[Inverted papilloma of the nose and paranasal sinuses : Diagnosis, treatment, and malignant transformation]

Inverted papilloma (IP) are benign tumors that show a locally aggressive behavior, a high rate of recurrence, and a potential for malignant transformation. Specific radiological signs such as hyperostosis at the origin of the IP and convoluted cerebriform patterns, as well as the typical endoscopic aspect, can lead to diagnosis and enable preoperative planning of surgical access and the extent of surgery. Endonasal endoscopic techniques are considered the gold standard and the introduction of extended surgical techniques such as the prelacrimal approach, frontal drillout, or orbital transposition facilitate complete subperiosteal resection with preservation of important physiological structures. There is a risk of synchronous and metachronous squamous cell carcinomas (IP-SCC). Research focuses on radiological criteria to differentiate benign IP from IP-SCC, genetic and epigenetic factors in the process of malignant transformation, and estimation of the risk of IP progressing to IP-SCC.

Surgical Outcomes of Full Endoscopic Posterior Cervical Foraminotomy for Proximal Cervical Spondylotic Amyotrophy

STUDY DESIGN

Retrospective analysis of case series.

PURPOSE

This study aimed to clarify the effects of full endoscopic posterior cervical foraminotomy (FPCF) on cervical spondylotic amyotrophy (CSA).

OVERVIEW OF LITERATURE

The method for decompressing the ventral nerve root and anterior horn (AH) in CSA is controversial.

METHODS

Patients without myelopathy who underwent FPCF for proximal CSA between 2017 and 2022 were analyzed. The outcome measure was the results of the manual muscle testing (MMT) of the deltoid and biceps. Preoperative nerve root and AH compression were evaluated by magnetic resonance imaging. The intervertebral foramen morphology and bony decompression extent were evaluated by computed tomography.

RESULTS

FPCF was performed at the C4/5 level and at the C4/5 and C5/6 levels in 14 and 11 patients, respectively. The width of the narrowest intervertebral foramen was significantly narrower on the affected side than on the healthy side at the C4/5 (2.5 mm vs. 3.6 mm) and operated C5/6 (1.9 mm vs. 3.1 mm) levels. AH compression occurred at the C4/5 and C5/6 levels in 28% and 21% of the patients, respectively. Bony decompression was performed laterally beyond the narrowest foramen at the C4/5 and C5/6 levels in 96% and 91% of the patients, respectively. Compared with patients without AH compression, in those with AH compression, the lamina was resected medially by an average of >1.7 mm and >3.6 mm at the C4/5 and C5/6 levels, respectively. Furthermore, 76% and 81% of the facet joint surfaces were preserved at the C4/5 and C5/6 levels, respectively. Postoperative MMT grade improvement was excellent, good, and fair in 64%, 20%, and 16% of the patients, respectively.

CONCLUSIONS

FPCF was effective for treating proximal CSA.

Comparison of the effectiveness and safety of the "endoscope-assisted polypropylene mesh lift" and "gliding brow lift" techniques for the treatment of lateral brow ptosis

BACKGROUND

There are many techniques used to treat lateral brow ptosis. This study compared two techniques that are used for lateral brow rejuvenation in terms of effectiveness and safety-namely, endoscope-assisted polypropylene mesh lift (EAML) and gliding brow lift (GBL).

METHOD

Eighty-six patients who underwent brow lift surgery between March 2018 and June 2020 were included in this retrospective study. Forty-four patients were operated on using the EAML technique, whereas 42 patients were operated on using the GBL technique. The measurement of defined distances in photographs was carried out using a software, and the Brow Positioning Grading Scale (BPGS) and Global Aesthetic Improvement Scale (GAIS) were applied in the pre and postoperative periods.

RESULTS

The measurement results obtained in the postoperative period were better than those obtained in the preoperative period for both the techniques, whereas the results obtained at postoperative month 3 were found to be better than those obtained at month 12 (p < 0.05). The results were similar between the measurements at postoperative months 3 and 12 for both the techniques. The loss of brow height from postoperative months 3-12 was greater in the GBL group (p < 0.05). The postoperative scores on the BPGS were found to be better in both techniques than the preoperative scores (p < 0.05). The GAIS score at postoperative month 12 was found to be better in the EAML group. The two groups had similar rates of complications.

CONCLUSION

The two techniques were found to have similar effectiveness and safety profiles for brow rejuvenation.

LEVEL OF EVIDENCE: 4

Outcomes of endoscopic percutaneous suture lateralization for neonatal and infantal bilateral vocal ford paralysis

OBJECTIVE

Bilateral Vocal Fold Paralysis (BVFP) is a rare but significant resource of respiratory distress in neonates and infants. The objective of this study was to evaluate the efficacy and functional outcomes of Endoscopic Percutaneous Suture Lateralization (EPSL) for the treatment of BVFP in neonates and infants.

METHODS

A case series study of nine patients undergoing EPSL for BVFP between January 2019 and June 2021 was conducted. All patients were candidates for tracheostomy prior to EPSL. Demographic features including gender, age at diagnosis and surgery, main symptoms, airway comorbidities, airway support, and etiology were collected preoperatively. Patients were evaluated for breathing, swallowing and phonation postoperatively. Surgical success was defined as the ability to avoid tracheostomy. Functional Endoscopic Evaluation of Swallowing (FEES) was conducted to identify aspiration. Voice evaluation was based on clinical observation.

RESULTS

Nine patients underwent ten EPSL procedures (one in the left vocal fold, and nine in the right vocal fold). Eight patients (8/9) were able to successfully avoid tracheostomy and feed orally without aspiration after the procedure. One patient experienced clinical improvement in respiratory support requirements and underwent laparoscopic nissen and gastrostomy tube placement. At the last follow-up, two patients regained normal voice, two patients had mild dysphonia, and five patients had moderate dysphonia. Five patients showed partial return of the contralateral vocal fold function.

CONCLUSION

EPSL is an effective and safe treatment for neonatal and infantal BVFP, which enables patients free from tracheostomy without significant impact on swallowing function or phonation.

LEVEL OF EVIDENCE

Level 4.

Use of nasal mucosa graft in tympanoplasty

INTRODUCTION

Tympanoplasty techniques with different types of graft have been used to close tympanic perforations since the 19th century. Tragal cartilage and temporalis fascia are the most frequently used types of graft. They lead to similar functional and morphological results in most cases. Although little published evidence is present, nasal mucosa has also been shown to be a good alternative graft.

