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1.  Modified Subtotal Lothrop Procedure for Extended Frontal Sinus and Anterior Skull Base Access: A Cadaveric Feasibility Study with Clinical Correlates 
Objective The endoscopic modified Lothrop procedure (EMLP) is an established approach for recalcitrant frontal sinus disease and anterior skull base exposure. However, in select cases, this technique may involve unnecessary resection of sinonasal structures. In this study, we propose a modification of the EMLP, termed the modified subtotal-Lothrop procedure (MSLP), to access the anterior skull base and complex frontal sinus disease for which access to the bilateral frontal sinus posterior table is required.
Methods A cadaveric dissection with photo documentation was performed at an academic medical center on four cadaver heads using standard endoscopic techniques to demonstrate the MSLP and its feasibility.
Results The endoscopic MSLP allowed ample access for instrumentation in each of the dissections using a 30- or 70-degree endoscope. Adequate bilateral access to the posterior table of the frontal sinus was gained in all cases without the need for dissection of the contralateral frontal sinus recess (FSR).
Conclusion The MSLP appears to be a feasible technique for exposure of the anterior skull base and accessing complex frontal sinus pathology. This modification provides similar anterior skull base exposure and surgical maneuverability as the EMLP while limiting surgical dissection to one FSR, thereby preserving as much of the natural mucociliary drainage pathways as possible.
PMCID: PMC3709960  PMID: 24436902
endoscopic modified Lothrop procedure; Lothrop procedure; modified hemi-Lothrop procedure; modified mini-Lothrop procedure; modified subtotal-Lothrop procedure; extended Draf IIB; cadaveric technique
2.  High-Resolution Computed Tomography Analysis of Variations of the Sphenoid Sinus 
Purpose The sphenoid sinus is a complex structure with key variations that are important for endoscopic parasellar approaches. In this study, high-resolution computed tomography (HRCT) scans were analyzed for the frequency of these variations.
Methods A retrospective radiographic analysis was conducted on patients undergoing HRCT between July 2008 and September 2010.
Results Sphenoid sinus pneumatization was defined as conchal, presellar, sellar, and postsellar based on pneumatization relative to the anterior and posterior face of the sella. The distribution ranged from 1.8%, 7.3%, 47.6%, and 43.3%, respectively. We found a greater preponderance of sellar and postsellar variation than previously reported. No differences were found in regard to age, gender, and ethnicity (African American, Caucasian, Asian, and Hispanic) (p > 0.05). The prevalence of optic nerve, maxillary nerve, and internal carotid artery protrusion was 26.1%, 25.9%, and 28.2%, respectively, and dehiscence was 2.1%, 7.4%, and 2.9%, respectively. Accessory septae were present in 43.5% of cases. A lateral recess was identified in 72.4% and clinoid pneumatization in 20% of patients.
Conclusion This study demonstrates a greater prevalence of sphenoid sinus pneumatization and variations than previously reported. This has important implications in terms of preparation and anticipation of possible variations to avoid complications.
PMCID: PMC3699211  PMID: 24436893
congdon classification; sphenoid sinus pneumatization; parasellar anatomy; endoscopic sinus surgery; sphenoid sinus; computed tomography; endoscopic skull base surgery; optic nerve; internal carotid artery; transsphenoidal surgery
3.  Endoscopic nonembolized resection of an extensive sinonasal cavernous hemangioma: A case report and literature review 
Allergy & Rhinology  2013;4(3):e179-e183.
Sinonasal hemangiomas, although rare, must be considered in the evaluation of intranasal masses with profuse epistaxis. Although the availability of literature discussing cavernous hemangiomas in this location is limited, there have been no case reports of exclusively soft tissue sinonasal cavernous hemangiomas extending to the anterior skull base (ASB) that were resected purely endoscopically. Here, we describe the successful endoscopic resection of an extensive right sinonasal cavernous hemangioma extending to but not invading the ASB. Although highly vascular, in select cases, these tumors can be successfully resected endoscopically without embolization by experienced endoscopic sinus and skull base surgeons.
