Search

Background: Chondrosarcomas of the sinonasal cavity and skull base are uncommon malignancies. We sought to provide long‐term outcomes at two tertiary care centers. Methods: Patients with chondrosarcoma treated between 2000 and 2021 were included. The primary outcomes were overall survival (OS) and disease‐specific survival (DSS). Results: Thirty‐eight patients met inclusion criteria. Fourteen patients had sinonasal (36.8%), 7 petroclival (18.4%), and 17 other primary skull base lesions (44.7%). Twenty‐eight patients (73.7%) underwent radiation with an average dose of 67.3 ± 15.1 Gy. Eighteen patients (47.4%) required revision surgery for recurrence. 1, 5, and 10‐year OS were 97.3%, 93.1%, and 74.7%. DSS at 5‐ and 10‐year survival was 95.7%. Adjuvant radiation was associated with improved OS (HR: 0.12; 95% CI: 0.02–0.75, p = 0.023). Conclusion: We present our experience over the last 20 years treating chondrosarcomas. Favorable survival outcomes can be achieved but recurrence requiring repeat resection is common. [ABSTRACT FROM AUTHOR]

Background: Glossopharyngeal neuralgia is a rare but severe and disabling pain condition often caused by vascular compression of the glossopharyngeal nerve. Treatment is similar to that of trigeminal neuralgia, but some patients may be refractory to both medical and surgical approaches. Here we present a case of refractory glossopharyngeal neuralgia that responded well to onabotulinumtoxinA (BTX‐A). Case: We report a case of a 65‐year‐old man with well‐controlled human immunodeficiency virus disease with glossopharyngeal neuralgia symptoms since 2015. He had partial response to medications but was limited by side‐effects. He underwent microvascular decompression twice with initial relief both times, but experienced recurrence of attacks 1–3 years after each surgery. He was treated with BTX‐A using the chronic migraine PREEMPT protocol (i.e., 31–39 injection sites in head and neck muscles), which led to significant relief of his glossopharyngeal neuralgia pain. Conclusions: This is the first case to our knowledge of glossopharyngeal neuralgia treated with BTX‐A. BTX‐A can be an effective treatment for glossopharyngeal neuralgia, even when injections are not administered directly over the sensory distribution of the glossopharyngeal nerve. [ABSTRACT FROM AUTHOR]

We also did not conduct performance characterisation studies and relied upon imaging and infusion protocols from a prior proof of concept study.12 The fluorophore dose and imaging time points were not individually optimised for each of the imaging platforms, but these techniques have demonstrated efficacy in NIR imaging of multiple malignancies.14-16 Finally, our study relies upon the primary surgeon's subjective impression of tumour NIR fluorescence and adequate tumour-margin delineation, rather than a standardised, quantifiable measure of fluorescence. Head and neck cancer, indocyanine green dye, intraoperative imaging, optical imaging, near-infrared imaging, precision surgery In this study, we compared the performance of a surgical robot-integrated NIR camera system to a dedicated NIR imaging platform for SWIG imaging during TORS for OPSCC. Keywords: head and neck cancer; indocyanine green dye; intraoperative imaging; near-infrared imaging; optical imaging; precision surgery EN head and neck cancer indocyanine green dye intraoperative imaging near-infrared imaging optical imaging precision surgery 589 593 5 08/05/22 20220901 NES 220901 Key Points Prior studies demonstrated a failure to identify and localise head and neck cancers via near-infrared (NIR) imaging of indocyanine green (ICG) with a robot-integrated platform. [Extracted from the article]

Objective: To characterize the patient and clinical factors that determine variability in hospital costs following endoscopic transphenoidal pituitary surgery. Methods: All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in this retrospective single‐institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software. Results: The analysis included 190 patients and average length of stay was 4.71 days. Average total in‐hospital cost was $28,624 (95% confidence interval $25,094–$32,155) with average total direct cost of $19,444 ($17,136–$21,752) and total indirect cost of $9181 ($7592–$10,409). On multivariate regression, post‐operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474–$66,489, P =.002). Current smoking status was associated with an increased total cost of $20,189 ($6,638–$33,740, P =.004). Self‐reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (−$12,760 to −$532, P =.033). Post‐operative DI was associated with increased costs across all variables that were not statistically significant. Conclusions: Post‐operative CSF leak, current smoking status, and non‐Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives. Level of Evidence: 3 Laryngoscope, 131:760–764, 2021 [ABSTRACT FROM AUTHOR]

