Effect of endoscopic endonasal skull base approaches on olfactory function and facial development in children.

INTRODUCTION: Endoscopic approaches for skull base pathologies are increasingly being performed, and the subsequent complications, especially in the long term, have also been partially clarified. However, there is no information on the effects of endoscopic endonasal skull base surgeries (EESBS) in children on odor and facial development in parallel with long-term development. We conducted this study to investigate postoperative olfactory function and facial development in pediatric patients who underwent skull base surgery using the endoscopic endonasal method. METHODS: We evaluated the smell test, sinonasal symptoms, and facial development of pediatric patients who underwent endoscopic endonasal skull base surgery after long-term follow-up. Odor was evaluated using the "Sniffin' Sticks" test kit, which assessed the T (odor threshold), D (odor discrimination), and I (odor identification) parameters. Sinonasal symptoms were evaluated using the SNOT-22 (sinus-nose outcome test) questionnaire. SNA (sella-nasion-A point), SNB (sella-nasion-B point), and ANB (A point-nasion-B point) angles were calculated from maxillofacial tomography and magnetic resonance imaging) to evaluate facial development. Data were compared with those of the healthy control group. RESULTS: We included 30 patients comprising 19 (63.3%) boys and 11 (36.7%) girls, with no age difference between case and control groups. The mean follow-up period was 7 years. Odor test data, cephalometric measurements, and SNOT-22 analysis results showed no statistically significant differences between the two groups. CONCLUSION: To our knowledge, this is a comprehensive study with the longest follow-up period in terms of evaluation of facial development after EESBS in children to analyze odor using the Sniffin' Sticks test kit and the quality of life using SNOT-22. Olfactory function, facial development, and quality of life remained unaffected after long-term follow-up after EESBS  in children. Although this surgical approach is minimally invasive, we recommend considering the possibility of complications, and the procedure should be performed by an experienced surgical team with adequate equipment.

Single-institution comparative analysis for odontoid resection: posterior transaxis versus anterior transnasal approach.

OBJECTIVE: The resection of an upwardly migrated odontoid is most widely performed via an anterior endoscopic endonasal approach after the addition of posterior occipitocervical instrumentation. In patients with craniovertebral junction (CVJ) anomalies like basilar invagination (BI), surgery is usually achieved in two separate stages. However, the authors have recently introduced a novel posterior transaxis approach in which all the therapeutic goals of the surgery can be safely and effectively accomplished in a single-stage procedure. The aim of the current study was to compare the widely used anterior and the recently introduced posterior approaches on the basis of objective clinical results in patients who underwent odontoid resection for BI. METHODS: Patients with BI who had undergone odontoid resection were retrospectively reviewed in two groups. The first group (n = 7) consisted of patients who underwent anterior odontoidectomy via the standard anterior transnasal route, and the second group (n = 6) included patients in whom the novel transaxis approach was performed. Patient characteristics, neurological conditions, and modified Rankin Scale (mRS) scores at admission were evaluated. Operative time, changes in intraoperative neurophysiological monitoring, blood loss during surgery, odontoid resection rate, postoperative complications, and mortality were compared between the patient groups. RESULTS: Data were retrospectively reviewed for 13 patients who underwent odontoid resection, posterior CVJ decompression, and occipitocervical instrumentation at the Ankara University School of Medicine Department of Neurosurgery between 2009 and 2022. In the first group (n = 7), patients who underwent anterior odontoidectomy via the standard endonasal route, two serious complications were observed, pneumocephaly and basilar artery injury. In the second group (n = 6), patients in whom the novel transaxis approach was performed, only one complication was observed, occipital plate malposition. CONCLUSIONS: This study represents the results of what is to the authors' knowledge the first comparison of a novel approach with a widely used surgical approach to odontoid resection in patients with BI. The preliminary data support the successful utility of the transaxis approach for odontoid resection that meets all the operative therapeutic demands in a single-stage operation. Considering the diminished surgical risks and operative time, the transaxis approach may be regarded as a primary approach for the treatment of BI.

Endonasal endoscopic approach for sellar metastatic pathologies: a national observation.

PURPOSE: Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions. METHODS: A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes. RESULTS: Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients. CONCLUSION: To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Alternative Path for Optic Nerve Decompression in Pseudotumor Cerebri With Full Endoscopic Lateral Transorbital Approach.

