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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.)

Background: Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS)., Methods: Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus., Results: The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated., Conclusion: A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings., (© 2019 ARS-AAOA, LLC.)

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., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Cerebrospinal fluid (CSF) leak occurs in 1-11% of endoscopic Draf III, or endoscopic modified Lothrop, procedures. CSF leak can occur during surgery during a superior nasal septectomy. This study investigated whether the posterior edge of the nasofrontal beak (NFB) at the level of the internal frontal ostium is a safe landmark to use to avoid skull base injury when beginning the superior septectomy., Methods: Preoperative computed tomography maxillofacial scans were reviewed from 100 patients from the University of Pennsylvania sinus surgery data base. The narrowest anteroposterior distance between the posterior edge of the NFB and the anterior aspect of the olfactory fossa (OF) at the level of the internal frontal ostium was measured in each patient. Measurements were taken in the midline and to the left and right of midline. Six fresh cadaver heads were also dissected to evaluate these relationships., Results: On computed tomography analysis, the NFB was anterior to the OF on the left and right of the midline in 100% of the patients, with mean distances of 6.04 and 6.41 mm, respectively. The NFB was anterior to the OF in the midline in 98% of patients, with a mean distance of 9.02 mm. In all six cadavers, the posterior edge of the NFB was anterior to the OF in the midline and to the left and right of midline at the level of the internal frontal ostia., Conclusions: During Draf III, the posterior edge of the NFB was a reliable landmark for avoiding iatrogenic CSF leak during the superior septectomy.

Introduction: Postoperative CSF leak is the most common complication of endoscopic endonasal approach (EEA) to skull base lesions. Endoscopic multilayer closure of skull base defect using pedicled nasoseptal flaps (NSF) based off the sphenopalatine artery reduces CSF leaks. EEA robustly expands in surgical arena, yet postoperative imaging evaluation remains poorly studied. This work illustrates normal MR imaging appearance of skull base reconstruction utilizing NSFs during immediate postoperative period., Methods: We retrospectively identified patients who had skull base reconstructions utilizing NSFs following EEAs and immediate postoperative-enhanced brain MRI. NSFs and free grafts were evaluated for signal intensity, thickness, configuration, enhancement, vascular pedicle of NSF, relationship in multilayer reconstruction, and defect coverage. Imaging findings were correlated with surgical technique and CSF leaks., Results: Twenty-eight patients had 26 multilayer reconstructions and 34 NSFs. Twenty-nine NSFs showed enhancing C-shaped arc at the skull base. Of those, 26 flaps (90%) were confidently identified by visualization of their vascular pedicles, 3 were not distinguishable from adjacent mucosa and pedicles were not identified. Five NSFs showed no enhancement (1 CSF leak). Twenty-seven enhancing NSFs approximated defects with close abutment to free grafts. One flap was displaced; one incompletely covered the defect (2 CSF leaks). Fisher exact test demonstrated an association between incomplete defect coverage and displacement of NSFs with CSF leak (P=0.05)., Conclusion: Endoscopic skull base reconstruction utilizing NSF has characteristic MR imaging appearance. Non-enhancing mucosal gap or displacement of NSF may indicate incomplete defect coverage, identifying patients at risk for CSF leak., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: The goal of this study was to determine the potential role as well as the current limitations of the da Vinci Surgical System robot in transoral surgery of the skull base., Methods: The da Vinci robot was used to perform dissections of the skull base on 7 cadaver heads with their neck and clavicles intact. Neurosurgeons and otolaryngologists familiar with all facets of the open microscopic, minimally invasive, endoscopic and transoral robotic surgical procedure proceeded with the approach to and dissection of the human skull base., Results: The da Vinci robot provided superb illumination and 3-dimensional depth perception. The 30-degree endoscope improved cephalad visualization, and the 'intuitive' nature of the da Vinci surgical robot arms provided an advantage by their ability to suture the dura at the level of the clivus. An entirely transoral route provides access to the middle and lower clivus as well as the infratemporal fossa, but access to the sellar region and anterior cranial fossa is limited via a purely transoral route. Tremor-free dural closure was successfully performed., Conclusion: Our findings suggest that transoral robotic surgery utilizing the da Vinci robot system holds great potential for skull base surgical resection of extradural and intradural tumors of the middle and lower clivus and infratemporal fossa. A collaborative approach with neurosurgeon and otolaryngologist alternating at the master console and bedside is a successful strategy. Further instrument development is necessary, and continued investigation is warranted., (Copyright 2010 S. Karger AG, Basel.)

