Lindsey F. Jackson, Jennifer K. Mulligan, Jeb M. Justice, Steven N. Roper, Jason E. Blatt, Brian C. Lobo
Abstract Objective The assessment of baseline olfactory function before endoscopic skull base surgery (ESBS) has been relatively limited compared with analysis before functional endoscopic sinus surgery (FESS). Our study addresses this knowledge gap, assessing preoperative olfactory function in ESBS and FESS and elucidating any differences. Study Design We conducted a retrospective review of patients undergoing anterior ESBS or FESS at a single institution between 2021 and 2022. We included 171 patients and compared their reported and measured preoperative olfactory function using the Sino-Nasal Outcome Test questionnaire and the 40-item University of Pennsylvania Smell Identification Test. Results Of the 171 patients included in this study, 30% of patients underwent ESBS and 70% underwent FESS. Of all patients, only 57% correctly reported their objective preoperative olfactory function. Of the 36 ESBS patients with measured preoperative hyposmia, only 31% correctly reported hyposmia, while 69% incorrectly reported normosmia. This distribution significantly differs (p < 0.0001) from the FESS subset (89 patients), with 64% correctly reporting hyposmia and 36% incorrectly reporting normosmia. Conclusions Our analysis demonstrates higher than anticipated underreporting of preoperative hyposmia in patients undergoing ESBS as well as discrepancies between subjective and objective olfactory functions in the FESS population. The results highlight several gaps in knowledge regarding perioperative olfactory function that would be best examined with more thorough pre- and postoperative objective olfactory testing. This analysis demonstrates significant prognostic uncertainty for patients and providers and creates significant medicolegal uncertainty regarding the appropriate attribution of postoperative olfactory loss in cases without objective preoperative testing.
{"title":"Significant Underreporting of Preoperative Hyposmia in Patients Undergoing Endoscopic Skull Base Surgery: Discrepancies Between Subjective and Objective Measurements","authors":"Lindsey F. Jackson, Jennifer K. Mulligan, Jeb M. Justice, Steven N. Roper, Jason E. Blatt, Brian C. Lobo","doi":"10.1055/s-0043-1775851","DOIUrl":"https://doi.org/10.1055/s-0043-1775851","url":null,"abstract":"Abstract Objective The assessment of baseline olfactory function before endoscopic skull base surgery (ESBS) has been relatively limited compared with analysis before functional endoscopic sinus surgery (FESS). Our study addresses this knowledge gap, assessing preoperative olfactory function in ESBS and FESS and elucidating any differences. Study Design We conducted a retrospective review of patients undergoing anterior ESBS or FESS at a single institution between 2021 and 2022. We included 171 patients and compared their reported and measured preoperative olfactory function using the Sino-Nasal Outcome Test questionnaire and the 40-item University of Pennsylvania Smell Identification Test. Results Of the 171 patients included in this study, 30% of patients underwent ESBS and 70% underwent FESS. Of all patients, only 57% correctly reported their objective preoperative olfactory function. Of the 36 ESBS patients with measured preoperative hyposmia, only 31% correctly reported hyposmia, while 69% incorrectly reported normosmia. This distribution significantly differs (p < 0.0001) from the FESS subset (89 patients), with 64% correctly reporting hyposmia and 36% incorrectly reporting normosmia. Conclusions Our analysis demonstrates higher than anticipated underreporting of preoperative hyposmia in patients undergoing ESBS as well as discrepancies between subjective and objective olfactory functions in the FESS population. The results highlight several gaps in knowledge regarding perioperative olfactory function that would be best examined with more thorough pre- and postoperative objective olfactory testing. This analysis demonstrates significant prognostic uncertainty for patients and providers and creates significant medicolegal uncertainty regarding the appropriate attribution of postoperative olfactory loss in cases without objective preoperative testing.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"4 8","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135391520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Stage cT4a and cT4b SCCa typically require multimodal treatment with adjuvant or neoadjuvant therapy. This study aims to evaluate the impact of different treatment modalities on survival outcomes in patients with stage cT4a-b SCCa exclusively of the maxillary sinus. Methods: A multivariate survival analysis was conducted, evaluating treatment modalities for patients diagnosed between 2004 and 2020 utilizing the National Cancer Data Base (NCDB). Cox hazard regression was performed for variables. Results: The study identified a total of 1788 patients with SCCa of the maxillary sinuses, of which 71.2% were cT4a. Increasing age, Charlson-Deyo score ≥1, and undifferentiated/anaplastic grade were associated with worse rates of survival. Multivariate analysis revealed that neoadjuvant treatment exhibited the lowest hazard ratio (HR 0.574, 95% CI0.370 - 0.892) across the entire cohort (cT4a-b). Neoadjuvant treatment plus surgery, adjuvant treatment plus surgery, and surgery alone demonstrated the highest adjusted 5-year survival for cT4a-b tumors. On the other hand, radiation alone exhibited the highest hazard ratio (1.939, 95% CI 1.555-2.418)) in multivariate analysis and the lowest adjusted 5-year survival. Conclusion: Multimodal treatment of advanced-stage maxillary SCCa has a variable effect on outcomes by tumor stage. Our findings suggest that surgery plus neoadjuvant and surgery plus adjuvant treatment are associated with higher rates of survival. Increasing age, Charlson-Deyo score ≥1, and undifferentiated/anaplastic grade were associated with worse rates of survival. Further randomized controlled trials are required to quantify the therapeutic benefit of these treatments on survival and organ sparing in advanced-stage disease.
