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Objective Spinal intradural arachnoid cysts (SIACs) are rare pathological lesions that can arise via outpouchings of the arachnoid layer in the spinal canal that can result in neurological deficits. We performed a systematic literature review regarding the current surgical techniques used in the management of SIACs and discussed the prevailing hypotheses surrounding the etiology of SIACs. Methods A systematic search of the literature was performed in December 2020 using EMBASE and MEDLINE for reports regarding the surgical management of SIACs. Data were collected regarding the demographics of the patients, classification system used, presence or absence of syrinxes, preoperative imaging modality, surgical approach and extent of resection, and postoperative outcomes and follow-up. Results Our search yielded 19 reports for inclusion in the present study. The 19 studies included a total of 414 cases, with an overall male/female ratio of 0.93:1. The most common site for the SIACs was the thoracic spinal cord at 77.5%. The symptoms were very similar across the 19 studies. Of the 19 studies, 15 had used resection to manage the SIACs, 10 had used fenestration or marsupialization, and 4 had used cystoarachnoid or cystoperitoneal shunts. Conclusions SIACs are rare and debilitating spinal pathological lesions, with the etiology of primary SIACs still not fully elucidated. Multiple surgical approaches have been effective, with the optimal operative strategy largely dependent on the individual patient and cyst factors on a case-by-case basis.

While Bartholin gland abscesses are less commonly seen outpatient pathology, prompt diagnosis and treatment are essential to preventing serious complications such as sepsis and rectovaginal fistula. Owing to an unacceptably high recurrence rate, simple incision and drainage is insufficient for primary treatment; preferably, placement of a Word catheter or Jacobi ring device to reepithelize the duct may be done under local anesthesia in an outpatient clinic. Destruction of the gland through silver nitrate application or alcohol sclerotherapy is an alternative. Marsupialization is often reserved for recurrent cases, although can be offered as primary management in some situations.

This paper is to explore the effectiveness of a new modified transnasal endoscopic marsupialization through Nd:YAG (neodymium: yttrium-aluminum-garnet) laser in treating nasolabial cysts in office. A prospective study was undertaken. Patients who suffered from nasolabial cysts from April 2016 to May 2017 at our hospital were involved. They were all treated with Nd:YAG laser transnasal endoscopic marsupialization. All patients were treated in the outpatient treatment room under local anesthesia. The patients ranged in age from 27 to 82 years, with an average age of 45 years. We made the diagnosis by the anatomical site, radiological imagings, and histopathology of the cyst. A total of 12 consecutive patients (men, n = 2; women, n = 10) with nasolabial cysts were involved in this study. Of the 12 patients, 6 were on the left and 8 were on the right side, and 2 had bilateral nasolabial cysts. All patients returned to clinic at 1, 6, and 36 months after treatment. At the follow-up time, none of the patients has mucus accumulation in the sinus or cyst recurrence, except for one patient who received treatment twice. No complications and recurrence during follow-up. In this study, we find that transnasal endoscopic marsupialization through Nd:YAG laser in treating nasolabial cysts is relatively effective, especially for patients who do not want to be hospitalized or treated under general anesthesia.

Objective We aimed to assess which metabolic pathways would be implicated in the phenotypic changes of the epithelial lining of odontogenic keratocyst after marsupialization, comparing pre- and post-marsupialized lesions with adjacent oral mucosa. Materials and methods Eighteen formalin-fixed and paraffin-embedded tissues from six subjects were divided into three paired groups: odontogenic keratocyst pre (n=6) and post marsupialization (n=6), and adjacent oral mucosa (n=6). The metabolic pathways found in these groups were obtained by high-performance liquid chromatography-mass spectrometry-based untargeted metabolomics performed. Results Through putative metabolite annotation followed by pathway enrichment and predictive analysis with automated algorithms (Mummichog and Gene Set Enrichment Analysis), we found differences in many cellular processes that may be involved in inflammation, oxidative stress response, keratinocyte-basal membrane attachment, differentiation, and proliferation functions, all relevant to odontogenic keratocyst pathobiology and the phenotype acquired after marsupialization. Conclusion Our study was able to identify several metabolic pathways potentially involved in the metaplastic changes induced by marsupialization of odontogenic keratocysts. An improved comprehension of this process could pave the way for the development of targeted therapies.

Nonmineralized cysts and cyst-like lesions that frequently occur in the mandible include ameloblastomas, odontogenic keratocysts, and dentigerous cysts. They have specific features of well-demarcated, unilocular, and radiolucent lesions that are often associated with tooth impaction. Although it rarely occurs, these cysts can become extremely large. Furthermore, cyst enlargement causes additional symptoms that can challenge the success of tooth recovery through orthodontic treatment. This clinical report presents the successful eruption of 2 impacted molars in a large dentigerous cyst treated with marsupialization and orthodontic traction using an orthodontic miniplate anchorage over a 4-year treatment period.

Although usually considered to be of developmental origin, dentigerous cysts (DCs) have been reported to form in response to chronic periapical inflammation associated with primary teeth that have necrotic, infected pulps. This article describes the management of a DC associated with tooth 21 in a seven-year-old Caucasian child with a history of multiple TDIs to the primary maxillary incisors. Chronic periapical inflammation associated with a necrotic pulp in tooth 61 was identified as the likely cause of the lesion. Initial conservative management involved marsupialization of the lesion by extracting the necrotic tooth 61. Following significant decompression of the cyst, surgical enucleation was carried out under general anaesthesia and an orthodontic attachment was bonded to the crown of the unerupted tooth 21 to facilitate traction. Histopathological assessment of the enucleated tissue confirmed it to be a DC. Two years after the initial presentation, teeth 21 and 22 had erupted into the oral cavity, improving patient aesthetics. However, the root of tooth 22 was transposed with the crown of the unerupted tooth 23. This case highlights the undesirable sequelae that may occur following delayed and inappropriate management of TDIs.

The aim of the present study was to evaluate the 5-year recurrence-free survival and prognostic factors of odontogenic keratocyst (OKC) from a single-center retrospective cohort in the northeastern region of Brazil. Forty cases of OKC comprised the study population. In the cohort analyzed, 18 (45%) cases were recurrent OKCs and 22 (55%) were non-recurrent OKCs. Recurrence-free survival was defined as the period from the release of the histopathological report to the occurrence of relapse or last visit to the service. Comparison of the clinicopathological variables between primary and recurrent OKC lesions revealed no differences in the frequency of epithelial thickness, presence of satellite cysts and cystic spaces, presence of an inflammatory infiltrate, locularity, and lesion borders. The frequency of symptoms was practically the same even after recurrence. Satellite cysts were more frequent in the group of recurrent lesions (n = 9, p = 0.002) and the presence of an inflammatory infiltrate was also significantly associated with recurrent lesions (n = 15, p = 0.006). Previous decompression or marsupialization was associated with recurrence of the lesion (p = 0.010). In conclusion, the most significant prognostic factors were previous decompression or marsupialization, as well as, morphological parameters associated with the recurrence cases were the presence of an inflammatory infiltrate and satellites cysts. The risk of recurrence is low but continues due to the particularities of epithelial proliferation in OKC.

