Superior rectus/levator complex in acquired anophthalmic socket repaired with spheric implant—a computed tomography scan and topographic study

AIM:To determine whether the levator palpebrae superioris(LPS)/superior rectus(SR)muscle complex,can influence the position of the upper lid and fornix in acquired anophthalmic sockets.METHODS:This comparative non-randomized and non-interventional study included retrospective data of 21 patients with unilateral acquired anophthalmic sockets repaired with spheric implants.High-resolution computed tomography(CT)measurements of the LPM/SR muscle complex and clinical topographic position of the upper lid,superior and inferior fornix depth in primary gaze position were evaluated.Demographic data were presented as frequency and percentage proportions and quantitative variables comparing the socket measurements with the normal contralateral orbit was statistically analyzed using non-parametric tests considering P<0.05.RESULTS:The anophthalmic orbits had a significantly shorter LPS length(P=0.01)and significantly thicker SR(P=0.02)than the normal orbit.Lagophthalmos was present in anophthalmic sockets but not in normal orbits(P=0.002),while levator function was normal in both(P>0.05,all comparisons).The superior fornix depth was similar in the anophthalmic socket and the contralateral normal orbit(P=0.192)as well the inferior fornix depth(P=0.351).CONCLUSION:Acquired anophthalmic sockets repaired with spheric implants have shorter LPS,thicker SR,and more lagophthalmos than normal orbits.The relationship of the LPS and SR with other orbital structures,associated with passive or active forces acting in the final position of the lids and external ocular prosthesis should be further investigated.

Accurate Application of the Levator Palpebrae Superioris Anterior Migration and Shortening Technique in Blepharoptosis Correction Surgery

Background Accurate preoperative evaluation of the levator palpebrae superioris(LPS)strength is required for specific calculation of anterior migration or shortening.This information serves as a surgical reference for more accurate correction of ptosis.Methods Between June 2017 and June 2019,155 eyes of 97 patients were studied.Patients were divided into the following 3 groups based on the ptosis degree:mild(28 cases),moderate(53 cases),and severe(16 cases).The LPS strength was evaluated preoperatively and used to calculate LPS anterior migration and shortening.The LPS aponeurosis and Müller’s muscle(L-M)complex was separated from the upper margin of the tarsal plate to the calculated height according to the levator muscle suspension system retention approach.The complex was subsequently fixed to the planned tarsal plate location.The upper eyelid margin(UEM)height,eyelid morphology,eyelid closure,eye symmetry,exposure keratitis status,and patient satisfaction were evaluated at 1 week and at 1 and 6 months postoperatively.Results In all cases,the UEM positions were normal,and only patients with severe ptosis exhibited lagophthalmos in the early posterative period.Six months postoperatively,13%of eyes in the severe group had residual ptosis;all mild and moderate cases exhibited good surgical outcomes.The eyelids closed well with no exposure keratitis.All patients were satisfied with the eyelid contour.Conclusions Accurate LPS anterior migration and aponeurosis shortening can eliminate various factors affecting surgical blepharoptosis treatment.These procedures not only reduce operation time but also enhance the stability of postoperative correction.

Severe unilateral congenital ptosis with poor levator function:tarsoconjunctival mullerectomy plus levator resection vs frontalis sling procedure

AIM:To compare frontalis sling and tarsoconjunctival mullerectomy plus levator resection(TCMLR)in subjects with severe unilateral congenital ptosis with poor levator function(LF).METHODS:A prospective non-randomized nonblinded single center clinical trial.Fifty patients with severe unilateral congenital ptosis with poor LF were recruited.The frontalis sling and TCMLR were performed and the functional,cosmetic outcomes,complications,and success rate were evaluated at 1,3,and 6mo postoperatively.The t-test,Chi-square,Fishers exact,and nonparametric MannWhitney tests were used by SPSS software.RESULTS:Frontalis sling and TCMLR procedures were performed on 26 and 24 patients respectively.The mean age was 10.97±10.67y.LF was significantly better in the TCMLR group at months 1,3,and 6(P=0.002).Lagophthalmos was more common in the TCMLR group(no significant difference).At month 3,mild punctate epithelial erosions were observed more in the frontalis sling group(P=0.002).Significant complete success rate of 1st and 6th month for the frontalis sling vs TCMLR groups were 50%vs 20.8%(P=0.02),and 38.4%vs 50%(P=0.03)respectively.CONCLUSION:Complete success rate of TCMLR is higher in long-term follow-up in contrast with the frontalis sling in the short-term.Transient complications are more detected in mid-term follow-ups in both groups.

