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Background: The endoscopic superior eyelid transorbital route to the skull base is gaining progressive popularity in the neurosurgical community., Objective: To evaluate the anatomy of the middle cranial fossa from this novel ventral perspective to reach the skull base through the transorbital route and to show limits for possible safe middle fossa drilling from the transorbital route., Methods: Anatomic study was performed; 5 cadaveric specimens (ie, 10 sides) and 2 dry skulls (ie, 4 sides) were dissected., Results: To obtain a functional result, there are boundaries that correspond to neurovascular structures that traverse, enter, or leave the middle fossa that must be respected: inferiorly, the lateral pterygoid muscle; medially, the Gasserian ganglion and the lateral border of the foramen rotundum; laterally, the foramen spinosum with the middle meningeal artery; superiorly, the lesser sphenoid wing; posteriorly, the anterior border of the foramen ovale. Average bone resected was 6.49 ± 0.80 cm3 which is the 63% of total middle fossa floor. The mean axial surgical length calculated was 3.85 cm (3.18-5.19 cm) while the mean sagittal surgical length was 5.23 cm (4.87-6.55 cm). The mean horizontal angle of approach was 38.14° (32.87°-45.63°), while the mean vertical angle of approach was 18.56° (10.81°-26.76°)., Conclusion: Detailed anatomy of the middle cranial fossa is presented, and herewith we demonstrated that from the endoscopic superior eyelid transorbital approach removal of middle cranial fossa floor is possible when anatomic landmarks are respected., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Purpose: Spontaneous skull base cerebrospinal fluid leaks occurring without any apparent cause are rare. But those patients that present such leaks simultaneously, or successively, in multiple locations are even rarer. Given the rarity of this condition, we collected data from other groups in a multicentre study to reach an adequate number of patients and draw some preliminary considerations., Methods: We carried out a multicentre retrospective study on a cohort of patients treated at third level hospitals in Italy, Spain, United Kingdom and Greece for multiple spontaneous-CSF leaks and we compared them with a control group of patients treated for recurrent spontaneous-CSF leaks. Data regarding clinical aspects, radiological findings, surgical techniques and outcome were collected and preliminary considerations on the results were discussed., Results: A total of 25 patients presented multiple simultaneous spontaneous CSF leaks while 18 patients fit with the criteria of recurrent spontaneous CSF leaks. Data analysis was conducted separately., Conclusions: Our understanding of the pathogenesis of this condition is currently very limited. A causative role of IIH may be present but the differences that emerged from the comparison with patients with recurrent fistulas seem to promote the possible role of other cofactors. A longer follow-up period is needed, and, in our opinion, prospective and multicentre studies are the only solution to seriously deal with such a complex topic.

Objectives/hypothesis: To evaluate the versatility of the pericranial flap (PCF) to reconstruct the ventral skull base, using the frontal sinus as a gate for its passage into the sinonasal corridor "money box approach.", Study Design: Anatomic-radiological study and case series., Methods: Various approaches and their respective defects (cribriform, transtuberculum, clival, and craniovertebral junction) were completed in 10 injected specimens. The PCF was introduced into the nose through the uppermost portion of the frontal sinus (money box approach). Computed tomography (CT) scans (n = 50) were used to measure the dimensions of the PCF and the skull base defects. The vertical projection of the external ear canal was used as the reference point to standardize the incisions for the PCF., Results: The surface area and maximum length of the PCF were 121.5 ± 19.4 cm 2 and 18.3 ± 1.3 cm, respectively. Using CT scans, we determined that to reconstruct defects secondary to transcribriform, transtuberculum, clival, and craniovertebral approaches, the PCF distal incision must be placed respectively at -3.7 ± 2.0 cm (angle -17.4 ± 8.5°), -0.2 ± 2.0 cm (angle -1.0 ± 9.3°), +5.5 ± 2.3 cm (angle +24.4 ± 9.7°), +8.4 ± 2.4 cm (angle +36.6 ± 11.5°), as related to the reference point. Skull base defects in our clinical cohort (n = 6) were completely reconstructed uneventfully with the PCF., Conclusions: The PCF renders enough surface area to reconstruct all possible