Effectiveness of dupilumab versus endoscopic sinus surgery for the treatment of type-2 chronic rhinosinusitis with nasal polyps: a preliminary report.

PURPOSE: Historically managed with intranasal corticosteroids (INCS) and endoscopic sinus surgery (ESS), type-2 Chronic RhinoSinusitis with Nasal Polyps (CRSwNP) treatment was revolutionized by the introduction of dupilumab but universally accepted guidelines are still lacking. METHODS: Patients treated at our University Hospital for type-2 CRSwNP were enrolled. Demographic data were collected, as well as laboratory (eosinophils, total IgE), endoscopic [nasal polyps score (NPS), modified Lund-Kennedy score (mLKS)], radiological [Lund-Mackay score (LMS) at CT scan], SNOT-22, and olfactory [Sniffin' Sticks identification test (SSIT)] features. Patients were treated with dupilumab or ESS and re-evaluated after 3 and 12 months. RESULTS: At 3 and 12 months, patients undergoing ESS achieved a higher reduction of NPS and mLKS, while patients receiving dupilumab experienced a higher improvement at SNOT-22 and SSIT with a greater positive variation in the prevalence of anosmia (- 57.7% vs - 42.9%) and normosmia (+ 37.8 vs + 28.5%). Mean mLKS and LMS were quite similar. Results were independent of clinical features known to contribute to CRSwNP severity, except for patients with ≥ 2 prior ESS who had a significantly lower smell improvement. CONCLUSION: ESS and dupilumab were effective at reducing CRSwNP inflammatory burning. CRSwNP smell impairment cannot be attributed only to olfactory cleft obstruction and other mechanisms may be involved. Dupilumab acts systemically with poor correlation with NPS. As of today, dupilumab appears to be more suitable for elderly patients with anesthesiological contraindications and/or several previous surgeries, while ESS may represent the first-line choice in surgery-naive patients.

Intravascular papillary endothelial hyperplasia of the maxillary sinus extending into the contralateral nasal cavity.

INTRODUCTION: Intravascular papillary endothelial hyperplasia (IPEH) predominantly occurs in the subcutaneous and dermal regions and rarely originates from the sinonasal mucosa. CASE PRESENTATION: We report on the case of a 58-year-old male patient who presented with progressive bilateral nasal obstruction, left-sided epiphora, and intermittent epistaxis. Computed tomography revealed a soft tissue opacity in the left maxillary sinus with intersinusoidal nasal wall demineralization, extending into the surrounding ethmoid cells and the right nasal cavity through a contralateral deviation of the nasal septum. Contrast-enhanced T1-weighted magnetic resonance imaging further confirmed these findings. The IPEH originating from the maxillary sinus extended into the contralateral nasal cavity, and it was successfully removed using an endoscopic endonasal approach, avoiding overly aggressive treatment. CONCLUSION: This case report highlights the diagnostic challenges of IPEH in the sinonasal region and the importance of considering IPEH as a differential diagnosis in patients presenting with nasal obstruction, epiphora, and intermittent epistaxis.

Sublabial excision versus transnasal endoscopic marsupialization for nasolabial cysts: A systematic review and meta-analysis.

OBJECTIVES: To compare the intraoperative and postoperative outcomes of sublabial excision and transnasal endoscopic marsupialization, the two primary surgical approaches for nasolabial cysts. DESIGN AND SETTING: A comprehensive meta-analysis of studies identified from PubMed, Embase, and the Cochrane Library. PARTICIPANTS: Patients diagnosed with nasolabial cysts who underwent surgical treatment. MAIN OUTCOME MEASURES: Operative time, postoperative pain, overall postoperative complications, admission rate, length of hospital stay, use of general anaesthesia, medical costs, and recurrence rate. RESULTS: The pooled analysis revealed that the transnasal endoscopic marsupialization group had shorter operative time (mean differences [MD], -32.51; 95% confidence interval [CI], -38.52 to -26.51), reduced postoperative pain (MD, -4.25; 95% CI, -7.62 to -0.89), fewer overall postoperative complications (risk difference [RD], -0.68; 95% CI, -0.90 to -0.46), lower admission rates (RD, -0.86; 95% CI, -1.11 to -0.61), shorter hospital stays (MD, -1.74; 95% CI, -2.58 to -0.89), decreased use of general anaesthesia (RD, -0.40; 95% CI, -0.76 to -0.03), and reduced medical costs (MD, -229.69; 95% CI, -338.64 to -120.75). The recurrence rate between the two groups showed no significant difference (RD, -0.01; 95% CI, -0.05 to 0.04). CONCLUSION: Transnasal endoscopic marsupialization presents as a promising alternative to sublabial excision in the treatment of nasolabial cysts. It offers advantages like reduced operative time, decreased postoperative pain, fewer complications, lower admission rates, shorter hospital stays, diminished need for general anaesthesia, and cost savings. Clinicians can leverage these findings to select the most suitable surgical approach for their patients.

