Endoscopic medial maxillectomy in patients treated at the Otorhinolaryngology and Laryngological Oncology Clinic of Military Institute of Medicine in Warsaw in the years 2008–2018

<b>Introduction:</b> Endoscopic medial maxillectomy (EMM) refers to surgical resection of the medial wall of the maxillary antrum. The primary indications for EMM are recalcitrant maxillary sinusitis, ablation of malignant and specific benign diagnoses such as Schneiderian Papilloma. Maxillectomy is potentially complicated by injuries to the orbital contents, lacrimal apparatus, optic nerve, ethmoidal arteries that may be accompanied by brisk bleeding. <br><b>Aim:</b> The purpose of this paper is to conduct a retrospective analysis of patients treated with EMM surgery at the Otorhinolaryngology and Laryngological Oncology Clinic of Military Institute of Medicine in Warsaw in the years 2008–2018. <br><b>Material and methods:</b> The retrospective analysis was conducted on patients who underwent EMM treated at the the Otorhinolaryngology and Laryngological Oncology Clinic of Military Institute of Medicine in Warsaw in the years 2008–2018. The research included 18 patients aged 15–94; 8 women and 10 men. <br><b>Results:</b> Out of 18 patients, 8 had been operated before EMM. 16 of them presented with histological examinations, though 5 of which were not confirmed with postoperative histological result. The most common indication for the operation was inverted papilloma. <br><b>Conclusion:</b> Endoscopic surgical approach is effective and precious way to manage tumors which involve the neighboring structures especially medial maxillary sinus. EMM itself is a safe surgical method in managing maxillary sinus disorders and is favored for its decreased invasiveness and avoidance of the deformity of face.

Frontal Ethmoidal Dural Arteriovenous Fistula: 2-Dimensional Operative Video

Anterior cranial fossa dural arteriovenous fistulas (DAVFs) are an infrequent subtype of cranial DAVFs. These lesions are most commonly derived from the ophthalmic artery. These lesions are often best treated utilizing endovascular embolization; however, this modality can be challenging because of the difficulty in catheterizing the ophthalmic or ethmoidal arteries. Surgical intervention is therefore indicated and requires approaching the proximal portion of the drainage vein to appropriately obliterate the fistulous point. For ethmoidal DAVFs, this is frequently along the dura of the cranial base adjacent to the cribriform plate. This patient had a right frontal hematoma with a typical ethmoidal DAVF. The fistula was exposed through a frontal craniotomy, and the ethmoidal branch was identified at the fistulous point. Intraoperative angiography was used to test for obliteration, which revealed a contralateral DAVF. The contralateral fistula was then obliterated in a similar manner, demonstrated on a second intraoperative angiogram. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Transorbital clipping of the ethmoidal arteries as a method of early devascularization in cranioorbital tumors removal

Objective: To improve the results of surgical treatment of patients with cranioorbital tumors. For this purpose, for patient with high vascularized tumor of ethmoidal bone, adjacent to the medial wall of the orbit, early devascularization as the first stage and transnasal endoscopic removal of the tumor as the second stage was performed. Tumor devascularization was performed by clipping of anterior and posterior ethmoidal arteries through a transcaruncular endoscopic approach. For this, the incision of the conjunctiva, after infiltration with local anesthetics, was carried out posteriorly from the lacrimal caruncle, continuing it above and below the posterior border of the medial canthal ligament. Then, after dissection of the periosteum posterior to the posterior lacrimal crest, further stages of the surgical intervention are performed under the control of an endoscope with a viewing angle of 0°. Results. Transorbital endoscopic clipping of the ethmoid arteries allowed to significantly reduce the intensity of blood flow in the tumor tissue and perform endoscopic transnasal removal of the tumor with minimal blood loss. Intraoperative blood loss was 100 ml. No complications were recorded. Conclusion. Transorbital endoscopic clipping of the anterior and posterior ethmoidal arteries is an effective and safe method for early devascularization of partially embolized or non-embolized cranioorbital tumors. The technique is promising and requires further development.

Anterior Cranial Fossa Dural Arteriovenous Fistula Presenting as Recurrent Multifocal Lobar Intracerebral Hemorrhages: A Case Report

We report a unique case and presentation of a 77-year-old man with atrial fibrillation who presented with complex imaging features, including bifrontal cerebral hematomas that progressed to multifocal macro- and microhemorrhages, vasogenic edema, and cortical/meningeal enhancement. Cerebrospinal fluid analysis was only remarkable for a protein elevation of 65 mg/dL. Leptomeningeal vessel biopsy failed to demonstrate evidence of amyloid angiopathy but did show concentric obstructive intimal fibroplasia, suggestive of chronic venous congestion. Conventional cerebral angiography showed a Cognard type IV dural arteriovenous fistulae fed by bilateral ethmoidal arteries draining directly into ectatic cortical veins. A chronic occlusion of the anterior third of the superior sagittal sinus was also noted. The fistula was successfully surgically obliterated via an uncomplicated left frontal craniotomy approach. After rehabilitation therapy, he was discharged home with a modified Rankin Scale score of 3. Because effective treatment exists, this case underscores the importance of identifying this rare etiology of intracerebral hemorrhage and pursuing adequate workup.

Anatomy of the posterior and middle ethmoidal arteries via computed tomography

Objective: The aim of this study is to investigate the anatomy of the posterior and middle ethmoidal arteries from the viewpoint of an endoscopic sinus surgeon. Methods: Based on 100 computed tomography images, the anatomical position of the posterior ethmoidal artery in relation to the posterior ethmoid cells was classified into five types. The presence of the posterior and middle ethmoidal arteries, their distance from the skull base, and their length exposed in the ethmoid cells were measured. The association of patients’ age and sex, presence of the middle ethmoidal artery, and anatomical type of the posterior ethmoidal artery with the posterior ethmoidal artery distance from the ethmoid roof was analyzed. Results: The posterior ethmoidal artery’s position, relative to the ethmoid cell walls, was most often near the first wall, anterior to the optic canal (92.5%). The posterior ethmoidal artery’s distance from the skull base ranged from 0 to 6.4 mm (mean: 1.2 mm). Older age, longer length of the posterior ethmoidal artery exposed in the ethmoid cells, and absence of the middle ethmoidal artery were positively associated with a longer posterior ethmoidal artery distance from the skull base. Conclusion: Attention should be paid to the posterior and middle ethmoidal arteries.