defects in the ventral and median skull base. Using the uppermost frontal sinus as a gateway into the nose (money box approach) is feasible and simple., Level of Evidence: NA. Laryngoscope, 127:2482-2489, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Unlabelled: Little is known about the long-term effects of either transnasal transsphenoidal endoscopic approach (TTEA) or expanded endonasal approach (EEA). This study assessed the long-term impact of endoscopic skull base surgery on olfaction, sinonasal symptoms, mucociliary clearance time (MCT), and quality of life (QoL). Patients with pituitary adenomas underwent TTEA (n = 38), while patients with other benign parasellar tumours who underwent an EEA with vascularised septal flap reconstruction (n = 17) were enrolled in this prospective study between 2009 and 2012. Sinonasal symptoms (Visual Analogue Scale), subjective olfactometry (Barcelona Smell Test-24, BAST-24), MCT (saccharin test), and QoL (short form SF-36, rhinosinusitis outcome measure/RSOM) were evaluated before, and 12 months after, surgery. At baseline, sinonasal symptoms, MCT, BAST-24, and QoL were similar between groups. Twelve months after surgery, both TTEA and EEA groups experienced smell impairment compared to baseline. Moreover, EEA (but not TTEA) patients reported increased posterior nasal discharge and longer MCTs compared to baseline. No significant changes in olfactometry or QoL were detected in either group 12 months after surgery. Over the long-term, expanded skull base surgery, using EEA, produced more sinonasal symptoms (including loss of smell) and longer MCTs than pituitary surgery (TTEA). EEA showed no long-term impact on smell test or QoL., Level of Evidence: IIb.

Objective: To study the long-term radiological findings after endonasal endoscopic approach to the skull base., Material and Methods: Prospective study that included 55 patients who underwent advance endoscopic skull base surgery. All patients were evaluated with MRI before, 3 months and 12 months after surgery. We used the Lund-Mackay staging system for chronic rhinosinusitis to evaluate the paranasal cavities and the sinonasal scoring system to assess sinonasal symptoms., Results: Seventeen patients (30.9%) underwent extended endonasal approach that required a nasoseptal flap (NSF) for reconstruction of skull base. At baseline the mean total Lund-Mackay score was 0.63 ± 1.2 (range 0-4), and at 3 and 12 months postoperatively the mean scores were 3.5 ± 3.8 (range 0-14) and 2.0 ± 2.5 (range 0-8) respectively. Patients who needed an NSF for reconstruction had a greater Lund-Mackay score (p<0.05). Moreover, NSF is correlated with sinonasal mucosal thickening and fluid retention at 3 months (r=0.45, p<0.01) and 12 months (r=0.4, p<0.01). Total 5-symptom score (T5SS) was similar between both groups at baseline. Patients with extended endoscopic approach reported more smell loss (40.1 ± 26.2; p<0.05) and posterior nasal discharge (49.3 ± 30.1; p<0.05) than TTEA patients (21.6 ± 30.9 and 22.5 ± 27.5 respectively)., Conclusions: We observed that sinus opacity is still present after one year of advance endoscopic skull base surgery but symptoms seems to return to basal after 12 months of follow-up., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction and Objectives: Cerebrospinal fluid leaks associated to meningoencephaloceles of the sphenoid lateral recess are rare entities. A congenital bony defect at this level results in the persistence of Sternberg's canal, or a lateral craniopharyngeal canal, which is supposed to be the origin of these lesions. Our objective was to show that the endoscopic transpterygoid approach is an effective technique for their treatment., Methods: We present a series of 5 cases of meningoencephaloceles of the sphenoid lateral recess treated with endoscopic sinus surgery (4 women and one man; mean age=59, range 37-72 years). Cerebrospinal fluid rhinorrhoea was present in all of them and they all underwent a transpterygoid approach with reconstruction of the skull base. We describe the surgical technique and review the literature., Results: No complications were observed during surgery or the postoperative period. After a mean follow-up of 81 months, only one recurrence was seen., Conclusions: The transpterygoid approach has proven to be effective for the treatment of meningoencephaloceles of the sphenoid lateral recess. Providing wide access to identify the defect, followed by meningoencephalocele ablation, is the key for successful surgery., (Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Otorrinolaringología y Patología Cérvico-Facial. All rights reserved.)