Treatment of mild and moderate congenital ptosis via the levator imbrication technique

Background:To correct mild and moderate congenital ptosis,traditional surgical techniques usually include dissection of the Müller’s muscle.Meanwhile,both the levator palpebrae superioris and the Müller’s muscle play a synergistic role to elevate the upper eyelid.Thus,to protect the Müller muscle and minimize injury,we developed and applied a levator imbrication technique in patients with mild and moderate congenital ptosis and followed it up to evaluate its clinical efficacy.Methods:This retrospective case series included 53 patients with mild and moderate congenital ptosis,all of whom had undergone ptosis correction using the levator imbrication technique at the Plastic and Aesthetic Department of the Second Affiliated Hospital of Zhengzhou University between June 2018 and June 2020.The outcomes of correction,upper eyelid appearance,and operative complications were observed and analyzed.The postoperative follow-up was 3–12 months.Results:Fifty cases of ptosis were fully corrected,and the bilateral double eyelids were smooth and natural.The eyelids of 20 patients were incompletely closed immediately after the operation but were able to close spontaneously within 2 weeks.No serious complications such as exposure keratitis were reported.Three patients with undercorrection underwent reoperation 3 months after the first operation,and ptosis was corrected.Conclusion:The levator imbrication technique for mild and moderate congenital ptosis is simple to perform and shortens the operation time with less damage,stable postoperative outcomes,and no long-term complications.

Vascular anomaly in the levator aponeurosis of neurofibromatosis type 1

Dear Editor,I am Satoru Kase,from the Department of Ophthalmology,Faculty of Medicine and Graduate School of Medicine,Hokkaido University,Sapporo City,Japan.I write to present a case of neurofibromatosis type 1（NF1）showing massive hemorrhage during involutional blepharoptosis surgery.

The Perineal Membrane: Its Composite Fibers and Nerve Content, and Relationship to the Levator Ani and Deep Transverse Perineal Muscles

The perineal membrane (PM) is a thick, elastic fiber-rich, smooth muscle-poor membrane extending along the vestibule and lower vaginal wall and embedding the urethrovaginal sphincter and compressor urethrae muscles. To provide a better understanding of the topographical relationship between the PM and the levator ani muscle, we examined histological sections from 15 female cadavers. The composite fibers of the PM were usually continuous with that of a fascia covering the inferior or lateral surface of the levator ani (fascia diaphragmatis pelvis inferior) rather than the endopelvic fascia covering the superior or medial surface of the latter muscle. However, this fascial connection was sometimes interrupted by a venous plexus. The deep transverse perineal muscle was consistently adjacent to the posterolateral aspect of the PM, but whether it extended superficially or deeply to the PM depended on size of the muscle. In contrast to the endopelvic fascia embedding abundant middle-sized nerves (cavernous and sphincter nerves;0.05 - 0.1 mm in thickness), the PM contained very thin nerves: many in 10 cadavers but few in 5 cadavers. Most of the nerves seemed to be sensory on the basis of immunohistochemistry. The levator ani muscle was considered likely to provide traction force to the PM, but active elevation appeared to be difficult because of the highly elastic nature of the PM and the interrupting venous plexus. Loss of nerves in the PM might be one of a number of factors that can accelerate pelvic organ prolapse.

Evaluation of the Levator Palpebrae Superioris Muscle Plication in the Treatment of Ptosis (About 12 Cases)

Introduction: The ptosis is a fall of the upper eyelid in relation to a deficit of the levator device of this one. In practice, it poses two major problems, the first one is the eminent risk of amblyopia during severe congenital ptosis, and the second is of an aesthetic nature, representing the main reason for consultation. The aim of this work is to evaluate the interest of the levator palpebrae superioris muscle plication in the ptosis surgery. Materials and Methods: We collected 12 patients who received a correction of their ptosis by plication of the levator palpebrae superioris muscle over a period of 3 years from January 2012 to December 2014. Result: The mean age at treatment was 22 years;the ptosis was congenital in 8 cases, and acquired in 4. The ptosis was major in 67% and moderate in 33% of the cases. Muscle plication was the basic surgical technique in all patients in our series. The function and aesthetic results were satisfying in 6 cases (50%), good in 4 cases (34%), acceptable in 1 case and bad in 1 case (8%). Discussion: The comparative study has shown that the plication of the levator palpebrae superioris muscle is a possible alternative for the correction of ptosis whatever the type of ptosis with results comparable to the reference technique compared to the degree of correction, whereas the operative follow-up is simpler and more minor complications. Conclusion: The surgical treatment of ptosis should be done after a systematic clinical examination and after very precise indications. However, the plication of the levator muscle of the upper eyelid has shown its functional and aesthetic efficiency in congenital ptosis and in the ptosis of the adult.

