Search

Background: Traditional management of olfactory neuroblastoma (ONB) includes margin‐negative resection with removal of cribriform plate, dura, and olfactory bulb, regardless of intracranial disease. This approach may be overtreating certain patients. Our investigation examines risk factors associated with occult intracranial disease to optimize therapeutic outcomes. Methods: This retrospective, multi‐institutional cohort study examined clinical covariates associated with occult intracranial involvement. Patient demographics, staging, Hyam's grade, and pathologic involvement of dura, olfactory bulb/tract, and brain were collected. Diagnostic imaging was reviewed. Positive and negative predictive value (NPV) were estimated along with effect size estimates. Cox hazard regression examined associations with overall survival (OS) and disease‐free survival (DFS). Results: A total of 224 subjects with new diagnoses of ONB (2005–2021) were identified. Skull base bone involvement on computed tomography (CT) had the highest NPV for pathologic dura (88.0%), olfactory bulb (88%), and brain involvement (97.3%). Hyam's grade category was significantly associated with dural involvement (φC = 0.26; 95% confidence interval [CI]: 0.16, 0.42). Subjects without radiologic skull base involvement (n = 66) had pathologic positivity of 12.1%. Within this subgroup, Hyam's grade was clinically significant for dural positivity (φ = 0.34; 95% CI: −0.12, 0.71) with 28.6% involvement in high grade tumors. Neither clinical nor pathologic positivity of intracranial structures were associated with significantly different OS or DFS. Conclusions: Both CT and magnetic resonance imaging (MRI) had reasonably good NPV for involvement of dura and olfactory bulb. Higher Hyam's grade was associated with dural involvement. Patients with low‐grade tumors not involving the skull base may be suitable for avoiding skull base resection; however, further investigation is warranted. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this article is to provide a state‐of‐the‐art review of the literature and summarize the latest publications on medical and surgical treatment of cystic fibrosis (CF) chronic rhinosinusitis (CRS), with an emphasis on describing recent advancements in cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies. Methods: A comprehensive literature review was conducted utilizing the PubMed database with search phrases detailed within the body of the article. Abstracts were reviewed to include publications detailing medical, surgical, and CFTR modulating therapies for CF CRS. Findings from studies not previously reviewed and publications regarding CFTR modulators were emphasized. Results: No clear guidelines for treatment of CF CRS are available. Nasal saline rinses, topical steroids, topical antibiotics, and topical dornase alfa are reported medical therapies. Ivacaftor has some sinonasal symptomatic benefit. A new triple therapy CFTR modulator, elexacaftor/tezacaftor/ivacaftor, is capable of treating 90% of patients with CF and has shown the greatest FEV1 improvement of any CFTR modulator yet. There is no clear consensus on surgical indications or technique, though aggressive surgery in recalcitrant disease has shown some symptomatic benefit. Endoscopic sinus surgery after lung transplantation may benefit some patients in whom the sinuses serve as a reservoir for recurrent pulmonary infections by decreasing rates of bronchiolitis obliterans syndrome and improving 5 year survival. Conclusion: As lifespan increases for patients with CF, further investigation into medical therapy, CFTR modulator sinonasal outcomes, and surgical technique and outcomes for CF CRS is needed. Level of Evidence: 5. [ABSTRACT FROM AUTHOR]

This article discusses the use of the vascularized lateral nasal wall flap (LNWF) in endoscopic endonasal surgery (EES) for closure of complex skull base defects. The study presents a 15-year single-institutional experience with the LNWF, focusing on its role in providing durable closure after intradural endoscopic endonasal tumor resection. The LNWF is an axial transposition flap based on the inferior turbinate artery and its branches, and it can be modified to include the nasal floor and nasal septum for reconstruction of large skull base defects. The primary outcomes measured were postoperative flap necrosis and cerebrospinal fluid (CSF) leak. The study found that the LNWF successfully addressed CSF leak in 64% of cases and that postoperative CSF leak occurred in 28.5% of cases with intraoperative leak. The most common adverse outcomes associated with LNWF closures were CSF leak and flap necrosis. Overall, the LNWF is a valuable technique for the treatment of persistent CSF leaks after endonasal surgery. [Extracted from the article]

