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Recent studies highlighted how exoscopes may be employed to approach the lateral skull base. The use of exoscope-assisted procedures to repair middle cranial fossa (MCF) defects has not been fully explored. The surgical microscope in the same circumstances has been associated with relevant limitations, such as its physical obstruction, among others. The aim of this study was to present a proof of concept of exoscope-assisted surgery for MCF defects.A detailed step-by-step MCF approach was performed on 2 alcohol-preserved, latex-injected cadaveric specimens under exoscopic magnification. An illustrative clinical case of encephalocele secondary to a spontaneous tegmen tympani defect repaired via an exoscope-assisted MCF approach was presented.The most common sites of MCF defects, the tegmen tympani and the arcuate eminence, were successfully exposed under exoscopic magnification. Dissection was easily performed; no damage to the dura mater or to vascular or neural structures occurred. In the clinical case, the exoscope-assisted technique demonstrated adequate maneuverability and magnification quality. After localization, the encephalocele was resected, and the MCF defect was repaired. The surgeon's position was comfortable, and operative time was not prolonged.The exoscope allows adequate exposure of the MCF floor with identification and preservation of key anatomical structures. The exoscope represents a valuable alternative to the microscope in reconstruction of MCF defects, offering high-quality magnification and proven maneuverability.

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.

Resumen La papilomatosis respiratoria recurrente (PRR) consiste en tumores benignos en las vias respiratorias causados por la infeccion del virus del papiloma humano. Las lesiones pueden provocar cambios en la fonacion y obstruir las vias respiratorias. El objetivo de este estudio es evaluar las diferentes terapias quirurgicas y adyuvantes disponibles para el tratamiento de esta afeccion que se han reportado en los anos recientes. Se realizo una busqueda en PubMed de articulos sobre el tratamiento de la PPR publicados entre 2014 y 2018. De los encontrados, 40 articulos con 1.425 pacientes con PRR cumplieron con los criterios. De estos, 24 articulos evaluaban el uso de terapias adyuvantes como el bevacizumab, el cidofovir y la vacuna contra el virus del papiloma humano. Ha habido un aumento en las opciones terapeuticas adyuvantes para la PRR en los ultimos anos. El conocimiento de estas opciones resalta las lagunas y oportunidades en la atencion de estos pacientes, abre la puerta a nuevos protocolos para controlar la enfermedad, aumenta los intervalos quirurgicos y nos guia hacia nuevos caminos en el futuro.

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.

Objective The objective of the present study was to describe and evaluate the feasibility, mobility, and surface area provided by the simple and extended transorbital pericranial flap (TOPF). Furthermore, we compared this novel technique with the current practice of pericranial flap harvesting and insetting techniques. We also studied the adequacy of the TOPF in the reconstruction of postoperative anterior cranial fossa (ACF) defects. Methods The TOPF was performed bilaterally in 5 alcohol-preserved, latex-injected human cadaveric specimens. The TOPF was harvested in 2 stages: the orbitonasal stage and the cranial stage. For the orbitonasal stage, a transorbital superior eyelid approach was used. We have described 2 harvesting techniques for creating 2 distinct TOPF types (simple and extended) according to the main vascular pedicle. The superficial flap areas offered by the simple and extended TOPF and the traditional bicoronal pericranial flap were calculated and compared. The distances from the supratrochlear and supraorbital arteries to specified anatomical landmarks were also measured. Additionally, the ACF defect area of relevant surgical cases performed using endoscopic transcribriform approaches were measured on immediate postoperative computed tomography head scans using radiological imaging software. Results The harvest of both the simple and the extended TOPFs was efficient. As expected, the areas offered by simple and extended TOPFs were smaller than that offered by the traditional bicoronal flap. However, the surface area offered by either the simple or extended TOPF provides sufficient coverage for most ACF defects. A high spatial distribution was observed between the vascular pedicles and their respective foramen or notch. Conclusions The TOPF represents a novel harvesting, tunneling, and insetting technique that offers a large, versatile, pedicled flap for coverage of most standard ACF defects after endoscopic surgery.

Minimally invasive trans-sulcal parafascicular port-based approaches can provide safe access to a wide variety of deep brain lesions.1,2 This surgical video illustrates the use of a minimally invasive port-based approach for resection of a subcortical right medial occipital lobe lesion in a 63-year-old woman who presented with seizures and bilateral left homonymous hemianopia. MRI showed a 2.5-cm contrast enhancing lesion with a necrotic center and significant T2 and fluid-attenuated inversion recovery signal consistent with vasogenic edema. Diffusion tensor imaging revealed compromise of the right optic radiations and edema extending through the right corticospinal tract. A minimally invasive trans-sulcal parafascicular port-based approach to the deep occipital lobe and periatrial region was performed under full exoscopic visualization. A gross total tumor resection was achieved, and histopathology revealed an IDH1-mutant, MGMT-methylated-positive glioblastoma. The patient's presentation, rationale, key surgical steps, and outcomes are discussed, and informed consent for surgery was obtained. The participants and any identifiable individuals consented to the publication of their image. Images at 3:50 used with permission from Nico Corporation. All rights reserved.

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.

Objective Provide a detailed anatomical description of the olfactory filaments (OF) and their distribution in the nasal cavity through endoscopic endonasal dissection. Methods Four cadaveric specimens (8 sides) were used in this study. Nasoseptal (NSM), middle (MTM) and superior turbinate (STM) mucosa dissection was performed to identify the OF and follow them superiorly to the cribriform plate (CP). Measurements of the OF were taken on the NSM, MTM, STM under direct endoscopic visualization. A Student’s T-Test was performed to compare means. Results The NSM contained a mean of 11 OF, distributed over surface area (SA) of 173 ± 31 mm2 with the highest density of OF being found at the posterior NSM. The MTM contained a mean 6 OF, covering a mean SA of 77 mm2, with the first OF found 5 mm from the anterior border of the MTM, on average. The STM had a mean 9 OF, with the OF covering a mean SA of 96 mm2. Overall mean OF length was 6 mm. The STM OF were significantly greater in number, with a greater distance from the first OF to last OF (p Summary The STM and MTM combined were found to have a greater density of OF than the NSM. The STM contains a significantly greater number of OF covering a greater area than the MTM OF. Preservation of the STM and MTM in skull base defect repair, and in routine sinus surgery, can be as beneficial for olfactory function as preservation of the NSM; particularly in CP defect repair. Moreover, our findings indicate that nasoseptal flap harvest performed at least 6 mm from the skull base preserves OF in the NSM. To our knowledge, this is the first anatomical study of the OF through direct endoscopic observation and measurements.

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.

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.