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Objective Computed tomography (CT) is a powerful tool for delineating the anatomy of the anterior skull base. The goal of this study is to further characterize the relevant anatomical features of this area, along with other parameters important for endoscopic sinus surgery. Design Retrospective case review. Setting Tertiary care hospital. Participants Thirty patients who had CT scans of the paranasal sinuses. Main Outcome Measures The following features were assessed using image analysis software: olfactory fossa depth, the length and angle of the lateral lamella, fovea ethmoidalis length and shape, ethmoid roof height and slope, and the position and course of the anterior ethmoid artery. Statistical analysis was performed assessing for differences in the above parameters. Results The mean olfactory fossa depth of the anterior and posterior skull base was 3.4 ± 1.1 and 2.4 ± 0.9 mm, respectively (p Conclusion Thorough preoperative assessment of CT scans is crucial to understanding the inherent variability of skull base anatomy. Even “safe” anatomy can still contain features such as long and acutely angled lateral lamella, which may predispose patients to iatrogenic injury.

Objectives (1) To determine the occult rate of dural invasion in patients with tumors extending to and/or eroding the bony anterior skull base but without evidence of dural invasion on preoperative imaging. (2) To determine the impact of dural resection and of skull base erosion on survival outcomes in this group of patients (without evidence of dural invasion upon preoperative imaging). Study Design Retrospective study. Setting Tertiary care academic center. Participants Patients with sinonasal malignancies with anterior skull base encroachment/erosion without dural invasion on preoperative imaging treated surgically. Main Outcome Measures (1) Histopathologic disease in the dura in patients who had dural resection and (2) Oncologic outcomes (5-year local recurrence, dural recurrence, disease-specific survival, and overall survival) in patients with and without dural resection, and patients with and without skull base erosion. Results Thirty-seven patients were included. The occult rate of dural invasion was 54%. Patients with dural resection had improved margin control versus those without dural resection (90% vs 56%, p = 0.02). Dural resection improved 5-year overall survival only in patients with esthesioneuroblastoma compared with bony skull base resection alone (100% vs 75%, p = 0.03). Patients with skull base erosion had reduced local control versus those without erosion (63% vs 93%, p = 0.047). Conclusion This study suggests a substantial rate of occult dural invasion despite no overt imaging findings. Dural resection may be associated with improved margin control, but no oncologic benefit except for esthesioneuroblastomas, although treatment heterogeneity and small sample size may limit conclusions.

Objective To compare financial and perioperative outcomes between endoscopic and open surgical approaches in the surgical management of sinonasal malignancies. Design Retrospective chart review. Setting Tertiary care hospital. Participants Patients undergoing surgical resection of a sinonasal malignancy from January 2000 to December 2014. Main Outcome Measures In-hospital costs, complications, and length of stay (LOS). Results Of 106 patients, 91 received open surgery (19 free flap and 72 non-free flap) and 15 were treated with purely endoscopic approaches. Free flaps had a significantly higher average cost, operative time, and LOS compared to both non-free flap (p Conclusion Hospital costs are comparable between endoscopic and open approaches when no free tissue reconstruction is required. Longer operative times, higher CSF leak rates, and our institutional protocol necessitating ICU admission for endoscopic cases may account for the failure to demonstrate cost savings with endoscopic surgery.

Objective Skull base tumors are associated with quality of life (QOL) changes. A qualitative case-study approach may help better understand patients' experiences. Methods A total of 34 skull base surgery patients were selected into focus groups using a criterion-based maximum variation sampling strategy from a sampling frame of 138 patients. Eight groups were organized based on a factorial design of surgical approach (endoscopic/pen) and tumor location (anterior/central). Data were analyzed using a conceptual framework. Qualitative analysis was performed on focus group transcripts to identify major themes and determine if surgical approach or tumor location had differential effects on QOL. Concepts were quantitatively tallied from written workbooks. Results The 34 participants (19 men, 15 women; mean age: 48 years, standard deviation: 14 years) had mixed reactions to their diagnosis ranging from relief to fear. Participants reported physical and nonphysical changes in QOL with some variation in physical complaints by tumor location. Several major themes emerged from the analysis. Skull base tumors are associated with fear and frustration, loss of physical senses and self-identity, social isolation, and coping mechanisms. Conclusions Skull base surgery may impact patients' lives. Qualitative study of patient experiences can provide rich information to better understand this disease.

