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In this study, we investigated the effect of chronic environmental stress, due to long-term residence in a conflict zone, on the lengths of the anterior and posterior cranial base, maxilla, and mandible in healthy children and adolescents. A retrospective cohort of 158 Israeli children (mean age: 13.42 ± 1.41 years) was divided into two groups: children from Gaza envelope ( n  = 82), with chronic exposure to security threats, and their counterparts from central Israel ( n  = 76), with low exposure. Cephalometric measurements were obtained from lateral radiographs using standardized protocols. The children’s skeletal and dental maturation stages were assessed via cervical vertebral maturation and Demirjian’s tooth development index. Compared with children in the central Israel, Gaza envelope children presented significantly shorter lengths of both the anterior (mean difference: 3.37 mm, p  = 0.008) and posterior cranial bases (mean difference: 2.92 mm, p  = 0.005). No significant differences were found in mandibular body length, ramus height, effective mandibular or maxillary length, or the maxillomandibular differential. Correlation analyses revealed weakened associations among craniofacial measurements in the conflict-exposed group, suggesting environmental disruption of coordinated craniofacial growth. Notably, female children in the Gaza envelope group were more affected, with significantly smaller measurements across most craniofacial parameters. Chronic exposure to conflict-related stress is associated with reduced cranial base growth in children, particularly in females. These findings underscore the vulnerability of endochondral growth structures to environmental stress, especially anterior cranial base, and suggest a potential link between psychosocial factors and altered craniofacial development.

Few quantitative data are available to describe Kawase's exposure of the posterior fossa. We used a cadaveric model to compare Kawase's and the retrosigmoid approach to the petroclival region. Eighteen cadaveric specimens were dissected and analyzed (6 retrosigmoid, 6 Kawase's, and 6 retrosigmoid intradural suprameatal approaches). Clival and brainstem working areas and surgical freedom were measured. The retrosigmoid approach provided a significantly larger clival and brainstem working area than Kawase's approach. Surgical freedom at the trigeminal root entry zone, origin of the anterior inferior cerebellar artery, and Dorello's canal was equivalent across approaches. Kawase's approach provided the most surgical freedom at the trigeminal porus. However, the addition of a suprameatal extension significantly improved the surgical freedom provided by the retrosigmoid approach. The retrosigmoid approach is a powerful approach to lesions of the cerebellopontine angle and ventral brainstem. Lesions involving the trigeminal porus and Meckel's cave can be approached through Kawase's approach or a suprameatal extension of the retrosigmoid approach. Kawase's approach is best suited for accessing middle fossa lesions with smaller petroclival components located above the internal auditory canal.

Background: The sphenoid sinus (SS) is located close to vital structures, such as the pituitary gland, and it has significant clinical relevance. This study aimed to clarify the growth pattern of the SS in Japanese children using three-dimensional computed tomography (CT). Methods: Seventy-eight participants with congenital, acquired, or external auditory canal cholesteatoma were recruited and underwent CT more than twice during their treatment. Using the volume-rendered images, the size and volume of the SS were measured. Furthermore, on the scout image, the morphological measurements of the cranial base were determined. Results: The size and volume of the SS increased with age, and peaked at the mean age of 15 years. For males, the volume of the SS was smaller than that of females aged <5 years. The growth rate of the SS was significantly higher in males than in females. The maximum growth rate was detected at the age of 12 years for males and 10 years for females. For females, the increase in the length of the anterior cranial base ceased at approximately 10 years of age and remained constant thereafter. In contrast, for males, the length of the anterior cranial base increased gradually until 15 years of age. Conclusions: Considering the similarity of the periods between the adolescent growth spurt and the maximum growth rate of the SS, changes in the size of the SS may be used as an indicator of the physical growth spurt.