PMCID: PMC3911809  PMID: 24498525
Anterior skull base; benign tumor; cavernous hemangioma; endoscopic endonasal approach; endoscopic skull base surgery; epistaxis; hemangioma; paranasal sinus; sinonasal tumor; skull base tumor
4.  Geometric alopecia after preoperative angioembolization of juvenile nasopharyngeal angiofibroma 
Allergy & Rhinology  2013;4(1):e21-e24.
Resection of a juvenile nasopharyngeal angiofibroma (JNA) is challenging because of high intraoperative blood loss secondary to the tumor's well-developed vascularity. Endoscopic sinus and skull base surgeons commonly collaborate with neurointerventionalists to embolize these tumors before resection in an attempt to reduce the vascular supply and intraoperative bleeding. However, angioembolization can be associated with significant complications. Geometric alopecia from angioembolization of JNA has not been previously reported in the otolaryngologic literature. In this study, we discuss geometric alopecia from radiation exposure during preoperative angioembolization of a JNA.
PMCID: PMC3679562  PMID: 23772321
Alopecia; angioembolization; endoscopic endonasal approach; endoscopic skull base surgery; geometric alopecia; JNA; juvenile nasopharyngeal angiofibroma; pediatric sinonasal tumor; skull base; skull base tumor
5.  Assessment of mucocele formation after endoscopic nasoseptal flap reconstruction of skull base defects 
Allergy & Rhinology  2013;4(1):e27-e31.
Advances in endoscopic skull base (SB) surgery have led to the resection of increasingly larger cranial base lesions, resulting in large SB defects. These defects have initially led to increased postoperative cerebrospinal fluid (CSF) leaks. The development of the vascularized pedicled nasoseptal flap (PNSF) has successfully reduced postoperative CSF leaks. Mucocele formation, however, has been reported as a complication of this technique. In this study, we analyze the incidence of mucocele formation after repair of SB defects using a PNSF. A retrospective review was performed from December 2008 to December 2011 to identify patients who underwent PNSF reconstruction for large ventral SB defects. Demographic data, defect site, incidence of postoperative CSF leaks, and rate of mucocele formation were collected. Seventy patients undergoing PNSF repair of SB defects were identified. No postoperative mucocele formation was noted at an average radiological follow-up of 11.7 months (range, 3–36.9 months) and clinical follow-up of 13.8 months (range, 3–38.9 months), making the overall mucocele rate 0%. The postoperative CSF leak rate was 2.9%. Proper closure of SB defects is crucial to prevent CSF leaks. The PNSF is an efficient technique for these repairs. Although this flap may carry an inherent risk of mucocele formation when placed over mucosalized bone during repair, we found that meticulous and strategic removal of mucosa from the site of flap placement resulted in a 0% incidence of postoperative mucocele formation in our cohort.
PMCID: PMC3679564  PMID: 23772323
Anterior skull base defect; anterior skull base floor; endoscopic endonasal approach; endoscopic skull base surgery; expanded skull base approaches; mucocele; mucosal denuding; vascularized pedicled nasoseptal flap
6.  In-office balloon dilation and drainage of frontal sinus mucocele 
Allergy & Rhinology  2013;4(1):e36-e40.
Treatment of frontal sinus disease represents one of the most challenging aspects of endoscopic sinus surgery. Frontal sinus mucocele drainage may be an exception to the rule because in many instances, the expansion of the mucocele widens the frontal sinus recess and renders surgical drainage technically undemanding. Recently, there has been an increased interest in in-office procedures in otolaryngology because of patient satisfaction and substantial savings of time and cost for both patients and physicians. Similarly, the past few years have witnessed an increased use of balloon dilation devices in sinus surgery. Previously, we have described the in-office use of this device in treating patients who failed prior conventional frontal sinusotomy in the operating room. In this report, we describe our step-by-step in-office experience using this tool for drainage of a large frontal sinus mucocele.