Background In this case report we present a case of endometriosis in the Bartholin gland without surgery in the perineal area. So far, only five cases concerning endometriosis in the Bartholin gland, which may or may not be an isolated finding, have been reported in the literature. Case presentation A 31-year-old Indo-surinamese woman with primary infertility presented at our out-patient clinic with cyclical vulvar pain. On gynecological examination, a cyst of 1 × 2 cm was found in the right gland of Bartholin. A transvaginal ultrasound revealed normal gynecological anatomy and did not reveal any contributing information. Due to the recurring pain of the cyst, surgery was scheduled. During surgery, the marsupialization of the cyst resulted in drainage of a chocolate-colored fluid. Pathological examination revealed stroma lined with non-typical columnar epithelium with hemosiderin pigments, which confirmed a diagnosis of endometriosis in the Bartholin gland. Conclusion Our findings revealed a case of endometriosis outside the pelvis, without any deep intraperitoneal involvement. So far, only five cases concerning endometriosis in the Bartholin gland, which may or may not be an isolated finding, have been reported in literature.

OBJECTIVE To explore the current practice patterns for the management of renal cysts internationally among pediatric urologists and nephrologists. MATERIALS AND METHODS A survey composed of 21 questions and 4 clinical scenarios was distributed to pediatric urologists and nephrologists. Survey questions evaluated optimal imaging modality, management, and follow-up period. Interspecialty comparisons were made using chi-square analysis where appropriate. RESULTS A total of 183 respondents completed the survey (128 pediatric urologists, 37 pediatric nephrologists, and 19 other specialists). Most (57%) respondents agreed or strongly agreed with using an ultrasound based Bosniak classification to categorize renal cysts in children. The most commonly used follow-up intervals were 6-12 months for pediatric urologists and 1-2 years for pediatric nephrologists. Symptomatic mass effect (80.9%), gross hematuria (79.2%), or family history were the most common reasons for escalating surveillance. Pediatric nephrologists were more likely to increase follow-up with development of bilateral simple renal cysts (P = .008) or chronic kidney disease (P = .027) when compared to pediatric urologists. Laparoscopic marsupialization (39.4%) was the most common treatment for a simple renal cyst in a symptomatic child. Modified Bosniak III cysts had more heterogeneity in treatment based on the physician responses. CONCLUSION There is currently no consensus on the optimal protocol for the surveillance, imaging, or treatment of renal cysts in children. Most respondents agree that using an ultrasound-based Bosniak classification is reasonable. A call to action is therefore necessary for the development of registries and guidelines on the management of pediatric renal cysts and their associated malignancies.

Objective Paranasal sinus mucoceles are accumulation of mucoid secretions and desquamated epithelium within the sinus causing distension of its wall. They occur mostly in the frontal and ethmoid sinuses. Patients with giant frontal or ethmoidal sinus mucoceles suffer from orbital symptoms such as proptosis, visual disturbance, periorbital swelling, pain, or visual disturbance mostly, but they can also have rhinologic or neurologic symptoms. The purpose of this study is to evaluate the efficacy of endoscopic marsupialization for treating giant frontal and ethmoidal sinus mucoceles causing orbital symptoms. Methods This study was a retrospective, consecutive clinical review of patients with giant frontal and ethmoidal sinus mucoceles with orbital symptoms, who were treated by endoscopic marsupialization between January 2012 and August 2019. Medical records including age, gender, nasal and orbital symptoms, imaging findings, and surgical methods were reviewed. Results There were 15 patients with giant frontal and/or ethmoidal sinus mucoceles accompanied with orbital symptoms. The mean age of the patients was 50.5 years. One patient had previously undergone endoscopic sinus surgery for chronic rhinosinusitis. Within 15 patients, the main orbital symptoms were visual disturbance (6 patients), proptosis (8 patients), eyelid swelling (6 patients), and periorbital pain (1 patient). Other symptoms included nasal congestion, rhinorrhea, and headache. All patients underwent endoscopic marsupialization of the mucocele and had improvement in nasal and orbital signs and symptoms. Conclusion Endoscopic marsupialization is an effective treatment for giant frontal and ethmoidal mucoceles with orbital symptoms.

Background: Percutaneous aspiration with sclerotherapy (PAS) and laparoscopic marsupialization (LM) are minimally invasive treatment modalities for renal cysts. We aimed to compare the efficacy and...

Epinephric diverticula are frequently associated with esophageal motility disorder. Their management implies surgery, with 15% morbidity and 3% mortality rates. Flexible endoscopy could be an effective and safer approach for treating esophageal diverticulum with motility disorder. We report our experience of seven consecutive cases treated with per-oral endoscopic submucosal septotomy and myotomy (D-POEM). Seven consecutive patients were referred for symptomatic non-zenker’s esophageal diverticulum. The steps of the procedure were as follows: (i) analysis of the esophageal anatomy; (ii) vertical mucosal incision just above the upper edge of the diverticulum; (iii) submucosal tunneling by submucosal dissection, alongside the submucosal window of the diverticulum and the downstream septum; (iv) identification of the septum and the diverticular area; (v) diverticular septotomy followed by antegrade esocardial myotomy up to 2 cm below the cardia; and (vi) closure of the mucosal incision. Three men and four women aged from 62 to 90 years were treated. Four patients had a diet with adapted texture before the treatment and five patients had weight loss (4 kg to 24 kg). At preoperative evaluation, all had an esophageal motility disorder at high-resolution manometry. The procedures were successfully performed in all the patients without per-operative complications. During the 30 postoperative days, no significant adverse events occurred. Three months after treatment, six patients (85%) had clinical improvement with complete or partial regression of dysphagia. All the patients stabilized or gained weight after the treatment. The D-POEM technique is a mini-invasive effective and safe technique to treat symptoms due to both esophageal motility disorder and distal esophageal diverticula. It could be a very interesting solution for non-surgical patients in the first time that could be extended to other patients after favorable larger series.

Aim The prevalence of antenatally-detected hepatic cysts is increasing owing to increased use of maternal ultrasonography (USS). Diagnostic precision, however, is challenging and subsequently there is no clear consensus on postnatal management. The aim of the study was to evaluate the natural history and long-term follow up of congenital simple hepatic cysts. Methods Single-center review of prospectively-maintained dataset collected over a 25-year period. Data are quoted as median (range). Results In the period 1991–2016, 31 infants presented with an antenatally-detected cyst which, on postnatal imaging, was likely confirmed as a simple parenchymal hepatic cyst. These together with a further infant who presented at 4 days without any antenatal imaging comprised the study group (n = 32). Gestational age at detection was 23 (13–38) weeks. Maximum antenatal cyst diameter was measured at 19 (4–120) mm. Only the largest required percutaneous aspiration at 35 weeks’ gestation being associated with polyhydramnios. Postnatally, serial USS was performed alongside MRI/CT or liver scintigraphy if there was diagnostic doubt. Initial maximum cyst diameter was 30 (12–120) mm. Five infants came to surgical intervention and this included excision ± marsupialization (n = 4), and a cyst-jejunostomy en Roux in one child thought to have a connection with the biliary tract on intraoperative cholangiography. The mucosal lining in two cysts showed areas of squamous metaplasia, with one more showing an intact squamous lining probably more consistent with an epidermoid cyst. In the remaining cases (n = 27), all asymptomatic, serial USS showed volume maintenance (n = 16) actual volume regression (n = 4) and resolution (n = 7). Median follow-up in these cases was 42 (4–252) months. Conclusion This is the largest case series to date of antenatally-detected simple hepatic cysts. Most can be managed conservatively, and relative regression or resolution is likely. Surgical intervention should be reserved for those: that are large at the outset; show rapid cyst growth — these being typically exophytic in nature; wall irregularity or where there is diagnostic doubt. Type of study Case series. Level of evidence Level IV.

