Search

Objectives Obstructive sleep apnea (OSA) presents several challenges in skull base surgery, including increased intracranial pressure, worsened OSA with nasal packing, and avoidance of positive airway pressure (PAP) therapy postoperatively. The objective of this study was to examine the risk of postoperative complications in a skull base population with OSA in which PAP therapy is withheld. Study Design Retrospective cohort study. Setting Tertiary care hospital. Subjects and Methods Medical records of 414 adult patients undergoing anterior skull base procedures between January 1, 2014, and January 7, 2017, were retrospectively reviewed. Revision surgeries, skull base infections, sinus surgery, and orbital cases were excluded. Results Fifty-four (13.0%) patients with a diagnosis of OSA were identified. While the known patients with OSA were more likely to require postoperative supplemental oxygen (odds ratio [OR], 4.29; 95% confidence interval [CI], 2.38-7.75; P 30 kg/m2 and hypertension) and demonstrated an increased risk of serious respiratory events (OR, 4.41; 95% CI, 1.24-15.7; P = .034) and CSF leak (13.6% vs 4.7%; P = .018). Conclusions Skull base patients with known OSA can be successfully managed with diligent care in the perioperative period when PAP therapy is withheld. However, OSA is likely underdiagnosed in the skull base population, and patients at high risk for undiagnosed OSA may be at the greatest risk for respiratory complications and CSF leak. Increased presurgical awareness and implementation of a perioperative management algorithm is needed.

We compare the management of patients with severe epistaxis before and after the implementation a clinical care pathway (CCP) to standardize care, minimize hospital stay, and decrease cost.Single prospective analysis with historical control.Tertiary academic hospital.Patients treated for epistaxis between October 2012 to December 2013 were compared with a prospective analysis of patients treated for severe epistaxis after implementation of a CCP from June 2014 to February 2015. Severe epistaxis was defined as nasal bleeding not able to be controlled with local pressure, topical vasoconstrictors, or simple anterior packing.Severe epistaxis was similar in the pre- and post-CCP cohorts: 24.7% (n = 42) vs 18.9% (n = 22), respectively. Implementation of early sphenopalatine artery ligation resulted in decreased number of days packed (3.2 ± 1.6 to 1.4 ± 1.6; P = .001), decreased hospital stay (5.2 ± 3.9 to 2.1 ± 1.3 days; P.001), an increased percentage of sphenopalatine artery ligations (31.0% vs 54.5%; P = .035), admission to an appropriate hospital location with access to key resources (41.7% vs 83.3%; P = .007), and decreased overall cost of hospitalization by 66% ($9435 saved). No patients received embolization after the CCP was implemented.Implementation of a CCP decreased hospital stay and days of packing, facilitated definitive care in patients with severe epistaxis, improved patient safety, and decreased cost. The results of this study can serve as a model for the management of severe epistaxis and for future quality improvement measures.

Olfactory neuroblastoma and the management of neck disease has posed considerable challenges to the treating physician. The aims of the study were to determine the incidence and factors influencing neck disease and to identify at-risk patients with cervical node-negative disease at presentation.Multicenter case series with retrospective chart review.In sum, 113 patients with a histopathologic diagnosis of olfactory neuroblastoma across 6 tertiary hospitals in Australia and the United States.Treatment modalities for the primary site and neck included surgery, radiotherapy, and combined therapy. Treatment outcomes were measured in relation to date of primary treatment, and long-term follow-up was recorded. Disease-free survival was calculated as time for patients to develop delayed neck disease following primary treatment.A total of 113 patients (46 females, 49.7 ± 13.2 years) were identified with a median follow-up of 41.5 months (interquartile range, 58.2); 7.1% of patients presented with primary neck disease, while 8.8% of patients presented with delayed neck disease. Neck disease was present in patients with Hyams grade II (22.2%), III (55.6%), and IV (22.2%) lesions (χ(2) = 5.66, P = .13). Histologic grade was higher in patients with primary neck disease (χ(2) = 16.22, P = .001). Positive surgical margins were associated with a higher risk of delayed neck disease as compared with clear surgical margin (17.9% vs 5%, P = .034).Neck metastasis is an important clinical consideration for olfactory neuroblastoma at presentation and in surveillance. Primary treatment of the neck could be considered in select patients. Long-term surveillance of the neck and primary site is essential.

