Search Results (201)

Background: Endonasal endoscopic approaches to the skull base are still under investigation, with research aiming to achieve minimally invasive procedures that maximize resection while minimizing complications. This study shares our experience with a mononostril technique and compares it with the existing literature on mononostril approaches for sellar lesions. Methods: A systematic review of eight large series, totaling 1520 patients who underwent endoscopic mononostril transsphenoidal surgery, was performed. The surgical technique was detailed, and parameters such as resection completeness, operative time, complications, and nasal symptoms were analyzed. Results: Gross total resection ranged from 56% to 100% for non-functioning adenomas, 54% to 89% for hormone-secreting adenomas, and 83% to 100% for other sellar lesions. The most common complications were CSF leaks (1.5–4.1%) and nasal issues, such as epistaxis or sinusitis (0–6%). Internal carotid artery injury occurred in 0–1% of cases. The average surgical duration was 87 to 168 min. Conclusions: The mononostril approach offers comparable resection rates, CSF leak risks, and morbidity to binostril or microsurgical methods. The mononostril approach is fast, minimally invasive, and preserves the nasal mucosa, making it a viable option for many sellar lesions. Full article

Objective: To evaluate the outcomes of a modified infratemporal fossa approach (ITFA) that preserves the posterior external auditory canal (EAC) in patients with tumors in the infratemporal fossa and skull base, focusing on postoperative hearing and facial nerve function. Methods: This retrospective study included nine patients who underwent ITFA with posterior EAC preservation for tumor removal while minimizing facial nerve rerouting. All surgeries were performed by a single surgeon. Preoperative and postoperative hearing levels, facial nerve function, tumor characteristics, and surgical outcomes were analyzed. Air-bone gaps (ABG) were assessed using pure tone audiometry, and facial nerve function was assessed using the House–Brackmann grading system. Results: The cohort consisted of eight female patients and one male patient, with a mean tumor size of 3.0 cm. Surgical outcomes were promising, with no statistically significant increase in postoperative ABG and well-preserved facial nerve function. Only one patient developed postoperative grade II facial palsy. A residual tumor was identified in one case with extensive meningioma, which has remained stable, and no recurrence or regrowth was noted during the follow-up period (mean: 3.7 years). The modified approach minimized complications related to conductive hearing loss and facial nerve dysfunction. Conclusions: The modified ITFA with posterior EAC preservation provides a promising alternative to conventional ITFA for managing deep-seated tumors. It preserves both hearing and facial nerve function while ensuring adequate tumor resection. Full article

Pulsatile tinnitus (PT) is a subtype of tinnitus characterized by a perception of heartbeat-synchronous sound. It represents approximately 5–10% of all tinnitus cases and may have either a vascular or non-vascular etiology. Accurate diagnosis is crucial due to the potentially serious implications this condition can entail. Assessment through anamnesis and physical examination may often suggest a diagnosis of PT, but it is rarely definitive. Therefore, a comprehensive and specific imaging diagnostic protocol is essential when evaluating PT. A lack of consensus has been identified regarding the use of a standardized protocol for both pulsatile and non-pulsatile tinnitus, whether unilateral or bilateral. Consequently, neuroradiologists, otologists, and otoneurologists from a tertiary hospital have developed a new imaging diagnostic protocol for PT. The aim of this article is to present an updated approach to the diagnostic and therapeutic management of PT, aiming to establish a protocol that serves as a guide for clinicians assessing this symptom. In patients with bilateral PT, systemic conditions leading to increased cardiac output should generally be ruled out; in unilateral cases, focused imaging studies should be performed to exclude organic etiologies at the cervical and cranial levels. Full article

The paranasal sinuses are in close anatomical contact with the nasal and oral cavities, the orbit, the skull base, the brain, and important neurovascular structures, so complications of sinusitis can have serious and life-threatening consequences. Roughly, complications are divided into extracranial and intracranial. Of the extracranial complications, orbital complications are the most common. In addition to clinical examination and immediate referral to hospital, diagnostic imaging methods, particularly CT, are important in the diagnosis of complications. The treatment of complications of sinusitis is mainly multidisciplinary and may involve pediatricians, family physicians, emergency physicians, otorhinolaryngologists, neurologists, neurosurgeons, ophthalmologists, neuroradiologists, and infectious disease specialists. The cornerstone of treatment is early targeted antimicrobial therapy and surgery for abscess, visual impairment, or involvement of critical neurovascular structures. This paper reviews sinusitis complications and provides study material for physicians who manage this disease. Full article

