360 Degrees Endoscopic Access to and Through the Orbit.

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.

Salvage endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma in a non-endemic area.

PURPOSE: To analyze oncological outcomes of endoscopic surgical treatment of locally recurrent EBV-related undifferentiated non-keratinizing nasopharyngeal carcinoma (uNK-NPC) in a non-endemic area. METHODS: Retrospective review of patients affected by recurrent uNK-NPC treated with nasopharyngeal endoscopic resection (NER) in a tertiary-care referral center from 2003 to 2022, by evaluating survival rates, prognostic factors, and follow-up strategies. RESULTS: The oncological outcomes of 41 patients were analyzed, over a mean follow-up period of 57 months. The 5-year overall, disease-specific, and disease-free survival of the cohort were 60.7% ± 8.9%, 69% ± 9%, and 39.7% ± 9.2%, respectively. The local (rT) and regional (rN) extension of recurrent disease, stage of disease, and status of resection margins appeared to significantly influence survivals. After a mean follow-up period of 21 months, a further recurrence after NER was observed in 36.6% of cases. Skull base osteonecrosis induced by previous irradiation and post-surgical bone remodeling represent the major challenges for early detection of further local relapses during postoperative follow-up. CONCLUSION: NER appeared as a safe and effective treatment for recurrent uNK-NPC. The adequate selection of patients eligible for NER is essential, to maximize the chances to cure and minimize the risk of local complications.

Symptomatic ecchordosis physaliphora of the upper clivus: an exceedingly rare entity.

OBJECTIVE: This paper highlights the management of 5 patients affected by symptomatic ecchordosis physaliphora (EP), treated via endoscopic endonasal transsphenoidal-transclival approach and contextual multilayer skull base reconstruction. A detailed analysis of each case is provided, along with the review of the current body of literature. METHODS: A retrospective review of patients treated by means of endoscopic endonasal approach for EP from 2010 to 2020 in the Otolaryngology and Neurosurgery Departments of a tertiary-care referral center for endoscopic skull base surgery was analyzed. Only adult patients with a definitive histopathological and immunohistochemical diagnosis of EP were included in the study. A systematic literature review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed for EP. RESULTS: Five cases of EP were retrieved and included in the study. Four patients presented with CSF leakage: in two cases after minor head trauma, in one case with associated bacterial meningitis, and in one case as only referred symptom. One patient complained diplopia due to VI cranial nerve palsy. No complications or recurrences of the disease were observed after a median follow-up of 37.2 months (range, 18-72 months). A total of 27 studies were identified with the systematic literature review, encompassing 30 patients affected by symptomatic EP who were addressed to surgical treatment. Twenty-five patients underwent complete surgical removal of the EP, while in 5 cases, only subtotal resection was performed. CONCLUSIONS: EP might result in a "locus minoris resistentiae" of the skull base, predisposing, in rare cases, to CSF leakage and meningitis, spontaneously or after minor trauma. In cases of symptomatic EP, endoscopic endonasal transsphenoidal-transclival approach represents a safe and effective technique for both EP resection and contextual skull base reconstruction.

Performing otolaryngological outpatient consultation during the Covid-19 pandemic.

BACKGROUND: The Covid-19 pandemic has had a profound impact on the Otolaryngology outpatient clinical practice, which is at high risk of respiratory viral transmission due to the close contact between the examiner and the patient's airway secretions [1]. Moreover, most otolaryngological procedures, including oropharyngoscopy, generate droplets or aerosols from high viral shedding areas [1]. Thus, only non-deferrable consultations were performed in the outbreak's acute phase. Along with the re-opening of elective clinical services and the impending second wave of the outbreak, a reorganization is necessary to minimize the risk of nosocomial transmission [1]. METHODS: This video (Video 1) shows how to safely conduct an outpatient Otorhinolaryngological consultation, focusing on complete ear, nose and throat examination, according to evidences from the published literature and Otolaryngological societies guidelines [2,3]. RESULTS: After telephonic screening, patients reporting Covid-19 symptoms or closecontact with a Covid-19 case within the last 14 days are referred to telehealth services [1-3]. To avoid crowding, the patient is admitted alone, after body temperature control, except for underage or disabled people [1]. The waiting room assessment must guarantee a social distance of 6 ft [1-3]. The consultation room is reorganized into two separate areas (Fig. 1): 1) a clean desk area, where an assistant wearing a surgical mask and gloves, handles the patient's documentation and writes the medical report, keeping proper distance from the patient, and 2) a separate consultation area, where the examiner, equipped with proper personal protective equipment (Fig. 2) [3,4], carries out the medical interview and physical examination. Endoscopic-assisted ear, nose and throat inspection using a dedicated monitor allows the examiner to maintain an adequate distance from the patient throughout the procedure while providing an optimal view (Figs. 3-6) [3]. Recent evidence shows that nasal endoscopy does not increase droplet production compared to traditional otolaryngological examination [5]. When necessary, nasal topic decongestion and anesthesia must be performed using cottonoids rather than sprays [3]. The patient keeps the nose and mouth covered throughout the consultation, lowering the surgical mask on the mouth for nasal endoscopy and removing it only for oropharyngoscopy. After the consultation, the doffing procedure must be carried out carefully to avoid contamination [4]. All the equipment and surfaces must undergo high-level disinfection with 70% alcohol or 0.1% bleach solutions [3]. Proper room ventilation must precede the next consultation [3]. CONCLUSIONS: The hints provided in this video are useful to ensure both patient and examiner safety during Otolaryngological outpatient consultations and to reduce SARS-CoV-2 transmission.

