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BackgroundMiddle meatal antrostomy (MMA) provides limited access to the anteromedial and inferior aspect of the maxillary sinus (MS) often resulting in residual disease and inflammatory burden. Newer extended procedures, such as mega‐antrostomy (Mega‐A) and extended modified mega‐antrostomy (EMMA), have been developed to address this limitation. This study assesses the effect of varying extent of MS surgery on irrigation penetration and access of instrumentation.MethodsThe MS of 5 fresh‐frozen cadavers were sequentially dissected. Irrigation was evaluated with a squeeze bottle (SB) in different head positions and using different volumes of fluid. Surgical reach and visualization were examined using common sinus instruments and different angled endoscopes. A disease simulation was also performed to check for residual debris after instrumentation and irrigations.ResultsIrrigation penetration improved as antrostomy size increased (p < 0.0001), with a significant difference observed between the extended procedures and MMA. The effect of the volume was significant for SB (p < 0.0001) but head positions appeared irrelevant (p = 0.613). Overall visualization improved for Mega‐A and EMMA. A similar trend was seen for the reach of the instruments to all sinus wall subsites. EMMA facilitated the most removal of “sinus disease” in the disease simulation model when compared with both MMA and Mega‐A, due to its reach of the anteroinferior aspects of the maxillary sinus.ConclusionsHigh‐volume irrigation using SB achieved good sinus penetration, irrespective of head position. Extended MS procedures appear to further increase irrigation penetration as well as surgical access.

Epithelial migration occurred in an almost linear pattern in all quadrants, but the speed of migration was relatively slower in the anterior and inferior quadrants of a normal EAC. In the single KO patient, there were areas of normal migration and areas of abnormal keratin resurfacing at the inferior quadrant, which interfered with the migration of ink dots.

Purpose of review Sphenoid sinus lateral recess encephalocoeles (SSLRE) are rare occurrences and pose unique challenges due to limited surgical access for endoscopic endonasal repair and also the lack of consensus on optimal perioperative managements specifically in the spontaneous cases, which are also believed to be a variant of idiopathic intracranial hypertension (IIH). Endoscopic endonasal approaches have largely replaced the transcranial route and the techniques are continuously being refined to reduce the neurovascular morbidity and improve outcome. Recent findings Transpetrygoid is the most utilized approach with modifications suggested to limit bone removal, exposure and preservation of the neurovascular structures as dictated by the extent of the lateral recess. As more experience is gained, extended transphenoidal techniques were also successfully used for access. Lateral transorbital is a new approach to the lateral recess investigated in cadavers. IIH treatment is still controversial in the setting of SSLRE, but it appears rationale to evaluate, monitor and treat if necessary. Summary SSLRE management should be tailored to the specific anatomical variances and cause. Modifications of techniques have been described giving different options to access the lateral recess. Successful repair for spontaneous SSLRE may require treatment of IIH if present, but the long-term outcome is still unclear.

Purpose of review The endoscopic medial maxillectomy (EMM) has remained a relevant procedure for certain sinus diseases and at the same time reemerged as a salvage technique or even as a primary procedure for other diseases. Several mucosal-sparing techniques have also been described and the outcome of the surgeries is available for review. Recent findings Modifications of the EMM technique in the last two decades, aimed at mucosal preservation of the inferior turbinate, nasolacrimal duct, and medial maxillary wall have been successful in addressing a multitude of diseases. There are also evidences to support adjunct procedures/methods to improve access, healing, and to address associated dysfunction such as impaired mucociliary clearance. Tailored approaches have shown favourable outcomes with a low rate of adverse effects. Summary The EMM is appropriate for selected indications, in particular lesions causing medial wall destruction or extensive tumour involving the anterior wall or the prelacrimal recess. As for other maxillary sinus diseases including those identified to a limited site, a modified EMM is a reasonable consideration. The choice is appropriate provided instrument access, visualization, the ability for complete resection, postoperative care, and the requirement for surveillance is not compromised. A tailored approach with or without adjunct procedures is recommended.

A healthy 18-year-old man was in a motor vehicle accident and received a head injury that resulted in intracranial bleeding at multiple sites, fractures of facial bones, and immediate traumatic mydriasis and ptosis in the left eye. Two weeks later, he had recurrent profuse epistaxis from the left side of his nose. Examination was notable for normal results of nasal endoscopy. However, in the left eye, he had complete ophthalmoplegia, ptosis (Panel A and Video), and mild exophthalmos, and vision was restricted to perception of light. The left eye showed no chemosis, pulsation, or bruit. Ophthalmologic examination of the left eye revealed traumatic optic neuropathy. Because vascular injury was suspected, computed tomographic angiography was performed, which revealed a carotid-cavernous sinus fistula and pseudoaneurysm in the fractured sphenoid sinus (Panels B and C, arrows). The patient subsequently underwent endovascular intervention, and the intracavernous internal carotid artery was successfully occluded with a detachable balloon. No further epistaxis occurred, but the neurologic deficit in the left eye remained unchanged.

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