Abstract BACKGROUND The nasoseptal flap is the main pedicled flap used for endoscopic cranial base reconstruction. For large anterior cranial base defects, the anterior edge is a concern for the nasoseptal flap reach. OBJECTIVE To present a surgical technique that completely releases the vascular pedicle of the nasoseptal flap from the sphenopalatine artery (SPA) foramen improving considerably the reach of the flap. METHODS A patient with left anterior cranial base fracture involving the posterior table of the frontal sinus, who presented with cerebrospinal fluid leak and contused brain herniation to the ethmoid and frontal sinuses. Unilateral endoscopic endonasal anterior cranial base reconstruction was performed with left sided nasoseptal flap. The nasoseptal flap pedicle was dissected and completely released from the SPA foramen. The flap was left attached only to the internal maxillary artery (IMAX) vascular bundle. RESULTS The flap covered the entire left anterior cranial base, from the planum sphenoidale to the posterior table of the frontal sinus. There was complete obliteration of the cerebrospinal fluid fistula postoperatively with resolution of the radiographic pneumocephalus and the patient's rhinorrhea. CONCLUSION The complete release of the nasoseptal flap pedicle from the SPA foramen is feasible and remarkably improves the reach of the flap. It also increases the reconstructive area of the flap since the entire septal mucosa can be used for reconstruction and the pedicle length is based exclusively upon the SPA/IMAX.

BACKGROUND:The facial nerve has a short intracranial course but crosses critical and frequently accessed surgical structures during cranial base surgery. When performing approaches to complex intracranial regions, it is essential to understand the nerveʼs conventional and topographic anatomy from different surgical perspectives as well as its relationship with surrounding structures. OBJECTIVE:To describe the entire intracranial course of the facial nerve as observed via different neurosurgical approaches and to provide an analytical evaluation of the degree of nerve exposure achieved with each approach. METHODS:Anterior petrosectomies (middle fossa, extended middle fossa), posterior petrosectomies (translabyrinthine, retrolabyrinthine, transcochlear), a retrosigmoid, a far lateral, and anterior transfacial (extended maxillectomy, mandibular swing) approaches were performed on 10 adult cadaveric heads (20 sides). The degree of facial nerve exposure achieved per segment for each approach was assessed and graded independently by 3 surgeons. RESULTS:The anterior petrosal approaches offered good visualization of the nerve in the cerebellopontine angle and intracanalicular portion superiorly, whereas the posterior petrosectomies provided more direct visualization without the need for cerebellar retraction. The far lateral approach exposed part of the posterior and the entire inferior quadrants, whereas the retrosigmoid approach exposed parts of the superior and inferior quadrants and the entire posterior quadrant. Anterior and anteroinferior exposure of the facial nerve was achieved via the transfacial approaches. CONCLUSION:The surgical route used must rely on the size, nature, and general location of the lesion, as well as on the capability of the particular approach to better expose the appropriate segment of the facial nerve. ABBREVIATIONS:AICA, anterior inferior communicating arteryCPA, cerebellopontine angleGG, geniculate ganglionIAC, internal auditory canalPICA, posterior inferior communicating artery

Objectives One of the key aspects of three-dimensional (3D) craniofacial cephalometry is the measurement of posterior cranial base angle as this area is deeply involved in craniofacial development. The purpose of our retrospective study was to define the best reproducible 3D posterior cranial base angles among five 3D angles transposed from 2D cephalometry (Cousin, BL1 of Ross and Ravosa, Bjork, Delaire, CBA4 of Liberman) and seven 3D angles based on physical anthropology studies and on new concepts (R1 to R7). The null hypothesis was that all 3D posterior cranial base angles were equally reproducible. Material and methods We used a preoperative low-dose computed tomography (CT) data from 20 adult patients undergoing orthognathic surgery after approval by local ethical committee. Two independent observers performed two series of 23 3D landmark identifications on 3D CT surface rendering of each patient using Maxilim software. Then, the same observers performed twice 3D cephalometric analyses (23 landmarks, 4 midpoints, 19 planes) that provided the automatic measurement of 12 posterior cranial base angles. Results Inter-observer correlation coefficient varied from 0.545 (Cousin) to 0.695 (CBA4 of Liberman) and from −0.177 (R2) to 0.827 (R4). Conclusions The null hypothesis was rejected. The most reproducible angle was 3D angle R4 based on “basion,” “superior optic” (right, left), and “crista galli inferior” landmarks. Clinical relevance R4 angle might be used as reference 3D posterior cranial base angle in further clinical studies involving 3D cephalometry as a diagnostic tool for orthodontics and for orthognathic surgery.

