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To define anatomical variations associated with arterial blood supply of the nose which has clinical implications on the management of different disorders, especially intractable posterior epistaxis.Case series.Selective angiography of external and internal carotid arteries of 100 patients scheduled for routine angiography was done.Different anatomical variations were documented. The ophthalmic artery can arise from the middle meningeal artery in 1% while ethmoidal arteries can be absent in 5%. The maxillary artery courses as 2 loops in the pterygopalatine fossa in 64% of cases where the descending palatine artery originates before the first loop or on its top so that caution is needed in controlling epistaxis. The sphenopalatine artery has different patterns of branching and may have more than 2 branches in 18% of cases. In 19% of cases, there is cross-circulation between both sides through the nasal blood supply.Angiographic study of the nose is a very helpful tool for accurate knowledge of anatomical variations of the arteries with a tremendous effect on our surgical approaches and techniques for the management of different diseases in the nasal region, especially intractable posterior epistaxis.

Chirurgia della base del cranio laterale: 50 anni di impegno.La base del cranio non è anatomicamente divisa in anteriore e laterale, ma è per semplicità che comunemente si intendono i corridoi chirurgici con direzione antero-laterale, laterale pura e postero laterale come “Approcci chirurgici della base del cranio laterale”. Una relazione con titolo “Cinquant’anni di impegno”, di sforzo o di dedizione, vuole essere il riconoscimento a questa chirurgia che nel corso degli anni ha sviluppato interventi sempre più complessi con una morbidità sempre minore. Il principio della chirurgia della base del cranio laterale si fonda sulla possibilità di “fare spazio”, esporre adeguatamente, rimuovere osso per salvaguardare il cervello, insieme alla possibilità di preservare la funzione e adattare l’approccio chirurgico all’istologia della lesione. Il concetto che l’istologia detta l’entità della resezione chirurgica, bilanciando la morbidità intrinseca di ciascun approccio, è oggetto di trattazione nella prima sezione di questa relazione. Nella seconda sezione sono descritti i principali approcci chirurgici, intesi non come descrizione tecnica di ciascun tempo chirurgico, ma dei principi che sono alla base di ciascun approccio. La terza sezione è dedicata alle questioni aperte, quelle ancora irrisolte, inerenti alcuni tumori ed il loro trattamento. L’argomento del neurinoma sporadico dell’ottavo nervo cranico è trattato riportando l'attuale dibattito sulla osservazione, la chirurgia di preservazione dell’udito, la riabilitazione con l’impianto cocleare, la radioterapia e le ricerche recenti su marcatori tumorali predittivi di crescita. Il paraganglioma del forame giugulare è trattato nel contesto della chirurgia radicale, chirurgia parziale, osservazione e radioterapia. La terapia dei meningiomi della base del cranio analizza il punto di vista specifico dell’otochirurgo e del neurochirurgo. Cordomi e condrosarcomi, tumori del sacco endolinfatico, carcinomi dell’orecchio e colesteatoma della rocca sono le altre lesioni affrontate. Infine, nella quarta sezione è proposto un contributo a libera scelta ad autori di riconosciuta esperienza. Lo scopo di questa relazione è stato quello di fornire un aggiornamento della chirurgia della base del cranio laterale dopo 50 anni di duro lavoro e, o forse soprattutto, di permettere alle tante questioni irrisolte, alle domande che ancora non hanno risposta, di trovare espressione, affinchè il dibattito ed il progresso possano continuare con la condivisione di esperienze. Se al termine della lettura vi saranno più domande che risposte, potremo dirci che l’obiettivo di questa relazione è stato raggiunto.Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

Middle ear anatomy and physiology is highly complex, yet familiarity is important to perform middle ear surgery and understand surgically relevant ventilation pathways of the ear compartments. The middle ear is divided into five subspaces: the mesotympanum, the retrotympanum posteriorly, the epitympanum superiorly, the protympanum anteriorly, and the hypotympanum inferiorly. The Eustachian tube plays a crucial role in maintaining middle ear aeration and atmospheric pressure. There are two independent aeration routes of the epitympanum. Thanks to the advent of the endoscope, this anatomic and physiologic knowledge has allowed one to understand the pathophysiology of ear diseases, improving surgical concepts.

Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

Background Management of penetrating ocular splinter injuries is very controversial. Penetrating wounds of the orbit represent a complex therapeutic problem that requires a multidisciplinary approach. Endoscopic approaches to the orbit are currently performed through the lamina papyracea to access the medial part, or through large orbitotomies to access the lateral part. Objective To describe a novel combined approach to the lateral part of the orbit. Methods Clinical and surgical findings of intraorbital foreign body removal are presented. A minimal supraorbital osteotomy was performed, combined with endoscopic intraorbital dissection. Results The foreign body was removed, no postoperative complications were reported, and visual acuity increased from 2/10 preoperatively, to 8/10 one month after surgery. Conclusion The present technique can be considered a safe and novel surgical approach to access the retrobulbar space and to treat the pathology of this anatomic region.

Purpose: Post-traumatic facial nerve (FN) paralysis might need surgical decompression in selected patients. Different microscope-based surgical techniques are described in the literature such as the transmastoid, the middle cranial fossa and the translabyrinthine approach. The effectiveness of the transcanal endoscopic approach (TEA) in managing such condition has never been described and its possible indications has to be defined. Methods: Retrospective multi-centric case series of patients with post-traumatic FN paralysis surgically treated with TEA. From July 2013 to July 2017, 6 patients underwent TEA for post-traumatic FN paralysis with involvement of the second genu and/or the tympanic segment of the nerve. The surgical technique is described step by step, with focus on anatomic landmarks. Post-operative outcomes are specified in terms of FN postoperative function and audiologic results. Results: The TEA showed to recover a House–Brackmann grade I–II FN function in 83.2% of the patient. Post-operative air–bone gap significantly improved; whereas, the pure-tone average bone conduction did not differ significantly. Conclusions: TEA represents a viable option for the treatment of post-traumatic facial palsy in patients with radiologic evidence of tympanic segment and/or perigeniculate region involvement with no involvement of the mastoid segment of the FN. Transcanal endoscopic facial nerve decompression is a safe and effective approach in highly selected cases. Level of evidence: 4

Objective: Vestibular schwannoma (VS) is a benign tumor of the lateral skull base. Different microscopic surgical techniques are described in literature: the retrosigmoid and translabyrinthine approaches are used to treat big tumors located in the cerebellopontine angle, and the middle cranial fossa approach is utilized for small tumors with good hearing preservation. The expanded transcanal transpromontorial (ExpTT) approach is a combined microscopic-endoscopic technique previously indicated for Koos stage I and II VS and now proposed for larger VS, up to 3 cm in diameter, with linear progression into the cerebellopontine angle and touching the brainstem. Study Design: The study was a retrospective case series of patients who underwent ExpTT surgery for VS in our ear, nose, and throat department. Setting: We reviewed the surgical videos and electrophysiologic data recorded during the surgical operations. Subjects and Methods: From January 2015 to January 2017, 20 patients affected by Koos stage II and III VS underwent surgery in our department with the ExpTT approach. This novel technique is described step by step, with a focus on the surgical procedure and anatomic landmarks; outcomes are detailed in terms of early and late complications. The mean follow-up was 15 months. Results: The ExpTT approach permitted, in all patients, gross total resection of the tumor without any complication and with preservation of facial nerve function. All patients had a good postoperative recovery. Conclusion: The ExpTT technique is a new approach that combines the advantages of a microscopic technique with the ones offered by the endoscope in removal of VS.