OBJECTIVE

Surgical and audiological outcomes at the six-month follow-up in type I tympanoplasty using nasal mucosa and temporalis fascia grafts were analyzed.

METHODS

A total of 40 candidates for type I tympanoplasty were randomly selected and divided into the nasal mucosa and temporalis fascia graft groups with 20 in each group. The assessed parameters included surgical success; the rate of complete closure of tympanic perforation and hearing results; the difference between post- and pre-operative mean quadritonal airway-bone gap, six months after surgery.

RESULTS

Complete closure of the tympanic perforation was achieved in 17 of 20 patients in both groups. The mean quadritonal airway-bone gap closures were11.9 and 11.1 dB for the nasal mucosa and temporalis fascia groups, respectively. There was no statistically significant difference between the groups.

CONCLUSION

The nasal mucosa graft can be considered similar to the temporal fascia when considering the surgical success rate of graft acceptance and ultimate audiological gain.

Evaluation of the factors affecting the necessity for revision surgery in choanal atresia

OBJECTIVE

This study aims to compare the effects of different surgical techniques for congenital choanal atresia (CCA), and particular emphasis is given to the analysis of the factors affecting the surgical outcome. The necessity for revision surgery and surgical outcomes were retrospectively investigated in patients undergoing revision surgery according to a recently proposed classification system.

MATERIAL AND METHOD

A retrospective study was conducted on patients operated for CCA between January 2007 and December 2018 at a university hospital. Data in the medical records, including patient age when the initial surgery was performed, gender, additional anomalies and medical conditions, the duration of gestation, side and type of atresia, type of surgery and need for revision surgery were reviewed.

RESULTS

Forty-five patients treated for CCA in our university hospital were screened. The mean follow-up duration was 82.16 months. Revision surgery was required in 9 of 26 cases, which are included in the study (34.6%). Fourteen patients presented with bilateral CCA, while 12 were unilateral cases. Sixteen patients (61.5%) had comorbid medical conditions. While the removal of vomer and mucoperiosteal flap use affects successful surgical repair, no differences were observed in choanal atresia type, laterality, use of stent and the presence of additional medical conditions.

CONCLUSION

The most important factors affecting surgical success for CCA are the removal of the vomer and closure of all bare bone tissues using a mucoperiosteal flap. Use of stents provides no additional benefit, apart from preventing synechiae formation.

[Endoscopic ear surgery in Germany : Survey on the current situation and an international comparison]

BACKGROUND

Endoscopic ear surgery (EES) has become firmly established internationally. In Germany this technology is controversially discussed and used very differently. Therefore, a survey was carried out on the availability, indications, contraindications, and future significance of EES.

METHODS

A questionnaire with 20 questions was sent to 141 German university and central departments of otorhinolaryngology, head and neck surgery. The results are discussed on the basis of current literature retrieved in a search of PubMed and Google Scholar.

RESULTS

The response rate was 32% (45 clinics). Of these respondents, 27 clinics (60%) stated that EES was usually carried out as an accompanying measure. Only one clinic performed ear surgery endoscopically alone. In cases of intraoperative bleeding, mastoid drilling, or if bimanual work was required, the surgeons switched to microscopic ear surgery (MES). The most common indications for EES were tympanoscopy, cholesteatoma, retraction pockets, and interventions on the tympanic membrane and external auditory canal. The necessary resources for EES were estimated to be higher than for MES in 49-50% of the responding clinics. Tragus cartilage dominated as the graft material for reconstruction in EES clinics, at 78%. Only 4 of 45 responding clinics rated the future significance of ESS in Germany as high.

CONCLUSION

Although EES is used in Germany, only few ENT clinics use it extensively. Reservations relate to one-handed working, drilling, management of bleeding, and the expected high resource demand. Thus, EES in Germany is often performed as an accompanying procedure, with switching between EES and MES.

Results of Endoscopic Surgery in Patients with Pituitary Adenomas : Association of Tumor Classification Grades with Resection, Remission, and Complication Rates

Objective

The endoscopic endonasal transsphenoidal approach is a widely-used method for the surgical treatment of pituitary adenomas. We aimed to evaluate the results of endoscopic surgery by comparing preoperative classification methods and investigating their relationship with postoperative resection and remission rates and complications.

Methods

We retrospectively reviewed the medical records of 236 patients (118 males) who underwent surgery for pituitary adenomas. Preoperative Knosp classification, tumor size (TS), suprasellar extension (SSE), postoperative resection and remission rates, and complications were evaluated.

Results

The follow-up period was 3 months to 6 years. The patients’ ages ranged between 16 and 84 years. Endocrinologically, 114 patients (48.3%) had functional adenoma (FA), and 122 patients (51.7%) had non-functional adenoma (NFA). Among the FA group, 92 (80.7%) showed remission. A statistically significant difference was found between patients with and without remission in terms of the Knosp, TS, and SSE classifications (p<0.01). Knosp, TS, and SSE classification grades were found to be correlated with the resection rates (p<0.01). Meningitis was seen in seven patients (3.0%), diabetes insipidus in 16 (6.9%; permanently in two [0.9%]), and rhinorrhea in 19 (8.1%). Thirty-six patients (15.3%) developed pituitary insufficiency and received hormone replacement therapy.

Conclusion

The resection categories and remission rates of FAs were directly proportional to the adenoma sizes and Knosp grades, while the degree of suprasellar growth further complicated resection and remission rates. Adenoma sizes less than 2 cm and SSEs less than 1 cm are associated with favorable remission and resection rates.

Endoscopic-assisted pediatric transcutaneous bone-anchored hearing implant: how I do it

BACKGROUND

Conventional technique for transcutaneous bone-anchored hearing implants surgery requires the elevation of a large retroauricular skin flap to expose the site of implantation, that may cause a large scar and the interruption of retroauricular vasculature.

METHODS

A less invasive, endoscopic-assisted modification of the surgical technique is described, which provides access to the implant site through two small skin incisions and the creation of a pocket in the retroauricular area.

CONCLUSION

Endoscopic-assisted bone-anchored hearing implant surgery could be a viable option for transcutaneous bone-anchored hearing implant surgery, especially for pediatric patients.

Comparison of Single Incision Endoscopic Nipple-Sparing Mastectomy and Conventional Nipple-Sparing Mastectomy for Breast Cancer Based on Initial Experience

Purpose

Endoscopic breast surgery for patients with breast cancer was introduced for its superior cosmetic outcomes; it was initially studied in the field of breast-conserving surgery and, more recently, in robotic-assisted nipple-sparing mastectomy (NSM). The main purpose of this study was to investigate the feasibility and safety of endoscopic NSM (E-NSM) in patients with breast cancer by comparing E-NSM and conventional NSM (C-NSM).

