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Objective: To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management., Methods: Longitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed., Results: The frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement., Conclusions: Our long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Here we report our experience of patients with squamous cell carcinoma (SCC) of the nasal cavity and ethmoid sinus (NC&ES) together with an analysis of treatment outcomes., Methods: A retrospective analysis was performed using data from 25 consecutive patients treated between 2000 and 2012. Four patients were diagnosed with T1, 3 with T2, 4 with T3, 7 with T4a, and 7 with T4b disease. No patient had lymph node metastasis., Results: Twelve patients were treated with surgery with/without radiotherapy and with/without chemotherapy. Of these, 4 underwent endoscopic surgery without an open approach and 3 required an anterior skull base approach. Thirteen were treated with radiotherapy; 1 with radiotherapy alone, and 4 and 8 with intravenous and intra-arterial chemotherapy, respectively. The 5-yr overall survival for T1-3, T4a, and T4b disease was 53.9%, 71.4%, and 29.0%, respectively. The 5-yr disease-specific survival for T1-3, T4a, and T4b disease was 74.1%, 71.4%, and 29.0%, respectively., Conclusion: Our treatment policy for patients with SCC of NC&ES, which basically follows the NCCN guideline, was considered to be appropriate. However, several points in terms of surgery and non-surgical approach remain to be solved through further research., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To determine the indications for the addition of a transcaruncular approach along with detachment of the medial rectus muscle during the removal of small apical cavernous hemangiomas using an endoscopic transethmoidal approach., Design: Retrospective, noncomparative case series., Methods: Multicenter study of 12 patients with apical orbital tumors removed using an endoscopic transethmoidal approach. The decision to detach the medial rectus muscle with the addition of a transcaruncular approach was made during surgery for tumors largely lateral to the medial rectus muscle. Tumors adjacent to the medial orbital wall were removed via an endoscopic transethmoidal approach alone., Results: Seven tumors were removed via an endoscopic transethmoidal approach combined with medial rectus muscle detachment, whereas 5 patients underwent removal without detachment of the medial rectus. All patients had visual impairment. Complete excision of the hemangiomas was achieved in all patients and tumor size ranged from 6 × 5 mm to 20 × 12 mm. The mean postoperative follow-up time was 11.8 ± 4.3 months. At final follow-up, the best-corrected visual acuity improved in 11 patients. Three patients had transient horizontal diplopia resulting from partial paralysis of the medial rectus muscle after detachment during surgery., Conclusions: The endoscopic transethmoidal approach with or without medial rectus detachment is a promising approach for selected small cavernous hemangiomas located at the deep medial orbital apex. Detachment of the medial rectus muscle can be a useful technique for tumors located largely lateral to the medial rectus muscle. Further studies will be required to demonstrate the safety and efficacy of this technique., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Osteoblastoma is categorized as a benign bone-forming tumor, which occurs rarely in the craniofacial region. We report a case of osteoblastoma developed in the nasal cavity and ethmoid sinus in a 14-year-old girl whose chief symptom was nasal obstruction and exophthalmos on the right side. CT revealed the lesion having the same density as bone and a ground-glass border, expanding to the nasal and paranasal cavities. Complete removal was accomplished under endoscopic view, although the tumor was removed piece by piece. Histologic inspection showed exuberant osteoid trabeculae and immature bone formation by osteoblasts with vascularized connective tissue. We diagnosed the tumor as osteoblastoma based on the clinical presentation and the size of the tumor. No recurrence was evident at the 1-year follow-up visit., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Fibrous dysplasia, ossifying fibroma and osteomas are collectively known as fibro-osseous lesions. Occurrence in the sinonasal region is rare, and its management can be technically challenging. We report a case of an 8-year-old female with cemento-ossifying fibroma of the ethmoid sinus who underwent a two-staged, endoscopically assisted, transfacial resection of the lesion and a 31-year-old male with fibrous dysplasia of the ethmoid sinus who underwent endoscopic removal of the tumor. Both cases utilized intraoperative computed tomography (CT)-updated image-guided systems (IGS) to improve surgical precision. In the second patient, further resection was undertaken after CT-update in the same surgery. The postoperative courses were uneventful, and at 1-year follow-up no tumor recurrence was observed in either patient. Our experience suggested that the use of intraoperative CT-updated IGS in endoscopic or endoscopically assisted surgeries for sinonasal fibro-osseous lesions will lead to more optimal tumor control, which can translate into greater patient safety., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: For transnasal endoscopic repair procedures to be successful, it is critical to identify leak locations during surgery. We aim to evaluate different methods to more accurately detect leak locations during the endoscopic repair of cerebrospinal fluid rhinorrhea., Materials and Methods: We performed a retrospective chart review of 39 cases undergoing endoscopic repair of cerebrospinal fluid rhinorrhea. The leak locations were determined using preoperative nasal endoscopy, radioisotope scanning, the intraoperative image-guided system, and intraspinal normal saline injection., Results: The cerebrospinal fluid leak location was in the sphenoidal sinus in 9 cases, the ethmoid sinus in 17 cases, and in the frontal sinus in 1 case. The leak locations could not be determined in the remaining 12 cases using this method alone. For these 12 cases, after the ethmoid sinus was opened and the lateral wall of sphenoidal sinus was exposed with the aid of the intraoperative image-guided system, outflow of cerebrospinal fluid was present on the lateral wall of sphenoidal sinus (in 1 case) and on the ethmoid roof (in 3 cases). Furthermore, using intraspinal saline injection (20-30 ml), leak locations were detected in the sphenoidal sinus (2 cases) and in ethmoid sinus (6 cases) of the remaining cases., Conclusion: For cerebrospinal fluid rhinorrhea patients whose leak locations are difficult to determine, surgeons can increase their operative success rates by performing radioisotope scanning and intraspinal saline injections and by using image-guided surgical systems. These safe and effective methods can be used to successfully detect leak locations during transnasal endoscopic repair of cerebrospinal fluid leaks., (Copyright © 2011. Published by Elsevier Ireland Ltd.)

