Anterior Ethmoid Research Articles

Frontal Infundibular Cells: Pathway to the Frontal Sinus

A frontal infundibular cell (FIC) is an uncommon anatomic variant of an anterior ethmoid pneumatization that originates from the frontal recess and typically extends into the lumen of the frontal sinus ostium. FICs may show several anatomic variants that impact the anatomy of the frontal recess. Familiarity with these variants is required for safe endoscopic sinus surgical procedures. We conducted a retrospective chart review, examining 1,040 frontal recesses in 520 adults with no frontal sinus disease, to explore the anatomy of the healthy frontal recess and to describe the prevalence of FICs in patients without a history of conditions that cause frontal pneumatization. Review of axial and coronal computed tomography data, which were reformatted for sagittal reconstruction, was performed at a computer workstation. Bent and Kuhn's classification was used to define types of FICs. We identified 167 patients (32.1%) as having unilateral or bilateral FICs. Type I infundibular cells were the most common type (found in 15.7% of the entire study population). Type II and type III FICs were found in 3.8% and 12.1%, respectively; type IV FICs were present in 0.4%. The FIC has not been emphasized as an important potential cause of frontal sinus obstruction in the radiology literature, but clinicians should specifically watch for it on all routine computed tomography of the frontal sinus. Fine-cut computed tomography scans aid in the identification of each individual cell and allow the surgeon to formulate a clear and precise surgical plan. A surgical plan with a thorough understanding of the anatomy enables confident dissection of this complex and difficult area.

Cadaveric Anatomical Comparison of the Lateral Nasal Wall After External and Endonasal Dacryocystorhinostomy

Much literature has accumulated espousing the relative merits of endonasal and external dacryocystorhinostomy (DCR). However, there is comparatively little information on the relative anatomic differences between these 2 approaches. The purpose of this study is to investigate the anatomic relationships of the lateral nasal wall for endonasal and external DCR. Ten cadaver half heads were used in this study. Half were subject to endonasal and half to external DCR procedures. The lateral nasal wall was then dissected and measurements were taken of ostium and anastomosis size and position relative to other landmarks on the lateral nasal wall. Relationships were compared between the 2 procedures. The dimensions and area of the ostium and the anastomosis were similar between the 2 procedures. The lower portion of the ostium was located more inferiorly in endonasal DCR. Additionally, the ostium was more likely to be found lateral to the axilla of the middle turbinate in endonasal DCR, when compared with anterior for external. External DCR was also more likely to involve opening the anterior ethmoid air cells than endonasal approach. Endonasal and external DCR osteomies appear to be of similar size, with the endonasal opening being located slightly lower and more posterior on the lateral nasal wall.

Two‐year results: transantral balloon dilation of the ethmoid infundibulum

Multiple prospective and retrospective studies have reported results from balloon-only procedures and hybrid balloon sinus surgeries through intermediate follow-up periods of up to 1 year. Long-term durability results beyond 2 years are limited. One-year results from the original study of standalone transantral balloon dilation in patients with computed tomography (CT) evidence of chronic inflammation in the maxillary sinuses alone or maxillary and anterior ethmoid sinuses combined were previously reported. Revision rate, symptom improvement, and productivity improvement were prospectively evaluated after a minimum follow-up of 2 years. Fifty-nine patients (107 maxillary ostia) underwent balloon dilation of the maxillary sinus outflow tract and completed postprocedure follow-up assessment at 27.0 ± 3.6 months. Patient 20-item Sino-Nasal Outcome Test (SNOT-20) score improved from 2.65 ± 0.97 at baseline to 0.79 ± 0.71 at long-term follow-up (p < 0.0001). Improvement in work productivity and activity due to sinus-related health issues for all patients was statistically significant across all survey instrument characteristics (p range, <0.0001 to 0.02). An analysis of the outcomes in a subgroup of patients with maxillary and anterior ethmoid disease (20; 34%) showed similar significant improvement in symptoms (SNOT-20 decrease = -2.1; p < 0.0001). Approximately 92% of all patients reported satisfaction with the balloon procedure. Four (6.8%) patients underwent revision sinus surgery at 11.1 ± 7.3 months after treatment. Patients with chronic rhinosinusitis and radiographic evidence of isolated maxillary disease with or without anterior ethmoid disease have reported clinically meaningful and statistically significant improvement in symptoms, productivity, and activity through a minimum of 2 years following standalone balloon dilation.