Objective: Complex middle and inner ear malformations are considered an important limitation for cochlear implant (CI) with traditional microscopic techniques. The aim of the present study is to describe the results of the endoscopic-assisted CI procedure in children with malformed ears. Study Design: Case series with chart review of consecutive patients. Setting: Two tertiary referral centers: University Hospital of Verona and University Hospital of Modena, Italy. Subjects and Methods: In total, 25 children underwent endoscopic-assisted cochlear implantation between January 2013 and January 2018. The audiologic and neuroradiologic assessment showed profound hearing loss and malformation of the middle and inner ear in all children. A complete review of anatomic features, surgical results, and audiologic outcomes was performed. The surgical technique is described step-by-step, and the outcomes are detailed. Results: All patients (mean age, 3.6 years; range, 2.8-9 years) underwent a transattical/endoscopic-assisted CI procedure. All children showed varying degrees of auditory benefit, as measured by routine audiometry, speech perception tests, and Categories of Auditory Performance scores (mean, 6). No immediate or late postoperative complications were noted. Conclusion: The endoscopic-assisted approach proved to be successful in cochlear implantation. The direct visualization and magnification allow (1) exploration of the tympanic cavity; (2) confirmation of all anatomic features, with strict control of the course of the facial nerve, round window area, and inner ear; and (3) performance of the cochleostomy with adequate insertion of the array.

Tympanic facial nerve segment surgery has been traditionally performed using microscopic approaches, but currently, exclusive endoscopic approaches have been performed for traumatic, neoplastic, or inflammatory diseases, specially located at the geniculate ganglion, greater petrosal nerve, and second tract of the facial nerve, until the second genu. The tympanic segment of the facial nerve can be reached and visualized using an exclusive transcanal endoscopic approach, even in poorly accessible regions such as the second genu and geniculate ganglion, avoiding mastoidectomy, bony demolition, and meningeal or cerebral lobe tractions, with low complication rates using a minimally invasive surgical route.

Background: Recently, the transcanal approach for the removal of acoustic neuromas has been introduced. Facial nerve (FN) preservation is one of the main challenges of this kind of surgery. Objective: To describe our experience in the surgical treatment of acoustic neuromas, focusing on the functional results of FN preservation after a transcanal approach. Methods: A retrospective chart review was carried out on clinical data and videos from operations on 49 patients who underwent surgery with a totally transcanal exclusive endoscopic approach for Koos stage I-II lesions, or an enlarged transcanal transpromontorial approach for Koos stage II-III tumors, between March 2012 and February 2017. Patients and tumor characteristics, clinical manifestations, radiologic features, audiological results, FN outcomes (according to the House-Brackmann [HB] grading system) and complications were evaluated. Tumors were classified according to the Koos grading system. Results: The age of the patients (34 females and 15 males) ranged from 27 to 77 years (mean age: 54.9 yr). Preoperative diagnosis was "vestibular schwannoma" in all patients. At the last follow-up (range 1-60 mo, mean 13.9 mo), 42 of 49 showed grade I HB FN function, 5 of 49 grade II HB, and 2 of 49 grade III HB. Overall, in 95.9%, FN function was preserved (grade I-II HB) with stable results at follow-up; in 4.1% of cases, FN function was reduced, but not worse than grade III. Conclusion: The transcanal approach represents a feasible, minimally invasive, and conservative technique for the management of acoustic neuromas of the internal auditory canal.

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The aim of this study is to investigate the contribute of the endoscopic exclusive transcanalar approach for the management of stapes malformations. A retrospective chart review was made at our tertiary referral centers. 17 patients with stapes malformations underwent surgery with endoscopic exclusive transcanal approach. A complete audiological and radiological assessment before and after surgery was performed. 12/17 (70%) underwent a surgical endoscopic correction, In case of fixed platina underwent five endoscopic stapedotomy and one endoscopic stapedectomy were performed. In case of mobile platina five endoscopic ossiculoplasties with partial ossiculoplasty replacement prosthesis were performed, 3 with autologous remodeling incus and 2 with malleus head remodeling. In 1 case, only an endoscopic stapes mobilization was made. In 5/17 (30%), due to difficult anatomical findings an endoscopic explorative tympanotomy was finally performed. The mean preoperative air conduction (AC), bone conduction (BC) and air-bone gap (ABG) were, respectively, 60.7, 26.3 and 34.4dB. The mean postoperative AC, BC and ABG were, respectively, 33.8, 26.5 and 7.3dB, with a mean improvement of the ABG of 27.1dB. Discharge from hospital was on the first post-surgery day. No relevant postoperative complications were noted. The median follow-up was 3.6years (range 1–6). The endoscopic approach results very adequate for the diagnosis and treatment of stapes malformations, checking variations of the ossicles conformation and functioning and performing safe surgery, under direct control of middle ear structures.