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]

Objective: To determine in-hospital costs associated with performing an EEA to anterior skull base pathology and to identify drivers of cost variability for patients undergoing endoscopic anterior skull base surgery. Methods: All endoscopic anterior skull base surgeries performed over a period from January 1st, 2015 to October 24th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using Stata software. Results: An EEA was associated with an average total in-hospital cost of $44 545. Compared to patients undergoing a transsphenoidal approach to pituitary tumor resection, EEA patients incurred higher in-hospital costs across all variables including a total cost increase of $15 921 (95% confidence interval $5720-26 122, P =.002). Univariate analysis of all endoscopic anterior skull base surgery patients showed a cost increase of $30 616 associated with post-operative cerebrospinal fluid (CSF) leak ($10 420-50 811, P =.004), $14 610 with post-operative diabetes insipidus (DI) ($4610-24 609, P =.004), and $11 522 with African-American patients relative to Caucasian patients ($3049-19 995, P =.008). Conclusions: Patients who undergo endoscopic EEA for resection of anterior skull base tumors typically incur greater in-hospital costs than patients undergoing a standard TSA. Post-operative complications such as CSF leak and DI, as well as ethnicity, are significant drivers of cost-variability. [ABSTRACT FROM AUTHOR]

Objective  Radiation therapy represents an uncommon but important component of treatment plans for some pituitary adenomas (PAs). Although radiation therapy has been used to treat pituitary adenomas for over a century, general trends in the usage of radiation therapy for this purpose have not been reviewed. Additionally, there are few large studies evaluating how radiation therapy is used for the treatment of these benign tumors. Investigating these trends and identifying any variations in radiation therapy utilization would help to better inform treatment decisions and improve patient outcomes. Design  Present study is a retrospective analysis of cases using the National Cancer Database. Setting  The research was organized at a tertiary academic medical center. Participants  Patients were diagnosed with pituitary adenoma between 2004 and 2014 within the National Cancer Database (NCDB). Methods  Temporal trends in the usage of radiation therapy to treat pituitary adenoma were analyzed through a retrospective analysis of 77,142 pituitary adenoma cases from the NCDB between 2004 and 2014. Univariate and multivariate analyses were to examine the relationship between patient, tumor, and treatment factors, and the incorporation of radiation therapy into the treatment of pituitary adenomas. We adjusted for potential confounders such as age, sex, race, comorbidity score, facility type, and year of diagnosis. Results  A total of 77,142 patients met inclusion criteria. Inclusion of radiation therapy in pituitary adenoma treatment was 8.0% in 2004 and steadily declined to a low of 3.1% in 2014. Overall, patients were less likely to receive radiation for their pituitary adenoma over time (p  < 0.001). Similarly, patients were found to be less likely to receive any type of treatment for PA over time (p  < 0.001). Multivariable evaluation found patients who were female, between 54 and 64 years of age, or treated at either a Comprehensive Community Cancer Program or an Integrated Network Cancer Program were more likely to receive radiation as part of their pituitary adenoma treatment (p  < 0.001, odds ratio [OR] = 2.01, confidence interval [CI]: 1.54–2.63; p  < 0.001, OR = 1.84, CI: 1.38–2.44, respectively). Patients were less likely to receive radiation for their PA if they were African American (p  < 0.001, OR = 0.81, CI: 0.72–0.91). Logistic regression also identified a progressive increase in the likelihood of receiving radiation after a PA diagnosis with increasing tumor size starting with microscopic tumors, peaking at 4 to 5 cm (p  < 0.001; OR = 15.57; CI: 12.20–19.87). Conclusion  In this sample of pituitary adenoma patients treated at NCDB institutions between 2004 and 2014, we found a steady decline in the incorporation of radiation therapy in treatment, as well as in the use of any type of intervention for PA treatment, suggesting a rise in noninterventional observation of PA. [ABSTRACT FROM AUTHOR]

