Sphenoid Sinus Fungal Ball and Reestablishing Sinus Function.

OBJECTIVES: The aim was to assess the developmental attributes of sphenoid sinuses affected by fungal balls and describe a surgical approach which reestablishes gravity-dependent drainage to compensate for any mucociliary dysfunction. METHODS: A within-patient case-control analysis was performed on sphenoid sinus dimensions from patients with sphenoid sinus fungal ball (SSFB). Radiological dimensions were assessed to determine the dominant or larger sinus by volume and width. Pneumatization in the sagittal and lateral extent was assessed. The influence of sinus size and pneumatization variants within a patient was analyzed. Patency and the presence of mucostasis from radical reshaping of the sinus cavity were documented at least 3 months after surgery. Complications (bleeding, cerebrospinal fluid leak, and cranial nerve palsy) were recorded. RESULTS: Twenty-three patients (59 ± 19 years, 86% female, 46 sphenoid sinuses) were assessed. Fungal ball was more common in the smaller (non-dominant) sinus, by width (78% vs. 22%, p < 0.01) and by proportion of total sphenoid volume (0.39 ± 0.16 vs. 0.61 ± 0.16, p < 0.01). Pneumatization variants did not influence the development of SSFB within a patient. All patients had patency and the absence of mucostasis or persistent inflammation at last follow-up. No complications were reported. CONCLUSION: The smaller or nondominant sphenoid sinus is more affected by SSFB. Surgical reshaping of the sphenoid to prevent mucostasis is favorable in managing the smaller affected sinus cavity. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Isolated sphenoid sinus opacification: A systematic review.

OBJECTIVE: Unilateral sphenoid sinus opacification (SSO) on imaging is a common incidental radiologic finding. Inflammatory sinus disease is rarely isolated to one sinus cavity therefore SSO raises the potential for neoplastic etiology. The clinical significance of SSO was evaluated and compared to maxillary sinus opacification (MSO). METHODS: A systematic review of unilateral sinus opacification was performed via Medline (1966-January 12th, 2015) and Embase (1980-January 12th, 2015), limited to English literature and human subjects. Case series of patients treated with radiologic evidence of unilateral sinus opacification either from maxillary or sphenoid sinuses and with pathology results were included. Individual cases were classified as neoplastic, malignant, or a condition requiring surgical intervention (i.e. fungal ball). Exclusion criteria were single case reports, lack of primary data, series of complications, or single pathology series. Case-by-case analysis was performed for both SSO and MSO. RESULTS: Search strategy revealed 3264 studies. A total of 31 studies including 1581 patients met the inclusion criteria. In these studies, SSO was described in n=1215 (76.9%) and MSO in n=366 (23.1%). For SSO, the final diagnosis was neoplasia 18%, (malignancy in 10.9%). 58.3% of cases required surgical intervention and 13% were inflammatory. For MSO, neoplasia represented 18.3% (malignancy 7.1%), surgical intervention required in 47% of cases and 27.6%. were inflammatory. CONCLUSION: Isolated MSO and SSO is a marker of neoplasia in 18% and malignancy in 7-10% of patients presenting with these radiologic findings. Clinicians should be wary of conservative management given the high incidence of neoplasia and consider a lower threshold for early surgical intervention.

Cadaveric study of the endoscopic endonasal transtubercular approach to the anterior communicating artery complex.

