Pre-Operative Planning of a DCR Surgery Using Virtual Reality.

PURPOSE: To assess a novel Virtual Reality (VR) tool designed to enhance understanding of the nasal anatomy in patients eligible for DCR surgery. METHODS: Preoperative Computed Tomography (CT) scans of the orbit were obtained and loaded as DICOM (Digital Imaging and Communications in Medicine) files onto the D2P software (3D Systems Inc. Littleton, CO) for tissue segmentation and 3D model preparation. Segmentation was performed on several anatomical structures, including the skull, lacrimal sac, nasal septum, inferior and middle turbinate. The resulting 3D model was visualized using a VR headset. After completing the segmentation procedure, ten cases were evaluated by a panel of six surgeons, including both senior and resident physicians from ENT and oculoplastic specialties. RESULTS: The dataset under examination comprised images from 10 preoperative CT scans of the orbits of patients eligible for Endo-DCR. When evaluating the CT using the VR tool, in 73.3% of the cases ENT surgeons were right about the side of pathology, while only 43.3% ophthalmologists were right (chi-square, p = .018). In 72.8% of the cases ENT surgeons were evaluated right that there is a septum deviation, while only in 47.2% of the cases the ophthalmologists were right (chi-square, p = .094).When evaluating the CT using the VR tool, in 60% of the cases consultants were right about the pathology, while 57.7% of the residents were right (chi-square, p = .853). In 81.7% of the cases consultants were evaluated right that there is a septum deviation, while only in 58.3% of the cases the ophthalmologists were right (chi-square, p = .198). DISCUSSION: ENT surgeons, as well as consultants, interpreted the CT better than the ophthalmologists and residents. Surprisingly, the VR system did not help them to interpret the CT better. Further, more extensive studies should be done to build a VR system that assists in the correct interpretation of the preoperative CT before DCR surgery as well as during DCR surgery.

The implications of concomitant mucosal inflammation on clinical manifestations and outcomes of sinonasal inverted papilloma.

PURPOSE: This study examines the impact of concomitant mucosal inflammation on clinical manifestations and long-term outcomes of Inverted Papilloma (IP). METHODS: This retrospective cohort study was conducted in five tertiary medical centers. The included patients underwent an attachment-oriented surgical resection for IP with a minimum follow-up of 3 years. RESULTS: Of 185 patients with IP, 65 patients (35.1%) had synchronous mucosal inflammation with polypoid changes. The mean age was 56.7 years, and 69% were males. Most tumors originated from the maxillary sinus. Age, gender, Krouse stage, and tumor attachment site did not differ between the mucosal inflammation and IP-only groups. IP recurrence rate was twofold in the patients with mucosal inflammation (15.4% vs. 7.5%, p = 0.092). However, the difference was not significant, with a similar median time to recurrence between the two groups [15.5 (3-36) months vs. 16(6-96) months, p = 0.712]. In revision cases, IP recurred only in patients with mucosal inflammation (19% vs. 0%, p = 0.07). This group had a significantly worse 5-years recurrence-free survival than revision cases without mucosal inflammation (80.6% vs. 100%, p = 0.04). CONCLUSIONS: IP in the setting of mucosal inflammation might be associated with a higher recurrence rate, predominantly after revision surgery. Otolaryngologists should consider this during these patients' diagnosis, surgical planning, and follow-up.

Applicability of Transnasal Echography for Identification of Internal Carotid Artery.

OBJECTIVE: To study the applicability of transnasal echography for the internal carotid artery (ICA) imaging during endoscopic procedures, primarily nasopharyngectomy. STUDY DESIGN: Non-randomized controlled cohort. METHODS: The tip of a pediatric transducer for transesophageal echography was inserted into each nostril under endoscopic control and placed in the ipsilateral Rosenmuller's fossa. The ICA's internal diameter and distance between the nasopharyngeal wall and the artery's closest point were measured on each side. Two independent examiners measured the same parameters on the axial plane of the skull base computer tomography (CT). Agreement between CT and echography measurements was estimated by the Bland-Altman approach. RESULTS: Twenty-seven ICAs (sides) were available for the echography-CT agreement analysis. Inter method agreement for both parameters was similar to the inter examiner agreement for the CT measurements. CONCLUSIONS: Our first study on endoscopic echography demonstrated that this method is applicable, potentially allowing safer transnasal surgery in the ICA vicinity. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1184-1188, 2022.