Assessment of Levator Hiatus by 3D Ultrasound Volume Contrast Imaging in Normal Nulliparas

The ability of 3D ultrasound volume contrast imaging in C-plane （VCI-C） in the assessment of female levator hiatus was analyzed in eighty normal nullipaxas. Interoperator variability in levator hiatus measurements was analyzed. The comparison of the axial image of magnetic resonance imaging （MRI） and C-plane image of volume contrast imaging （VCI） in thirty normal nulliparas was also done. It shows that VCI-C can clearly demonstrate the structure and accurately quantitates the size of the levator hiatus. It is reliable, convenient and without contraindication in assessment of female levator hiatus. The technology opens up entirely new modality for assessing female pelvic floor.

The "central six" of ptosis repair: eliminating contour as a variable in external levator surgery

Aim:Eyelid contour is a key component to satisfactory lid position and appearance following ptosis repair,the components of which have been highly debated and remain difficult to objectively measure.We sought to minimize the number of intraoperative adjustments required and reduce reoperation rates by addressing only the central 6 mm of tarsus when reapproximating levator to the anterior surface of tarsus,thereby eliminating contour as an adjustable variable.Methods:All patients who underwent external levator resection with blepharoplasty for correction of involutional ptosis between 2012 and 2019 by a single surgeon at one center were retrospectively reviewed.Patients who underwent concomitant brow lifting surgery were excluded.The same technique was used for each eyelid with uniform suture placement.One 6-0 silk horizontal mattress suture was placed partial thickness through the superior third of tarsus 3 mm lateral to the center of tarsus;another was passed 3 mm medial to the center of tarsus.No sutures were placed outside of this central 6-mm zone.Patient fixation was used to determine lid height and symmetry.Once satisfactory,the sutures were tied down in a permanent fashion and the eyelid position again verified.In total,153 eyelids in 85 patients were evaluated.Data obtained included preoperative and postoperative margin-to-reflex distance(MRD1),intraoperative and postoperative complications,reoperation rates,and patient satisfaction with appearance of lid contour and symmetry.Results:The mean follow up time was 3.41 months.The mean preoperative MRD1 was 1.05 mm.The mean post-operative was 3.18 mm.All patients had recovery of an anatomically normal temporal peak height.Two of 153 ;eyelids(1.31%)required reoperation due to residual ptosis or overcorrection.No patients had postoperative lagophthalmos.Ninety-one percent of patients who underwent bilateral surgery had satisfactory symmetry defined as less than or equal to 1-mm difference between right and left MRD1.Eighty-two of the 85 patients were satisfied with their postoperative appearance.Conclusion:This simple and standardized technique for suture placement gives reliable and effective results for external elevator advancement for ptosis repair by eliminating contour as an adjustable variable.Addressing the central 6 mm of tarsus is not only paramount but also in and of itself satisfactory in achieving optimal contour during external levator resection,without regard to more medial or lateral lid anatomy.

Clinically significant changes in anal sphincter hiatal area in patients with gestational diabetes mellitus and pelvic organ prolapse

