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PURPOSE OF REVIEW: To evaluate the current evidence and literature on treatment options for proximal hamstring injuries. RECENT FINDINGS: Patients with 3-tendon complete tears with greater than 2 cm of retraction have worse outcomes and higher complication rates compared to those with less severe injuries. Endoscopic and open proximal hamstring repair both have favorable patient reported outcomes at 5-year follow up. Proximal hamstring repair in patients who are male, with isolated semimembranosus injury, and have proximal hamstring free tendon rupture are more likely to have earlier return to sports. The Parisian Hamstring Avulsion Score (PHAS) is a validated patient-reported outcome measure to predict return to sports. Proximal hamstring injuries may occur in both elite and recreational athletes and may present with varying degrees of chronicity and severity. Injuries occur most commonly during forceful eccentric contraction of the hamstrings and often present with ischial tuberosity tenderness, ecchymosis, and hamstring weakness. Treatment decision-making is dictated by the tendons involved and chronicity. Many proximal hamstring injuries can be successfully treated with non-surgical measures. However, operative treatment of appropriately indicated proximal hamstring tendon injuries can result in significantly better functional outcomes and faster and more reliable return to sports compared to nonoperative treatment. Both endoscopic and open surgical repair techniques show high satisfaction levels and excellent patient-reported outcomes at short- and mid-term follow-up. Postoperative rehabilitation protocols vary across the literature and ongoing study is needed to clarify the optimal program, though emphasis on eccentric hamstring strengthening may be beneficial.

Introduction Deep interarytenoid groove (DIG) may cause swallowing dysfunction in children; however, the management of DIG has not been established. Objective We evaluated the subjective and objective outcomes of interarytenoid augmentation with injection in children with DIG. Methods Consecutive children under 18 years of age who underwent injection laryngoplasty for DIG were reviewed. Data pertaining to demographics, past medical history, past surgical history, and results of pre and postoperative video fluoroscopic swallow study (VFSS) were obtained. The primary outcome measure was the presence of thin liquid aspiration or penetration on postoperative VFSS. The secondary outcome measure was caregiver-reported improvement of symptoms. Results Twenty-seven patients had VFSS before and after interarytenoid augmentation with injection (IA). Twenty (70%) had thin liquid penetration and 12 (44%) had thin liquid aspiration before the IA. Thin liquid aspiration resolved in 9 children (45%) and persisted in 11 (55%). Of the 12 children who had thin liquid aspiration prior to IA, 6 (50%) had resolution of thin liquid aspiration after IA. Conclusions Injection laryngoplasty is a safe tool to improve swallowing function in children with DIG. Further studies are needed to assess the long-term outcomes of IA and identify predictors of successful IA in children with DIG. [ABSTRACT FROM AUTHOR]

Abstract Background To identify and predict risk factors associated with recurrent spontaneous cerebrospinal fluid (CSF) rhinorrhea, a cohort study included a total of 37 adult patients with spontaneous CSF rhinorrhea were analyzed. Results Over a 2-year period, 37 patients of spontaneous CSF leak with exclusion of other etiologies (traumatic, congenital) were enrolled: primary (non-recurrent) (n = 20) and secondary (recurrent) (n = 17), where 83.8% were females with an average body mass index (BMI) of 36.4 kg/m2. Associated symptoms of high intracranial pressure (ICP) namely, blurred vision and unsteadiness (P-value = 0.006 and 0.01, respectively), multiparity (92.3%), and failure to localize the defect (17.6%) contributed to patients having more recurrence. Although the cribriform plate was detected frequently (n = 29.4%), they were associated with lower recurrence compared to lateral recess of sphenoid (66.6% vs 20%). Conclusion Direct endoscopic visualization and repair of skull base defects achieve a high success rate, but failure is still a possibility especially in spontaneous etiology of leaks. In a multiparous female, with high CSF pressure, lateral sphenoid recess, large size, or unidentified defect, the incidence of recurrence is much higher. Level of evidence 4

Introduction Deep interarytenoid groove (DIG) may cause swallowing dysfunction in children; however, the management of DIG has not been established.