Objective: The objective of this study was to report the cases of three patients with sinonasal malignant tumors who underwent en bloc tumor resection using endoscopic endonasal approaches, and to discuss the advantages and limitations of endoscopic endonasal tumor resection., Methods: Three patients with malignant naso-ethmoidal tumors underwent en bloc resection with endoscopic endonasal approach., Results: In very carefully selected cases of naso-ethmoidal malignant tumors that were preoperatively evaluated on endoscopic findings and magnetic resonance imaging to be limited to within the nasal cavity and/or ethmoid sinus and to have some safe margins between the tumor and skull base and/or lamina papyracea, tumors were resected en bloc using endoscopic endonasal approaches. A case of cerebrospinal fluid leakage was safely managed with the endoscopic approach., Conclusions: In selected T1-T2 naso-ethmoidal malignant tumors with some safe margins, endoscopic endonasal surgery may offer a satisfactory alternative to external procedures., (Copyright (c) 2009. Published by Elsevier Ireland Ltd.)

Carcinoid tumors arise from neuroendocrine cells, many of which are present in the digestive tract and lungs. There have been few reports of carcinoid tumors occurring in the nose and paranasal sinus area, and they are very rare. We encountered a patient with a carcinoid tumor that arose in the nose and paranasal sinuses, and we report the case with a review of the literature. The patient was a 75-year-old woman who began to experience right-sided nasal obstruction, and when her nose began to bleed on the right-side she was examined in our department. A tumor lesion that easily bled and had filled the right nasal cavity was observed. CT revealed a mass lesion with a marked contrast enhancement in the right nasal cavity, ethmoid sinus, and sphenoid sinus, and MRI showed numerous flow voids in the interior that seemed to be tumor blood vessels. The tumor was excised through a lateral rhinotomy. The histopathological diagnosis was a carcinoid tumor. Tumor recurrence was subsequently detected in the vicinity of the opening of the sphenoid sinus, and because the tumor was tending to grow larger, the tumor was resected. The patient has been followed up in the outpatient clinic, recurrence-free., (Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.)

Background: Intravascular papillary endothelial hyperplasia (IPEH) is an abundant, usually intravascular, benign endothelial proliferation that may mimic angiosarcoma clinically and histopathologically. Its occurrence in the sinonasal cavity is extremely rare. To the best of our knowledge, we present the first case with the most extensive IPEH ever found within the sinonasal cavity., Methods: A 42-year-old man of intravascular papillary endothelial hyperplasia in the sinonasal cavity was reported. He complained of a 1-year history of left-sided nasal obstruction accompanied by unilateral rhinorrhea, repeated epistaxes and frontal headache. Anterior rhinoscopy demonstrated a smooth-surfaced reddish mass occupying the left nasal cavity. Endoscopic surgery was used to clear this uncommon tumor in the sinonasal cavity. A review of the pertinent literature was also presented., Conclusions: IPEH may be mistaken for an angiosarcoma clinically and histopathologically. Complete endoscope-guided surgical excision is the best choice of therapy for patients with IPEH and is both diagnostic and curative. Awareness of this lesion will prevent incorrect diagnosis and overly aggressive treatment.