OBJECTIVE To provide long-term follow up of a unique patient with history of massive petrous apex congenital cholesteatoma. PATIENT 75-year-old man who presented at age 18 with left Gradenigo-like syndrome. INTERVENTION Staged left radical mastoidectomy and open transsphenoidal marsupialization. Followed with routine in-office cholesteatoma debridement. MAIN OUTCOME MEASURES Bony erosion on computed tomography (CT), monitoring for new symptoms. RESULTS Interval development of sensorineural component of hearing loss due to cochlear fistulization. Very slow skull base bony erosion continues without neck destabilization. No new or recurrent cranial neuropathies have developed. CONCLUSIONS Marsupialized cholesteatoma may be followed with routine debridement and interval imaging for monitoring over many decades.

Background Unicystic ameloblastoma is a distinct clinicopathological entity with its cyst-like radiographic appearance and occurrence in the mandible of young patients. Surgical resection of the mandible leads to jaw deformity and challenging reconstruction burden, especially among young patients. Conservative treatment, however, results in less serious function and esthetic impairment. Purpose We aimed at evaluating dredging method as an alternative conservative surgical approach in young patient with large unicystic ameloblastoma. Patients and methods Twenty patients (n=20) with histologically-diagnosed unicystic ameloblastoma were recruited for this prospective study. The surgical treatment protocol comprised an initial deflation (marsupialization) step, followed by later enucleation and subsequent repeated separate dredging procedures. Results The study population comprised 16 males and 4 females. The average age at the time of diagnosis was 18.5 years. At the last follow-up period, achievement of normal mandibular bone contour with no radiographic signs of recurrence was evident. Conclusion The dredging method as a modified surgical technique may represent a reliable approach for management of unicystic ameloblastoma in young patients.

Background Coexistence of sinonasal and skull base tumors is uncommon but possible, and the endonasal route seems to be the best option to manage both lesions simultaneously. We report the first case in the English literature of concomitant sphenoid sinus inverted papilloma and pituitary macroadenoma treated through an endoscopic endonasal approach. Case Description A 68-year-old man presented with a history of progressive visual loss and nasal obstruction. Clinical examination disclosed bitemporal hemianopsia. Computed tomography scan and magnetic resonance imaging obtained on admission showed a large sellar/suprasellar enhancing lesion with a marked mass effect on the optic chiasm. Imaging also showed a second mass extending from the sphenoid sinus to the left nasal cavity with obstruction of the maxillary sinus ostium and development of maxillary sinus mucocele. Both tumors were entirely resected by an endoscopic endonasal approach. Additionally, middle meatal antrostomy and marsupialization with drainage of the maxillary mucocele was performed. Biopsy confirmed the coexistence of a pituitary macroadenoma and sphenoid sinus inverted papilloma. Conclusions This case and the literature suggest that patients with concomitant nasal and skull base pathologies can be simultaneously managed. The otolaryngologist plays an essential role in removing the sinonasal lesion to ensure a safe surgical corridor before entering the intracranial cavity and for planning for the skull base reconstruction.

The objective of the present study was to assess the epidemiology including demographic variables, diagnostic features, and the management of odontogenic keratocyst (OKCs) at several European departments of maxillofacial and oral surgery. This study is based on a systematic computer-assisted database that allowed the recording of data from treated OKCs. The following data were recorded for each patient: gender, age, voluptuary habits, comorbidities, site, size, radiographic features, treatment of OKCs, length of hospital stay, complications, recurrence, management and complications of eventual recurrence. A total of 405 patients, 249 male and 156 female, with 415 OKCs (407 sporadic and 8 syndromic lesions) were included in the study: 320 lesions were found in the mandible, whereas 95 were found in the maxilla. In the mandible, the most frequently involved subsite was the angle, whereas in the maxilla it was the molar region. The most frequently performed treatment option was enucleation plus curettage/peripheral ostectomy in 204 OKCs (recurrence rate, 9%). Decompression without residual cystectomy (recurrence rate, 66%), marsupialization with residual enucleation with the use of Carnoy's solution (recurrence rate, 50%), decompression with residual cystectomy (recurrence rate, 43%), and simple enucleation (recurrence rate, 24%) were the treatment options with the highest recurrence rates. An appropriate management of odontogenic keratocysts should be individualized, taking into consideration clinical and radiological findings, as well as patients’ age and comorbidities.

Paranasal sinus mucocele is a mostly benign disease but can cause irreversible complications depending on its location. A sphenoethmoidal mucocele (SEM) can cause compressive neuropathy due to its proximity to the optic nerve. Urgent endoscopic marsupialization is considered the treatment of choice for SEM. However, there is a scarcity regarding recurrence or operative size. Herein, the authors report a case of SEM that recurred after small endoscopic drainage. The patient was reoperated with wide cyst removal and nasal cavity ventilation expansion. Vision was partially resolved, and no recurrence was reported in the 6-month follow-up period.

Purpose To study the functional metagenomic profile of the microbes isolated from the lacrimal sac of patients with primary acquired nasolacrimal duct obstruction. Methods A prospective study was performed on 10 consecutive lacrimal sac samples obtained for the metagenomic analysis from patients with primary acquired nasolacrimal duct obstruction ( who underwent endoscopic dacryocystorhinostomy at a tertiary care Dacryology service. The samples were collected intraoperatively soon after a full-length lacrimal sac marsupialization and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina NOVASEQ 6000TM platform. The downstream processing and bioinformatics of the samples were performed using multiple software packaged in SqueezeMetaTM pipeline and functional analysis using the MG-RASTTM pipeline. Results The microbial gene mapping and protein prediction demonstrated proteins with known functions to range from 66.41% to 84.03% across the samples. The functional category distribution of Kyoto Encyclopedia of Genes and Genomes ortholog (level 1 data) showed metabolism to be the most commonly involved function followed by environmental information processes, genetic information processes and cellular processes. The functional subsystem profiling demonstrated genes associated with carbohydrate, protein and RNA metabolism, Amino acids and their derivatives, cofactors and prosthetic groups and factors involved in cell structure regulation and cell cycle control. Conclusion This is the first functional metagenomic profile of the lacrimal sac microbiota from patients with primary acquired nasolacrimal duct obstruction. Functional analysis has provided newer insights into the ecosystem dynamics and strategies of microbial communities inhabiting the lacrimal sac. Further Lacriome studies may provide clues for better understanding of the disease etiopathogenesis.

Objective In what follows, it is extremely rare for the inferior turbinate to occur with a mucocele. The authors aim to evaluate the characteristics, clinical features, and treatment outcome of the inferior turbinate mucocele in our hospital. Patients and methods Five patients with radiologically confirmed inferior turbinate mucocele between January 2006 and December 2017 were enrolled in this study. Results Out of the 5 patients with inferior turbinate mucocele reviewed, 2 out of the 5 patients had symptoms of nasal obstruction and headache respectively, whereas the other 3 remaining patients were found incidentally by radiological examinations without any nasal symptoms. Four patients were performed the surgery by the transnasal endoscopic marsupialization. One patient had a very small size of an inferior turbinate mucocele and had no symptoms, and in that case the authors decided to do a periodic observation without a surgical intervention. There were no major complications resulting from this surgical intervention, and no recurrence of the inferior turbinate mucocele. Conclusions The inferior turbinate mucocele is an extremely rare disease and can be diagnosed accurately by the use of radiologic examinations. The prevailing discipline is that endoscopic marsupialization is the best treatment for the inferior turbinate mucocele, which is known for showing very good results without recurrence of the condition.

