommended levels. This may lead to rhytidectomy patients having unrealistic or inaccurate expectations related to their surgical procedure.

The authors present the case of a 20-year-old male with a history of headaches and blurred vision found to have a pineal mass and chronic hydrocephalus. The patient initially underwent an endoscopic third ventriculostomy and pineal mass biopsy that revealed a low-grade neuroepithelial neoplasm. A microsurgery-endoscope–assisted paramedian supracerebellar-infratentorial approach was chosen and a gross-total resection was achieved. The patient’s postoperative and follow-up course has been unremarkable, with early postoperative imaging demonstrating no residual tumoral mass. The operative video highlights the advantages of endoscopic visualization for deep lesions in the pineal region and posterior third ventricle. The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2119.