Changes in the use of Otorhinolaryngology Emergency Department during the COVID-19 pandemic: report from Lombardy, Italy.

PURPOSE: This paper aims to report the impact of COVID-19 outbreak on Emergency Ear nose and Throat (ENT) activity, in Lombardy (Italy), during COVID-19 pandemic. METHODS: The number of accesses to Emergency Department requiring ENT consultations between February 21st and May 7th, 2020, was retrospectively collected, along with the conditions treated. Data were stratified in 1-week time spans, to evaluate the evolving trends during the on-going epidemic and a comparison with the two previous years was performed. RESULTS: A significant reduction in the number of consultations performed during the pandemic was observed, as high as - 91% compared to the same period of 2018. CONCLUSION: Multiple reasons can explain such a reduction of Emergency ENT consultations, not least the fear of potentially being infected by SARS-CoV-2 by while accessing the hospital. The analysis performed might be useful as a starting point for a future reorganization of first aid consultations once the epidemic will be resolved.

Transoral Robotic Surgery in the Management of a Tongue Base Schwannoma.

Schwannomas are the most common benign tumors arising from the peripheral nerve sheath, and the intraoral location is very atypical, representing less than 1% of all cases. Surgical excision is the treatment of choice, and a variety of surgical approaches have been described. The authors report the first described case of tongue base schwannoma treated with transoral robotic surgery (TORS). A 47-years-old female patient complaining mild dysphagia and snoring, presented a submucosal swelling at the right side of the tongue base. MRI showed a large well-circumscribed solid mass, homogeneously isointense in T1WI and hyperintense on T2WI, with no lymph node metastasis. According to size, location and radiological characteristic of the mass a TORS approach was chosen. An extracapsular dissection was performed, and the lesion was completely removed with no intraoperative complications. The final diagnosis based on histopathological examination and IHC analysis (S-100 positive) was a schwannoma of the tongue base. The post-operative course was uneventful, and no recurrence was observed after 6 months of follow-up. This study demonstrates the feasibility of TORS in the treatment of a tongue base schwannoma. This is a valid alternative to the common transoral approach in order to avoid more invasive external approaches, and further studies are recommended in order to clarify if this approach could be proposed as the first line treatment in selected cases.

Septal branches of the anterior ethmoidal artery: anatomical considerations and clinical implications in the management of refractory epistaxis.

PURPOSE: Epistaxis is a commonly presenting complaint. In severe cases, nosebleeds may occur despite antero-posterior nasal packing and often in the absence of identifiable sources of bleeding. In such cases, epistaxis may occur from septal branches of the anterior ethmoidal artery (sbAEA). The purposes of this study are to highlight the clinical role of the sbAEA in different fields of endoscopic endonasal surgery and to evaluate the efficacy and safety of their selective endoscopic endonasal ligation in the management of refractory epistaxis. METHODS: A retrospective review was performed of all patients presenting with epistaxis who underwent endoscopic endonasal coagulation of sbAEA in three Italian tertiary-care referral centers between October 2010 and October 2017. RESULTS: A total of 30 patients met the inclusion criteria. Sixteen patients had never experienced nosebleeds before, while 14 patients recalled previous epistaxes. Seventeen patients were treated under local anesthetic, while 13 required general anesthesia. No intra- or post-operative complications were observed and none of the patients received nasal packing after the procedure. In all cases the coagulation was effective in controlling the bleeding, with only two relapses in the series (2/30, 6.7%). CONCLUSIONS: The sbAEA are of great interest in endoscopic endonasal surgery, both as surgical landmarks and as feeding vessels for a variety of pedicled nasal flaps. What is more, they can be crucial for the management of refractory epistaxis. Their selective endoscopic coagulation represents an effective and safe procedure in cases of difficult-to-control epistaxis from the upper nasal fossa, with several advantages over nasal packing.