Objectives Paranasal sinus mucocele is a benign cystic lesion, lined with respiratory epithelium and filled with mucoid secretions, which is generally seen in the ethmoid or frontal sinuses. Inflammation, trauma, fibrosis, neoplasm, and previous surgery play a role in etiology. Treatment of this condition requires marsupialization and drainage. Endoscopic surgery is the gold standard procedure. Methods A 2-year-old boy was referred to our clinic with a diagnosis of bilateral ethmoid mucocele causing proptosis in the right eye. General clinical examinations and routine blood analysis revealed normal health condition of the patient and comorbidities such as cystic fibrosis (CF) and/or ciliary dysfunction were excluded. The patient was operated with an endoscopic endonasal approach. Results As far as we know, our article reports the first case of bilateral ethmoidal sinus mucocele with no underlying comorbidity, such as cystic fibrosis or ciliary dyskinesia. Conclusions Children are rarely affected by mucocele and if present at early age, there is usually an underlying cause. In pediatric patients with signs and symptoms suggestive of a mucocele, it is important to rule out other benign and malignant paranasal sinus pathologies. Marsupialization and drainage via endoscopic endonasal approach is the preferred treatment modality.

Objective Infected mucocele of the paranasal sinuses can induce orbital infection, including orbital subperiosteal abscess, which may lead to life-threatening intracranial complications. Effective diagnosis is important, and treatment should be aggressive. This paper presents our experiences in endoscopic surgical management of orbital complications secondary to infected paranasal sinus mucoceles. Methods From our retrospective review of the medical charts for 82 patients with 92 sides diagnosed with paranasal sinus mucoceles, we present 7 sides in 7 adult patients with orbital complications secondary to infected mucoceles. The collected data include the suggested etiology, side of sinus involvement, localization of abscess in the orbit, orbital wall bone defects caused by mucocele compression, ophthalmic symptoms, duration between symptom onset and initial visit, operation date, type of surgery performed, and follow-up. Results The mucocele was located in the ethmoid-frontal region in 9.8% of the sides (9/92), in the frontal sinus in 7.6% (7/92), in the ethmoidal sinus in 9.8% (9/92), in the maxillary sinus in 67.4% (62/92), in the maxillary-ethmoidal sinus in 3.3% (3/92), and in the sphenoid sinus in 2.2% (2/92). The patients with ethmoid-frontal mucoceles had a significantly higher incidence of orbital complications (6/9) as compared with the other sub-types of mucoceles (frontal, 0/7; ethmoidal, 0/9; maxillary, 1/62; maxillary-ethmoidal, 0/3; sphenoid, 0/2). Chandler's classification showed Type I in one, Type II in three, and Type III in three. Sinus involvement was observed at the ethmoid-frontal sinuses in six cases and the maxillary sinus in one case. All seven cases had a partial defect of the orbital wall bone (lamina papyracea, or inferior orbital wall bone) by mucocele compression, and the patients underwent endoscopic marsupialization. For the cases with subperiosteal abscess, the lamina papyracea was also removed partially for draining the abscess. In all cases, symptoms were resolved without any recurrence of the mucocele. Conclusions Infected ethmoid-frontal mucoceles with a defect of the lamina papyracea tend to induce orbital infection, so prompt surgery for the infected mucoceles should be considered early even with Types I and II, before visual acuity is impaired, because surgery is the only curative treatment for the mucoceles.

PURPOSE To analyze the reason for the diversity of the clinical course of subglottic cysts and discuss their pre- and coexistence with subglottic stenosis. METHODS The medical records of patients who were treated for subglottic cysts between 2003 and 2020 were retrospectively reviewed and direct laryngoscopy videos were analyzed to assess the healing patterns of their disease. RESULTS Of the 15 patients, 10 had a history of intubation in the neonatal period. In 11 patients, the cysts were transparent and well defined, and no recurrence of subglottic cysts occurred after the initial surgery. In four patients, the cysts were located deep in the mucosa and did not have the typical appearance of a cyst, but rather of a stenotic segment; all of them had a history of intubation and three of them required laryngotracheal reconstruction. CONCLUSION Transparent, thin-walled superficial subglottic cysts with healthy surrounding mucosa can easily be treated with endoscopic marsupialization; however, the treatment of deep subglottic cysts can be challenging. The coexistence of subglottic cysts and subglottic stenosis is not rare. We point out the need for considering the possibility of a missed deep submucosal cyst in a seemingly refractory case of pediatric subglottic stenosis with atypical endoscopic findings and with a background history of prior intubation.

A urinoma is an unusual complication following renal transplant biopsy that can easily be missed or mistaken for a hematoma. In addition to trauma to the renal collecting system, a degree of urinary tract obstruction is required for urine to leak into the surrounding tissues and form a urinoma, which can in turn cause pressure on surrounding structures. This case report describes a patient who developed ipsilateral leg swelling several months after a renal transplant biopsy. Imaging demonstrated a perirenal transplant fluid collection, which biochemical analysis confirmed to be urine. This was successfully managed with percutaneous nephrostomy and antegrade ureteric stent insertion. The fluid collection persisted as a seroma however, and the patient proceeded to have peritoneal fenestration and marsupialization surgery. To our knowledge, this is the first reported case of urinoma complicating a renal transplant biopsy. This case highlights a diagnosis that can be easily missed and is therefore a potential pitfall for clinicians.

Objective Thornwaldt cyst is a rare nasopharyngeal lesion that develops from primitive notochord residues. The aim of this study is to evaluate the long-term results of transnasal endoscopic marsupialization surgery in the treatment of Thornwaldt's cyst, its success and its qualification in the treatment. Method The data of 21 patients who underwent transnasal endoscopic marsupialization surgery for symptomatic Thornwaldt cyst in our hospital between 2009 and 2015 and followed up regularly after the operation were reviewed retrospectively. Results Eleven patients were female and 10 were male. The mean age of the patients was 35.5 years (15-60). All patients underwent transnasal endoscopic marsupialization as a surgical technique. No intraoperative and postoperative complications were observed. In all cases, the complaints regressed postoperatively. There was no recurrence at 4-year follow-up. Conclusion Transnasal endocopic marsupialization as a surgical method can be performed safely in Thornwaldt cyst cases because of its easy applicability, short surgical time, low recurrence rates and efficacy in treatment.

Dentigerous cysts in young adults may compromise the natural evolution of the dentition and can be treated surgically or non-surgically. We report the minimally-invasive treatment of dentigerous cysts in two young patients using a modified Hawley plate to avoid traumatic injury to anatomical structures, with up to four years' follow up.

Canaliculops is a non-inflammatory dilatation of the canaliculus which can be secondary to trauma, punctal agenesis, herpetic infections or chronic drug use. This condition can affect either canaliculi and has shown female preponderance. Treatment described so far has consisted of cyst marsupialization with no literature on the post-operative epiphora in these cases. We describe two cases of canaliculops with punctal agenesis where we have tried to establish lacrimal patency.