Background Asthma is a prevalent disease characterized by chronic inflammatory changes of the airway and marked by airway hyperresponsiveness, edema, and excess mucus production. Management of the disease has focused upon reversing the early airway changes and limiting the late effects of airway remodeling. Several classes of medications are available for the effective treatment and long-term control of asthma and novel therapeutic options are in development that hold promise in improving patient outcome. Methods A review of updated guidelines and current literature was conducted to identify available pharmacologic treatments of asthma and determine future directions in development of novel therapeutic options. Results Inhaled corticosteroids are the most effective medications in long-term asthma control with adjunct medications such as β2-agonists, which can provide symptomatic relief. Other classes of asthma control medications including anticholinergics, cromolyns, and leukotriene receptor modifiers can also be used to develop an effective management strategy based on asthma severity. Conclusion Several classes of medications are available for the effective management of asthma. Inhaled corticosteroids play a central role in control of inflammation and several other adjuncts are available to tailor therapy to the patient's symptoms. New therapeutic options that target downstream inflammatory mediators can provide increased efficacy while limiting side effects. [ABSTRACT FROM AUTHOR]

Papillary thyroid cancer (PTC) is the most common malignancy of the thyroid gland. It typically spreads via lymphatic extension. The rate of regional PTC metastasis to the neck is relatively high, while metastases outside the deep cervical chain are rare. Distant metastases are found in only 1% of patients with PTC at the time of surgery; the two most common sites are the lung and bone. We report 4 cases of PTC metastasis to unusual sites: (1) the occipital skull and internal jugular vein, (2) the parapharyngeal space, (3) the sternocleidomastoid muscle, and (4) the right atrium of the heart. It has been well documented that aggressive distant metastasis is a characteristic of PTC, and it is known to be an indicator of a poor prognosis. Some of our patients' sites ofmetastatic disease have not been previously reported. Patients in this series exhibited aggressive histologic findings, including columnar cell andfollicular variants of papillary disease. In addition, all 4 patients demonstrated "PET-avid" disease with decreased iodine avidity. [ABSTRACT FROM AUTHOR]

Objective When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design Cadaveric anatomical study. Participants Cadaveric specimens. Main Outcome Measures Flap size, arc of rotation, and reconstructive applications were assessed. Results The average width of the flap was 5.46 ± 0.58 cm (7.32 ± 0.59 cm with septal mucosa). The average length of the flap was 5.01 ± 0.58 cm (5.28 ± 0.37 cm with septal mucosa). The average surface area of the flap was ∼ ± 27.26 ± 3.65 cm2 (40.53 ± 6.45 cm2 with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable. [ABSTRACT FROM AUTHOR]

To assess the impact of tumor extension into the occipital condyle (OC) in lower clival chordoma management and the need for occipito-cervical fusion (OCF). A retrospective analysis was conducted on 35 patients with lower clival chordoma. The preoperative area of the intact OCs, Hounsfield units, and the integrity of the apical ligament and the tectorial membrane were assessed using preoperative imaging. Seven (20%) patients were in the OCF group. The OCF group exhibited a higher prevalence of preoperative pain in the neck or head (P = 0.006), ligament absence (P = 0.022), and increased propensity for postoperative wound issues (P = 0.022) than the non-OCF group. The OCF group had less intact OCs (P < 0.001) and higher spinal instability neoplastic score (P = 0.002) than the non-OCF group. All patients with intact OCs < 60% underwent OCF, and those with OCs ≥ 70% were treated without OCF. Those with OCs between 60% and 69% underwent OCF if the ligaments were eroded, and did not undergo OCF if the ligaments were intact. Treatment strategies varied, with endoscopic endonasal approach alone being common. Radiation therapy was administered to 89% of patients. All 3 patients treated with OCF after tumor resection had wound issues; none treated with OCF before resection had wound issues. None developed atlanto-occipital instability. Survival rates did not significantly differ between groups. In the absence of mobility-related neck pain, patients with lower clival chordoma and intact OC ≥ 60%, intact apical ligament, and intact tectorial membrane, may not require OCF. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Patients with sinonasal malignancy (SNM) present with significant sinonasal quality of life (QOL) impairment. Global sinonasal QOL as measured by the 22‐item Sinonasal Outcomes Test (SNOT‐22) has been shown to improve with treatment. This study aims to characterize SNOT‐22 subdomain outcomes in SNM.Patients diagnosed with SNM were prospectively enrolled in a multi‐center patient registry. SNOT‐22 scores were collected at the time of diagnosis and through the post‐treatment period for up to 5 years. Multivariable regression analysis was used to identify drivers of variation in SNOT‐22 subdomains.Note that 234 patients were reviewed, with a mean follow‐up of 22 months (3 months–64 months). Rhinologic, psychological, and sleep subdomains significantly improved versus baseline (all p < 0.05). Subanalysis of 40 patients with follow‐up at all timepoints showed statistically significant improvement in rhinologic, extra‐nasal, psychological, and sleep subdomains, with minimal clinically important difference met between 2 and 5 years in sleep and psychological subdomains. Adjuvant chemoradiation was associated with worse outcomes in rhinologic (adjusted odds ratio (5.22 [1.69–8.66])), extra‐nasal (2.21 [0.22–4.17]) and ear/facial (5.53 [2.10–8.91]) subdomains. Pterygopalatine fossa involvement was associated with worse outcomes in rhinologic (3.22 [0.54–5.93]) and ear/facial (2.97 [0.32–5.65]) subdomains. Positive margins (5.74 [2.17–9.29]) and surgical approach—combined versus endoscopic (3.41 [0.78–6.05])—were associated with worse psychological outcomes. Adjuvant radiation (2.28 [0.18–4.40]) was associated with worse sleep outcomes.Sinonasal QOL improvements associated with treatment of SNM are driven by rhinologic, extra‐nasal, psychological, and sleep subdomains. [ABSTRACT FROM AUTHOR]