Background/Objectives: The endoscopic transsphenoidal approach constitutes an excellent technique for adrenocorticotropin hormone (ACTH)-producing pituitary tumours. It is associated with subnormal postoperative serum cortisol levels, which may guide decisions regarding immediate re-operation. Methods: The authors retrospectively reviewed patients with Cushing’s disease who had undergone endoscopic transsphenoidal surgery between 2013 and 2023. All operations were performed by neurosurgeons and skull-base otolaryngologists. Surgical outcomes were evaluated in combination with prognostic factors such as cortisol and ACTH levels in terms of long-term remission and late recurrence rates of Cushing’s disease. Results: Fifty patients aged between 15 and 69 (average 37.8) years were evaluated, having undergone 50 operations. The median follow-up was 76.5 months (range: 23–122 months). Major complications with a transient CSF leak resulting from the surgical approach occurred in three patients. Two patients in the series experienced minor complications, developing a deep vein thrombosis, and thirteen patients developed transient diabetes insipidus. The initial remission rate was 84% (n = 42/50). Initial non-remission occurred in eight (8) patients (16%), with three macro- and five microadenomas. A total of 3 of the 42 patients with initial remission had a late recurrence after 50 months follow-up and required repeat transsphenoidal surgery. Seven patients (16.6%) who did not exhibit early postoperative cortisol reduction subsequently achieved remission. Male gender was the only factor that was significantly associated with lower remission rates in either short- or long-term follow-up (p = 0.003 and 0.038, respectively). An immediate postoperative ACTH nadir of ≤5 pg/mL was significantly related to long-term remission (p = 0.004). In our study, a significant correlation was confirmed between remission of the disease and 24 h urinary cortisol values, both early and late (p = 0.019), and serum cortisol <138 nmol/L. In this retrospective study from a single institution specialising in pituitary tumour management, the endoscopic transsphenoidal approach was shown to be both safe and effective. Additionally, we found that the risk of relapse in patients with Cushing’s disease persisting for more than 5 years after surgery is real but low. Moreover, failure to achieve an early postoperative cortisol reduction does not preclude a subsequent remission. Conclusions: Our findings demonstrate that ACTH, postoperative serum cortisol, and urinary free cortisol are valuable predictors of relapse over a five-year period and are closely correlated to each other. Full article

Background and Objectives: The foramen lacerum (FL), located at the base of the skull, is generally considered the safest anatomical pathway for accessing the internal carotid artery (ICA) and the vidian canal (VC) during surgical procedures. We aimed to evaluate the morphometric characteristics of FL, VC, and related structures. Materials and Methods: This study utilized cranial computed tomography (CT) images obtained between 2016 and 2018 at Balıkesir University Faculty of Medicine for various clinical indications. A retrospective analysis was performed on cranial CT images from 77 patients, comprising 42 females and 35 males. The length and width of the FL, the length of the VC, and the angles formed between the VC and the pterygosphenoidal fissure and between the VC and the palatovaginal canal were measured. All measurements were performed using the three-dimensional (3D) Slicer software to ensure precision and consistency. Results: Males had significantly longer right and left FL lengths and left FL width than females (p < 0.05). No significant gender-based differences were found in VC length on either side. The angle between the VC and the pterygosphenoidal fissure was significantly larger in males (p < 0.05). Additionally, increased FL length and width were significantly correlated with larger angles between the VC and the pterygosphenoidal fissure in all subjects (p < 0.05). The anatomical variations of the FL Type 1 (normal) were identified as the most prevalent configuration across the study population. Type 2 (canal-shaped) ranked as the second most frequent variant in females, whereas Type 3 (bridged) was the second most commonly observed form in males. Conclusions: Preoperative identification of FL anatomical variations, which differ between individuals and sexes, may enhance the safety of skull base surgeries and minimize postoperative complications. The morphometric data presented in this study provide valuable guidance for clinicians planning interventions involving the FL and surrounding structures, and contribute valuable insights to anatomists regarding regional morphology. Full article