Endonasal endoscopic approaches are the most preferred surgical methods in patients with pseudotumor cerebri because of easy access to the optic nerve, but the choice of this technique may not apply to all endoscopic endonasal cases. Moreover, there may be difficulties in practice in some cases, including the coronavirus disease 2019 pandemic. This study aimed to suggest an alternative endoscopic approach by lateral orbitotomy for optic nerve decompression in patients with pseudotumor cerebri. The study was performed using 5 fresh-frozen cadaver heads (bilaterally, total of 10 sides) injected intravenously with colored silicone preserved in the cold chain. An average of 2.5 cm skin incision was made to fit the lateral orbitotomy. The lengths of the recurrent meningeal artery (mm), the meningo-orbital band (mm), and the optic nerve (mm) to the orbital margin were measured. After these morphometric measurements, optic nerve decompression was performed endoscopically, and the length of the decompression was measured (mm). The average length (mm) between the orbital rim and meningeal recurrent artery (or meningolacrimal branch) was 16.2 mm, between the orbital rim and the meningo-orbital band was 18.5 mm, and between the orbital rim and optic nerve was 44.1 mm. The average optic nerve decompression length was 4.4 mm. The endoscopic lateral orbitotomy approach provides easy access to the optic nerve by anatomically following the recurrent meningeal artery and the meningo-orbital band. It can be a safe second-line approach after endonasal approaches for optic nerve decompression in pseudotumor cerebri.

Purely Endonasal Endoscopic Approaches for Extracranial Trigeminal Nerve Schwannoma.

OBJECTIVE: The aim of this study is to assess the effectiveness and safety of purely endonasal endoscopic resection of extracranial trigeminal schwannomas (TGSs), with assessment of surgical and clinical outcomes in order to identify optimal candidates for an endonasal endoscopic approach (EEA). METHODS: A retrospective review of patient's records operated for TGSs between 2008 and 2021 was conducted. Patients operated with a purely EEA were included in this study. Pictures from a frozen fresh cadaver head dissection were used to demonstrate the surgical approach and to show anatomic relationships, complexity of the surgical area and safe corridors for surgery. RESULTS: A total of 5 patients (4 females and 1 male) were operated for TGS. All patients had facial numbness (100%) as a presenting symptom, followed by facial pain in 2 patients (40%), and orbital pain in 1 (20%). Also, 3 patients (60%) had a tumor originating at the level of the foramen ovale and 2 (40%) at the foramen rotundum. The mean tumor diameter was 3,7 ± 2 cm. Gross total resection were achieved in all cases. Postoperatively, 1 patient had severe mastication problems, 1 had blurred vision, and in the long-term follow-up, 1 had frontal sinusitis. The mean follow up was 106.6 (min:49, max:132, SD: 29.82) months. No recurrences were detected. CONCLUSIONS: In cases with the extradural TGS having limited extension into Posterior Cranial Fossa, or located in the Middle Cranial Fossa, a purely EEA is possible even for tumors bigger in size. Unilateral endonasal corridors are adequate for resection in most cases.

Comparison of Three Surgical Approaches for Frontobasal Meningiomas: Purely Endoscopic Endonasal, Purely Microscopic Bifrontal Transcranial, and Combined Endoscopic and Microscopic Supraorbital Transciliary Approaches.

