Bilateral sinonasal inverted papillomas originating from both sides of the frontal sinus and the left lamina papyracea: A case report.

RATIONALE: The present investigation documented a case of bilateral sinonasal inverted papilloma (SNIP) that arose from both sides of the frontal sinus and ethmoid sinus. The occurrence of bilateral involvement of the nasal cavities and frontal sinus is rather infrequent. PATIENT CONCERNS: Informed consent was obtained from the patient. DIAGNOSIS: Bilateral SNIP. INTERVENTIONS: The tumor was completely removed by Draf III endoscopic resection complemented by an external eyebrow arch approach, and the postoperative recovery was uneventful. OUTCOMES: The purpose of this paper is to present a comprehensive reference for the management of bilateral SNIP that affects the frontal sinuses. LESSONS: This study addresses the staging and surgical management of bilateral SNIP, along with a review of the factors contributing to its recurrence. The recommended treatment method involves applying the Draf III technique combined with an external nasal approach.

Relation between anterior ethmoidal artery course on computed tomography and supraorbital ethmoid cell and Keros classification.

PURPOSE: The anterior ethmoidal artery (AEA) is an important risk area in endoscopic sinus surgery. This study aimed to evaluate the course of AEA according to the Keros classification and the presence of supraorbital ethmoid cell (SOEC) and to prevent possible complications by emphasizing the importance of preoperative paranasal computed tomography (CT) imaging. This approach will increase the effectiveness of endoscopic sinus surgery and improve patient safety. METHODS: The paranasal CT scan images of patients aged > 18 years between October 2020 and November 2021 from our center were retrospectively analyzed. The images were primarily evaluated in the coronal plane, and the sagittal and axial planes were utilized to evaluate variations in AEA regarding the skull base. Furthermore, the relation of AEA course with Keros classification and SOEC was evaluated. The study included 1000 patients aged 18-80 years (right and left, a total of 2000 samples). RESULTS: Grade 3 AEA was the most common regarding the skull base. Keros Type 2 was the most common classification. Overall, 48.7% patients had SOEC. The incidence of Grade 3 AEA was higher among patients with SOEC and a higher Keros classification compared with those without SOEC and a lower Keros classification. Furthermore, Keros Type 3 was the most associated with SOEC presence. CONCLUSION: Consistent with the literature, the probability of Grade 3 AEA in patients with high Keros classification and SOEC was significantly higher in our study. Therefore, we consider that preoperative imaging according to Keros classification and SOEC presence can predict AEA course and guide surgery.

Examination of ethmoidal roof regarding Keros and Yenigun classifications in a Turkish population: a computerized tomography study.

PURPOSE: Understanding ethmoid roof morphology is crucial to prevent complications in endoscopic sinus surgery. This study aimed to evaluate the morphological properties of the ethmoidal roof regarding gender and age differences using Keros and Yenigun classifications on high-resolution computed tomography images. METHODS: We retrospectively analyzed 891 high-resolution computed tomography paranasal sinus study images and measured the depth of the cribriform plate in coronal sections and the anterior-posterior length in axial planes. The study retrospectively examined CT images of paranasal sinuses of patients living in the eastern Anatolian region of Turkey. RESULTS: In both Keros and Yenigun Classifications, the most common class was type 2, and the least common class was type 3. According to Keros et al.'s method, no significant difference was observed between men and women (p = 0.698). However, according to Yenigun et al., the average values of women in terms of the anterior-posterior distance of the ethmoid roof were significantly higher than men (p = 0.001). When examined according to age, a very low, negative correlation was revealed regarding Keros and Yenigun classifications (p = 0.047 and p < 0.001 retrospectively). According to Keros and Yenigun's classification, there was no significant difference between the left and right sides (p = 0.488 and p = 0.919, respectively). CONCLUSION: The morphological properties of the ethmoidal roof have importance to be considered for preoperative planning. Studying larger patient groups and meta-analyses that gather various research results about this subject might help better understand the ethmoidal roof morphology among populations.

The Upper Attachment of the Uncinate Process and Anterior Ethmoidal Artery.