Background: Bimaxillary (BiMax) advancement surgeries are one of the most frequently performed procedures in the orthognathic subspecialty of craniomaxillofacial surgery. The growing digitalization of the planning process and the shift from physical to virtual settings in procedure design have allowed, among other things, for better visualization of surgeries, improved preparation, and a more profound understanding of individual anatomy. Therefore, the question of the accuracy of performed virtual planning (VP) as well as the available methods of its evaluation arises naturally. The aim of this study was to determine the accuracy of performed BiMax advancement surgeries and propose a new planning accuracy coefficient (PAC). Methods: A group of 35 patients who underwent BiMax surgery were included in the study. Computed tomography (CT) of the head and neck region was performed 2 weeks preoperatively and 6 months postoperatively. Acquired Digital Imaging and Communications in Medicine (DICOM) files were used to perform a VP and a 3-dimensional (3D) cephalometry analysis using IPS CASE DESIGNER^® software, v2.5.7.1 (KLS Martin Group, Tuttlingen, Germany). Statistical significance evaluation and basic measures of central tendency and dispersion of the analyzed variables were calculated. The accuracy of the performed planning was assessed based on the mean absolute error (MAE) between the planned and achieved cephalometric data variables. Additional assessment was performed based on the proposed PAC. Results: VP was found to be accurate in terms of cephalometric data assessing the height of the maxilla and mandible, the inclination of the occlusal plane, the position of the jaws in relation to the skull base, as well as overjet and overbite. There was a discrepancy in results between the classic and proposed methods of accuracy assessment in the case of several of the evaluated variables. Conclusions: The accuracy of the VP of BiMax advancement surgeries can be evaluated based on 3D cephalometry, and it is accurate in the assessment of the previously mentioned variables. There is a need for further analysis and potential development of the proposed PAC; however, the data obtained based on PAC are promising, and by taking into account the magnitude of planned movements, it can facilitate a fair comparison of results presented in different studies based on various assessment methods. Full article

Background/Objectives: Surgical removal is the treatment of choice for cholesteatoma control. Depending on the size, the surgery involves partial resection of the ossicular chain and, if necessary, the bony skull base. Titanium foreign materials (prostheses, meshes) can be used to restore sound transmission and to cover larger defects of the skull base. After the operation, recurrence and residual control are necessary. This can be achieved by means of second-look surgery or an MRI examination with a non-EPI DWI sequence. Similarly to other metal implants, artifacts may occur in the image due to the titanium used. In this study, we assessed the magnitude of the MRI hardware differences induced by titanium prostheses and meshes and whether these differences could obscure cholesteatoma detection. Methods: 28 MRI examinations (T1-, T2-, non-EPI DWI sequences) in 14 males and 14 females (5.2–92.4 years) after cholesteatoma surgery and single-staged implantation of a PORP, TORP, or titanium mesh were considered. The size of the respective artifacts was measured, and the mean artifact sizes of the respective prosthesis types were compared. A second look surgery was performed in all cases due to the MRI result or clinical findings. Both were also compared. Results: Artifacts occurred in all titanium foreign bodies depending on the used MRI sequence (PORP, TORP, Mesh). We found a positive association between the size of the prosthesis and the size of the artifact. All subsequent second-look surgeries confirmed the MRI examinations according to a positive control for the presence of cholesteatoma. The detection rate was 82.1%. All false results were false negatives, and there were no positive results. Conclusions: Titanium material-related artifacts might influence the MRI detectability of recurrent cholesteatoma. Small cholesteatoma might be missed by an MRI-based follow-up. This finding supports the reevaluation of single-stage versus staged reconstruction modern approaches. Full article

Background: One-step cranioplasty combined with tumor removal is a recognized approach in neuro-oncology for patients with neoplastic skull invasion. The use of advanced technologies, including Mixed Reality (MR), has introduced new possibilities in surgical workflows. MR technology may provide additional benefits in preoperative planning, patient engagement, and intraoperative guidance. Can the proposed treatment algorithm, which includes Mixed Reality (MR) for preoperative planning and intraoperative navigation, demonstrate tangible utility and improve outcomes in the surgical management of skull-invasive tumors? Methods: A retrospective study was conducted on 14 patients treated at Cannizzaro Hospital, Catania, Italy, for skull-invasive tumors. The treatment algorithm incorporated tumor removal and one-step cranioplasty using custom-made titanium alloy meshes. Standard intraoperative navigation was compared with MR-based navigation. MR headsets and the Virtual Surgery Intelligence (VSI) platform were employed for preoperative planning, surgical guidance, and patient/family communication. Tumor types included nine meningiomas and five other tumor variants. Results: The integration of MR proved beneficial for preoperative planning, facilitating enhanced visualization of patient anatomy and aiding communication with patients and families. MR-assisted intraoperative navigation offered improved anatomical familiarity but demonstrated slightly lower accuracy compared with standard navigation. Postoperative outcomes were satisfactory across the cohort, with no significant complications reported. Conclusions: The study highlights the potential utility of the proposed treatment algorithm including MR technology in the surgical management of skull-invasive tumors. While MR provides enhanced visualization and preoperative engagement, standard navigation remains more precise during surgery. Nevertheless, MR serves as a valuable complementary tool, and its role in neuro-oncological workflows is expected to grow with technological advancements. Full article