Is intraoperative margin sampling necessary in inverted papilloma resection?

PURPOSE: To explore the association between intraoperative surgical margin sampling by the frozen sections and recurrence in inverted papilloma surgery. METHODS: A multicenter, retrospective study of patients who underwent attachment-oriented IP resection in four tertiary care medical centers with a minimal follow-up of 36 months. RESULTS: The study included 220 surgeries with a mean follow-up period of 49 months (range 36-204). The endoscopic approach was used in all but 4 cases; 73% of procedures were primary. Overall recurrence was 10.45% (n = 23). Squamous cell carcinoma was found in 5 cases (2.2%). Intraoperative margin sampling was obtained in 145 cases. There was no difference in the recurrence rate between frozen section and no-frozen section groups (p = 0.44). Furthermore, margin sampling in various sites of tumor origin, in cases with concomitant nasal polyps (p = 0.53) and in revision cases (p = 0.08) showed no correlation with recurrence. In 26 cases when the surgery was extended following a positive frozen section, there was a significantly higher recurrence rate (OR = 6.94). CONCLUSIONS: According to our results, intraoperative margin sampling did not affect the recurrence rate of IP, and therefore, its routine use should be questioned.

How face masks influence the sinonasal quality of life during the COVID-19 pandemic.

PURPOSE: To study different mask types' impact on a sinonasal quality of life. METHODS: For this observational cross-sectional study, a web-based survey was distributed via social media forums. We used the validated Hebrew version of the Sinonasal Outcome Test-22 followed by a questionnaire developed specifically for the present study, focusing on the time of the COVID-19 pandemic (Mask Sinonasal Outcome Test), and questions regarding general health issues. The participants' mask-wearing routine was also studied. RESULTS: Seventy percent of 351 participants had experienced a change in their breathing during the time of the pandemic. The median total Sinonasal Outcome Test-22 score was 13, and 10% of the participants reported a significantly impaired quality of life. According to multivariate analyses, the only subject-related variables significantly associated with the reduced sinonasal quality of life were female gender, younger age, a background of chronic rhinitis and sinusitis, and the mask-wearing average daily duration. The mask sinonasal outcome test convergent validity was confirmed. CONCLUSION: The majority of our survey's responders, predominantly female and younger participants, reported reduced sinonasal quality of life in the COVID-19 pandemic period. It can be attributed to mask-wearing, especially for a prolonged time, irrespective of the existing mask type. These findings should encourage medical companies to produce more "airway-minded" personal protection equipment.

Can Computed Tomography Findings Predict the Recurrence of Sinonasal Inverted Papilloma?

OBJECTIVE: To evaluate the correlation between the ability to predict the attachment site of sinonasal inverted papilloma by computed tomography and the long-term surgical outcome. STUDY DESIGN: Retrospective cohort study. SETTING: Five tertiary medical centers. METHODS: Study patients underwent attachment-oriented resection of inverted papilloma. The primary outcome was tumor recurrence. RESULTS: Among 195 patients eligible for the study, focal hyperostosis was recognized on computed tomography in 65% (n = 127), in 71% of primary cases (n = 101), and in 50% of revision procedures (n = 26). There was a trend for a higher incidence of squamous cell carcinoma among the patients without detectable hyperostosis (P = .051). Location of hyperostosis coincided with the actual tumor attachment site in 114 patients (90%). Discordance between these parameters did not differ significantly (P = .463) between 11 primary and 2 revision cases. The overall rate of recurrence was 9.7% (n = 19), with a mean time to recurrence of 20 months (range, 7-96 months). The rate of recurrence did not correlate with any of the following: tumor stage, surgical approach, presence of squamous cell carcinoma, whether the surgery was primary or revision, and the presence or location of focal hyperostosis on computed tomography. Inverted papilloma recurred significantly more often (38.5%) when the intraoperative findings of the tumor attachment site did not match the location of hyperostosis observed on computed tomography (odds ratio, 6.5; 95% CI, 1.78-23.66). CONCLUSION: Detectability of focal hyperostosis on preoperative computed tomography does not affect the long-term outcome of inverted papilloma resection.

Microflora of normal maxillary sinuses: does it justify perioperative antibiotic treatment in sinus augmentation procedures.