ABSTRACT: Surgical removal of frontobasal meningiomas (FBMs) can be achieved using different techniques, including endoscopic, transcranial, and combined approaches. The advantages and disadvantages of the outcomes of these approaches should be compared to provide the most convenient surgical treatment to the patient. This study aimed to compare 3 surgical approaches for FBMsin terms of outcomes and determine the superiority of each on the basis of anatomical, surgical, and clinical efficacy. Systematic review was performed to identify studies comparing techniques for the surgical removal of FBMs. Each group included 13 patients; 39 patients with FBMshad undergone surgery. These groups were endoscopic endonasal approach (EEA), microscopic bifrontal transcranial approach (MTA), and endoscopic plus microscopic combined supraorbital transciliary approach (STA) groups. Data on the demographics of patient population, pre- and post-operative neurological examination, tumor properties, imaging studies, and surgical complications were extracted. The mean age at the time of surgery for the patient population was 53.2 years. Among the groups, no statistically significant differences were observed with regard to sex (P = 0.582). The mean follow-up time was 56.7 months. A statistically significant difference was observed in the mean tumor volume among the groups; the MTA group showed the highest mean tumor volume. However, no significant difference was found in the mean tumor volume between EEA and STA groups. Regarding operation duration, the STA group had the shortest operation time (mean = 281.5 minutes), whereas the average surgical duration in MTA group was the longest (mean = 443.8 minutes). The average bleeding volume was highest in the MTA group (mean = 746.2 ml) and lowest in the EEA group (mean = 320.8 ml). Tumor removal was incomplete in three patients (two in the EEA group and one in the MTA group). Recurrence was detected in two cases. One patient with recurrence was operated using the endoscopic surgical approach, whereas the other patient underwent the microscopic bifrontal approach. Post-operative hyposmia/anosmia or decreased olfactory function was the most common complication observed in 5 patients, 2 patients each in the EEA and MTA groups and one in the STA group. The second most common complication was wound infection in one patient in the MTA group and two patients in the STA group (7.7%). Both cerebrospinal fluid (CSF) leakage and meningitis were present in two patients (5.1%), one patient each from the EEA and STA groups. Pre-operative visual disturbances were reported in 13 patients (33.3%), all of which resolved post-operatively No statistical differences were found among the groups. Mortality occurred in a patient in the MTA group (2.6%) caused by cardiac arrest on post-operative day 1. This is the first study comparing the surgical outcomes of three surgical approaches for FBMs. Although recent literature suggests that both endoscopic and transcranial approaches have their own advantages and disadvantages, the authors showed that none of the surgical approaches have obvious superiority over the others with regard to outcomes. Thus, the selection of the ideal surgical approach should be based on surgical experience and tumor characteristics.

Endonasal Endoscopic Management of Pterigopalatine Fossa Hydatid Cyst.

Hydatid cyst (echinococcosis) is an infectious disease caused mainly by Echinococcus granulosus, a parasite transmitted by dogs and encountered first in the liver and then in the lungs. Involvement in the head and neck region is uncommon, and pterygopalatine fossa disease resulting from hydatid cyst is extremely rare, with only 4 reported patients. In this report, the authors present a patient with exophthalmus caused by a primary hydatid cyst and involving the pterygopalatine fossa which treated only with endoscopic endonasal approach.

Preference and Perception of Enhanced Images During Endonasal Endoscopic Surgery.

Image enhancement is used widely in endoscopic sinonasal surgery. It is yet to be established whether image enhancement has advantages over white-light endoscopy. The authors aimed to evaluate the preferences and subjective visual perception of image enhancement in diagnostic images acquired at the beginning of endonasal endoscopic surgeries. An online survey consisting of 12 endoscopic images, 4 enhanced with Clara mode, 4 enhanced with Chroma mode, and 4 enhanced with Clara+Chroma mode, was distributed. The enhanced images were randomly presented with nonenhanced white-light images. These images were captured at the beginning of endonasal endoscopic surgeries for septal perforation, septal deviation, and chronic rhinosinusitis. Survey respondents (n = 205) included 81 otorhinolaryngologists, 94 other specialty physicians (35 endoscopy/laparoscopy users and 59 nonusers), and 30 nonmedical image experts. They were asked to choose superior images according to brightness, contrast and sharpness, depth of field, and overall preference. A quantitative study was also conducted to evaluate different enhancement modes. The authors found that Clara enhanced brightness and Chroma enhanced contrast and sharpness significantly (P < 0.001). Overall, 91.8% chose Clara and 91.7% chose Clara+Chroma-enhanced images for brightness enhancement. For contrast and sharpness, 87% chose Clara+Chroma and 86.7% chose Chroma. There was no significant difference between perception scores among the groups. Our survey group showed a significantly high overall preference for enhanced images. This preference was independent of profession or experience, but closely related to the quantitative enhancement of the specific mode. Continuous use of image enhancement in endonasal surgery may have advantages over white-light endoscopy.

