Background and Aim: „CI-Wizard“ is a new, three-dimensional software planning tool for cochlear implant surgery with manual and semi-automatic algorithms to visualize anatomical risk structures of the lateral skull base preoperatively. Primary endpoints of the study represented the evaluation of the CI Wizards usability, accuracy, subjectively perceived and objectively measured time in clinical practice. Materials and Methods: In a period from January 2014 to March 2015, n=36 participants were included in this study. These members were divided into three groups of equal number (n=12), but different level of experience. Senior doctors and consultants (group 1), residents (group 2) and medical students (group 3) segmented twelve different CT-scan data sets of the CI Wizard (four per participant). In total, n=144 data sets were collected. The usability of the CI Wizard was measured by the given questionnaire with an interval rating scale. The Jaccard coefficient (JT) was used to evaluate the accuracy of the anatomical structures segmented. The subjectively-perceived time was measured with an interval rating scale in the questionnaire and was compared with the objectively mean measured time (time interact). Results: Across all three groups, the usability of the CI Wizard has been assessed between 1 ('very good') and 2 ('with small defects'). Subjectively, the time was stated as 'appropriate' by questionnaire. Objective measurements of the required duration revealed averages of n=9.8 minutes for creating a target view. Concerning the accuracy, semi automatic anatomical structures such as the external acoustic canal (JT=0.90), the tympanic cavity (JT=0.87), the ossicles (JT=0.63), the cochlea (JT=0.66) and the semicircular canals (JT=0.61) reached high Jaccard values, which describes a great match of the segmented structures between the partcipants and the gold standard. Facial nerve (JT=0.39) and round window (JT=0.37) reached lower Jaccard values. Very little overlap tendency was found for the chorda tympani (JT=0.11). Conclusion: This software program represents a further important step in the development of pre-operative planning tools in cochlear implant surgery. The study revealed a high level of satisfaction in the usability. The subjectively required time was considered as „appropriate“ and the objectively mean measured time was n=9.8 minutes short enough, so that a clinical application seems realistic. Particularly for semi-automatically segmented structures, it represented a good accuracy. For purely manual segmented structures, further improvements are desirable. Finally, this program also provides a good learning tool for medical students and residents to become familiar with the anatomy of the lateral skull base.:1 Einführung 1 1.1 Cochlea Implantate (CI) 1 1.2 Bildverarbeitungsprogamme zur präoperativen Planung eines Cochlea Implantates 2 1.2.1 Segmentierung in der Medizin 2 1.2.2 CI-Wizard 4 1.3 Fragebogen 6 1.4 Zielsetzung 6 1.5 Zusammenfassung der Ergebnisse 7 2 Publikation 8 3 Zusammenfassung 19 4 Literaturverzeichnis 23 Anlagen 26 Beitrag der Promovendin bei geteilter Erstautorenschaft 34 Erklärung über die eigenständige Abfassung der Arbeit 35 Lebenslauf 36 Danksagung 37

Facial Artery Musculomucosal Flap in Skull Base Reconstruction Xie L. MD, Lavigne F. MD, Rahal A. MD, Moubayed SP MD, Ayad T. MD Introduction: Failure in skull base defects reconstruction can have serious consequences such as meningitis and pneumocephalus. The nasoseptal flap is usually the first choice but alternatives are necessary when this flap is not available. The facial artery musculomucosal (FAMM) flap has proven to be successful in head and neck reconstruction but it has never been reported in skull base reconstruction. Objective: To show that the FAMM flap can reach some key areas of the skull base and be considered as a new alternative in skull base defects reconstruction. Methods: We conducted a cadaveric study with harvest of modified FAMM flaps, endoscopic skull base dissection and maxillectomies in 13 specimens. Measures were taken for each harvested FAMM flap. Results: The approximate mean area for reconstruction from the combination of the distal FAMM and the extension flaps is 15.90 cm2. The flaps successfully covered the simulated defects of the