Utilidad de los colgajos e injertos endonasales en cirugía endoscópica nasosinusal y de base de cráneo. Documento de consenso / Usefulness of endonasal flaps and grafts in skull base surgery. Consensus document

Introducción: La reconstrucción de base de cráneo constituye uno de los mayores retos de la cirugía endoscópica endonasal expandida. Existen multitud de injertos y colgajos de origen endonasal que han demostrado su utilidad en el control de complicaciones como las fístulas de LCR, entre otras. Se hace necesaria la revisión y el análisis de los recursos endonasales y su uso en cirugía endoscópica endonasal expandida.ObjetivosDocumento de consenso sobre el uso de los distintos injertos y colgajos de origen endonasal y su uso en cirugía endoscópica endonasal expandida.Material y métodosRevisión bibliográfica sobre los injertos libres y colgajos vascularizados de origen endonasal más relevantes. Análisis mediante el método Delphi, sobre el uso de los distintos recursos endonasales para la reparación endoscópica de defectos de base de cráneo.ResultadosSe obtuvieron dos resultados. 1) Una selección de los colgajos e injertos de origen endonasal más representativos, describiendo origen, superficie e indicaciones, a partir de una revisión bibliográfica. 2) Un documento de consenso, utilizando la metodología Delphi, con las consideraciones generales (2), recomendaciones (10) y limitaciones (6) sobre el uso de los distintos colgajos e injertos de origen endonasal.ConclusionesPresentamos el primer documento de consenso en el campo de la cirugía endoscópica endonasal utilizando el método Delphi como herramienta de trabajo. Se destaca la utilidad del colgajo nasoseptal junto con el resto de colgajos e injertos de origen endonasal para la cirugía reconstructiva de base de cráneo. (AU)

Introduction: Skull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes.ObjectivesThe target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery.Material and methodsLiterature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects.ResultsWe obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts.ConclusionsWe present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction. (AU)

Usefulness of endonasal flaps and grafts in skull base surgery. Consensus document.

INTRODUCTION: Skull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes. OBJECTIVES: The target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery. MATERIAL AND METHODS: Literature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects. RESULTS: We obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts. CONCLUSIONS: We present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction.

Three-Dimensional Reconstruction of the Sphenoid Sinus Anatomy for Presurgical Planning with Free OSIRIX Software.

Background A preoperative three-dimensional (3D) surgical field understanding remains a key factor to achieve safer endonasal transsphenoidal endoscopic approaches (ETSE). The aim of this article is to describe how we can get a reliable 3D sphenoidal anatomical reconstruction for surgical planning by using a user-friendly, accurate, and free image software. Methods Free computer software (OSIRIX Medical Imaging Software) was used to create in a personal computer a three-dimensional (3D) reconstruction of the sphenoid sinus (SS) based on head computed tomography angiographies (CTAs) from a series of 67 patients who were operated for sellar tumors during a 4-year period (March 2016 to March 2020). The aim of the 3D reconstruction with OSIRIX was to reveal preoperatively the most important intrasphenoidal structures seen from the endonasal point of view. Results The intraoperative visible sphenoidal structures were previously recognized in the virtual 3D reconstructed image with 100% of specificity (SP) and positive predictive value. The OSIRIX view by using region of interest points allowed us to see preoperatively the internal carotid artery parasellar course even in those cases in which it was hidden by bone or tumor. Moreover, the 3D reconstruction was able to provide a clear differentiation between the tumor and the pituitary gland when both structures were in contact with the sellar floor. Conclusion Our experience with the OSIRIX software from CTA as preoperative planning for endonasal pituitary surgery was valuable, because it gave us access in simple way to a free and reliable 3D image of the SS.

Research in Cerebrospinal Fluid Leak (Rhinorrhea and Otorrhea): A Bibliometric Analysis From 1945 to 2018.

