Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma.

Petrous apex cholesterol granulomas (PACG) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. A 19-year-old woman presented with a recurrent right abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom- and recurrence-free. Endoscopic endonasal surgery must be adapted to manage recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences

Endoscopic transnasal transpterygopalatine fossa approach to the lateral recess of the sphenoid sinus

Q1Q1528-532Objectives Lesions affecting the lateral recess of the sphenoid sinus are rarely discussed in the literature as a separate entity. This region is difficult to visualize and manipulate through the transnasal routes, especially when extensive pneumatization is present. External approaches to this area involve extensive surgery and are associated with significant morbidity. The objectives of this study are to present our experience with the endoscopic transpterygopalatine fossa approach as a method for exposing and manipulating lesions of the lateral recess of the sphenoid and to illustrate the detailed surgical steps of the procedure. Study Design Retrospective review. Methods Clinical charts of patients who had lesions originating from or extending into the lateral recess of the sphenoid sinus and who were treated at our institutions from September 1995 to June 2002 were retrospectively reviewed. All these patients were managed by the endoscopic transpterygopalatine fossa approach. Results Twelve patients (7 males and 5 females) were included in the study. Lesions included seven cerebrospinal fluid (CSF) leaks and five tumors. One patient with squamous cell carcinoma (SCC) of the sphenoid died of his disease. All CSF leaks were successfully repaired, and benign tumors were removed with good local control through the follow‐up period. Conclusion The endoscopic transpterygopalatine fossa approach is an excellent approach for dealing with lesions of the sphenoid lateral recess

Endoscopic approach to the infratemporal fossa

Introduction: Multiple surgical approaches have been described to access the infratemporal fossa. One of them is the endoscopic endonasal transpterygoid approach to the infratemporal fossa. The endoscopic endonasal transpterygoid approach is considered the best to access the midline structures such as the nasopharynx, Eustachian tube, sella, and clivus. Through this work, we try to describe the anatomical structures and landmarks of the infratemporal fossa from the endosopic endonasal transpterygoid point of view. Methods: A cadaveric study was performed on five adult specimens. Endoscopic medial maxillectomy and complete resection of the posterior wall of the maxillary antrum were performed. Extension of the medial maxillectomy anteriorly was done to reach the lateral part of the infratemporal fossa. Endoscopic Denker’s or Sturman–Canfield approach was done. Dissection of the pterygopalatine fossa was done with identification of maxillary artery branches, V2 (maxillary nerve) and masticatory muscles. Resection of the lateral pterygoid muscle and drilling the lateral pterygoid plate improve exposure of the infratemporal fossa, including V3 (mandibular nerve), which lies posterior to the lateral pterygoid plate. Results: A total of ten infratemporal and pterygopalatine fossae (five cadaveric specimens) were dissected endoscopically using a transpterygoid approach. Dissection of different anatomical structures in the infratemporal fossa was done to describe the anatomical structures and landmarks of the infratemporal fossa. Conclusions: Endoscopic endonasal transpterygoid approach is considered one of the most useful surgical solutions to manage selected tumors that involve the infratemporal fossa. A good understanding of the endoscopic anatomy of infratemporal fossa allows safe and complete resection of lesions arising or extending to infratemporal fossa

Possible esthesioneuroblastoma metastasis to paranasal sinuses: Clinical report and literature review

BACKGROUND: Local recurrence, and regional and distant metastases, respectively, develop in 30% and 15% of patients with esthesioneuroblastoma (ENB). METHODS: This case report includes 3 patients with unusual recurrences of ENB in the sinonasal tract. RESULTS: Patient 1 developed ENB in the bilateral maxillary sinuses after unilateral endoscopic resection of a left ENB followed by postoperative proton radiotherapy. Patient 2 developed ENB at the left optic-carotid recess 7 years after a craniofacial resection and postoperative radiotherapy. Patient 3 developed ENB over the left zygomatic process of the maxilla 4 years after a cranioendoscopic resection and postoperative radiation therapy for ENB of the ethmoid sinuses with intracranial extension. The possibility of venous tumor emboli must be considered as a likely etiology. However, alternative explanations include the development of a second primary or potential transformation because of tumor signaling. CONCLUSION: We present 3 cases that may represent metastasis of ENB within the sinonasal tract

Preauricular Infratemporal Fossa Surgical Approach: Modifications of the Technique and Surgical Indications

A retrospective clinical analysis was performed to evaluate the effectiveness of the preauricular infratemporal fossa (ITF) surgical approach using modifications based on tumor pathology and extension, without compromising outcomes. Patients were surgically treated for tumors involving the ITF via a preauricular surgical approach during 1990 to 2000. Their clinical charts were reviewed to determine the association among pathological variables, details of the surgical procedure, and outcomes. Tumors in 65 patients were categorized as “malignant” and “benign.” The malignant group included 44 patients (mean age, 49.5 years). Squamous cell carcinoma was the most common pathology followed by sarcomas. To achieve complete tumor resection, the ITF approach and dissection were combined with other procedures in 74% of these patients. No surgical complications were encountered in 74.4%, and a clinical cure was obtained in 55% of patients (follow-up, 2 years). The benign group included 21 patients (mean age, 36.7 years). Juvenile angiofibromas and meningiomas constituted most of the tumors in this group. An ITF approach alone was sufficient to achieve complete tumor excision in 66.7% of these patients. A clinical cure was achieved in 85% of patients (follow-up, 2 years), and 76.2% had no surgical complications. Chi-square tests revealed significant correlations between tumor extensions and surgical treatment variables. These were more evident in the malignant group, indicating the use of wider surgical exposures and more aggressive, extirpative surgery. The preauricular surgical approach to the ITF can be used to achieve a complete resection of a variety of tumors arising from or extending into the ITF. This approach can be tailored to the nature of the tumor and its extensions