Background Rathke cleft cysts (RCCs) are benign cysts arising from the pars intermedia as a result of incomplete obliteration of the Rathke pouch during development of the pituitary gland. The most common presenting symptoms are headaches, visual disturbances, and endocrinopathies. Recurrence of RCCs after surgical treatment is a well-known phenomenon after surgery with reported recurrence rates as high as 30%. Various methods have been employed to reduce the rate of recurrence. Complete cyst wall resection has been associated with increased rates of perioperative cerebrospinal fluid leak, diabetes insipidus, and carotid injury, while inconsistently demonstrating reduced recurrence rates. Marsupialization, in which the cyst cavity is widely exposed and left open with or without a fat graft suspension, has similarly shown increased morbidity without clear improvement in outcomes. We report here the use of a steroid-eluting sinus stent to maintain patency of the cyst opening. Case Description A 39-year-old female presented with a symptomatic RCC. She underwent 4 different surgeries including cyst wall resection, marsupialization, and fat graft placement. She developed short-term symptomatic and radiographic recurrence within 3 months of each surgery. She then underwent placement of a steroid-eluting sinus stent. At 3 months, the patient remained symptom free, without radiographic recurrence and with patent cyst fenestration on nasal endoscopy. Conclusions Recurrent RCCs are challenging to manage. Strategies to reduce recurrence are typically associated with higher risk and varying success. Stent placement represents a simple, low-risk method of potentially maintaining patency of cyst fenestration.

Purpose: To review and summarize the epidemiology, clinical presentations, histopathologic characteristics and management of dacryops.Methods: A comprehensive PubMed, Embase and Google Scholar search of all articles written in English and non-English language articles with abstract translated to English on dacryops were reviewed. Data reviewed included epidemiology, etiology, pathogenesis, clinical presentations, histopathologic characteristics and management of dacryops.Results: Lacrimal ductal cysts or dacryops are classified based on locations: palpebral lobe cysts (simple dacryops); orbital lobe cysts; cysts of the accessory lacrimal glands of Krause and Wolfring; and cysts of ectopic (choristomatous) lacrimal glands. The exact etiology of dacryops remains unknown. Dacryops is usually asymptomatic but can present with varied symptoms depending on the type and associated complications. While complete excision of dacryops is generally recommended, marsupialization is also a safe and effective method for the treatment of dacryops in the palpebral lobe of lacrimal gland. Complete surgical excision via orbitotomy is required for deep orbital lesions.Conclusion: Dacryops is an uncommon benign cystic lacrimal gland tissue neoplasm. Dacryops can be classified into four types based on locations. Lesions could be either superficial that can be seen through the fornix or deep into the orbit. Observation is also an option for small or asymptomatic lesions. Surgery remains the mainstay of treatment for symptomatic cases, but approaches are different depending on the location of the lesions.

The marsupialization of Stensen's duct after buccal cancer excision and free flap reconstruction has seldom been reported. In this study, we evaluated the alteration in Stensen's duct and parotid gland, without marsupialization or relocation, between the time of surgery and 24 months postoperatively to determine whether ductal management is needed in patients with buccal squamous cell carcinoma (BSCC).Eighty-five patients with BSCC receiving primary radical surgery and free flap reconstruction were recruited. Alterations in Stensen's duct and parotid gland were assessed by computed tomography during the postoperative period.The 81 males and 4 females enrolled in study had a tumor status of cT2 (n = 52, 61%) or cT3 (n = 33, 39%). In total, 52 (61%) patients received surgery alone, and 33 (39%) received adjuvant concurrent chemoradiotherapy (CCRT) postoperatively. Stensen's duct on the affected side was significantly dilated compared to the non-affected side (p 0.001). The difference in diameter of Stensen's duct between the surgery plus CCRT group and the surgery alone group was not significant (p 0.05), indicating that changes in parotid gland occurred mainly due to surgery. In both the surgery and surgery plus CCRT groups, inflammation of parotid gland had regressed by 24 months.Stensen's duct in BSCC dilatation peaked in the 3rd month after surgery. Changes in parotid gland on the surgically treated side regressed into fatty change by 24 months after surgery.

Gartner’s duct cysts (GDC) are benign lesions that may become symptomatic, leading to surgical intervention. There is no standard surgical technique for management of GDC. This article provides a comprehensive review of surgical the management of GDC. We also present a new technique using fluorescein dye to help delineate GDC walls and facilitate complete cyst excision. We conducted a PubMed search for English-language articles without a defined time range. The search combined subject headings, title, abstract, and text words relating to Gartner duct cysts. Articles describing surgical management of GDC were included. Exclusion criteria included inadequate diagnosis of GDC, infected cysts, nonsurgical management, or article unavailable for interlibrary loan. A novel approach using intra-cyst fluorescein dye injection is described. Two hundred sixty-seven articles were identified via PubMed, and 34 articles were included in the review based on eligibility criteria. Concomitant genitourinary malformations occurred in 19 of the 92 surgically managed patients. Surgical techniques included cyst excision (50 patients), tetracycline injection following aspiration (15), marsupialization (14), unroofing/partial excision (9), and puncture/evacuation (4). Recurrences occurred in 4, 1, 0, 0, and 1 patient, respectively. One patient underwent uncomplicated fluorescein dye-assisted cyst excision with no recurrence 30 months post-procedure. The low incidence of GDCs necessitating surgical intervention has resulted in a lack of standard surgical technique, especially in patients with concurrent genitourinary malformations. Utilizing fluorescein dye provides a surgical method that can help confirm the absence of urologic involvement as well as facilitate precise excision of GDC.

Purpose To provide a systematic review of the literature on congenital dacryocystoceles (CDCs) and summarize their presentations, investigations, management, and outcomes. Methods The authors performed a PubMed search of all articles published in English on CDCs. Data captured include demographics, clinical presentations, investigations, management modalities, complications, and outcomes. Fourteen major series (10 or more than 10 cases) and 89 isolated case reports/series on CDCs with a collective patient pool of 1,063 were studied in detail. Specific emphasis was laid on addressing the controversial issues including initial conservative versus surgical management and the role of endoscopic evaluation. Results Numerous terminologies have been used to describe CDC. Congenital dacryocystoceles are rare variants of congenital nasolacrimal duct obstructions and comprise of 0.1% to 0.3% of all such cases. There is a female predilection (64.2%, 683/1,063) and the mean age at presentation is at 7 days of birth. Initial conservative treatment can be a viable option in the absence of an acute dacryocystitis or a respiratory distress. Endoscopy-assisted probing appears to have better outcomes as compared with the in-office probing. Congenital dacryocystoceles with acute dacryocystitis are preferably managed with intravenous antibiotics and an early probing under endoscopy guidance to avoid missing intranasal cysts. Marsupialization is the preferred technique in the management of intranasal cysts. Silicone intubation was rarely used and has no definitive indications. Dacryocystorhinostomy is very rarely needed in the management of CDC. Conclusions Congenital dacryocystocele is a commonly accepted term and its use should be advocated to enhance uniformity in reporting. Endoscopic evaluation of CDC is useful in the diagnosis and treatment of associated intranasal cysts and enhances the rates of successful outcomes.