Surgical management of advanced sinonasal cancer: a 10-year mono-institutional experience.

Objective: Endoscopic endonasal surgery is effective in the treatment of sinonasal cancers. However, in cases of well-differentiated locally advanced neoplasms as well as recurrences, the most appropriate treatment is debated. The purpose of this study is to report a mono-institutional experience on craniofacial surgery performed in a tertiary-care referral centre. Methods: This was a retrospective analysis of 90 patients treated with transcranial and/or transfacial resection for sinonasal cancer between 2010 and 2020. Outcome measures included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and recurrence-free survival (RFS). Results: The 5-year OS, DSS and DFS were 48.2%, 60.6% and 28.7%, respectively. Factors correlated with prognosis were pT-classification (p = 0.002), histotype (p = 0.012) and dural involvement (p = 0.004). Independent prognostic factors were orbital apex infiltration (p = 0.03), age (p = 0.002) and adjuvant therapy (p = 0.03). Conclusions: When endoscopic endonasal surgery is contraindicated and chemoradiotherapy is not appropriate, craniofacial and transfacial approaches still represent an option to consider, despite the non-negligible morbidity.

Endoscopic-assisted transorbital extended orbital exenteration: A multi-institutional preclinical study.

BACKGROUND: Sinonasal malignancies with orbital invasion have dismal prognosis even when treated with orbital exenteration (OE). Sugawara et al. developed a surgical strategy called "extended-OE (EOE)," showing encouraging outcomes. We hypothesized that a similar resection is achievable under endoscopic guidance through the exenterated orbit (endoscopic-EOE). METHODS: The study was conducted in three institutions: University of Vienna; Mayo Clinic; University of Insubria; 48 orbital dissections were performed. A questionnaire was developed to evaluate feasibility and safety of each step, scoring from 1 to 10, ("impossible" to "easy," and "high risk" to "low risk," respectively), most likely complication(s) were hypothesized. RESULTS: The step-by-step technique is thoroughly described. The questionnaire was answered by 25 anterior skull base surgeons from six countries. Mean, median, range, and interquartile range of both feasibility and safety scores are reported. CONCLUSIONS: Endoscopic-EOE is a challenging but feasible procedure. Clinical validation is required to assess real-life outcomes.

Endoscopic-assisted orbital exenteration: Technical feasibility and surgical results from a single-center consecutive series.

The purposes of this study were to describe the endoscopic-assisted orbital exenteration surgical techniques, to report preliminary outcomes and to discuss advantages, indications and limitations of this approach. All patients who underwent endoscopic-assisted orbital exenteration at a single tertiary-care center were retrospectively reviewed. A concomitant reconstruction was performed in all cases. The extent of surgical resection was tailored to the size and location of tumor and was classified into four subtypes. A total of 40 patients were included in this series. Orbital exenteration type 1 was performed in 7 cases, type 2 in 11 cases, type 3 in 19 cases, and type 4 in 3 cases. The reconstruction was performed with a pedicled temporal flap in 5 patients and with a free vascularized flap in 34 cases. A radical resection of disease was obtained in 32 cases. After a mean follow-up of 36 months, 14 patients died of disease, one patient died of other causes, 7 are alive with disease, and 18 patients are currently alive without evidence of disease. The preliminary data emerging from this case-series support the feasibility and safety of endoscopic-assisted orbital exenteration.

Maxillary Sinus Floor Infiltration: Results From a Series of 118 Maxillary Sinus Cancers.