Objective: To define a new surgical option, with lower morbidity, for the treatment of intralabyrinthine schwannomas. Study design: Retrospective case review. Setting: Tertiary referral centers. Patients: Eight patients affected by an intralabyrinthine schwannoma, with or without extension to the internal auditory canal, that underwent surgery with a transcanal transpromontorial approach, were included in the study. The average age at presentation was 47years. Patients’ characteristics, symptoms, tumor features, and surgical results were analyzed. Interventions: All patients were diagnosed and evaluated pre-operatively with high-resolution, gadolinium-enhanced MRI and CT scan of the temporal bone, and underwent surgery via either transcanal transpromontorial endoscopic approach (TTEA) or enlarged transcanal transpromontorial endoscopic approach (ETTA). Main outcome measures: Hearing function was evaluated with the Hearing Classification System according to the Committee on Hearing and Equilibrium Guidelines. Facial nerve function was evaluated using the House–Brackmann grading system (HB). Results: In six patients out of eight, a TTEA was performed, whereas, due to the extension of the pathology to the cerebellopontine angle, two patients underwent an ETTA. The mean follow-up period was 15.5months (range 1–69). No intra-operative and post-operative major complications were observed. Post-operative facial nerve function was normal in seven out of eight patients (grade I HB). One patient presented a grade II HB. Conclusion: The endoscopic approach to cochlear schwannoma represents a good treatment option for patients and should be preferred to other more invasive surgical techniques when indicated, to reduce complications, hospitalization, and offer to patients the chance to eradicate the disease, thus avoiding the stress of a long-life radiological follow-up. Level of evidence: 4.

Hypothesis Ossification of the cochlea was once considered to be a contraindication for cochlear implantation. Advances in cochlear implant technology and coding strategies have led to developments in different surgical procedures to manage cochlear ossification. The endoscopic technique allows a direct approach to the round window and the cochlea, especially in remodeled labyrinth, allowing a better vision of scala tympani. Background Tertiary referral ENT center. Methods Between January 2011 and February 2015 three patients with far advanced otosclerosis with partial obliteration of the cochlea were selected and underwent endoscopic-assisted cochlear implantation. Results In far advanced otosclerosis, endoscopy allowed a magnification of the anatomy of the round window, permitting the surrounding anatomical structures forming the anatomy of the niche to be identified, and avoiding a blind dissection. No postoperative complications were noted, in particular, no surgical site infection, no vertigo, and no facial nerve injuries. Implant activation was routinely performed 1 month after surgery. All monitoring till date has indicated that the external auditory ducts are well ventilated and there are no signs of extrusion. Conclusions Ossification may occur as a consequence of the pathology of meningitis, chronic otitis media, severe otosclerosis, autoimmune inner ear diseases, temporal bone traumas, and other diseases. Advances in cochlear implant technology and coding strategies have led to developments in different surgical procedures to manage cochlear ossification. Supported by a number of years of experience in the field of otoendoscopic surgery, we propose a technique for cochlear implantation under unfavorable conditions using endoscopic-assisted surgery, especially in advanced otosclerosis. This technique permits us to extend the indication for cochlear implantation, and in our opinion will reduce the morbidity associated with this surgical procedure.