Objective In this study, we aimed to analyze research activity on cerebrospinal fluid (CSF) leaks in general and CSF rhinorrhea and otorrhea in particular and to identify the main topic clusters in these areas. Methods We identified all relevant documents, using the medical subject heading (MeSH) term "Cerebrospinal Fluid Leak", that are indexed in the MEDLINE database between 1945 and 2018. We performed a descriptive bibliometric analysis and analyses of networks and research clusters in order to identify the main topic areas of research. Results From 1945 to 2018, a total of 4,130 records were published with the term CSF leak, including 2,821 documents (68.1%) with the term CSF rhinorrhea and 1,040 documents (25.8%) with CSF otorrhea. The number of documents published increased from 10 in 1945-49 to 642 in 2010-14. Articles represented the dominant document type (86.8% of the documents analyzed), while case reports were the main type of study (37.4%). In terms of geographical distribution, researchers from the USA led in the number of signatures (39.1%), followed by those from the UK (7.5%). The most active areas of research in the field were "Postoperative Complications," "Tomography, X-Ray Computed," and "Magnetic Resonance Imaging." The terms "Adults," "Young Adult," and "Middle-Aged" were most common in CSF rhinorrhea research; and the terms "Infant," "Child, Preschool," "Child," and "Adolescent" were more common in CSF otorrhea. Conclusions Based on our findings, articles and case reports related to "Surgery" and "Postoperative Complications" associated with the diagnosis are the main topics of study, highlighting the importance of this document type in advancing knowledge in the field.

Usefulness of endonasal flaps and grafts in skull base surgery. Consensus document. / Utilidad de los colgajos e injertos endonasales en cirugía endoscópica nasosinusal y de base de cráneo. Documento de consenso.

INTRODUCTION: Skull base reconstruction is one of the greatest challenges extended endonasal endoscopic surgery. Many grafts and flaps from the endonasal fossa have been demonstrated to be useful in the control of complications such a cerebrospinal fluid leaks. Review and analysis of these resources are necessary in skull base recontruction to improve outcomes. OBJECTIVES: The target is to create a consensus document on the use of different endonasal flaps and grafts in the skull base surgery. MATERIAL AND METHODS: Literature review of the most relevant free grafts and vascularized flaps from the endonasal fossa. Analysis using the Delphi method on the use of the different endonasal resources for endoscopic repair of skull base defects. RESULTS: We obtained two results: 1) A selection of the most representative flaps and grafts from the endonasal fossa, describing origin, surface and indications, based on a literature review. 2) A consensus document, using Delphi methodology, with general considerations (2), recommendations (10) and limitations (6) of the different endonasal flaps and grafts. CONCLUSIONS: We present the first consensus document in the field of extended endonasal endoscopic surgery using the Delphi method as a working tool. We highlight the usefulness of the nasoseptal flap together with other endonasal flaps and grafts for skull base reconstruction.

Top-cited articles in cerebrospinal fluid leak (rhinorrhea and otorrhea) (1945-2018).

INTRODUCTION: As scientific knowledge has grown in biomedicine, it has also become necessary to develop tools to manage and understand the body of evidence. In that sense, bibliometrics has become a consolidated discipline for analyzing scientific activity, enabling the characterization of a particular field or area of knowledge by means of the quantification of the bibliographic characteristics of scientific publications. OBJECTIVE: The objective of this study was to determine the most frequently cited articles in the field of cerebrospinal fluid rhinorrhea and otorrhea. METHODS: The searches took place on the Clarivate Analytics Web of Science platform, which includes the MEDLINE database. The study period was limited to 1945-2018. RESULTS: The 101 most cited articles in the field of cerebrospinal fluid leak were published in 36 journals, and the most important specialties contributing to the literature were neurosurgery and otorhinolaryngology. Of the 101 top-cited articles, 70% were published from 1990 to 2018, with two distinct periods of high scientific productivity: 1990-1999 and 2000-2009. In the first period, the main topic of research interest was endoscopic sinus surgery for cerebrospinal fluid fistulas, whereas from 2000 to 2009, documents focused more on surgical aspects of extended skull base approaches. The articles received 73-767 citations. The top article over the whole study period was "A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap" by Hadad et al., which was published 2006 in Laryngoscope. Its publication represented an inflection point in the literature on cerebrospinal fluid leak and endoscopic skull base surgery, and it gave rise to numerous other research publications. CONCLUSION: Different surgical innovations in the field of cerebrospinal fluid leak sparked two different periods of intense scientific activity. Otorhinolaryngology and neurosurgery were the dominant specialties. The most frequent topic studied was endoscopic surgery; others included clinical and diagnostic features, neurinoma surgery, and cerebrospinal fluid leak related to temporal bone fractures.