[Complications of transnasal endoscopic orbital decompression in thyroid eye disease]. / Oslozhneniya transnazal'noi endoskopicheskoi dekompressii orbity pri endokrinnoi oftal'mopatii.

PURPOSE: The study evaluates the frequency of complications after transnasal endoscopic orbital decompression (TEOD). MATERIAL AND METHODS: The study included 40 patients (75 orbits) with thyroid eye disease (TED; also termed Graves' ophthalmopathy, GO; thyroid-associated orbitopathy, TAO), who were divided into three groups depending on the method of surgical treatment. The first group consisted of 12 patients (21 orbits) who were treated with TEOD as the only method of surgical treatment. In the second group, there were 9 patients (18 orbits) who underwent TEOD and lateral orbital decompression (LOD) simultaneously. The third group consisted of 19 patients (36 orbits) who underwent TEOD as the second stage after LOD. Pre- and postoperative observation included assessment of visual acuity, visual field, exophthalmos, heterotropia/heterophoria angle. RESULTS: In group I the new-onset strabismus with binocular double vision was detected in 1 patient (8.3%). In 5 patients (41.7%), there was an increase in the angle of deviation and an increase in diplopia. In group II the new-onset strabismus with diplopia occurred in 2 patients (22.2%). In 8 patients (88.9%), an increase in the angle of deviation and an increase in diplopia were revealed. In group III the new-onset strabismus and diplopia occurred in 4 patients (21.0%). An increase in the deviation angle and an increase in diplopia were noted in 8 patients (42.1%). The number of postoperative otorhinolaryngologic complications in group I was 4 (19.0% of the number of orbits). Two intraoperative complications were recorded in group II - 1 case of cerebrospinal rhinorrhea (5.5% of the number of orbits) and 1 case of retrobulbar hematoma without permanent vision loss (5.5% of the number of orbits). The number of postoperative complications was 3 (16.7% of the number of orbits). In group III the number of postoperative complications was 3 (8.3% of the number of orbits). CONCLUSION: The study showed that the most common ophthalmological complication after TEOD is strabismus with binocular double vision. Otorhinolaryngologic complications included synechiae of the nasal cavity, sinusitis and mucocele of the paranasal sinuses.

[Transnasal endoscopic orbital decompression in the algorithm of surgical treatment of endocrine ophthalmopathy]. / Transnazal'naya endoskopicheskaya dekompressiya orbity v algoritme khirurgicheskogo lecheniya endokrinnoi oftal'mopatii.