The purpose of this study was to report the clinical efficacy of decompression for 3 cases with large periapical lesions and to review technique details. Three cases with large periapical cystic lesions were treated with decompression after root canal treatment. A traditional decompression technique was used for the first case. After aspiration, mucogingival incision, irrigation, and incisional biopsy, a pediatric endotracheal tube was sutured in place and kept for 3 weeks for lesion debridement. An aspiration/irrigation technique was adopted for the second case. An 18-G needle with a syringe was used to aspirate the cystic lesion. Two needles were then inserted into the lesion; copious saline irrigation was delivered from 1 needle and until clear saline was expressed from the other. For the third case, decompression was accomplished with a surgical catheter that was subsequently replaced with a gutta-percha plug after 1 month. None of the 3 cases underwent complete enucleation and root-end surgery. Healed lesions or lesions in healing were observed after 1 to 2 years. Based on the presented cases and published case reports on decompression, a literature review was provided covering indications, technique details, modification, and prognosis of decompression in endodontics. For large periapical cystic lesions, conservative decompression may be used for certain cases before or in lieu of apical surgery. Decompression enables healing of large, persistent periapical lesions after root canal treatment.

OBJECTIVES Rathke cleft cysts (RCCs) are rare, benign lesions formed from remnants of Rathke pouch during embryologic development. However, following marsupialization, maintaining tract patency remains a challenge. Several techniques for decreasing stenosis have been described, including free mucosal grafting, silastic spacing, and using steroid-eluting stents. Nasoseptal flaps (NSFs) have a reliable vascular supply and are widely utilized in skull base reconstruction. We present a novel technique to maintain patency of the marsupialized RCC cavity by lining it with an NSF to promote long-term drainage and re-epithelialization of the RCC cavity. METHODS Retrospective chart review of all patients who underwent surgery for symptomatic RCCs. These patients underwent endoscopic endonasal surgery between February 3, 2016, and June 12, 2018, with marsupialization followed by circumferential NSF lining. Primary outcomes include symptomatic control, surgical complications, and RCC cavity patency. RESULTS Seven patients underwent RCC marsupialization with no intraoperative cerebrospinal fluid leak, followed by circumferential lining of the marsupialized cavity with an NSF. In each case, no cyst re-accumulation or recurrent symptoms were noted, and the NSF lining provided long-term patency of the tract in all cases to a mean of 6.7 ± 10.1 months of follow-up, including one patient with sustained patency at 29 months follow-up. CONCLUSION Utilization of the NSF to "stent open" the RCC cavity following marsupialization is a safe and effective means to prevent restenosis. Advantages include sustained patency of RCC cavity for complete drainage and a dependable vascular supply. LEVEL OF EVIDENCE 4 Laryngoscope, 129:2258-2261, 2019.

Purpose Lingual thyroglossal duct cysts (L-TGDCs) are rare and sometimes lethal owing to their association with asphyxia. We aimed to analyze our single institutional experience with L-TGDCs. Methods Twelve L-TGDC cases treated at our institution between January 2010 and December 2017 were investigated. Results The male/female ratio was 6/6. The age at the diagnosis was 2 ± 1.4 months (7 days to 6 months), and 3 patients were diagnosed in the neonatal period. The patients presented with stridor (n = 12; 100%), growth retardation (n = 5; 42%), apnea (n = 3; 25%), and vomiting (n = 1; 8.3%). Lateral X-rays were obtained in 8 cases (66.7%); a lingual mass was suspected in 7 (87.5%). Transoral marsupialization of the cyst was performed under direct vision in all cases. All cases were nasally and orally intubated using a laryngoscope, bronchoscope, or airway scope. The mean operative time was 18 ± 2.9 min. The mean cyst size was 10.5 ± 1.8 mm. No recurrence was observed during the follow-up period (37.5 ± 18 months). Conclusion L-TGDC requires a precise diagnosis and rapid intervention because of the risk of asphyxia resulting in sudden death. Transoral marsupialization under direct vision is an effective and secure approach. L-TGDC should be considered when patients younger than six months of age present with respiratory distress. Type of study Retrospective Study. Level of evidence Level IV.

Background: Bulbourethral syringocele is an uncommon and under-diagnosed condition most commonly seen in the paediatric population, although there is increasing recognition in adults. Due to the difficulty in diagnosis, we report our experience of urethral syringocele in a quaternary paediatric hospital, with differing presentations, diagnosis and treatment. Methods: This is a retrospective review of seven cases of children over a period of 14 years, including their presentations, diagnosis, treatment and follow-up. A review of the current literature is presented. Results: The median age of these seven cases at presentation was 11 years (6 days to 16 years). Clinical features varied with age, with obstructive uropathy in a neonate, urinary tract infection in an infant, scrotal abscess in two children and lower urinary tract obstructive symptoms in three teenagers. Diagnostic voiding cystogram diagnosed the majority of syringoceles and two were seen on magnetic resonance imaging. Five boys underwent endoscopic transurethral deroofing and two children required transperineal marsupialization. Long-term follow-up showed all had complete resolution of symptoms. Conclusion: Urethral syringocele presents from the neonatal period to late adolescence, with the presenting features reflective of age. Surgical management can be performed endoscopically or by open approach. Awareness of this condition and inclusion in the differential diagnosis, particularly in the setting of an atypical or recurrent scrotal abscess, could avoid a prolonged therapeutic course.

Background Anterior lumbar approach, routinely used in spinal surgery, provides many advantages, specifically avoidance of manipulation and potential injury to nervous system structures; it also provides indirect central and foraminal decompression, with a complication rate of 1%–3%. Chyloretroperitoneum is a rare complication of spinal procedures using anterior lumbar approach. The aim of this study was to discuss diagnosis, treatment, and management of chyloretroperitoneum based on review of the international literature through 2017. Methods The literature review was conducted using the terms “chyloretroperitoneum,” “spinal surgery,” and “lymphocele.” Additionally, an illustrative case of chyloretroperitoneum following anterior retroperitoneal lumbar approach was presented. Results In 33 cases, including the present case, clinical symptoms appeared after discharge in 75.8% (n = 25) and reflected direct mass effect. Abdominopelvic computed tomography permitted assessment of the fluid collection observed as a hypodense collection around the psoas muscle. In 24 cases, drainage of the chyloretroperitoneum was maintained for a mean duration of 2.9 days. Surgery was performed in 14 patients (42.4%) owing to lymphatic collection. In 5 cases, surgery was performed for direct lymphatic vessel treatment. Laparoscopic marsupialization of the collection and peritoneal fenestration were performed, especially after percutaneous drainage failure. Conclusions Computed tomography was the most useful imaging modality for diagnosis and assessment of associated complications. If puncture alone is not sufficient and should be avoided, percutaneous computed tomography–guided drainage with sclerosing agent administration appears to be a safe and efficient first-line treatment. Laparoscopic fenestration should be used in cases of complicated or recurrent lymphoceles.