frontal sinus, the ethmoid areas, the planum sphenoidale, and the sella turcica. Conclusion: The FAMM flap can be considered as a new alternative in the reconstruction of skull base defects. Modifications add extra length to the traditional FAMM flap and can contribute to a tighter seal of the defect as opposed to the FAMM flap alone. / Le lambeau musculomuqueux de la joue dans la reconstruction de la base du crâne Xie L. MD, Lavigne F. MD, Rahal A. MD, Moubayed SP MD, Ayad T. MD Introduction: Un échec dans la reconstruction de la base du crâne peut avoir des conséquences graves telles que la méningite ou la pneumocéphalie. Le premier choix de la reconstruction est le lambeau nasoseptal. Lorsque ce dernier n’est pas disponible, d’autres alternatives sont nécessaires. Le lambeau musculomuqueux de la joue (FAMM) a une place établie dans la reconstruction des déficits de la tête et du cou, mais il n’a pas jamais été décrit dans la reconstruction de la base du crâne. Objectif: Démontrer que le lambeau de FAMM peut atteindre des zones clés de la base du crâne et être considéré comme une nouvelle option de reconstruction de cette région. Méthode: Nous avons entrepris une étude cadavérique avec prélèvement de lambeaux de FAMM modifiés et une dissection endoscopique de la base du crâne sur 13 spécimens. Des mesures ont été prises pour chaque lambeau prélevé. Résultats: L’aire de reconstruction moyenne du lambeau de FAMM et des extensions est de 15.90 cm2. Les lambeaux couvrent totalement les déficits simulés du sinus frontal, des ethmoïdes, le toit du sphénoïde et la selle turcique. Conclusion: Le lambeau de FAMM peut être considéré comme une nouvelle alternative dans la reconstruction des déficits de la base du crâne. Les modifications apportent une longueur additionnelle et contribuent à une couverture plus étanche du déficit que le lambeau de FAMM seul.

INTRODUÇÃO. Durante a última década, os avanços tecnológicos, o maior domínio da anatomia e das técnicas operatórias e de reconstrução da base do crânio por via endonasal propiciaram a expansão da cirurgia endoscópica para além dos limites da sela túrcica. O acesso transpterigóideo é uma etapa comum ao acesso as fossas cranianas média e posterior, e o conhecimento da anatomia endoscópica da artéria carótida interna (ACI) é um ponto fundamental e comum a estes acessos. OBJETIVO. Descrever a anatomia endoscópica relacionada ao acesso transpterigóideo e da ACI utilizando um modelo anatômico em cabeças cadavéricas frescas procurando definir os parâmetros seguintes: reparos anatômicos do acesso endoscópico a região supra e infrapetrosa, os limites para exposição endoscópica da ACI, os reparos anatômicos para localização dos seus segmentos lacerum, petroso e parafaríngeo. MÉTODOS. Foi realizado estudo anatômico em 20 espécimes (10 cabeças) de cadáveres frescos. As cabeças foram previamente preparadas com a injeção intravascular de silicone corado para enaltecer as estruturas vasculares (ACI, artéria maxilar e seus ramos e seio cavernoso). Em todos os casos foi realizado o acesso transpterigóideo às regiões supra e infrapetrosa, assim como a fossa infratemporal, e a dissecção endoscópica da ACI. RESULTADOS. A injeção de silicone corado no sistema arterial e venoso proporcionou modelo anatômico adequado para dissecção e documentação do acesso transpterigóideo assim como dos diferentes segmentos da ACI. A dissecção por etapas proporcionou exposição adequada da ACI do seu segmento cavernoso ao parafaríngeo distal. O acesso transpterigóideo forneceu exposição adequada do segmento lacerum da ACI e região suprapetrosa e seus principais reparos anatômicos foram o nervo vidiano, nervos maxilar e mandibular (V2, V3) e gânglio de Gasser. A exposição caudal da ACI (segmentos petroso e parafaríngeo) e região infrapetrosa requer maxilectomia medial para exposição e remoção de todo o processo pterigóideo, seguida pela ressecção da tuba auditiva e do tecido fibrocartilaginoso do forame lacerum. Os principais reparos anatômicos desta etapa foram a tuba auditiva e V3. CONCLUSÃO. Durante o acesso endoscópico à região suprapetrosa, o nervo vidiano, os ramos maxilar e mandibular do nervo trigêmeo (V2 e V3) e o gânglio de Gasser são reparos anatômicos para localização da artéria carótida interna e fossa craniana média. Durante