BACKGROUND The prevalence of pelvic organ prolapse(POP)increases with age and parity.Specifically,the prevalence of POP among women aged 20 to 39 is 9.7%,while it rises to 49%among women over 80 years old.Additionally,as the number of deliveries increases,the prevalence of POP also rises accordingly,with a rate of 12.8%for women with one delivery history,18.7%for those with two deliveries,and 24.6%for women with three or more deliveries.It causes immense suffering for pregnant women.AIM To evaluate the relationship between the levator ani muscle’s hiatus(LH)area and POP in patients with gestational diabetes mellitus(GDM)using perineal ultrasound.METHODS The study cohort comprised 104 patients aged 29.8±3.7 years who sought medical care at our institution between January 2021 and June 2023.All were singleton pregnancies consisting of 75 primiparas and 29 multiparas,with an average parity of 1.7±0.5.According to the POP diagnostic criteria,the 104 subjects were divided into two groups with 52 members each:POP group(patients with GDM combined with POP)and non-POP group(patients with GDM without POP).Perineal ultrasound was used to measure differences in the anteroposterior diameter,transverse diameter,and LH area.Receiver operating characteristic curves were drawn to determine the optimal cutoff values for the LH anteroposterior diameter,transverse diameter,and area for diagnosing POP.RESULTS Statistically significant increase in the LH area,anteroposterior diameter,and lateral diameter were observed in the POP group compared with the non-POP group(P<0.05).Both groups exhibited markedly elevated incidence rates of macrosomia and stress urinary incontinence.For the POP group,the area under the curve(AUC)for the LH area was 0.906 with a 95%confidence interval(CI):0.824-0.988.The optimal cutoff was 13.54cm²,demonstrating a sensitivity of 83.2%and a specificity of 64.4%.The AUC for the anteroposterior diameter reached 0.836 with a 95%CI:0.729-0.943.The optimal cutoff was 5.53 cm with a sensitivity of 64.2%and a specificity of 73.4%.For the lateral diameter,its AUC was 0.568 with a 95%CI:0.407-0.729.The optimal cutoff was 4.67 cm,displaying a sensitivity of 65.9%and a specificity of 69.3%.Logistic regression analysis unveiled that age,body weight,number of childbirths,total number of pregnancies,and gestational weight gain constituted the independent risk factors for the cooccurrence of GDM and POP.CONCLUSION Three-dimensional perineal ultrasonography of LH size and shape changes can effectively diagnose POP.Age,weight,number of births,number of pregnancies,and weight gain during pregnancy are independent risk factors affecting the cooccurrence of GDM and POP.GDM can increase the LH area in patients,and an enlarged LH leads to an increased incidence of POP.

A new technique for correction of iatrogenic upper eyelid retraction by using a composite flap of the orbicularis muscle and fascia on the anterior surface of the tarsal plate

Background:Upper eyelid retraction is a challenging complication of cosmetic upper eyelid blepharoplasty.To avoid extra trauma,we developed a new technique for correcting iatrogenic upper eyelid retraction by postmigrating a compound flap of the orbicularis muscle and fascia(OFC)on the anterior surface of the tarsal plate.This method extends the aponeurosis of the levator palpebrae superioris muscle(LPS),which can achieve a good correction for post-blepharoplasty retraction.Methods:We collected data from 15 patients with mild to moderate iatrogenic upper eyelid retraction who were treated at our hospital between February 2017 and December 2019.The OFC was used to replace the missing part of the LPS,and post-migration of the LPS and fixation of the OFC to the tarsal margin were conducted.Postoperative outcome measurements included postoperative binocular symmetry,double eyelid smoothness,eyelid fullness,margin reflex distance(MRD1),degree of eyelid closure,and exposure keratitis.The patients were followed-up at seven days,one month,and six months postoperatively.Results:One patient with moderate eyelid retraction showed undercorrection 6 months postoperatively,with the upper eyelid margin located at the upper edge of the pupil.The remaining patients had the upper eyelid margin stabilized at 1.0–2.0 mm below the upper corneal margin.Other observational indicators were satisfactory,including binocular symmetry,double eyelid fluency,and eyelid fullness.During the follow-up,no exposure keratitis was identified.The MRD1 indexes after the operation were significantly different(P<0.001)from those before the procedure.Conclusions:Extension and post-migration of the LPS using the orbicularis muscle and OFC structure can effectively correct mild iatrogenic eyelid retraction after ptosis with less damage and good postoperative eyelid morphology and closure function.

Chronic proctalgia and chronic pelvic pain syndromes:New etiologic insights and treatment options

This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs:chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence available to guide their diagnosis and treatment. This situation appears to be changing:A recently published large randomized,controlled trial by our group comparing biofeedback, electrogalvanic stimulation, and massage for the treatment of chronic proctalgia has shown success rates of 85% for biofeedback when patients are selected based on physical examination evidence of tenderness in response to traction on the levator ani muscle-a physical sign suggestive of striated muscle tension. Excessive tension (spasm) in the striated muscles of the pelvic floor appears to be common to most of the pelvic pain syndromes. This suggests the possibility that similar approaches to diagnostic assessment and treatment may improve outcomes in other pelvic pain disorders.