This article, titled "Artificial Intelligence in Skull Base Surgery: A Scoping Review," examines the use of artificial intelligence (AI) in the field of skull base surgery. The authors conducted a systematic review of relevant articles published between January 2018 and September 2023. They found that AI is being increasingly utilized in skull base surgery, particularly for diagnostic and prognostic purposes. The majority of the studies focused on radiomics, with MRI being the most common imaging modality used. However, there are still many areas within skull base surgery that have not been explored with AI and warrant further investigation. [Extracted from the article]

The article discusses the versatility of the SPIWAY, an endonasal access guide (EAG) used in surgery. The SPIWAY is a stent that can be placed in the nasal cavity to provide access during endoscopic endonasal surgery. The study includes a retrospective review of cases, a cadaveric model, and a literature review to demonstrate the various uses of the SPIWAY. The article highlights the advantages of the SPIWAY, such as reducing aerosol spread, improving efficiency, and preventing tumor spillage. Overall, the SPIWAY is a useful tool in facilitating access in different surgical approaches within the head and neck. [Extracted from the article]

This article presents a case series of patients with Tuberculum Sella Meningiomas (TSMs) who underwent endoscopic endonasal resection. TSMs are challenging to diagnose and treat due to their location near critical neurovascular structures and the optic chiasm. The study included 74 patients, predominantly female, with a median age of 56.7 years. The surgical approach resulted in a high rate of gross total resection and improved visual outcomes. However, CSF leak remains a concern, although it has decreased over time. Overall, the endoscopic endonasal approach is considered a safe and effective treatment for TSMs. [Extracted from the article]

This article discusses the use of endoscopic endonasal approaches (EEA) in the management of foramen magnum meningiomas (FMM). FMM is a rare type of intracranial meningioma, and traditional treatment involves transcranial corridors. The study presents the experience of the authors in using EEA for FMM resection and highlights its role and limitations. The results show that EEA can be an alternative corridor for carefully selected patients with ventral FMM, especially when involvement or encasement of the anterior spinal arteries is suspected. However, CSF leak remains a significant limitation. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, compares four transorbital approaches to the skull base: the lateral orbitotomy, the modified orbitozygomatic approach through a palpebral incision, the modified orbitozygomatic approach through an eyebrow incision, and the supraorbital craniotomy through an eyebrow incision. The study used cadaveric dissections to assess the working corridors and map the anatomical points on the cranial base. The article concludes that each approach has its own advantages and limitations, and appropriate case selection is crucial for successful surgical outcomes. [Extracted from the article]