o acesso endoscópico à região infrapetrosa, o tecido fibrocartilaginoso do forame lacerum, a tuba auditiva e o nervo mandibular (V3) são reparos anatômicos para identificação da artéria carótida interna. O acesso endoscópico endonasal por etapas permite acesso à artéria carótida interna extracraniana desde o segmento cavernoso até seu segmento parafaríngeo inferiormente ao nível do assoalho da cavidade nasal. O reparo anatômico para localização do segmento lacerum e porção horizontal do segmento petroso da ACI é o nervo vidiano; para as porções petrosa horizontal junto ao joelho posterior e canal carotídeo os reparos anatômicos são o nervo mandibular (V3), forame oval, tecido fibrocartilaginoso do forame lacerum e a tuba auditiva; para o segmento parafaríngeo os reparos anatômicos são o tronco posterior do nervo mandibular (V3) e a tuba auditiva / INTRODUCTION. During the last decade, the technological advances, the mastery of the anatomy and operative techniques and skull base reconstruction using endonasal approaches have propelled endoscopic surgery for beyond the limits of sella turcica. The transpterygoid approach is a common step of the endoscopic approach to the middle and posterior cranial fossa and knowledge of the endoscopic anatomy of the internal carotid artery (ICA) is a common and paramount point to these approaches. OBJECTIVE. Describe the endoscopic anatomy related to the transpterygoid approach and ICA using an anatomical model with fresh human cadaveric heads to define: anatomical landmarks related to the endoscopic supra and infrapetrous areas approach, limits for endoscopic exposure of the ICA, anatomical endoscopic landmarks to lacerum, petrous and parapharyngeal ICA segments. METHODS. An anatomical study was performed using 20 specimens (10 heads) of fresh cadaveric heads. The heads were previously prepared with the injection of colored silicone to enhance the vascular structures (ICA, maxillary artery and its branches and cavernous sinus). In all cases we performed the transpterygoid approach to the supra and infrapetrous areas, as well as the infratemporal fossa, and the endoscopic dissection of the ICA. RESULTS. The injection of colored silicone in the arterial and venous system provided an adequate anatomical model for dissection and documentation of the transpterygoid approach as well as the different segments of the ICA. A stepwise dissection provided adequate exposure of the ICA from its cavernous to the distal parapharyngeal segment. The transpterygoid approach provided adequate exposure of the lacerum segment of the ICA and suprapetrous area and the landmarks were the vidian nerve, maxillary and mandibular nerves (V2, V3) and the Gasserian ganglion. Exposure of the caudal ICA (petrous and parapharyngeal) and the infrapetrous area required a medial maxillectomy for exposure and resection of the entire pterygoid process, followed by the Eustachian tube and the fibrocartilaginous tissue of the foramen lacerum. The main anatomical landmarks to this step were V3 and the Eustachian tube. CONCLUSION. During the endoscopic approach to the suprapetrous area, the vidian nerve, the maxillary and mandibular divisions of the trigeminal nerve (V2, V3) and the Gasserian ganglion are the anatomical landmarks to the internal carotid artery and middle cranial fossa. During the endoscopic approach to the infrapetrous area, the fibrocartilaginous tissue of the foramen lacerum, the Eustachian tube and V3 are the landmarks to the internal carotid artery. A stepwise endoscopic endonasal approach provided access to the extracranial internal carotid artery from its cavernous to the parapharyngeal segment down to the level of the nasal fossa floor. The anatomical landmark to the lacerum and horizontal petrous segments of the internal carotid artery is the vidian nerve; to the horizontal petrous segment before the posterior bend and carotid canal, the anatomical landmarks are the mandibular nerve (V3), foramen ovale, fibrocartilaginous tissue of the foramen lacerum and the Eustachian tube; to the parapharyngeal segment, the anatomical landmarks are the posterior trunk of the mandibular nerve (V3) and the Eustachian tube