Electromyography and Fos immunostaining study establish a possible functional link between trigeminal proprioception and the oculomotor system in rats

The objective of this study was to explore whether there was a functional link between trigeminal proprioception and the oculomotor system mediated through jaw muscle afferents.Electromyography（EMG） was undertaken of the levator palpebrae（LP） and superior rectus（SR）,and Fos expression was detected in the brainstem following consecutive down-stretching of the lower jaw at 2-4 Hz in rats.Retrograde tracing was undertaken of the interstitial nucleus of Cajal and Darkschewitsch nucleus（INC/DN） pre-oculomotor neurons.FMG-like responses were recorded from the LP/SR during down-stretching of the lower jaw at 2-4 Hz in 3 out of 11 rats.Fos expression was induced by consecutive down-stretching of the lower jaw at 2-4 Hz for 20-30 seconds.Interestingly,Fos expression was distributed mainly in the bilateral INC/DN area.We also examined Fos-like immunoreactivity in central mesencephalic and paramedian pontine reticular formation that harbors premotor neurons controlling horizontal eye movement,but no Fos-like staining was observed therein.By injection of retrograde tracers into the oculomotor nucleus combined with Fos immunostaining,double labeled pre-oculomotor neurons were visualized to distribute in the INC/DN.In conclusions,there may exist a trigeminal proprioceptive-oculomotor system neural circuit through jaw muscle afferents in rats.Judging from Fos distribution pattern,this pathway might be related to vertical and torsional eye movements.

Factors associated with corneal astigmatism change after ptosis surgery

AIM: To evaluate the predictive factors of postoperative corneal astigmatism change in ptosis patients who underwent ptosis surgical repair.METHODS: Patients who underwent levator resection at Oculoplastic service of the Department of Ophthalmology, Naresuan University Hospital, Thailand between September 2017 and August 2019 were retrospectively evaluated. Changes in degree and axis of corneal astigmatism after ptosis surgery were compared based on patient factors consisting of age at operation, sex, preoperative marginreflex distance(MRD) 1, and preoperative degree and axis of corneal astigmatism.RESULTS: Forty-two eyes of 28 patients were included in the study. Wilcoxon signed ranks test showed a significant postoperative corneal astigmatism change only in a subgroup of eyes with preoperative astigmatism of ≥1.5 diopters(D;P=0.006). Furthermore, 72.2%(13/18) of the eyes with preoperative astigmatism of ≥1.5 D showed a reduction of astigmatism after eyelid surgery, with the mean astigmatic change of 0.65 D. Majority of preoperative eyes demonstrated with-the-rule astigmatism pattern(45.2%), of which 57.9% showed a reduced degree of astigmatism.CONCLUSION: In patients undergoing ptosis surgery, the data demonstrate for the first time the association between postoperative corneal astigmatism change and a preoperative corneal astigmatism of ≥1.5 D. Thus, we encourage considering severity of corneal astigmatism prior to cataract or refractive surgery planning in ptosis patients, especially with toric-intraocular lens, to avoid the possibility of calculation error.

Supportive tissues of the vagina with special reference to a fibrous skeleton in the perineum: A review

With the aid of immunohistochemistry, the present review attempts to demonstrate the composite fibers and nerve topographical anatomy in the vaginal supportive tissues. Along the tendinous arch of the pelvic fasciae, distal parts of the pelvic plexus extend antero-inferiorly and issue nerves to the internal anal sphincter as well as the cavernous tissues. At the attachment of the levator ani muscle to the rectum, smooth muscles in the endopelvic fascia lining the levator ani merge with the longitudinal smooth muscle layer of the rectum to provide the conjoint longitudinal muscle coat or the longitudinal anal muscle (LAM: smooth muscle). However, at the rectovaginal interface, the longitudinal smooth muscle layer of the rectum continues to the LAM without any contribution of the endopelvic fascia. The bilateral masses of the perineal smooth muscles (PSMs) are connected by the perineal body, and the PSMs receive 1) the longitudinal anal muscle, 2) the internal and external anal sphincters and, 3) the perineal membrane lining the vestibular wall. Tensile stress from the levator ani seems to be transferred to the PSMs via the LAM. Because of their irregularly arrayed muscle fibers, instead of a synchronized contraction in response to nerve impulses, the PSMs are likely to act as a barrier, septum or protector against mechanical stress because, even without innervation, such smooth muscle fibers resist (not absorb) pressure, in accordance with Bayliss’ rule. The external anal sphincter, a strong striated muscle, inserts into the PSMs and seems to play a dynamic role in supporting the rectovaginal interface to maintain the antero-posterior length of the urogenital hiatus. However, we do not think that smooth muscles play an active traction role without cooperation from striated muscle. The fibrous skeleton composed of smooth muscle in the female perineum is explained in terms of a “catamaran” model.