OBJECTIVE: To develop an algorithm for the use of transnasal endoscopic orbital decompression (TEOD) in endocrine ophthalmopathy (EOP). MATERIAL AND METHODS: The results of 225 TEODs are analyzed. 139 patients with EOP were under observation, who were divided into two groups. Group 1 included 64 patients with an inactive form of EOP, group 2 included 75 patients with EOP complicated by optical neuropathy. Group 2 patients are divided into three subgroups. In the first subgroup there were 36 patients who underwent only TEDO, in the second subgroup there were 17 patients who underwent simultaneous TEOD and lateral bone orbital decompression (LBOD), in the third subgroup there were 22 patients who underwent TEOD and with an interval of 7-14 days - LBOD. After surgery, visual acuity, visual fields and color perception, regression of exophthalmos, as well as the presence of strabismus and diplopia were evaluated. RESULTS: In patients of group 1 (64 patients, 104 TEODs), the average regression rate of exophthalmos was 5.49±1.22. Diplopia was observed in 23 (36%) patients, strabismus - in 18 (28%) patients. The transient nature of diplopia and strabismus was noted in 11% of cases. Patients of the first subgroup showed an increase in visual acuity from 0.4±0.28 to 0.7±0.2 (p<0.05). Strabismus and diplopia were observed in 54% of cases. In the subgroup with step-by-step performed TEOD and LBOD, the increase in visual acuity was more pronounced and amounted to 74% (from 0.78±0.71 to 0.2±0.3 according to LogMAR, p<0.05), postoperative strabismus and diplopia remained at a high level - 40% of the number of surgical operations performed. The best results of improving visual functions were obtained in patients of the second subgroup with simultaneous TEOD and LBOD (balanced orbital decompression): the increase in visual acuity was 79% (from 0.57±0.47 to 0.12±0.2 according to LogMAR, p<0.05). In patients of this subgroup, strabismus develops less frequently (22% of the number of operated orbits). CONCLUSION: Transnasal endoscopic decompression of the orbit in the inactive form of the disease is indicated for exophthalmos of more than 4-8 mm. In optical neuropathy, transnasal endoscopic orbital decompression is indicated regardless of the initial visual acuity of the patient and should be supplemented with lateral bone orbital decompression with visual acuity below 0.1. The obtained results allowed us to form an algorithm for surgical treatment of patients with endocrine ophthalmopathy and optical neuropathy using transnasal endoscopic orbital decompression as a surgical intervention.

Imaging in chronic rhinosinusitis: A systematic review of MRI and CT diagnostic accuracy and reliability in severity staging.

BACKGROUND: Computerized tomography (CT) severity scores are frequently used as an objective staging tool in chronic rhinosinusitis (CRS). Magnetic resonance imaging (MRI) has also been proposed as a valid option in CRS imaging. PURPOSE: The aim of this systematic review was to briefly present the recent developments on sinus imaging utilized in clinical practice with regard to diagnostic accuracy of imaging and severity staging in CRS according to evidence-based medicine (EBM) principles. MATERIAL AND METHODS: This review paper has been assembled following PRISMA guidelines. A PubMed and Scopus (EMBASE) search using CRS, "severity staging", "diagnostic accuracy "and "imaging "resulted with 80 results. Of these, only 12 (59%) contained original data, constituting the synthesis of best-quality available evidence. RESULTS: CT is the most commonly used imaging technique for the severity staging of CRS, but a question of higher cumulative radiation dose should be taken into consideration when repeating CT examinations in evaluating treatment efficacy. MRI may be a complementary diagnostic and staging tool, especially when repeated examinations are required, or when paediatric CRS patients are evaluated. The severity staging system may be improved to better correlate with subjective scores. CONCLUSIONS: MRI may be utilized as a staging tool with comparable diagnostic accuracy, using the same staging systems as with CT examinations.

Relationship between the posterior septal artery and the upper edge of the choana.

BACKGROUND: The pedicled nasoseptal flap has been a key element in advancing the endoscopic transnasal approach (ETA) for the treatment of skull base lesions from the anterior cranial fossa to the occipitocervical junction. To preserve vascular supply, an anatomical knowledge of the location of the posterior septal artery (PSA) is essential. The objective of this work is to establish the relationship between PSA and the superior edge of the choana to define a safety margin during the opening of the sphenoidal rostrum preserving PSA. METHODS: One hundred and eighty angiotomographies of the brain were assessed. The sphenopalatine artery (SPA) was evaluated in the pterygopalatine fossa and PSA at its entrance into the nasal cavity and on the sphenoidal rostrum. RESULTS: PSA was found in all 3 tomographic planes (axial, coronal and sagittal) in 100 patients (200 PSAs). Thirty-five were male and 65 were females. Average age was 62 years with a range of 19-90 years. Total average distance between PSA and the superior edge of the choana was 8.5 mm with a range of 2.5-18 (12.45 90th percentile). CONCLUSION: Although the distance between the choanal edge and PSA is 8.5 mm on average, due to its variability, a distance of at least 12.45 mm for the opening of the sphenoidal sinus in the ETA approach should be considered as a safety margin.