The hamartoma is a benign rare tumor constituted by a mixture of tissue. It is very unusual in the nasal cavity. The objective of the study is to describe an unusual case of bilateral nasal hamartoma. We report a 52-year-old male patient with a bilateral paranasal hamartoma of the ethmoid and maxillary sinus. Functional endoscopic sinus surgery was performed to completely remove the masses. The reported localization is unusual because the most common site in the nose is the posterior septum. Although hamartoma arising from the rhino sinusal region is very rare, head and neck surgeons must know this entity in order to differentiate it from inverted papilloma and adenocarcinoma. Misinterpretation of this lesion may result in aggressive surgery for a benign lesion.

Leptomeningeal carcinomatosis is rare in evolution of head and neck cancers. Prognosis is poor and treatment is through supportive care. We report an atypical rapid post-operative leptomeningeal carcinomatosis after skull base resection for an ethmoidal adenocarcinoma. The anterior skull base resection was near-total and we suspect a seeding of subarachnoid space either before surgery, either during surgical extirpation or from the residual intracranial nodule. It is the first description of rapid LMC after surgery (less than 1 month). Post-operative MRI diagnosed the LMC through the detection of contrast enhancing leptomeningeal nodules at bilateral second and eighth cranial nerves and at bilateral interpedoncular area. A strong index of suspicion along with clinical and radiological correlation is essential to arrive at a correct diagnosis. Otolaryngologists should be aware of the possibility of leptomeningeal carcinomatosis, before or after surgery, in a patient presents with an appropriate constellation of neurologic symptoms and a history of cancer.

Extracranial meningioma of the paranasal sinus is a very rare condition of unclear etiology. Surgical excision is currently the only curative treatment but sometimes entails difficulties because of the complicated anatomic loci of the tumor. For the case reported here, we used a navigation system in endoscopic surgery for an extracranial meningioma of the paranasal sinus and were able to remove the tumor without complications by a transnasal approach alone. This is the first report of the use of such a system with endoscopic surgery for this condition. We discuss the clinical presentation, diagnosis, and treatment of this case as well as present a review of the literature.

Objective: Transnasal endoscopic surgery is the most common approach to removal of pituitary tumors. This study evaluated the transnasal transethmosphenoidal approach (TTES) in terms of its operative manipulability and the postoperative status of the paranasal cavities., Methods: A total of 132 patients with pituitary tumors underwent surgery by one of the following three approaches: (1) bilateral TTES, in which the surgical procedures were performed via the bilateral paranasal cavities, (2) unilateral TTES, in which the procedures were performed via one side only, and (3) unilateral TTES and resection of the posterior portion in the nasal septum approach (RPS), which is a modification of approach (2) and enables performance of the procedures from both sides., Results: The degree of freedom for the surgical procedures with each of the approaches decreased in the following order: bilateral TTES, unilateral TTES and RPS, and unilateral TTES. The postoperative CT images and endoscopic findings were good with each of the surgical approaches, but the incidences of olfactory disturbance and nasal dryness were significantly higher with the bilateral TTES compared with the unilateral TTES and RPS and the unilateral TTES., Conclusion: The unilateral TTES and RPS was for us most suitable approach of the three methods. In the case of advanced tumors, the bilateral TTES should be selected because it permits superior operative manipulability. Finally, the unilateral TTES is most appropriate for removal of tumors that are deviated to one side and localized within the sella.

The Onodi cell is a large pneumatized posterior ethmoid cell and closely related to optic nerve. We present an extremely rare case of retrobulbar optic neuropathy caused by mucocele in an Onodi cell. A 79-year-old man complained of headaches and simultaneous bilateral visual disturbance. A computed tomography (CT) scan demonstrated a mucocele in an Onodi cell, which involved bilateral optic nerves. The surgical treatment with a transnasal endoscopic approach was performed, resulting in the improving of visual acuity. The bilateral optic nerves were identified along each lateral wall into an Onodi cell accompanied with bone defect. In an Onodi cell, even if the lesion is isolated and/or small, it may be closely related to ocular symptoms. Imaging studies should be considered for the differential diagnosis because early diagnosis and prompt surgical treatment for mucocele are needed for recovery of visual impairment.