简介:cT4a和cT4b期SCCa通常需要辅助或新辅助治疗的多模式治疗。本研究旨在评估不同治疗方式对单纯上颌窦cT4a-b期SCCa患者生存结果的影响。方法:利用国家癌症数据库(NCDB)进行多变量生存分析，评估2004年至2020年诊断的患者的治疗方式。对变量进行Cox风险回归。结果:本研究共发现上颌窦SCCa患者1788例，其中71.2%为cT4a。年龄增加、Charlson-Deyo评分≥1和未分化/间变性分级与较差的生存率相关。多因素分析显示，在整个队列(cT4a-b)中，新辅助治疗的风险比最低(HR 0.574, 95% CI0.370 - 0.892)。新辅助治疗加手术、辅助治疗加手术和单独手术显示cT4a-b肿瘤的调整5年生存率最高。另一方面，在多因素分析中，单纯放疗的风险比最高(1.939,95% CI 1.555-2.418)，调整后5年生存率最低。结论:上颌晚期SCCa的多模式治疗对不同肿瘤分期的预后有不同的影响。我们的研究结果表明，手术加新辅助治疗和手术加辅助治疗与更高的生存率相关。年龄增加、Charlson-Deyo评分≥1和未分化/间变性分级与较差的生存率相关。需要进一步的随机对照试验来量化这些治疗对晚期疾病的生存和器官保留的治疗益处。
{"title":"Analysis of Treatment Modalities for Advanced Stage Squamous Cell Carcinoma of the Maxillary Sinus: A National Cancer Database Study","authors":"Kue Lee, Duncan Kleinbub, Camilo Reyes","doi":"10.1055/a-2201-8466","DOIUrl":"https://doi.org/10.1055/a-2201-8466","url":null,"abstract":"Introduction: Stage cT4a and cT4b SCCa typically require multimodal treatment with adjuvant or neoadjuvant therapy. This study aims to evaluate the impact of different treatment modalities on survival outcomes in patients with stage cT4a-b SCCa exclusively of the maxillary sinus. Methods: A multivariate survival analysis was conducted, evaluating treatment modalities for patients diagnosed between 2004 and 2020 utilizing the National Cancer Data Base (NCDB). Cox hazard regression was performed for variables. Results: The study identified a total of 1788 patients with SCCa of the maxillary sinuses, of which 71.2% were cT4a. Increasing age, Charlson-Deyo score ≥1, and undifferentiated/anaplastic grade were associated with worse rates of survival. Multivariate analysis revealed that neoadjuvant treatment exhibited the lowest hazard ratio (HR 0.574, 95% CI0.370 - 0.892) across the entire cohort (cT4a-b). Neoadjuvant treatment plus surgery, adjuvant treatment plus surgery, and surgery alone demonstrated the highest adjusted 5-year survival for cT4a-b tumors. On the other hand, radiation alone exhibited the highest hazard ratio (1.939, 95% CI 1.555-2.418)) in multivariate analysis and the lowest adjusted 5-year survival. Conclusion: Multimodal treatment of advanced-stage maxillary SCCa has a variable effect on outcomes by tumor stage. Our findings suggest that surgery plus neoadjuvant and surgery plus adjuvant treatment are associated with higher rates of survival. Increasing age, Charlson-Deyo score ≥1, and undifferentiated/anaplastic grade were associated with worse rates of survival. Further randomized controlled trials are required to quantify the therapeutic benefit of these treatments on survival and organ sparing in advanced-stage disease.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"102 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135871761","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ahmed Alsayed, Abdulaziz Alrasheed, Saif Aljabab, Mohammad Alshareef, Buthaina Jaber Yahya, Abdulmajeed Alharbi, Ahmad Alroqi, Hussain Albaharna, Saud Alromaih, Yasir Alayed, Ashwag Alqurashi, Saad Alsaleh, Abdulrazag Ajlan
Objective: Chordoma is a low-grade malignant tumor that originates from the remnant tissue of the embryonic notochord. Postoperative or definitive radiotherapy has been used to enhance local control. This study aims to assess the outcomes of the expanded EEA for maximal removal of clival chordomas followed by CyberKnife radiosurgery for visualized residual or tumor recurrence. Methods: A retrospective review was performed on consecutive patients with clival chordoma who underwent endoscopic endonasal resection in the Otorhinolaryngology and Neurosurgery Departments, between 2016 and 2021. We included all patients with pathologically confirmed clival chordoma who were treated using the endoscopic endonasal approach. Patients who underwent combined external and endoscopic approaches or transcranial surgery were excluded. Results: 17 patients were included in this study. Most of them had tumors located in the middle clivus. Regarding radiation therapy (RT), the majority of patients underwent postoperative RT. Almost half of them underwent CyberKnife (CK) RT. None of them had severe toxicities (grade 3 or higher). Three patients died, resulting in a mortality rate of 17.6% none on them related to radiation side effect. The 2-year overall survival was 82.4% (Mean S.E. = 1.765, 95% CI = 1.505–2.024), and the progression-free survival (PFS) was 76.5% (Mean S.E. = 3.403, 95% CI = 2.791–4.016). No distal metastasis was reported in our series. Conclusions: This series illustrates that the expanded EEA to resection of skull-base chordomas followed by CyberKnife radiosurgery is an acceptable alternative to proton therapy. The 2-year overall survival was 82.4% and PFS was 76.5%.