Development, reliability, validity and sensitivity of the Sino-Nasal Outcome Test for Neurosurgery (SNOT-NC).

BACKGROUND: The transnasal endoscopic approach to lesions of the skull base has come into routine practice in recent years. Standardized questionnaires to assess the postoperative sequelae are missing. The authors present a custom-made questionnaire for the sino-nasal outcome test for neurosurgery (SNOT-NC) in accordance with the SNOT-22. METHODS: The SNOT-NC was developed with respect to the German version of the Sino-Nasal Outcome Test (SNOT-22) which is used for patients suffering from rhinosinusitis. It consists of 23 items covering "Nasal Discomfort", Sleep Problems/Reduced Productivity", "Ear and Head Discomfort", "Visual Impairment" and "olfactory impairment". The SNOT-NC was specifically adapted to patients undergoing transnasal operations of skull base lesions. The Short Form 36 health survey (SF-36), a nasal ad hoc questionnaire and the "Sniffin' Sticks" test were used for analyzing convergent and divergent validity. The psychometric and clinimetric analyses were performed using the data of 102 consecutive patients treated by transnasal operations for skull base lesions. RESULTS: Factorial validity was secured by a confirmatory factor analysis. The internal consistency (Cronbach's Alpha) for the subscales ranged from .62 to .85, while it was .84 for the whole instrument. The Guttman's lower reliability limits range estimates corresponded closely to the Cronbach's Alpha coefficients obtained. Examination of convergent and divergent validity revealed substantial associations between the SNOT-NC and a wide range of related nasal symptoms (p < .05). Different aspects of sensitivity were analyzed statistically with Cohen's t statistic for change (pairwise t tests) exhibiting at least p < .05) underlining the sensitivity of the SNOT-NC. CONCLUSIONS: The SNOT-NC appears to be a valid, reliable and sensitive measure for assessing the clinical outcome of patients undergoing transnasal endoscopic skull base surgery. The SNOT-NC proved to be a valuable tool to assess the nasal discomfort outcome of patients at follow-up examinations. Further analyses encompassing analyses for retest reliability are called for the future.

[Radicality of maxillary sinus surgery and size of the maxillary sinus ostium]. / Radikalität der Kieferhöhlenoperation und Größe des Kieferhöhlenfensters.

Until the 1990s, radical sinus surgery was considered a standard procedure for maxillary sinus diseases, but it is no longer favored due to the high morbidity. Today, functional endoscopic sinus surgery (FESS) is considered the gold standard in sinus surgery. Modifications of surgical approaches also allow access to regions of the maxillary sinus that were previously difficult to reach. Depending on anatomy and pathology, different methods for widening the maxillary ostium can be selected. In type I sinusotomy, the natural ostium is widened dorsally by a maximum of 1 cm. Sinusotomy type II involves widening the natural ostium up to a maximum diameter of 2 cm. In sinusotomy type III, the natural ostium is widened dorsally to the posterior wall of the maxillary sinus and caudally to the base of the inferior turbinate. Beside the prelacrimal approach, more invasive approaches are the medial maxillectomy, in which the dorsal part of the inferior turbinate and the adjacent medial wall of the maxillary sinus is resected, as well as its modifications "mega antrostomy" and "extended maxillary antrostomy." Correct selection of the size of the maxillary sinus window is prerequisite for successful treatment and long-term postoperative success. Isolated purulent maxillary sinusitis can usually be treated by a type I sinusotomy. Sinusotomy type II addresses nasal polyps with involvement of the mucosa of the ostium, recurrent stenosis after previous surgery, chronic maxillary sinusitis due to cystic fibrosis, and purulent maxillary sinusitis with involvement of other adjacent sinuses. Sinusotomy type III is required for choanal polyps with attachment to the floor of the maxillary sinus, for extensive polyposis and fungal sinusitis, and for inverted papilloma. Particularly for (recurrent) disease and extensive interventions in the maxillary sinus, medial maxillectomy or a modification thereof may be required.

Multimaterial and multicolor 3D-printed model in training of transnasal endoscopic surgery for pituitary adenoma.

