Surgical treatment of 186 sinonasal inverted papillomas and analysis of the immunohistochemical and molecular features associated with recurrences.

INTRODUCTION: Inverted papillomas (IP) are benign epithelial tumors with a tendency to be locally invasive and with disposition to recur. The aim of our study is to present the results of IP treatment, considering pathological, immunohistochemical and molecular features of recurrence. MATERIAL AND METHODS: From 1978 to 2020, 186 sinonasal IPs surgeries corresponding to 152 patients were treated in our center. We performed a pathology evaluation of all the recurrent cases reviewing the histological diagnosis, the presence of mixed component other than IP, the koilocytic changes, the p16 over expression and HPV-DNA detection. RESULTS: Overall recurrence rate was 19 % (35/186). The 35 IP recurrences correspond to 22 patients, 9 of whom presented a single recurrence (single recurrence group) while 13 of them presented more than one recurrence (multi-recurrent group). Immunohistochemical analysis showed a higher percentage of p16 overexpression (54 % vs 33 % p = 0.415) and HPV-DNA presence (23 % vs 0 % p = 0.240) in the multi-recurrent group compared with single recurrence group. In addition, the revision showed more IP with exophytic papilloma focus (38 vs 22 % p = 0.648) and a higher proportion of IP with koilocytotic changes (61 % vs 22 % p = 0.099) in the multirecurrent group. There is no significant difference between groups in our results. CONCLUSION: The analysis of our patients may differentiate between two groups with recurrent papillomas. A single recurrence group where the cause of recurrence is probably an anatomical problem related to an incomplete resection, and a second pattern, the multi-recurrence group, where HPV infection may be the main cause of recurrence.

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.

"The Accessory Ethmoidal Canal Does Not Necessarily Contain an Arterial Structure".

Introduction: The aim of our study is to describe the prevalence of the accessory ethmoidal artery in endonasal endoscopic cadaver dissections and to identify its intraorbital origin. Material and Methods: From 2018 to 2020, thirty-four nasal dissections were performed in seventeen adult cadaveric heads. We performed a complete ethmoidectomy to identify the ethmoidal canals. Then, we removed the bony canal and the lamina papiracea to verify the injected vessel and to confirm the vascular structure inside the canal. Results: We found the anterior ethmoidal canal (AEC) and the posterior ethmoidal canal (PEC) in 100% of nasal cavities (34/34). We identified 4 accessory ethmoidal canals (AcEC) in the 34 nasal fossae dissected (12%). All AEC contained an arterial vessel. The AcEC contained an arterial vascular structure in 2 cases, a neural structure in other specimen, and in the fourth case no structure could be verified. In 32 of 34 nasal cavities, the PEC contained an artery and only in 2 cases the PEC did not contain any vascular structure. In these specimens, we observed that the AcEC with an arterial vessel inside (6%) was closer to the posterior canal than the anterior canal. Conclusion: According to our findings, we can suggest that the presence of a canal does not necessarily imply the presence of an arterial vessel, and that presence of the accessory ethmoidal artery could be associated with the absence of posterior ethmoidal artery.

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.

Intracavernous Branches of the Internal Carotid Artery Through an Endoscopic Endonasal Approach: Anatomical Study and Review of the Literature.

OBJECTIVE: The endoscopic endonasal transcavernous (EET) approach is an increasingly popular approach for the cavernous sinus and surrounding structure lesions as well as a surgical corridor to pre-mesencephalic cisterns. This endoscopic study describes the main intracavernous branches of the internal carotid artery, providing nuances to improve the safety of this approach. MATERIAL AND METHODS: Forty-six fresh cavernous sinus (23 heads) were injected with colored silicon and studied via an EET approach; 6 were excluded due to insufficient injection. The internal carotid artery, the meningohyphophyseal trunk (MHT) and its branches, and the inferolateral trunk were dissected, and branching patterns identified and classified. RESULTS: The MHT was identified in 82.5% of cases. Two main MHT types were identified: complete, with 3 main branches, and incomplete, with fewer than 3. The main branches encountered were the inferior hypophyseal artery, present in 92.5% of cases, the dorsal meningeal artery (DMA), present in 87.5%, and the tentorial artery, present in 87.5%. The DMA was classified as prominent medial (48.6%), prominent lateral (20%), or bifurcation type (25.7%). Complete and incomplete MHT were further classified as complete MHT (A, B, and C) and incomplete MHT (A, B, C, and D) according to the combination of the different DMA types with other branches. The inferolateral trunk was a branch of the MHT in 7% of cases. CONCLUSIONS: The MHT is a highly prevalent intracavernous branch, with 7 identifiable patterns based on DMA morphology and branch combination. This knowledge could guide surgeons in performing a safer EET approach.

Pérdida de agudeza visual progresiva en paciente con proptosis. Caso clínico y revisión de la literatura / Progressive visual impairment in a patient with proptosis. Case report and review of the literature.

