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Objective: Skull base osteomyelitis may rarely present in the sphenoid bone or clivus without an otologic source. This is referred to as central skull base osteomyelitis (CSBO). Knowledge regarding CSBO is limited to case reports and small case series. Here we present a case series to further describe typical patient characteristics, clinical presentation, and clinical course associated with this rare infection., Methods: All patients treated at a single academic tertiary care institution for CSBO from 2016 through 2020 were identified. Inclusion criteria included culture proven CSBO without an otologic or iatrogenic source. Data were extracted via patient chart review and qualitatively analyzed., Results: Seven patients were identified with CSBO, 5 male and 2 female. Age ranged from 63 to 87 (average 76). Risk factors included advanced age, diabetes, and history of radiation. The most common presenting symptom was headache (6), followed by otalgia (4). Two patients presented with cranial neuropathies. Diagnosis was facilitated by history and exam (including flexible laryngoscope exam), imaging (MRI), and labs (ESR). All patients received endoscopic biopsy and culture (most commonly polymicrobial, with diverse species). Treatment involved IV antibiotics, with a limited role for surgery. All patients survived and achieved resolution of infection., Conclusions: CSBO remains a diagnostic challenge due to its rarity and vague presenting symptoms that overlap with presentation of sinonasal malignancies. A high index of suspicion is required by the evaluating provider to ensure a timely diagnosis with early treatment in order to limit the significant morbidity which can be associated with this infection., Level of Evidence: 4.

Objective: To demonstrate anatomic relationships pertinent to the endoscopic multiport approach to the infratemporal fossa (ITF). Discuss advantages and limitations of each individual approach., Study Design: Cadaveric study., Methods: Endoscopic and endoscopic-assisted endonasal transpterygoid, sublabial transmaxillary, endoscopic transorbital, and endoscopic transoral approaches to accessing the ITF were completed in five silicone-injected fresh cadaveric specimens (10 sides) with the assistance of 0, 30, and 45 0 rods-lens endoscopes. Image guidance was used to confirm and document the anatomical relationships encountered in each approach., Results: The endonasal endoscopic transpterygoid approach provides better visualization and more direct exposure to median structures. Endoscopic-assisted sublabial transmaxillary approach enhances the field of exposure, angle of attack, and ease of instrumentation to the lateral part of the ITF. Endoscopic-assisted transorbital approach via the inferior orbital fissure provided cephalic and anterior access. Endoscopic-assisted transoral approach complements the access to lesions extending inferior to the hard palate or far lateral to the mandibular condyle., Conclusions: A combination of minimal access infratemporal approaches can provide adequate exposure of the entire ITF while avoiding some of the morbidity associated with open approaches., Level of Evidence: NA Laryngoscope, 133:1367-1374, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Acquiring proficiency for the repair of a cerebrospinal fluid (CSF) leak is challenging in great part due to its relative rarity, which offers a finite number of training opportunities., Objective: The purpose of this study was to evaluates the use of a 3-dimensional (3D) printed, anatomically accurate model to simulate CSF leak closure., Methods: Volunteer participants completed two simulation sessions. Questionnaires to assess their professional qualifications and a standardized 5-point Likert scale to estimate the level of confidence, were completed before and after each session. Participants were also queried on the overall educational utility of the simulation., Results: Thirteen otolaryngologists and 11 neurosurgeons, met the inclusion criteria. A successful repair of the CSF leak was achieved by 20/24 (83.33%), and 24/24 (100%) during the first and second simulation sessions respectively (average time 04:04 ± 1.39 and 02:10 ± 01:11). Time-to-close-the-CSF-leak during the second session was significantly shorter than the first (p < 0.001). Confidence scores increased across the training sessions (3.3 ± 1.0, before the simulation, 3.7 ± 0.6 after the first simulation, and 4.2 ± 0.4 after the second simulation; p < 0.001). All participants reported an increase in confidence and believed that the model represented a valuable training tool., Conclusions: Despite significant differences with varying clinical scenarios, 3D printed models for cerebrospinal leak repair offer a feasible simulation for the training of residents and novice surgeons outside the constrictions of a clinical environment.