Primary osteogenic sarcoma arising from the ethmoid sinus is an extremely rare condition. We report herein a 50-year-old female presenting with lacrimation. Computed tomography (CT) scan showed tumor calcification, which is a common feature of osteogenic sarcoma. Exploratory ethmoidectomy was performed, and histological examination confirmed the diagnosis of osteogenic sarcoma. Radiation therapy and chemotherapy failed to reduce the tumor size. The patient was finally treated by anterior craniofacial resection and orbital exenteration. Although primary osteogenic sarcoma of the ethmoid sinus is uncommon, the authors emphasize that osteogenic sarcoma should be suspected when tumor calcification was observed on CT scan and that adequate surgical resection with negative surgical margins remains the mainstay of treatment of this lesion.

Pulmonary embolism (PE) is a prominent cause of morbidity and mortality in surgical patients. Here, we report two cases of PE following head and neck surgery: (1) in case 1, the patient underwent endoscopic sinus surgery (ESS), and (2) in case 2, the patient was suspected PE after resection of the parotid gland and radical neck dissection. Prophylactic compression devices were used during the operation in both cases. In case 1, PE was diagnosed 3 days following surgery after the patient complained of dyspnea while walking. PE was successfully treated by intravenous administration of heparin. In case 2, PE was strongly suspected 13 days following surgery after the patient experienced syncope and chest pain and exhibited abnormal findings on a cardiac echogram. This patient died 18 h after the onset of cardiac symptoms. Despite prophylactic measures taken during surgery, the prognosis was poor for this patient due to numerous high-risk factors (e.g., advanced age, obesity, prolonged immobilization). Although the incidence of postoperative PE in our department during the last 7 years is very low (0.04%), the frequency of postoperative PE in Japan has steadily increased in recent years. PE still is one of the most significant complications leading to morbidity and mortality following surgery. Given the gaining prominence of PE, we conclude that otolaryngologists including those in Japan should be reminded of high-risk factors associated with PE and be made aware of prophylactic treatments newly aimed at reducing the frequency of PE.

We report a rare case of complete orbital apex syndrome due to sphenoethmoid mucocele. A 61-year-old male presented with a 3-day-history of right-sided sudden proptosis, ophthalmoplegia, and visual loss. Computed tomographic scan and magnetic resonance imaging revealed a cystic mass measuring 25-mm in diameter of the right sphenoethmoid region. At first intravenous antibiotics and corticosteroids had been given but not effective. He underwent endonasal marsupialization using endoscopy. His post-operative course was good. The eye symptoms gradually recovered, and his visual acuity completely recovered 3 months after surgery.

A case of an 11-year-old female with cementifying fibroma in the ethmoidal sinus extending to the anterior cranial base was presented. She complained of slowly progressive nasal obstruction and anosmia. Magnetic resonance imaging (MRI) revealed a tumor in both ethmoidal and sphenoidal sinuses and nasal cavity. Although a tumor reduction surgery was attempted through a transnasal approach, tumor size increased gradually and right exophthalmos subsequently appeared. The pathological diagnosis was cementifying fibroma of the nose. Total tumor removal was consequently accomplished through the intracranial anterior transbasal approach. The surgical approach should be selected according to the site and expansion of the lesion in individual patients.

We experienced the clinical courses of two cases of destructive Aspergillus in paranasal sinuses in which an Aspergillus fungus ball was formed, and which caused bony destruction are described. The case in which a nidus could not be completely surgically removed and with intervening diabetes had an unfavorable prognosis. It is recommend to perform an early expanded operation as well as to administer a sufficient amount of antifungal drugs for the treatment of destructive Aspergillus in paranasal sinuses.

Osteomas of paranasal sinuses are usually asymptomatic. When enlarged, they may cause serious complications. We report a case of huge frontoethmoidal osteoma associated with brain abscess. If an osteoma associated with an intracerebral pathology is detected, it should be remembered that this could have been a complication of the osteoma and a detailed radiological examination should be performed to show the extent of the osteoma and to confirm any defect at the posterior wall of the sinus which may lead intracerebral complications. Such an osteoma should be operated after the abscess was resolved and patient became stable neurologically.

Nonchromaffin paragangliomas are unusual tumours arising from widely distributed paraganglionic tissues probably of neural crest origin. In the head and neck region they are usually seen as carotid body or jugulotympanic tumours. Other rarely reported sites in the head and neck region are the orbit, nose and larynx. This report deals with a case of sinonasal paraganglioma which was initially treated with surgery and radiotherapy. Twenty two years later the tumour recurred and showed a rapid growth due to malignant transformation which we believe is late effect of radiotherapy. The clinical features, histopathology and role of radiotherapy in sinonasal paragangliomas together with a review of the medical literature have been discussed.