目的:脊索瘤是一种起源于胚胎脊索残余组织的低度恶性肿瘤。术后或最终放疗已用于加强局部控制。本研究旨在评估扩大EEA最大限度切除斜坡脊索瘤的效果，然后再进行射波刀放射手术，以观察残余或肿瘤复发。方法:回顾性分析2016年至2021年在耳鼻喉科和神经外科连续行鼻内窥镜切除的斜坡脊索瘤患者。我们纳入了所有病理证实的经鼻内窥镜入路治疗的斜坡脊索瘤患者。排除了接受外部和内窥镜联合入路或经颅手术的患者。结果:17例患者纳入本研究。多数肿瘤位于中斜坡。关于放疗(RT)，大多数患者接受了术后放疗，几乎一半的患者接受了射波刀(CK)放疗。它们都没有严重的毒性(3级或更高)。3例患者死亡，死亡率为17.6%，与放射副作用无关。2年总生存率为82.4%(平均S.E. = 1.765, 95% CI = 1.505-2.024)，无进展生存期(PFS)为76.5%(平均S.E. = 3.403, 95% CI = 2.791-4.016)。在我们的研究中未发现远端转移。结论:这一系列的研究表明，扩大EEA切除颅底脊索瘤后再进行射波刀放射手术是一种可接受的替代质子治疗的方法。2年总生存率为82.4%，PFS为76.5%。
{"title":"Outcomes of the endonasal endoscopic approach for the treatment of Clival chordomas: a single-center experience","authors":"Ahmed Alsayed, Abdulaziz Alrasheed, Saif Aljabab, Mohammad Alshareef, Buthaina Jaber Yahya, Abdulmajeed Alharbi, Ahmad Alroqi, Hussain Albaharna, Saud Alromaih, Yasir Alayed, Ashwag Alqurashi, Saad Alsaleh, Abdulrazag Ajlan","doi":"10.1055/a-2198-9169","DOIUrl":"https://doi.org/10.1055/a-2198-9169","url":null,"abstract":"Objective: Chordoma is a low-grade malignant tumor that originates from the remnant tissue of the embryonic notochord. Postoperative or definitive radiotherapy has been used to enhance local control. This study aims to assess the outcomes of the expanded EEA for maximal removal of clival chordomas followed by CyberKnife radiosurgery for visualized residual or tumor recurrence. Methods: A retrospective review was performed on consecutive patients with clival chordoma who underwent endoscopic endonasal resection in the Otorhinolaryngology and Neurosurgery Departments, between 2016 and 2021. We included all patients with pathologically confirmed clival chordoma who were treated using the endoscopic endonasal approach. Patients who underwent combined external and endoscopic approaches or transcranial surgery were excluded. Results: 17 patients were included in this study. Most of them had tumors located in the middle clivus. Regarding radiation therapy (RT), the majority of patients underwent postoperative RT. Almost half of them underwent CyberKnife (CK) RT. None of them had severe toxicities (grade 3 or higher). Three patients died, resulting in a mortality rate of 17.6% none on them related to radiation side effect. The 2-year overall survival was 82.4% (Mean S.E. = 1.765, 95% CI = 1.505–2.024), and the progression-free survival (PFS) was 76.5% (Mean S.E. = 3.403, 95% CI = 2.791–4.016). No distal metastasis was reported in our series. Conclusions: This series illustrates that the expanded EEA to resection of skull-base chordomas followed by CyberKnife radiosurgery is an acceptable alternative to proton therapy. The 2-year overall survival was 82.4% and PFS was 76.5%.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"12 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134907542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lucie Ferguson, Victoria Ruane, Hussein Mansoor, Jenna Quail, KS Manjunath Prasad, Nitin Mukerji, Noweed Ahmad
Objectives To assess whether vestibular prehab with intratympanic gentamicin is a useful preoperative adjunct in allowing for early mobilisation and short length of stay in patients with vestibular schwannoma Design Retrospective single centre study and literature review Setting Tertiary neurosurgical centre Participants Adult patients undergoing surgery for vestibular schwannoma Main Outcome Measures Our primary outcome measures were evidence of compensation following prehab (defined as saccades becoming more covert and clustered on video Head Impulse Testing – vHIT), length of stay and days until mobilisation. Secondary outcome measures were reduction in gain on vHIT testing following treatment as well as need for anti-emetics post-operatively. Results Ten patients have been treated at our centre and the majority have shown pre-operative reduction in gain and evidence of compensation on video head impulse testing (VHIT). Median time to mobilisation was 1 day and modal length of stay was 6 days. We found the current evidence to be variable, with small sample sizes and significant variation in outcome measures used. Conclusions Overall we have found that the use of vestibular prehab enables early mobilisation, shortened length of stay and appears to be a promising pre-operative adjunct in this population. Further research and assessment with a multi-centre prospective clinical trial is merited.