Objective: The pediatric skull base may present anatomic challenges to the skull base surgeon, including limited sphenoid pneumatization and a narrow nasal corridor. The rare nature of pediatric skull base pathology makes it difficult to gain experience with these anatomic challenges. The objective of this study was to create a 3-dimensionally (3D) printed model of the pediatric skull base and assess its potential as a training tool., Methods: Twenty-eight participants at various stages of training and practice were included in our study. They completed a pre- and postdissection questionnaire assessing challenges with endoscopic endonasal skeletonization of the carotid arteries and sella face using the 3D printed model., Results: The majority of participants had completed a skull base surgery fellowship (60.7%), were <5 years into practice (60.7%), and had <10 cases of pediatric skull base experience (82.1%). Anticipated challenges included limitation of maneuverability of instruments (71.4%), narrow nasal corridor and nonpneumatized bone (57.1%). On a scale of 0-10, 10 being very difficult, the average participant expected level of difficulty with visualization was 6.89 and expected level of difficulty with instrumentation was 7.3. On postdissection assessment, there was a nonstatistically significant change to 6.93 and 7.5, respectively. Participants endorsed on a scale of 0-10, 10 being very realistic, an overall model realism of 7.0 and haptic realism of 7.1., Conclusions: A 3D printed model of the pediatric skull base may provide a realistic model to help participants gain experience with anatomic limitations characteristic of the pediatric anterior skull base., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To determine the feasibility of a patient-specific, three-dimensionally (3D)-printed reconstruction plate for repair of lateral skull base defects., Study Design: Prospective case series and cadaveric study., Setting: A university-based, tertiary care hospital., Patients: Three patients with lateral skull base defects and five cadavers., Main Outcome Measure(s): Caliper gauge fit testing was performed in the cadaver temporal bones to determine the fit of the tegmen plate in engaging the tegmen defect. Additionally, three patients underwent standard of care reconstruction of their middle fossa floor using autografts or allografts. Temporary plate insertion during standard operative repair was performed to gauge feasibility and fit. Operative time required for standard grafting compared with placement of the tegmen plate was examined., Results: Real-time, intraoperative placement of the tegmen plate in our patients under 1 minute compared with nearly 60 minutes for standard surgical repair. Tegmen plates covered the defects and locked into place from contour matching without impinging on critical structures. Fit testing revealed flush-fitting plates to the cadaveric temporal bone surface with all gaps less than 500 μm., Conclusions: Computer modeling and 3D printing can design custom fitted tegmen reconstruction plates for temporal bone defects. Versatility in prefabrication and 3D modeling shows potential in allowing the construct to avoid critical structures and adequately cover defects with high precision to the tegmen surface.

This article, published in the Journal of Neurological Surgery, describes the use of a Latissimus dorsi muscle free flap to reconstruct the anterior skull base in the treatment of an infected gunshot wound. The procedure involved removing an infected prior frontal craniotomy bone flap and split-thickness bone grafts, followed by combined open-endoscopic latissimus dorsi muscle reconstruction. The authors of the article are Claudio Callejas, Lucas Carlstrom, Kyle Wu, Joseph Lee, Michael Li, Lauren Miller, Matthew Old, Prevedello Daniel, Ricardo Carrau, and Kyle VanKoevering. [Extracted from the article]