OBJECTIVE: The aim of the present study was to investigate the practical value of a multimaterial and multicolor 3D-printed model in anatomical teaching, surgical training, and preoperative planning of transnasal endoscopic surgery for pituitary adenoma. METHODS: Multimodality neuroimaging data were obtained in a 42-year-old healthy male volunteer and a 40-year-old female patient with an invasive nonfunctional pituitary adenoma. Three 3D-printed models were produced: a monomaterial and monocolor model, a monomaterial and multicolor model, and a multimaterial and multicolor model. The effects on anatomical teaching and surgical training for exposing the vidian nerve were assessed by 12 residents, and the training effect was validated on cadavers. The practical values for preoperative planning were evaluated by 6 experienced neurosurgeons. All evaluations were based on 5-point Likert questionnaires. RESULTS: The multimaterial and multicolor model was superior to the monomaterial models in surgical training for exposing the vidian nerve (Fisher test; p < 0.05). In addition, the multimaterial and multicolor model was superior to the monomaterial models in anatomical teaching and preoperative planning (Friedman test; p < 0.05). CONCLUSIONS: Multimaterial and multicolor 3D printing technology makes it convenient and efficient to produce a practical model for simulating individualized and complex anatomical structures in the sellar region. Furthermore, the multimaterial model can provide a more realistic manipulative experience for surgical training and facilitate the preoperative planning.

Intranasal endoscopic prelacrimal recess approach for maxillary sinus inverted papilloma.

PURPOSE: This study aims to determine the indications and effectiveness of transnasal endoscopic prelacrimal recess approach (PLRA) in patients with maxillary sinus inverted papilloma (IP). METHODS: We retrospectively analyzed 71 patients treated in our institution for maxillary sinus IP between August 2008 and April 2015. 20 patients underwent endoscopic surgery via PLRA. All the patients who had postoperative follow-up for 3 years were enrolled. Demographic data, surgical technique, location of IP attachment, intra- and postoperative complications, follow-up duration and recurrence were recorded. RESULTS: The outpatient follow-up period was 3-10 years after surgery. Recurrence of IP was seen in 6 (8.5%) of 71 patients, including 1 patient in the PLRA group. The recurrence rate was 5% in the PLRA group. Six of 71 patients experienced postoperative complications, but none was observed in the PLRA group. CONCLUSION: Transnasal endoscopic PLRA is a minimally invasive, safe and effective method for maxillary sinus IP. The indication for PLRA is tumor pedicle located on the antero-inferior or infero-lateral wall or at multiple attachment sites of the maxillary sinus.

The ethmoidal arteries: a cadaveric study based on cone beam computed tomography and endoscopic dissection.

PURPOSE: To describe the anatomical variability of the ethmoidal arteries (EAs). To evaluate the reliability of cone beam computed tomography (CBCT) in preoperative assessment of EAs. METHODS: Fourteen cadaver heads underwent CBCT and endoscopic dissection. The following anatomical features were evaluated for anterior (AEA), middle (MEA), and posterior (PEA) EAs: presence, cranio-caudal position, antero-posterior position, and dehiscence of the bony canal. Accuracy of radiological assessment was calculated. RESULTS: AEA, MEA, and PEA were identified in 100, 28.6, and 100% of sides. They were caudal to the skull base in 60.7, 25, and 17.9%, respectively. CBCT showed a high accuracy in identifying these features. The antero-posterior position of EAs, which was highly variable, was correctly assessed by CBCT. A dehiscent bony canal of AEA, MEA, and PEA was found in 46.4, 12.5, and 28.6% of sides, respectively. Accuracy of CBCT in picking up this feature was poor but negative predictive value was high. CONCLUSIONS: CBCT was adequate in identifying and localizing EAs. In addition, it can be used to exclude the presence of MEA and dehiscence of ethmoidal canals, whereas the accuracy in detecting these anatomic variants was low.

Mucocele of the Sphenoid Sinus.