OBJECTIVES/HYPOTHESIS: Maxillary cancers are rare and aggressive tumors, which can spread beyond the sinus bony walls. Preoperative assessment of infiltration of maxillary sinus floor (MSF) is paramount for surgical planning, as palatomaxillary demolition significantly impacts patients' quality of life. This study investigates the challenges involved in the preoperative and intraoperative evaluation of MSF infiltration and analyzes its prognostic relevance. STUDY DESIGN: Retrospective case series. METHODS: A retrospective review of patients treated for sinonasal malignancies at a single Institution was performed. Patients receiving surgical-based treatment with curative intent for primary maxillary sinus cancers, between January 2000 and November 2019, were included. RESULTS: A cohort of 118 patients was analyzed. By comparing intraoperative findings (endoscopic assessment and frozen sections) with preoperative radiological assessment, diagnostic changes with regard to MSF infiltration were found in 27.1% (32/118 cases). MSF infiltration negatively affected the prognosis in both univariate and multivariate analyses in the overall population. In the subgroup of pT1-T3 tumors, MSF infiltration was significantly associated with reduced overall (P = .012), disease-free (P = .011), and distant recurrence-free (P = .002) survival rates. Conversely, pT classification was not able to stratify patients according to prognosis, mainly because early-staged cancers (pT1-T2) with MSF infiltration showed reduced survival rates, similar to those observed in pT3 cancers. CONCLUSIONS: Preoperative imaging should be integrated with intraoperative findings based on endoscopic inspection and frozen sections. Future studies are required to investigate the opportunity to incorporate MSF infiltration in the TNM staging system, considering its crucial role in defining the extent of surgery and its potential as prognosticator. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:26-35, 2022.

Patterns of recurrences in sinonasal cancers undergoing an endoscopic surgery-based treatment: Results of the MUSES* on 940 patients: *MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers.

OBJECTIVES: The improvements in survival with expansion of the survivors' population, along with evolution of endoscopically-based treatment modalities, have contributed to emphasize the clinical relevance of recurrences in sinonasal cancers. However, at present, literature is scant regarding the pattern of recurrences and the therapeutic strategies available to manage long survivors who experienced single or multiple failures. The aim of the present study was to analyze sinonasal cancers recurrences to provide data regarding rates and patterns of relapse, predictors of failure and prognostic impact of the recurrence. MATERIALS AND METHODS: All patients receiving multimodal treatments including endoscopic surgery between 1995 and 2021 in three European referral centers were included. Statistical analysis of survival was performed through univariable, multivariable and unidirectional multistate models. Survival after recurrence analysis was implemented for patients experiencing at least one recurrence. RESULTS: The 5- and 10-year recurrence free survival rates were 34.1% and 38.4% for the whole population. With a mean follow-up time of 60 months, a global recurrence rate of 32.9% was observed. The 5- and 10-year survival after recurrence rates were 27.2% and 21.7%, respectively. Incidence and rates of recurrences were significantly associated with histology subtypes. CONCLUSION: This study provides valuable oncologic outcomes regarding a large homogenous cohort of patients affected by sinonasal malignances treated within a multimodal framework, emphasizing the strong correlation of histologic type with prognosis, as well as with pattern of recurrences.

Endoscopic Endonasal Removal of Orbital Schwannoma: Focus on Surgical Technique.

Orbital schwannomas are a rare disease, representing about 1% of orbital tumors, potentially involving any subsite within the orbit. They usually present with painless, nonpulsatile proptosis, while diplopia and vision impairment due to extrinsic ocular muscles or optic nerve involvement are rarely observed.1 A wait-and-see policy is advocated in case of small asymptomatic lesions. However, if progressive dimensional increase or symptoms are observed, surgical resection represents the treatment of choice.2 Different surgical approaches have been proposed, mainly depending on tumor dimension and location inside the orbit, as well as surgical expertise. With advances in technology,3 knowledge,4 and surgical techniques,5 transnasal endoscopic approaches have emerged as a valid option in the management of lesions located medially to the optic nerve, with the advantage of improved visualization and overall decreased morbidity as compared with external approaches.6 We present the case of a 19-year-old woman, affected by an intraextraconal orbital schwannoma located in the left orbit's inferomedial aspect, with a 1-year history of left proptosis associated with retrobulbar pain exacerbated by the upward gaze. The lesion was completely removed with an endoscopic transnasal approach (Video 1), without evidence of postoperative sequelae or visual impairment. Magnetic resonance imaging performed 3 months after surgery showed good surgical results without evidence of persistence of disease. A multidisciplinary approach, involving different specialists familiar with orbital anatomy and physiology, is required for a proper management of patients affected by orbital pathologies.

Combined Endonasal-Transorbital Approach to Manage the Far Lateral Frontal Sinus: Surgical Technique.