While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications. [ABSTRACT FROM AUTHOR]

Background: To identify and predict risk factors associated with recurrent spontaneous cerebrospinal fluid (CSF) rhinorrhea, a cohort study included a total of 37 adult patients with spontaneous CSF rhinorrhea were analyzed. Results: Over a 2-year period, 37 patients of spontaneous CSF leak with exclusion of other etiologies (traumatic, congenital) were enrolled: primary (non-recurrent) (n = 20) and secondary (recurrent) (n = 17), where 83.8% were females with an average body mass index (BMI) of 36.4 kg/m2. Associated symptoms of high intracranial pressure (ICP) namely, blurred vision and unsteadiness (P-value = 0.006 and 0.01, respectively), multiparity (92.3%), and failure to localize the defect (17.6%) contributed to patients having more recurrence. Although the cribriform plate was detected frequently (n = 29.4%), they were associated with lower recurrence compared to lateral recess of sphenoid (66.6% vs 20%). Conclusion: Direct endoscopic visualization and repair of skull base defects achieve a high success rate, but failure is still a possibility especially in spontaneous etiology of leaks. In a multiparous female, with high CSF pressure, lateral sphenoid recess, large size, or unidentified defect, the incidence of recurrence is much higher. Level of evidence: 4 [ABSTRACT FROM AUTHOR]

BackgroundLittle is known about the relative efficacy of open (OGR) vs endoscopic (EGR) gluteal tendon repair of gluteal tendon tears in minimizing pain and restoring function. Our aim is to compare these 2 surgical techniques and quantify their impact on clinical outcomes.MethodsAll patients undergoing gluteal tendon tear repair at our institution between 2015 and 2018 were retrospectively reviewed. Pain scores, limp, hip abduction strength, and the use of analgesics were recorded preoperatively and at last follow-up. The Hip disability and Osteoarthritis Outcome Score Junior and Harris Hip Score Section1 were obtained at last follow-up. Fatty degeneration was quantified using the Goutallier-Fuchs Classification (GFC). Statistical analysis was conducted using one-way analysis of variance and t-tests.ResultsForty-five patients (mean age 66, 87% females) met inclusion criteria. Average follow-up was 20.3 months. None of the 10 patients (22%) undergoing EGR had prior surgery. Of 35 patients (78%) undergoing OGR, 12 (27%) had prior hip replacement (75% via lateral approach). The OGRs had more patients with GFC ≥2 (50% vs 11%, P = .02) and used more anchors (P = .03). Both groups showed statistical improvement (P ≤ .01) for all outcomes measured. GFC >2 was independently associated with a worst limp and Harris Hip Score Section 1 score (P = .05). EGR had a statistically higher opioid use reduction (P < .05) than OGR. Other comparisons between EGR and OGR did not reach statistical significance.ConclusionIn this series, open vs endoscopic operative approach did not impact clinical outcomes. More complex tears were treated open and with more anchors. Fatty degeneration adversely impacted outcomes. Although further evaluation of the efficacy of EGR in complex tears is indicated, both approaches can be used successfully.

Introduction: Adult isolated supraglottic stenosis is rare in its presentation and management is often challenging. There are various etiologies of the condition which make standardization of treatment difficult. We present a series of isolated supraglottic stenosis of different etiologies managed successfully by an endoscopic approach using Coblation. Case description: Five patients presented with isolated supraglottic stenosis. The supraglottic airway showed significant stenosis and cicatrical scars severely limiting the airway extending from the epiglottic level up to the false cords sparing the arytenoids. Coblation laryngeal and microlaryngeal wands were used to ablate the stenosed segments. Stent was placed in three of the patients for six weeks. There were no significant intra-operative or post-operative complications encountered. All patients were relieved of their presenting symptoms and none of them had any evidence of restenosis even after 12 months following the procedure. Conclusion: Isolated supraglottic stenosis, even though scarce in literature poses significant challenges in its management. Coblation is an effective treatment option with good success rate and requiring fewer interventions.

Introduction: Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition. Objective: To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach. Methods: A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined. Results: Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 − 41 months). Conclusion: Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

To analyse the outcome of transnasal endoscopic repair of CSF Rhinorrhea in a tertiary care centre. This is a retrospective study conducted on 81 patients who underwent CSF Rhinorrhea repair in a tertiary care hospital for a period of 11 years. Following confirmation of diagnosis using bio-chemical and radiological investigations, all patients underwent transnasal endoscopic repair of CSF Rhinorrhea using a multilayer graft. Patients were followed up for 6 months. The most common etiology in our study was spontaneous CSF rhinorrhea (60.49%) and subjects with BMI > 25.5 kg/m2 were more prone to it. Cribriform plate was found to be the most frequent site of leak in our study (58.02%), followed by fovea ethmoidalis (12.35%). Overall success rate was 96.30%. Transnasal endoscopic approach for cerebrospinal fluid rhinorrhea repair shows good success rate and also offers the advantages of better visualization and identification of site of leak, less complications, rapid postoperative recovery, and low recurrence rate. Transnasal endoscopic CSF Rhinorrhea repair has shown good results in terms of low recurrence rates and high patient satisfaction among other advantages. Hence this approach should be commonly used for CSF rhinorrhea repair by surgeons. [ABSTRACT FROM AUTHOR]