Cartilage reinforcement graft versus fascia graft in tympanoplasty

Background/aim: The purpose of this study was to compare cartilage reinforcement graft results with temporalis fascia graft alone in terms of hearing and anatomical outcomes in tympanoplasty. Materials and methods: Patients who underwent tympanoplasty with/without ossiculoplasty and/or mastoidectomy at a university hospital from 2006 through 2013 were reviewed retrospectively. The patients were divided into those grafted with temporalis muscle fascia alone and with fascia reinforced with cartilage. The postoperative air bone gap, gain in hearing thresholds, and graft status were evaluated for each group. Results: The study subjects included 179 patients. There were 82 patients in the fascia group and 97 patients in the cartilage group. Successful hearing results were elicited in 79.2% of the fascia group and 85.5% of the cartilage group. There was no significant difference in overall graft success. The graft was intact in 82.9% of the fascia group and 86.5% of the cartilage group. Conclusion: In this comparative study the use of cartilage to reinforce the temporalis muscle fascia was analyzed, showing better hearing and anatomical results than sole use of fascia in tympanoplasty both for primary and revision cases. Thus, in the light of our results, when performing tympanoplasty we recommend the use of cartilage reinforcement grafting whenever needed and indicated.

Does Dehiscence of the Facial Nerve Canal Affect Tympanoplasty Results?

This study aimed to evaluate the prevalence of facial nerve canal dehiscence in tympanoplasty patients and its influence on the need for revision surgery and on hearing results and anatomical outcomes. Patients who underwent tympanoplasty with/without mastoidectomy at Ankara University Otolaryngology Department from 2006 through 2013 with a minimum follow-up period of 6 months were reviewed retrospectively in this original study. Patients were divided into those with and without cholesteatoma. Numbers and frequencies of dehiscence were recorded according to disease type, the need for revision surgery, and hearing results and anatomical outcomes. Study subjects included 206 patients, of whom 15 (7.3%) had dehiscence. The prevalence of dehiscence was significantly high in the patients with cholesteatoma (13/50 patients) compared with those without (2/156 patients). The dehiscence frequency was significantly high in cholesteatoma (42.8%), as well as overall (14.7%), revision-surgery patients. Hearing results (P < 0.05) and anatomical outcomes were better in patients without dehiscence. Dehiscence is more common in patients with than without cholesteatoma and negatively affects tympanoplasty outcomes, including hearing results, anatomical outcomes, and the need for revision surgery.

How Often Does Isolated Sphenoid Sinus Disease Turn Out to be a Neoplasm?

Isolated sphenoid sinus disease (ISSD) describes a wide spectrum of pathologies including inflammatory, vascular, bony dysplastic, and neoplastic diseases. The aim of this study was to assess the frequency with which a neoplastic process was diagnosed in patients of ISSD and patient management strategies. A retrospective analysis was conducted for all ISSD patients who underwent surgery between January 2005 and January 2014 at a tertiary center. The clinical characteristics, radiologic studies, operative findings, endoscopic surgical techniques, pathology results, and treatment outcomes of the patients were analyzed. In all, 42 patients (31 women and 11 men) were included in the study. Histopathologic examinations revealed that 10 patients (23.4%) had neoplasms (8 benign and 2 malignant), 19 (45.2%) had mucocele, 7 (16.7%) had fungal disease, and 6 (14.3%) had meningoencephalocele and cerebrospinal fluid leakage. With the exception of 2 patients with plasmacytoma, complete removal of the lesions was achieved in all patients using transnasal or transethmoidal endoscopic approaches, and no local recurrences were observed during the mean follow-up period of 42 months. More than one fifth of the patients with ISSD were diagnosed with neoplasms. The results indicated that endonasal endoscopic approaches could effectively help manage patients with ISSD lesions, including those that were neoplastic. It is clear that precaution during preoperative planning is imperative to avoid unexpected situations and complications that may put surgeons in a difficult position during surgery.

Pneumocephalus after endoscopic odontoidectomy in a pediatric patient: the lesson learned.

INTRODUCTION: Postoperative pneumocephalus is an unexpected condition after endoscopic odontoidectomy surgery. CASE: We present the first case of pneumocephalus after odontoidectomy in a pediatric patient. The clinical presentation, radiological findings, and surgical procedures are described with related pathophysiology. CONCLUSION: We outline the key for management of a rare intracranial air entrapment case after an endoscopic odontoidectomy surgery in a pediatric patient and the measures taken to prevent its occurrence in the future.

Surgical management of elongated styloid process: intraoral or transcervical?