OBJECTIVE: Variations in the upper attachment of the uncinate process (UP) are important because they can affect frontal sinus drainage and change the morphology. Functional endoscopic sinus surgery (FESS) is the primary technique used to treat chronic medically refractory rhinosinusitis. Uncinectomy is the basis of FESS technique to obtain the best possible result from surgery. The anterior ethmoidal artery (AEA) enters the nasal cavity through the orbital medial wall (lamina papyracea) may also be affected by the upper attachment of the UP. The aim of this study was to investigate a possible link between UP variations and the course of the AEA. MATERIALS AND METHODS: This retrospective, computed tomography (CT)-based, anatomic study was conducted on 200 healthy adults (100 females and 100 males) by screening bilateral paranasal sinus images. The upper attachment of the UP was classified in 6 types (1-6) based on the Liu classification. The AEA was divided into 4 types (A-D) based on location: anterior to the frontal sinus (A), between the frontal sinus and the middle nasal turbinate (B), and anterior to the posterior ethmoidal cells (C and D). All the CT images were evaluated simultaneously by 2 anatomists and 1 radiologist. RESULTS: Of the total cases (200 right and 200 left side), 48.8% were type 1 UP attachment, 11.0% type 2, 12% type 3, 9% type 4, 18% type 5, and 1.2% type 6. The AEAs were classified as 12.2% type A, 71.8% type B, 15.2% type C, and 0.8% type D. CONCLUSION: The course of the AEA through the nasal cavity was observed to shift anteriorly from the ethmoidal bulla to the frontal sinus in patients with UP attached to the lamina papyracea and middle turbinate. Remarkably, the AEA always coursed anterior from the middle nasal turbinate line.

A Consistent Endoscopic Landmark to Identify the Anterior Ethmoidal Artery.

OBJECTIVE: The anterior ethmoidal artery (AEA) is an important structure to identify during endoscopic sinus surgery. Although identification on imaging is easily taught, a consistent endoscopic landmark for the AEA, independent of anatomic ethmoid cell variation, is lacking, leaving many surgeons unclear about the exact location without dependence on navigation. Here, we describe a consistent endoscopic landmark, regardless of anatomical ethmoid variation. METHODS: We prospectively enrolled adult patients undergoing endoscopic surgery involving frontal and ethmoid sinuses in this observational study. The AEA landmark was defined simply as the septation or ridge one step back along the ethmoid skull base from the posterior table of the frontal sinus. The gold standard to calculate the sensitivity of our endoscopic landmark was an image-navigation system, registered to within 1.5 mm accuracy, locating the AEA within three planes. Both endoscopic and computerized tomography (CT) images of the pointer at the landmark were taken simultaneously. The concordance of endoscopic to navigation images was independently assessed by three blinded rhinologists. RESULTS: Forty patients were included in our study with 73 sides analyzed. Diagnoses included chronic rhinosinusitis without polyps (52.5%), with polyps (22.5%), recurrent acute sinusitis (15%), sinonasal tumors (7.5%), and odontogenic sinusitis (2.5%). The AEA was accurately identified using our endoscopic landmark in 97.3% of the cases (71/73). Of the two cases in which the AEA was not found within the landmark, the artery was located ≤1 mm posteriorly. CONCLUSION: We describe a consistent endoscopic landmark to identify the AEA, conserved across various clinical diagnoses and anatomic variations in sinus structure. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1096-1099, 2024.

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

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

Maxillary ostium preservation in ethmoidectomy.

The paranasal sinuses play a role in producing and storing nitric oxide (NO). NO is a powerful antiviral and antibacterial gas which may be involved in the non-specific immune defenses of the respiratory tract. Conducted by the inspiratory current at the alveolar-capillary membrane, it increases pulmonary venous blood oxygenation. NO is actively released in the form of independent boluses in the respiratory tract, thanks to a sphincter function that can be identified during ethmoidectomy under general anesthesia. Safeguarding paranasal sinus physiology necessarily involves conserving this ostial sphincter function, which is essential to the respiratory role of the paranasal sinuses. Although it has not yet been demonstrated that the destruction of this ostial function has measurable consequences for respiratory function, it makes sense to avoid systematic antrostomy and to preserve this ostial function whenever possible, depending on the clinical conditions. This technical note describes step-by-step how to conserve the maxillary ostium, in the example of radical ethmoidectomy with mucosal ablation for nasal polyposis (nasalization). It is illustrated by two videos. The discussion focuses on the respective indications for ostial preservation and middle meatotomy (antrostomy).