{"title":"Vestibular prehabillitation – a single UK centre experience and literature review","authors":"Lucie Ferguson, Victoria Ruane, Hussein Mansoor, Jenna Quail, KS Manjunath Prasad, Nitin Mukerji, Noweed Ahmad","doi":"10.1055/a-2198-8205","DOIUrl":"https://doi.org/10.1055/a-2198-8205","url":null,"abstract":"Objectives To assess whether vestibular prehab with intratympanic gentamicin is a useful preoperative adjunct in allowing for early mobilisation and short length of stay in patients with vestibular schwannoma Design Retrospective single centre study and literature review Setting Tertiary neurosurgical centre Participants Adult patients undergoing surgery for vestibular schwannoma Main Outcome Measures Our primary outcome measures were evidence of compensation following prehab (defined as saccades becoming more covert and clustered on video Head Impulse Testing – vHIT), length of stay and days until mobilisation. Secondary outcome measures were reduction in gain on vHIT testing following treatment as well as need for anti-emetics post-operatively. Results Ten patients have been treated at our centre and the majority have shown pre-operative reduction in gain and evidence of compensation on video head impulse testing (VHIT). Median time to mobilisation was 1 day and modal length of stay was 6 days. We found the current evidence to be variable, with small sample sizes and significant variation in outcome measures used. Conclusions Overall we have found that the use of vestibular prehab enables early mobilisation, shortened length of stay and appears to be a promising pre-operative adjunct in this population. Further research and assessment with a multi-centre prospective clinical trial is merited.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"32 5","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135215971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objective: Suprameatal tubercle (SMT), a bony prominence located above the internal acoustic meatus, is reported to impede the microscopic view during microvascular decompression (MVD) for trigeminal neuralgia (TN). For an enlarged SMT, removal of the SMT may be required in addition to the routine MVD to precisely localize the offending vessels. The objective of this study is to investigate the predictive factors influencing the requirement of SMT removal during trigeminal MVD. Methods: We retrospectively reviewed 197 patients who underwent MVD for TN, and analyzed the correlation of the SMT height and other clinico-surgical data with the necessity to remove the SMT during MVD. The parameters evaluated in the statistical analyses included maximum SMT height, patient clinical characteristics, surgical data including the type and number of offending vessels, and surgical outcomes. Results: SMT removal was required for 20 patients among a total of enrolled 197 patients. In the univariate analysis, maximum SMT height, patient age, and number (≥ 2) of offending vessels were associated with the requirement for SMT removal. Multivariate analysis with binary logistic regression revealed that the maximum SMT height and number (≥ 2) of offending vessels were significant factors influencing the necessity for SMT removal. A receiver operating characteristic curve analysis revealed that an SMT height ≥ 4.8 mm was the optimal cut-off value for predicting the need for SMT removal. Conclusions: Large SMTs and the presence of multiple offending vessels are helpful in predicting the technical difficulty of trigeminal MVD associated with the necessity of SMT removal.