In recent decades, the ever-expanding use of endoscopes and development of dedicated instrumentation have reshaped the panorama of surgical approaches to the frontal sinus.1 Nonetheless, the far lateral portion of the sinus might still represent a concern, especially in cases with unfavorable or distorted anatomy.2,3 We report the case of a 52-year-old man, referred to our department for recurrent episodes of left orbital swelling and supraorbital headache, 3 months after Draf III frontal sinusotomy for marsupialization of multiple frontal mucoceles. Computed tomography and magnetic resonance imaging scans were consistent with persistent inflammatory tissue in the far lateral left frontal sinus. Revision surgery was performed, adopting a combined endonasal orbital transposition3 and superior eyelid transorbital approach.4,5 The postoperative course was uneventful, and the microbiologic and histologic examinations demonstrated noninvasive Aspergillus fumigatus infection. The radiologic control showed patency of the frontal recess and complete clearance of the sinus. The patient is asymptomatic after 16 months (Video 1). The transorbital approach is effective in managing orbital and frontal sinus diseases,6 and the combination with the endonasal route grants complete access to the frontal sinus, even in cases of high pneumatization and lateral extension.4,7 Multiportal transorbital approaches represent additional techniques in the rhinologist's surgical armamentarium, which can overcome the limits of a single port approach.8,9 Reports on their use providing technical hints and critical considerations are to be encouraged to ease and stimulate the surgical training in this field.

Temporoparietal Fascia Flap Endonasal Transposition in Skull Base Reconstruction: Surgical Technique.

Reconstruction of wide skull base defects resulting from multimodal treatment of cranial base malignancies are challenging.1 Endonasal pedicled flaps (e.g., Hadad-Bassagusteguy flap)1,2 are generally the first choice; however, inadequacy for the size and location of the defect or their unavailability are common occurrences in salvage reconstructions, and prior irradiation is an additional unfavorable condition for local flap viability. The temporoparietal fascia flap (TPFF)3 is a regional flap vascularized by the superficial temporal artery, which is able to survive and integrate even in postirradiated areas. Its properties, such as thinness, pliability, foldability, and the long pedicle, make it a versatile flap for reconstruction of various defects of the skull base, both in adults3-7 and children.8 In lateral skull surgery, TPFF proved to be effective in patients at higher risk of cerebrospinal fluid leak,7 whereas its transposition into the nasal cavity through a temporal-infratemporal tunnel has been widely reported to repair defects of the ventral skull base.3-6 It represents a safe and effective technique with minimal additional morbidity (potential alopecia or scalp necrosis).4,5 A recently described modification of this technique supports TPFF transposition via a supraorbital epidural corridor to reach the anterior skull base, especially for large defects with supraorbital extension.6 The present video (Video 1) shows the step-by-step TPFF harvesting and endonasal transposition via a temporal-infratemporal tunnel to repair a wide middle cranial fossa defect resulting from osteoradionecrosis after endoscopic resection and heavy-particle radiation therapy for sinonasal adenoid-cystic carcinoma. At 6-months follow-up, optimal healing without complications was observed.

Endoscopic Endonasal Prelacrimal Approach: Radiological Considerations, Morbidity, and Outcomes.

OBJECTIVE/HYPOTHESIS: This study describes a multicentric experience with the use of prelacrimal approach (PLA), focusing on preoperative radiological parameters potentially associated with surgical outcomes and postoperative morbidity. STUDY DESIGN: Retrospective case-series. METHODS: A retrospective review of patients undergoing PLA in three European referral centers was performed. The post-operative morbidity was analyzed in relation to two radiological parameters: width of prelacrimal recess (WPR) and internal angle of pyriform notch (APN). RESULTS: The study included 28 patients affected by Schneiderian papilloma (20 cases), inflammatory disease (6 cases), schwannoma (1 case), and osteoma (1 case). The most reported sequela was paresthesia of ipsilateral anterior superior alveolar process (25% of the cases). An association between post-operative morbidity and APN was observed (P = .047). CONCLUSIONS: Preoperative radiological evaluation of WPR is crucial in understanding the feasibility of the approach, while APN measurement may predict postoperative morbidity, which is paramount in the patients' counseling. LEVEL OF EVIDENCE: 4 case-series Laryngoscope, 131:1715-1721, 2021.

Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate.

