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BackgroundTransverse sinus stenosis is commonly seen in patients with idiopathic intracranial hypertension (IIH). Although the aetiology remains controversial, limited studies of treating IIH with transverse venous sinus stenting (VSS) have shown promising results.Materials and MethodWe studied the first 27 consecutive patients prospectively with IIH who underwent VSS. Eligibility criteria were: medically refractory IIH, papillodema, significantly raised intracranial venous sinus pressures above the stenosis and a significant pressure gradient across the stenosis.ResultsTwenty-seven patients with a mean age of 32 years and a mean BMI of 36 Kg/m2 pre-procedure were included and followed up for a median of 20 (range 5–45) months. The mean pressure gradient across the transverse sinus was 19.2 mmHg. Twenty-five out of the twenty-seven patients successfully underwent VSS. Stent placement was unsuccessful in the remaining two patients (7%). Papillodema resolved in 21 cases; headache resolved in 14 cases and improved in 8 cases. In summary, 22 out of 25 (88%) patients stented had resolution of their symptoms and signs of raised intracranial pressure, giving an overall success rate of 22/27 (81%).ConclusionOur study suggests that VSS is effective at treating refractory IIH and offers an alternative to CSF shunting.

Treatment of idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, generally prioritizes alleviating headaches and preserving vision. If medical management is unsuccessful, possible surgical treatment options depending on symptom severity include serial lumbar punctures, venous sinus stenting, optic nerve sheath fenestration (ONSF), and cerebrospinal fluid (CSF) shunting. Venous sinus stenting has remained controversial as cerebral vein stenosis may not be a primary cause.In our case, we present a 38-year-old female with known pseudotumor cerebri who underwent a diagnostic cerebral angiogram with manometry and high-volume lumbar puncture. Pre-lumbar puncture manometry demonstrated venous pressures throughout the left and right transverse sinuses and distal superior sagittal sinus ranging from 25–30 mmHg with associated bilateral transverse-sigmoid junction stenoses. The patient was then placed in the lateral decubitus position and a lumber puncture at L2-3 was performed. Opening pressure was measured at 29 cm H2O, 30 mL of clear CSF was removed, and closing pressure was measured at 8.5 cm H2O. Post-lumbar puncture manometry demonstrated normalization of respective venous pressures ranging from 8–12 mmHg with resolution of associated bilateral transverse-sigmoid junction stenoses and improved venous sinus calibers. Following the procedure, the patient reported resolution of headache.These results indicate that cerebral venous stenoses in the setting of IIH may be a secondary phenomenon. Thus, patients may benefit from CSF shunting as a primary surgical treatment option. In order to establish treatment efficacy, future studies could evaluate for stenosis and pressure gradient recurrence after CSF shunting.Disclosures M. Brown: None. T. Wolfe: None.

Category: Trauma; Hindfoot Introduction/Purpose: While the optimal surgical approach for operative treatment of calcaneus fractures is controversial. Regardless of index approach, post-injury sequelae such as malunion may require subsequent extensile exposures for reconstruction. In the tenuous soft tissues overlying the Whether a lateral extensile approach is safe following a previous sinus tarsi exposure has yet to be demonstrated. Methods: In this case report, two individuals underwent an initial sinus tarsi approach for reduction and fixation of calcaneus fractures, but went on to malunion or subtalar arthritis. A 'sham' surgery consisting of skin incision and initial flap elevation was performed to evaluate the efficacy of a lateral extensile approach to the calcaneus after previous sinus tarsi incision. Results: In each instance, the patients experienced uneventful skin incision healing, and subsequently had successful reconstruction with distraction subtalar arthrodesis via lateral extensile exposures. Conclusion: The lateral extensile approach to the calcaneus may be safely performed following sinus tarsi exposure.

Objectives: The etiology of pilonidal sinus disease is still controversial. Acquired theory in its etiology has become more popular nowadays. The aim of this study was to investigate the effects of dominant hand use on sinus features and sinus direction. Methods: Eight hundred and sixty-five patients with diagnosis of primer pilonidal sinus disease were included. Data on patients’ ages, BMI, over-sitting histories, duration of disease, dominant hand use histories, the condition of their sinuses at the time of presentation, the number of sinus openings, sinus directions, and sinus extension directions were collected. Relationship was evaluated between dominant hand use and sinus direction or sinus extension direction. Results: There was no statistically significant difference between the patients’ ages, sexes, BMI figures, the durations of disease and over- sitting history and dominant hand use. While the sinus directions of patients who had shorter duration of disease were towards the midline, it was seen that as the duration of disease increased the sinus extensions were oriented any side (p = 0.01). There was, however, a significant relationship between the sinus extension direction and dominant hand use. It was observed that the sinus extension direction of the patients who dominantly used their right hands was towards the left, while the sinus extension direction of the patients with dominant left hands was towards the right (p = 0.04, RR:2.05). Conclusions: The fact that sinus extension directions can change against factors affecting body positions proves to be another factor which shows that pilonidal sinus disease is an acquired disease.