To emphasize the need for high clinical suspicion in the diagnosis of Laryngeal cleft in paediatric population, to catalogue the pattern of presentation, time to treatment and the evolution of surgical techniques for Laryngeal cleft repair at our center. A retrospective review of laryngeal cleft cases which presented over a period of 8 years (May 2012–May 2020), from a tertiary care center, was done. Data includes—patient demographics, preliminary investigations, diagnostic methods, type of cleft, surgical steps and post-operative follow up. Extensive literature search was done and we could not find similar studies from South East Asia and the Indian subcontinents. Of the 10 patients 7 were managed surgically and 3 conservatively. There was an equal distribution of type 1 (n = 5) and 2 (n = 5) clefts. 80% cases were males and 9 out of 10 patients had associated congenital anomalies. 80% cases had symptom resolution (75% were managed surgically and 25% managed medically). Surgical intervention should be based on the extent of anatomical defect and the functional impairment caused by cleft such as respiratory problems, persistence of feeding issues despite maximal medical management and feeding therapy. Early surgical management of type I and II clefts have satisfactory outcomes. [ABSTRACT FROM AUTHOR]

Objective: To make an estimate of magnitude of cerebrospinal fluid rhinorrhea patients presenting in Otorhinolaryngology department of CMH Lahore and further elaboration of our experience of different techniques of endonasal endoscopic repair of cerebrospinal fluid leak. Study Design: Cross-sectional analytical study. Place and Duration of Study: Combined Military Hospital Lahore, from Jan 2017 to Dec 2017. Methodology: For this analytical study last one year’s data of cerebrospinal fluid rhinorrhea patients as well as all endoscopic surgeries was collected retrospectively from ENT department registers. Both male and female patients of all ages undergoing functional endoscopic sinus surgery were included in study to calculate the magnitude of cerebrospinal fluid rhinorrhea. Results: During the last one year, 832 ENT surgeries were performed out of which 234 (28%) were functional endoscopic sinus surgeries. Total 10 cerebrospinal fluid rhinorrhea patients presented in ENT department of CMH Lahore in the last one year and all these underwent endonasal endoscopic repair surgery in operation theatre. Out of these 3 were males and 7 females. Age range was 43 to 67 years (average age was 53.2 years). Out of 10 cases of cerebrospinal fluid rhinorrhea treated endoscopically, 4 (40%) were iatrogenic, 3 (30%) were traumatic and 3 (30%) had spontaneous cerebrospinal fluid leakage. Conclusion: Cerebrospinal fluid leakage is quite rare happening and its surgical management is also difficult to master. In our study use of facialata (alone or with septal cartilage) to endoscopically repair the leak has proved to be successful in 90% of cases.

Introduction: Fourth branchial anomalies, the rarest among anomalies of the branchial apparatus, often present diagnostic and therapeutic challenges. We evaluated the clinical presentation and radiographic features, the treatment and the long-term outcome of patients in this setting.Patients and Methods: Of 12 patients treated in the University Hospitals Leuven from 2004 until 2020, 12 variables were collected: date of birth, gender, age of onset of the symptoms, age at final diagnosis, presentation, laterality, previous procedures, diagnostic tools, treatment (open neck surgery, endoscopic laser excision, or combination), complications, recurrence, and period of follow-up. Descriptive statistics were calculated and results were compared to the existing literature.Results: The most common clinical manifestations were recurrent neck infections with and without abcedation. Definitive diagnosis using direct laryngoscopy, visualizing the internal sinus opening, was possible in all patients. A CT study revealed the typical features of fourth branchial anomalies in seven patients out of nine, an ultrasound study in five out of nine patients. All patients underwent open neck surgery. If this was insufficient, secondary endoscopic laser resection of the ostium at the apex of the piriform sinus was performed (n = 4). In eight patients a thyroid lobectomy was needed for safe complete resection. Postoperative complications were minimal and at long-term, none of the patients showed further recurrence. Average time of follow-up was 8.6 years.Conclusions: Direct laryngoscopy and CT are the most accurate diagnostic tools. Our recommended treatment schedule consists of complete excision of the sinus tract by open neck surgery as the primary treatment because this ensures the best results. In case of recurrence afterwards, endoscopic laser resection of the pharyngeal ostium solved the problem.