Cranio-maxillofacial bone defect repair poses significant challenges in oral and maxillofacial surgery due to the complex anatomy of the region and its substantial impact on patients’ physiological function, aesthetic appearance, and quality of life. Inaccurate reconstruction can result in serious complications, including functional impairment and psychological trauma. Traditional methods have notable limitations for complex defects, underscoring the need for advanced computational approaches to achieve high-precision personalized reconstruction. This study presents the Internal Diffusion Network (IDNet), a novel framework that integrates a diffusion model into a standard U-shaped network to extract valuable information from input data and produce high-resolution representations for 3D medical segmentation. A Step-Uncertainty Fusion module was designed to enhance prediction robustness by combining diffusion model outputs at each inference step. The model was evaluated on a dataset consisting of 125 normal human skull 3D reconstructions and 2625 simulated cranio-maxillofacial bone defects. Quantitative evaluation revealed that IDNet outperformed mainstream methods, including UNETR and 3D U-Net, across key metrics: Dice Similarity Coefficient (DSC), True Positive Rate (RECALL), and 95th percentile Hausdorff Distance (HD95). The approach achieved an average DSC of 0.8140, RECALL of 0.8554, and HD95 of 4.35 mm across seven defect types, substantially surpassing comparison methods. This study demonstrates the significant performance advantages of diffusion model-based approaches in cranio-maxillofacial bone defect repair, with potential implications for increasing repair surgery success rates and patient satisfaction in clinical applications. Full article

Background/Objectives: Giant pituitary adenomas (GPAs) pose significant surgical challenges due to their large size, parasellar/suprasellar extensions, and proximity to critical neurovascular structures. Although the endoscopic endonasal approach (EEA) is preferred for pituitary tumors, achieving gross total resection (GTR) in GPAs remains difficult. Additional transcranial approaches may improve resection rates while minimizing morbidity. This study evaluates the impact of endoscopic and combined surgical approaches on resection outcomes using a classification system previously defined in GPA patients treated over the past year. Methods: Among 517 pituitary adenomas treated in our clinic between September 2023 and September 2024, 49 GPA patients underwent endoscopic endonasal, transcranial, or combined surgery. Their medical records and surgical videos were retrospectively reviewed. Data included demographics, symptoms, imaging, surgical details, and follow-up outcomes. Tumor resection rates were analyzed based on the “landmark-based classification”, considering radiological and pathological features and surgical approach. Results: The mean age was 45.5 years (female/male: 14/35). Zone distribution was 8 (Zone 1), 21 (Zone 2), and 20 (Zone 3). GTR was achieved in 34.6%, near-total resection in 36.7%, and subtotal resection in 28.5%. Endoscopic surgery was performed in 41 patients, combined surgery in 7, and a transcranial approach in 1. Complications included diabetes insipidus (9/49), cerebrospinal fluid leakage (2/49), apoplexy (2/49), hypocortisolism (3/49), epidural hematoma (1/49), and epistaxis (1/49). Conclusions: While EEA is effective for Zone 1 and 2 GPAs, Zone 3 tumors often require combined or transcranial approaches for better resection. A multimodal strategy optimizes tumor removal while minimizing morbidity. Individualized surgical planning based on tumor classification is crucial for improving outcomes. Full article

Background: Naso-ethmoidal schwannoma is a rare slow-growing tumor arising from the Schwann cells of the sinonasal tract. This study discusses the evolution of surgical approaches to naso-ethmoidal schwannomas with respect to tumor growth and recent advances in minimally invasive techniques. Materials and Methods: A comprehensive literature review on Embase online electronic database on benign naso-ethmoidal schwannoma was performed. Demographic, clinical, neuroradiological, pathological, and surgical factors were analyzed and discussed. Results: Twenty-five cases met the inclusion criteria. No predilection for gender was evident. The mean age at diagnosis was 40.2 years old. Nasal obstruction was the most common presenting symptom (64%), followed by headache (60%), hypo-anosmia (24%), and visual impairment (24%). Skull base and orbital involvement were registered in 64% and 16% of cases, respectively. Surgery is the unique curative treatment, with the endoscopic endonasal approach which plays the leading role (44%). Gross total resection was possible in all cases and was associated with no recurrence. The perioperative complication rate was 32% and mainly consisted of cerebrospinal fluid leakage. The mean time for treatment was 21 months. All patients were alive at last follow up. Conclusion: Surgery is the only curative treatment for naso-ethmoidal schwannomas, with the main goal to relief clinical manifestations. The endoscopic endonasal route represents the master approach for lesions confined to the midline. Transcranial and transorbital approaches play a complementary role when large intracranial extension and orbital involvement occur, respectively. Full article