Introducción: a raíz del siguiente reporte de caso clínico se pretende repensar el diagnóstico diferencial de los tumores orbitales y revisar la literatura existente al respecto. Caso: paciente de 54 años, fumadora, acude a nuestro centro por una pérdida de agudeza visual progresiva de dos años de evolución en el ojo derecho, que se acompañaba de proptosis. Las pruebas de imagen basadas en resonancia magnética y tomografía por emisión de positrones ­ tomografía computarizada (PET-TC) realizadas describían una lesión intraconal derecha de morfología indefinida, que rodeaba el nervio óptico. El estudio inmunohistoquímico y molecular anatomopatológico confirmó la sospecha de síndrome linfoproliferativo extranodal de bajo grado. Discusión: el manejo endoscópico de estas lesiones puede resultar en una menor comorbilidad en comparación con el abordaje externo tradicional. El papel de la cirugía radica en la obtención de una muestra de la lesión que permita un correcto diagnóstico. Conclusiones: el abordaje multidisciplinar con oftalmólogos, hematólogos y expertos en radioterapia permite obtener buenos resultados quirúrgicos y clínicos en la inmensa mayoría de casos.

Introduction: as result of the following clinical case report, we intend to review the differential diagnosis of orbital tumors and review the existing literature in this regard. Case report: a 54-year-old smoking patient, consulted to our department due to a progressive visual impairment over the last two years in her right eye. She presented proptosis in her clinical examination. Imaging studies based on MRI and PET-CT described a right intraconal lesion with an undefined morphology surrounding the optic nerve. Orbital tumors differential diagnosis is delicate. Nevertheless, Non-Hodgkin lymphomas followed by metastasis are the two most common found in this location. The immunohistochemistry and molecular studies, confirmed the suspected diagnosis of extranodal low-grade lymphoproliferative syndrome. Discussion: endoscopic management of these lesions may result in a lower comorbidity compared to traditional external approaches. Role of surgery lays in obtainment of a quality sample which allows a proper diagnosis. Conclusions: multidisciplinary approach with ophthalmologists, hematologists and radiotherapy experts enhance good surgical and clinical results in the vast majority of cases.

Nuestra experiencia en el manejo de las complicaciones orbitarias en la rinosinusitis aguda / Our experience in the management of orbital complications in acute rinosinusitis

ANTECEDENTES Y OBJETIVO: La propagación de una infección a partir de los senos paranasales es poco frecuente pero grave. Entre un 4 y un 20% de las rinosinusitis se pueden complicar; de ellas, las orbitarias (60-75%) son las más prevalentes. La gran mayoría se presentan en la edad pediátrica, si bien en la edad adulta son más graves. Nuestro objetivo es analizar las características epidemiológicas de estos pacientes así como plantear un protocolo de actuación ante esta situación. MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo de 21 pacientes diagnosticados de una complicación orbitaria en el curso de una rinosinusitis aguda entre 2005 y 2018. El diagnóstico se basó en la historia clínica, la exploración endoscópica y las pruebas de imagen. Todos los pacientes recibieron antibioterapia intravenosa y fueron valorados por oftalmología. Se llevó a cabo un tratamiento quirúrgico urgente en caso de existir un absceso o mala evolución con el tratamiento médico. RESULTADOS: La edad media de los pacientes fue de 24 años. El 52% fueron varones y el 48% mujeres. Según la clasificación de Chandler, el 43% (9/21) fueron celulitis preseptales (7 adultos y 2 niños), el 10% (2/21) celulitis orbitarias (un adulto y un niño), el 43% (9/21) abscesos subperiósticos (2 adultos y 7 niños), hubo un caso de absceso orbitario en un adulto y ningún caso de trombosis de seno cavernoso. Se solicitó una TC a todos los pacientes y se optó por el tratamiento quirúrgico en caso de absceso subperióstico u orbitario, a excepción de 2 abscesos de pequeño tamaño (< 4 mm), subperiósticos mediales y en edad pediátrica (< 4 años) que presentaron una correcta evolución con tratamiento conservador. El abordaje quirúrgico fue por vía endoscópica endonasal: se resecó la lámina papirácea y se mantuvo intacta la periórbita en el caso de abscesos subperiósticos, pero se incidió en ella en el absceso orbitario. Se complementó con un abordaje externo palpebral en los 4 casos que presentaron una colección en el techo de la órbita o en la pared lateral. Dos pacientes adultos jóvenes (10%) presentaron de manera concomitante una complicación intracraneal. CONCLUSIONES: Las complicaciones orbitarias de la rinosinusitis aguda son poco frecuentes pero potencialmente graves. Es importante conocerlas y sospecharlas para actuar con rapidez. El tratamiento multidisciplinar, la localización y la extensión del cuadro son esenciales para el correcto manejo de estas complicaciones. El abordaje quirúrgico se realiza mediante endoscopia endonasal. Su limitación son las colecciones localizadas en el techo de la órbita o en pared lateral, en las que se tendrá que complementar la actuación con un abordaje externo palpebral

BACKGROUND AND OBJECTIVE: The spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60-75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm. MATERIALS AND METHODS: We carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management. RESULTS: The average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (< 4 years) with a small and medial subperiosteal abscess (< 4 mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly. CONCLUSION: Orbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required

Our experience in the management of orbital complications in acute rhinosinusitis. / Nuestra experiencia en el manejo de las complicaciones orbitarias en la rinosinusitis aguda.