The purpose of this study is to compare the results of surgical approaches in management of elongated styloid process. Eight patients with Eagle's syndrome due to elongated styloid process were included in this study. All necessary preoperative diagnostic work-ups were done and four of them were operated transorally and four were operated extraorally. Preoperative and postoperative symptoms and postoperative patient satisfaction were investigated. No early or late postoperative complications were encountered in transoral group. One of the patients who was operated transcervically experienced a transient weakness in the marginal mandibular branch of facial nerve which resolved spontaneously within 2 weeks. Complete remission of symptoms was achieved in seven patients at the final follow-up, only one of the patients, who was operated intraorally, had partial remission. Only one of the patients who had unilateral excision of elongated styloid process transcervically complained about the permanent scar. Transoral approach is a safe surgical alternative achieving adequate treatment. The advantages of intraoral approach include less surgical travma, less surgical time and lack of servical scar, with similar outcomes when compared with transcervical approach.

The effects of dietary and physical activity interventions on tinnitus symptoms: An RCT.

OBJECTIVE: Subjective tinnitus is defined as the perception of irregular sound at different frequencies. Although the underlying cause of tinnitus is unclear, increased body weight is known to increase tinnitus symptoms. The present study aimed to determine the effects of dietary and physical activity interventions on tinnitus symptoms. METHODS: Sixty-three obese subjects with tinnitus aged 20 to 65 years were divided into diet + physical activity (P.A.) (n = 15), diet (n = 16), P.A. (n = 15), and control (n = 17) groups. Dietary records, anthropometric measurements, Tinnitus Handicap Inventory (THI), Beck Depression Inventory (BDI), Short-Form Health Survey (SF-36), and Visual Analogue Scale (VAS) of all individuals were recorded and compared at the baseline and at study completion. RESULTS: Body weight decreased in the diet + P.A. (-5.9 (3.5) kg), diet (-3.4 (0.9) kg), and P.A. (-2.0 (2.1) kg) groups compared to the baseline (p < 0.05). There was a more significant decrease in tinnitus frequency, tinnitus severity, and VAS scores in individuals with a weight loss of ≥ 5.0% than in those with < 5.0% (p < 0.05). A decrease of 1 kg/m2 in BMI decreased the BDI score by 0.485 units and the THI score by 0.523 units. Step counts were increased in the diet + P.A. (3562.3±739.9) and P.A. (3797.1 ± 1801.1) groups compared to baseline (p < 0.01). Each increase of 1000 steps increased the SF-36 score by 1.592 units and decreased the THI score by 0.750 units (p < 0.05). CONCLUSION: Dietary and physical activity interventions, alone or in combination, alleviated tinnitus symptoms and increased quality of life in individuals with tinnitus. Due to its contribution to obesity prevention and positive effects on tinnitus, organizing dietary and physical activity programs for obese individuals with tinnitus would improve these individuals' quality of life.

Incidentally Found Killian-Jamieson Diverticulum During Thyroidectomy: A Case Report.

The aim of this case study is to demonstrate the very rare coincidental existence and management of a Killian-Jamieson diverticulum (KJD) during thyroid surgery. A 57-year-old woman was referred to our clinic with a malignant thyroid nodule and the complaint of a sore throat. There were no suspicions concerning a diverticulum on examining her with flexible laryngoscopy or ultrasound imaging. During the right central neck dissection, we noticed a 3 × 3 cm KJD and resected it while preserving the recurrent laryngeal nerve. After the successful operation, we questioned the patient and learned that for 1 year she had an occasional complaint of dysphagia. Postoperatively, there was no vocal cord palsy or hypocalcemia, and there was no pharyngoesophageal leak after oral alimentation. There was no recurrence or complaint for KJD or papillary carcinoma for 8 years follow-up. Nonspecific symptoms like a sore throat should be investigated, and patients should be questioned for all aerodigestive symptoms. If necessary, further investigation should be undertaken for a differential diagnosis.

Survival Outcomes of Non-squamous Cell Carcinoma and Rare Squamous Cell Carcinoma Variants of the Larynx.