Methods

Between May 2017 and October 2020, we retrieved the records of 45 patients who underwent NSM with permanent silicone implants and divided them into the E-NSM group (20 patients) and the C-NSM group (25 patients), depending on the use of the endoscopic device. We also analyzed demographic information, pathology, operative time, and complications.

Results

No significant differences were observed between the 2 groups based on demographic information, postoperative pathological data, mean length of hospital stay, and total number of complications. The mean preparation time for surgery was comparable between both groups. Compared to the C-NSM group, the E-NSM group had a significantly longer mean operative time and, subsequently, a significantly longer mean total operative time and number of complications.

Conclusion

The results showed that E-NSM was feasible and safe with a more inconspicuous incision in patients with breast cancer.

The Technical Feasibility of Unilateral Biportal Endoscopic Decompression for The Unpredicted Complication Following Minimally Invasive Transforaminal Lumbar Interbody Fusion: Case Report

Minimally invasive techniques for transforaminal lumbar interbody fusion (MIS-TLIF) are advantageous because they allow for sufficient surgical exposure and fewer complications through a smaller incision than conventional TLIF. It could be difficult to maintain minimally invasive spine surgery following the unexpected complications after MIS-TLIF. Because MIS-TLIF is usually done via a paramedian small incision with posterior fusion using screws and rods, visualization of the surgical field is limited, and it is difficult to directly assess the neural structure without removing instrumentation. Unilateral biportal endoscopic decompression (UBE) is a rapidly growing surgical method using two 1-cm incisions that are 2 to 3 cm apart. We would like to suggest UBE as an option for immediate reoperation after MIS-TLIF because it has the advantages of targeting pathologic regions and a wide field of visualization through small wounds. The operation is independent of the existing incision from MIS-TLIF, enabling immediate revision surgery without the removal of the screws and rods. UBE has the advantages of targeting specific surgical regions and providing a wide visualization of the operation field through small incisions. UBE can be very useful for discectomy or decompression surgery as well as in immediate reoperation after MIS-TLIF.

Endoscopic Endonasal Approach to Foramen Magnum Meningioma: Two-Dimensional Surgical Video

Even for the most experienced neurosurgeons, foramen magnum meningiomas represent a surgical challenge owing to their delicate position surrounded by the brainstem, lower cranial nerves, and vertebral arteries. The treatment goal is gross total resection, but choosing the most appropriate approach is crucial. Basically, 3 surgical approaches are commonly used: posterolateral approach (far-lateral), anterolateral approach (extreme-lateral), and posterior midline approach. However, over the years, skull base surgery has evolved from standard open craniotomies to the use of microscopes and, more recently, to the development of endoscopic techniques. The endoscopic endonasal approach (EEA) permits a direct extradural route without brain retraction and shorter postoperative recovery. In contrast to the oral route, the soft palate and retropharyngeal soft tissues are preserved, allowing patients to resume a regular diet on the first postoperative day. Despite the advantages, the EEA is yet not widely used for treating foramen magnum meningiomas, even in cases where EEA use is possible. The EEA is feasible especially in cases with no vascular encasements and with a limited inferior extension allowing minimal manipulation of lower cranial nerves. Care must be taken with tumors with a more lateral and caudal extension (below the tip of the odontoid process), when a far lateral approach may be the best approach. In this surgical Video 1, we present the surgical details with a stepwise narrative of the EEA for ventrolateral foramen magnum meningiomas through an illustrative case of a 48-year-old woman. Institutional informed consent was obtained for surgery and publication of this video.

The short-term outcomes of laparoscopic-endoscopic cooperative surgery for colorectal tumors (LECS-CR) in cases involving endoscopically unresectable colorectal tumors

PURPOSE

Laparoscopic and endoscopic cooperative colorectal surgery (LECS) is widely used for the removal of endoscopically unresectable colonic polyps. We evaluated the invasiveness of LECS in comparison to conventional laparoscopic surgery (CLS) for endoscopically unresectable colorectal tumors.

METHOD

We retrospectively analyzed the data of patients with colorectal adenoma or mucosal cancer and submucosal tumors who underwent either LECS or CLS at a single, high-volume center in Japan between 2004 and 2017. The short-term and oncological outcomes were compared between groups.

RESULTS

Of the 83 eligible patients, 15 underwent LECS and 68 underwent CLS. There was no conversion to open surgery in either group. En bloc resection was achieved in all cases in both groups. The median time to solid diet intake was the same in both groups (2 days, p = 0.39). The median duration of hospital stay after surgery was 6 days (range 4-12 days) in the LECS group and 10 days (range 5-68 days) in the CLS group (p = 0.01). Clavien-Dindo grade ≥ 3 postoperative complications only occurred in the CLS group (two cases, p = 0.37).

CONCLUSION

Our results indicated that LECS is a safe and feasible technique that results in high-quality colorectal polyp resection with quicker recovery and favorable 30-days postoperative outcomes.

Evaluation of Dimensions of Kambin's Triangle to Calculate Maximum Permissible Cannula Diameter for Percutaneous Endoscopic Lumbar Discectomy : A 3-Dimensional Magnetic Resonance Imaging Based Study

Objective

To evaluate 3-dimensional magnetic resonance imaging (MRI) of Kambin’s safe zone to calculate maximum cannula diameter permissible for safe percutaneous endoscopic lumbar discectomy.

Methods

Fifty 3D MRIs of 19 males and 31 females (mean, 47 years) were analysed. Oblique, axial and sagittal views were used for image analysis. Three authors calculated the inscribed circle (cannula diameter) individually, within the neural (original) and bony Kambin’s triangle in oblique views, disc heights on sagittal views and root to facet distances at upper and lower end plate levels on axial views and their averages were taken.

Results

The mean root to facet distances at upper end plate level measured on axial sections increased from 3.42±3.01 mm at L12 level to 4.57±2.49 mm at L5S1 level. The mean root to facet distances at lower end plate level measured on axial sections also increased from 6.07±1.13 mm at L12 level to 12.9±2.83 mm at L5S1 level. Mean maximum cannula diameter permissible through the neural Kambin’s triangle increased from 5.67±1.38 mm at L12 level to 9.7±3.82 mm at L5S1 level. The mean maximum cannula diameter permissible through the bony Kambin’s triangle also increased from 4.03±1.08 mm at L12 level to 6.11±1 mm at L5S1 level. Only 2% of the 427 bony Kambin’s triangles could accommodate a cannula diameter of 8mm. The base of the bony Kambin’s triangle taken in oblique view (3D MRI) was significantly higher than the root to facet distance at lower end plate level taken in axial view.