{"title":"Surgical nuances and predictors of requirement for suprameatal tubercle removal in microvascular decompression for trigeminal neuralgia","authors":"koichi iwasaki, minami uezato, namiko nishida, kazushi kitamura, naoya yoshimoto, Masanori Gomi, hirokuni hashikata, isao sasaki, hiroki toda","doi":"10.1055/a-2198-8279","DOIUrl":"https://doi.org/10.1055/a-2198-8279","url":null,"abstract":"Objective: Suprameatal tubercle (SMT), a bony prominence located above the internal acoustic meatus, is reported to impede the microscopic view during microvascular decompression (MVD) for trigeminal neuralgia (TN). For an enlarged SMT, removal of the SMT may be required in addition to the routine MVD to precisely localize the offending vessels. The objective of this study is to investigate the predictive factors influencing the requirement of SMT removal during trigeminal MVD. Methods: We retrospectively reviewed 197 patients who underwent MVD for TN, and analyzed the correlation of the SMT height and other clinico-surgical data with the necessity to remove the SMT during MVD. The parameters evaluated in the statistical analyses included maximum SMT height, patient clinical characteristics, surgical data including the type and number of offending vessels, and surgical outcomes. Results: SMT removal was required for 20 patients among a total of enrolled 197 patients. In the univariate analysis, maximum SMT height, patient age, and number (≥ 2) of offending vessels were associated with the requirement for SMT removal. Multivariate analysis with binary logistic regression revealed that the maximum SMT height and number (≥ 2) of offending vessels were significant factors influencing the necessity for SMT removal. A receiver operating characteristic curve analysis revealed that an SMT height ≥ 4.8 mm was the optimal cut-off value for predicting the need for SMT removal. Conclusions: Large SMTs and the presence of multiple offending vessels are helpful in predicting the technical difficulty of trigeminal MVD associated with the necessity of SMT removal.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"40 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134973485","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sabrina Heman-Ackah, Daksh Chauhan, Alexandra Quimby, Rachel Blue, Michael Ruckenstein, Douglas Bigelow, M. Sean Grady
Objective: Spontaneous temporal encephaloceles (STEs) are increasingly recognized as sequelae of idiopathic intracranial hypertension (IIH), which in turn may further complicate their management. We endeavored to review the University of Pennsylvania institutional experience on operative management of STEs, with a focus on factors which may influence surgical outcomes, particularly IIH. Design: Retrospective chart review over 9 years from 2013 – 2022. Setting: Single-center, two-hospital, tertiary care, academic setting. Participants: Patients undergoing middle cranial fossa (MCF, 43.9%), transmastoid (TM, 44.9%) or combined (11.2%) approaches for repair of STEs during the study period (n=107). Main Outcome Measures: Post-operative complication rates, recurrence and diagnosis of IIH. Results: The majority of patients were female (64.5%), with a mean BMI of 37 kg/m2 and mean age of 57 years. Twelve patients (9%) represented re-operations after failed primary repairs. Fourteen percent of patients undergoing primary surgical repair of STE were diagnosed with IIH, compared to 42% of patients undergoing re-operations (p = 0.015). In addition, there was a significant difference in the average BMI of patients undergoing primary (36.4 kg/m2) versus revision surgery (40.9 kg/m2, p=0.04). Half of those undergoing re-operation were placed on post-operative acetazolamide compared to 11% of patients undergoing primary operations. No patient experienced recurrent leak after re-operation. Conclusion: Based on our institutional experience, elevated BMI and the presence of IIH are significant predictors of re-operation for STE. In our experience, acetazolamide is a common adjunct management strategy in addition to re-operation for patients with recurrent CSF leak in the setting of STE.
{"title":"Idiopathic Intracranial Hypertension is Associated with Recurrent CSF Leak and Reoperation for Spontaneous Temporal Encephalocele","authors":"Sabrina Heman-Ackah, Daksh Chauhan, Alexandra Quimby, Rachel Blue, Michael Ruckenstein, Douglas Bigelow, M. Sean Grady","doi":"10.1055/a-2198-8374","DOIUrl":"https://doi.org/10.1055/a-2198-8374","url":null,"abstract":"Objective: Spontaneous temporal encephaloceles (STEs) are increasingly recognized as sequelae of idiopathic intracranial hypertension (IIH), which in turn may further complicate their management. We endeavored to review the University of Pennsylvania institutional experience on operative management of STEs, with a focus on factors which may influence surgical outcomes, particularly IIH. Design: Retrospective chart review over 9 years from 2013 – 2022. Setting: Single-center, two-hospital, tertiary care, academic setting. Participants: Patients undergoing middle cranial fossa (MCF, 43.9%), transmastoid (TM, 44.9%) or combined (11.2%) approaches for repair of STEs during the study period (n=107). Main Outcome Measures: Post-operative complication rates, recurrence and diagnosis of IIH. Results: The majority of patients were female (64.5%), with a mean BMI of 37 kg/m2 and mean age of 57 years. Twelve patients (9%) represented re-operations after failed primary repairs. Fourteen percent of patients undergoing primary surgical repair of STE were diagnosed with IIH, compared to 42% of patients undergoing re-operations (p = 0.015). In addition, there was a significant difference in the average BMI of patients undergoing primary (36.4 kg/m2) versus revision surgery (40.9 kg/m2, p=0.04). Half of those undergoing re-operation were placed on post-operative acetazolamide compared to 11% of patients undergoing primary operations. No patient experienced recurrent leak after re-operation. Conclusion: Based on our institutional experience, elevated BMI and the presence of IIH are significant predictors of re-operation for STE. In our experience, acetazolamide is a common adjunct management strategy in addition to re-operation for patients with recurrent CSF leak in the setting of STE.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"129 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134973619","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Larissa Vilany, Danielle D. Dang, Edoardo Agosti, Pedro Plou, Luciano C. P. C. Leonel, Stephen Graepel, Carlos D. Pinheiro-Neto, Giuseppe Lanzino, Michael J. Link, Maria Peris-Celda
Abstract Introduction The transbasal approach traditionally uses a bicoronal scalp incision with bifrontal craniotomy to establish an extradural midline skull base working corridor. Depending on additional craniofacial osteotomies, this approach can expand its reach to the nasal cavity and paranasal sinuses and may be employed for the resection of particularly complex sinonasal and midline skull base tumors. Given its discrepancy in nomenclature and differences in interoperator technique, we propose a practical, operatively oriented guide for trainees performing this approach. Methods Three formalin-fixed, latex-injected specimens were dissected under microscopic magnification and endoscopic-assisted visualization. Stepwise dissections of the transcranial-transbasal approach with common modifications were performed, documented with three-dimensional photography, and supplemented with representative case applications. Results The traditional transbasal approach via bifrontal craniotomy affords wide extradural access to the anterior cranial fossa and central skull base. The addition of craniofacial osteotomies further expands access into the sinonasal cavities, clivus, and craniocervical junction. Key steps described include patient positioning, bicoronal skin incision, pericranial graft harvest, bifrontal craniotomy, orbital rim osteotomy, sphenoidotomy, bilateral ethmoidectomies, and microsurgical dissection of the sellar region. Basal superior sagittal sinus ligation and durotomy allow for intradural exposure. Reconstruction techniques are also discussed. Conclusion While the transbasal approach is rich with historical descriptions, illustrations, and modifications, its stepwise performance may be relatively unknown and unclear to younger generations of trainees. We present a comprehensive guide to optimize familiarity with the transbasal approach and its indications in the surgical anatomy laboratory, mastery of the relevant microsurgical anatomy, and simultaneous preparation for learning and participation in the operating room.
