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Objective  Surgical resection is widely accepted as a critical component for definitive treatment of sinonasal mucosal melanoma. Systemic immunotherapy, including multiple newer agents, has been used to treat metastatic or unresectable disease. In this study, we examine its efficacy in locoregional control when used in conjunction with surgical resection for primary mucosal lesions. Design  Present study is a retrospective review of all patients at a tertiary academic medical center with primary sinonasal mucosal melanoma and distant metastatic disease. Results  A total of four patients were identified. In all cases, patients were treated with a combination of surgical resection of the primary tumor and systemic immunotherapy. Three patients were initially treated with surgery at the primary site followed by immunotherapy for distant metastases. Response to immunotherapy at the sites of primary and metastatic disease was seen in two patients. All four patients developed progression or recurrence at the primary site following initiation of immunotherapy for which they underwent surgical resection. One patient remains in follow-up without evidence of disease 20 months after initial treatment; three succumbed to the disease at 135, 37, and 16 months after initial treatment. Conclusion  Surgical resection for local control plays a critically important role in the treatment of sinonasal mucosal melanoma regardless of the presence of metastases and whether immunotherapy will be given. This case series suggests that, though immunotherapy may demonstrate efficacy in managing distant disease, surgery should remain the first-line treatment for the primary site.

Olfactory neuroblastoma (ONB) is an uncommon neuroendocrine malignancy arising from the olfactory neuroepithelium. ONB frequently presents with nonspecific sinonasal complaints, including nasal obstruction and epistaxis, and diagnosis can be obtained through a combination of physical examination, nasal endoscopy, and computed tomography and magnetic resonance imaging. Endoscopic resection with negative margins, with or without craniotomy, as necessary, is the standard of care for definitive treatment of ONB. Regional metastasis to the neck is often detected at presentation or may occur in a delayed fashion and should be addressed through elective neck dissection or radiation. Adjuvant radiotherapy should be considered, particularly in the case of high grade or tumor stage, as well as positive surgical margins. Systemic therapy is an area of active investigation in both the neoadjuvant and adjuvant setting, with many advocating in favor of induction chemotherapy for significant orbital or intracranial involvement prior to surgical resection. Various targeted immunotherapies are currently being studied for the treatment of recurrent or metastatic ONB. Prolonged locoregional and distant surveillance are indicated following definitive treatment, given the tendency for delayed recurrence and metastasis. [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: 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. [ABSTRACT FROM AUTHOR]

