IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition that can affect various organs. Localized sinonasal IgG4-RD is a rare condition characterized by bone and soft-tissue invasion. In this report, we present a case of a patient initially diagnosed with chronic rhinosinusitis, who underwent endoscopic sinus surgery and was later found to have biopsy proven IgG4-related sinonasal disease despite having normal serum levels of IgG4, resulting in erosion of the right lamina papyracea.

Periorbital emphysema is a rare complication following functional endoscopic sinus surgery (FESS) with potential sight-threatening consequences. We present a case of an eight-year-old male who developed periorbital emphysema after FESS for allergic fungal sinusitis. Prompt diagnosis was made using point-of-care ultrasound (POCUS), facilitating timely intervention and conservative management. This case underscores the importance of perioperative imaging to identify lamina papyracea abnormalities, smooth extubation to prevent complications, and the innovative use of POCUS in diagnosing perioperative orbital emphysema and managing it conservatively while examining the eye at regular intervals. These findings highlight the significance of vigilance during FESS procedures and the utility of POCUS in diagnosing and managing rare perioperative complications.

BACKGROUND: The lamina papyracea is the thin line between the ethmoid sinus and the medial orbital wall. Knowledge of the presence of the lamina papyracea dehiscence (LPD) bears critical importance to prevent misdiagnosis of fractures at this level and to define the anatomy before sinonasal surgery, including Functional Endoscopic Sinus Surgery (FESS). The present study is therefore intended to determine the incidence of LPD in paranasal computed tomography, to identify its imaging characteristics in CT, and to compare with the literature.
METHODS: The current study included patients who underwent paranasal CT scanning for any reason in our clinic between January 2018 and January 2022. Patients were evaluated in terms of age, gender, and presence of LPD. Patients with dehiscence were evaluated in terms of age, gender, dehiscence localization (right, left), tissue at the level of dehiscence, dehiscence size, and dehiscence grade.
RESULTS: 1000 patients with a mean age of 32. ± 16.3 (min = 18-max = 79) were included in the study. 20 patients (2%) were found to have LPD. Of those with LPD, 14 (70%) were grade 1, 4 (20%) were grade 2 and 2 (10%) were grade 3. Again of those with LPD, 14 (70%) had LPD localized on the right and 6 (30%) had LPD on the left. In 12 (60%) of the patients with LPD, herniated tissue was detected. Among these patients with herniation, fatty tissue herniation was observed in 10 (83.3%) and medial rectus muscle herniation was observed in 2 (16.7%).
CONCLUSIONS: Comprehensive evaluation for and identification of LPD are very important before possible sinus surgery.

Introduction  Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods  Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed. Results  EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion  EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

The ossifying fibroma is a rare fibro-osseous benign lesion of bone in the head and neck region. The mandible is the most common site reported followed by maxilla and other bones of the skull. A paediatric male presented with protrusion of the right eyeball for one-month duration. Further evaluation by diagnostic nasal endoscopy revealed a smooth mass confined to the superior and middle meatus on the right side. Computed tomography of paranasal sinus showed a large heterogenous bony lesion involving the ethmoid and sphenoid sinus and extending laterally into the orbit and superiorly into anterior skull base. Endoscopic biopsy was suggestive of ossifying fibroma. Transnasal endoscopic excision of the lesion was done and the patient is currently on follow-up. This case is reported for the rarity of presentation and the difficulties in management.

Our case report demonstrates the management of a unique penetrating orbital injury. The intraorbital foreign body was an approximately 22 cm long metal dishwasher spring hook lodged into the left orbital apex. An ophthalmological check-up a couple of weeks following the removal surgery discerned the patient had an unprecedented case of orbital apex syndrome. We present this unique case so physicians, medical students, and other emergency and medical professionals can learn about the diagnostic, surgical, and multidisciplinary management necessary to achieve a favorable clinical outcome.