{"title":"Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Bifrontal Transbasal Approach, Surgical Principles, and Illustrative Cases","authors":"Larissa Vilany, Danielle D. Dang, Edoardo Agosti, Pedro Plou, Luciano C. P. C. Leonel, Stephen Graepel, Carlos D. Pinheiro-Neto, Giuseppe Lanzino, Michael J. Link, Maria Peris-Celda","doi":"10.1055/s-0043-1775875","DOIUrl":"https://doi.org/10.1055/s-0043-1775875","url":null,"abstract":"Abstract Introduction The transbasal approach traditionally uses a bicoronal scalp incision with bifrontal craniotomy to establish an extradural midline skull base working corridor. Depending on additional craniofacial osteotomies, this approach can expand its reach to the nasal cavity and paranasal sinuses and may be employed for the resection of particularly complex sinonasal and midline skull base tumors. Given its discrepancy in nomenclature and differences in interoperator technique, we propose a practical, operatively oriented guide for trainees performing this approach. Methods Three formalin-fixed, latex-injected specimens were dissected under microscopic magnification and endoscopic-assisted visualization. Stepwise dissections of the transcranial-transbasal approach with common modifications were performed, documented with three-dimensional photography, and supplemented with representative case applications. Results The traditional transbasal approach via bifrontal craniotomy affords wide extradural access to the anterior cranial fossa and central skull base. The addition of craniofacial osteotomies further expands access into the sinonasal cavities, clivus, and craniocervical junction. Key steps described include patient positioning, bicoronal skin incision, pericranial graft harvest, bifrontal craniotomy, orbital rim osteotomy, sphenoidotomy, bilateral ethmoidectomies, and microsurgical dissection of the sellar region. Basal superior sagittal sinus ligation and durotomy allow for intradural exposure. Reconstruction techniques are also discussed. Conclusion While the transbasal approach is rich with historical descriptions, illustrations, and modifications, its stepwise performance may be relatively unknown and unclear to younger generations of trainees. We present a comprehensive guide to optimize familiarity with the transbasal approach and its indications in the surgical anatomy laboratory, mastery of the relevant microsurgical anatomy, and simultaneous preparation for learning and participation in the operating room.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"50 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135045899","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Edoardo Agosti, A. Yohan Alexander, Luciano C. P. C. Leonel, Stephen Graepel, Garret Choby, Carlos D. Pinheiro-Neto, Maria Peris Celda
Abstract Introduction The development of endoscopic techniques has made endoscopic endonasal approaches (EEAs) to the anterior cranial fossa (ACF) increasingly popular. Still, the steps and nuances involved in the approach may be difficult to understand for trainees. Thus, we aim to didactically describe the EEAs to the ACF in an anatomically based, step-by-step manner with supplementary clinical cases. Methods Six cadaveric head specimens were dissected. Endoscopic endonasal Draf I, IIA, IIB, and III frontal sinusotomies, endoscopic endonasal superior ethmoidectomy, and endoscopic endonasal transcribriform and transplanum approaches were modularly performed. The specimens were photodocumented with endoscopic techniques. Results Draf I frontal sinusotomy started with the complete removal of the anteromedial portion of the agger nasi cell, exposing the medial orbital wall, cranial base, and anterior cribriform plate. Draf II frontal sinusotomy proceeded with the removal of the floor of the frontal sinus between the lamina papyracea and the middle turbinate (IIa), and the nasal septum (IIb) until the first olfactory filaments were exposed. Draf III proceeded by creating a superior septal window just below the floor of the frontal sinus. The bone of the ACF bounded by the limbus sphenoidale posteriorly, frontal sinus anteriorly, and the medial orbital walls bilaterally was removed; the cribriform plate was removed; and the crista galli was dissected free from the dural leaflets of the falx cerebri and removed. Conclusion We provide a step-by-step dissection describing basic surgical steps and anatomy of the EEAs to the ACF to facilitate the learning process for skull base surgery trainees.