OBJECTIVES: To investigate bacterial flora of normal maxillary sinuses in order to facilitate perioperative antibiotic management in sinus augmentation procedures. MATERIALS AND METHODS: Specimens of maxillary sinus mucosa were harvested during planned orthognatic surgery in 18 patients with no evidence of rhinosinusitis. The samples were processed according to hospital routine for aerobic and anaerobic cultures. RESULTS: Ten maxillary sinuses were found sterile. Twenty-six (72%) maxillary mucosa specimens were culture-positive. Aerobes were recovered in 21 sinus samples (58%), predominantly as polymicrobial flora (18 cultures, 50% of all specimens), S. aureus in 2 sinuses of the same patient (6% of the samples), and Bacillus sp. in 1 sinus (3%). Anaerobes were isolated in 20 of 26 culture-positive specimens (56% of all sinus samples). They were recovered alone in 5 samples. Fifteen anaerobic cultures were polymicrobial (42% of all samples). Propionibacterium acnes was isolated from another 5 sinuses (14%) of 3 patients. CONCLUSIONS: Our data support the policy of perioperative antibiotic prophylaxis in sinus augmentation procedures where Schneiderian membrane is perforated. CLINICAL RELEVANCE: Evaluating the need of a perioperative antibiotic therapy in sinus augmentation procedures.

Awake Tracheostomy: Indications, Complications and Outcome.

BACKGROUND: Awake tracheostomy (AT) is aimed at securing the airway of patients with upper airway obstruction when other means are not feasible or have failed. Reports on AT in the literature are scarce. The goal of this study was to review our experience with the indications, complications and outcome of AT. METHODS: A retrospective chart review was conducted on all ATs performed between 2010 and 2016 in two university-affiliated, tertiary medical centers. Data on demographics, indications, techniques, urgency and postoperative complications were retrieved from the medical charts. RESULTS: The 37 of the 1023 recorded tracheostomies (3.62%) that were ATs comprised the study group (mean age of the patients 60.3 years, 32 [86.5%] males). The most common indication was head and neck (HN) malignancy (oncologic group, 70.3%), with the larynx (53.8%) being the most commonly involved site. Patients in the non-oncologic group (n = 11) were significantly younger (P = 0.048) and had a significantly higher prevalence of urgent surgery compared to the oncologic group (P = 0.0009). Major postoperative complications included tube dislodgement (n = 2) and pneumothorax (n = 1) that were managed successfully. One of the two patients with severe hypoxia and arrhythmia that necessitated cardiopulmonary resuscitation died. CONCLUSION: Whether the etiology of the AT was related to HN oncological disease or not was the most important clinical factor in our cohort. The non-oncologic group was significantly younger, suffered from more urgent events and tended to have more complications (nonsignificant). ATs had a 97.3% rate of immediate survival, a 5.4% risk of major irreversible complications and a 2.7% risk of mortality.

Endoscopic Surgery for Delayed Sinonasal Complications of Radiation Therapy for Nasopharyngeal Carcinoma: A Subjective Outcome.

PURPOSE: Delayed sinonasal complications of radiation therapy include choanal stenosis, osteoradionecrosis, chronic sinusitis, and intranasal synechiae. Only sporadic cases on their surgical treatment have been reported, with equivocal results. METHODS AND MATERIALS: We performed a prospective case series of all patients who had been surgically treated for delayed sinonasal complications of radiation therapy in our institution during the past 10 years. The inclusion criteria required ≥6 months of follow-up after surgery. The included patients were asked to complete a Sino-Nasal Outcome Test 16-item questionnaire preoperatively and 6 months after surgery. RESULTS: Nine patients with history of radiation therapy for nasopharyngeal carcinoma were included in our series. In all cases, partial or complete subjective improvement occurred. CONCLUSIONS: In select cases, endoscopic sinus surgery could be of benefit in the treatment of delayed sinonasal complications of radiation therapy.

Warthin tumor within the superficial lobe of the parotid gland: a suggested criterion for diagnosis.