Cirugía endoscópica endonasal en adenomas hipofisarios: resultados quirúrgicos en una serie de 86 pacientes consecutivos / Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients

Introducción: El abordaje endoscópico endonasal se ha convertido en la técnica quirúrgica de elección para el tratamiento de los adenomas hipofisarios. Objetivos: El objetivo de este trabajo es presentar los resultados obtenidos en nuestro hospital en cirugía puramente endoscópica de los adenomas hipofisarios. Métodos: Hemos realizado un estudio prospectivo, recogiendo a los pacientes intervenidos de adenoma hipofisario mediante un abordaje endonasal puramente endoscópico, desde febrero de 2011 hasta agosto de 2016, obteniendo una muestra total de 86 pacientes. Todos los pacientes fueron intervenidos conjuntamente por un ORL y un neurocirujano con la técnica de four hands-two nostrils. El seguimiento medio postoperatorio fue de 32 meses. Todos los pacientes fueron evaluados según criterios clínicos, radiológicos y endocrinológicos. Resultados: En nuestra serie un 53% eran mujeres y un 47% hombres; el rango de edad variaba desde los 14 hasta los 84 años, siendo la media de 54 años. El síntoma inicial más habitual fue el déficit visual (42%), seguido por la hiperfunción hormonal (21%), siendo la acromegalia el síndrome clínico observado con más frecuencia. Los tumores más frecuentes fueron los no funcionantes (73%), y de entre los adenomas funcionantes el más frecuente fue el productor de GH (65%). En cuanto a tamaño tumoral, un 76% eran macroadenomas, un 11% microadenomas y un 13% gigantes. Un 63% presentaban extensión supraselar y un 37% invasión de seno cavernoso (grado de Knosp ≥3). Se consiguió una exéresis total en un 77% de los casos. Tras la intervención se consiguió en un 91% mejoría visual y hasta en un 73% remisión de la hiperfunción endocrina. En cuanto a las complicaciones, la más frecuente fue la insuficiencia de al menos un eje de la hipófisis anterior (9%), sin presentar casos de fístula de LCR posquirúrgica. Conclusiones: Nuestros resultados, en términos de calidad quirúrgica, se asemejan a las series publicadas y avalan la eficacia y seguridad del abordaje endoscópico endonasal como técnica de elección en el manejo quirúrgico de la glándula hipofisaria. Sin embargo, es necesario un estudio con mayor número de casos para obtener resultados con significación clínica