Objectives: The aim of this study was to determine the relationship between septum deviation and anatomic variations of the paranasal sinus. Methods: A total of 157 (79 males, 78 females) patients between the ages of 17 and 77 years (mean age: 33.7 ± 14.9 years) were included in the study. Using paranasal sinus computed tomography imaging, anatomical variations including nasal septal deviation, Agger nasi cells, Haller cells, Onodi Cells, sphenoid sinus pneumatisation, paradoxical middle turbinates, middle turbinate pneumatisation, maxillary sinus septa,vertical septa in the sphenoid sinus, optic nerve dehiscenceand cribriform plate lamina lateralis height were evaluated. Results: Agger nasi cells were present in 47.1% of cases, Haller cells were seen in 5% of cases and Onodi cells were observed in 23.6% of cases. In 70.1% of cases, one vertical septa in the sphenoid sinus was observed. Maxillary sinus septa was observed in 16.5% of cases. There was a significant negative correlation between the female gender and increased sphenoid sinus pneumatisation (p = 0.035). There was a positive correlation between maxillary sinus septa and the presence of Onodi cells (pright =0.045, pleft = 0.017). There was also a negative correlation between maxillary sinus septa and sphenoid sinus pneumatisation (pright = 0.001, pleft = 0.005). Conclusions: In our study, we found that maxillary sinus septa, Agger nasi, Haller cells, cribriform plate lamina lateralis height, sphenoid sinus septation and Onodi cells were interrelated. We recommend that surgeons evaluate patients with these variations to prevent complications.

Category: Trauma; Hindfoot Introduction/Purpose: Fractures of the calcaneus are life-changing events with a major socioeconomic impact from lost productivity. Traditional operative treatment with the extensile lateral approach has shown relatively high rates of wound complications. Less invasive approaches can improve fracture alignment and decrease wound healing complications. The purpose of this study is to report our experience with the sinus tarsi approach in treating calcaneus fractures. Methods: We retrospectively identified patients at our institution treated with a limited sinus tarsi approach for calcaneus fractures from 2009-2018. Demographic and radiographic data were collected including: age, sex, mechanism of injury, occupation, presence of diabetes, smoking status, Sanders classification, Bohler and Gissane angles. Postoperatively, we recorded the presence of complications, return-to-work time, and radiographic measurements. Results: Our analysis included 105 fractures in 100 patients: 86% males, 42% smokers, 4% diabetics, with an average body mass index of 26.5. The fractures were: Sanders type 2 (32%), type 3 (48%), type 4 (18%), and 2% were a tongue-type variant. Preoperatively 38% of fractures displayed a negative angle, 50% had an angle 0-20 degrees, and 12% over 20 degrees; postoperatively 13% had an angle 0-20 degrees, and 87% had an angle over 20 degrees. Of patients working prior to the injury, 72% had returned to work by 6 months, and 89% by 12 months. The wound complication rate was 12% (12/100), with only 2% (2/100) requiring additional procedures. There was no significant difference in wound complication rates in smokers versus nonsmokers (11.9% vs 12.2%, p=0.55). Conclusion: The limited sinus tarsi approach for depressed calcaneus fractures allows radiographic restoration of calcaneal height with a low rate of wound complications, even amongst active smokers. To the authors’ best knowledge, this is the largest published case series of calcaneus fractures treated with the sinus tarsi approach. Further follow up is needed to determine the success of this approach in mitigating long term complications.

Category: Hindfoot, Trauma Introduction/Purpose: Intra-articular fractures of the calcaneus are a common injury to the hindfoot following high energy trauma to the lower extremity. Treatment of these fractures has evolved. Due to the concern of wound complications associated with extensile open treatments, smaller incision techniques, such as the sinus tarsi approach, are increasing in popularity. A number of fixation strategies are utilized with this approach, and it is unknown which most accurately restores radiographic alignment. The purpose of this study is to compare the postoperative radiographic outcomes of a plate and screw construct versus a cannulated screw construct when using the sinus tarsi approach for open reduction and internal fixation (ORIF) of calcaneus fractures. Methods: After IRB approval, records for all patients treated surgically at our institution for calcaneus fractures from 2012 to 2017 were reviewed. Inclusion criteria were intra-articular calcaneus fractures, patients aged 18 years or older, and use of the sinus tarsi approach. Exclusion criteria were open fractures and clinical follow up less than 6 weeks. A total of 51 fractures underwent ORIF using cannulated screws alone (Group 1), and 23 fractures underwent ORIF using a sinus tarsi plate (Group 2). The primary outcomes of interest included pre- and postoperative Bohler and Gissane angles, wound complications, and unplanned return to OR. Results: There was no statistically significant difference between preoperative Bohler angles for Group 1 (14.5 degrees) versus Group 2 (12.3 degrees) (p=0.35), nor was there a significant difference between postoperative Bohler angles between Group 1 (30.1 degrees) and Group 2 (27.0 degrees) (p=0.09). Similarly, preoperative Gissane angles for Group 1 (128.4 degrees) and Group 2 (134.5 degrees) (p=0.17) and postoperative Gissane angles for Group 1 (116.7 degrees) and Group 2 (118.8 degrees) (p=0.44) showed no statistically significant difference. There were a total of 3 wound complications in Group 1 versus 2 wound complications in Group 2 (p=0.76). There was no statistically significant difference in operative duration (p=0.97) or the number of unplanned returns to the OR between the two groups (p=0.77). Conclusion: When comparing the cannulated screw and plate and screw fixation techniques, there was no difference in restoration of the Bohler and Gissane angles. Both techniques had similar rates of postoperative complications and return to the OR. Our data suggests that fixation using cannulated screws alone versus sinus tarsi plate provide similar radiographic outcomes and risk of complications. The two techniques are also similar in terms of implant costs. Our results indicate that either technique effectively improves radiographic parameters.

Clinical findings such as symptoms, signs, and preoperative hearing are frequently nonspecific in cases of temporal bone cholesteatoma, the surgical removal of cholesteatoma in this region is great challenge for the skull base surgeons.