Resection of Orbital Myxoma With Magnetic Resonance Imaging Evidence of Ethmoid Sinus Origin: Case Report and Review of 20 Patients in the Literature.

A 41-year-old woman showed a palpable mass at the superonasal orbital edge on the right side. Magnetic resonance imaging demonstrated a lobulated fluid-containing tubular mass which extended anteriorly to posteriorly along the medial orbital wall, nasal to the eyeball. She was followed once a year for 8 years until the age of 49 years when she decided to undergo surgical resection because of the enlarged mass. The lobulated large mass was resected and the pathology showed sparsely distributed spindle cells, positive for CD34, in alcian blue-positive mucous substances, indicative of myxoma. Postoperative magnetic resonance imaging showed residual lobulated tubular mass along the optic nerve on the medial side and superior to the eyeball. The residual orbital mass showed stable structure with more evident connection with the ethmoid sinus lesion, suggestive of the ethmoid origin, in 12 years until the age of 61 years. In the review of 20 patients with orbital myxomas in the literature, in addition to this case, roughly classified locations in the orbit were retrobulbar in 8 patients, on the lateral side of the orbit in 4, on the superior side in 6, on the medial side in 1 (this patient), and in the orbit with no specific description in 2. In pathological examinations, immunohistochemistry was not done in 8 patients, done but all negative in 2, and positive in 11 patients: nerve sheath myxoma was diagnosed in 3 patients based on positive S100 staining. Orbital myxoma is rare but considered in differential diagnosis of orbital masses.

Clinical and imaging features of ethmomaxillary sinus compared to Haller's cell.

PURPOSE: Understanding the anatomy of the paranasal sinuses and their variations is essential to achieving safe and effective endoscopic sinus surgery. The ethmomaxillary sinus (EMS) is a relatively under-researched anatomical variation. This study investigated the prevalence, clinical features, and effect of EMS on the maxillary sinus in comparison with Haller's cells. METHODS: Patients who visited the Rhinology Clinic at our hospital for rhinologic symptoms between January 2020 and December 2020. Computed tomography (CT) scans of paranasal sinuses were obtained at 1 mm-section thickness. Using CT scans, we investigated the clinical features of EMS, measured maxillary sinus volume, and analyzed the presence of maxillary sinusitis. RESULTS: EMS was observed in 26 of the 250 patients (10.4%). The male-to-female ratio was equal. The age ranged from 18 to 83 years (mean age, 56.3). Of the patients with EMS, 65.4% were unilateral and 34.6% were bilateral. The prevalence of Haller's cells was similar to that in EMS (10.8%). In the analysis of patients with unilateral EMS, the EMS side was found to have a significantly reduced maxillary sinus volume compared to the opposite side, whereas the difference was not significant in Haller's cells. There was no significant relationship between EMS or Haller's cells and maxillary sinusitis. CONCLUSIONS: EMS can significantly affect maxillary sinus volume. Therefore, surgeons should thoroughly review PNS CT scans before paranasal sinus surgery to determine the presence and features of EMS.

SMARCB1-Deficient Sinonasal Carcinoma: Case Report and Review of the Literature.