Skull-base chordomas are aggressive tumors with a propensity for recurrence/progression. Even with standard of care (SoC), 5-year recurrence rates are variable (19%–54%). This high recurrence/progression rate correlates with increased morbidity and mortality. We sought to analyze a multicenter cohort of skull base chordomas to identify predictors of progression in patients receiving SoC. The [Blinded]-Neurosurgery data registry was queried for skull base chordomas treated from 2008–2020. Patients with the histopathologic diagnosis of chordoma were included. The cohort was composed of patients with preoperative and postoperative magnetic resonance imaging. Tumor volume and radiologic characteristics were obtained from axial T2 sequences using a Digital Imaging and Communications in Medicine viewer. Survival analysis was performed using Kaplan-Meier method, and time-to-event multivariate regression was performed to identify independent predictors of progression. The cohort included 195 patients, of which 66 patients met inclusion criteria; median age was 44, and 28 (42%) were females. Fifty-four (82%) received SoC, 7 (11%) resection only, and 5 (8%) radiotherapy only. Median preoperative and postoperative tumor volumes were 11.55 cm3 (0.33–54.89) and 0.34 cm3 (0–42.52), respectively. Recurrence rate with SoC was 37%. Postoperative tumor volume (P = 0.010) correlated with progression. A postoperative volume of >4.9 cm3 (P = 0.044), ≤81.3% of tumor resection (P = 0.02), and lower-clivus location (P < 0.005) correlated with decreased time to progression. Skull base chordomas can be challenging to resect. Even though maximal resection and radiotherapy improve rate of tumor progression, many of these lesions eventually recur. We have identified a postoperative tumor volume of ≥4.9 cm3 and extent of resection of ≤81.3% in this cohort as predictors of progression in patients receiving SoC. [ABSTRACT FROM AUTHOR]

Background: Post‐viral olfactory dysfunction (PVOD) is one of the most common causes of olfactory loss. Despite its prevalence, optimal treatment strategies remain unclear. This article provides a comprehensive review of PVOD treatment options and provides evidence‐based recommendations for their use. Methods: A systematic review of the Medline, Embase, Cochrane, Web of Science, Scopus, and Google Scholar databases was completed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Studies with defined olfactory outcomes of patients treated for PVOD following medical, surgical, acupuncture, or olfactory training interventions were included. The Clinical Practice Guideline Development Manual and Conference on Guideline Standardization (COGS) instrument recommendations were followed in accordance with a previously described, rigorous, iterative process to create an evidence‐based review with recommendations. Results: From 552 initial candidate articles, 36 studies with data for 2183 patients with PVOD were ultimately included. The most common method to assess olfactory outcomes was Sniffin' Sticks. Broad treatment categories included: olfactory training, systemic steroids, topical therapies, a variety of heterogeneous non‐steroidal oral medications, and acupuncture. Conclusion: Based on the available evidence, olfactory training is a recommendation for the treatment of PVOD. The use of short‐term systemic and/or topical steroids is an option in select patients after careful consideration of potential risks of oral steroids. Though some pharmacological investigations offer promising preliminary results for systemic and topical medications alike, a paucity of high‐quality studies limits the ability to make meaningful evidence‐based recommendations for the use of these therapies for the treatment of PVOD. [ABSTRACT FROM AUTHOR]

Background  There is little data regarding postoperative outcomes of patients with obstructive sleep apnea (OSA) undergoing skull base surgery. The purpose of this study is to determine an association between risk factors and proximity of cerebrospinal fluid (CSF) leak to surgery in patients with OSA undergoing endoscopic skull base surgery. Methods  A retrospective review of neurosurgical inpatients, with and without OSA, at a tertiary care institution from 2002 to 2015 that experienced a postoperative CSF leak after undergoing endoscopic skull base surgery. Results  Forty patients met inclusion criteria, 12 (30%) with OSA. OSA patients had significantly higher body mass index (BMI; median 39.4 vs. 31.7, p  < 0.01) and were more likely to have diabetes (41.7 vs. 10.7%, p  = 0.04) than non-OSA patients; otherwise there were no significant differences in clinical comorbidities. No patients restarted positive pressure ventilation (PPV) in the inpatient setting. The type of repair was not a significant predictor of the time from surgery to leak. Patients with OSA experienced postoperative CSF leak 49% sooner than non-OSA patients (Hazard Ratio 1.49, median 2 vs. 6 days, log-rank p  = 0.20). Conclusion  Patients with OSA trended toward leaking earlier than those without OSA, and no OSA patients repaired with a nasoseptal flap (NSF) had a leak after postoperative day 5. Due to a small sample size this trend did not reach significance. Future studies will help to determine the appropriate timing for restarting PPV in this high risk population. This is important given PPV's significant benefit to the patient's overall health and its ability to lower intracranial pressure. [ABSTRACT FROM AUTHOR]