To assess delayed nasoseptal flaps as a viable reconstructive option for sellar defects, evaluate postoperative vascularity of delayed nasoseptal flaps, and compare cerebrospinal fluid leak and surgery-specific complication rates of primary to delayed nasoseptal flaps.Case series with chart review.University of Pittsburgh Medical Center.All patients undergoing transsellar approaches for skull base tumors from 2009 to 2013 were evaluated. In cases where the necessity of a vascularized reconstructive flap was made evident only after tumor resection, the nasoseptal flap was raised after tumor resection and/or cerebrospinal fluid leak development, thus constituting a delayed nasoseptal flap. Outcome measures include postoperative magnetic resonance imaging (MRI) findings, cerebrospinal leak rates, and complication rates.During this timeframe, 437 patients underwent transsellar approaches. Primary nasoseptal flaps were used to reconstruct 179 patients while 32 patients had delayed flaps. All available postoperative MRI scans of delayed nasoseptal flap patients maintained vascularity on examination of T1 postcontrast images. There was no significant difference in cerebrospinal fluid leak rate between primary (3.4%) and delayed flaps (3.1%) (P = .95). There was no significant difference in surgery-specific complication rates between primary flaps (10.6%) and delayed flaps (3.1%; P = .14). Logistic regression analysis demonstrated no significant effect of flap type, age, or sex on cerebrospinal fluid leak rates.Delayed nasoseptal flaps are a viable reconstructive option for sellar skull base defects. They maintain vascularity as evidenced on postoperative MRI and are comparable to primary nasoseptal flaps with regard to cerebrospinal fluid leak rates and complication rates.

Reactive oxygen species (ROS) can potentiate cellular injury and inflammation. This study aimed to (1) assess the presence of reactive oxygen species in the sinus tissue of patients with chronic rhinosinusitis (CRS) and (2) assess the impact of secondhand smoke (SHS) exposure on reactive oxygen species (ROS) production.Retrospective cohort study.Academic medical center.Sinus tissue samples from patients undergoing sinus surgery were analyzed using diaminobenzidine (DAB) staining to assess for ROS. Stained specimens were photographed at random by a blinded photographer and then quantified by 3 blinded graders. The patient's SHS exposure was determined by hair nicotine levels.were compared between non-smoke exposed cohorts and those exposed to secondhand smoke and by diagnosis.Sixty-nine adults undergoing sinus surgery were included in the study. For the non-SHS-exposed cohorts, chronic rhinosinusitis with nasal polyps (CRSwNP) had the highest number of DAB+ cells/high-powered field (hpf) followed by chronic rhinosinusitis without nasal polyps (CRSsNP) and controls. When comparing the control patients to their SHS-exposed counterparts, SHS exposure yielded statistically significantly higher levels of DAB-positive cells/hpf. SHS exposure did not affect DAB staining in CRSsNP or CRSwNP patients.ROS are differentially expressed in various subtypes of CRS. SHS exposure increases ROS in sinus tissue of control patients, but the clinical significance of this is unclear.

The 95 percent confidence interval about the mean demarcates the range of values in which the mean would fall if many samples from the universal parent population were taken. In other words, if the same observation, experiment, or trial were done over and over with a different sample of subjects, but with the same characteristics as the original sample, 95 percent of the means from those repeated measures would fall within this range. This gives a measure of how confident we are in the original mean. It tells us not only whether the results are statistically significant because the CI falls totally on one side or the other of the no difference marker (0 if continuous variables; 1 if proportions), but also the actual values so that we might determine if the data seem clinically important. In contrast, the P value tells us only whether the results are statistically significant, without translating that information into values relative to the variable that was measured. Consequently, the CI is a better choice to describe the results of observations, experiments, or trials.