We describe a 52-year-old woman who presented with meningitis secondary to a pseudomeningocele within the sphenoid sinus derived from a bony defect in the clivus. The bony defect was radiologically characteristic of an ecchordosis physaliphora (EP). She underwent surgical repair of the defect and had resolution of her symptoms. This case report will discuss the second case of transclival pseudomeningocele in the English literature and present EP as a cause.

Solitary fibrous tumors (SFTs) are uncommon neoplasms of mesenchymal origin that were first described as primary spindle-cell tumors of the pleura in 1931. Since then, infrequent case reports of extrapleural SFTs have been described including various subsites within the head and neck. Based on a review of the literature and a description of the endoscopic treatment of three patients with SFTs of the nasal cavity and ethmoid sinuses, the challenges associated with the management of sinonasal SFTs are discussed. Successful endoscopic resection was performed at a tertiary referral rhinology practice within a university center in three cases of sinonasal SFTs with no evidence of recurrence at 26, 35, and 49 months following resection. Summarized are the common presenting symptoms, appropriate diagnostic workup, and indicative computed tomography and magnetic resonance imaging appearance of SFTs. Further discussed are the challenge associated with accurate histological and immunohistochemical diagnosis, the difficulty in assessing the aggressiveness and malignant potential of these lesions, and the appropriate treatment and follow-up duration that these neoplasms require.

Objective: Olfactory groove meningiomas may be associated with significant brain edema and surgical removal of these tumors may be associated with further injury to the frontal lobes. Endonasal access avoids frontal lobe manipulation, but little objective benefit has been demonstrated. Study Design: Retrospective case-cohort matched pair analysis. Methods: A retrospective review was performed at two institutions to identify patients who had either endonasal or open approach for resection of olfactory groove meningiomas. A matched pair analysis was performed and tumor volume, edema, FLAIR change, and porencephalic cave were volumetrically quantified. Results: Ten matched pairs (20 patients) were identified. The open approach was associated with more postoperative FLAIR change on MRI compared with the endoscopic approach although not statistically significant (13.3 cm3 [SD = 12.0] vs. 6.9 cm3 [SD = 10.0], p = 0.17). The endoscopic approach was also associated with smaller porencephalic cave volumes (1.7 cm3[SD=2.8] vs. 6.9 cm3[SD = 10.0), p = 0.058). In a multivariable model, the endoscopic approach was associated with less postoperative FLAIR change (p = 0.016) and smaller porencephalic cave volumes (p = 0.028). Conclusions: This study provides preliminary evidence that the endoscopic endonasal approach is associated with quantifiable improvements in postoperative brain imaging. Further studies including neurocognitive function are needed to confirm the significance of these findings.

Objectives/Hypothesis Image-guided surgery (IGS) systems are frequently utilized during cranial base surgery to aid in orientation and facilitate targeted surgery. We wished to assess the performance of our recently developed localized intraoperative virtual endoscopy (LIVE)-IGS prototype in a preclinical setting prior to deployment in the operating room. This system combines real-time ablative instrument tracking, critical structure proximity alerts, three-dimensional virtual endoscopic views, and intraoperative cone-beam computed tomographic image updates. Study Design Randomized-controlled trial plus qualitative analysis. Methods Skull base procedures were performed on 14 cadaver specimens by seven fellowship-trained skull base surgeons. Each subject performed two endoscopic transclival approaches; one with LIVE-IGS and one using a conventional IGS system in random order. National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores were documented for each dissection, and a semistructured interview was recorded for qualitative assessment. Results The NASA-TLX scores for mental demand, effort, and frustration were significantly reduced with the LIVE-IGS system in comparison to conventional navigation (P