Conclusion

The largest mean diameter of endoscopic cannula passable through “bony” Kambin’s triangle was distinctively smaller than the largest mean diameter of endoscopic cannula passable through “neural” Kambin’s triangle at all levels. Although proximity of exiting root to the facet joint is always taken into consideration before PELD procedure, our 3D MRI based anatomical study is the first to provide actual maximum cannula dimensions permissible in this region.

Treatment for gastric ‘indefinite for neoplasm/dysplasia’ lesions based on predictive factors

BACKGROUND

Gastric ‘indefinite for neoplasm/dysplasia’ (IFND) is a borderline lesion that is difficult to diagnose as either regenerative or neoplastic. There is a need for guidance in the identification of a subset of patients, who have an IFND lesion with a higher risk of malignant potential, to enable risk stratification and optimal management.

AIM

To determine the clinical and pathologic factors for the accurate diagnosis of gastric IFND lesions.

METHODS

In total, 461 gastric lesions diagnosed via biopsy as IFND lesions were retrospectively evaluated. Endoscopic resection (n = 134), surgery (n = 22), and follow-up endoscopic biopsy (n = 305) were performed to confirm the diagnosis. The time interval from initial biopsy to cancer diagnosis was measured, and diagnostic delays were categorized as > 2 wk, > 2 mo, > 6 mo, and > 1 year. The IFND lesions presenting as regenerating atypia (60%) or atypical epithelia (40%) at initial biopsy were adenocarcinomas in 22.6%, adenomas in 8.9%, and gastritis in 68.5% of the cases.

RESULTS

Four clinical factors [age ≥ 60 years (2.445, 95%CI: 1.305-4.580, P = 0.005), endoscopic size ≥ 10 mm (3.519, 95%CI: 1.891-6.548, P < 0.001), single lesion (5.702, 95%CI: 2.212-14.696, P < 0.001), and spontaneous bleeding (4.056, 95%CI: 1.792-9.180, P = 0.001)], and two pathologic factors [atypical epithelium (25.575, 95%CI: 11.537-56.695, P < 0.001], and repeated IFND diagnosis [6.022, 95%CI: 1.822-19.909, P = 0.003)] were independent risk factors for gastric cancer. With two or more clinical factors, the sensitivity and specificity for carcinoma were 91.3% and 54.9%, respectively. Ten undifferentiated carcinomas were initially diagnosed as IFND. In the subgroup analysis, fold change (5.594, 95%CI: 1.458-21.462, P = 0.012) predicted undifferentiated or invasive carcinoma in the submucosal layers or deeper. Diagnostic delays shorter than 1 year were not associated with worse prognoses. Extremely well-differentiated adenocarcinomas accounted for half of the repeated IFND cases and resulted in low diagnostic accuracy even on retrospective blinded review.

CONCLUSION

More than two clinical and pathologic factors each had significant cut-off values for gastric carcinoma diagnosis; in such cases, endoscopic resection should be considered.

Angioleiomyoma in the Orbital Apex: A Case Report

A 56-year woman presented eyeball pain and blurred vision. MRI revealed a small well-delineated solid tumor in the apex of right orbit with optic nerve compression. Intraoperatively, the tumor was found very fibrous, hypervascular and adhesive to surrounding structures. The tumor was completely removed with the combination of endoscopic and microscopic technique. Patient experienced transient oculomotor nerve palsy, which completely recovered 3 months after surgery. Herein we report a rare case of angioleiomyoma in the orbital apex.

Clinical and Radiological Outcomes of Foraminal Decompression Using Unilateral Biportal Endoscopic Spine Surgery for Lumbar Foraminal Stenosis

Background

Since open Wiltse approach allows limited visualization for foraminal stenosis leading to an incomplete decompression, we report the short-term clinical and radiological results of unilateral biportal endoscopic foraminal decompression using 0° or 30° endoscopy with better visualization.

Methods

We examined 31 patients that underwent surgery for neurological symptoms due to lumbar foraminal stenosis which was refractory to 6 weeks of conservative treatment. All 31 patients underwent unilateral biportal endoscopic far-lateral decompression (UBEFLD). One portal was used for viewing purpose, and the other was for surgical instruments. Unilateral foraminotomy was performed under guidance of 0° or 30° endoscopy. Clinical outcomes were analyzed using the modified Macnab criteria, Oswestry disability index, and visual analogue scale. Plain radiographs obtained preoperatively and 1 year postoperatively were compared to analyze the intervertebral angle (IVA), dynamic IVA, percentage of slip, dynamic percentage of slip (gap between the percentage of slip on flexion and extension views), slip angle, disc height index (DHI), and foraminal height index (FHI).

Results

The IVA significantly increased from 6.24° ± 4.27° to 6.96° ± 3.58° at 1 year postoperatively (p = 0.306). The dynamic IVA slightly decreased from 6.27° ± 3.12° to 6.04° ± 2.41°, but the difference was not statistically significant (p = 0.375). The percentage of slip was 3.41% ± 5.24% preoperatively and 6.01% ± 1.43% at 1-year follow-up (p = 0.227), showing no significant difference. The preoperative dynamic percentage of slip was 2.90% ± 3.37%; at 1 year postoperatively, it was 3.13% ± 4.11% (p = 0.720), showing no significant difference. The DHI changed from 34.78% ± 9.54% preoperatively to 35.05% ± 8.83% postoperatively, which was not statistically significant (p = 0.837). In addition, the FHI slightly decreased from 55.15% ± 9.45% preoperatively to 54.56% ± 9.86% postoperatively, but the results were not statistically significant (p = 0.705).

Conclusions

UBEFLD using endoscopy showed a satisfactory clinical outcome after 1-year follow-up and did not induce postoperative segmental spinal instability. It could be a feasible alternative to conventional open decompression or fusion surgery for lumbar foraminal stenosis.

[Minimally invasive proximal hamstring insertion repair]

OBJECTIVE

Minimally invasive endoscopic reconstruction of avulsion injuries of the proximal hamstring insertion to prevent persistent weakness and pain.

INDICATIONS

Fresh retracted 2‑ and 3‑tendon avulsion injuries of the proximal hamstring insertion. Unsuccessful conservative therapy of less retracted injuries. Painful chronic partial lesions of the proximal hamstring insertion.

CONTRAINDICATIONS

Major comorbidities with an increased surgical risk, older patients with low functional demands. Chronic injuries without functional deficits.