{"title":"Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Anterior Cranial Fossa","authors":"Edoardo Agosti, A. Yohan Alexander, Luciano C. P. C. Leonel, Stephen Graepel, Garret Choby, Carlos D. Pinheiro-Neto, Maria Peris Celda","doi":"10.1055/s-0043-1775754","DOIUrl":"https://doi.org/10.1055/s-0043-1775754","url":null,"abstract":"Abstract Introduction The development of endoscopic techniques has made endoscopic endonasal approaches (EEAs) to the anterior cranial fossa (ACF) increasingly popular. Still, the steps and nuances involved in the approach may be difficult to understand for trainees. Thus, we aim to didactically describe the EEAs to the ACF in an anatomically based, step-by-step manner with supplementary clinical cases. Methods Six cadaveric head specimens were dissected. Endoscopic endonasal Draf I, IIA, IIB, and III frontal sinusotomies, endoscopic endonasal superior ethmoidectomy, and endoscopic endonasal transcribriform and transplanum approaches were modularly performed. The specimens were photodocumented with endoscopic techniques. Results Draf I frontal sinusotomy started with the complete removal of the anteromedial portion of the agger nasi cell, exposing the medial orbital wall, cranial base, and anterior cribriform plate. Draf II frontal sinusotomy proceeded with the removal of the floor of the frontal sinus between the lamina papyracea and the middle turbinate (IIa), and the nasal septum (IIb) until the first olfactory filaments were exposed. Draf III proceeded by creating a superior septal window just below the floor of the frontal sinus. The bone of the ACF bounded by the limbus sphenoidale posteriorly, frontal sinus anteriorly, and the medial orbital walls bilaterally was removed; the cribriform plate was removed; and the crista galli was dissected free from the dural leaflets of the falx cerebri and removed. Conclusion We provide a step-by-step dissection describing basic surgical steps and anatomy of the EEAs to the ACF to facilitate the learning process for skull base surgery trainees.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"42 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135534870","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dan Yaniv, Lindsay M. Niccolai, Jeffrey S. Wefel, Catherine M. Sullaway, Jack Phan, Clifton David Fuller, Kareem B. Haroun, Ehab Y. Hanna, Shirley Y. Su
Abstract Importance Few recent studies have examined neurocognitive functioning (NCF) in patients with sinonasal and nasopharyngeal cancers (NPCs) prior to and following multimodality therapy or the potential differences in NCF by disease variables such as disease site. Objective The objective of this study is to determine rates of NCF impairments prior to and following multimodality therapy, declines in NCF following radiotherapy (RT), and possible differences in NCF by the disease site. Design, Setting, and Participants We conducted a retrospective chart review of 39 patients with sinonasal and NPCs who underwent comprehensive neuropsychological evaluations. Twenty patients were evaluated prior to RT, of which eleven received follow-up evaluation after completion of RT. Nineteen patients were evaluated following various treatments without a pre-RT evaluation. Main Outcomes and Measures Patients completed comprehensive neuropsychological evaluations. Decline from pre-RT to follow-up was defined on the basis of reliable change indices. Results Thirty-nine patients completed comprehensive neuropsychological evaluations. For the entire cohort, the most frequently demonstrated impairments were in verbal memory (47%) and learning (43%), executive functioning (33%), and verbal fluency (22%). At post-RT follow-up, the most frequently observed declines were in verbal learning (46%) and memory (18%). Demographic and disease variables were not significantly associated with NCF at pre-RT or post-RT. Conclusion and Relevance Patients with sinonasal and NPCs are at risk for NCF impairments in multiple areas at baseline and memory decline following RT. Future prospective studies are needed to investigate the impact of each treatment modality on NCF and specific risk factors for cognitive dysfunction.