To compare outcomes of proton radiation therapy (PRT), stereotactic radiosurgery (SRS), and x-ray-based radiation with an SRS boost (XRT + SRS) for newly diagnosed clival chordoma. Consecutive patients who underwent PRT or SRS in our facility were retrospectively reviewed. A total of 59 patients were identified (PRT, 36; SRS, 11; XRT + SRS, 12). The mean age (± standard deviation) was 46 ± 20 years, with 54% being male. The mean tumor diameter (± standard deviation) was 3.7 ± 1.5 cm, and 21 (36%) involved the lower clivus. Gross total or near-total resection was attained in 27 patients (46%), all of whom received PRT. PRT was administered with a median prescribed dose of 70.8 Gy (range, 66.0–76.0). SRS involved a median marginal dose of 16 Gy (range, 14–20) and a median maximal dose of 36 Gy (range, 30–45). The XRT + SRS group was treated with an SRS marginal dose of 12.5 Gy (range, 10–20), a maximal dose of 27 Gy (range, 20–40), and an XRT prescription dose of 50.4 Gy (range, 45.0–59.4). Fifteen recurrences were observed (PRT, 6; SRS, 5; XRT + SRS, 4). For the entire cohort (n = 59), recurrence was associated with the degree of resection (P = 0.042), but not with radiation groups (P = 0.98). For patients after subtotal resection or biopsy (n = 32), the SRS ± XRT group was associated with few recurrences (hazard ratio, 0.260; 95% confidence interval, 0.069–0.98; P = 0.046). Patients after subtotal resection or biopsy may benefit from the incorporation of SRS. [ABSTRACT FROM AUTHOR]

Hospitals, payors, and patients increasingly expect us to report our outcomes in more detail and to justify our treatment decisions and costs. Although there are many stakeholders in surgical outcomes, physicians must take the lead role in defining how outcomes are assessed. Skull base lesions interact with surrounding anatomy to produce a complex spectrum of presentations and surgical challenges, requiring a wide variety of surgical approaches. Moreover, many skull base lesions are relatively rare. These factors and others often preclude the use of prospective randomized clinical trials, thus necessitating alternate methods of scientific inquiry. In this paper, we propose a roadmap for implementing a skull base registry, along with expected benefits and challenges. [ABSTRACT FROM AUTHOR]

Background: Olfactory nerve fibers are at risk of injury during transnasal endoscopic skull‐base approaches. Olfactory outcomes for various techniques have not been thoroughly investigated. This study aims to report long‐term olfactory outcomes when a cold knife upper septal limb incision technique is used compared to monopolar cautery. Methods: A prospective cohort study was performed at a tertiary referral center. Adult patients undergoing endoscopic approaches with septal incisions were randomized to cold knife or monopolar cautery groups. Patient demographics, clinical history, surgical data, and outcomes were collected. Preoperative, 3‐month, and 12‐month postoperative scores on the University of Pennsylvania Smell Inventory Test (UPSIT) and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) were measured. Fisher's exact tests were performed for categorical variables and t tests were performed for continuous variables. Results: Twenty‐two (22) patients (10 cold knife, 12 cautery) were enrolled between March 2016 and August 2017. The average age ± standard deviation was 50.2 ± 14.0 years (p = 0.59), 54% (p = 0.69) were female, and the primary pathology was pituitary adenoma (73%, p = 1.00). Preoperative, 3‐month, and 12‐month postoperative UPSIT scores were similar between the cold knife and cautery groups (32.8 vs 32.4, p = 0.80; 33.1 vs 33.0, p = 0.96; 33.6 vs 33.3, p = 0.84). On the "sense of smell/taste" question of the SNOT‐22, there was also no difference at all time points (p > 0.22). Conclusion: There was no significant change in patient UPSIT scores 1 year after transnasal skull‐base approaches, and no short‐term or long‐term differences between cold knife and cautery upper septal limb incision techniques. Our study supports an individualized approach based on surgeon preference. [ABSTRACT FROM AUTHOR]

Background: To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo “Petri dishes” for active wound healing. The pedicled nasoseptal flap (NSF) for skull‐base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing. Methods: In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases. Results: Twenty‐one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion. Conclusion: This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards. [ABSTRACT FROM AUTHOR]