Introduction  Olfactory groove meningiomas (OGMs) are often associated with loss of smell following resection. Loss of smell has a measurable impact on quality of life. Smell preservation has been previously described in open approaches for early stage or unilateral OGMs. Evidence of smell preservation in endoscopic approaches is lacking. Design  A multi-institutional retrospective review was performed on consecutive patients who underwent unilateral endoscopic endonasal resection of OGM. A gross total resection was achieved with preservation of the contralateral olfactory cleft and bulb. Olfactory function was assessed with a six-point olfactory symptom score and the Sniffin' Sticks 12-item smell identification test (SS-12). Contralateral olfactory bulb volume was measured on postoperative magnetic resonance imaging. Results  Four patients (age 42.0 ± 7.5, 75% female) were assessed. Olfactory function was assessed at 21.8 ± 5.6 months following surgery. All patients reported some degree of smell preservation (75% described a slight/mild impairment in smell or better). Olfactory identification was preserved with an SS-12 score of 9 ± 1.4 (anosmia defined as ≤6). The olfactory bulb volume was calculated to be 47.4 ± 15.9 mm 3 (normal >40 mm 3). Conclusion  Smell preservation is possible following unilateral endoscopic endonasal resection of carefully selected OGM. [ABSTRACT FROM AUTHOR]

Background Meningiomas of the anterior skull base are attractive tumors for resection via an endoscopic endonasal route. The use of the vascularized Hadad-Bassagasteguy nasoseptal flap has dramatically reduced the cerebrospinal fluid (CSF) leak rate—the veritable Achilles heel of this surgical approach. Benign meningiomas, however, can erode through the nasal mucosa—the very same mucosa that is used to reconstruct the anterior cranial fossa floor. The goal of this study was to describe the presence of meningioma invasion into the mucosa in patients who underwent endoscopic endonasal resection of ventral skull base meningiomas. The implications of this finding are discussed with respect to resection, reconstruction, and recurrence. Patients, Materials, and Methods This is a retrospective review of three patients who underwent endoscopic endonasal complete resection of ventral skull base meningiomas. Surgically excised tissues were processed for routine histopathological analysis. Results A complete resection of the bone, dura, and tumor was performed in all three cases. Both patients with visual deficits improved. The first patient to undergo endoscopic surgical resection developed a CSF leak, but the later two patients with larger tumors did not. Histopathological analysis demonstrated mucosal invasion by World Health Organization (WHO) grade I meningioma in two of the three cases. Conclusion Ventral anterior skull base meningiomas can invade through bone into the mucosa. Because the endoscopic endonasal resection of these meningiomas often requires the use of a vascularized nasoseptal flap to minimize CSF leak complications, it is possible that the nasoseptal flap itself may be compromised by tumor tissue. The creation of the nasoseptal flap should take the findings of this study into consideration to minimize late recurrence. [ABSTRACT FROM AUTHOR]

Background: Postoperative nausea and vomiting (PONV) are adverse effects after surgery, which may increase the risk of complications. Aprepitant is a neurokinin‐1 receptor blocker and has been shown to reduce chemotherapy‐related nausea and vomiting and PONV. However, its role in endoscopic skull base surgery remains unclear. The purpose of this study was to evaluate the effect of aprepitant in reducing PONV in endoscopic transsphenoidal (TSA) pituitary surgery. Methods: A retrospective chart review between July 2021 and January 2023 of 127 consecutive patients who underwent TSA was performed at a tertiary academic institution. Patients were divided into 2 groups based on preoperative aprepitant use. Two groups were matched based on known risk factors of PONV (age, sex, nonsmoking, and history of PONV). The primary outcome was the incidence of PONV. Secondary outcome measures included the number of anti‐emetic use, length of stay, and postoperative cererebrospinal fluid (CSF) leak. Results: After matching, 48 patients were included in each group. The aprepitant group demonstrated a significantly lower incidence of vomiting than the non‐aprepitant group (2.1% vs 22.9%, p = 0.002). The number of nausea episodes and anti‐emetic use decreased with aprepitant use (p < 0.05). There was no difference in the incidence of nausea, length of stay, or postoperative CSF leak. Multivariate analysis demonstrated that aprepitant decreased the incidence of postoperative vomiting with odds ratio of 0.107. Conclusion: Aprepitant may serve as a useful preoperative treatment to reduce PONV in patients undergoing TSA. Further studies are needed to evaluate its impact in other arenas of endoscopic skull base surgery. [ABSTRACT FROM AUTHOR]

An abstract of a study which examined patients undergoing extended endoscopic approach (EEA) for skull base tumors is presented.