Search

Introduction  As the limits of advanced skull base malignancies that can be managed through an endoscopic endonasal approach continue to be expanded, the resultant anterior skull base defects are of increasing size and complexity. In the absence of nasoseptal or turbinate flaps, the vascularized pericranial flap has been employed at our institution with excellent results. Objective  The study aimed to review the outcomes of patients who underwent endonasal anterior craniofacial resection with anterior skull base reconstruction using a vascularized pericranial flap. Design  Retrospective chart review of patients treated by the University of California - San Francisco minimally invasive skull base service from the years 2011 to 2017. Average duration of follow-up was 16.4 months. Setting  This study was conducted at Academic tertiary referral center. Participants  A total of nine patients with advanced anterior cranial base malignancies were identified who were treated with a minimally invasive, endoscopic anterior craniofacial resection from the years 2011 to 2017. Due to the nature of the resection in these patients, nasoseptal flaps and inferior/middle turbinate flaps were unavailable or insufficient for anterior skull base defect repair. Each patient underwent reconstruction of the anterior cranial base defect using an anteriorly based pericranial flap harvested by bicoronal incision, and tunneled anteriorly to the nasal cavity through a frontoethmoidal incision.

While the use of image-guided navigation is an excellent adjunct to the use of anatomical landmarks, dynamic changes that may occur in the position of critical structures are not accounted for during and after tumor resection. Unlike navigation, Doppler ultrasonography provides real-time imaging of the anterior skull base and can be used to accurately identify the location of vital structures during skull base surgery. A 56-year-old female initially presented with new onset left eye visual deficits. She previously underwent sublabial transsphenoidal subtotal resection of the tumor, confirmed as clival chordoma. She subsequently presented to our institution. She was treated with an expanded endonasal resection of the remaining chordoma followed by CyberKnife radiosurgery. Two years later, surveillance imaging identified tumor recurrence within the right clivus posterior to the carotid artery. Intraoperatively, in the previously operated irradiated skull base, the normal bony architecture of the sella was absent, resulting in the inability to distinguish the anterior genu of the internal carotid artery (ICA) from the adjacent tumor. Using Doppler ultrasonography, the course of the ICA was imaged in real time, allowing for safe, gross total tumor resection. In the setting of prior operation, radiation, or extensive disease, the normal bony architecture of the sella may be disrupted, placing the cavernous ICA at risk. We report what we believe is the first use of intraoperative ultrasound during the endoscopic endonasal approach in the setting of a previously operated, radiated sella.

BackgroundThe global COVID-19 pandemic brings new challenges to otolaryngology resident education. Surgical volume and clinic visits are curtailed, personal protective equipment for operating room participation is restricted, and the risk of COVID-19 disease transmission during heretofore routine patient care is the new norm.MethodsWe describe a small-team "cohorting" protocol including guidelines for faculty and resident in common clinical scenarios with attention paid to the risk of common otolaryngologic procedures.ResultsA rotating small-team approach was implemented at each clinical site, limiting interaction between department members but providing comprehensive coverage. Faculty were involved at the earliest phase of clinical interactions. Guidelines delineated faculty and resident roles based on risk stratification by patient COVID status and anticipated procedures. Special consideration was given to high-risk procedures such as endoscopy and tracheotomy.ConclusionsA small-team-based approach with guidelines for faculty/resident roles may mitigate risk while optimizing patient care and maximizing education.

BackgroundThe coronavirus disease (COVID-19) pandemic has raised concern of transmission of infectious organisms through aerosols formation in endonasal and transoral surgery.MethodsRetrospective review. We introduce the negative-pressure otolaryngology viral isolation drape (NOVID) system to reduce the risk of aerosol. NOVID consists of a plastic drape suspended above the patient's head and surgical field with a smoke evacuator suction placed inside the chamber.ResultsFour patients underwent endonasal (4) and endo-oral surgery (1). Fluorescein was applied to the surgical field. Black light examination of fluorescein-treated operative fields revealed minimal contamination distant to the surgical field. In two prolonged cases with high-speed drilling, droplets were identified under the barrier and on the tip of the smoke evacuator. Instruments and cottonoids appeared to be a greater contributor to field contamination.ConclusionsNegative-pressure aspiration of air under a chamber barrier, which appears to successfully keep aerosol and droplet contamination to a minimum.