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasal cavity that predominantly affects young boys. Surgical removal remains the gold standard for the management of this disease. Preoperative intra-arterial embolization (PIAE) is useful for reductions in intraoperative blood loss and surgical complications. In our series of 79 patients who underwent preoperative embolization from 1999 to 2020, demographics, procedural aspects, surgical management and follow-up outcome were analyzed. Embolization was performed in a similar fashion for all patients, with a superselective microcatheterization of external carotid artery (ECA) feeders and an injection of polyvinyl alcohol (PVA) particles, followed, in some cases, by the deployment of coils . Procedural success was reached in 100% of cases, with no complications such as bleeding or thromboembolic occlusion, and surgical intraoperative blood loss was significantly decreased. In conclusion, PIAE is a safe and effective technique in JNA treatment, minimizing intraoperative bleeding.

A Surgical Variant of the Pre-Lacrimal Approach to the Maxillary Sinus.

INTRODUCTION: When dealing with maxillary sinus pathology, some areas of the sinus remain difficult to examine. In this regard, the pre-lacrimal approach is a minimally invasive technique to reach anterolateral areas of the maxillary sinus while preserving the physiological nasal function. MATERIALS AND METHODS: The present study aimed to provide technical hints related to pre-lacrimal approach acquired through a large number of performed procedures. RESULTS: According to the results, the mucosa incision was performed more anteriorly than the osteotomy using the proposed surgical variant. Moreover, this procedure prevented post-operative annoying symptoms related to the possible presence of an inferior meatotomy. CONCLUSION: The pre-lacrimal approach to the maxillary sinus should be considered as a part of the surgical armamentarium to address the maxillary sinus.

Endoscopic-assisted maxillectomy: Operative technique and control of surgical margins.

BACKGROUND: When amenable to radical excision, cancer involving the maxilla is typically treated with maxillectomy followed by adjuvant therapy. Posterior tumor extension beyond the maxillary box leads to the invasion of complex areas, where achieving clear margins may be challenging. METHODS: Patients undergoing endoscopic-assisted maxillectomy for nasoethmoidal, maxillary, or hard palate cancer between 2007 and 2017 were included in the study. Surgical technique, margin status, and recurrences were analyzed. Extension of posterior resection was classified in 3 types (type 1: resection of the pterygopalatine fossa; type 2: resection of the pterygoid plates and related muscles; type 3: resection of the upper parapharyngeal space). The analysis of putative risk factors for involvement of margins and local recurrence was performed with special focus on the posterior and medial margin. RESULTS: The study included 79 patients (75 with available follow-up; mean: 20.6 months, range: 6-101 months), 37 (46.8%) of whom underwent type 1 resection, 34 (43.0%) type 2, and 8 (10.1%) type 3. According to pT category, 57 (72.2%) tumors were classified as T4a/T4b. Posterior and medial clear margins were achieved in 76/79 (96.2%) and 75/79 (94.9%) patients, respectively. T4b category, extension to the ethmoid, sphenoid sinus, pterygoid process, orbital cavity, and premaxillary tissues were significantly associated with a higher rate of margin involvement. None of the factors was significantly associated with medial margin involvement. CONCLUSION: Endoscopic-assisted maxillectomy combines several refinements including the facilitated detachment of the maxilla from the skull base and precise delineation of the posterior and medial margins of resection.

Septal Flip Flap for Anterior Skull Base Reconstruction After Endoscopic Transnasal Craniectomy: Long-Term Outcomes.

BACKGROUND: Endoscopic endonasal anterior skull base malignant sinonasal tumor resection and reconstruction remains a challenge. We describe our septal flip flap (SFF) reconstruction, a new surgical technique for repairing anterior skull base defects and report our outcomes. METHODS: We retrospectively reviewed the clinical data of 24 patients who underwent skull base reconstruction using a SFF following endoscopic resection with transnasal craniectomy. We raise the SFF from the contralateral nasal septum based on the septal branches of the anterior and posterior ethmoidal arteries; the SFF is then rotated laterally for anterior skull base reconstruction after transnasal resection with craniectomy. RESULTS: The SFF was used for multiple tumor types including, most commonly, intestinal-type adenocarcinoma, followed by olfactory neuroblastoma, squamous cell carcinoma, sinonasal undifferentiated carcinoma, and other types. All of the cases had either preoperative or postoperative radiation therapy. All flaps remained viable postoperatively. Postoperatively, nasal crusting was significantly reduced with faster healing of the surgical cavity. CONCLUSIONS: The SFF adds to the clinical armamentarium the opportunity to provide vascularized mucosal coverage extending from the frontal recess back to the planum sphenoidalis. The use of SFF requires careful consideration when dealing with paranasal sinus cancers so as not to infringe oncologic principles.