Background: Cerebrospinal Fluid (CSF) leaks usually happen after damaging the cribriform plate due to trauma, and it’s less likely spontaneous. Case Description: We are presenting a case that suffered from spontaneous refractory CSF leak which did not resolve after multiple surgical interventions. During treatment, a decision was made to place a lumbar drain to promote healing and recovery. Once the drain was removed, the patient deteriorated suddenly. Decompressive craniectomy was performed with transcranial skull base repair with the application of cement (Methyl methacrylate) around the cribriform defect. The patient then gradually recovered with no further leak. Discussion: Using bone cement in transcranial CSF leak repair is not commonly reported, compared to the routine use of a pericranial flap. Nevertheless, it showed a high success rate and less recurrence of CSF leak. Lumber drain can be used as a post-op adjuvant technique. Conclusion: We are proposing that the patient’s deterioration was related to the closure of lumbar drain, hence the presence of a one-way valve where air enters and cannot escape with no other means of reducing ICP. We are also demonstrating that bone cement (Methyl methacrylate) can be considered in the management of CSF leak due to skull base defects which is resistant to conventional repair methods including nasoseptal flap and/or pericranial flap.

Introduction: Cerebrospinal fluid (CSF) rhinorrhoea is a leakage of CSF fluid from the subarachnoid space through the frontal, sphenoidal or ethmoidal sinuses to the nose. Methods: In this study we present our experience in endoscopic repair of 55 cases of CSF rhinorrhoea who were operated endoscopically trans-nasally. Results: The success rate of the procedure in preventing CSF leak after the first endoscopic repair was 85.5% which increased to 90.9% following the second endoscopic repair in patients with persistent leak. Conclusion: Endoscopic approach in repair of cerebrospinal fluid rhinorrhoea is remarkably well tolerated and complication rates are low, including the risk for haemorrhage, infection, and graft failure.

Iatrogenic colonic perforation is an unusual but life‑threatening complication of colonoscopy. The recent advancement in endoscopy technology has made nonoperative treatment a safe and effective option for managing such perforations. A 70‑year‑old man sustained an iatrogenic sigmoid perforation during diagnostic colonoscopy. The abdominal X‑ray showed free gas under diaphragm. He was started on conservative management and intravenous antibiotics. He underwent a second colonoscopy after 2.5‑h, perforation was identified and closed with standard hemoclips. He recovered well and was discharged from hospital 6 days later. There are only a handful of reports in the medical literature describing successful outcomes following endoscopic management. Most of the cases have been managed with over‑the‑scope clips or endoscopic sutures that are quite expensive. In the present report, an iatrogenic sigmoid perforation was managed endoscopically with standard hemoclips. The hemoclip can be an effective, yet economical method of perforation repair in selected cases.

Abstract Background Piriform sinus fistulas occur due to developmental abnormalities of the third and fourth branchial arches, and almost always occur unilaterally. They generally present as recurrent abscesses in the anterior-inferior neck, with concurrent thyroiditis. They have conventionally been managed with complete removal of the sinus tract, and thyroidectomy if required; however, endoscopic approaches have been increasingly favored. Herein we describe a case of bilateral piriform sinus fistulas, and present a review of the literature concerning their endoscopic management. Case presentation Our patient was determined to have bilateral piriform sinus fistulas based on computer tomography, magnetic resonance imaging and microlaryngoscopy. We performed electrocauterization of the proximal fistula tracts, followed by injection of fibrin sealent. Our patient has not had a recurrence in the ten months since his procedure. There were no complications. Twenty-three articles describing an endoscopic approach to these fistulas were identified through PubMed, and a search through the references of related articles was completed. Conclusion Of one hundred and ninety-five patient cases we reviewed, an endoscopic procedure success rate of 82% and complication rate of 5.6% was determined. Piriform sinus fistulas that occur bilaterally are a rare congenital abnormality of the neck. Endoscopic approaches are an acceptable alternative option to open procedures, with similar success and a lower rate of complications.