BackgroundDuring the SARS-CoV-2 pandemic, tracheostomy may be required for COVID-19 patients requiring long-term ventilation in addition to other conditions such as airway compromise from head and neck cancer. As an aerosol-generating procedure, tracheostomy increases the exposure of health care workers to COVID-19 infection. Performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care.MethodsThis study is a multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. Modifications to support clinical decision making in the context of COVID-19 were derived by consensus and available evidence.ResultsModified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of COVID-19 are presented.DiscussionDuring the various phases of the COVID-19 pandemic, clinicians must carefully consider the indications, procedural precautions, and postoperative care for tracheostomies. We present guidelines to mitigate risk to health care workers while preserving the quality of care.

Arterial injuries are the most feared complication of endoscopic skull base surgery. During resection of the middle fossa component of a large ventral skull base chondrosarcoma, arterial bleeding was encountered near the right internal carotid artery (ICA). Durable hemostasis could not be achieved with packing and the patient was taken for an emergent angiogram that revealed a pseudoaneurysm of the proximal intradural ICA. Given the presence of good collateral flow through the anterior and posterior communicating arteries, the right ICA was sacrificed by coil embolization. The patient was taken back to the operating room for closure then transferred to the intensive care unit and maintained on vasopressors for five days to ensure adequate perfusion. The right ICA was coil embolized and the patient was taken back to the operating room for closure. The patient recovered without complication. Arterial injuries, although serious, are not always catastrophic. Critical steps are immediate recognition of bleeding, vascular imaging, and vessel sacrifice if necessary.

This article, published in the Journal of Neurological Surgery, discusses the use of endoscopic nasopharyngectomy (ENP) as a surgical method for treating tumors in the nasopharynx. The study focuses on the application and outcomes of ENP at a North American tertiary-care hospital over the past decade. The results show that ENP is increasingly used for tumors in the nasopharynx, with nasopharyngeal carcinoma (NPC) being the most common indication. The study also highlights common postoperative complications, such as dysphagia and eustachian tube dysfunction, and emphasizes the importance of improved vascularized closure techniques. [Extracted from the article]

This article discusses the predictors of biochemical remission after surgical resection of somatotroph adenomas, which are tumors that produce excessive growth hormone. The study analyzed data from 97 patients who underwent surgery for somatotroph adenomas and found that larger tumor size, cavernous sinus invasion, and higher levels of preoperative growth hormone and IGF-1 were associated with a higher likelihood of remission failure. A machine learning model identified 3D tumor volume and preoperative IGF-1 as important predictors of remission status. The study concludes that patients who achieve postoperative remission typically have preoperative 3D tumor volumes less than 1.51 cm3. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, explores the frequency and significance of hyperenhancement in pituitary neuroendocrine tumors (PitNETs) on preoperative MRI scans. The study involved a retrospective review of patients who underwent transsphenoidal surgery for PitNETs at a single pituitary center from 2012 to 2019. The results showed that 8.5% of PitNETs exhibited hyperenhancement on preoperative contrasted imaging studies. These hyperenhancing tumors were smaller and more commonly microadenomas compared to PitNETs with conventional hypoenhancement. Additionally, patients with hyperenhancing tumors were more likely to present with hypothyroidism and had a higher risk of postoperative diabetes insipidus. [Extracted from the article]