Lingual thyroglossal duct cysts (LTDCs) are rare congenital anomalies of the neck. The authors described the presentation, management, and outcome of LTDC in pediatric and adult cases through a retrospective observational analysis between 2008 and 2018. Data included patients' demographics, main complaint, preoperative investigations, surgical management, and recurrences. Seventeen patients were included: 8 pediatric and 9 adult patients. The most common presenting symptom was foreign body sensation (35.3%). In all, 50% (4/8) of the children had respiratory problems, while the most common symptom in adults was difficulty swallowing (8/9). Five patients were of recurrent LTDC; 3 referred patients were suspected of having recurrent epiglottic cysts. The total misdiagnosis rate was 35.3% (6/17): 14.3% (1/7) in children and 55.6% (5/9) in adults. Fiber optic laryngoscopic examination revealed that LTDCs mostly occurred at the base of the tongue (53.3%) and vallecula epiglottica (33.3%). Ultrasound examination revealed low to anechoic masses on the root of the tongue; 50% were regular in shape and 50% were irregular. All pediatric patients had regular masses (100%), but most adults had irregular masses (85.7%). In total, 76.5% of the patients underwent the Sistrunk procedure, and 23.5% underwent marsupialization alone. The mean follow-up length was 37.5 ± 32.8 months. All patients were well at follow-up. In conclusion, direct laryngoscopy and ultrasound examination are essential for diagnosis as LTDCs can be confused with vallecular cysts. Surgical treatment such as marsupialization or the Sistrunk operation must be performed thoroughly.

Unicystic ameloblastoma (UAM) is a variant of intraosseous ameloblastoma that occurs as a single cystic cavity. This report describes a case of UAM of the mandible in a seven-year-old girl. The lesion radiographically mimicked a dentigerous cyst. Under the primary diagnosis of a dentigerous cyst, marsupialization was performed to erupt the first molar involved in the cystic lesion and to obtain a definitive diagnosis. The biopsy specimen revealed ameloblastoma. During careful observation, orthodontic treatment, which was performed to upright and promote the eruption of the first molar involved in the tumor, maintained the space needed for enucleation of the tumor. Finally, the second primary molar was extracted, and the lesion was enucleated at 3 years and 4 months after marsupialization. The results of the histological examination revealed UAM. Conclusively, the treatment course not only avoids a resection of the mandible but also induces eruption of the teeth involved in the tumor. Thus, the combination of conservative surgery and orthodontic treatment was effective in the management of UAM that mimics a dentigerous cyst.

Mucoceles are common salivary gland disorders. Mucoceles are benign, mucus-filled extravasation pseudocysts that commonly arise on the lower lip of children and young adults. Although surgical excision is commonly performed to remove these lesions, other treatments include marsupialization, micromarsupialization laser ablation, cryotherapy, intralesional steroid injection, and sclerosing agents. Traumatic sialoceles commonly arise from injury to the parotid duct. Treatment of sialoceles from acute parotid duct injury and for delayed presentations after injury are discussed. Ranulas are a subtype of mucocele from the sublingual gland classified as superficial or plunging. Treatment of ranulas must address the sublingual gland.

Neurenteric cysts (NECs) of the central nervous system (CNS) are uncommon congenital entities arising from embryonal elements. Intracranial NECs in the pediatric population are rare. The authors describe the presentation, radiographic imaging, and pathologic findings of an 11-year-old boy with a right oculomotor nerve NEC. A literature review was performed to identify additional cases of pediatric intracranial NECs published in the English language, over the past 30 years (1990–2020). The authors discuss the presentation, investigations, management, and prognosis of this interesting entity. We describe an 11-year-old boy who presented to neurosurgical attention with disconjugate gaze, anisocoria, and ptosis. Magnetic resonance imaging (MRI) demonstrated a lobulated, cystic, and peripherally enhancing mass involving the right oculomotor nerve. The patient underwent pterional craniotomy for drainage of the cyst and subtotal resection of the cyst wall. The tan-colored mass was displacing the basilar artery, compressing the cerebral peduncle, and adherent to the inferior surface of the tentorium. The lesion was within the oculomotor nerve and splitting the fibers, and the cystic contents were thick and mucinous. Histopathological examination of the specimen demonstrated a thin fibrous cyst wall with scattered inflammatory cells and lined by simple columnar epithelium containing mucin. The lining cells were immunoreactive with epithelial membrane antigen (EMA) and pan-keratin AE1/AE3. The diagnosis of a NEC was rendered. A comprehensive literature review of pediatric intracranial NECs yielded 46 additional lesions published in the literature, involving the skull base, posterior fossa, cerebral convexity, and cranial nerves. NECs present with local mass effect and less commonly, with aseptic meningitis or intracystic hemorrhage. Maximal safe GTR remains the mainstay management, although cyst drainage and marsupialization, cyst shunting, and fenestration of cystic contents into the ventricle or basal cisterns have been reported with variable success. CNS NECs are rare congenital entities; although they occur less frequently in the intracranial components compared to the spine, their diagnosis and management should be considered for intracranial cystic lesions. Maximal safe GTR is the mainstay treatment and frequently yields favorable outcomes.

Background A dentigerous cyst (DC) is a pathology embracing the crown of an unerupted tooth at risk of malignant transformation. The causal tooth is usually removed together with the cyst. However, if there are orthodontic contraindications for extraction, two questions arise. (1) Which factors favor spontaneous eruption? (2) Which factors imply the necessity of applying orthodontic traction? This systematic review aimed to identify factors conducive/inconducive to the spontaneous eruption of teeth after dentigerous cyst marsupialization. Methods In accordance with the PRISMA guidelines, the main research question was defined in the PICO format (P: patients with dentigerous cysts; I: spontaneous tooth eruption after surgical DC treatment; C: lack of a spontaneous tooth eruption after surgical DC treatment; O: determining factors potentially influencing spontaneous tooth eruption). The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched for keywords combining dentigerous/odontogenic/follicular cysts with teeth and/or orthodontics, as well as human teeth and eruption patterns/intervals/periods/durations. The following data were extracted from the qualified articles (4 out of 3005 found initially): the rate of tooth eruption after surgical treatment of the cyst, the age and sex of the patients, the perpendicular projection distance between the top of the tooth cusp and the edge of the alveolar process, tooth angulation, the root formation stage, the cyst area, and the eruption space. The articles were subjected to risk of bias and quality analyses with the ROBINS-I protocol and the modified Newcastle–Ottawa QAS, respectively. Meta-analyses were performed with both fixed and random effects models. The GRADE approach was used to evaluate the quality of the evidence. The systematic review was registered in PROSPERO under ID CRD42020189044. Results Nearly 62% of DC-associated premolars erupted spontaneously after cyst marsupialization/decompression. Young age (mean = 10 years) and root formation not exceeding 1/2 of its fully developed length were the factors likely to favor spontaneous eruption. Conclusion The small number of published studies, as well as their heterogeneity and the critical risk of bias, did not allow the creation of evidence-based protocols for managing teeth with DC after marsupialization. More high-quality research is needed to draw more reliable conclusions.

Petrous apex cholesterol granulomas are believed to result from blockage of the normal aeration of the petrous air cells, resulting in a repetitive cycle of mucosal engorgement, hemorrhage, and granuloma formation.1 The lesion usually progressively expands causing compressive symptoms. The thick granulomatous wall envelopes various ages of breakdown products, including a cholesterol-containing fluid, which is typically hyperintense on T1 and T2 weighted magnetic resonance imaging. Drainage procedures, regardless of the route (endoscopic, endonasal, or transtemporal), with or without stenting or marsupialization, will only temporarily drain this cholesterol-containing fluid, with consequently frequent recurrences.2-5 A total exoneration of the granuloma and obliteration of the cavity with vascularized tissue will assure a more durable outcome.1 The extradural zygomatic/middle fossa approach provides a short distance to the petrous apex and is purely extradural. By sectioning the zygoma, temporal lobe retraction is avoided.6 We present a case of a 29-yr-old male who presented in the year 2000 with progression of a left petrous apex cholesterol granuloma despite 2 previous drainage and stenting procedures. The patient consented for surgery and photo publication. Images in video at 2:41 © JNSPG, republished from Eisenberg et al1 with permission.