Skull base anatomy is extremely complex, with vital neurovascular structures passing through multiple channels and foramina. Brain tumors such as pituitary tumors, acoustic neuromas, and meningiomas are challenging to treat due to their close proximity to cranial nerves and blood vessels in the brain, neck, and spinal cord. Medical imaging is an essential tool for identifying lesions and critical adjacent structures. Detecting and precisely mapping out the extent of disease is imperative for appropriate and optimal treatment planning and ultimately patient outcome. Eugene Yu and Reza Forghani have produced an exceptional, imaging-focused guide on various neoplastic diseases affecting the skull base, with contributions from a Who's Who of prominent radiologists, head and neck surgeons, neurosurgeons, and radiation oncologists. The content is presented in a clear and concise fashion with chapters organized anatomically. From the Anterior Cranial Fossa, Nasal Cavity, and Paranasal Sinuses - to the Petroclival and Lateral Skull Base, an overview and detailed analysis is provided for each region. Key Highlights * Fundamentals of skull base imaging, including recent developments in diagnostic modalities * More than 400 radiographs, color anatomical drawings, and color intraoperative photos elucidate the imaging appearances of a wide spectrum of disease affecting the skull base, as well as important anatomic variants and pathways of disease spread * Clinically oriented imaging approach focuses on diagnostic and prognostic features important in the evaluation of skull base abnormalities * Atlas of skull base CT and MRI anatomy provides an easy to access, quick reference for identifying important anatomic landmarks * Insights on the pathways of tumor growth and the role of clinical imaging in the management of skull base cancers * Critical and contrasting viewpoints from multidisciplinary experts provide a well-rounded perspective This invaluable resource chronicles current knowledge in state-of-the-art skull base tumor imaging with clinical pearls on pathophysiology, prognosis, and treatment options. It is a must-have for radiology, neurosurgery, and otolaryngology residents and clinicians who care for patients with head and neck neoplasms.

Abstract Background Although persistent fontanelles (PFs) are common in adult Chihuahuas, their association with cranial morphology remains unknown. Objectives To identify whether cranial morphology is associated with PFs in Chihuahuas and if bodyweight is associated with cranial morphology in this breed. Animals Fifty client-owned Chihuahuas. Methods In this retrospective cross-sectional study using computed tomography images, we measured two different cranial base lengths (1 and 2), cranial length, height, and width, and two craniofacial angles. We calculated the ratios of cranial height to cranial base lengths 1 and 2, cranial height to length, cranial height to width, and cranial width to length (cranial index [CrI]). We evaluated if total PF area and number of cranial sutures affected by PFs were associated with craniometric measurements and their ratios and craniofacial angles. Additionally, we evaluated if the craniometric ratios were associated with bodyweight. Results Total PF area was larger and number of cranial sutures affected by PFs higher in dogs with higher cranial height to cranial base length ratios 1 (estimate, [95% confidence interval], p: 2.295, [1.204–4.377], p = 0.01 and 1.720, [1.212–2.442], p = 0.002, respectively) and 2 (1.203, [1.069–1.354], p = 0.003 and 1.087, [1.011–1.169], p = 0.02, respectively) and CrI (1.225, [1.079–1.391], p = 0.002, and 1.134, [1.057–1.215], p < 0.001, respectively). Higher CrI was associated with lower bodyweight (−2.600, [−4.102 to −1.098], p = 0.001). Conclusion and Clinical Importance Our results suggest that in Chihuahuas, lower bodyweight is associated with more extreme brachycephaly and extreme brachycephaly is associated with PFs.

Endoscopic cranial base surgery is a minimal access, maximally aggressive alternative to traditional transfacial, transcranial, or combined open cranial base approaches. Previous descriptions of endoscopic approaches have used varying terminology, which can be confusing to the new practitioner. Indications for surgery are not well defined. Our objective was to create a comprehensive classification system of the various approaches and describe their indications with case examples. We prospectively compiled a comprehensive database of our endonasal endoscopic operations, detailing the nasal sinus transgressed, the cranial base approach, and the intracranial target for the first 150 consecutive cases performed at our institution. All cases were performed collaboratively by a neurosurgeon and an otolaryngologist. We categorized the endonasal endoscopic cranial base operations into four nasal corridors, nine cranial base approaches, and 13 intracranial targets. Each of the various approaches is described in detail and illustrated with case examples. Pathology encountered included pituitary tumor (50%), meningocele/encephalocele (14%), craniopharyngioma and Rathke cleft cyst (10%), meningioma (8%), chordoma (5%), esthesioneuroblastoma (2%), and other (11%). Endonasal endoscopic cranial base surgery is a minimal access, maximally invasive alternative to open transcranial cranial base approaches for specific indications. A clear understanding of the possible approaches is facilitated by an awareness of the nasal corridors and intracranial targets.