Effect of Previous Sinonasal Surgery on Long-Term Radiographic Incidence of Sinus Disease in Patients Following Endoscopic Skull Base Surgery

Objective: The purpose of this study was to determine whether prior history of sinonasal surgery affects the incidence of long-term radiographic sinus disease after endoscopic skull base surgery. Study Design: A retrospective review was conducted at a university medical center. Methods: All patients that underwent a transnasal transsphenoidal endoscopic approach to the skull base with both preoperative and postoperative imaging greater than 6 months after surgery were identified. Lund-Mackay scores for CT images and an analog scoring system for MRI were used to stage all images. Change in preoperative and postoperative imaging scores were calculated and compared between patients with and without a history of a previous sinonasal intervention (i.e., septoplasty, transnasal transsphenoidal skull base surgery, or endoscopic sinus surgery). Results: Eighty-five patients were included in the study, 37 patients without a history of prior surgery and 20 patients with a history of prior surgery. Patients with a history of prior surgery had worse mean preoperative imaging scores compared with the group undergoing primary surgery in the left maxillary sinus (difference = 0.5 vs. 0.1, P = <0.01), left frontal (difference = 0.1 vs. 0.0, P = 0.05), and left sphenoid (difference = 0.2 vs. 0.0, P = <0.01), and right sphenoid sinuses (difference = 0.3 vs. 0.0, P = <0.01). The mean postoperative changes in radiographic scoring of sinusitis differed between patients with prior surgery and those undergoing primary surgery in the right anterior ethmoids (difference = −0.05 vs., 0.3 P = 0.02), left posterior ethmoids (difference = −0.3 vs. 0.1, P = 0.01), right posterior ethmoids (difference = −0.3 vs. 0.2, P = 0.03), and left sphenoid sinus (difference = −0.05 vs. 0.2, P = 0.04). Patients with a prior sinonasal surgery showed no increase in incidence of radiographic sinusitis in the postoperative MRIs. In contrast, patients with no history of prior sinonasal surgery had worse radiographic scores in the right anterior ethmoids, right posterior ethmoids, left and right maxillary, and left and right sphenoid sinuses (P ≤ 0.01, 0.03, 0.02, <0.01, 0.02, respectively). Conclusion: Patients with a history of sinonasal surgery show no increased incidence of radiographic evidence of sinusitis after endoscopic transnasal transsphenoidal skull base surgery.

Outcomes of Endoscopic Sphenopalatine Artery Ligation for Epistaxis: A Five-Year Series from a Single Institution

Epistaxis is a common emergency seen by the otolaryngologist. A minority of cases require surgical intervention. Multiple surgical procedures have been tried in the past, including endoscopic ligation of the sphenopalatine artery (ELSPA), which is considered an effective surgical modality in the management of epistaxis. This study examines the outcome of 33 ELSPA procedures over a 5-year period. Three of 4 cases that were not controlled with ELSPA were successfully managed with subsequent anterior ethmoidal ligation. Failed ELSPA procedures may represent an incorrect choice of procedure rather than a failure of the procedure. High-resolution computed tomography can identify the position of the anterior ethmoidal artery; it may be possible to infer vulnerability to hemorrhage from this artery and hence target procedure selection.