Mucocele of the paranasal sinuses is a rare disease with slow evolution. It is a benign, encapsulated and destructive formation filled with mucous fluid and tapistrated with respiratory epithelium. Of all the paranasal sinuses, the sphenoid sinus is affected in only 1-7% of the cases. We present two cases of mucocele of the sphenoid sinus involving the posterior ethmoidal cells. We consider here their clinical presentation, use of neuroimaging in the diagnosis, surgical care and postoperative results. Both patients presented with a history of persistent headache and in addition, one of them had a paresis of the right oculomotor and abducens nerves. A transnasal endoscopic sphenoidectomy was performed in both patients, in one - with an evacuation of the mucocele and marsupialization, and in the other - with a balloon dilatation of the natural foramen of the sinus. Postoperatively, a complete reversal of the symptoms was observed in both patients. Mucocele of the paranasal sinuses should be considered as a diagnosis in cases of persistent headache with a primarily retrobulbar location and eye symptoms. Computed tomography and magnetic resonance imaging can be used to successfully diagnose the disease. The transnasal endoscopic sphenoidectomy is the therapeutic method of choice which allows evacuation of the mucocele, while the marsupialization allows good drainage and prevents recurrence.

The infundibulochiasmatic angle and the favorability of an endoscopic endonasal approach in type IV craniopharyngioma: illustrative case.

BACKGROUND: Lesions located in the floor of the third ventricle are among the most difficult to access in neurosurgery. The neurovascular structures can limit transcranial exposure, whereas tumor extension into the third ventricle can limit visualization and access. The midline transsphenoidal route is an alternative approach to tumor invading the third ventricle if the tumor is localized at its anterior half and a working space between the optic apparatus and the pituitary infundibulum exists. The authors introduce the "infundibulochiasmatic angle," a valuable measurement supporting the feasibility of the translamina terminalis endoscopic endonasal approach (EEA) for resection of type IV craniopharyngiomas. OBSERVATIONS: Due to a favorable infundibulochiasmatic angle measurement on preoperative magnetic resonance imaging (MRI), an endoscopic endonasal transsellar transtubercular approach was performed to resect a type IV craniopharyngioma. At 2-month follow-up, the patient's neurological exam was unremarkable, with improvement in bitemporal hemianopsia. Postoperative MRI confirmed gross-total tumor resection. LESSONS: The infundibulochiasmatic angle is a radiological tool for evaluating the feasibility of EEA when resecting tumors in the anterior half of the third ventricle. Advantages include reduced brain retraction and excellent rates of resection, with minimal postoperative risks of cerebrospinal fluid leakage and permanent pituitary dysfunction.

Comparative analysis of transnasal endoscopic reconstruction techniques for managing cerebrospinal fluid rhinorrhea in skull base defects.

The nasal skull base is located into the deep position of nasal cavity and closely related to important nerves and vessels. The complete removal of tumors in this area poses a complex surgical challenge.In order to investigate the clinical efficacy of utilizing free middle turbinate mucosa (FMT), fascia lata, and pedicled nasal septum flap (known as the Hadad-Bassagasteguy flap, HBF) for the treatment of cerebrospinal fluid (CSF) rhinorrhea, a retrospective analysis was conducted on clinical data from 65 patients who underwent skull base reconstruction following endoscopic resection of nasal-skull base tumors. The selection of the repair material was based on the size and location of the defect. For defects less than 1.5 cm (n = 24), FMT was chosen, while for defects greater than or equal to 1.5 cm (n = 16), HBF was preferred. In cases where HBF was not available or not suitable (specifically, when the defect was located on the posterior wall of the frontal sinus), fascia lata was selected (n = 25). The repair outcomes of all 65 patients were summarized, and subsequently, a comparison was made between the use of fascia lata and HBF. The overall success rate for one-time repairs was 93.8 %. Specifically, the success rates for repairs using FMT, fascia lata, and HBF were 91.7 %, 96.0 %, and 93.8 %, respectively. Throughout the follow-up period, there were 2 cases of postoperative CSF leakage out of 24 patients who underwent FMT reconstruction, 1 case out of 25 patients who underwent fascia lata reconstruction, and 1 case out of 16 patients who underwent HBF reconstruction. The occurrence of postoperative complications, such as intracranial infection, lung infection, and epistaxis, was observed in both the fascia lata group and the HBF group. However, there were no statistically significant differences between the two groups. The transnasal endoscopic reconstruction of skull base defect using HBF, fascia lata, and FMT demonstrated satisfactory repair effects in managing CSF rhinorrhea. Generally, FMT has been found to be a dependable repair material for small defects measuring less than 1.5 cm, while in the case of larger defects equal to or exceeding 1.5 cm, both HBF and fascia lata can be utilized with comparable repair outcomes. The selection of fascia lata becomes a viable option when HBF is unavailable or not suitable.