Lacrimal sac mucopeptide concretions are not uncommon and usually identified following the lacrimal sac marsupialization during a dacryocystorhinostomy. A 39-year-old female presented with epiphora and discharge of 8 months duration and was diagnosed as primary acquired nasolacrimal duct obstruction. During the endoscopic dacryocystorhinostomy, a large intrasaccal polyp arising from the posterosuperior wall of the lacrimal sac with multiple inspissated mucopeptide concretions was noted. The lesion was excised, and the mucopeptide concretions were removed. Histopathology was suggestive of an intrasaccal polypoidal granuloma. To the best of the authors' knowledge, this is the first report of an intrasaccal polyp-like lesion secondary to a granulomatous response to a lacrimal sac mucopeptide concretion. It is important to be aware of this entity. The retrieval of mucopeptide concretion or lacrimal sac dacryoliths should prompt the surgeon to initiate an intraoperative endoscopic assessment of the sac before proceeding with the surgery.

The aim of this paper is to describe active decompression and distraction sugosteogenesis as an alternative for the management of odontogenic cystic lesions. The technique, demographics, success rate, and complications will be presented. A retrospective case series study design was implemented. This included patients found in our database from 2015 to 2018 with a diagnosis of any odontogenic cyst, in whom active decompression with distraction sugosteogenesis was implemented. The patient’s medical history, demographics, radiographic characteristics of the cyst, technique/device employed, complications, and rate of success were recorded. The sample consisted of 10 patients, with a mean age of 19.6 years (range 14–34). Sixty percent of all cases occurred in male patients and 40% in females. Forty percent of cases were consistent with odontogenic keratocysts with all cysts presenting in the mandible. No maxillary cases were documented. Seventy percent of such lesions were unilocular and 30% multilocular. Cortical fenestration/perforation was documented in 30% of cases and 1 pathologic fracture was seen. Active decompression was performed for an average of 37 days (range 30–50 days). With this system, radiographic resolution occurred in 1–3 months in 50% of cases, 6–12 months in 30% of cases, and 12 months in 20% of cases. Mean follow-up was 24.3 months. No recurrence was documented. Complications included fistula development (2 cases), flap dehiscence (1 case), and the size of the intraoral unit. This investigation reviewed the authors’ 5-year experience employing active decompression with distraction sugosteogenesis for the management of odontogenic cystic lesions and showed that this is a reliable alternative for the management of odontogenic cysts.

Background: This study aims to determine the positional alterations in the course of mandibular canal, which were caused by the common cystic lesions in the posterior mandible. Also, the effects of treatment methods on bone formation were evaluated. Methods: We designed a retrospective cohort study with patients which were treated due to cystic lesions in the maxillofacial region between the years 2012–2018. Forty eight subjects were included and grouped regarding histopathologic diagnoses (radicular dentigerous and odontogenic keratocyst) and treatment methods (enucleation and marsupialization). The mean (range) of patients’ age was 31.25 (18–66) years, and there were 32 male and 16 female individuals. The displacement of mandibular canals was verified on preoperative cone-beam computed tomographic images. The measurements of displacement and bone formation were performed on panoramic radiographs. In the statistical analysis of the data, descriptive statistics, parametric independent sample t-test, non-parametric Kruskal Wallis test, and one-way analysis of variance test were utilized. Results: All the evaluated mandibular canals were replaced by a mean(SD) of 5.46(2.59) mm after the lesions eliminated, which was significant in the marsupialization group (p = 0.002). The bone formation was significantly higher in the enucleation group (p = 0.003). The multiple regression analyses revealed that the treatment methods significantly influenced the replacement of mandibular canal (p < 0.001) and the bone formation (p = 0.026). Conclusion: In cases where there is an adequate distance between the lesion and the mandibular canal, the enucleation technique was found to be superior in terms of bone formation and the amount of bone height obtained. © 2021 Elsevier Masson SAS None.

In recent decades, the ever-expanding use of endoscopes and development of dedicated instrumentation have reshaped the panorama of surgical approaches to the frontal sinus. 1 Nonetheless, the far lateral portion of the sinus might still represent a concern, especially in cases with unfavorable or distorted anatomy. 2 , 3 We report the case of a 52-year-old man, referred to our department for recurrent episodes of left orbital swelling and supraorbital headache, 3 months after Draf III frontal sinusotomy for marsupialization of multiple frontal mucoceles. Computed tomography and magnetic resonance imaging scans were consistent with persistent inflammatory tissue in the far lateral left frontal sinus. Revision surgery was performed, adopting a combined endonasal orbital transposition 3 and superior eyelid transorbital approach. 4 , 5 The postoperative course was uneventful, and the microbiologic and histologic examinations demonstrated noninvasive Aspergillus fumigatus infection. The radiologic control showed patency of the frontal recess and complete clearance of the sinus. The patient is asymptomatic after 16 months ( Video 1 ). The transorbital approach is effective in managing orbital and frontal sinus diseases, 6 and the combination with the endonasal route grants complete access to the frontal sinus, even in cases of high pneumatization and lateral extension. 4 , 7 Multiportal transorbital approaches represent additional techniques in the rhinologist's surgical armamentarium, which can overcome the limits of a single port approach. 8 , 9 Reports on their use providing technical hints and critical considerations are to be encouraged to ease and stimulate the surgical training in this field.

OBJECTIVES/HYPOTHESIS The endoscopic endonasal approach (EEA) is increasingly utilized for management of petrous apex cholesterol granuloma (PACG). Surgical goals include drainage and marsupialization of the cyst. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of mucosal grafting on recurrence. STUDY DESIGN Retrospective Cohort study. METHODS Patients who underwent EEA for PACG at two tertiary care centers between 1999 and 2018 were identified and divided into two cohorts: Mucosal versus no mucosal reconstruction. Surgical approach, reconstructive method, and recurrence were recorded. Primary endpoint was symptomatic or radiographic recurrence. RESULTS Thirty-four patients were identified undergoing 37 surgeries. Four patients developed recurrences of which three elected to undergo revision. Some form of mucosa was used to line the drainage tract in 20 cases. A free mucosal graft was used in 8, and a small customized nasal septal flap (miniflap) in 12. All four recurrences occurred in cases where no mucosa was used, demonstrating decreased recurrences with mucosal reconstruction (P

Frontal Mucocele grows gradually and unnoticed as a benign lesion but, as the frontal mucocele expands to and compresses surrounding organs like brain, orbit, etc., it can cause diverse symptoms and signs. Although the surgical approaches of mucocele include open, endoscopic and combined approach, endoscopic marsupialization has been commonly used because endoscopic marsupialization was reported with high success rates, low complication rates and better operative vision. However, recently we experienced rare complication of endoscopic marsupialization of huge frontal mucocele, large amount of intracerebral hemorrhage, immediately after successful surgery and report this rare case with short review.