PMCID: PMC3679566  PMID: 23772325
Balloon dilation; balloon sinuplasty; endoscopic sinus surgery; frontal sinus; frontal sinusitis; frontal sinus mucocele; frontal sinusotomy; frontoethmoidal mucocele; in-office procedure; in-office rhinology
7.  Postoperative cerebrospinal fluid leak after septoplasty: A potential complication of occult anterior skull base encephalocele 
Allergy & Rhinology  2013;4(1):e41-e44.
Postoperative cerebrospinal fluid (CSF) rhinorrhea after septoplasty is a known entity resulting from errors in surgical technique and improper handling of the perpendicular plate of the ethmoid bone. When these occur, urgent management is necessary to prevent deleterious sequelae such as meningitis, intracranial abscess, and pneumocephalus. Encephaloceles are rare occurrences characterized by herniation of intracranial contents through a skull base defect that can predispose patients to CSF rhinorrhea. In this report, we present a case of CSF rhinorrhea occurring 2 weeks after septoplasty likely from manipulation of an occult anterior skull base encephalocele. To our knowledge, no previous similar case has been reported in the literature. Otolaryngologists should be aware of the possibility of occult encephaloceles while performing septoplasties because minimal manipulation of these entities may potentially result in postoperative CSF leakage.
PMCID: PMC3679567  PMID: 23772326
Anterior skull base defect; anterior skull base encephalocele; cerebrospinal fluid leakage; cribriform defect; CSF leak; encephalocele; septoplasty complications
8.  The central Onodi cell: A previously unreported anatomic variation 
Allergy & Rhinology  2013;4(1):e49-e51.
Preoperative recognition of the Onodi cell is necessary to avoid injury to closely associated structures, including the internal carotid artery and the optic nerve. This article describes the central Onodi cell, a variation in which a posterior ethmoid cell lies superior to the sphenoid sinus in a midline position with at least one optic canal bulge. To our knowledge, this anatomic variation has not been previously reported in the literature. Radiographic and endoscopic imaging of this unique variation is provided.
PMCID: PMC3679569  PMID: 23772328
Anatomic variation; computed tomography; endoscopic sinus surgery; endoscopic skull base surgery; ethmoid sinus; Onodi cell; optic nerve; parasellar anatomy; sphenoid sinus; transsphenoidal surgery
9.  Skull base defect in a patient with ozena undergoing dacryocystorhinostomy 
Allergy & Rhinology  2011;2(1):36-39.
Ozena, which is often used interchangeably with atrophic rhinitis or empty nose syndrome, is a progressive and chronically debilitating nasal disease that results in atrophy of the nasal mucosa, nasal crusting, fetor, and destruction of submucosal structures. Although the etiology is not completely understood, infection with Klebsiella ozaenae is widely believed to contribute to the destructive changes. We present a case of a patient with ozena secondary to K. ozaenae with extensive destruction of bony structures of the nasal cavity undergoing elective dacryocystorhinostomy. An extensively thinned skull base secondary to the disease process resulted in an unforeseen complication in which the skull base was entered leading to a cerebrospinal fluid leak. Patients with known history of ozena or atrophic rhinitis often have extensive destruction of the lateral nasal wall and skull base secondary to progression of disease. Submucosal destruction of these bony structures mandates the need for extreme caution when planning on performing endoscopic intervention at or near the skull base. If physical examination or nasal endoscopy is suspicious for atrophic rhinitis or a patient has a known history of infection with K. ozaenae, we recommend preoperative imaging for surgical planning with careful attention to skull base anatomy.
PMCID: PMC3390128  PMID: 22852113
Atrophic rhinitis; cerebrospinal fluid leak; cerebrospinal fluid rhinorrhea; CSF; dacryocystorhinostomy; DCR; empty nose syndrome; endoscopic sinus surgery; ozena; Klebsiella ozaenae; skull base; skull base defect

Results 1-9 (9)