SURGICAL TECHNIQUE

Endoscopic refixation using suture anchors after freshening the footprint on the tuber ischiadicum. Visualization of the sciatic nerve to ensure its protection.

POSTOPERATIVE MANAGEMENT

Partial loading with a knee brace for strict prevention of combined knee extension and hip flexion for 4-6 weeks. Start of active exercise and stretching 8 weeks postoperatively.

RESULTS

From 2014-2016, 12 patients were treated with an endoscopic reconstruction of the proximal hamstring insertion. After a mean follow-up of 25 months (range 16-34 months), an average visual analog scale (VAS) of 0 (range 0-2) and an average subjective assessment of function (Subjective Hip Value) of 94% (range 80-100%) were found. No neurovascular complications were seen in our collective, in particular no evidence of hypesthesia in the area of the posterior femoral cutaneous nerve. All patients were able to return to their original level of activity (Tegner Activity Scale 5.2 preoperatively vs. 5.2 postoperatively), while the average time until return to sport was 6.5 months (range 3-12 months). All patients were able to return to their original occupation.

Repair of Anterior Skull Base Defect by Dual-Layer/Split-Frontal Pericranial Flap

INTRODUCTION

Normal skull base structures are destroyed either by the skull base pathology itself or during surgery that results in cerebrospinal fluid (CSF) leak. Skull base repair is usually performed transnasally by using a nasal septal flap. But when NSF is not available and failed repeated transnasal repair, a cranionasal repair with frontal pericranial flap (PF) can be attempted to achieve the highest successful chance. We performed a dual layer/split PF repair of a skull base defect using cranionasal approach and here we describe the technique.

CASE DESCRIPTION

A 74-year-old man suffered from CSF leak and ventriculitis after multiple transnasal surgeries for pituitary macroadenoma despite multiple repairs with intranasal vascularized flaps. We performed repair by cranionasal approach and using frontal PF. The frontal PF was divided into left and right halves. The left half went intradural, through the chiasmatic window to reach the sella and cover the tubercular and sellar defect from above. The right half went through the nasion into the nose to cover the defect from below. So the defect was covered by two vascularized flap from a single frontal PF. The repair was successful with no CSF leak and infection successfully treated by antibiotics.

CONCLUSION

We introduced the cranionasal dual layer/split PF technique to repair anterior skull base and successfully stopped the CSF leak in a patient after multiple EEA surgeries. This technique should only be considered in specific difficult situation where usual repair by EEA is impossible.

[Endoscopic triple neurectomy for tumor-induced inguinal pain syndrome]

We report on an endoscopic triple neurectomy in a female patient with vulvar carcinoma metastasized to the left groin with refractory neuropathic inguinodynia. Using a retroperitoneoscopic approach we resected the ilioinguinal, iliohypogastric, and genitofemoral nerves. The inguinodynia improved significantly; especially the reduced ability to walk was enhanced considerably. Endoscopic triple neurectomy could be a useful therapeutic option in refractory inguinal pain caused by local tumor manifestation.

Trans-sacral epiduroscopic laser decompression versus the microscopic open interlaminar approach for L5-S1 disc herniation

Context/Objective: Trans-sacral epiduroscopic laser decompression (SELD) is an alternative to microscopic open lumbar discectomy (OLD). SELD and OLD for L5-S1 lumbar disc herniation (LDH) have not been compared. We compared clinical results, including pain control, between SELD and OLD.Design: Retrospective analysis.Setting: Korean hospital.Participants: Eighty patients treated with SELD (n = 40) or microscopic OLD (n = 40) for L5-S1 LDH.Interventions: N/A.Outcome Measures: Clinical data were compared over 6 months. Functional status was evaluated using Oswestry Disability Index (ODI, 0-100%) and time to return to work. Preoperative and postoperative pain was measured using a visual analog scale (VAS, 0-10). Radiological assessment was performed preoperatively and postoperatively.Results: The ODI and VAS scores for leg and back pain significantly improved in both groups. At 6-months after the procedure, the average ODI decreased to 13.2 ± 11.2 from 54.5 ± 14.5 for SELD and 9.5 ± 10.4 from 57.5 ± 16.0 for OLD. The average leg VAS decreased to 1.9 ± 1.2 from 6.0 ± 1.4 for SELD and 2.3 ± 1.3 from 6.7 ± 1.6 for OLD. Back VAS reduced to 2.6 ± 1.3 from 7.2 ± 1.5 for OLD. Time to return to work was 1.1 ± 1.1 weeks for SELD and 5.4 ± 2.1 weeks for OLD. Clinical outcomes of SELD were non-inferior to those of OLD in terms of pain control.Conclusion: A scar-free procedure and early return to normal life are advantages of SELD.

Endoscopic transpterygoid approach to a mass in a child

The endoscopic transterygoid approach to the petrous apex is a feasible/alternative approach in carefully selected patients with specific favorable anatomy, even children. This approach, unlike traditional approaches, spares cochlear and vestibular function. We report a case of a six-year-old boy with embryonal rhabdomyosarcoma of the petrous apex that was diagnosed via the endoscopic transpterygoid approach.

Transnasal endoscopic ultrasound-guided reduction of maxillary sinus wall fracture

Surgical morbidity from open reduction and internal fixation (ORIF) of maxillary sinus wall fracture often surpasses the benefits of ORIF. Hence, the authors devised transnasal endoscopic-assisted reduction of maxillary sinus wall fracture (TERM) without internal fixation as a minimally invasive surgery for maxillary sinus wall fracture. The purpose of this study was to investigate the feasibility of TERM in cadavers and patients. Six cadavers were dissected to evaluate the feasibility of TERM. In addition, 20 patients with maxillary sinus wall fractures who underwent TERM in a tertiary hospital from August of 2013 to December of 2015 were enrolled in this study. Demographic factors, type of anesthesia, computed tomography (CT) scans, clinical characteristics of patients, and patient satisfaction with surgery were analyzed. Cadaveric study showed that endoscopic inferior meatus antrostomy is a feasible method of approaching the maxillary sinus wall in cadavers. In addition, counterforce could be applied to the maxillary sinus wall by pushing packed Vaseline-soaked gauze or using a zygomatic process approach via a Gillies incision. Clinical experience revealed that patients experienced good facial contour restoration postoperatively. The extent of fractured bony segments was reduced on postoperative CT without complications. Patient satisfaction with TERM was greater than that with ORIF (p = 0.031). TERM showed its feasibility in both cadaveric study and clinical study. TERM can be a good alternative to ORIF, especially in patients who are reluctant to undergo a facial incision.