Introduction: The endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas. Objectives: The aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas. Methods: From February 2011 to August 2016, we conducted a prospective study on a series of 86 patients with pituitary adenoma, all of whom underwent surgery with a purely endoscopic endonasal approach. The ‘four hands-two nostrils’ technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon. Mean follow-up was 32 months. All patients were evaluated according to clinical, radiological and endocrinological criteria. Results: In our series, 53% were women and 47% men. The age ranged from 14 to 84 years of age, with a mean of 54 years of age. The most common initial symptom was visual deficit (42%), followed by hormonal hyperfunction (21%), with acromegaly being the most common clinical syndrome. The most common tumours were non-functioning tumours (73%), while GH-secreting tumours (65%) were the most common functioning adenoma. Regarding tumour size, 76% were macroadenomas, 11% microadenomas and 13% giant adenomas. Approximately 63% of the adenomas exhibited suprasellar extension and 37% involved invasion of the cavernous sinus (Knosp grade ≥3). Total excision was achieved in 77% of the cases. After the intervention, visual improvement was achieved in 91% and remission of endocrine hyperfunction in up to a 73% of cases. The most common complication was anterior pituitary insufficiency of at least one axis (9%). There were no cases of postoperative cerebrospinal fluid fistula. Conclusions: In terms of surgical quality, our results are similar to those of published series, and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas. However, further studies with a higher sample size are necessary to obtain clinically significant results

[Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients]. / Cirugía endoscópica endonasal en adenomas hipofisarios: resultados quirúrgicos en una serie de 86 pacientes consecutivos.

INTRODUCTION: The endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas. OBJECTIVES: The aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas. METHODS: From February 2011 to August 2016, we conducted a prospective study on a series of 86 patients with pituitary adenoma, all of whom underwent surgery with a purely endoscopic endonasal approach. The 'four hands-two nostrils' technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon. Mean follow-up was 32 months. All patients were evaluated according to clinical, radiological and endocrinological criteria. RESULTS: In our series, 53% were women and 47% men. The age ranged from 14 to 84 years of age, with a mean of 54 years of age. The most common initial symptom was visual deficit (42%), followed by hormonal hyperfunction (21%), with acromegaly being the most common clinical syndrome. The most common tumours were non-functioning tumours (73%), while GH-secreting tumours (65%) were the most common functioning adenoma. Regarding tumour size, 76% were macroadenomas, 11% microadenomas and 13% giant adenomas. Approximately 63% of the adenomas exhibited suprasellar extension and 37% involved invasion of the cavernous sinus (Knosp grade ≥3). Total excision was achieved in 77% of the cases. After the intervention, visual improvement was achieved in 91% and remission of endocrine hyperfunction in up to a 73% of cases. The most common complication was anterior pituitary insufficiency of at least one axis (9%). There were no cases of postoperative cerebrospinal fluid fistula. CONCLUSIONS: In terms of surgical quality, our results are similar to those of published series, and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas. However, further studies with a higher sample size are necessary to obtain clinically significant results.

Transsphenoidal Approach in Endoscopic Endonasal Surgery for Skull Base Lesions: What Radiologists and Surgeons Need to Know.

In the last 2 decades, endoscopic endonasal transsphenoidal surgery has become the most popular choice of neurosurgeons and otolaryngologists to treat lesions of the skull base, with minimal invasiveness, lower incidence of complications, and lower morbidity and mortality rates compared with traditional approaches. The transsphenoidal route is the surgical approach of choice for most sellar tumors because of the relationship of the sphenoid bone to the nasal cavity below and the pituitary gland above. More recently, extended approaches have expanded the indications for transsphenoidal surgery by using different corridors leading to specific target areas, from the crista galli to the spinomedullary junction. Computer-assisted surgery is an evolving technology that allows real-time anatomic navigation during endoscopic surgery by linking preoperative triplanar radiologic images and intraoperative endoscopic views, thus helping the surgeon avoid damage to vital structures. Preoperative computed tomography is the preferred modality to show bone landmarks and vascular structures. Radiologists play an important role in surgical planning by reporting extension of sphenoid pneumatization, recesses and septations of the sinus, and other relevant anatomic variants. Radiologists should understand the relationships of the sphenoid bone and skull base structures, anatomic variants, and image-guided neuronavigation techniques to prevent surgical complications and allow effective treatment of skull base lesions with the endoscopic endonasal transsphenoidal approach.