Objective: To describe our designed protocol for the reconstruction of three-dimensional (3D) models applied to various endoscopic endonasal approaches that allows performing a 3D virtual dissection of the desired approach and analyzing and quantifying critical surgical landmarks., Methods: All human cadaveric heads were dissected at the Laboratory of Surgical Neuroanatomy of the University of Barcelona. The dissection anatomic protocol was designed as follows: 1) virtual surgery simulation systems, 2) navigated cadaver dissection, and 3) postdissection analysis and quantification of data., Results: The virtual dissection of the selected approach, the preliminary exploration of each specimen, the real dissection laboratory experience, and the analysis of data retrieved during the dissection step provide a complete method to improve general knowledge of the main endoscopic endonasal approaches to the skull base, at the same time allowing the development of new surgical techniques., Conclusions: The methodology for surgical training in the anatomic laboratory described in this article has proven to be very effective, producing a depiction of anatomic landmarks as well as 3D visual feedback that improves the study, design, and execution in various neurosurgical approaches. The Dextroscope as a virtual surgery simulation system can be used as a preoperative planning tool that can allow the neurosurgeon to perceive, practice reasoning, and manipulate 3D representations using the transsphenoidal perspective acquiring specifically visual information for endoscopic endonasal approaches to the skull base. The Dextroscope also can be used as an advanced tool for analytic purposes to perform different types of measurements between surgical landmarks before, during, and after dissection., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: We present our experience in the reconstruction of these leaks depending on their size and location., Material and Methods: Fifty-four patients who underwent advanced skull base surgery (large defects, >20 mm) and 62 patients with CSF leaks of different origin (small, 2-10 mm, and midsize, 11-20 mm, defects) were included in the retrospective study. Large defects were reconstructed with a nasoseptal pedicled flap positioned on fat and fascia lata. In small and midsized leaks. Fascia lata in an underlay position was used for its reconstruction covered with mucoperiosteum of either the middle or the inferior turbinate., Results: The most frequent etiology for small and midsized defects was spontaneous (48.4%), followed by trauma (24.2%), iatrogenic (5%). The success rate after the first surgical reconstruction was 91% and 98% in large skull base defects and small/midsized, respectively. Rescue surgery achieved 100%., Conclusions: Endoscopic surgery for any type of skull base defect is the gold standard. The size of the defects does not seem to play a significant role in the success rate. Fascia lata and mucoperiosteum of the turbinate allow a two-layer reconstruction of small and midsized defects. For larger skull base defects, a combination of fat, fascia lata, and nasoseptal pedicled flaps provides a successful reconstruction.