A novel grasp-and-loop closure method for defect closure after endoscopic full-thickness resection (with video)

BACKGROUND

Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal (GI) lesions originating from the muscularis propria layer. Successful closure of the wall defect is a critical step.

OBJECTIVE

The aim of this study was to evaluate the feasibility and efficacy of a novel and simplified endoscopic grasp-and-loop (GAL) closure method using an endo-loop assisted with grasping forceps for defect closure.

METHODS

From January 2015 to March 2016, 13 patients with submucosal tumors (SMTs) originating from the muscularis propria (MP) layer underwent EFTR and were enrolled in this study. After successful tumor resection, an endo-loop was anchored onto the circumferential margin of the gastric defect with grasping forceps assistance and tightened gently. Patient characteristics, tumor size, en bloc resection, and postoperative complications were evaluated.

RESULTS

Of the 13 lesions in the stomach, two were located in the greater curvature of the mid-upper body, 11 were located in the fundus. The endoscopic GAL closure method was successfully performed after EFTR in all the 13 patients without laparoscopic assistance. The mean procedure time was 43.5 min (range 20-80 min), while the GAL closure procedure took a mean of 9.4 min (range 3-18 min). The mean resected lesion size was 1.5 cm (range 0.5-3.5 cm). Pathological diagnoses of these lesions were 11 gastrointestinal stromal tumors (GISTs) and two leiomyomas. No major adverse events occurred during or after the procedure. All the patients were discharged after a mean time of 2.4 days (range 1-4 days). No residual lesion or tumor recurrence was found during the follow-up period (median, 5 months; range, 1-15 months).

CONCLUSIONS

The endoscopic GAL closure method is feasible, effective, and safe for closing the gastric defect after EFTR in patients.

Endoscopic sinus surgery in adult patients with chronic rhinosinusitis with nasal polyps (PolypESS): study protocol for a randomised controlled trial

BACKGROUND

Chronic rhinosinusitis with nasal polyps is a chronic disease frequently seen in otorhinolaryngological practice. Along with its chronic disease burden it creates high societal costs. Therapy consists of long-term use of medication and, if insufficient, endoscopic sinus surgery. No consensus exists on the right timing and extent of disease that warrants surgery. Furthermore, there is lack of clinical knowledge about the benefit of surgery over medication only. The current trial evaluates the clinical effectiveness and cost-effectiveness of endoscopic sinus surgery in addition to drug treatment versus medication exclusively in the adult patient group with nasal polyps.

METHODS

A prospective, multicentre, superiority, randomised controlled (PolypESS) trial in 238 patients aged 18 years or older selected for primary or revision endoscopic sinus surgery by the otorhinolaryngologist was designed. Patients will be randomised to either endoscopic sinus surgery in addition to medication or medical therapy only. Relevant data will be collected prior to randomisation, at baseline and 3, 6, 12, 18 and 24 months after start of treatment. Complete follow-up will be 24 months. Primary outcome is disease-specific Health-related Quality of Life quantified by the SNOT-22 after 12-month follow-up. Secondary outcomes are generic Health-related Quality of Life, cost-effectiveness, objective signs of disease and adverse effects of treatment. Subgroup analyses will be performed to verify whether treatment effects differ among patient phenotypes.

DISCUSSION

The PolypESS trial will investigate tailored care in adult patients with chronic rhinosinusitis with nasal polyps and will result in improved clinical pathways to help to determine in which circumstances to perform surgery.

TRIAL REGISTRATION

Dutch Trial Register, NTR4978 . Registered on 27 November 2014.

Co-occurrence of Pituitary Adenoma with Suprasellar and Olfactory Groove Meningiomas

Introduction:

The co-existence of pituitary adenoma and meningioma is extremely rare. It is even rarer in patients with no previous known risk factors for either tumour. Here, we present a case of synchronous non-functioning pituitary adenoma with suprasellar and olfactory groove meningiomas in a patient without previous irradiation.

Methods:

The tumours were diagnosed on MRI in the 65-year-old patient who presented with patchy visual deficits. The decision was made to undergo surgery for resection of the suprasellar meningioma and the pituitary adenoma, leaving the small olfactory groove meningioma intact. Extended endoscopic transsphenoidal surgery was performed.

Results:

Macroscopic clearance was achieved for pituitary macroadenoma and suprasellar meningioma. Postoperatively, visual field tsting and pituitary axis hormonal levels were normal. The pituitary macroadenoma was confirmed to be a non-functioning pituitary adenoma. The meningioma was diagnosed to be of WHO grade 1.

Conclusion:

The rationale for choosing such management option, including its risks and benefits in this challenging patient is discussed.

Per Oral Endoscopic Myotomy in Children with Achalasia Cardia

Background/Aims

Achalasia cardia (AC) is a motility disorder, characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis. AC is rare in children with unclear optimum management strategies. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with encouraging results in adult patients. The efficacy and safety of POEM is not known for pediatric AC. The aim of our study was to evaluate the safety and efficacy of POEM in children with achalasia cardia

Methods

The data of all children (< 18 years) who underwent POEM at our center was retrospectively analysed. Symptoms were analysed using a validated score (Eckardt score) at regular predefined intervals. Objective parameters including high-resolution manometry, timed barium swallow and esophagogastroduodenoscopy were assessed before the procedure and at 1-year follow-up. Clinical success was defined as an Eckardt score ≤ 3.

Results

A total of 15 children underwent POEM during the specified period. Ten out of 15 (10/15) completed 1-year follow-up. Median operative time was 100 (38–240) minutes. Mean pre and post procedure LES pressure were 36.64 ± 11.08 mmHg and 15.65 ± 5.73 mmHg, respectively (P = 0.001). Mean Eckardt score before and after the POEM was 7.32 ± 1.42 and 1.74 ± 0.67, respectively (P = 0.001). Mean percentage improvement in barium emptying at 5 minutes was 63.70 ± 4.46%. All children had complete resolution of symptoms at 1 year. Median weight gain of children at 1 year was 0.65 kg (range, 0.0–4.6).

Conclusions

POEM is safe and effective for children and adolescents with achalasia. Future trials with larger sample size are warranted to establish its efficacy in pediatric AC.

[Surgical treatment of lumbar disc herniation]

OBJECTIVE

Herniated disc tissue removal to decompress the spinal nerve/cauda equina. Minimization of iatrogenic trauma and associated injuries.