Objectives:(1) Describe the treatment patterns for the management of severe epistaxis at a tertiary-care center. (2) Develop a clinical care pathway (CCP) for system-wide management of severe epistaxis.Methods:A review of patients admitted for epistaxis from August 2012 to December 2013 was performed using: (1) CPT codes and (2) a digital archive of all medical records. Severe epistaxis was defined as persistent bleeding not controlled using local pressure, vasoconstrictive medication, and anterior packing. A root cause analysis identified factors contributing to the morbidity and mortality of patients with severe epistaxis.Results:Of 332 cases of epistaxis, 48 met criteria for severe epistaxis. Of these, 64.6% (31/48) presented via the Emergency Department and 35.4% (17/48) as an inpatient. All were packed initially. Average duration of packing was 3.02 ± 1.88 days. Nearly half (45.8%) failed packing and had either sphenopalatine artery ligation (37.5%) or embolization (8.3%). Intubation was required in ...

Program Description:Does learning on a simulator really help surgeons operate better? Can learning or directed practice on a simulator contribute to faster or better skill acquisition? What are the advantages and disadvantages of virtual, high tech, or home-made simulators? How do I get started? A panel of experts will provide examples from otology, sinus, and airway surgery; and describe their experiences, recommendations, and visions for the future. Dr. Fried: virtual sinus surgery; Dr. Wiet: virtual temporal bone surgery; Dr. Amin: simulation for office-based procedures; Dr. Malekzadeh: make it yourself; Dr. Ishman: how do we assess competency? Dr. Wang: return on investment.Educational Objectives:1) Describe how simulators can be used to develop or improve surgical skills. 2) Compare the advantages of different types of simulators. 3) Use a competency-based assessment tool.

Objective: Macrophages are major producers of inflammatory cytokines; however, their role in chronic rhinosinusitis (CRS) has not been clearly defined. The aim of this study was to quantify monocytes and macrophages in sinonasal tissue of patients with various subtypes of CRS.Method: Human sinonasal tissue was taken from patients with CRS with nasal polyposis (CRSwNP), CRS without nasal polyposis (CRSsNP), and allergic fungal rhinosinusitis (AFRS). Control tissue was taken from patients without evidence of inflammatory sinus disease. Samples were immunhisotychemically stained for macrophage/monocyte markers Mac387, CD68, and PM-2K.Results: AFRS patients had approximately 4 times as many Mac387 and CD68 staining cells as CRSsNP and control patients (P < .05). CRSwNP patients had approximately 2.5 times as many Mac387 cells and 3 times as many CD68 cells as CRSsNP and control patients (P < .05). There were trends toward increased numbers of cells staining positively for PM-2K in tissue samples of AFRS and C...

Objective: 1) Examine the efficacy of FESS combined with aggressive postoperative medical management in the treatment of allergic fungal sinusitis (AFS). 2) Determine prognostic factors associated with disease recurrence and the need for subsequent revision surgery in a population of AFS patients.Method: A retrospective case control study examined demographic and disease-related characteristics and adjuvant therapies in patients undergoing combined surgical and medical treatment of AFS in a single tertiary academic center. Exclusion criteria included follow-up of less than 6 months. The dependent variable was revision surgery. Average follow-up was 29.4 months.Results: Eighty consecutive AFS patients from 2002 to 2009 were identified and 62 patients did not require revision surgery (78%).Conclusion: AFS can be effectively controlled with multimodality therapy. Compliance with postoperative medical therapy and topical steroid use are prognostic factors associated with treatment success, decreasing the rate...

Objective: Vitamin D3 (VD3) is a steroid hormone that acts on the immune system similar to oral steroids. In asthmatics VD3 deficiency contributes to increased Th2 skewing and steroid use. We examined if children with allergic fungal rhinosinusitis (AFRS) or chronic rhinosinusitis with nasal polyposis (CRSwNP) were VD3 deficient.Method: Plasma levels of 25-hydroxyvitamin D3 were measured by ELISA in children (