Prognostic factors in transnasal endoscopic surgery for paediatric patients with ossifying fibroma of the paranasal sinuses and skull base.

BACKGROUND: Ossifying fibroma of the paranasal sinuses and skull base in paediatric patients is difficult to operate and can recur easily after surgery. This study aimed to analyse factors associated with recurrence after transnasal endoscopic resection of ossifying fibroma in paediatric patients. METHODS: This retrospective observational study included 34 patients under 17 years of age who underwent transnasal endoscopic resection of ossifying fibroma of the paranasal sinuses and skull base from 2005 to 2021 at a single tertiary medical centre. Clinical indicators such as age; surgical history; pathological type; intraoperative bleeding; and orbit, anterior skull base, sphenoid bone, sella turcica, clivus, or frontal sinus involvement were subjected to univariate analysis using the χ2 test, to investigate whether any of these factors affected recurrence. RESULTS: All 34 patients underwent transnasal endoscopic resection. The follow-up period was 6-120 months (mean: 48.0 months). Five patients experienced local recurrence during the follow-up period (14.7%). Results of χ2 tests indicated that a history of previous surgery, the amount of intraoperative bleeding, and sphenoid and/or sella turcica and clivus involvement were significantly associated with recurrence (P < 0.05). Age; pathological stage; and orbit, anterior skull base, and frontal sinus involvement were not associated with recurrence (P > 0.05). CONCLUSIONS: The increased risk of recurrence after transnasal endoscopic resection of nasal-skull base ossifying fibroma should be considered during endoscopic surgery in paediatric patients with a history of previous surgery, intraoperative bleeding tendency, and sphenoid and/or sella turcica and clivus involvement. These patients require careful postoperative follow-up.

Comparing Endoscopic Measurements of the Anterior and Posterior Ethmoidal Arteries with CT Measurements: A Cadaveric Study.

OBJECTIVE: To reveal the reliability of radiological measurements of the ethmoid arteries. METHOD: Five fresh frozen cadaveric heads underwent computed tomography and endoscopic sinus surgery. The lateromedial length of the anterior ethmoidal artery (AEA) and its distance to the axilla of the middle turbinate (MTA), the sphenoethmoidal recess (SR) and the posterior ethmoidal artery were measured. The posterior ethmoidal artery (PEA) was referenced to the SR. These anatomical parameters were measured both radiologically and endoscopically, and the compatibility of the two was examined. RESULTS: Ten nasal cavities were dissected. We found that the distance of MTA to the AEA was 16±8 mm in dissection, 21±4 mm radiologically in the sagittal section, the distance of SR to the AEA was 14±3 mm in dissection, 19±4 mm radiologically in the sagittal section, and the distance of the AEA to the PEA was 10±3 mm in dissection, 12±3 mm radiologically in the axial section. The distance of the PEA to SR was 6±3 mm in dissection, 8±2 mm radiologically in the sagittal section. CONCLUSIONS: The distance of the AEA to the MTA, the distance of the AEA to the PEA and the distance of the PEA to the SR were compatible with each other in the dissection and in the radiologically evaluation, whereas the distance of the AEA to the SR was not compatible.

Pituicytoma: A rare tumor of the sella. A case report and review of literature for diagnosis and management.