While optical imaging with near-infrared (NIR) fluorescent dye has been used in oncologic surgery, its use in the head and neck has not been established. We aimed to evaluate the feasibility of using NIR to visualize primary tumor and regional metastasis in head and neck malignancy. Patients undergoing resection of primary head and neck tumors were included in this pilot study. Each patient was injected with indocyanine green dye (ICG) the day prior to surgery. The VisionSense Iridium camera system was used to visualize the primary lesion, its margins, and neck dissection specimen intraoperatively. Fourteen patients were enrolled. Eighty-six percent of primary tumors showed fluorescence as compared with surrounding tissues. ICG positivity showed 100% sensitivity for pathologic nodes in 7 neck dissection specimens; however, for 3 patients, nonpathologic nodes also showed ICG positivity. NIR imaging with ICG dye can be considered for intraoperative imaging of head and neck lesions. [ABSTRACT FROM AUTHOR]

Objective: A better understanding of the natural history of vestibular schwannoma (VS) has resulted in a change in treatment paradigms. It has also been proposed that increased use of high-resolution magnetic resonance imaging has allowed for an increased identification of small tumors. The aim of this study was to evaluate recent trends in the presentation and primary management of VS in the United States.Study Design: Retrospective analysis of the National Cancer Database (NCDB).Setting: NCDB database.Subjects and Methods: All patients with a diagnosis of VS between 2004 and 2014 were included. Data were analyzed with univariable and multivariable logistic regression.Results: In total, 28,190 patients (mean age 55 years, 52.9% female) with VS were analyzed. Linear regression showed a small decrease in average tumor size over time (-0.06 mm/year, P = .03). Overall, 11,121 patients (40%) received surgery, 8512 (30%) radiation, and 7686 (27%) observation. Controlling for patient, tumor, and treatment center factors, the odds ratio (OR) for receiving surgery in 2014 was 0.60 (confidence interval [CI], 0.50-0.71) while the OR for receiving radiation was 0.75 (CI, 0.64-0.87) as compared to those diagnosed in 2004. The largest increases in observation rates occurred among tumors ≤2 cm (P < .001).Conclusion: There was not a clinically significant change in the average tumor size at diagnosis. Although surgery remained the most common treatment modality in the United States, there was a strong shift in the management of VS away from primary surgery and radiation and toward a "wait-and-scan" approach. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediatric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns.Study Design: Retrospective chart review.Methods: A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center.Results: A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total operative time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959).Conclusions: Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase complications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes.Level Of Evidence: 4 Laryngoscope, 129:832-836, 2019. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the incidence and factors associated with 30-day readmission and to analyze risk factors for prolonged hospital length of stay following transsphenoidal pituitary surgery.Study Design: Retrospective longitudinal claims analysis.Setting: American College of Surgeons National Surgical Quality Improvement Program.Subjects and Methods: The database of the American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent transsphenoidal pituitary surgery (Current Procedural Terminology code 61548 or 62165) between 2005 and 2014. Patient demographic information, indications for surgery, and incidence of hospital readmission and length of stay were reviewed. Risk factors for readmission and prolonged length of stay, defined as >75th percentile for the cohort, were identified through logistic regression modeling.Results: A total of 1006 patients were included for analysis. Mean hospital length of stay after surgery was 4.1 ± 0.2 days. Predictors of prolonged length of stay were operative time (P < .001, odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 1.5-2.0), bleeding disorder (P = .049, OR = 3.1, 95% CI = 1.0-9.5), insulin-dependent diabetes (P = .007, OR = 2.4, 95% CI = 1.3-4.4), and reoperation (P < .001, OR = 10.3, 95% CI = 4.7-23.9). In a subset analysis of 529 patients who had surgery between 2012 and 2014, 7.2% (n = 38) required hospital readmission. History of congestive heart failure (CHF) was a predictor of hospital readmission (P = 0.03, OR = 12.7, 95% CI = 1.1-144.0).Conclusion: This review of a large validated surgical database demonstrates that CHF is an independent predictor of hospital readmission after transsphenoidal surgery. Although CHF is a known risk factor for postoperative complications, it poses unique challenges to patients with potential postoperative pituitary dysfunction. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Malignant sinonasal and skull base tumors are now being resected using an endoscopic technique, but there has been controversy regarding the oncologic safety of this approach. Various studies have compared the outcomes from endoscopic surgery to those from open techniques; however, all have been limited by substantial differences in the patient populations receiving each approach. In this study we compare outcomes of open and endoscopic techniques and use propensity score matching to control for these differences in the patient populations.Study Design: Retrospective cohort study including all patients > 18 years old receiving primary surgery for malignant sinonasal or skull base tumors at our institution from 2002 to 2013.Results: One hundred twenty-four patients met criteria; 82 received endoscopic-only surgery, and 42 had an open component to their approach. There was an 86% 3-year overall survival and a 74% disease-free survival. Without controlling for differences in the groups, the endoscopic patients fared significantly better in survival, recurrence rates, wound infections, and length of hospital stay. When using propensity score matching to account for patient comorbidities and tumor size, there were no significant differences in any outcomes except length of the hospital stay. A multivariate regression analysis yielded the same results.Conclusion: In this study, endoscopic surgery was shown to be a safe alternative to the open technique, even when controlling for the favorable patient and tumor characteristics in endoscopic patients. This is the first study to account for these differences with a rigorous statistical methodology.Level Of Evidence: 4. Laryngoscope, 126:1724-1729, 2016. [ABSTRACT FROM AUTHOR]