This article discusses the creation of a module-based and structurally accurate 3D anatomical model for endoscopic skull base surgery. The model was created using a photogrammetry pipeline, which obtains graphical information about physical objects from photographs. The article explains the methods used to dissect cadaveric heads and acquire still images of the anatomical regions of interest. The 3D model allows for a more effective understanding of the intricate anatomical relationships seen at the ventral skull base and may reduce reliance on wet-laboratory learning environments in surgical education and training. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, discusses two cases of frontoethmoidal osteoma, a rare type of benign bone tumor. The patients presented with neurological deficits and cerebral spinal fluid (CSF) leaks. Both cases were successfully treated with different surgical approaches, resulting in complete tumor resection and no complications or signs of CSF leak. The authors emphasize the need for more cases to better understand the epidemiology, clinical presentation, treatment strategies, and outcomes of this condition. The article also includes a literature review of eight previously reported cases. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, discusses a novel surgical technique for reconstructing defects in the clival and craniovertebral junction (CVJ) regions of the skull base. The technique involves using a nasopharyngo-septal butterfly flap, which is a vascularized flap that provides adequate mucosal coverage for the reconstruction. The study was conducted on cadaveric heads and found that the flap was able to cover the entire clivus with CVJ in all 15 cadavers. This technique may be particularly useful when the traditional nasoseptal flap is not viable. [Extracted from the article]

Introduction Radiation-induced hypopituitarism (RIH) has long been recognized as one of the deleterious side effects of skull base radiation. This study aims to assess the quality of life (QoL) among patients with RIH compared with radiated patients who did not develop hypopituitarism using the validated Anterior Skull Base Questionnaire (ASBQ). Methods This was a single-institution retrospective cohort study. Included patients had a history of anterior skull base tumor, underwent at least one round of radiation to the skull base, and had filled out at least one ASBQ survey after their radiation treatment. Three statistical models were used to determine the effect of hypopituitarism and treatment on QoL scores. Results A total of 145 patients met inclusion criteria, and 330 ASBQ surveys were analyzed. Thirty-five percent (51/145) had evidence of RIH at some point after their radiation treatment. Those with hypopituitarism had significantly lower overall ASBQ scores across all three models even after adjusting for potential confounders and intraperson correlation (average decrease of 0.24–0.45 on a 5-point Likert scale; p -values ranging from 0.0004 to 0.018). The increase in QoL with hormonal replacement was modulated by time out from radiation, with long-term survivors (5+ years out from radiation) gaining the most benefit from treatment (increase of 0.89 on a 5-point Likert scale, p 0.0412), especially in the vitality domain. Conclusion This data demonstrates that hypopituitarism is an independent predictor of lower QoL. Early detection and appropriate treatment are essential to avoid the negative impact of hypopituitarism on QoL. [ABSTRACT FROM AUTHOR]

Objectives Sinonasal neuroendocrine carcinomas (SNECs) are among the rarest paranasal sinus cancers. Consensus guidelines for therapy are difficult to develop due to limited data regarding the natural history and successful treatment of these tumors. This study presents 15 years of experience treating SNEC at a single institution and a review of the literature. Design Retrospective review. Setting Academic medical center in the United States. Participants Patients diagnosed with primary SNEC. Main Outcome Measures Overall survival. Results Thirteen patients were identified and included. Overall estimated survival was 74.6% at 5 years. Ten of 13 (76.9%) patients were diagnosed with high-grade neuroendocrine carcinoma and three (23.1%) with intermediate or low grade. All three patients with low- or intermediate-grade cancer survived more than 10 years from their initial diagnosis (median survival: 11.6 years) and are currently alive. The four patients who died had high-grade carcinoma, and estimated overall 5-year survival for all patients with high-grade carcinomas was 65.6%. Five patients, all with high-grade carcinoma, of seven who completed primary chemoradiation therapy (CRT) required salvage resection, and 60% are alive without disease. Conclusion This cohort has a higher overall rate of survival than many recent case series and reviews. There is consensus that multimodal therapy is preferred over monotherapy, but approaches to treatment vary widely. Our approach of surgical resection as primary therapy for low-grade tumors and primary CRT for high-grade SNEC has been successful, and could indicate hope for improved survival among these patients. [ABSTRACT FROM AUTHOR]