INDICATIONS

Conservative treatment did not sufficiently improve clinical symptoms. This is true for progressive or persisting neurological deficits, as well as for persisting pain which alters the quality of the patient`s life. Results of surgery are strongly dependent on the preoperative duration of symptoms. Paramount is the "timing" of surgery: poorer surgical results associated with increasing preoperative duration of symptoms.

CONTRAINDICATIONS

Conservative treatment modalities have not been exhausted.

SURGICAL TECHNIQUES

There are 2 technologies (endoscopic/microsurgical) and 5 different approach strategies (endoscopic: interlaminar, transforaminal; microsurgical: interlaminar, translaminar, extraforaminal), whereby the choice is determined by morphology and location of the herniated disc. All techniques are minimally invasive and lead to comparable clinical results.

POSTOPERATIVE MANAGEMENT

For all techniques, patients are mobilized early. Light sports activities allowed after 2 weeks and return to work after about 4 weeks.

RESULTS

Good clinical outcomes in meta-analyses/large case series are between 80-95 %.

Accuracy of diagnostic demarcation of undifferentiated-type early gastric cancer for magnifying endoscopy with narrow-band imaging: surgical cases

BACKGROUND AND AIM

The usefulness of magnifying endoscopy with narrow-band imaging (ME-NBI) in undifferentiated-type early gastric cancers (UD-type EGCs) is unclear. This study investigated the accuracy of ME-NBI in the diagnostic demarcation.

METHODS

Among UD-type EGCs that were initially surgically resected between June 2011 and August 2014 in this hospital, 74 lesions were studied that were preoperatively diagnosed with white-light imaging (WLI) or endoscopic ultrasonography as lesions for which endoscopic treatment was not indicated and found to be early gastric cancers by postoperative pathology. The demarcation line was marked on the most oral and anal sides with argon plasma coagulation using WLI and ME-NBI, and the diagnostic demarcation of cancer was defined as correct, if consistent with the results of postoperative pathology. The length of extension into the proliferative zone, distance between crypts and inflammatory cell infiltration (updated Sydney classification: USC) were compared between the correctly diagnosed and the misdiagnosed cases.

RESULTS

The diagnosis was correct in 62 cases (83.8 %). The average distance between crypts in correctly diagnosed and misdiagnosed cases was approximately 1.9 and 1.3 times, respectively, that in normal mucosa (p < 0.0001). The accuracy of diagnosis was higher when atrophy and neutrophil and monocyte infiltration were mild according to the USC (p < 0.05). The additional use of ME-NBI improved the accuracy of diagnosis by 36.5 % compared with the use of WLI alone.

CONCLUSION

The use of ME-NBI in the preoperative diagnosis of the demarcation of cancer is useful to prevent postoperative positive surgical margins.

Successful endoscopic closure of a colonic perforation one day after endoscopic mucosal resection of a lesion in the transverse colon

A 73-year-old man underwent endoscopic mucosal resection (EMR) of a 20-mm flat elevated lesion on the transverse colon. The morning after the procedure, he started to have severe right upper quadrant pain after his first meal. A computed tomography scan revealed free air and a stomach filled with food. He was diagnosed to have delayed post-EMR intestinal perforation. He underwent emergent colonoscopy and clipping of the perforated site. He was discharged 8 d after the endoscopic closure without the need for surgical intervention. The meal was not the cause of the colon transversum perforation.

Prospective comparative study of endoscopic via unilateral axillobreast approach versus open conventional total thyroidectomy in patients with papillary thyroid carcinoma

BACKGROUND

Total thyroidectomy can be accomplished in one of two ways. The first is an open conventional approach, and the other is an endoscopic unilateral axillobreast approach (UABA). However, the two have not been thoroughly compared. In the study described herein, we compare the technical feasibility, safety, and surgical completeness of open versus endoscopic total thyroidectomy procedures.

METHODS

A total of 152 patients who underwent open (n = 102) or endoscopic (n = 50) total thyroidectomy via UABA for papillary microcarcinoma from January to December 2011 were enrolled in this study. Data were collected prospectively after obtaining informed consent. We analyzed the clinical characteristics, pathologic results, postoperative thyroglobulin (Tg) levels, and results of radioactive iodine treatment between the two groups.

RESULTS

We conclude that endoscopic thyroidectomy resulted in a younger age, lower body mass index, longer operation time and drain maintenance, and larger drain amount. There were no significant differences with respect to gender, hospital stay, tumor size, time for central compartment neck dissection, number of harvested ipsilateral lymph nodes, or bleeding amount between groups. The proportion of extrathyroidal extension, multifocality, and bilaterality did not differ, and the surgical complication rate was similar. In addition, the postoperative stimulated and non-stimulated Tg levels did not differ significantly, nor did the thyroid bed/brain iodine uptake ratio.

CONCLUSIONS

Based on our results, endoscopic total thyroidectomy via UABA is technically feasible and has comparable surgical completeness to open total thyroidectomy for papillary microcarcinoma within 1 cm.

Cost comparison between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors

Purpose

To compare medical costs of endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal tumors.

Methods

The records of 80 patients who underwent ESD and 32 who underwent TEM for the treatment of rectal tumors were collected. Factors compared in the two groups included patient age, sex and clinical characteristics, as well as hospital stay, procedure time, instrument use, medications, postoperative complications, and imaging and laboratory findings. Costs were analyzed based on medical insurance fees, as set publicly by the Ministry of Health & Welfare, Korea. Medical costs were also divided into patient copayments and National Health Insurance (NHI) Corporation charges.

Results

Patient characteristics, including age, sex, and comorbidities, were similar in the two groups, as were procedure time, histologic diagnosis, tumor size and distance from the anal verge, hospital stay, and complication rates. Median total hospital costs were significantly lower in the ESD than in the TEM group (1,214 United State dollars [USD] vs. 1,686 USD, P < 0.001). The costs for consumables, drugs and laboratory as well as operation fee were also significantly lower in the ESD than in the TEM group. However, patient copayments in the ESD group were significantly higher than in the TEM group (928 USD vs. 496 USD, P < 0.001), because ESD procedure for rectal tumors is not yet covered by the Korean NHI.

Conclusion

Overall direct medical costs were significantly lower for ESD than for TEM in the treatment of rectal tumors.

Early Outcomes of Endoscopic Vein Harvesting during the Initial Learning Period

Background

The endoscopic vein harvesting (EVH) method has been used in coronary artery bypass surgery in many countries. We started using the EVH method recently, and investigated the results during the early learning period.