The location of Warthin tumor (WT) in the parotid gland impacts the surgical approach and may be indicative of the elusive origin of this intriguing entity. Location in the deep versus superficial lobe of the gland is not directly addressed when defining WT characteristics. Our observation, of rare occurrence of deep lobe WT, if at all, led to the current investigation. The study design is cohort study. This is a retrospective chart review of all patients undergoing parotidectomy for WT in two tertiary academic referral centers: the Sheba Medical Center (SMC), Israel, and the Christiana Care (CC), Newark, Delaware, USA. 122 consecutive adult patients underwent parotidectomy for WT (72 from SMC and 50 from CC). Seventy percent were males, with a mean age of 60.6 years. Bilateral WT or multi-centric WT were found in 9.8 and 17.2% of the cases, respectively. In one case, the tumor was described as originating in the deep lobe. In all other cases, the tumor originated and was limited to the superficial lobe. 99.2% of WT originated in the superficial lobe, corresponding with the few reports directly addressing its location in the gland. The reason for the tumor to be limited almost uniformly to the superficial lobe is unknown, and could be related to the etiopathogenesis of this elusive entity. We suggest adding tumor location within the superficial lobe to the common characteristics of WT (male, smoking, and lower pole) that serve as "common criterion" while evaluating a parotid lesion.

Cholesteatoma and coexisting findings diagnosed incidentally on MRI.

The explosive growth in the use of diffusion-weighted magnetic resonance imaging (MRI) in the pre- and postoperative evaluations of patients with cholesteatoma has led to a concomitant increase in the number of incidental findings in this population. We describe our retrospective examination of MRI studies in cholesteatoma patients to look for the presence of other coexisting abnormalities. We examined the brain MRIs of 103 patients-45 males and 58 females, aged 3 to 81 years (mean: 31.9 ± 21.3)-who had undergone pre- or postoperative imaging during the management of a cholesteatoma. The MRIs revealed the presence of at least one other anomaly in 79 of these patients (76.7%)-36 males and 43 females, aged 3 to 81 years (mean: 43.5 ± 18.2). These 79 MRIs detected a total of 124 lesions that had been coexisting with cholesteatomas; some of these lesions had overlapped with the cholesteatoma. The two most common findings were sinonasal mucoperiosteal thickening and polyposis (n = 66) and white-matter changes (n = 29). Our results establish the need for routine skilled interpretation of brain MRIs by expert neuroradiologists to ensure that findings coexisting with cholesteatoma are detected so that appropriate management can be provided.

Acute Invasive Fungal Rhinosinusitis in Children With Hematologic Malignancies: Outcome of Surgical Treatment.

The incidence of acute invasive fungal rhinosinusitis (AIFR) is rising due to more aggressive chemotherapy and longer survival of immunosuppressed patients. Early diagnosis and appropriate but nonmutilating surgical treatment are particularly problematic in the pediatric population. This study aimed to evaluate the outcome of surgery for pediatric AIFR. Medical records of children surgically treated for AIFR between 1998 and 2014 were reviewed. Diagnosis was based on both histopathological and microbiological confirmation. Surgery was performed with curative intent and repeated for any resectable extension. The children underwent endoscopy and magnetic resonance imaging every 2 and 6 months, respectively, during the first postoperative year. Thirteen patients (2-18 years old) met the EORTC/MSG criteria for proven invasive fungal sinusitis; fungal invasion was diagnosed by preoperative biopsy and confirmed in the surgical specimen. All patients underwent an average of two endoscopic procedures (range 1-3), and four of them also underwent an open surgery. The local control rate was at least 79%. There was no facial disfiguration during follow-up (average 41 months). Although AIFR is still associated with high mortality, aggressive medical and surgical treatment provides local control in most cases. Fair outcome should encourage a maximal joint effort of pediatric hemato-oncologists and otorhinolaryngologists in the management of AIFR.

The utility of minimally invasive transcanal endoscopic approach for removal of residual/recurrent cholesteatoma: preliminary results.

To investigate the feasibility of applying the transcanal endoscopic approach (TEA) for surgical treatment of residual/recurrent cholesteatoma and present the preliminary results of 17 revision procedures that were carried out with this minimally invasive approach. The records of 17 patients (aged 5-76 years) who underwent transcanal revision procedure using rigid 3-mm diameter, 0°, 30° and 45° endoscopes between 2009 and 2012 were retrospectively reviewed. A wide posterior tympanomeatal flap was elevated via the external auditory canal and then transposed inferiorly in cases of cholesteatoma situated in the middle ear under a tympanic membrane. In certain cases, cholesteatoma was assessed and removed using the endoscopes directly from the radical cavity or from the mastoid cavity remaining after a canal-wall-down procedure. Six patients had originally undergone the canal-wall-up mastoidectomy, 6 patients had a canal-wall-down mastoidectomy and 5 patients had radical mastoid cavities. The interval between the previous and the index surgery ranged between 1 and 6 years. The attic was the most common site involved with cholesteatoma, followed by the tympanic portion of the facial nerve, sinus tympani, mastoid, supratubal recess, promontory, round and oval windows. The size of residual/recurrent lesion varied between 3 and 15 mm. The patients were followed up 26-67 months (mean 52.1 months). The single recurrence (a 4-mm pearl over the tympanic portion of the facial nerve) was eradicated by a transcanal re-revision 1 year following the index surgery. Minimally invasive TEA can be successfully applied in carefully selected patients with endoscopically accessible cholesteatoma subsequent to various types of mastoidectomy.