The literature focuses primarily on laryngeal differentiated squamous cell carcinoma (SCC), and only a limited number of studies have evaluated the outcomes of rare variants of SCC (vSCC) and non-SCC malignancies (nSCC). To our knowledge, this is the first study to compare the survival outcomes of these two groups. We retrospectively reviewed the records of 816 patients who underwent laryngeal surgery from January 2010 to November 2022. Forty-nine (6.2%) were identified as having unusual larynx malignancies and categorized in the nSCC or vSCC groups. The patients' clinicopathological features were then recorded. We compared the two groups' overall survival (OS) and recurrence-free survival (RFS) outcomes. Thirty-three (4.2%) patients had vSCC, and 16 (2%) had nSCC. Forty-two (85.7%) were male, and the mean age was 58.57 years. The median follow-up time was 69 months. The 5-year OS rate was 71.4% in the nSCC group vs. 87.9% in the vSCC group (p = .055). Only surgical margin (HR: 4.68; 95% CI:1.13-19.37, p = .033) was an independent prognostic factor for OS in the multivariable analysis. The 5-year RFS rate was 50% for the nSCC group compared to 90.9% for the vSCC group (p < .001). In the multivariable analysis, surgical margin positivity (HR: 21.0, 95% CI 3.97-98.1, p < .001), and lymphovascular invasion (HR: 0.043, 95% CI 0.005-0.357, p = .004) were independent prognostic factors for RFS. Although OS did not show a statistical difference, nSCC malignancies of the larynx demonstrated worse OS and RFS outcomes than vSCC malignancies. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03934-8.

The Elderly Voice: Mechanisms, Disorders and Treatment Methods.

The elderly population is increasing globally. In Turkey, the population aged 65+ is predicted to grow to more than 15% of the whole population by 2050. Just like the rest of the body, the voice also changes with age. Voice changes throughout life have been reported in up to 52.4% of aged individuals and may have a negative impact on their quality of life. Voice is affected by various factors, including age, disease, hormones, medications, and physiological, psychological, and social conditions. A multidisciplinary approach is therefore needed to achieve the best voice outcomes. In this review, we summarize the mechanisms involved in voice changes in the elderly together with the applicable diagnostic and treatment methods.

Endonasal Endoscopic Removal of a Langerhans Cell Histiocytosis from Far Lateral Frontal Sinus.

Introduction: Langerhans cell histiocytosis (LCH) is a rare disease in adults, and it is even uncommon in pediatric populations, affecting only 1-2 people per million. A LCH located in the frontal sinus is exceptionally unusual. We present a case of LCH located in the far lateral of the frontal sinus and discuss management as well as surgical techniques to control this far lateral frontal sinus lesion. Case Presentation: A 39 year old female, presented with a history of progressive headaches and purulent nasal discharge for three months. Computed tomography (CT) of the sinuses showed an approximately 15 × 10 mm soft tissue with osteolytic bony changes located in lateral wall of the frontal sinus on the left side. Total tumor removal was achieved by minimally invasive endonasal endoscopic surgery with a periorbital suspension technique. Histopathologic analysis revealed LCH and the patient was referred to a hematologist for further treatment. Conclusion: LCH is a rare hematological pathology. It should be diagnosed timely and treated with a multidisciplinary approach. To get a definitive diagnosis a biopsy is mandatory. Having LCH in the far lateral frontal sinus can be challenging for a biopsy even for experienced surgeons. Using curved instruments while performing an endonasal periorbital suspension technique makes it possible to access the lateral wall of the frontal sinus safely and provides an effective surgical route similar to traditional open approaches without causing any external scars.

Management of a Spontaneous Thyroid Nodule Hemorrhage Causing Acute Airway Obstruction.

Spontaneous intrathyroidal hemorrhage (ITH) causing airway obstruction is relatively rare. We report a case with no known history of a thyroid disease that presented with an ITH causing severe airway obstruction as a life-threatening situation. A 57-year-old female patient presented to the emergency department with sudden onset of swelling of the anterior neck, severe dyspnea, and unconsciousness. Computerized tomography scan after intubation revealed a 6.2x5.3 cm mass originating from the right thyroid lobe and compressing the airway. Drainage of hematoma with right lobectomy was done. When the patient was extubated one day after the surgery the vocal cords were found to be mobile. She was discharged after two days and there was no need for further intervention during the one-month follow-up. Spontaneous life-threatening ITHs are rare entities. Immediate assessment of airway obstruction and achieving a secure airway are crucial. Besides drainage of hematoma, thyroidectomy may also be necessary.