Methods

Between March 2012 and June 2014, 75 patients (31 patients in the EVH method group, and 44 patients in the open method group) who underwent isolated first-time coronary artery bypass grafting using vein grafts were retrospectively analyzed with respect to the early outcomes including graft patency and risk factors for leg wound complications. For assessing the patency of vein graft, we performed coronary computed tomography angiography during the immediate postoperative period and 6 months later.

Results

Mean harvesting time of endoscopic method was about 15 minutes. Patency rate during the immediate operative period and the 6-month patency rate were similar between the two groups (postoperative period: EVH 100% vs. open method 94.4%, p=0.493; at 6 months: EVH 93.3% vs. open method 90.9%, p=0.791). Leg wound complications occurred more frequently in the open method group (EVH 3.2% vs. open method 13.6%, p=0.127). According to the analysis, age was an independent risk factor for leg wound complications.

Conclusion

EVH is a feasible method even for beginners and can be performed satisfactorily during their learning period.

Comparison of electrical current and ultrasonic device for incision of the septum of the pharyngoesophageal diverticulum in a pig model

BACKGROUND

Complications of endoscopic treatment of pharyngoesophageal diverticulum (PED) such as bleeding and perforation occur in up to 15 % of cases. Our objective was to compare incision of the PED septum using the ultrasonic device (group H) with incision using electrical current (group M) in a pig model.

METHODS

Twenty domestic pigs were divided into groups H and M. The incision of the PED septum was performed using the ultrasonic device or using electrical current, respectively. The procedural time, complication rate, length of the border of the incised septum, and thermal tissue damage were compared between groups.

RESULTS

Mean time to divide the septum and total procedure time were significantly shorter in group H. Mean length of the border of the incised septum was significantly higher in group H. The lateral thermal spread caused by electrical current (group M) was more intense. Hemorrhage was exclusively observed in group M.

CONCLUSION

Experimental endoscopic diverticulotomy using ultrasonic device was faster and caused less tissue damage when compared to electrical current.

Utility of the over-the-scope-clip system for treating a large esophageal perforation

We report here a case of esophageal perforation made by an endoscope while treating cicatrical stenosis that developed after wide circumferential dissection of superficial esophageal carcinoma. Perforation closure with a conventional endoclip was difficult as the perforation was large and the surrounding tissue was fragile as a result of steroids administration for stenosis prevention. To avoid surgical intervention, we employed the over-the-scope-clip system and successfully closed the perforation. The favorable outcome suggests the utility of the over-the-scope-clip system for closing perforations when conventional methods are ineffective.

Endoscopic therapies for Barrett's neoplasia

The standard of care for treatment of Barrett's esophagus (BE) with early esophageal neoplasia, including high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC), has undergone a revolution over the past several years. With the introduction and popularization of endoscopic ablative technologies, along with the refinement of endoscopic mucosal resection (EMR) techniques, the majority of cases of early neoplasia in the setting of BE now are managed by endoscopic approaches. As a result, many patients who previously would have been referred for esophagectomy now may be spared from this major surgical procedure with its inherent morbidity, potential for mortality, and negative impact on long-term gastrointestinal function. The esophageal surgeon must be knowledgeable about the indications for such endoscopic therapies, as well as their limitations and potential pitfalls, so as to apply them in the appropriate clinical scenarios.

Endoscopic dacryocystorhinostomy with flap suturing

Multiple reports have demonstrated the efficacy of endoscopic dacryocystorhinostomy (DCR). However the results of the same have varied from centre to centre. Many still regard external DCR as the gold standard. To describe an endoscopic DCR technique which anatomically simulates an external DCR and assess its results. Prospective, nonrandomized and noncomparative interventional case series. Clinical charts of patients with nasolacrimal duct obstruction based on symptomatic, clinical and radiological basis were included in the study. All surgeries were done endonasally using standard operative technique. The modification in the standard technique included creating a wide exposure of the lacrimal sac, incising the sac and the suturing the medial wall of the lacrimal sac with the lateral nasal wall. The same was achieved by using either vascular clips or 5.0 vicryl sutures. Twenty (11 females and 9 males) were included in the study. The average age of the patients was 56.86 years old (range 27-85 years old). The main presenting symptom was epiphora and 1 patient with mucocele. Successful outcome was measured in terms of relief of sympto anatomical patency assessed by sac syringing and nasal endoscopy showing a wide patent lumen. A primary success rate of 95% and ultimate rate of 100% was achieved in the cases with a nasolacrimal duct (NLD) block while an overall success rate of 82.6% was noted when the cases with NLD block and common canalicular block were considered together. Endoscopic DCR can now easily replace external DCR as a standard. It is not only minimally invasive, but has minimal complications and using this technique, we have been able to achieve very high success rates.

Low grade chondrosarcoma of the nasal septum

Chondrosarcoma of the nasal septum is extremely rare. In some cases, it may be difficult to preoperatively differentiate low grade chondrosarcoma from benign cartilaginous tumors such as chondroma. We report a case of low grade chondrosarcoma of the nasal septum with characteristic radiologic findings. Characteristic radiologic findings such as calcifications on computed tomography scan and a ring-and-arc pattern on enhanced T1 weighted image were useful in the preoperative diagnosis of low grade chondrosarcoma of the septum. Awareness of radiologic findings of low grade chondrosarcoma can help to make an accurate diagnosis and perform appropriate excision, leading to successful local control.

Fungus balls of the bilateral paranasal sinuses

We describe the clinical and radiographic characteristics of fungus balls in the bilateral paranasal sinuses. The medical records of 8 of 245 patients with fungus balls of the bilateral paranasal sinuses between 2000 and 2010 were retrospectively reviewed. The incidence of bilateral paranasal sinus fungus balls was 3.3%. Fungus balls were located in the maxillary sinuses bilaterally in 4 cases (50%), followed by the maxillary sinus and contralateral sphenoid sinus in 3 cases (37.5%), and the sphenoid sinuses bilaterally in 1 case (12.5%). There were no predisposing anatomic variations for the occurrence of bilateral paranasal fungus balls. Although the presenting symptoms and signs were non-specific, CT findings were helpful in the diagnosis of bilateral fungus balls. Endonasal removal by an endoscopic approach was performed in all patients. No peri-operative complications or recurrences were noted. Fungus balls in the bilateral paranasal sinuses are most frequently found in the maxillary sinuses bilaterally. Because symptoms of bilateral paranasal fungus balls and findings on nasal endoscopic examination are frequently non-specific, a high index of suspicion is needed and imaging studies, such as CT, are essential to establish the correct pre-operative diagnosis.