Colgajos pediculados procedentes de la arteria esfenopalatina: estudio anatómico y quirúrgico / Pedicle flaps based on the sphenopalatine artery: Anatomical and surgical study

Introducción: Los colgajos locales pediculados a la arteria esfenopalatina permiten reconstruir amplios defectos de la base del cráneo (BC). Material y métodos: De enero de 2008 a enero de 2013 se analizaron 64 lesiones con afectación de la BC intervenidos con un abordaje endonasal endoscópico que requirieron una reconstrucción con colgajos locales pediculados a la arteria esfenopalatina. Adicionalmente se estudiaron cuatro fosas nasales correspondientes a dos cabezas de cadáver donde se analizaron endoscópicamente las medidas y la flexibilidad de cada uno de los colgajos. Resultados: Grupo quirúrgico. Se emplearon 64 colgajos nasoseptales (CNS), en cuatro casos asociados a un colgajo cornete medio (CCM) y en un caso complementado con un colgajo del cornete inferior (CCI). Se evidenciaron 5 fístulas postquirúrgicas (8%). Un 7% de los pacientes con lesiones iniciales presentaron una anosmia definitiva. Disección anatómica. La longitud del CNS varió entre 5,2 cm y 7,7 cm oscilando la anchura entre 3 cm y 4,5 cm. El CCI presentó una distancia anteroposterior entre 4,2 cm y 5 cm y una anchura entre 1,2 cm y 2,8 cm. La longitud media del CCM varió entre 3,5 cm y 4,2 cm con una anchura entre 1,4 cm y 1,9 cm. Conclusión: El CNS es el colgajo local que presenta una mejor versatilidad en el sellado de los defectos craneales, siendo los colgajos pediculados a la arteria nasal posterolateral una excelente alternativa (AU)

Introduction: Local pedicle flaps based on the sphenopalatine artery make it possible to reconstruct large defects of the skull base (SB). Material and methods: From January 2008 to January 2013, 64 lesions with involvement of SB were analysed. These lesions were treated using endoscopic endonasal approach and required a pedicle flap based on the sphenopalatine artery. In addition, measurements and flexibility of the flaps were examined in 4 cadaveric nasal cavities. Results: Surgical group. Sixty-four nasoseptal flaps (NSF) were used, in 4 cases associated with a middle turbinate flap (MTF), and in 1 case supplemented with an inferior turbinate flap (ITF). Five cerebrospinal fluid fistulas (8%) were noted. Among patients with initial lesions, 7% presented an anosmia. Cadaveric group. The length of the NSF varied between 5.2 cm and 7.7 cm and the width ranged from 3 cm to 4.5 cm. The ITF provided an anterior-posterior distance between 4.2 cm and 5 cm, with a width between 1.2 cm and 2.8 cm. The mean length of MTFs varied between 3.5 cm and 4.2 cm, with a width between 1.4 cm and 1.9 cm. Conclusion: The most versatile local flap for the reconstruction of skull base defects is the NSF, and flaps pedicled to the posterolateral nasal artery offer an excellent alternative (AU)

[Pedicle flaps based on the sphenopalatine artery: anatomical and surgical study]. / Colgajos pediculados procedentes de la arteria esfenopalatina: estudio anatómico y quirúrgico.

INTRODUCTION: Local pedicle flaps based on the sphenopalatine artery make it possible to reconstruct large defects of the skull base (SB). MATERIAL AND METHODS: From January 2008 to January 2013, 64 lesions with involvement of SB were analysed. These lesions were treated using endoscopic endonasal approach and required a pedicle flap based on the sphenopalatine artery. In addition, measurements and flexibility of the flaps were examined in 4 cadaveric nasal cavities. RESULTS: Surgical group. Sixty-four nasoseptal flaps (NSF) were used, in 4 cases associated with a middle turbinate flap (MTF), and in 1 case supplemented with an inferior turbinate flap (ITF). Five cerebrospinal fluid fistulas (8%) were noted. Among patients with initial lesions, 7% presented an anosmia. Cadaveric group. The length of the NSF varied between 5.2 cm and 7.7 cm and the width ranged from 3 cm to 4.5 cm. The ITF provided an anterior-posterior distance between 4.2 cm and 5 cm, with a width between 1.2 cm and 2.8 cm. The mean length of MTFs varied between 3.5 cm and 4.2 cm, with a width between 1.4 cm and 1.9 cm. CONCLUSION: The most versatile local flap for the reconstruction of skull base defects is the NSF, and flaps pedicled to the posterolateral nasal artery offer an excellent alternative.