Objectives: Rathke cleft cysts (RCCs) are rare, benign lesions formed from remnants of Rathke pouch during embryologic development. However, following marsupialization, maintaining tract patency remains a challenge. Several techniques for decreasing stenosis have been described, including free mucosal grafting, silastic spacing, and using steroid-eluting stents. Nasoseptal flaps (NSFs) have a reliable vascular supply and are widely utilized in skull base reconstruction. We present a novel technique to maintain patency of the marsupialized RCC cavity by lining it with an NSF to promote long-term drainage and re-epithelialization of the RCC cavity.Methods: Retrospective chart review of all patients who underwent surgery for symptomatic RCCs. These patients underwent endoscopic endonasal surgery between February 3, 2016, and June 12, 2018, with marsupialization followed by circumferential NSF lining. Primary outcomes include symptomatic control, surgical complications, and RCC cavity patency.Results: Seven patients underwent RCC marsupialization with no intraoperative cerebrospinal fluid leak, followed by circumferential lining of the marsupialized cavity with an NSF. In each case, no cyst re-accumulation or recurrent symptoms were noted, and the NSF lining provided long-term patency of the tract in all cases to a mean of 6.7 ± 10.1 months of follow-up, including one patient with sustained patency at 29 months follow-up.Conclusion: Utilization of the NSF to "stent open" the RCC cavity following marsupialization is a safe and effective means to prevent restenosis. Advantages include sustained patency of RCC cavity for complete drainage and a dependable vascular supply.Level Of Evidence: 4 Laryngoscope, 129:2258-2261, 2019. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To determine the pediatric age groups viable for nasoseptal flap (NSF) reconstruction of endoscopic endonasal approaches (EEA) to intracranial pathology of suprasella neoplasms.Study Design: Retrospective cohort study.Methods: Retrospective review of 16 pediatric patients who underwent EEA with NSF reconstruction for a suprasellar defect from 2012 to 2014. Radioanatomic analysis was utilized to assess feasibility of NSF reconstruction of suprasellar neoplasms approached via EEA. Computed tomography (CT) measurements for defect size and potential flap coverage were measured by preoperative maxillofacial CT. Radiographic measurements and surgical outcomes were compared to determine if flap size would be sufficient to cover said defects in two pediatric age groups: those>10 years of age (mean age 14 years) and those<10 years (mean age 6 years).Results: Of all patients encountered in this cohort, one postoperative cerebrospinal fluid leak was identified in the >10 years of age population, and this was not due to insufficient flap coverage. Average potential flap length and width are sufficient to cover average suprasellar defect length and width in both age groups (P<.05 in all age groups).Conclusions: Patient selection is critical for successful pediatric EEA. Preoperative radiographic assessment of NSF feasibility is a critical to ensure adequate flap coverage for suprasellar defects. NSF appears to provide a sufficient and reliable coverage option in reconstruction of suprasellar defects in pediatric patients.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Objectives: Malignant tumors of the paranasal sinuses are traditionally approached by a variety of external incisions. Recent advances in endoscopie endonasal surgery have allowed for some of these tumors to be treated endoscopically. The purpose of this study was to assess the outcomes and complications of the endoscopie approach in a series of patients with paranasal sinus malignancies. Methods: A retrospective chart review was performed of patients with sinonasal or skull base malignancies treated with endoscopie or endoscopic-assisted resections at a tertiary care institution from 2002 to 2010. Patient data were collected on symptoms, tumor type, operative technique, and postoperative course. Baseline risk factors, overall and disease-free survival data, and surgical outcomes were compared between the two groups. Results: Of the total 49 patients, 36 (73%) underwent an endoscopie approach and 13 (27%) underwent endoscopic- assisted approaches. Sarcomas (9 cases) were the most common tumor type, followed by squamous cell carcinoma (8), adenocarcinoma (8), and melanoma (7). The mean follow-up time for all patients was 3.58 years (range, 1.1 to 8.8 years). Surgical complications were more frequent with open approaches than with endoscopie approaches (23.1% versus 5.6%; p = 0.11). Medical complications were significantly more common with open approaches (38.5% versus 8.3%; p = 0.02). The disease-specific mortality rate was 8% (4 of 49). The local tumor recurrence rate was 16% (8 of 49). The 3-year disease-free survival rates were 86.8% in the endoscopie group and 67.7% in the open group (p = 0.047); however, the patients in the endoscopie group had lower T stages (p = 0.0068) and lower ASA scores (p = 0.03). Conclusions: Endoscopie approaches to the sinuses and skull base have become progressively more sophisticated with advances in skull base reconstruction, advances in surgical technique, and improvements in technology. This study demonstrates the relative safety and utility of the endoscopie approach for sinonasal and skull base malignancies. In carefully selected patients, endoscopie approaches demonstrate survival rates comparable to those of traditional surgery, and fewer perioperative complications. With appropriate planning and careful surgical decision-making, endoscopie surgery shows promise as a minimally invasive alternative in the treatment of sinonasal malignancies. [ABSTRACT FROM AUTHOR]