A Case of Extranasopharyngeal angiofibroma of the Ethmoid Sinus: A Distinct Clinical Entity at an Unusual Site

Angiofibromas of the head and neck usually arise from the nasopharynx in adolescent boys. The term extranasopharyngeal angiofibroma (ENA) has been applied to vascular fibrous nodules that arise outside the nasopharynx. Because the clinical characteristics of ENA are not consistent with those of juvenile nasopharyngeal angiofibroma (JNA), diagnosis of the former can be challenging. Biopsy is ill advised in a patient with an ENA because it might result in brisk bleeding. A high index of suspicion and a methodical evaluation are essential in establishing the proper diagnosis and treatment. We report the rare case of a 16-year-old girl who presented with a pinkish lobulated mass in her left nostril that had arisen from the anterior ethmoid sinus. The mass was removed via a lateral rhinotomy approach. Postoperative histopathologic analysis identified it as an angiofibroma. To best of our knowledge, only 9 cases of ENA arising from the ethmoid sinus have been previously reported in the English-language literature.

Evaluation of the ethmoid skull‐base height prior to endoscopic sinus surgery: a preoperative computed tomography evaluation technique

Iatrogenic ethmoid skull base (ESB) injury during endoscopic sinus surgery (ESS) is a potentially devastating complication. The height of the ESB can vary substantially and should be assessed during preoperative evaluation of the sinus computed tomography (CT) scan. The objective of this study is to describe an objective preoperative CT evaluation technique to assist the surgeon in defining the height of the ESB prior to performing ESS. We propose a technique which measures the height of the ESB from a single horizontal mid-orbital line located on a standardized coronal sinus CT image at the level of the anterior ethmoid artery canal. Utilization of an objective preoperative CT measurement technique may quantify identification of a low ESB and optimize surgical awareness of this potentially dangerous anatomic skull base variation.

Origin oriented management of inverted papilloma of the frontal sinus.

Despite the great progress in endoscopic management of inverted papilloma (IP), involvement of the frontal sinus (FS) remains a challenge. Six cases of FS IP were assessed. Extent of surgery included simple frontal recess clearance, extended frontal sinusotomy, and modified Lothrop approach. There was no need for adjuvant frontal trephination or an external osteoplastic flap. FS involvement was observed in 6 out of 119 cases of IP (5%). In one case, IP was originating from the FS and in four it was extending to the FS. The sixth case had a wide origin from the anterior ethmoid and FS. Complete resection of FS IP was achieved in all cases with a single incidence of CSF leak. No recurrence was identified after a follow-up period of an average of 27 months. FS IP originating outside FS can be delivered transnasally with or without frontal ostium widening and preserving FS mucosa and bone. Inverted papillomata originating from FS proper and those with origin from inside and outside the FS can also be resected tranasnasally after widening of the frontal ostium with removal of surrounding mucosa and drilling or curettage of underlying bone at attachment sites.

Aneurysmal Bone Cyst Of The Anterior Ethmoid: Management Of This Rare Entity

Aneurysmal bone cysts (ABC) of the skull are rare osteolytic expansile lesions. There are few reports in the literature of ABC of the orbits and sinuses. We present computed tomography (CT), magnetic resonance (MRI) imaging and histopathologic findings of an aneurysmal bone cyst of the anterior ethmoids in an 8 year old boy, who presented to the department with a three month history of right epiphora and a right medial canthal mass. CT and MRI demonstrated a multiloculated expansile lesion arising from the right ethmoid air cells, displacing the right globe laterally. On biopsy bloody fluid was aspirated from the lesion. The histology was consistent with an aneurysmal bone cyst. The ABC was excised using a combined endoscopic and open approach. To date there have been 22 cases of ABC of the ethmoids reported in the English literature, the demographics, presenting features and management of these cases are discussed and a methodological approach is suggested.