Background Many surgeons have practiced endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea in past decade and have gained popularity. There are several centers that adopt endoscopic repair as a first-line treatment for CSF rhinorrhea with high success rate. Objective The aim of this study was to detect the role of the transnasal endoscopic approach in the repair of the CSF rhinorrhea and assess its surgical outcome. Patients and methods A prospective study of 40 patients having CSF rhinorrhea was conducted. All patients were treated with endoscopic repair for CSF rhinorrhea at Neurosurgery Departments of Al-Azher University and specialized Hospital of Otorhinolaryngology and Neurosurgery from January 2016 to January 2018. The majority of them were men. The defects were closed in multilayers using fascia lata, septal cartilage graft, and nasal mucosa in most patients. Results The left cribriform plate area was found as the most common site of CSF leak. The spontaneous CSF leak was the most common cause of CSF rhinorrhea in this study, and post-traumatic (iatrogenic) CSF leak was the second most common cause. Our success rate of the first attempt at endoscopic repair was 90%, and in the second attempt was 97.5%. The causes that lead to recurrence of leak were large defect, failure of localization of the defect, and comorbid conditions such as bone erosion and chronic cough that developed postoperatively. Conclusion Endoscopic endonasal approach is a safe and effective way to repair CSF leaks of different causes. Multilayer repair technique is safe and effective, with low complications and preservation of nasal and neurological functions. However, more studies and long series are recommended.

Objective: To make an estimate of magnitude of cerebrospinal fluid rhinorrhea patients presenting in Otorhinolaryngology department of CMH Lahore and further elaboration of our experience of different techniques of endonasal endoscopic repair of cerebrospinal fluid leak. Study Design: Cross-sectional analytical study. Place and Duration of Study: Combined Military Hospital Lahore, from Jan 2017 to Dec 2017. Methodology: For this analytical study last one year’s data of cerebrospinal fluid rhinorrhea patients as well as all endoscopic surgeries was collected retrospectively from ENT department registers. Both male and female patients of all ages undergoing functional endoscopic sinus surgery were included in study to calculate the magnitude of cerebrospinal fluid rhinorrhea. Results: During the last one year, 832 ENT surgeries were performed out of which 234 (28%) were functional endoscopic sinus surgeries. Total 10 cerebrospinal fluid rhinorrhea patients presented in ENT department of CMH Lahore in the last one year and all these underwent endonasal endoscopic repair surgery in operation theatre. Out of these 3 were males and 7 females. Age range was 43 to 67 years (average age was 53.2 years). Out of 10 cases of cerebrospinal fluid rhinorrhea treated endoscopically, 4 (40%) were iatrogenic, 3 (30%) were traumatic and 3 (30%) had spontaneous cerebrospinal fluid leakage. Conclusion: Cerebrospinal fluid leakage is quite rare happening and its surgical management is also difficult to master. In our study use of facialata (alone or with septal cartilage) to endoscopically repair the leak has proved to be successful in 90% of cases. [ABSTRACT FROM AUTHOR]

Introduction  Deep interarytenoid groove (DIG) may cause swallowing dysfunction in children; however, the management of DIG has not been established. Objective  We evaluated the subjective and objective outcomes of interarytenoid augmentation with injection in children with DIG. Methods  Consecutive children under 18 years of age who underwent injection laryngoplasty for DIG were reviewed. Data pertaining to demographics, past medical history, past surgical history, and results of pre and postoperative video fluoroscopic swallow study (VFSS) were obtained. The primary outcome measure was the presence of thin liquid aspiration or penetration on postoperative VFSS. The secondary outcome measure was caregiver-reported improvement of symptoms. Results  Twenty-seven patients had VFSS before and after interarytenoid augmentation with injection (IA). Twenty (70%) had thin liquid penetration and 12 (44%) had thin liquid aspiration before the IA. Thin liquid aspiration resolved in 9 children (45%) and persisted in 11 (55%). Of the 12 children who had thin liquid aspiration prior to IA, 6 (50%) had resolution of thin liquid aspiration after IA. Conclusions  Injection laryngoplasty is a safe tool to improve swallowing function in children with DIG. Further studies are needed to assess the long-term outcomes of IA and identify predictors of successful IA in children with DIG., Competing Interests: Conflict of Interests The authors have no conflict of interests to disclose., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ( https://creativecommons.org/licenses/by/4.0/ ).)

