A new radiological classification for the risk assessment of anterior skull base injury in endoscopic sinus surgery

Keros and Gera classifications are widely used to assess the risk of skull base injury during endoscopic sinus surgery. Although, both classifications are useful preoperatively to stratify risk of patients going for surgery, it is not practical to measure the respective lengths during surgery. In this study, we aimed to propose a new radiological classification (Thailand-Malaysia-Singapore (TMS)) to assess the anatomical risk of anterior skull base injury using the orbital floor (OF) as a reference. A total of 150 computed tomography images of paranasal sinuses (300 sides) were reviewed. The TMS classification was categorized into 3 types by measuring OF to cribriform plate and OF to ethmoid roof. Most patients were classified as TMS type 1, Keros type 2 and Gera class II, followed by patients classified as TMS type 3, Keros type 1 and Gera class 1. TMS has significant correlation with Keros classification (p < 0.05). There was no significant correlation between Keros and Gera classifications (p = 0.33) and between TMS and Gera classifications (p = 0.80). The TMS classification has potential to be used for risk assessment of skull base injury among patients undergoing ESS. It serves as an additional assessment besides the Keros and Gera classifications.