BACKGROUND SMARCB1-deficient sinonasal carcinoma is a rare neoplasm with inactivation of the SWI/SNF complex, with an aggressive clinical course as most of the lesions present as advanced in pT3/T4 stages with frequent recurrence, and many patients succumb to the disease. Reported initially in 2014, the lesion has male predominance, with an age range of 19 to 89 years and predilection for the ethmoid sinus and nasal cavity. Histopathological findings show a proliferation of small- to medium-sized monomorphic basaloid cells with indistinctive cytoplasmic borders and round variably prominent nuclei with scattered cells that show rhabdoid morphology. Cytoplasmic vacuoles are common. It has similar morphological findings to a wide array of neoplasms in the sinonasal area. CASE REPORT We report a case of SMARCB1-deficient sinonasal carcinoma in a 30-year-old man referred to our hospital with a preliminary diagnosis of sinonasal adenocarcinoma, intestinal type. Computed tomography showed a huge destructive soft tissue mass in the left maxillary sinus, extended to involve the left nasal cavity with extension to the skull base and perineural spread along the foramen rotundum. Histological examination revealed a malignant basaloid neoplasm embedded in a myxoid stroma that showed loss of SMARCB1 stain. The patient was treated with induction chemotherapy using etoposide and cisplatin for disease control. CONCLUSIONS SMARCB1-deficient sinonasal carcinoma is a rare neoplasm with an aggressive clinical course and high-grade behavior despite having uniform cytological features. This poses complex diagnoses, especially in small biopsies. Incorporating morphological findings with ancillary tests is required to identify this high-grade malignancy.

Osteoma of the ethmoid sinus in a pediatric patient - a case report.

BACKGROUND: Osteomas of the paranasal sinuses occur rarely in the pediatric population, we find only a few reference of symptomatic osteomas in the literature. Opinions on the indication for surgical treatment are controversial. CASE: The authors present a case of symptomatic osteoma of the right ethoimoidal sinus in a 12-year-old boy, who was treated surgically, with endoscopic endonasal approach. The symptomatology, diagnosis and therapy of these tumors in the pediatric patient are discussed. CONCLUSION: Osteomas of the paranasal sinuses are slow-growing benign lesions. Symptomatic osteomas can grow expansively and cause serious complications. The treatment of osteoma is surgical and the endoscopic approach offers the possibility of removal with cosmetic benefits.

[Efficacy of glucocorticoid stent implantation in ethmoid sinus after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyps].

Objective:To evaluate the efficacy of glucocorticoid sinus stents implanted 2 weeks after functional endoscopic sinus surgery（FESS） for the treatment of chronic rhinosinusitis with nasal polyps（CRSwNP）. Methods:CRSwNP patients with similar bilateral lesions were randomly divided into two groups, with a stent group of 25 patients and a control group of 24 patients. Patients in the stent group had glucocorticoid sinus stents implanted into the bilateral ethmoid sinuses 2 weeks after FESS, while the control group underwent postoperative debridement only. Follow-up assessments occurred at postoperative weeks 2, 4, 8, and 12. Patients were asked to assess their sensation of nasal symptoms using a 10-point visual analog scale. Efficacy was assessed by endoscopic evaluations. Sinus obstruction, crusting/coagulation, polyp formation, middle turbinate position, adhesions, mucosa epithelialization, and postoperative intervention were assessed as efficacy outcomes. GraphPad Prism 9 was applied for statistical analysis. Results:At 4 and 8 weeks postoperatively, the stent group showed significant improvement in VAS scores of nasal congestion and runny nose compared with the control group（P<0.05）. No significant difference was observed in the VAS scores of head and facial stuffiness, loss of smell, or nasal dryness/crusting between the two groups（P>0.05）. Compared with the control group, the stent group had a lower rate of polypoid formation at 4, 8, and 12 weeks postoperatively. At postoperative week 12, the rate of mucosal epithelialization in the ethmoid cavity was significantly higher in the stent group. During the follow-up, the frequency of postoperative intervention was significantly lower in the stent group than in the control group（P<0.05）. Besides, a lower incidence of middle turbinate lateralization was found in the stent group at 8 and 12 weeks postoperatively. At 8 weeks postoperatively, the stent group had a percentage of adhesion lower than that of the control group（all P<0.05）. Conclusion:Implantation of glucocorticoid sinus stents after FESS can maintain sinus cavity patency, improve the inflammatory status of the operative cavity, reduce postoperative interventions, and promote benign regression of the operative cavity.

Anatomical landmarks for localisation of the anterior ethmoidal artery: a combined radiological and cadaveric (endoscopic) study.