Pediatric primary brain tumors pose significant therapeutic challenges due to their aggressive nature and the critical environment of the developing brain. Traditional modalities like surgery, chemotherapy, and radiotherapy often achieve limited success in high-grade gliomas and embryonal tumors. Tumor-treating fields (TTfields), a non-invasive therapy delivering alternating electric fields, has emerged as a promising approach to disrupt tumor cell division through mechanisms such as mitotic disruption, DNA damage, and tumor microenvironment modulation. TTfields are thought to selectively target dividing tumor cells while sparing healthy, non-dividing cells. While TTfields therapy is FDA-approved for the management of glioblastoma and other cancers, its application in pediatric brain tumors remains under investigation. Preclinical studies reveal its potential in medulloblastoma and ependymoma models, while observational data suggest its safety and feasibility in children. Current research focuses on optimizing TTfields’ efficacy through advanced technologies, including high-intensity arrays, skull remodeling, and integration with immunotherapies such as immune checkpoint inhibitors. Innovative device-based therapies like magnetic field-based technologies further expand the treatment possibilities. As clinical trials progress, TTfields and related modalities offer hope for addressing unmet needs in pediatric neuro-oncology, especially for tumors in challenging locations. Future directions include biomarker identification, tailored protocols, and novel therapeutic combinations to enhance outcomes in pediatric brain tumor management. Full article

Background/Objectives: A sizeable population of patients with normal pure-tone audiograms endorse a consistent difficulty of following conversations in noisy environments. Termed hidden hearing loss (HHL), this condition evades traditional diagnostic methods for hearing loss and thus is significantly under-diagnosed and untreated. This review sought to identify emerging methods of diagnosing HHL via measurement of its histopathologic correlate: cochlear synaptopathy, the loss of synapses in the auditory nerve pathway. Methods: A thorough literature search of multiple databases was conducted to identify studies with objective, electrophysiological measures of synaptopathy. The PRISMA protocol was employed to establish criteria for the selection of relevant literature. Results: A total of 21 studies were selected with diagnostic methods, including the auditory brainstem response (ABR), electrocochleography (EcochG), middle ear muscle reflex (MEMR), and frequency-following response (FFR). Measures that may indicate the presence of synaptopathy include a reduced wave I amplitude of ABR, reduced SP amplitude of EcochG, and abnormal MEMR, among other measurements. Behavioral measures were often performed alongside electrophysiological measures, the most common of which was the speech-in-noise assessment. Conclusions: ABR was the most common diagnostic method for assessing HHL. Though ABR, EcochG, and MEMR may be sensitive to measuring synaptopathy, more literature comparing these methods is necessary. A two-pronged approach combining behavioral and electrophysiological measures may prove useful as a criterion for diagnosing and estimating the extent of pathology in affected patients. Full article

Background/Objectives: Chordomas are rare primary osseous tumors of the spine and skull base that may portend significant morbidity and mortality. Gender disparities in the management and outcomes of spinal and pelvic chordomas have been sparsely studied. This study aimed to examine the effect of gender on the treatment utilization and outcomes in patients with vertebral column and sacrum/pelvis chordomas. Methods: A retrospective cohort study was performed using the 2000 to 2020 Surveillance, Epidemiology, and End Results (SEER) Registry, a U.S. population-based cancer registry database. Patients with histologically confirmed chordoma of the vertebral column or the sacrum/pelvis were identified using ICD-O-3 codes. The study population was divided into gender-based cohorts: male and female. The patient demographics, tumor characteristics, treatment variables, and mortality were assessed. Results: A total of 791 patients were identified and stratified by gender: 485 (61.3%) male and 306 (38.7%) female. The mean tumor size was similar between the cohorts (p = 0.377), as was the tumor location, with most arising from the pelvic bones/sacrum/coccyx (p = 0.953). While the treatment characteristics did not significantly vary, among patients who received both radiotherapy and surgery, neo-adjuvant radiotherapy was utilized at higher frequencies in the male patients (p = 0.011). For vertebral column chordomas, the median (p = 0.230) and five-year survival (p = 0.220) was similar between cohorts, and gender was not a predictor of survival (p = 0.239). Similarly, for pelvic chordomas, the median (p = 0.820) and five-year survival (p = 0.820) was similar between cohorts, and gender was not associated with survival (p = 0.816). Conclusions: Our study suggests that gender may influence treatment utilization but not mortality in patients with chordomas of the spine and sacrum. Full article