Management of Intractable Spontaneous Epistaxis

Epistaxis is a common otolaryngology emergency and is often controlled with first-line interventions such as cautery, hemostatic agents, or anterior nasal packing. A subset of patients will continue to bleed and require more aggressive therapy. Intractable spontaneous epistaxis was traditionally managed with posterior nasal packing and prolonged hospital admission. In an effort to reduce patient morbidity and shorten hospital stay, surgical and endovascular techniques have gained popularity. A literature review was conducted. Transnasal endoscopic sphenopalatine artery ligation and arterial embolization provide excellent control rates but the decision to choose one over the other can be challenging. The role of transnasal endoscopic anterior ethmoid artery ligation is unclear but may be considered in certain cases when bleeding localizes to the ethmoid region. This article will focus on the management of intractable spontaneous epistaxis and discuss the role of endoscopic arterial ligation and embolization as it pertains to this challenging clinical scenario.

Nonkeratinizing Carcinoma of the Sinonasal Tract: A Diagnosis of Confusing Nomenclature

Objective: To describe a rare case of nonkeratinizing carcinoma of the sinonasal tract and review the literature on the nomenclature of its many synonyms.&#x0D; Method:&#x0D; Study design: Case report&#x0D; Setting: Tertiary Referral Center&#x0D; Patients: One&#x0D; Result: A 45-year-old female presented with a 6-month history of left nasal obstruction associated with epistaxis. Computed tomography revealed a mass expanding the left nasal cavity with the epicenter arising from the anterior ethmoidal air cells. Endoscopic resection of the tumor was carried out but as there was residual tumor, she then underwent endoscopic-assisted medial maxillectomy via a lateral rhinotomy. A subsequent computed tomography scan showed residual tumor adhering to the ipsilateral periorbita. The patient has so far declined intensity modulated radiotherapy that was advised though she is still under regular follow-up.&#x0D; Conclusion: Nonkeratinizing carcinoma of the sinonasal tract is a rare entity and there are very few reports concerning this type of malignancy. This may be partly due to its many synonyms, such as cylindrical cell carcinoma, Schneiderian carcinoma and transitional cell carcinoma. Nomenclature of this tumor should be standardized to avoid confusion and misdocumentation.&#x0D; Keywords: nonkeratinizing carcinoma, Schneiderian carcinoma, transitional cell carcinoma, cylindrical cell carcinoma, Ringertz carcinoma, respiratory epithelial carcinoma

Foreign Body in Paranasal Sinus: A Unique Accident and a Miraculous Escape for the Patient

An 18month old male child presented with the complaint of foreign body-one and half inch broken piece of quilt sewing needle fully impacted between nasal bridge and medial angle of left eye. The needle was safely removed endonasaly using 4mm 0° Karl stroz telescope avoiding external scar from anterior ethmoid area under general anaesthesia. Minimal exploration of lateral wall of nose, keeping anterior 1/3 of middle turbinate as the landmark, helped in safe removal of foreign body, as no CT scan was there and since the patient was poor. This is rare and unusual location of foreign body removed safely without any complications.

Inflammation and remodelling patterns in early stage chronic rhinosinusitis

A distinct set of inflammatory and remodelling factors have been found elevated in chronic rhinosinusitis. The investigation of their expression in early stage disease may reveal early events in this common disease. Sinonasal mucosal samples from nine patients with early stage CRSsNP were taken from the inferior and middle turbinates, the uncinate process, maxillary sinus, anterior ethmoid, bulla ethmoidalis and the posterior ethmoid and measured for TGF-beta 1 and it's receptors, MPO protein as well as pro-inflammatory cytokines (TNF-alpha and IL-1beta) and the Th1 cell signature (IFN-gamma and T-bet). As outcome parameter for TGF-beta signalling collagen deposition was analysed. Inferior turbinates from patients undergoing (rhino-) septoplasty were collected as controls. TGF-beta 1 protein concentrations were significantly increased in the maxillary sinuses (P=0.006), the uncinate process (P=0.01), the anterior ethmoid including the bulla ethmoidalis (P=0.005) and the posterior ethmoid (P=0.037) when compared to the inferior and middle turbinates. Collagen deposition was significantly increased in the maxillary sinus when compared to the inferior turbinates (P=0.008). In contrast, mRNA for TGF-beta receptors, Th1 related markers (IFN-gamma and T-bet), pro-inflammatory cytokines (IL-1 beta and TNF-alpha), and MPO protein as neutrophil marker were expressed at all locations but showed no significant differences between the various locations. TGF-beta 1 mRNA expression in inferior turbinates of CRSsNP was significantly higher when compared to inferior turbinates of controls (P=0.017). The pro-inflammatory cytokines and Th1-related cytokines did not show an upregulation in inferior turbinates of CRSsNP when compared to controls. In early stage chronic sinus disease, TGF-beta protein is expressed in significantly higher concentrations within the paranasal sinuses when compared to turbinates, whereas pro-inflammatory, neutrophilic and Th1 markers did not show any difference. These findings suggest that TGF-beta plays a central role in the initiation of CRSsNP, and represents a major target for further research and future intervention.