BACKGROUND AND OBJECTIVE: The spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60-75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm. MATERIALS AND METHODS: We carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management. RESULTS: The average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (<4 years) with a small and medial subperiosteal abscess (<4mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly. CONCLUSION: Orbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required.

Rhinocerebral mucormycosis in a 5-month heart transplant recipient.

Mucormycosis is an opportunistic acute fungal infection with a high mortality rate seen in immunocompromised patients. It is extremely rare in heart transplant recipients. Rhinocerebral mucormycosis (RM) is the most frequently observed presentation. We report a case of RM in a heart transplant recipient 5-month after the procedure, with a fatal outcome.

[Mucocele caused by postraumatic orbitary herniation]. / Mucocele por herniación orbitaria postraumática.

Sinusal mucoceles are expansive lesions related to ostium sinus obstruction and treatment is surgical. We present a case of frontal mucocele secondary to ostium drainage obstruction due to herniated orbital content. This entailed difficulties for intranasal surgical resolution so a combined approach was used. The different surgical options for treating such cases are discussed.

Mucocele por herniación orbitaria postraumática / Mucocele by postraumatic orbitary herniation

Los mucoceles de senos paranasales son lesiones expansivas relacionadas con la obstrucción del ostium sinusal, cuyo tratamiento es quirúrgico. Presentamos un caso de un mucocele frontal secundario a una obstrucción del ostium de drenaje por contenido orbitario herniado. Este hecho conllevó dificultad para la resolución quirúrgica endonasal, por lo que se optó por una vía combinada. Para tratar este tipo de casos, se analizan las diferentes opciones quirúrgicas

Sinusal mucoceles are expansive lesions related to ostium sinus obstruction and treatment is surgical. We present a case of frontal mucocele secondary to ostium drainage obstruction due to herniated orbital content. This entailed difficulties for intranasal surgical resolution so a combined approach was used. The different surgical options for treating such cases are discussed

[Revision of carcinomas in paranasal sinuses]. / Revisión de los carcinomas de senos paranasales.

The annual incidence rate for paranasal sinus cancer is quite low in Europe at approximately 1 case a year per 100 000 inhabitants. The most frequent site is the maxillary sinus; in some countries such as Spain, however, carcinomas of the ethmoidal sinus complex are more prevalent. Squamous cell carcinoma is the most frequent histological type and adenocarcinoma is the one with the best prognosis. In general terms, the association of surgery and radiotherapy continues to be the optimal therapeutic option. The inclusion of an endoscopic endonasal approach for the treatment of these lesions must be considered in very selective cases. Most authors currently accept invasion of the fat and muscles of the orbital apex and infiltration of the conjunctiva and/or sclera as an absolute indication for orbital exenteration. Lymph node involvement at diagnosis or in the course of the disease is infrequent, so prophylactic lymph node treatment would therefore not be indicated.

Revisión de los carcinomas de senos paranasales / Revision of carcinomas in paranasal sinuses

Los carcinomas de senos paranasales presentan una incidencia baja, aproximadamente un caso al año cada 100.000 habitantes entre la población europea. La localización más frecuente es el seno maxilar, aunque en algunos países como España los carcinomas de etmoides son el grupo más numeroso. El tipo histológico más frecuente es el carcinoma escamoso, y el adenocarcinoma es la variante histológica con mejor pronóstico. En términos generales, la combinación de cirugía y radioterapia sigue siendo la modalidad terapéutica óptima. La inclusión del abordaje endonasal endoscópico en el tratamiento de estas lesiones debe considerarse en casos muy seleccionados. Actualmente, la mayoría de los autores acepta como indicaciones para llevar a cabo una exenteración orbitaria la invasión de la grasa, la musculatura y el ápex orbitario y la infiltración de la conjuntiva y/o esclerótica. La afección ganglionar en el momento del diagnóstico o durante el curso de la enfermedad es poco frecuente, lo que justificaría no tratar las cadenas ganglionares de manera profiláctica

The annual incidence rate for paranasal sinus cancer is quite low in Europe at approximately 1 case a year per 100 000 inhabitants. The most frequent site is the maxillary sinus; in some countries such as Spain, however, carcinomas of the ethmoidal sinus complex are more prevalent. Squamous cell carcinoma is the most frequent histological type and adenocarcinoma is the one with the best prognosis. In general terms, the association of surgery and radiotherapy continues to be the optimal therapeutic option. The inclusion of an endoscopic endonasal approach for the treatment of these lesions must be considered in very selective cases. Most authors currently accept invasion of the fat and muscles of the orbital apex and infiltration of the conjunctiva and/or sclera as an absolute indication for orbital exenteration. Lymph node involvement at diagnosis or in the course of the disease is infrequent, so prophylactic lymph node treatment would therefore not be indicated