Data on stereotactic radiosurgery ( SRS) for four or more metastases are limited. Existing studies are confounded by significant proportions of patients receiving prior whole-brain radiation therapy ( WBRT) or concurrent WBRT with SRS. Furthermore, published results disagree about the impact of tumor volume on overall survival. A retrospective review identified 38 patients without prior intracranial radiation or surgery who received Gamma Knife ( GK) as sole treatment to ≥4 brain metastases in a single session. Twenty-eight cases with follow-up imaging were analyzed for intracranial progression. Prognostic factors were examined by univariate (log-rank test) and multivariate (Cox proportional hazards model) analyses. Common primary tumors were non-small cell lung (45%), melanoma (37%), and breast (8%). Cases were recursive partitioning analysis class II (94%) or III (6%). Patients harbored a median five tumors (range 4-12) with median total tumor volume of 1.2 cc. A median dose of 21 Gy was prescribed to the 50% isodose line. Patients survived a median 6.7 months from GK. Local treatment failure occurred in one case (4%) and distant failure in 22 (79%). On multivariate analysis, total tumor volume ≥3 cc was significantly associated with distant failure and worsened overall survival ( P = 0.042 and 0.040). Fourteen patients (37%) underwent salvage WBRT at a median 10.3 months from GK and seven patients received repeat GK. GK as sole initial treatment for four or more simultaneous metastases spares some patients WBRT and delays it for others. Increased total tumor volume (≥3 cc) is significantly associated with worsened overall survival. [ABSTRACT FROM AUTHOR]

BACKGROUND: The role of postoperative radiotherapy (PORT) in the management of low-grade glioma remains controversial. An analysis using data from the European Organization for Research and Treatment of Cancer 22844/22845 studies concluded that several factors portend a poor prognosis: age ≥40 years, astrocytoma histology, tumor size ≥6 cm, tumor crossing midline, and preoperative neurologic deficits. PORT may benefit patients with high-risk features. The aim of this study was to assess temporal trends and determinants of the use of PORT. METHODS: By using data from the Surveillance, Epidemiology, and End Results program, the authors identified 1127 adult patients diagnosed with low-grade glioma (World Health Organization grade I and II) who underwent surgical resection between January 1, 1998 and December 31, 2006. The primary outcome was receipt of PORT. The authors performed multivariate logistic regression to examine the association between clinical, patient, and demographic characteristics and receipt of PORT. RESULTS: Receipt of PORT declined during the study period, from 64% of patients in 1998 to 36% of patients in 2006. On multivariate analysis, significant predictors of receipt of PORT were age ≥40 years, tumor crossing midline, and partial surgical resection. CONCLUSIONS: The use of PORT for patients with low-grade glioma has declined in the period from 1998 to 2006 for both low-risk and high-risk patients. Cancer 2012. © 2011 American Cancer Society. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Cerebrospinal fluid (CSF) leaks continue to be the most common postoperative complication in expanded endonasal skull base procedures. Currently, a multilayer closure using a vascularized nasoseptal flap is most commonly performed for large ventral skull base defects in an effort to avoid postoperative CSF leaks. We correlated nasoseptal flap enhancement with postoperative CSF leak rates in a group of skull base reconstruction patients. The nasoseptal flap enhancement was determined by immediate postoperative gadolinium-enhanced magnetic resonance imaging (MRI), which allowed for imaging of the flap's vascular pedicle. Our aim was to identify whether nasoseptal flap enhancement contributed to reduction of postoperative CSF leak rates. Study Design: Retrospective cohort study. Methods: We reviewed 19 patients who underwent expanded endoscopic resections of skull base lesions of advanced complexity. We calculated the incidence of CSF leaks and measured the presence of nasoseptal flap enhancement. Results: Of the 19 patients with immediate postoperative MRIs, three developed postoperative CSF leaks. All three CSF leaks were in cases with enhancing vascular pedicles. In contrast, we had three patients without evidence of flap enhancement, none of whom developed a postoperative CSF leak (Fisher exact test, P = 1.0). CSF leak was associated with posterior fossa lesions ( P = .25). Nasoseptal flap enhancement was associated with younger age ( P = .15). Conclusions: This retrospective cohort study demonstrates that although the vascularized pedicled nasoseptal flap is effective for closure of expanded endonasal skull base procedures, our experience found the actual enhancement of the flap itself does not appear to effect postoperative CSF leak rates. Laryngoscope, 2012 [ABSTRACT FROM AUTHOR]