Estudio endoscópico endonasal 3D de la anatomía de la base de cráneo / Three-dimensional endoscopic endonasal study of skull base anatomy

INTRODUCCIÓN: El entrenamiento en la disección de los senos paranasales y la base de cráneo es esencial para el conocimiento anatómico y la correcta aplicación de las técnicas quirúrgicas. La visualización tridimensional de la anatomía endoscópica de la base de cráneo mejora la orientación espacial y permite la percepción de profundidad. OBJETIVO: Mostrar la anatomía endoscópica de la base de cráneo basándose en la técnica tridimensional. MÉTODOS: Realizamos disección endoscópica endonasal en especímenes cadavéricos fijados con formol y con la técnica de Thiel, ambos con inyección intravascular de colorantes. Los abordajes fueron realizados con endoscopios convencionales 2D. Posteriormente aplicamos la técnica 3D anaglífica para ilustrar las figuras en 3D. RESULTADOS: Se ilustran las más importantes estructuras y referencias anatómicas de la región selar desde la perspectiva endonasal endoscópica en 3D. CONCLUSIÓN: La base del cráneo está compuesta por complejas estructuras óseas y neurovasculares. La experiencia con la disección en cadáver es crucial para comprender la anatomía y desarrollar habilidades quirúrgicas. La visualización 3D representa una útil herramienta para comprender la anatomía de la base de cráneo

INTRODUCTION: Training in dissection of the paranasal sinuses and the skull base is essential for anatomical understanding and correct surgical techniques. Three-dimensional (3D) visualisation of endoscopic skull base anatomy increases spatial orientation and allows depthperception. OBJECTIVE: To show endoscopic skull base anatomy based on the 3D technique. METHODS: We performed endoscopic dissection in cadaveric specimens fixed with formalin and with the Thiel technique, both prepared using intravascular injection of coloured material. Endonasal approaches were performed with conventional 2D endoscopes. Then we applied the 3D anaglyph technique to illustrate the pictures in 3D. RESULTS: The mostimportant anatomical structures and landmarks of the sellar region underendonasal endoscopic vision are illustrated in 3D images. CONCLUSION: The skull base consists of complex bony and neurovascular structures. Experience with cadaver dissection is essential to understand complex anatomy and developsurgical skills. A 3D view constitutes a useful tool for understanding skull base anatomy

[Three-dimensional endoscopic endonasal study of skull base anatomy]. / Estudio endoscópico endonasal 3D de la anatomía de la base de cráneo.

INTRODUCTION: Training in dissection of the paranasal sinuses and the skull base is essential for anatomical understanding and correct surgical techniques. Three-dimensional (3D) visualisation of endoscopic skull base anatomy increases spatial orientation and allows depth perception. OBJECTIVE: To show endoscopic skull base anatomy based on the 3D technique. METHODS: We performed endoscopic dissection in cadaveric specimens fixed with formalin and with the Thiel technique, both prepared using intravascular injection of coloured material. Endonasal approaches were performed with conventional 2D endoscopes. Then we applied the 3D anaglyph technique to illustrate the pictures in 3D. RESULTS: The most important anatomical structures and landmarks of the sellar region under endonasal endoscopic vision are illustrated in 3D images. CONCLUSION: The skull base consists of complex bony and neurovascular structures. Experience with cadaver dissection is essential to understand complex anatomy and develop surgical skills. A 3D view constitutes a useful tool for understanding skull base anatomy.

Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver / Radiological anatomy of the ethmoidal arteries: CT cadaver study

Introducción y objetivos: El objetivo del trabajo es realizar un estudio de la anatomía radiológica de las arterias etmoidales. Métodos: Se realizó un estudio descriptivo con imágenes de tomografía computarizada correspondientes a 20 cabezas de cadáver perfundidas con material radiopaco. Se analizaron diferentes parámetros anatómicos. Resultados: La arteria etmoidal anterior se localizó en el 95% (38/40) de los casos. En el 87,55% (35/40) de las fosas se originó de la arteria oftálmica, encontrando en seis casos variantes de la normalidad. La longitud media del canal etmoidal anterior fue de 8,43±0,74mm con un ángulo de entrada en la base de cráneo de 37,3±5,48º. En el 90% de los casos (36/40), se localizó entre la segunda y la tercera lamela. La arteria etmoidal posterior sólo pudo localizarse en (14/40) fosas nasales. El 28,5% (4/14) presentaron variantes en su origen. La longitud media del canal etmoidal posterior fue de 7,1±1,02mm realizando un ángulo anterior a su salida de la órbita de 7,11±4,07º La distancia desde la espina nasal hasta la arteria etmoidal anterior fue de 55,51±5,52mm. El ángulo realizado entre la espina nasal y el canal etmoidal anterior fue de 57,67±1,68º. La distancia entre el nasión y el canal etmoidal anterior fue de 29,31±2,53mm, de la arteria etmoidal anterior a la arteria etmoidal posterior fue de 11,24±2,14mm y de la arteria etmoidal posterior al nervio óptico de 7,26±1,33mm. Se apreciaron celdas supraorbitarias en el 15% (6/40) de las fosas. Conclusiones: La técnica utilizada permitió realizar un análisis vascular completo del trayecto de las arterias etmoidales (AU)

Introduction and objectives: Our aim was to study the radiological anatomy of the ethmoidalarteries. Methods: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. Results: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43±0.74mm. The angle performed into the skull base was 37.3±5.48º. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1±1.02mm. The angle performed into the skull base was 7.11±4.07º. The distance from sill to the anterior ethmoid artery was 55.51±5.52mm. The angle between the nasalspine and the anterior ethmoidal canal was 57.67±1.68º. The distance between the nasion and the anterior ethmoidal canal was 29.31±2.53mm, the distance was 11.24±2.14mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26±1.33mm. Supraorbital cells were observed in 15% (6/40) of the cases. Conclusions: A complete vascular study of the ethmoidal arteries was possible by using this technique (AU)

[Radiological anatomy of the ethmoidal arteries: CT cadaver study]. / Anatomía radiológica de las arterias etmoidales: estudio por TC en cadáver.

INTRODUCTION AND OBJECTIVES: Our aim was to study the radiological anatomy of the ethmoidal arteries. METHODS: A descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. RESULTS: The anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In six cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43 ± 0.74 mm. The angle performed into the skull base was 37.3 ± 5.48°. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1 ± 1.02 mm. The angle performed into the skull base was 7.11 ± 4.07°. The distance from sill to the anterior ethmoid artery was 55.51 ± 5.52 mm. The angle between the nasal spine and the anterior ethmoidal canal was 57.67 ± 1.68°. The distance between the nasion and the anterior ethmoidal canal was 29.31 ± 2.53 mm, the distance was 11.24 ± 2.14 mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26 ± 1.33 mm. Supraorbital cells were observed in 15% (6/40) of the cases. CONCLUSIONS: A complete vascular study of the ethmoidal arteries was possible by using this technique.