Paranasal sinus osteoma is a slow-growing, benign, encapsulated bony tumor that may be commonly asymptomatic, being detected incidentally in 1% of plain sinus radiographs or in 3% of sinus computerized tomographic scans. In a patient presenting with orbital cellulitis and epiphora, computed tomography disclosed a large osteoma of the ethmoid sinus. Excision of the osteoma allowed recovery of vision, return of extraocular muscle function, and resolution of choroidal folds. Proptosis, diplopia, and visual loss are other frequent presenting signs of paranasal osteomas. Epidemiology, diagnosis, treatment, and pathologic findings in paranasal sinus osteoma are reviewed.

Chronic rhinosinusitis endoscopic surgery requires an accurate evaluation of diseases and paranasal sinus anatomic variations. This study aims to show the main anatomical variations in the ostiomeatal complex and paranasal sinuses which are usually depicted by computed tomography (CT). CT scans obtained 2 mm thickness in axial and coronal plane from a series of 200 patients with chronic sinusitis were examined to determine the prevalence of anatomic variants. Anatomical variations determined were supraorbital recess in 6%, concha bullosa in 30%, sphenomaxillary plate in 17%, infra-orbital ethmoid cells (Haller's cells) in 6%, spheno-ethmoid cells (Onodi's cells) in 12%, pneumatization of the anterior clinoid process in 6%, carotid artery bulging into the sphenoid sinus in 8%, pneumatization of the uncinate process in 2%, paradoxical curvature of the middle turbinate in 3% and septal deviation in 36%. Level difference between the ethmoid roof and nasal vault was an average of 8 mm in right side and 9.5 mm in left side. Awareness of these different variations will help the rhinologic surgeon in his orientation during endoscopic surgical procedures.

Purpose: To report an unusual case of orbital floor implant migration across the ethmoidal sinuses and nasal septum., Method: Case report. A 61-year-old woman with a history of right orbital floor fracture repair 25 years earlier is described., Results: The patient presented with sinus congestion and difficulty breathing through the right nostril. Computed tomographic scan disclosed medial migration of the right orbital floor implant across the ethmoidal sinuses and nasal septum. The patient underwent transorbital and transnasal endoscopic surgery with removal of the implant., Conclusions: When an alloplastic orbital floor implant is required, size and fixation of the implant are important. Late paranasal sinus or nasal airway problems may be sequelae, and the possibility of implant migration should be considered.

Improvements in reconstruction of the skull base have made craniofacial surgery safe. Reconstruction of the anterior skull base must provide a seal between the cranial cavity and upper respiratory tract, as well as offer structural support for the brain. A wide variety of local flaps have been designed. The choice of flap in individual cases depends on the location and size of the defect. We report a reconstructive technique for the anterior skull base with vertical median forehead flaps which we used to treat two patients, one patient with adenocarcinoma and the other with leiomyosarcoma. Both were lesions of the ethmoid sinuses and nasal cavity.

A two-wall decompression of the orbit, consisting of removal of the medial and lateral walls, was successful in eight patients with thyroid ophthalmopathy. The lateral wall was by removed by using the standard orbitotomy technique in addition to enlarging the space with a pneumatic burr, and the medial wall was removed through a direct medial canthal incision. Two patients had optic neuropathy, one had intermittent subluxation of the globe, and five had symptoms of exposure or increased pressure in the orbital area. In our eight patients, the two with optic neuropathy improved, the patient with subluxation of the globe became asymptomatic, and the other five had less exposure and were more comfortable. The amount of decompression ranged between 4 and 7 mm. The lacrimal sac was injured in one patient; temporary silicone intubation avoided any permanent sequela.

A case of subperiosteal orbital hemorrhage associated with chronic sinusitis is reported. A 57-year-old woman had a sudden onset of severe orbital pain and exophthalmos in the left eye. Computed tomography revealed a discrete round mass in the left retro-orbital space. An external frontoethmoidectomy was performed to evacuate the hematoma of the subperiosteal space. Additionally, the mucosa was edematous in the left ethmoid sinus. It appears that subperiosteal orbital hemorrhage in this case was caused by rupture of vessels which were inflamed as a result of sinusitis. Orbital hemorrhage associated with chronic sinusitis has rarely been reported. Diagnosis and treatment are discussed and etiologic factors are reviewed.