Background: A minority of patients with recurrent/metastatic (R/M) salivary gland cancers (SGCs) benefit from immune checkpoint inhibitors (ICIs), necessitating reliable biomarkers for ICI response prediction. Methods: Retrospective observational study of R/M SGC patients treated with pembrolizumab between 2016 and 2022, with a primary outcome of 6‐month progression‐free survival (PFS) and secondary outcome of 2‐year overall survival (OS). Univariate and multivariable Cox proportional hazards models were employed. Results: Twenty R/M SGC patients were included. After adjustment, NLR as a continuous variable was independently associated with 6‐month PFS (HR 1.30, 95% CI 1.10–1.54, p = 0.002) and 2‐year OS (HR 1.33, 95% CI 1.07–1.66, p = 0.010). Similarly, NLR ≥ 5 was associated with higher hazards of progression at 6 months (HR 12.85, 95% CI 2.17–76.16, p = 0.005) and death at 2 years (HR 11.25, 95% CI 1.67–75.77, p = 0.013). Conclusions: Higher pretreatment NLR was independently associated with inferior 6‐month PFS and 2‐year OS in pembrolizumab‐treated R/M SGC patients. [ABSTRACT FROM AUTHOR]

Rapid advances in the ability to produce nanoparticles of uniform size, shape, and composition have started a revolution in the sciences. Nano-sized structures herald innovative technology with a wide range of potential therapeutic and diagnostic applications. More than 1000 nanostructures have been reported, many with potential medical applications, such as metallic-, dielectric-, magnetic-, liposomal-, and carbon-based structures. Of these, noble metallic nanoparticles are generating significant interest because of their multifunctional capacity for novel methods of laboratory-based diagnostics, in vivo clinical diagnostic imaging, and therapeutic treatments. This review focuses on recent advances in the applications of nanotechnology in head and neck cancer, with special emphasis on the particularly promising plasmonic gold nanotechnology.

Objectives. To evaluate the knowledge base of hospital staff regarding emergent airway management of tracheotomy and laryngectomy patients, and the impact of the introduction of a bedside airway form. Methods. Cross-sectional surveys of physicians, nurses, and respiratory therapists at a tertiary care hospital prior to and 24 months after introduction of a bedside Emergency Airway Access (EAA) form. Results. Pre- and postintervention surveys revealed several knowledge deficits. Preintervention, 37% of medical internists and 19% overall did not know that laryngectomy patients cannot be orally ventilated, and 67% of internists could not identify the purpose of stay sutures in recently created tracheotomies. Postintervention, these numbers improved for all groups. Furthermore, 80% of respiratory therapists reported encountering the EAA form in an emergent situation and found it useful. Conclusion. A knowledge deficit is identified in caregivers expected to provide emergency management of patients with airway anatomy altered by subspecialty surgeons. Safety initiatives such as the EAA form may improve knowledge among providers.

Objective: Risk factors for a postoperative cerebrospinal fluid leak (CSF) after surgery include an intraoperative high flow of CSF, elevated body mass index, defect size, and defect site. In our prior series, a high postoperative CSF leak rate for tumors of the central skull base (planum, sella, and clivus) appeared to be due to graft migration. We changed our closure technique from a single layer of collagen +/− fat graft to a novel graft, termed a "Bow tie" (a tri‐layer fat graft with two pieces of collagen matrix), and report our results in this study. Methods: Retrospective temporal epoch study of a single otolaryngologist's experience of closing skull base defects in our skull base center from 2005 to 2017. Results: One hundred and forty‐nine patients met inclusion criteria in two time periods, pre‐ and post‐introduction of the Bow tie technique. In epoch I, from 2005 to 2013, 79 patients had reconstruction with a single layer of dural graft (25 had additional free fat graft). In epoch II, from 2014 to 2017, 70 patients had reconstruction with the Bow tie. Results: CSF leak rates were 8.7% overall: 15.2% in epoch I and 1.4% in epoch II (p = 0.01). After controlling the procedure, defects with a size greater than 2 cm had a 5.7 greater likelihood of failure. Epoch II had a lower incidence of major complications. Conclusion: Using a single surgeon's experience, the multilayer Bow tie has a significant reduction in postoperative CSF leak and associated major complications for defects of the central skull base. Level of Evidence: 3 Laryngoscope, 133:1568–1575, 2023 [ABSTRACT FROM AUTHOR]