Background: Endoscopic reconstruction of skull base defects remains a challenge. Laser tissue welding (LTW) is a technique in which a laser-activated solder is used to create instantaneous repairs of skull base defects with burst strengths far exceeding intracranial pressure (ICP). This study was designed to define the thermal and inflammatory profile of a novel polysaccharide soldering gel, to assess the burst strength of the repair, and to determine the time required for solder resorption. Methods: A prospective study was performed in rabbit and mouse models. Ten dorsal rabbit maxillary sinusotomies were laser welded and burst pressure thresholds were compared with control wounds on postoperative days (PODs) 0 and 5. All welds were examined histologically on PODs 0, 5, and 45 for thermal injury, inflammation, and degree of solder resorption. In mice, dura was exposed and laser welding was performed (n = 2). Results were compared histologically with dura exposed to laser energy alone (n = 2) on POD 7. Results: The burst pressures of the rabbit LTW group were significantly higher than control on PODs 0 (135.0 mmHg and SD = 5.8 versus 8.0 mmHg and SD = 0.5; n = 4) and 5 (155.4 mmHg and SD = 2.9 versus 41.7 mmHg and SD = 7.3; n = 4; p < 0.05). No significant thermal or inflammatory effect was found in any of the rabbit or mouse welds. Complete solder resorption was noted by POD 45. Conclusion: LTW using a polysaccharide gel is capable of creating mucosal repairs capable of withstanding over four times normal ICP without additional grafting materials. These repairs increase in strength over time, have no thermal or inflammatory sequelae, and establish complete solder resorption within 45 days. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Sinonasal malignancy surveillance paradigms are often based on Head and Neck National Comprehensive Cancer Network guidelines, which do not recommend standard surveillance imaging beyond 6 months without concerning symptomatology or physical examination findings.This was a retrospective analysis of all patients who underwent resection of sinonasal malignancy at a tertiary care center over a 20‐year period from 2000 to 2020, with an ensuing surveillance period demonstrating recurrence.Fifty‐two patients with sinonasal malignancy recurrence were included, with an average time to recurrence of 30.9 months and a follow‐up period of over 60 months. Recurrence was diagnosed by routine imaging or endoscopy in asymptomatic patients in a majority (60%) of cases, while the remaining minority of diagnoses followed new symptomatology. Asymptomatic recurrence was associated with perineural spread of tumor at initial resection (p = 0.025), but not with age (p = 0.85) or stage at diagnosis (p = 0.68). Expectedly, positron emission tomography/computed tomography (CT) more often detected regional or distant recurrence, while structural imaging (CT/magnetic resonance imaging) demonstrated more frequent detection of recurrence in those with perineural spread of tumor (p = 0.01).Our findings support high rates of asymptomatic recurrence in sinonasal malignancy, with the majority of recurrences diagnosed by routine endoscopy or imaging. Tailored and extended surveillance guidelines are necessary relative to those utilized for other head and neck mucosal cancers, and are especially appropriate when features such as perineural spread are present. [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]

Background: Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence‐based guidance. Methods: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated. Results: A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction. Conclusion: The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high‐quality studies are needed in order to devise optimal postoperative ESBS protocols. [ABSTRACT FROM AUTHOR]

Background Current guidelines have identified 10 to 12 weeks posttreatment as the ideal time-point for improved diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) for deep tissue sites of the head and neck. After treatment, the sinonasal skull base is predisposed to prolonged inflammation that may render this time-point inappropriate for initial posttreatment imaging surveillance for sinonasal malignancies. The purpose of this study is to evaluate temporal trends in 18F-fluorodeoxyglucose (18FDG) sinonasal uptake after treatment for sinonasal malignancies to better elucidate the optimal time-point for initial PET/CT posttreatment evaluation in this patient population. Methods A retrospective analysis of all successfully treated and non-locally recurrent sinonasal malignancies over a 15-year study period (2000 to 2015) was performed at our institution. Posttreatment 18FDG PET/CT standardized uptake value data were collected and compared between various time-points (2 to 4 months, 5 to 12 months, 5 to 24 months, and 13 to 24 months) using an independent-samples t test. Results A statistically significant difference was noted between the posttreatment time windows 2 to 4 and 5 to 12 months ( p = 0.048) as well as 2 to 4 and 5 to 24 months ( p = 0.02). A trend toward significance was seen when comparing 2 to 4 and 13 to 24 months ( p = 0.083). Conclusion Our analysis of PET/CT in patients previously treated for sinonasal malignancy suggests that the posttreatment sinonasal skull base is characterized by a prolonged period of hypermetabolism that endures beyond the period previously described for deep tissue sites of the head and neck. These findings prompt a reevaluation of the previously described 10- to 12-week cutoff point for initial posttreatment PET/CT for head and neck squamous cell carcinoma as applied to sinonasal malignancies. [ABSTRACT FROM AUTHOR]