Background: Pituicytomas are rare tumors of the pituitary gland derived from the ependymal cells and line the pituitary stalk and posterior lobe. These tumors are located in the vulnerable regions of the brain: Either in the sellar or suprasellar area. The location marks the difference in the clinical features of the tumor. Here, we report a case of histopathologically diagnosed pituicytoma of the sellar region. Literature is also reviewed and discussed to gain a better understanding of this rare disease. Case Description: A 24-year-old female presented to the outpatient department with complaints of headache, diplopia, dizziness, and decreased vision in the right eye for 6 months. Computed tomography scan brain without contrast showed a well-defined hyperdense lesion in the sella without associated bony erosion. Her magnetic resonance imaging showed well defined rounded lesion in the pituitary fossa which was isointense on T1-weighted image and hyperintense on T2-weighted images. A presumptive diagnosis of pituitary adenoma was made. She underwent endoscopic endonasal transsphenoidal resection of pituitary mass. Intraoperatively, normal pituitary gland was visualized and there was a grayish-green-colored, jelly like tumor which was pulled gently. On 9th postoperative day, she presented with cerebrospinal fluid (CSF) rhinorrhea. She underwent endoscopic CSF leak repair. Her histopathology was concluded to be Pituicytoma. Conclusion: Pituicytoma is an uncommon diagnosis. The surgical aim is to completely excise the tumor which results in complete cure, but incomplete resection may be performed due to high vascularity of this tumor. In case of incomplete excision, recurrence is common and adjuvant radiotherapy may be administered.

Postoperative vasospasm and cerebral infarction in a patient with large pituitary adenoma and cerebral superficial siderosis.

Background: Cerebral vasospasm and infarction are rare complications of transsphenoidal surgery for pituitary adenoma. Cerebral superficial siderosis may result from subarachnoid hemorrhage from a pituitary adenoma. The constellation of cerebral superficial siderosis, cerebral vasospasm, and pituitary adenoma is rare. We describe an extremely rare clinical constellation of immediately postoperative cerebral vasospasm and consequent cerebral infarction in a case with a large pituitary adenoma and cerebral superficial siderosis. Case Description: A 70-year-old man presented with a pituitary adenoma causing a worsening headache. Preoperative magnetic resonance (MR) images revealed cerebral superficial siderosis, suggesting subarachnoid hemorrhage from pituitary apoplexy. MR angiography (MRA) showed no vasospasm. During the transsphenoidal surgery, an intratumoral hematoma was found. The arachnoid membrane was partially torn and intratumoral hematoma entered the subarachnoid space. Intraoperatively, the intracranial vessels remained intact. The suprasellar tumor was almost entirely resected; however, the patient remained comatose postoperatively. Computed tomography revealed ischemic lesions in the bilateral insular and frontotemporal cortex. MRA revealed cerebral vasospasm in the bilateral middle cerebral arteries. The patient was treated with levetiracetam for nonconvulsive status epilepticus and underwent a lumbar peritoneal shunt surgery for secondary hydrocephalus. However, the patient remained listless. Conclusion: Postoperative cerebral vasospasm and infarction are severe but rare complications for a pituitary adenoma after transsphenoidal surgery. Preoperative and intraoperative subarachnoid hemorrhage might have been a risk factor in our case. Similar cases should be warranted to analyze whether cerebral superficial siderosis may also indicate the risk of severe postoperative vasospasm immediately after transsphenoidal surgery for pituitary adenoma.

Nasal Septal Ancient Schwannoma: Ancient and Rare.

Schwannoma is a rare benign neurogenic tumor arising from the Schwann cells of peripheral nerves. A 77-year-old man presented with progressively worsening left nasal block and hyposmia for the past six months. Nasal endoscopy revealed a polypoidal reddish mass occupying the left middle meatus. The biopsy was in favor of ancient schwannoma. Endoscopic transnasal excision of the mass arising from the left nasal septum was performed. A middle meatal antrostomy was also performed. The tumor cells were positive for S100 protein. Presenting symptoms are common to other sinonasal tumors, and the differential diagnoses include carcinoma, inverted papilloma, sarcoma, lymphoma, and neurofibroma. Schwannomas are composed of spindle cells with two histologically distinct patterns that can be mixed: Antoni type A and Antoni type B. A neural crest marker antigen, S-100 protein, is useful to corroborate our diagnosis. It is vital to consider nasal septal schwannoma in the differential diagnosis of patients complaining of unilateral nasal obstruction with polypoidal nasal mass, especially the posterior third of the nasal septum. Transnasal endoscopic surgery is the preferred approach for nasal septal schwannoma.