PURPOSE: The anterior ethmoidal artery is a major surgical landmark that is susceptible to iatrogenic injury during surgery of the anterior ethmoidal sinus, frontal sinus, and skull base. The present study aimed to define the location of the anterior ethmoidal artery in relation to specific anatomical landmarks using radiological imaging and endoscopic dissection. METHODS: Eighty-six anterior ethmoidal arteries were assessed using computed tomography scans (bilateral analyses) and forty anterior ethmoidal arteries were assessed using cadaveric specimens (bilateral analyses). The skull base, anterior nasal spine, anterior axilla of the middle turbinate, and nasal axilla were morphometrically analysed to determine their reliability as anterior ethmoidal artery landmarks. RESULTS: Distances to the skull base, anterior nasal spine, and nasal axilla displayed statistically significant differences between sexes and sides (p < 0.05). All landmarks demonstrated excellent reliability as anatomical landmarks for the localisation of the anterior ethmoidal artery, radiologically and endoscopically (ICC values ranged from 0.94 to 0.99). CONCLUSION: The middle turbinate axilla was the most reliable landmark, due to the lack of statistically significant differences according to sex and laterality, and the high inter-rater agreement between measurements. Anatomical knowledge of variations and relationships observed in the present study can be applied to surgeries of the anterior ethmoidal sinus, frontal sinus, and skull base to improve localisation of the anterior ethmoidal artery, preoperatively and intraoperatively, and avoid iatrogenic injury of the vessel.

A low-cost prosthetic orbital simulation model for endoscopic anterior ethmoid artery ligation.

OBJECTIVE: This study aimed to develop and evaluate a low-cost orbital prosthesis for simulation of endoscopically assisted intra-orbital anterior ethmoidal artery ligation. METHODS: A low-cost orbital prosthesis was built and evaluated by ENT surgical trainees. Feedback was given following the assessment in the form of a face validity questionnaire. RESULTS: Results were scored on a Likert scale of 1-7 (low to high). Trainees had limited exposure to the procedure (40 per cent) and predominantly low levels of confidence (mean, 3.67) that correlated with a lack of first-hand experience. The anatomy and likeness to human tissue of the prosthesis were both ranked highly, with mean scores of 5.0 and 4.93, respectively. CONCLUSION: The results of this study support the idea that a simple anatomical prosthesis for the simulation of endoscopic anterior ethmoidal artery ligation can be created with potential value to otolaryngology surgical training. To the authors' knowledge, this is the first documentation of simulated surgical epistaxis management using an artificial anatomical model.

CT analysis of predictors for visual acuity in optic neuropathy with mucocele.

OBJECTIVE: To evaluate the causative and risk factors for optic neuropathy with mucocele via imaging studies. METHODS: We included 21 patients with rhinogenous optic neuropathy with mucocele. We collected data on the sinus involved, age, sex, number of days from the onset of visual impairment to surgery, and computed tomography (CT) imaging findings (bone defects in the lamina papyracea, Onodi cell mucocele, exophthalmos, and optic nerve deviation). The results were compared between two groups, the one having nine patients with pre-operative visual acuity of <0.1 (the poor group) and the other having 12 patients with pre-operative visual acuity of ≥0.1 (the fair group). Whether or not there was a difference in pre-operative visual acuity between patients with and without Onodi cell mucocele was determined. RESULTS: After surgery, visual acuity improved in 16/21 (76.2%) patients, and a correlation analysis showed a significant positive correlation between pre-operative and post-operative visual acuity. In imaging, the causative sinuses accounted for 85.7% of both posterior ethmoid and sphenoid sinuses. Bone defects of the lamina papyracea at the optic canal and the vertical downward deviation of the optic nerve at each location, especially in 6/9 patients with Onodi cell mucocele, were characteristic in the poor group. In these conditions, increasing the contact areas of the optic nerve and mucocele can leads to more chances of direct downward compression of the optic nerve and infection occurring, and it may lead to severe pre-operative visual impairment. CONCLUSION: Imaging studies of optic neuropathy with mucocele help to determine the risk factors and perform early and precise diagnostic imaging and decision-making for surgery.