{"title":"Neurocognitive Functioning of Patients with Sinonasal and Nasopharyngeal Cancers Treated With Multimodality Therapy","authors":"Dan Yaniv, Lindsay M. Niccolai, Jeffrey S. Wefel, Catherine M. Sullaway, Jack Phan, Clifton David Fuller, Kareem B. Haroun, Ehab Y. Hanna, Shirley Y. Su","doi":"10.1055/s-0043-1775753","DOIUrl":"https://doi.org/10.1055/s-0043-1775753","url":null,"abstract":"Abstract Importance Few recent studies have examined neurocognitive functioning (NCF) in patients with sinonasal and nasopharyngeal cancers (NPCs) prior to and following multimodality therapy or the potential differences in NCF by disease variables such as disease site. Objective The objective of this study is to determine rates of NCF impairments prior to and following multimodality therapy, declines in NCF following radiotherapy (RT), and possible differences in NCF by the disease site. Design, Setting, and Participants We conducted a retrospective chart review of 39 patients with sinonasal and NPCs who underwent comprehensive neuropsychological evaluations. Twenty patients were evaluated prior to RT, of which eleven received follow-up evaluation after completion of RT. Nineteen patients were evaluated following various treatments without a pre-RT evaluation. Main Outcomes and Measures Patients completed comprehensive neuropsychological evaluations. Decline from pre-RT to follow-up was defined on the basis of reliable change indices. Results Thirty-nine patients completed comprehensive neuropsychological evaluations. For the entire cohort, the most frequently demonstrated impairments were in verbal memory (47%) and learning (43%), executive functioning (33%), and verbal fluency (22%). At post-RT follow-up, the most frequently observed declines were in verbal learning (46%) and memory (18%). Demographic and disease variables were not significantly associated with NCF at pre-RT or post-RT. Conclusion and Relevance Patients with sinonasal and NPCs are at risk for NCF impairments in multiple areas at baseline and memory decline following RT. Future prospective studies are needed to investigate the impact of each treatment modality on NCF and specific risk factors for cognitive dysfunction.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"41 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135478511","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Juan M. Revuelta-Barbero, Alejandra Rodas, Edoardo Porto, Jackson R. Vuncannon, Youssef M. Zohdy, Justin Maldonado, C. Arturo Solares, Oswaldo Henriquez, Gustavo Pradilla
Abstract Objective This study aimed to objectively compare maneuverability at the contralateral medial orbit when approached through the traditional endoscopic endonasal approach (EEA) and EEA with transeptal window (TW). Study Design Anatomic dissections were performed bilaterally on three latex-injected cadaveric heads. Approaches were performed sequentially; initially, an EEA was fashioned. Binostril access was achieved through a 2-cm posterior septectomy. The second stage pertained to the TW dissection. Area of exposure (AoE), surgical freedom (SF), and angles of attack (AoA) were measured along the contralateral medial orbital wall and compared for each approach. Additionally, the study presents an illustrative case describing the application of the EEA + TW for resection of an intraorbital schwannoma. Results Compared with EEA, EEA + TW yielded a significantly greater AoE along the contralateral medial orbital wall (39.45 vs. 48.45 cm2, respectively; p = 0.002). SF was statistically different between the EEA and EEA + TW (1153.25 vs. 2256.33 cm2, respectively; p = 0.002). AoA in the horizontal plane were significantly broader with the EEA + TW (6.36 vs. 4.9 degrees by EEA; p = 0.015). A 50-year-old male with a right medial extraconal orbital tumor was successfully treated through an EEA using the transeptal corridor to access the medial orbital region. No long-term complications were encountered after 31 months of follow-up. Conclusions EEA + TW is a minimally invasive technique that maximizes exposure and maneuverability within the medial orbital wall, allowing resection of lesions that extend anteriorly. EEA + TW limits disruption of the nasal septum and overcomes the obstacle that intranasal anatomy represents for instrumentation.
{"title":"The Role of the Transeptal Window in Endoscopic Endonasal Access to the Contralateral Orbit","authors":"Juan M. Revuelta-Barbero, Alejandra Rodas, Edoardo Porto, Jackson R. Vuncannon, Youssef M. Zohdy, Justin Maldonado, C. Arturo Solares, Oswaldo Henriquez, Gustavo Pradilla","doi":"10.1055/s-0043-1775755","DOIUrl":"https://doi.org/10.1055/s-0043-1775755","url":null,"abstract":"Abstract Objective This study aimed to objectively compare maneuverability at the contralateral medial orbit when approached through the traditional endoscopic endonasal approach (EEA) and EEA with transeptal window (TW). Study Design Anatomic dissections were performed bilaterally on three latex-injected cadaveric heads. Approaches were performed sequentially; initially, an EEA was fashioned. Binostril access was achieved through a 2-cm posterior septectomy. The second stage pertained to the TW dissection. Area of exposure (AoE), surgical freedom (SF), and angles of attack (AoA) were measured along the contralateral medial orbital wall and compared for each approach. Additionally, the study presents an illustrative case describing the application of the EEA + TW for resection of an intraorbital schwannoma. Results Compared with EEA, EEA + TW yielded a significantly greater AoE along the contralateral medial orbital wall (39.45 vs. 48.45 cm2, respectively; p = 0.002). SF was statistically different between the EEA and EEA + TW (1153.25 vs. 2256.33 cm2, respectively; p = 0.002). AoA in the horizontal plane were significantly broader with the EEA + TW (6.36 vs. 4.9 degrees by EEA; p = 0.015). A 50-year-old male with a right medial extraconal orbital tumor was successfully treated through an EEA using the transeptal corridor to access the medial orbital region. No long-term complications were encountered after 31 months of follow-up. Conclusions EEA + TW is a minimally invasive technique that maximizes exposure and maneuverability within the medial orbital wall, allowing resection of lesions that extend anteriorly. EEA + TW limits disruption of the nasal septum and overcomes the obstacle that intranasal anatomy represents for instrumentation.","PeriodicalId":16513,"journal":{"name":"Journal of Neurological Surgery Part B: Skull Base","volume":"49 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135534540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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