Objective: Using the disease‐specific, validated Penn Acoustic Neuroma Quality of Life (PANQOL) survey we proposed the following study objectives: 1) Understand the demographics for patients with acoustic neuromas undergoing conservative management verses stereotactic radiosurgery (gamma knife). 2) Determine if there is a difference in quality of life for these patient groups. Method: A retrospective chart review of acoustic neuroma patients who completed a PANQOL survey between the dates of October 1, 2010 and January 1, 2012 was performed. A total of 76 patients (38 conservative, 38 gamma knife) were included. Patient demographics, tumor characteristics, and PANQOL data for the 2 groups were statistically analyzed. Results: Patient age, sex, percentage of extracanalicular tumors, and time elapsed from diagnosis to the PANQOL survey were not significantly different for the 2 groups. There was a statistically significant difference in tumor size between the 2 groups (CON 8.59 mm vs GK 16.45 mm, P ≤. 001). The differences in PANQOL composite scores for hearing, balance, facial nerve symptoms, pain, anxiety, and energy were not statistically significant. However, there was a statistically significant difference in the general composite score (CON 5.97 vs GK 5.32, P =. 015). Conclusion: Despite significantly larger tumors, patients undergoing gamma knife experience a similar quality of life when compared to patients who are being conservatively managed. The use of disease‐specific quality of life measures, such as the PANQOL, will contribute to the development of "best evidence" treatment strategies for patients with acoustic neuromas. [ABSTRACT FROM AUTHOR]

Objective: Surgical resection of skull base tumors in children is increasingly accomplished through an expanded endonasal approach (EEA). We aim to evaluate the potential effect of the EEA on midfacial growth as a result of iatrogenic damage to nasal growth zones., Methods: We performed a retrospective review of children undergoing craniopharyngioma resection via an open transcranial or EEA. Pre- and postoperative magnetic resonance imaging was evaluated for growth in four midfacial measurements based on established cephalometric landmarks: anterior midface height, posterior midface height, palatal length, and sella-nasion distance. Statistical analysis was conducted using a mixed-effects linear regression model., Results: Twenty-two patients underwent an EEA (n = 12) or open transcranial approach (n = 10) for tumor resection with 3 years of imaging follow-up. There was no difference in midfacial growth between groups for each measurement. Compared to the open group, patients undergoing EEA demonstrated relative anterior midface height growth of -0.42 mm (P = 0.880), posterior midface height growth of -0.44 mm (P = 0.839), palatal length growth of 0.35 mm (P = 0.894), and sella-nasion distance growth of -2.16 (P = 0.365)., Conclusion: We found no difference in midfacial growth measurements between patients undergoing craniopharyngioma resection via an EEA and the open transcranial route after 3 years of imaging follow-up. Preliminary results on midfacial growth demonstrate that the EEA is a safe alternative to traditional transcranial approaches for the pediatric population. Further investigation with larger sample size and longer duration of follow-up is warranted to more thoroughly investigate the long-term implications of the EEA to the skull base., Level of Evidence: 3 Laryngoscope, 130:338-342, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Chronic rhinosinusitis (CRS) is a proposed risk factor for meningitis and other intracranial complications following the endoscopic endonasal transsphenoidal approach (TSA). Some have recommended staging TSA following surgery for CRS; however, delaying TSA has important ramifications. The objective of this study is to determine whether asymptomatic sinonasal inflammation (RSNI) on preoperative computed tomography scans, without clinical CRS, is associated with postoperative complications following TSA., Methods: All consecutive TSA cases performed at a single tertiary care institution from January 1, 2009, to December 31, 2017, were reviewed for patient demographics, prior surgery, presence of RSNI on preoperative computed tomography scan based on Lund-Mackay (LM) score, intraoperative cerebrospinal fluid (CSF) leak, and postoperative complications (postoperative CSF leak, bleeding, infection). The association between preoperative RSNI and postoperative complications was analyzed via multivariate logistic regression., Results: One hundred seventy-one cases of TSA were included with mean patient age of 52.6 years, 42.7% males, 18.1% revision cases, and mean LM score of 1.9 ± 2.7. Complications were identified in 9.9% of patients at the following rates: 5.3% postoperative CSF leak, 2.9% bleeding, and 1.8% infection (all sinusitis, no episodes of meningitis). Neither total LM score nor LM score > 5 (representative of clinically significant radiographic CRS) were predictors of any postoperative complication (both P > 0.05). Age, sex, revision status, intraoperative CSF leak, and total LM score were not independent predictors of any postoperative complication on multivariate analysis (all P > 0.05)., Conclusion: In asymptomatic patients, radiographic evidence of sinonasal inflammation is not associated with increased risk of complications following TSA., Level of Evidence: 4 Laryngoscope, 129:1545-1548, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)