Objective  to determine the anterior ethmoidal artery (AEA) anatomy and variations by computed tomography (CT) in adult and their relations to and presents new AEA classifications. Methods  One hundred and fifty paranasal CT scans (300 sides) were included. Axial images were acquired with multiplanar reformates to obtain delicate details in coronal and sagittal planes. Results  One hundred and forty-four AEAs canal (48%), 293 AEAs foramen (97.7%), and 229 AEAs sulcus could be detected (76.3%). The mean AEA intranasal length was 6.7 ± 1.27 mm (range: 4.24-10.6 mm). The mean angle between AEA and lamina papyracea was 105.49 ± 9.28 degrees (range: 76.41-129.76 degrees). Of them, 95.8% AEAs had an angle with lamina >90 degrees, while 4.2% had angle <90 degrees. The mean angle between AEA and lateral lamella of cribriform plate was 103.95 ± 13.08 degrees (range: 65.57-141.36 degrees). Of them, 87.5% AEAs had an angle >90 degrees and 12.5% had an angle <90 degrees. The mean distance between AEA and skull base was 1.37 ± 1.98 mm (range: 0-8.35 mm). The AEA types in relation to skull base was type 1 (0-2 mm from skull base; 64.6%), type 2 (2-4 mm; 22.2%), type 3 (4-6 mm; 11.1%), and type 4 (>6 mm; 2.1%). The mean distance between the AEA and frontal sinus ostium was 9.17 ± 4.72 mm (range: 0-25.36 mm). AEA classification according to distance from AEA to frontal sinus ostium was 17.4% type 1 (<5 mm), 41.7% type 2 (5-10 mm), 31.9% type 3 (10-15 mm), and 9% type 4 (>15 mm). Conclusion  Provided AEA details improve surgeons\' awareness of AEA variations in the endoscopic field and can help residents in training.

OBJECTIVE: The purpose of this study is to determine if removal of ethmoid cell septations as commonly performed in endoscopic sinus surgery leads to a change in orbital wall fracture patterns and the force required to create them.
METHODS: Six fresh-frozen cadaveric heads were acquired and underwent endoscopic uncinectomy, maxillary antrostomy, and anterior and posterior ethmoidectomy on one, randomized, side. The contralateral sinuses were used as intra-specimen control. Hyaluronic acid gel globe injections were performed to simulate normal intra-ocular pressure. Post-op CT scans confirmed no orbital fractures or violation of the lamina papyracea prior to trauma testing. Orbital trauma was induced using a guided weight-drop technique. Both orbits were tested in random order, and sequentially higher drops were performed until both the test and control side demonstrated an orbital fracture on CT scan.
RESULTS: In all six heads, the post-sinus surgery side incurred a medial orbital wall fracture, and no orbital floor fractures were identified. On the other hand, on the control side, all six heads incurred orbital floor fractures at drop heights equal to, or higher than, the surgical side. Fisher\'s exact test demonstrated a significant difference in fracture pattern (p <  0.001).
CONCLUSIONS: To our knowledge, this is the first demonstration that the structures removed during sinus surgery may act as a buttress for the medial orbital wall. The anatomic changes of sinus surgery may alter the biomechanics of the orbit and affect the pattern of subsequent traumatic blowout fractures.

BACKGROUND: Several techniques for performing ethmoidectomy have been reported. We describe a safe, effective and efficient technique during functional endoscopic sinus surgery (FESS). We present text, images and videos to illustrate our preferred technique during an antero-posterior ethmoidectomy and to provide a multimedia tool for educational purpose.
METHODS: A description of the technique without prospective or retrospective data is reported. A complete ethmoidectomy with an L-shape approach is described step-by-step, using the backbiting circular and miniature cutting forceps, with safe exposure of the lamina papyracea (LP) and skull base.
RESULTS: In our hands, the L-shape approach for chronic rhinosinusitis with or without polyposis, performed with punch circular cutting and miniature cutting forceps, allowed for a reliably safe and efficient ethmoidectomy.
CONCLUSIONS: The technique described can be added to the armamentarium of the endoscopic sinus surgeon.

UNASSIGNED: The microdebrider has become nearly universal in the treatment of sinonasal pathology; however, recent case reports have demonstrated the potential for major ophthalmic complications. The goal of this study was twofold: 1) determine the anatomical proximity of ophthalmic structures to the paranasal sinuses, and 2) assess the timeframe at which ophthalmic injury may occur with the use of a microdebrider during FESS utilizing a cadaveric model.
UNASSIGNED: Computed tomography scans from 50 patients were accessed retrospectively. The distances between the lamina papyracea (LP) and orbital structures were determined at varying depths. Seven cadavers (14 sides) were studied using three microdebrider systems operated by otolaryngology residents. Following removal of a window of LP, the time from activation of the microdebrider on the periorbita until transection of the medial rectus (MR), optic nerve (ON), and to aspiration of the globe were measured.
UNASSIGNED: The mean distance between the LP and MR at the level of the anterior aspect of the anterior ethmoid and basal lamella were 3.59 ±1.2mm and 1.5 ±0.8mm, respectively. The mean distance between the LP and ON at the level of the basal lamella was 8.1 ±2.1mm. Mean transection times for the MR and ON were 13.4 ± 7.3 seconds and 37.3 ± 9.2 seconds, respectively, with minimum times of 4 seconds and 26 seconds.
UNASSIGNED: The proximity of orbital structures to the paranasal sinuses and the rapidity of ophthalmic damage following violation of the periorbita reaffirms the need for cautious use of the microdebrider during FESS.