Improving the Accuracy of Maxillary Sinus Balloon Dilation Using Virtual Reality Navigation: A Proof-of-Concept Study.

BACKGROUND: The ability to reliably and accurately cannulate the natural ostium of the maxillary sinus during balloon sinus dilation (BSD) has been criticized. Conventional computed tomography (CT)-guided navigation systems are helpful when dilating other sinuses, but they fail to provide meaningful feedback to guide accurate dilation of the maxillary sinus. OBJECTIVE: This study explores the potential impact of a new navigation system with virtual reality (VR) functionality on successful BSD of the maxillary sinus. METHODS: Using the established methodology, a cadaveric evaluation of the accuracy of maxillary BSD with a VR-equipped navigation system and balloon was undertaken. The natural ostium was landmarked on CT images with a beacon, and a VR intrasinus camera view was used to guide balloon dilation by a team of 2 rhinologists. Following the procedure, uncinectomies were performed to directly assess the accuracy of dilation. Standardized video clips with a 30° endoscopic view of the area were reviewed by 3 blinded rhinologists from different institutions who were not part of the procedures. Dilation of the natural ostium was scored as "successful," "unsuccessful," or "unsure." RESULTS: Sixteen maxillary BSDs were completed in 8 cadavers using VR navigation. The medial wall of the maxillary sinus showing the natural ostium as well as any accessory ostia were readily visualized and labeled with a beacon in all cases using the 3D virtual rendering feature. Dilations were scored using a standardized rubric. Any "unsure" responses from the reviewers were categorized as "unsuccessful" for analysis purposes. The accuracy rate for dilation of the maxillary sinus natural ostium was 77%. Despite the use of cadaveric tissues, a fair interrater agreement (kappa 0.21) was achieved. CONCLUSION: Using VR navigation appears to improve the accuracy of cannulating the natural ostium during maxillary BSD, which could lead to better outcomes. Further study in live subjects is warranted.

Supraorbital ethmoid cells (SOECs), anterior ethmoid artery notch and ethmoid roof relation in PNSCT.

OBJECTIVES: We investigated supraorbital ethmoid cell (SOEC) presence and types in paranasal sinus computed tomography (PNSCT). METHODS: The PNSCT images of 188 adult patients (93 males and 95 females) were evaluated as SOEC group (n = 87 sides), and non-SOEC group (n = 289 sides, control). In both groups, anterior ethmoid artery (AEA) notch-ethmoid roof distance and presence of AEA canal were evaluated. In the SOEC group, SOEC types (type 1 to 3) and SOEC angle are also examined. RESULTS: SOEC was detected in 87 sides (23.13 %). SOEC type 2 was the most detected type (71.3 %). AEA notch-ethmoid roof distance of the SOEC group was significantly higher than those in the non-SOEC group. AEA notch-ethmoid roof distance of the SOEC Type 3 group was significantly higher than SOEC Type 2 group. AEA notch-ethmoid roof distance was 3.74 ± 1.81 mm in the SOEC group and 0.68 ± 1.16 mm in the non-SOEC group. When SOEC types were considered, this distance was 5.29 ± 2.66 mm in type 3, 3.35 ± 1.35 mm in type 2 and 3.48 ± 0.92 mm in type 1. In higher SOEC types, SOEC angle; and AEA notch-ethmoid roof distance increased. CONCLUSION: In more pneumatized SOEC presence, SOEC angle increase, and AEA notch-ethmoid roof distance increases, AEA runs inferiorly in the ethmoid cells and freely below the skull base; and is more susceptible to injury. The surgeons should be more careful not to damage AEA in the FESS when detecting well-pneumatized SOECs (SOEC Type 3).

Transcaruncular anterior ethmoidal artery ligation.

Recurrence of epistaxis after ligation or embolization of the sphenopalatine artery may require ligation of the ipsilateral anterior ethmoidal artery, which cannot be embolized because of the risk to the ophthalmic artery. We describe a transconjunctival transcaruncular approach that allows reliable low-risk access to the anterior ethmoidal artery. This technique offers a minimally invasive approach to the surgical site, without unsightly scar.