Das vom endonasalen Neuroepithel der Rima olfactoria entstandenen Aesthesioneuroblastom gehört zu den seltenen malignen Tumoren der Rhinobasis. Eine generelle Therapieempfehlung für die Behandlung dieses Tumors gibt es nicht, da bis heute etablierte, durch umfassende onkologische Studien untermauerte diagnostische und therapeutische Standards fehlen und der klinische Verlauf oft unberechenbar ist. Die Aufgabe der vorliegenden Arbeit bestand in der Überprüfung des chirurgischen Konzeptes bei der Therapie von Aesthesioneuroblastomen und in der erstmaligen molekularzytogenetischen Charakterisierung von Aesthesioneuroblastomen. Dazu wurden 18 Patienten mit Aesthesioneuroblastomen, die im Zeitraum zwischen 1988 und 2001 in der HNO-Klinik (17 Patienten) sowie in der Neurochirurgischen Klinik des Klinikums Fulda operiert wurden, untersucht. Die daraus resultierenden 22 Aesthesioneuroblastome wurden alle mit Hilfe der Vergleichenden Genomischen Hybridisierung (CGH) analysiert. Nach derzeitigem Kenntnisstand besteht die optimale Therapie der Aesthesioneuroblastome in der chirurgischen Resektion des Tumors mit nachfolgender stereotaktischer Bestrahlung. Für die operative Sanierung der Aesthesioneuroblastome und auch anderer Malignome der vorderen Schädelbasis ist das nachfolgende neue Fuldaer Konzept empfehlenswert: 1) Endonasale Resektion, wenn keine intrakranielle bzw. orbitale Tumorinfiltration vorliegt; 2) Subfrontaler Zugang, bei Infiltration des Gehirns; 3) Midfacial degloving, bei weit lateraler Tumorausbreitung; 4) Laterale Rhinotomie nur bei der Notwendigkeit der simultanen Exenteratio orbitae (bei orbitaler Tumorinfiltration). Aesthesioneuroblastomen sind durch ein typisches genetisches Muster charakterisiert, das Deletionen im Bereich der chromosomalen Arme 1p, 2q, 3p/q, 4p/q, 5p/q, 6q, 8p/q, 9p, 10p/q, 11p, 12q, 13q, 18q und 21q sowie Amplifikationen der Chromosomen 1p, 7q, 9q, 11q, 14q, 16p/q, 17p/q, 19p/q, 20p/q und 22p/q umfasst. Die beim Aesthesioneuroblastom häufigen DNA-Verluste im Bereich der chromosomalen Banden 1p21-p31 scheinen mit der Prognose dieser Tumoren assoziiert zu sein. Die Tumoren aller in der vorliegenden Studie am Malignom verstorbenen Patienten zeigten eine Kombination aus 1p21-p31-Deletion, dem Vorliegen des klinischen Stadiums C oder D sowie gleichzeitig einer schlechten Differenzierung (Grad III oder IV). Vermittels der CGH ist es möglich, eine klonale Zuordnung von Metastasen bzw. auch Rezidiven zu ihren primären Aesthesioneuroblastomen vorzunehmen. Die vorliegende Arbeit zeigt nicht nur neue Ansätze in der chirurgischen Therapie von Aesthesioneuroblastomen sondern auch die erste umfassende molekularzytogenetische Analyse dieser Tumorentität, auf dem Weg, das biologische Verhalten dieser Malignome genauer charakterisieren zu können. / Esthesioneuroblastoma (ENB) is a very rare malignant neoplasm arising from the olfactory epithelium which is recognized for its propensity for local recurrence and distant dissemination. Therapeutic management approaches for this neoplasm lack uniformity. The present study describes therapeutic management in ENB: Complete surgical resection combined with adjuvant stereotactic radiation therapy. Thereby, a new surgical concept is recommended: 1) Endonasal approach in cases without tumor infiltration of the orbit and/or the brain; 2) Subfrontal approach in cases with extended tumor infiltration of the intradural space or of the brain; 3) Midfacial degloving in cases with far lateral tumor spread, particularly fossa pterygoidea or pterygopalatina; 3) Lateral rhinotomy in all cases where an exenteratio orbitae is needed. Secondarily, the study characterizes the specific chromosomal alterations of ENB analyzed using Comparative Genomic Hybridization (CGH). ENB show frequently deletions of chromosoms 1p, 2q, 3p/q, 4p/q, 5p/q, 6q, 8p/q, 9p, 10p/q, 11p, 12q, 13q, 18q and 21q as well as DNA gains of chromosoms 1p, 7q, 9q, 11q, 14q, 16p/q, 17p/q, 19p/q, 20p/q and 22p/q. Deletions of the chromosomal region 1p21-p31 could be associated with bad prognosis since the tumors of all patients who died were of stage C or D and grade III or IV, and showed 1p21-p31 deletions. The analysis of primary ENB and their corresponding metastases shows clonality by a high concordance of alterations between the tumor pairs. For the first time, this study presents the specific chromosomal alterations of ENB pathogenesis and progression.