The usefulness of preoperative biopsy in unilateral nasal masses.

Unilateral nasal masses are considered suspicious for proliferative diseases. Several tools are routinely used to investigate unilateral lesions such as imaging and nasal biopsy. This study investigated the usefulness of nasal biopsy in predicting the actual nature of unilateral lesions. Preoperative nasal biopsy pathological results were compared with the final pathology obtained during an operation. Forty-six patients with unilateral nasal masses were included in the study group. In 40 patients the final pathology was similar to the preoperative nasal biopsy. In three patients the biopsy specimen was a benign polyp and the final pathology was of an inverted papilloma in two patients and hemangiopericytoma in one patient. In two patients the biopsy specimen was suspicious for an inverted papilloma and the final pathology was a benign polyp. In one patient the biopsy specimen was chordoma and the final pathology was osteosarcoma. The total agreement was 86.9%. The kappa value was 81.2%. Preoperative nasal biopsy is important and useful in evaluating unilateral nasal masses.

Delayed Sino-nasal Complications of Radiotherapy for Nasopharyngeal Carcinoma.

OBJECTIVE: There are only sporadic reports of delayed sino-nasal complications associated with nasopharyngeal carcinoma (NPC) treated with radiotherapy. These include choanal stenosis, osteoradionecrosis, chronic sinusitis, and intranasal synechiae. Most likely, these complications are underestimated as in many institutions nasal endoscopies in NPC patients are not performed routinely. The aim of this study was to identify the onset and incidence of delayed sino-nasal complications in NPC patients and their effect on quality of life (QOL). STUDY DESIGN: Case series with chart review. SETTING: Tertiary medical center. SUBJECTS AND METHODS: A retrospective chart review was performed on all patients treated for NPC in our institution between 1988 through 2009. The inclusion criteria required at least a 3-year follow-up without recurrence. Included patients were contacted prospectively and asked to fill a SNOT-16 questionnaire. RESULTS: Sixty-two patients were included in our review. There were 42 males and 20 females. The average age at onset was 42 years. The AJCC staging for T1, T2, T3, and T4 tumors was 22 (35%), 11 (18%), 18 (29%), and 11 (18%), respectively. Eleven patients (18%) suffered from chronic sinusitis. Nine patients (15%) developed choanal stenosis. Five patients (8%) developed osteoradionecrosis. Two patients suffered from nasal synechiae. Forty-eight patients completed the SNOT-16 questionnaire. Patients with choanal stenosis had the lowest QOL scores out of the cohort. CONCLUSION: The incidence of delayed sino-nasal complications after radiation treatment for NPC is not negligible and should be kept in mind when addressing the quality of life of NPC survivors.

Relation between preoperative computed tomographic criteria of injury to the nasofrontal outflow tract and operative findings in fractures of the frontal sinus.

Injury to the nasofrontal outflow tract is important in the treatment of fractures of the frontal sinus. In 2008 preoperative computed tomographic (CT) criteria or signs of such injuries were proposed and stated to be reliable. The aim of this study was to evaluate the validity of these criteria by comparing the radiological evidence with the operative findings. Thirty-nine patients for whom the data from preoperative CT could be compared with operative findings were eligible for the study, all but 4 of whom had at least one indicator of injury to the outflow tract. Patients whose tracts were found to be obstructed at operation had at least 2 preoperative CT signs of obstruction of the tract. If the outflow tract was obstructed all 3 criteria were significantly more likely to be present than if it was intact (p=0.02). Two criteria or fewer did not correlate significantly with obstruction. Fractures were managed by reconstruction (n=18), obliteration (n=11), or cranialisation (n=10). This study is the first to our knowledge to examine the correlation between preoperative CT criteria and operative findings, and there was a significant difference in the number of criteria present depending on whether the outflow tract was intact or injured. Our findings allow for more accurate planning of management of fractures of the frontal sinus.