Iatrogenic colonic perforation is an unusual but life-threatening complication of colonoscopy. The recent advancement in endoscopy technology has made nonoperative treatment a safe and effective option for managing such perforations. A 70-year-old man sustained an iatrogenic sigmoid perforation during diagnostic colonoscopy. The abdominal X-ray showed free gas under diaphragm. He was started on conservative management and intravenous antibiotics. He underwent a second colonoscopy after 2.5-h, perforation was identified and closed with standard hemoclips. He recovered well and was discharged from hospital 6 days later. There are only a handful of reports in the medical literature describing successful outcomes following endoscopic management. Most of the cases have been managed with over-the-scope clips or endoscopic sutures that are quite expensive. In the present report, an iatrogenic sigmoid perforation was managed endoscopically with standard hemoclips. The hemoclip can be an effective, yet economical method of perforation repair in selected cases. [ABSTRACT FROM AUTHOR]

Objectives To review the safety and efficacy of surgical management for spontaneous cerebrospinal fluid (CSF) leaks of the anterior and lateral skull base. Data Sources A systematic review of English articles using MEDLINE. Review Methods Search terms included spontaneous, CSF, cerebrospinal fluid, endoscopic, middle fossa, transmastoid, leak, rhinorrhea. Independent extraction of articles by 3 authors. Results Patients with spontaneous CSF leaks are often obese (average BMI of 38 kg/m2) and female (72%). Many patients also have obstructive sleep apnea (∼45%) and many have elevated intracranial pressure when measured by lumbar puncture. In addition to thinning of the skull base, radiographic studies also demonstrate cortical bone thinning. Endoscopic surgical repair of anterior skull base leaks and middle cranial fossa (MCF) approach for repair of lateral skull base leaks are safe and effective with an average short-term failure rate of 9% and 6.5%, respectively. Long-term failure rates are low. One randomized trial failed to show improved success of anterior leak repairs with the use of a lumbar drain (LD) (95% with vs. 92% without; P = 0.2). In a large retrospective cohort of MCF lateral skull base repairs, perioperative LD use was not necessary in >94% of patients. Conclusions Spontaneous CSF leaks are associated with female gender, obesity, increased intracranial hypertension, and obstructive sleep apnea. Endoscopic repair of anterior skull base leaks and MCF or transmastoid approaches for lateral skull base leaks have a high success rate of repair. In most cases, intraoperative placement of lumbar drain did not appear to result in improved success rates for either anterior or lateral skull base leaks. Level of Evidence 2a, Systematic Review. [ABSTRACT FROM AUTHOR]

A 24-year-old man referred to our clinic with complaint of intermittent right-sided watery rhinorrhea. Patient underwent nasal septoplasty one year ago and rhinorrhea occurred two weeks after the surgery. Rhinorrhea was ignored and then patient developed meningitis two months after the surgery. Subsequently, meningoencephalocele formation developed. In this case report, we present a case of meningoencephalocele associated with cerebrospinal fluid leak diagnosed one year after the septoplasty. Septoplasty is usually regarded as a relatively safe operation. However, forceful maneuvers to perpendicular lamina of the ethmoid bone may cause breakdown of the skull base structures, particularly the horizontal lamella of the cribriform plate. When this occur, immediate management is necessary to prevent intracranial complications including meningitis, intracranial abscess, and pneumocephalus. Delay in the diagnosis of such injury may cause erosion of the bone and gradual herniation of the intracranial contents through the skull base defect. [ABSTRACT FROM AUTHOR]

Introduction Posttraumatic cerebrospinal fluid (CSF) rhinorrhea frequently complicates anterior skull base fracture. Although skull base fracture is present in only about 7% cases of head injury, CSF rhinorrhea develops in 30% of cases with basal fracture. Materials and Methods A total of 43 cases admitted in our Institute (SGPGI Lucknow) from January 2000 to June 2011with history of head trauma followed by CSF rhinorrhea. Forty one cases were included in this study as two patients refused surgery. Result Out of forty one cases, 26 cases (63%) were admitted with history of recurrent meningitis, 21 cases (51%) with loss of smell, 26 cases (63%) with delayed onset CSF rhinorrhea, 3 cases (7%) with early onset rhinorrhea which did not improve after trauma, 12 cases (30%) with early onset rhinorrhea which improved but reappeared after some time. Twenty cases (48.8%) were repaired by extradural approach, 10 cases (24.4%) were repaired by intradural approach and 11 cases (26.8%) were repaired by endoscopic approach. 12 cases (29.0%) required re-surgery for persistent or recurrence of CSF rhinorrhea. Conclusion Although posttraumatic CSF rhinorrhea usually resolves with conservative management, its persistence makes an individual prone for further complications like meningitis, brain abscess and septicaemia. Timely surgical intervention usually gives promising results. Endoscopic repair was better than transcranial repair.