Facial Artery Musculomucosal Flap in Skull Base Reconstruction Xie L. MD, Lavigne F. MD, Rahal A. MD, Moubayed SP MD, Ayad T. MD Introduction: Failure in skull base defects reconstruction can have serious consequences such as meningitis and pneumocephalus. The nasoseptal flap is usually the first choice but alternatives are necessary when this flap is not available. The facial artery musculomucosal (FAMM) flap has proven to be successful in head and neck reconstruction but it has never been reported in skull base reconstruction. Objective: To show that the FAMM flap can reach some key areas of the skull base and be considered as a new alternative in skull base defects reconstruction. Methods: We conducted a cadaveric study with harvest of modified FAMM flaps, endoscopic skull base dissection and maxillectomies in 13 specimens. Measures were taken for each harvested FAMM flap. Results: The approximate mean area for reconstruction from the combination of the distal FAMM and the extension flaps is 15.90 cm2. The flaps successfully covered the simulated defects of the frontal sinus, the ethmoid areas, the planum sphenoidale, and the sella turcica. Conclusion: The FAMM flap can be considered as a new alternative in the reconstruction of skull base defects. Modifications add extra length to the traditional FAMM flap and can contribute to a tighter seal of the defect as opposed to the FAMM flap alone. / Le lambeau musculomuqueux de la joue dans la reconstruction de la base du crâne Xie L. MD, Lavigne F. MD, Rahal A. MD, Moubayed SP MD, Ayad T. MD Introduction: Un échec dans la reconstruction de la base du crâne peut avoir des conséquences graves telles que la méningite ou la pneumocéphalie. Le premier choix de la reconstruction est le lambeau nasoseptal. Lorsque ce dernier n’est pas disponible, d’autres alternatives sont nécessaires. Le lambeau musculomuqueux de la joue (FAMM) a une place établie dans la reconstruction des déficits de la tête et du cou, mais il n’a pas jamais été décrit dans la reconstruction de la base du crâne. Objectif: Démontrer que le lambeau de FAMM peut atteindre des zones clés de la base du crâne et être considéré comme une nouvelle option de reconstruction de cette région. Méthode: Nous avons entrepris une étude cadavérique avec prélèvement de lambeaux de FAMM modifiés et une dissection endoscopique de la base du crâne sur 13 spécimens. Des mesures ont été prises pour chaque lambeau prélevé. Résultats: L’aire de reconstruction moyenne du lambeau de FAMM et des extensions est de 15.90 cm2. Les lambeaux couvrent totalement les déficits simulés du sinus frontal, des ethmoïdes, le toit du sphénoïde et la selle turcique. Conclusion: Le lambeau de FAMM peut être considéré comme une nouvelle alternative dans la reconstruction des déficits de la base du crâne. Les modifications apportent une longueur additionnelle et contribuent à une couverture plus étanche du déficit que le lambeau de FAMM seul.