The endoscopic transnasal approach to the anterior communicating artery (ACoA) complex is not widely performed. This cadaveric study investigated the surgical relevance of the anterior endoscopic approach to the treatment of ACoA aneurysms. Bi-nasal endoscopic transtubercular surgery was carried out on fresh adult cadavers. Primary outcomes measures incorporated dimensions of the endonasal corridor (operative field depth, lateral limits, size of the transplanum craniotomy and dural opening); vascular exposure (proximal and distal anterior cerebral arteries [ACA], ACoA, clinoidal internal carotid artery [ICA] segment); and operative manoeuvrability defined by clip placements (ipsilateral and contralateral). Eight cadaver heads were used (mean age 84±7years, range 76-94 years, 75% female). Mean operative depth was 97±4mm. The lateral corridors were limited proximally by the alar rim openings (31±2mm), and distally by the optic nerves (22±6mm). The endonasal craniotomy dimensions were 21±5mm anteroposteriorly, and 22±4mm laterally. Vascular exposure was achieved in 100% of subjects for the ACoA segment and the ACA segments proximal to the ACoA (A1). The ACA segments distal to the ACoA (A2) were accessible only in 40% of subjects. Endonasal clip placement across the ACoA segment, clinoidal ICA, A1 and A2 were 100%, 90%, 90%, and 30%, respectively. The ventral endoscopic endonasal approach to the ACoA complex provides excellent vascular visualisation without brain retraction or gyrus rectus resection. However, the limitation in access to the A2 for temporary clip placement may prove to be a significant limitation of this approach.

Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy.

BACKGROUND: Dacryocystorhinostomy (DCR) is commonly performed for epiphora, dacryocystitis and during tumor surgery. External (EXT-DCR) and endoscopic DCR (END-DCR) are both practiced. END-DCR was initially performed with laser (EL-DCR) but has shifted to careful bone removal with mechanical drills (EM-DCR). High level evidence from comparative cohorts was sought to compare outcomes. METHOD: Medline (1966 - January 28th, 2013) and Embase (1980 - January 28(th), 2013) were searched for comparative studies (RCT/cohorts) of END-DCR to EXT-DCR for acquired nasolacrimal duct (NLD) obstruction. Primary outcome was DCR success, defined as resolution of symptoms and/or patent NLD on irrigation or dacroscintography. Secondary outcomes were scarring, infection and post-operative bleeding. Meta-analysis was performed with the Mantel-Haenszel Method and presented as Risk Ratios (RR) with Confidence Intervals (CI). RESULTS: The search identified 3582 studies and 355 were reviewed after screening. Full text review yielded 19 studies (4 RCTs and 15 cohorts). Overall, EXT-DCR had slightly better success rates than END-DCR (RR 0.96, CI 0.93-1.00). However, EM-DCR outcomes were comparable to EXT-DCR (RR 1.02, CI 0.98-1.06), whereas EL-DCR had poorer outcomes (RR 0.85, CI 0.79-0.91) when compared separately. The RR for scarring, bleeding and infection with END-DCR versus EXT-DCR was 0.07 (CI 0.02-0.22), 0.72 (CI 0.46-1.13) and 0.24 (CI 0.11- 0.54), respectively. The rates of reported revision surgery were similar. CONCLUSION: DCR is a procedure with high success rates. Endoscopic procedures differ greatly by technique with EM-DCR offering comparable results to EXT-DCR, without the risk of cosmetically unacceptable scars.

Endoscopic endonasal transplanum approach to the paraclinoid internal carotid artery.

Objective To investigate the relevance of an endoscopic transnasal approach to the surgical treatment of paraophthalmic aneurysms. Setting Binasal endoscopic transplanum surgery was performed. Participants Seven cadaver heads were studied. Main Outcome Measures (1) Dimensions of the endonasal corridor, including the operative field depth, lateral limits, and the transplanum craniotomy. (2) The degree of vascular exposure. (3) Surgical maneuverability and access for clip placements. Results The mean operative depth was 90 ± 4 mm. The lateral corridors were limited proximally by the alar rim openings (29 ± 4 mm) and distally by the distance between the opticocarotid recesses (19 ± 2 mm). The mean posteroanterior distance and width of the transplanum craniotomy were 19 ± 2 mm and 17 ± 3 mm, respectively. Vascular exposure was achieved in 100% of cases for the clinoidal internal carotid artery (ICA), ophthalmic artery, superior hypophyseal artery, and the proximal ophthalmic ICA. Surgical access and clip placement was achieved in 97.6% of cases for vessels located anterior to the pituitary stalk (odds ratio [OR] 73.8; 95% confidence interval [CI] 7.66 to 710.8; p = 0.00). Conclusion The endoscopic transnasal approach provides excellent visualization of the paraclinoid region vasculature and offers potential surgical alternative for paraclinoid aneurysms.