CSF rhinorrhea can be diagnosed with more accurate localizations of the site of leak with the help of modern radiological methods. The repair involves surgical intervention, which has changed from open craniotomy to minimally invasive techniques. Endoscopic repair has gained popularity in last decade and is being practiced by many neurosurgeons either alone or with their ENT colleagues. The overall success rate of endoscopic repairs has triggered several centers to adopt endoscopic repair as first line of treatment of CSF rhinorrhea. However the inexperience of neurosurgeon to sinus anatomy may pose some difficulties with the young neurosurgeons. The article presents a review of the techniques for confirmation of a CSF leak as well as endocscopic repair of CSF fistula.

Study Design: Retrospective descriptive study of an innovative surgical technique. Objective: To assess the feasibility and success of repair of transfrontal sinus cerebrospinal fluid (CSF) rhinorrhea through pterional transcranial extradural approach using endoscope. Summary of Background Data: Repair of CSF rhinorrhea has seen advancement with the evolution of endoscopic transnasal techniques. However, leaks from defect in the posterior wall of frontal sinus still remain a challenge for the skull base surgeons and requires conventional craniotomy more often. We describe a novel technique to repair these leaks by purely endoscopic pterional extradural (PEPE) approach thereby avoiding complications associated with conventional craniotomy and endoscopic transnasal approaches. Materials and Methods: Thirty-five patients with traumatic CSF rhinorrhea from the posterior wall of frontal sinus underwent repair with the present technique. They were followed up for 6-18 months and were evaluated for feasibility of procedure, recurrence of leak, and occurrence of the fresh neurological deficit. Results: Thirty-five patients underwent CSF rhinorrhea repair using the above technique. The procedure was accomplished in all patients without any intraoperative complications. There was no requirement of blood transfusion in any case. All patients had a cessation of CSF leak in the postoperative period, and there was no recurrence. There was no evidence of frontal lobe retraction injury in any of these patients, and no fresh neurological deficit was observed. Conclusion: This PEPE approach to repair CSF leak through the posterior wall of the frontal sinus is a novel technique in which we can avoid disadvantages associated with both conventional craniotomy as well as transnasal endoscopic approaches. [ABSTRACT FROM AUTHOR]

Cerebrospinal fluid (CSF) leak occurs due to an abnormal communication between the subarachnoid space and sinonasal tract. We reported a retrospective case series of five patients of spontaneous CSF rhinorrhea. These patients were undergone successful repair with a single transnasal endoscopic procedure. This is seen in anterior part of the cribriform plate of middle aged obese females. HRCT paranasal sinus (1 mm cuts) was an effective modality of investigation in our study with ancillary investigations been CT cisternography. Endoscopic repair of CSF rhinorrhea carries a high success rate with very low morbidity rate. [ABSTRACT FROM AUTHOR]

Background: In 1990, Ramirez introduced a new procedure to close abdominal wall hernia (AWH), called "components separation technique (CST)". Thanks to endoscopy, surgical repair possibilities have risen, reducing the operative trauma and preserving vascular and neuronal anatomical structures. This report aims to describe a single port endoscopic approach for CST to repair the abdominal wall of a patient undergoing surgery for abdominal aneurysm and already subject to placement of a mesh for AWH. Methods: We performed endoscopic-assisted CST, using a single-port access with a gasless technique. Conclusion: CST is a useful procedure to close large abdominal wall incisional hernia avoiding the use of mesh, notably under contamination, when prosthetic material use is contraindicated. The endoscopic-assisted CST produces same results than the conventional open separation technique and also minimised tissue trauma that ensures blood supply and prevents postoperative wounds complications. The described single port method was found to be safe and effective to close large midline abdominal hernias when a primary open or laparoscopic closure is not feasible or when patients have been previously treated with abdominal meshes.

Objective Cerebrospinal fluid (CSF) leaks from the frontoethmoid and sphenoid region can be easily dealt with endoscopic approaches, but CSF rhinorrhea due to frontal sinus fractures are difficult to treat solely by the nasal endoscopic approach and may require external repair. The technique described targets defects of the posterior table of the frontal sinus where conventional osteoplastic approach of obliteration is usually done. This technique is minimally invasive and involves repair using an endoscope via a frontal trephine. Methods We have treated five cases of traumatic CSF rhinorrhea with this technique, and the mean follow-up is 1 year (range: 10-14 months). The frontal sinus is opened by making a small stab incision (frontal trephine), and the defect site is localized by visualization via endoscope through the trephine. The repair is then performed with fat, bone graft, and fibrin glue. Results Closure of the defect was achieved in a single stage in all the patients, and none of them had a recurrence of leak in the 1-year follow-up period. Conclusion This is a good technique for superiorly and laterally placed posterior table defects of the frontal sinus with minimal morbidity and excellent closure rates. [ABSTRACT FROM AUTHOR]