Background  Management of anterior cranial base malignancies requires multidisciplinary care. Radiation therapy remains a mainstay of definitive or adjuvant treatment. Apart from primary hypothyroidism, the effects of radiation on the hypothalamic–pituitary axis after high-dose treatment of head and neck malignancies remain poorly described. We describe a comprehensive screening protocol for surveillance and characterize the incidence of pituitary dysfunction after radiation for anterior cranial base malignancies. Methods  A review of patients prospectively enrolled in a skull base registry at an academic center was performed. Included patients had a history of anterior skull base malignancy and external beam radiation to the primary site, with comprehensive post-treatment pituitary serologies and at least 1 year of post-radiation follow-up. Routine hormonal screening was initiated during the study period for all patients with anterior skull base irradiation. Results  Eighty-one patients met inclusion. Fifty-eight patients (71%) demonstrated some laboratory abnormality. Thirty patients (37%) demonstrated evidence of hypopituitarism. Twenty-four (29%) demonstrated central hypogonadism, and 16% of patients showed central hypothyroidism. Ten patients (12%) displayed central adrenal insufficiency with six patients demonstrating panhypopituitarism. Primary tumor location and maximum dose of radiation to the gland appeared to correlate with incidence of hypopituitarism. Conclusion  Radiation for malignancies of the anterior skull base resulted in a 37% incidence of hypopituitarism in our study. Given the potential morbidity of hypopituitarism, we recommend annual post-treatment screening in these patients. We describe a comprehensive set of serologies that can be utilized, and recommend updating clinical guidelines to reflect the necessity of this screening. [ABSTRACT FROM AUTHOR]

The expanded endoscopic endonasal approach (EEA) is currently well accepted for a variety of ventral skull base tumors. Such an approach often results in a transdural defect and intraoperative cerebrospinal fluid (CSF) leak, and adequate reconstruction is necessary to prevent postoperative CSF leak and its complications. Reconstruction is usually performed using a variety of materials along with the nasoseptal flap. This work's aim is to describe a new reconstructive technique called the "soft gasket seal" (SGS) in detail and compare it with the standard reconstructive technique at our institution for craniopharyngiomas operated via transtuberculum EEA. A retrospective chart review was achieved to identify patients who underwent transtubercular EEA for craniopharyngioma between 2010 and 2018, by the same neurosurgical and otolaryngology team using either the SGS or standard reconstructive technique. Of 36 patients who met criteria and were considered for analysis, 15 of them underwent SGS reconstruction and 21 had standard reconstruction. There were 16 female (44%) and 20 male (56%) patients. The median age was 42.2 ± 20.9 years. The rate of postoperative CSF leak in the group of patients treated with the standard technique was 14.2% and 6.6% in the SGS group (odds ratio 0.43 [confidence interval 95% 0.007–6.15], P = 0.62). The SGS technique provides a simple reconstructive technique in conjunction with the nasoseptal flap, showing a tendency of lower complications when compared with our standard technique while avoiding donor site morbidity. Such results are encouraging, but further studies are necessary to confirm these findings. [ABSTRACT FROM AUTHOR]

Craniocervical junction chordoma treated with surgery and Proton Beam Therapy evolved with Osteonecrosis and CSF leak. As the vascularization of the head was compromised, we harvested an Anterolateral thigh musculofascial flap to seal the leak. A 56-year-old man presented with a history of chronic headaches and dysarthria with tongue deviation to the right. Magnetic resonance imaging showed a lesion at the craniocervical junction with imaging characteristics compatible with chordoma. Endoscopic endonasal resection was followed by proton beam therapy. Recurrence of the chordoma was subsequently resected via far lateral approach again followed by proton beam therapy accumulating a total dose of 75 Gy. Unfortunately, this led to osteoradionecrosis of the skull base resulting in a cerebrospinal fluid (CSF) leak more than 1 year after treatment. After multiple failed attempts to seal the defect using local vascularized tissue and free fat grafts, the defect was reconstructed with a vastus lateralis free tissue transfer. Six weeks later, the flap had mucosalized, the patient was pain free, and there was no evidence of a CSF leak. In select cases, vascularized free flaps offer a superior reconstruction for osteoradionecrosis because radiotherapy often compromises the blood supply of local tissues. [ABSTRACT FROM AUTHOR]