An Anatomical Study of the Positional Relationship Between the Ethmoidal Foramina and the Frontoethmoidal Suture

To examine the positional relationship between the ethmoidal foramina and the frontoethmoidal suture. Eighty-four orbits of 42 Japanese cadavers (24 male and 18 female cadavers; average age at death, 81.0 years; range, 61-101 years), fixed in 10% buffered formalin, were used for investigation. The most anterior or posterior ethmoidal foramen was defined as the anterior or posterior ethmoidal foramen, respectively. All the intermediate foramina were determined as the accessory foramina. The vertical distances from the frontoethmoidal suture to the anterior, posterior, and accessory ethmoidal foramina were examined. Seventeen anterior ethmoidal foramina (20.2%) were situated above the frontoethmoidal suture (mean distance, 1.8 mm), and 2 posterior ethmoidal foramina (2.3%) were situated at 1.0 mm and 1.5 mm above the suture. Although accessory ethmoidal foramina were detected in 32 orbits (38.1%), one accessory foramen (middle ethmoidal foramen) was identified in 30 orbits, and 2 foramina (additional deep-middle ethmoidal foramina), in 2 orbits. One middle ethmoidal foramen (3.1%) and 1 deep-middle ethmoidal foramen (50.0%) were located at 1.5 mm above the suture. In total, 2 of the 34 accessory ethmoidal foramina (5.9%) exhibited the extrasutural location. Several ethmoidal foramina were situated above the frontoethmoidal suture. The anterior ethmoidal foramen most frequently showed the situation, followed by the accessory and posterior foramina, in order. Our findings help predict the anatomical variations in the location of the ethmoidal foramina in relation to the frontoethmoidal suture, thereby enhancing safety for medial orbital wall surgery.

Is there any relationship between the frontal cell and the Agger nasi cell and the localization of the anterior ethmoid artery?

In this article, we examined the effect of the presence or absence of a frontal cell or an Agger nasi cell on the localization of the anterior ethmoid artery. Coronal paranasal sinus computed tomography scans on 110 sides of 61 patients (35 males, 26 females; mean age 35.6 ± 12.7 years; range 15 to 72 years) who underwent surgery for septal deviation, concha bullosa, antrochoanal polyp between September 2006 and February 2008 were retrospectively evaluated and the anterior ethmoid foramen localization was measured according to the anterior nasal spine. The correlations of these measurements with the presence and absence of a frontal cell and an Agger nasi cell were investigated. The measurement of the anterior ethmoidal foramen according to anterior nasal spine was 18.2 ± 8.8 mm in the absence of an Agger nasi cell and was 20.3 ± 6.6 mm in the presence of an Agger nasi cell. This distance was measured as 20.0 ± 7.3 mm when the frontal cell was not determined. This measurement was 20.2 ± 6.5 mm in the presence of a frontal cell. According to the frontal cell types the results of the measurements were 20.5 ± 5.9 mm, 18.9 ± 8 mm, 20.6 ± 7.3 mm, for type 1, type 2 and type 3, respectively. Our results revealed that there were no significant relationship between the presence or absence of a frontal cell and an Agger nasi cell and the localization of the anterior ethmoidal foramen. The results of this study showed that the presence or absence of these cells does not affect localization of the anterior ethmoid artery.

Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach

To explore the feasibility and effectiveness of the approaches and methodology of the endoscopic surgery for maxillary sinus lesions through the medial wall of the maxillary sinus. From Jun. 2003 to Aug. 2010, endoscopic surgery through anterior or posterior nasolacrimal duct approaches to remove maxillary sinus lesions were conducted in 139 patients. Among them there were 43 cases with inverted papilloma, 63 cases with fungal maxillary sinusitis, 28 cases with maxillary sinus cyst, 3 cases with hemorrhagic necrotic polyps, and 2 cases with osteomas. All patients underwent preoperative CT scans, and patients with inverted papillomas also had MRI tests. Anterior-nasolacrimal canal paths included 3 ways: pyriform aperture, lacrimal bone recess (dissecting nasolacrimal duct or not were 2 subtypes), pyriform aperture-nasolacrimal duct approaches, and 97 patients were treated. Posterior-nasal lacrimal duct paths were also divided into 3 subtypes: the inferior turbinate flip flap, double pedicle inferior turbinate, single pedicle inferior turbinate, and 42 patients were treated. The postoperative effects were observed. All lesions were completely removed under endoscope, the nasolacrimal ducts and inferior turbinates were protected, no nasal lacrimal duct injury and inferior turbinate necrosis were found. Postoperative nasal congestion, headache, swelling discomfort, strange odor, dental pain and numbness and other symptoms gradually disappeared. Nine patients felt nasal dryness, and after nasal washing for about 1 month, the symptom gradually disappeared. Patients were followed up for 6 months to 79 months. In case of osteoma, and hemorrhagic and necrotic polyps, no recurrences were found. Apparent edema, hypertrophy of sinus mucosa could be seen during the surgery in all patients with fungal maxillary sinusitis, and the edema gradually disappeared after 3 months or so, with no relapse. Two cases of maxillary sinus cysts were found in other parts of the maxillary sinus 10 months and 18 months after the surgery, but the cysts were small and asymptomatic, so no further management needed, and they were still under follow-up. Three patients, recurred. In 1 case with inverted papilloma, a local lump on the opening were found 17 months after the surgery, and was removed in out-patient department and pathology showed papillary tumor recurrence, no relapse was found 1 year later; 1 patient had recurrence in anterior ethmoid sinus 15 months after operation, total ethmoidectomy was done and no relapse was found in 3 years. One patient had local recurrence in the posterolateral wall of the maxillary sinus 26 months after operation, and the secondary surgery was done via single pedicle inferior turbinate. The papilloma relapsed again after 1 year, an endoscopic Denker surgery was performed, with no recurrence after 18 months of follow-up. Three months after surgery, the maxillary sinus was scar-covered in all cases. Inferior turbinate maintained good shape, compared to those with inferior nasal meatus windowing surgery. Scars were significantly smaller, but no latch or obstruction of drainage were found. Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach can reduce the trauma, fully expose the sinuses, and facilitate postoperative treatment and review with a window. Retained inferior nasal turbinate is helpful to avoid dryness, crusting, headache and other complications due to too much removal of nasal exteral walls.

Primary Adenocarcinoma of the Frontal Sinus

When tumor involvement of the frontal sinus occurs, it is usually the result of the direct spread of the mass from the nasal cavity or anterior ethmoid sinuses. Primary frontal sinus tumors are extremely rare. We describe a case of primary adenocarcinoma of the frontal sinus in a 53-year-old man. The patient refused surgery, so he was treated with chemotherapy followed by radiotherapy. At the 1-year follow-up, only a slight reduction of the swelling was noted. Thereafter, he was lost to follow-up. This case represents a typical example of a paranasal cancer extending beyond the bony margins, with a silent onset that simulated benign disease. The best hope for an early diagnosis of such a tumor lies in the greater use of computed tomography to assess chronic rhinosinusitis.