The “Mothers’ Pelvic Floor Support (RECOUP) Clinic” Referral Patterns in Washington DC Area of the United States

Introduction: Childbirth entails many physical, emotional, and societal changes and repercussions, including postpartum depression affecting 20% - 30%, postpartum blues, and post-traumatic stress disorder. We hypothesized that many physical and mental health manifestations of pelvic floor disorders might be masked by the ordinary course of postpartum recovery and not referred out for specialized evaluation. Leveraging our RECOUP (Mothers’ Pelvic Floor Support) Clinic, we explored the referral patterns to this clinic to test our hypothesis. Methods: The study is a single-center observational study including women who presented to the RECOUP Clinic. The clinic’s target patient population includes those with a perineal injury, instrumental delivery, urinary retention, urinary or fecal incontinence, pain, or pelvic pressure associated with childbirth. Results: One hundred and one women were evaluated in the RECOUP Clinic. 45/101 (45%) were not referred but found their way to the clinic through social media and the internet. Very few patients 4/101 (4%) were referred with anal sphincter injuries. (52/101, 51%) were referred after many requests by the patients. Conclusions: Over ninety percent of women evaluated at RECOUP Clinic are self-referred or referred upon the mother’s request. There is an opportunity for physicians and other providers to become more familiar with dedicated clinics for postpartum pelvic floor care. Enhancing such clinical services allows one to reach patients who otherwise will go unserved. Summary: Childbirth is an event with substantial ramifications that should be addressed, and we believe a specialized clinic is an optimal facility, so the RECOUP was founded. In this paper, we explored the referral patterns to our RECOUP clinic.

Evolution of the Incision Technique to Construct a Superior Palpebral Fold

The construction of superior palpebral fold gained popularity in the far East and at the present time is the most frequently performed aesthetic operation in the Orient.Various incisional techniques have been reported to form upper eyelid crease,which also a confusion for plastic surgeons who lack clinical experience.It is essential to review the evolution of these incision techniques and outlined the pros and cons of each method.This study reviewed the anatomy theory of superior palpebral fold,and reported incision techniques according to different connecting tissue utilized.

En bloc resection concept for endoscopic endonasal nasopharyngectomy： surgical anatomy and outcome

Background Nasopharyngeal carcinoma （NPC） patients have a 19%-56% locoregional recurrence rate after primary therapy.For those recurrent NPC （rNPC） patients,re-irradiation may cause some complications.In recent years,endoscopic endonasal nasopharyngectomy （EEN） has become a surgical option for rNPC patients.Here we introduce the concept of en bloc excision （EBE） technique for EEN,including the surgical technique and clinical outcomes.Methods A retrospective study was conducted covering September 2009 to May 2013,involving the collection of Iocoregional rNPC cases from two institutions （Kuang-Tien General Hospital （KTGH） in Taiwan and National University Health System （NUHS） in Singapore）.These patients failed prior therapy and then underwent EEN.We reported the 2-year overall survival rate,the 2-year disease-free survival rate,and related complications.Results Nine patients （five from KTGH and four from NUHS） completed this study,with five,two,and two patients of recurrence tumors （rT1）,rT2,and rT3,respectively.The mean age was 46.4 years （range 32-63）; the mean follow-up period was 24.9 months （range 10-45）.The 2-year survival rate and the 2-year disease-free rate were 100% and 80%,respectively,in five patients.No significant complications or cases of mortality occurred.Conclusions The EBE concept of EEN is suitable for early rT1 and has relatively encouraging short-term outcomes.In selected rT2,careful EBE can be performed by expanding the surgical field.A clear view of the internal carotid arteryrelated anatomy is indispensable.In the future,more series may be needed to determine the role of EEN in rNPC patients.