Objective Cerebrospinal fluid (CSF) leaks from the frontoethmoid and sphenoid region can be easily dealt with endoscopic approaches, but CSF rhinorrhea due to frontal sinus fractures are difficult to treat solely by the nasal endoscopic approach and may require external repair. The technique described targets defects of the posterior table of the frontal sinus where conventional osteoplastic approach of obliteration is usually done. This technique is minimally invasive and involves repair using an endoscope via a frontal trephine. Methods We have treated five cases of traumatic CSF rhinorrhea with this technique, and the mean follow-up is 1 year (range: 10-14 months). The frontal sinus is opened by making a small stab incision (frontal trephine), and the defect site is localized by visualization via endoscope through the trephine. The repair is then performed with fat, bone graft, and fibrin glue. Results Closure of the defect was achieved in a single stage in all the patients, and none of them had a recurrence of leak in the 1-year follow-up period. Conclusion This is a good technique for superiorly and laterally placed posterior table defects of the frontal sinus with minimal morbidity and excellent closure rates. [ABSTRACT FROM AUTHOR]

Background: Surgical techniques for repair of rectovaginal fistula (RVF) have been continually developed, but the ideal procedure remains unclear. Endoscopic repair is a novel and minimally invasive technique for RVF repair with increasing reporting., Aim: To review the current applications and preliminary outcomes of this technique for RVF repair, aiming to give surgeons an alternative in clinical practice., Methods: Available articles were searched according to the search strategy. And the sample size, fistula etiology, fistula type, endoscopic repair approaches, operative time and hospital stay, follow-up period, complication and life quality assessment were selected for recording and further analysis., Results: A total of 11 articles were eventually identified, involving 71 patients with RVFs who had undergone endoscopic repair. The principal causes of RVFs were surgery ( n = 51, 71.8%), followed by obstetrics ( n = 7, 9.8%), inflammatory bowel disease ( n = 5, 7.0%), congenital ( n = 3, 4.2%), trauma ( n = 2, 2.8%), radiation ( n = 1, 1.4%), and in two patients, the cause was unclear. Most fistulas were in a mid or low position. Several endoscopic repair methods were included, namely transanal endoscopic microsurgery, endoscopic clipping, and endoscopic stenting. Most patients underwent > 1-year follow-up, and the success rate was 40%-93%, and all cases reported successful closure. Few complications were mentioned, while postoperative quality of life assessment was only mentioned in one study., Conclusion: In conclusion, endoscopic repair of RVF is novel, minimally invasive and promising with acceptable preliminary effectiveness. Given its unique advantages, endoscopic repair can be an alternative technique for surgeons., Competing Interests: Conflict-of-interest statement: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: To assess the long-term outcomes and independent predictors of surgical success of a one-stage minimally invasive surgical procedure for congenital choanal atresia (C.C.A.). Methods: a retrospective multicentric study was conducted between 2010 and 2022. An endonasal endoscopic approach was performed in 38 unilateral or bilateral C.C.A. children. All the patients were clinically and radiologically assessed and followed for at least 2 years. Seven outcome measures were applied. Consequently, surgical success was correlated with all the independent variables reported. Results: 18/38 (47.36%) patients presented normal postoperative healing, 8/38 (21.05) had moderate restenosis (<50%), while 12/38 (31.57%) cases were severe (>50%), requiring a surgical revision. No statistical significance was found for average hospital stay between stenosis >50% and <50% patients (p = 0.802) and postoperative pain (p = 0.075); instead, the severe restenosis group demonstrated a higher delay of breast suction (p < 0.001). Among the independent variables predictors of surgical success, the presence of Charge syndrome and rhinopharyngeal stenosis demonstrated higher risks for surgical revision (OR: 4.00, 95% CI: 0.57−28.01, and OR: 2.75, 95% CI: 0.55−13.69, respectively). On the contrary, the hypoplastic inferior turbinate and bilateral C.C.A. showed a lower risk for severe restenosis by a higher endoscopic surgical space and creating a single larger opening (OR: 0.88, 95% CI: 0.22−3.52, and OR: 0.45, 95% CI: 0.10−2.08). Conclusion: Several independent variables could influence the surgical success after C.C.A. endoscopic repair; however, more high-quality evidence is needed to generate an effective predictive model.

Introduction: Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition., Objective: To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach., Methods: A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined., Results: Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 - 41 months)., Conclusion: Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination., (Copyright © 2020 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.)