Use of the vessel sealing system in tracheostomy.

BACKGROUND: Tracheostomy is a frequent, and at times semiurgent, surgical procedure. It is performed in close proximity to the thyroid gland, and in many cases requires division of its isthmus, putting a patient in danger of significant bleeding. OBJECTIVES: To examine prospectively the feasibility of vessel sealing in tracheostomy. METHODS: A vessel-seating device was used in 24 consecutive patients undergoing tracheostomy. There were no exclusion criteria for enrolling the patients. No other hemostatic technique was used for dividing the isthmus. RESULTS: There were no bleeding events throughout the postoperative period. The operating time saving was 5-10 minutes. CONCLUSIONS: Use of the vessel sealer was found to be straightforward, efficacious, rapid and safe.

Development of allogeneic NK cell adoptive transfer therapy in metastatic melanoma patients: in vitro preclinical optimization studies.

Natural killer (NK) cells have long been considered as potential agents for adoptive cell therapy for solid cancer patients. Until today most studies utilized autologous NK cells and yielded disappointing results. Here we analyze various modular strategies to employ allogeneic NK cells for adoptive cell transfer, including donor-recipient HLA-C mismatching, selective activation and induction of melanoma-recognizing lysis receptors, and co-administration of antibodies to elicit antibody-dependent cell cytotoxicity (ADCC). We show that NK cell activation and induction of the relevant lysis receptors, as well as co-administration of antibodies yield substantial anti-cancer effects, which are functionally superior to HLA-C mismatching. Combination of the various strategies yielded improved effects. In addition, we developed various clinically-compatible ex vivo expansion protocols that were optimized according to fold expansion, purity and expression of lysis receptors. The main advantages of employing allogeneic NK cells are accessibility, the ability to use a single donor for many patients, combination with various strategies associated with the mechanism of action, e.g. antibodies and specific activation, as well as donor selection according to HLA or CD16 genotypes. This study rationalizes a clinical trial that combines adoptive transfer of highly potent allogeneic NK cells and antibody therapy.

Endoscopic surgery for juvenile angiofibroma: a critical review of indications after 46 cases.

BACKGROUND: At present, transnasal endoscopic surgery is considered a viable option in the management of small-intermediate size juvenile angiofibromas (JAs). The authors critically review their 14-year experience in the management of this lesion to refine selection criteria for an endoscopic approach. METHODS: From January 1994 to May 2008, 46 patients were treated by a pure endoscopic resection after vascular embolization (87%). The lesions were classified according to Andrews (Andrews JC, et al., The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach, Laryngoscope 99:429-437, 1989) and Onerci (Onerci M, et al. Juvenile nasopharyngeal angiofibroma: A revised staging system, Rhinology 44:39-45, 2006) staging systems. All patients were followed by regular endoscopic and magnetic resonance imaging (MRI) examinations. RESULTS: Lesions were classified as follows: stage I, n = 5; stage II, n = 24; stage IIIa, n = 14; stage IIIb, n = 3 according to Andrews classification system; stage 1, n = 9; stage II, n = 12; stage III, n = 26 according to Onerci's system. Unilateral blood supply was detected in 39 (85%) cases. Feeding vessels from the internal carotid artery (ICA) were also reported in 14 (30%) patients. Intraoperative blood loss ranged from 250 to 1300 mL (mean, 580 mL). In four (8.7%) cases, suspicious residual disease was detected by MRI. In one patient, a 1-cm persistent lesion was endoscopically removed because septoplasty was required and a slight increase in size was noticed. The other three lesions, all located in the root of the pterygoid plate, are nearly stable in size and are currently under MRI follow-up. CONCLUSION: The improvement of surgical instrumentation and the experience acquired during a 14-year period have contributed to expanding the indications for endoscopic surgery in the management of JAs. Even stage III lesions may be successfully managed, unless the ICA is encased or if it provides an extensive blood supply. An external approach may be required when critical structures such as the ICA, cavernous sinus, or optic nerve are involved by lesions that are persistent after previous treatment; such a situation may prevent safe and radical dissection with a pure endoscopic approach. Better understanding of the factors influencing the growth of residual lesions is needed to differentiate those requiring re-treatment from those which can be simply observed.