Objective: The goal of the present article was to describe our dissection training system applied to a variety of endoscopic endonasal approaches. It allows one to perform a 3D virtual dissection of the desired approach and to analyze and quantify critical surgical measurements., Methods: All the human cadaveric heads were dissected at the Laboratory of Surgical Neuro-Anatomy (LSNA) of the University of Barcelona (Spain). The model surgical training protocol was designed as follows: 1) virtual dissection of the selected approach using our dissection training 3D model; 2) preliminary exploration of each specimen using a second 3D model based on a preoperative computed tomographic scan; 3) cadaveric anatomic dissection with the aid of a neuronavigation system; and 4) quantification and analysis of the collected data., Results: The virtual dissection of the selected approach, preliminary exploration of each specimen, a real laboratory dissection experience, and finally, the analysis of data retrieved during the dissection step was a complete method for training manual dexterity and hand-eye coordination and to improve the general knowledge of surgical approaches., Conclusions: The present model results are found to be effective, providing a valuable representation of the surgical anatomy as well as a 3D visual feedback, thus improving study, design, and execution in a variety of approaches. Such a system can also be developed as a preoperative planning tool that will allow the neurosurgeon to practice and manipulate 3D representations of the critical anatomic landmarks involved in the endoscopic endonasal approaches to the skull base., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: To apply a three-dimensional geometric model to various endoscopic endonasal approaches to analyze the bony anatomy of this area, quantify preoperatively bone removal, and optimize surgical planning., Methods: Investigators dissected 18 human cadaveric heads at the Laboratory of Surgical NeuroAnatomy (LSNA) of the University of Barcelona (Spain). Before and after each dissection, a computed tomography (CT) scan was performed to create a three-dimensional geometric model of the approach performed in the dissection room. The model protocol was designed as follows: (i) a preliminary exploration of each specimen using the preoperative CT scan, (ii) creation of a computer-generated three-dimensional virtual model of the approach, (iii) cadaveric anatomic dissection, and (iv) development of a CT-based model of the approach as a result of the superimposition of predissection and postdissection digital imaging and communications in medicine (DICOM) images of specimens., Results: This method employing preliminary virtual exploration of each specimen, the creation of a three-dimensional virtual model of the approach, and the overlapping of the predissection and postdissection three-dimensional models was useful to define the exact boundaries of the endoscopic endonasal craniectomy., Conclusions: Aside from laboratory anatomic dissection itself, this model is very effective in providing a depiction of bony landmarks and visual feedback of the amount of bone removed, improving the design of the craniectomy in the endoscopic endonasal midline skull base approach., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: Endoscopic surgery of the anterior skull base has become the standard procedure for the repair of cerebrospinal fluid (CSF) leaks of various origins. Closure of the leaks is believed to prevent ascending meningitis, although no report has specifically shown this., Material and Methods: Retrospective chart study of 39 patients who underwent endoscopic skull base surgery from 1/1993 to 11/2002., Setting: Tertiary University Hospitals., Outcome Measurement: Incidence of ascending meningitis after endoscopic skull base repair in patients with anterior skull base defects associated or not with meningitis and CSF leak., Results: Forty-one endoscopic repairs of anterior skull base defects of various origins were performed in 39 patients. Fifteen (36.5%) had suffered bacterial meningitis before surgery. Mean follow-up was 65 months (range 22-120). The defect was repaired using an "underlay" technique with lyophilized dura (n=11) or fascia lata (n=30), and covered with free mucosal grafts from either the middle or the inferior turbinates. Closure was achieved in 40/41 cases at first attempt. No recurrence of ascending bacterial meningitis was observed during follow-up in any of the fifteen patients who had previously presented with a CSF leak or skull base defect with meningitis. Also, no new bacterial meningitis occurred in all other patients. One case of meningoencephalocele of the lateral sphenoid wall developed a recurrent CSF fistula associated with bacterial meningitis two years after endoscopic repair, requiring endoscopic revision surgery. No patient received vaccination in this series., Discussion: Closure of active CSF leaks and reconstruction of skull base defects without CSF-leak in patients with prior ascending bacterial meningitis seem to provide excellent long-term results with neither recurrence of ascending meningitis nor incidence of meningitis in the other patients, unless a CSF leak re-appears. Conservative treatment of CSF leaks may lead to bacterial meningitis, therefore surgical closure of leaks or defects at the skull base should be considered treatment of choice to prevent ascending meningitis.