Radiological Anatomy of the Ethmoidal Arteries: CT Cadaver Study

Introduction and objectivesOur aim was to study the radiological anatomy of the ethmoidal arteries. MethodsA descriptive study was performed including CT images of 20 cadaver heads. The specimens were perfused with a radiopaque material and various anatomical parameters were analysed. ResultsThe anterior ethmoidal artery was found in 95% (38/40) of cases. It originated from the ophthalmic artery in 87.5% (34/40) of nasal cavities. In 6 cases, normal variants were found. The mean length of the anterior ethmoidal canal was 8.43±0.74mm. The angle performed into the skull base was 37.3±5.48°. In 90% of cases (36/40), it was located between the second and third lamella. The posterior ethmoidal artery was localised only in 14/40 cases, with 28.5% (4/14) of them showing normal variants. The mean length of the posterior ethmoidal canal was 7.1±1.02mm. The angle performed into the skull base was 7.11±4.07°. The distance from sill to the anterior ethmoid artery was 55.51±5.52mm. The angle between the nasal spine and the anterior ethmoidal canal was 57.67±1.68°. The distance between the nasion and the anterior ethmoidal canal was 29.31±2.53mm, the distance was 11.24±2.14mm from the anterior ethmoid artery to the posterior ethmoid artery and from the posterior ethmoid artery to the optic nerve, 7.26±1.33mm. Supraorbital cells were observed in 15% (6/40) of the cases. ConclusionsA complete vascular study of the ethmoidal arteries was possible by using this technique.

Atypical meningioma presenting as a nasal mass-multidisciplinary management

ObjectiveTo report a case of recurrent extracranial atypical meningioma successfully managed by a multidisciplinary team. MethodsCase report and literature review concerning successful management of recurrent extracranial meningioma based on pathology and extent of resection. ResultsA 48-year-old woman who presented with a nasal mass, anosmia and headaches. Physical exam and imaging showed recurrent meningioma involving the entire anterior frontal meninges extending into the frontal bone and down into the nasal cavity via the anterior ethmoid. Combined modality surgical intervention was successful and the patient recovered suffering no neurological sequelae. ConclusionThis is a very rare presentation of meningioma that the craniomaxillofacial surgeon should consider when formulating a differential diagnosis for a nasal mass. Long-term surveillance is crucial as recurrence can have devastating consequences. Aggressive multidisciplinary care is needed to prevent future recurrences and to improve survival.

A Technique with Manipulator‐Assisted Endoscope Guidance for Functional Endoscopic Sinus Surgery

The goal of this study was to examine the theoretical feasibility of a new manipulator system for endoscope guidance in functional endoscopic sinus surgery. The accuracy of endoscope positioning and time of endoscope movement with an endoscope manipulator system were determined with an artificial sinus model. A laboratory trial was performed. The time for 60 repetitions of manual compared to manipulator-assisted endoscope movements directed at 3 different target positions was evaluated. In addition, the alignment of the position vector for each endoscope movement was examined. A zero-degree Hopkins II telescope with a camera was used to head for the target positions. First, the endoscope movements were done manually, and afterward the endoscope manipulator system was used for endoscope guidance. The alignment of the position vector of the endoscope was measured with a portable measuring arm. There was no statistical difference between the time for manual and manipulator-assisted endoscope movements for all target positions. The alignment of the position vector of the endoscope was statistically different at 2 target positions: anterior ethmoid left side and ostium of maxillary sinus left side. There was no statistical difference at all other positions. The endoscope manipulator system has the potential to be integrated into the operating workflow without extending the time for endoscope guidance. The surgeon will be able to use both hands for the manipulation of the instruments. Less frequent endoscope movements and instrument changes may be expected after technical modification.