INTRODUÇÃO. Durante a última década, os avanços tecnológicos, o maior domínio da anatomia e das técnicas operatórias e de reconstrução da base do crânio por via endonasal propiciaram a expansão da cirurgia endoscópica para além dos limites da sela túrcica. O acesso transpterigóideo é uma etapa comum ao acesso as fossas cranianas média e posterior, e o conhecimento da anatomia endoscópica da artéria carótida interna (ACI) é um ponto fundamental e comum a estes acessos. OBJETIVO. Descrever a anatomia endoscópica relacionada ao acesso transpterigóideo e da ACI utilizando um modelo anatômico em cabeças cadavéricas frescas procurando definir os parâmetros seguintes: reparos anatômicos do acesso endoscópico a região supra e infrapetrosa, os limites para exposição endoscópica da ACI, os reparos anatômicos para localização dos seus segmentos lacerum, petroso e parafaríngeo. MÉTODOS. Foi realizado estudo anatômico em 20 espécimes (10 cabeças) de cadáveres frescos. As cabeças foram previamente preparadas com a injeção intravascular de silicone corado para enaltecer as estruturas vasculares (ACI, artéria maxilar e seus ramos e seio cavernoso). Em todos os casos foi realizado o acesso transpterigóideo às regiões supra e infrapetrosa, assim como a fossa infratemporal, e a dissecção endoscópica da ACI. RESULTADOS. A injeção de silicone corado no sistema arterial e venoso proporcionou modelo anatômico adequado para dissecção e documentação do acesso transpterigóideo assim como dos diferentes segmentos da ACI. A dissecção por etapas proporcionou exposição adequada da ACI do seu segmento cavernoso ao parafaríngeo distal. O acesso transpterigóideo forneceu exposição adequada do segmento lacerum da ACI e região suprapetrosa e seus principais reparos anatômicos foram o nervo vidiano, nervos maxilar e mandibular (V2, V3) e gânglio de Gasser. A exposição caudal da ACI (segmentos petroso e parafaríngeo) e região infrapetrosa requer maxilectomia medial para exposição e remoção de todo o processo pterigóideo, seguida pela ressecção da tuba auditiva e do tecido fibrocartilaginoso do forame lacerum. Os principais reparos anatômicos desta etapa foram a tuba auditiva e V3. CONCLUSÃO. Durante o acesso endoscópico à região suprapetrosa, o nervo vidiano, os ramos maxilar e mandibular do nervo trigêmeo (V2 e V3) e o gânglio de Gasser são reparos anatômicos para localização da artéria carótida interna e fossa craniana média. Durante o acesso endoscópico à região infrapetrosa, o tecido fibrocartilaginoso do forame lacerum, a tuba auditiva e o nervo mandibular (V3) são reparos anatômicos para identificação da artéria carótida interna. O acesso endoscópico endonasal por etapas permite acesso à artéria carótida interna extracraniana desde o segmento cavernoso até seu segmento parafaríngeo inferiormente ao nível do assoalho da cavidade nasal. O reparo anatômico para localização do segmento lacerum e porção horizontal do segmento petroso da ACI é o nervo vidiano; para as porções petrosa horizontal junto ao joelho posterior e canal carotídeo os reparos anatômicos são o nervo mandibular (V3), forame oval, tecido fibrocartilaginoso do forame lacerum e a tuba auditiva; para o segmento parafaríngeo os reparos anatômicos são o tronco posterior do nervo mandibular (V3) e a tuba auditiva / INTRODUCTION. During the last decade, the technological advances, the mastery of the anatomy and operative techniques and skull base reconstruction using endonasal approaches have propelled endoscopic surgery for beyond the limits of sella turcica. The transpterygoid approach is a common step of the endoscopic approach to the middle and posterior cranial fossa and knowledge of the endoscopic anatomy of the internal carotid artery (ICA) is a common and paramount point to these approaches. OBJECTIVE. Describe the endoscopic anatomy related to the transpterygoid approach and ICA using an anatomical model with fresh human cadaveric heads to define: anatomical landmarks related to the endoscopic supra and infrapetrous areas approach, limits for endoscopic exposure of the ICA, anatomical endoscopic landmarks to lacerum, petrous and parapharyngeal ICA segments. METHODS. An anatomical study was performed using 20 specimens (10 heads) of fresh cadaveric heads. The heads were previously prepared with the injection of colored silicone to enhance the vascular structures (ICA, maxillary artery and its branches and cavernous sinus). In all cases we performed the transpterygoid approach to the supra and infrapetrous areas, as well as the infratemporal fossa, and the endoscopic dissection of the ICA. RESULTS. The injection of colored silicone in the arterial and venous system provided an adequate anatomical model for dissection and documentation of the transpterygoid approach as well as the different segments of the ICA. A stepwise dissection provided adequate exposure of the ICA from its cavernous to the distal parapharyngeal segment. The transpterygoid approach provided adequate exposure of the lacerum segment of the ICA and suprapetrous area and the landmarks were the vidian nerve, maxillary and mandibular nerves (V2, V3) and the Gasserian ganglion. Exposure of the caudal ICA (petrous and parapharyngeal) and the infrapetrous area required a medial maxillectomy for exposure and resection of the entire pterygoid process, followed by the Eustachian tube and the fibrocartilaginous tissue of the foramen lacerum. The main anatomical landmarks to this step were V3 and the Eustachian tube. CONCLUSION. During the endoscopic approach to the suprapetrous area, the vidian nerve, the maxillary and mandibular divisions of the trigeminal nerve (V2, V3) and the Gasserian ganglion are the anatomical landmarks to the internal carotid artery and middle cranial fossa. During the endoscopic approach to the infrapetrous area, the fibrocartilaginous tissue of the foramen lacerum, the Eustachian tube and V3 are the landmarks to the internal carotid artery. A stepwise endoscopic endonasal approach provided access to the extracranial internal carotid artery from its cavernous to the parapharyngeal segment down to the level of the nasal fossa floor. The anatomical landmark to the lacerum and horizontal petrous segments of the internal carotid artery is the vidian nerve; to the horizontal petrous segment before the posterior bend and carotid canal, the anatomical landmarks are the mandibular nerve (V3), foramen ovale, fibrocartilaginous tissue of the foramen lacerum and the Eustachian tube; to the parapharyngeal segment, the anatomical landmarks are the posterior trunk of the mandibular nerve (V3) and the Eustachian tube

La rhinosinusite chronique (RSC) est une maladie avec une haute prévalence au Canada et des impacts économiques et individuels importants. Une des options thérapeutiques dans l’algorithme complexe de traitement est la chirurgie endoscopique des sinus (CES), qui est préconisée chez les patients qui ont une réponse insatisfaisante à la thérapie médicale. Le présent mémoire porte sur les critères minimaux nécessaires à l’atteinte du succès en matière de CES. Dans un premier temps, une consultation d’experts en RSC Canadiens provenant de 12 institutions nous a permis d’offrir des définitions du succès acceptable ainsi que du succès optimal du point de vue des prestataires de santé. Dans un deuxième temps, une étude auprès de 22 patients souffrant de RSC nous a permis d’identifier les thèmes importants qui doivent guider le processus décisionnel collaboratif. La première étude a permis de conclure qu’une définition du succès post-opératoire en CES se doit de comporter 2 composantes : un aspect objectif (endoscopie nasale) et un aspect subjectif (test d’issues mesurées par le patient ou questionnaire spécifique). Selon les experts, pour parler de succès optimal il faut une résolution complète des symptômes ainsi qu’un résultat endoscopique parfait. La deuxième étude a permis de démontrer que les patients accordent beaucoup plus d’importance à la résolution du symptôme cardinal qui les a amenés à consulter. Cette dernière étude a également permis une exploration plus large des objectifs et attentes, ainsi que de l’expérience patient en ce qui a trait à la RSC et à la CES. En conclusion, l’évaluation des aspects subjectifs devrait être l’aspect le plus important que les cliniciens évaluent pour parler de succès. Une évaluation de la cavité nasale et des sinus devrait complémenter cette évaluation environ 3 mois après la chirurgie. Ce mémoire inclus des algorithmes pour aider les cliniciens dans l’évaluation du succès opératoire après une CES. / Chronic rhinosinusitis (CRS) is a prevalent, complex disease with important economic and individual impacts. Functional endoscopic sinus surgery (FESS) is widely used treatment for CRS, which is considered in patients with an unsatisfactory response to maximal medical therapy. This thesis examines the different ways clinicians may obtain feedback with regards to post-operative success and aims to offer definitions of acceptable success and optimal success. First, a consultation of Canadian experts in CRS from 12 institutions permitted us to construct definitions of acceptable and optimal success from healthcare providers’ viewpoint. Second, a study in collaboration with 22 patients suffering from CRS allowed us to identify key themes which will facilitate the inclusion of primary stakeholders in shared decision-making. The first study allowed us to conclude that a definition of postoperative success must be based on 2 components: an objective aspect (nasal endoscopy) and a subjective aspect (patient-reported outcome measure or specific questionnaire). According to experts, optimal success requires a complete resolution of symptoms as well as a perfect endoscopic result. With the second study, we demonstrated that patients tend to focus on the resolution of their cardinal symptom. This last study also allowed us to widely explore patients’ objectives and expectations, as well as their experience with CRS and FESS. In conclusion, subjective aspects should be the most important determinants of success after FESS. In addition, an evaluation of the nasal cavity and sinuses should complement the subjective evaluation approximately 3 months after surgery. This thesis includes algorithms to aid clinicians in evaluating the outcome of FESS for patients with CRS.