Objectives The aim of the present study is to describe our experience in the management of tympanic cavity cholesteatoma in pediatric patients, treated with endoscopic exclusive transcanal approach. Methods A chart review of clinical data and videos from the operations of 54 pediatric patients, undergoing surgery between January 2007 and December 2013, was made. Patients presenting with cholesteatoma involving the tympanic cavity (mesotympanum, epitympanum, protympanum and/or hypotympanum), with no mastoid involvement, were included in the first group and underwent an exclusive transcanalar endoscopic approach (TEA). In case of mastoid extension of the pathology, patients were included in the control group and underwent a canal wall up microscopic technique (CWU). Results In this study, 34 males and 20 females, including 5 bilateral cases, giving a total of 59 ears, were reviewed. Median age was 9.6 years (range 4–16 years). 31 cholesteatomas underwent a TEA approach, while 28 underwent a CWU approach, based on inclusion criteria. No differences from congenital vs acquired form was made, due to the difficult to correctly distinguish always the two forms. The ossicular chain was preserved in 26.6% of patients (16 ears): 42% of patients (13 ears) undergoing a transcanal endoscopic approach and 10% of patients undergoing a canal wall up microscopic approach (3 ears) ( P = 0.006). Second look surgery was executed in 41.6% of patients (25 ears). In partial ossicular prosthesis reconstructions, the mean preoperative pure-tone average was 29.4 dB, while the mean postoperative pure-tone average was 27.1 dB, with a mean increase of 2.3 dB. In total ossicular prosthesis reconstructions, the mean preoperative pure-tone average was 47.8 dB, while the mean postoperative pure-tone average was 26.5 dB, with a mean increase of 21.3 dB. Recurrence rate was 12.9% (4 ears) for the transcanal endoscopic approach group and 17.2% (5 ears) for the canal wall up microscopic approach. Residual disease was present in 26.6%: 19.3% (6 ears) for the transcanal endoscopic approach group and 34.4% (10 ears) for the canal wall up microscopic approach. The mean follow up was 36 months (range 8–88). Kaplan–Meier analysis at 36 months showed a lower recurrence risk for the transcanal endoscopic approach compared with the canal wall up microscopic approach, but this data was not statistically significant ( P = 0.58). Conclusion The transcanal endoscopic approach represents a feasible, minimally invasive and conservative technique for the management of pediatric middle ear cholesteatoma.

The aim of present study is to describe the use of the endoscopic assisted cochlear implant approach in cases with severely malformed temporal bones and with anomalous anatomy of the inner ear and tympanic cavity. Eight patients with malformed middle and inner ear and bilateral profound hearing loss were operated using an endoscopic assisted cochlear implant procedure at our tertiary university referral center between January and September 2013. Five patients received a cochlear implant using a suprameatal endoscopic assisted approach. A chart review of clinical data and videos from the operations was performed. All procedures were re-analyzed and codified. In all patients, discharge from hospital was on the third day post-surgery. No immediate or late postoperative complications were noted. The current mean follow-up is 6months, with range between 4 and 12months. This approach proved to be successful in cochlear implant placement. It guaranteed a very good control on the facial nerve, even in cases with difficult anatomical conditions, mainly thanks to the endoscopic procedure. It also permitted an appropriate anatomical orientation of the abnormal middle ear with a direct safe cochleostomy, when the round window position would have been difficult to treat using a traditional approach.

Facial nerve hemangiomas are rare benign tumors arising from the venous plexus surrounding the facial nerve. Surgical management of these tumors is controversial. The goal of surgery is complete tumor removal with restoration of facial nerve function and preservation of hearing, wherever possible. The approaches most used are the translabyrinthine and middle cranial fossa approaches. In this report, we describe the first facial hemangioma treated with an endoscopic transcanal approach, combined with a retroauricular transmastoid minicraniotomy for closure of the dural defect. A great auricular nerve graft was used to reconnect interrupted nerve segments. Histopathological examination confirmed the diagnosis of a hemangioma of the first genu of the facial nerve. With magnification of the structures, the transcanal endoscopic approach allowed a radical excision of the neoplasm permitting hearing function preservation, with the possibility to work with a minimally invasive approach with respect to the labyrinthine block and cochlea. Compared to a middle cranial fossa approach, the transcanal endoscopic approach avoided labyrinthine block removal and brain retraction.

We report the case of a 5-year-old boy affected by a CMF of the ethmoid sinus invading the papyracea and ethmoidal roof. This is the second case of acquired CMF involving the sinonasal spaces in a pediatric patient. Although this neoplasm is very uncommon, particularly in young patients and at this anatomical site, it is very important to correctly diagnose these tumors for adequate treatment, which generally consists of surgical resection. © 2013 Elsevier Ireland Ltd.