Epidemiología de las epistaxis ingresadas en un hospital de tercer nivel / Epidemiology of epistaxes admitted to a tertiary hospital

Introducción y objetivos: La epistaxis es un cuadro que se conoce desde la antigüedad. Sin embargo, los datos epidemiológicos de los que disponemos son escasos. Los objetivos de este trabajo son conocer las principales características epidemiológicas de las epistaxis ingresadas y determinar qué factores se asocian con la aparición de resangrado. Métodos: Se realizó un estudio retrospectivo sobre los ingresos por epistaxis en el servicio de ORL de nuestro centro hospitalario en el periodo comprendido entre enero de 2003 y diciembre de 2008. Se analizó la distribución por sexo, edad, localización y época estacional. Entre las causas etiológicas se determinaron los factores sistémicos y los factores locales. Se examinaron las variables que se asociaron al resangrado. Resultado: Se valoraron 178 ingresos por epistaxis. El 68% fueron hombres (121/178), frente al 32% de mujeres (57/178). La mediana de edad (p25–p75) fue de 65 (53–75) años. Predominaron las epistaxis en los meses de enero y abril. Las causas sistémicas más prevalentes fueron la HTA (56%), el tratamiento antiagregante (23%) y el tratamiento anticoagulante (18,5%). Los factores locales fueron menos frecuentes (11% frente a 68%). Se presentó resangrado en el 14% de los casos (25/178) y solo la localización posterior demostró tener influencia sobre esta variable (p<0,05). Conclusiones: El patrón típico del paciente que ingresa por epistaxis en nuestro centro es un paciente varón, de edad media o avanzada, con alguna enfermedad de base y que presenta una epistaxis de localización posterior (AU)

Introduction and objectives: Epistaxis has been known since antiquity. However, we have limited epidemiological data at our disposal. The aim of this study is to know the main epidemiological characteristics of the cases of epistaxis admitted and to determine the factors associated with the recurrence of bleeding. Methods: A retrospective study was conducted including admissions for epistaxis in the ENT department of our hospital during the period between January, 2003, and December, 2008. We analyzed the distribution by gender, age, location and time of year. The aetiological causes identified included systemic and local factors. We analyzed the variables related to bleeding recurrence. Results: We evaluated 178 cases of epistaxis: 68% of patients were male (121/178), compared to 32% of women (57/178). The median age (p25–p75) was 65 (53–75) years. The epistaxes were most noticeable during the months of January and April. Among the systemic causes, hypertension (56%), anti-platelet treatment (23%) and anti-coagulant therapies (18.5%) predominated. Local factors were much less numerous than general ones (11% v. 68%). Recurrent bleeding was present in 14% of cases (25/178) and only the posterior location was shown to influence this variable (P<.05). Conclusions: The typical pattern of the patients admitted to our department for epistaxis is a middle-aged or elderly male with underlying co-morbidity and posterior epistaxis (AU)

Epidemiology of epistaxes admitted to a tertiary hospital.

INTRODUCTION AND OBJECTIVES: Epistaxis has been known since antiquity. However, we have limited epidemiological data at our disposal. The aim of this study is to know the main epidemiological characteristics of the cases of epistaxis admitted and to determine the factors associated with the recurrence of bleeding. METHODS: A retrospective study was conducted including admissions for epistaxis in the ENT department of our hospital during the period between January, 2003, and December, 2008. We analyzed the distribution by gender, age, location and time of year. The aetiological causes identified included systemic and local factors. We analyzed the variables related to bleeding recurrence. RESULTS: We evaluated 178 cases of epistaxis: 68% of patients were male (121/178), compared to 32% of women (57/178). The median age (p25-p75) was 65 (53-75) years. The epistaxes were most noticeable during the months of January and April. Among the systemic causes, hypertension (56%), anti-platelet treatment (23%) and anti-coagulant therapies (18.5%) predominated. Local factors were much less numerous than general ones (11% v. 68%). Recurrent bleeding was present in 14% of cases (25/178) and only the posterior location was shown to influence this variable (P<.05). CONCLUSIONS: The typical pattern of the patients admitted to our department for epistaxis is a middle-aged or elderly male with underlying co-morbidity and posterior epistaxis.