Background: In the last decades, skull base surgery had passed through an impressive evolution. The role of neuroanatomic research has been uppermost, and it has played a central role in the development of novel techniques directed to the skull base. Indeed, the deep and comprehensive study of skull base anatomy has been one of the keys of success of the endoscopic endonasal approach to the skull base. In the same way, dedicated efforts expended in the anatomic lab has been a powerful force for the growth of the endoscopic transorbital approach to the lateral skull base. Therefore, in this conceptual paper, the main steps for the anatomic description of the endoscopic transorbital approach to the skull base have been detailed. Methods: The anatomic journey for the development of the endoscopic transorbital approach to the skull base has been analyzed, and four "conceptual" steps have been highlighted. Results: As neurosurgeons, the eyeball has always represented a respectful area: to become familiar with this complex and delicate anatomy, we started by examining the orbital anatomy on a dry skull (step 1). Hence, step 1 is represented by a detailed bone study; step 2 is centered on cadaveric dissection; step 3 consists in 3D quantitative assessment of the novel endoscopic transorbital corridor; and finally, step 4 is the translation of the preclinical data in the real surgical scenario by means of dedicated surgical planning. Conclusions: The conceptual analysis of the anatomic journey for the description of the endoscopic transorbital approach to the skull base resulted in four main methodological steps that should not be thought strictly consequential but rather interconnected. Indeed, such steps should evolve following the drives that can arise in each specific situation. In conclusion, the four-step anatomic rehearsal can be relevant for the description, diffusion, and development of a novel technique in order to facilitate the application of the endoscopic transorbital approach to the skull base in a real surgical scenario. [ABSTRACT FROM AUTHOR]

Background: The endoscopic transorbital approach to the skull base is currently growing in popularity, and it is nowadays progressively used as a skull base approach. Clinical experience, along with detailed anatomical knowledge, makes this technique safe and effective. Method: We present a step by step description of our technique based on the most recent anatomic references, and clinical experience. In order to better understand every phase of the procedure, we propose to keep on the following scheme, that is (1) skin phase; (2) working space; (3) lesion removal; (4) reconstruction. Hence, alone or in combination with the well-known endonasal pathway, the transorbital avenue seems to be a useful approach for selected skull base lesions. We present our technique, along with an anatomic analysis on cadaveric specimens. Conclusions: Detailed knowledge of surgical anatomy, and a specific stepwise analysis of each part of the surgical procedure, is notably useful in order to safely and effectively perform a superior eyelid endoscopic transorbital surgery to the skull base. [ABSTRACT FROM AUTHOR]

Background: Endoscopic transsphenoidal surgery is currently the optimal treatment for skull base tumors. This study was designed to assess patient's sinonasal symptoms and quality of life (QoL) after resection of pituitary adenoma or skull base tumors using vascularized septal flap (VSF) reconstruction. Methods: Patients with pituitary adenoma underwent the transnasal transsphenoidal endoscopic approach (TTEA; n = 38), and patients with other benign parasellar tumors underwent the expanded endonasal approach (EEA; n = 17) with VSF. Assessment of sinonasal symptoms and QoL by the 36-item Short- Form (SF-36) and the 31-item Rhinosinusitis Outcome Measure (RSOM-31) were performed before and 3 months after surgery. Results: At baseline, the total seven-sinonasal symptom score (T7SSS) was similar between both groups. After surgery, T7SSS significantly increased in EEA but not in TTEA patients. EEA patients reported more smell loss (40.1 ± 26.2; p < 0.05) and posterior nasal discharge (49.3 ± 30.1; p < 0.05) than TTEA patients (21.6 ± 30.9 and 22.5 ± 27.5, respectively). At baseline, both groups had poorer SF-36 compared with the general population. TTEA patients had poorer QoL (on general health, vitality, and mental health) than EEA patients. After surgery, TTEA patients showed impaired physical role and bodily pain compared with baseline, and EEA patients showed impaired physical role and mental health. At baseline, RSOM scores were similar in TTEA and EEA groups. After surgery, EEA but not TTEA patients reported poorer nasal and general symptoms. Conclusion: The EEA with VSF produces more sinonasal symptoms than pituitary surgery, surgery for skull base and pituitary tumors has negative impact on QoL, and functioning tumors have no further negative effect on sinonasal symptoms and QoL. [ABSTRACT FROM AUTHOR]

In the original publication of the article, the following affiliation "Medical school, University of Nicosia, Nicosia, Cyprus" of the author "Christos Georgalas" was missed and included in this correction. [ABSTRACT FROM AUTHOR]