Emergency department visits following endoscopic skull base surgery: An opportunity for improvement

BACKGROUND

Readmissions are major healthcare expenditures, key hospital metrics, and are often preceded by an evaluation in the emergency department (ED). The purpose of this study was to analyze ED visits within 30 days of endoscopic skull base surgery (ESBS), risk factors for readmission once in the ED, and ED-related evaluation and outcomes.

METHODS

Retrospective review from January 2017 to December 2022 at a high-volume center of all ESBS patients who presented to the ED within 30 days of surgery.

RESULTS

Of 593 ESBS cases, 104 patients (17.5%) presented to the ED following surgery within 30 days, with a median presentation of 6 days post-discharge (IQR 5-14); 54 (51.9%) patients were discharged while 50 (48.1%) were readmitted. Readmitted patients were significantly older than discharged patients (median 60 years, IQR 50-68 vs. 48 years, 33-56; p < 0.01). Extent of ESBS was not associated with readmission or discharge from the ED. The most common discharge diagnoses were headache (n = 13, 24.1%) and epistaxis (n = 10, 18.5%); the most common readmitting diagnoses were serum abnormality (n = 15, 30.0%) and altered mental status (n = 5, 10.0%). Readmitted patients underwent significantly more laboratory testing than discharged patients (median 6, IQR 3-9 vs. 4, 1-6; p < 0.01).

CONCLUSIONS

Approximately half of patients who presented to the ED following ESBS were discharged home but underwent significant workup. Follow-up within 7 days of discharge, risk-stratified endocrine care pathways, and efforts to address the social determinants of health may be considered to optimize postoperative ESBS care.

Fascia Lata: Another Workhorse for Complex Skull Base Reconstruction

BACKGROUND

Multiple methods exist for skull base reconstruction of defects created by expanded endonasal approaches. While the nasoseptal flap (NSF) has been well established as the workhorse of mucosal reconstruction in complex skull base defects in multi-layered closures, a variety of options exist for the inner layer of multilayer reconstruction, including fascia lata (FL).

OBJECTIVE

To present our experience and outcomes in utilizing FL in multiple ways to reconstruct a wide variety of complex skull base defects.

METHODS

Retrospective review was performed from May 2017 to February 2022 to identify 50 consecutive patients who underwent endoscopic skull base reconstruction using FL.

RESULTS

FL was employed for reconstruction in 50 patients included in the study: 37 undergoing primary expanded endonasal skull base surgery and 13 revision cases. A wide range of complex pathology was treated, with meningioma and craniopharyngioma being the two most common. FL was utilized as a "button" graft (34/50, 68.0%), free graft inlay/onlay (13/50, 26.0%), and as a button graft combined with onlay (3/50, 6.0%). Expanded surgery defects addressed included tuberculum sella/sphenoid planum (36/50, 72.0%), clivus (6/50, 12.0%), and cribriform/planum (8/50, 16.0%). Successful reconstruction with fascia lata was accomplished in 46/50 cases (92%), with only 4 cases (8%) requiring revision for post-op CSF leak. Donor-site complications were rare with only 1 case (2.0%) of post-op seroma.

CONCLUSION

FL, usually with NSF, offers a versatile option for the reconstruction of challenging defects with excellent outcomes and minimal morbidity. FL is emerging as a workhorse for reconstruction of the inner layer of complex skull base defects.

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

OBJECTIVES

Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi-modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic-assisted approach for the management of ORN of the skull base using fascia lata for MFTT.

STUDY DESIGN

Retrospective case series.

METHODS

Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long-term follow-up were reviewed.

RESULTS

Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post-op follow-up was 23 months.

CONCLUSIONS

With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:562-568, 2023.

Use of Radiofrequency Technology in Endonasal Skull Base and Transcranial Procedures

Objective Radiofrequency ablation is widely utilized in otorhinolaryngology. It is used for ablation, coagulation and resection, and hemostasis. It causes tissue destruction through a chemical interaction of ions. The potential benefit is to cause less thermal injury to surrounding tissues compared with other coagulative tools. In this article, we present novel uses of radiofrequency ablation in endoscopic endonasal, and transcranial surgery. This is the first study to describe its use in transcranial cases.

Design, Setting, and Participants This is a retrospective study of patients between 2016 and 2018 who underwent either endoscopic endonasal or transcranial surgery where radiofrequency ablation was used.

Main Outcome Measures We looked at indication for usage, blood loss, postoperative imaging to identify any stroke or edema, and clinical outcomes of these patients.

Results The radiofrequency device was used in eight endoscopic endonasal cases and four craniotomies. Four cases were for encephalocele repair and eight were for various intracranial pathologies. In endonasal encephalocele repair, the radiofrequency ablation helped in shrinking the herniated brain while minimizing thermal injury to the surrounding tissue. In tumors resection, the combination of ablation and coagulation effect was particularly effective for highly vascularized tumors. There were no vascular or major neurologic injuries. Postoperative periencephalocele edema was noted in one case.

Conclusion Initial experience with radiofrequency ablation showed that it was a safe technique to use in both endonasal skull-base and transcranial procedures. It seemed particularly useful for highly vascularized tumors but a greater experience is needed to further clarify its role in these procedures.

Systematic Review of Olfactory Outcomes After Nasoseptal Flap Harvest for Endoscopic Skull Base Surgery: Does Using Cold Steel or Olfactory Strip Preservation Matter?

BACKGROUND

Several studies have described techniques aimed at mitigating olfactory dysfunction after nasoseptal flap (NSF) harvest for endoscopic skull base surgery (ESBS). No consensus exists as to whether popular methods including using cold-steel (CS) versus electrocautery (EC) or septal olfactory strip (SOS) preservation offer an advantage. This systematic review was performed to examine the impact of these two technical variations of NSF harvest on postoperative olfactory outcomes.

METHODS

Following PRISMA guidelines, Pubmed, Scopus, and Web of Science were searched for articles reporting olfactory outcomes in ESBS cases employing a NSF. Original articles focusing on technique variations of the NSF and reporting at least 1 objective olfactory measure were included.

RESULTS

Nine studies comprising 610 patients were included. Various, olfactory testing outcomes were reported, and post-op follow-up ranged from 6 weeks to 12 months. Three studies, including a randomized-controlled trial, compared the use of CS and EC for the superior incision of the NSF. No significant difference was found in objective olfactory function (p>0.05) when comparing these techniques. Five studies comprising 504 patients reported results from SOS sparing. SOS sparing technique in NSF harvest demonstrated smell preservation in the post-op setting when compared to pre-op measures (p>0.05), however, no direct comparison to non-SOS sparing techniques was made.

CONCLUSION

Use of CS as opposed to EC for the superior NSF incision does not appear to confer an advantage in preserving post-op olfactory function (grade B evidence). SOS preservation may be associated with better olfactory outcomes in NSF harvest (grade C evidence). This article is protected by copyright. All rights reserved.

Postoperative Oral Antibiotics and Sinonasal Outcomes Following Endoscopic Transsphenoidal Surgery for Pituitary Tumors Study: A Multicenter, Prospective, Randomized, Double-Blinded, Placebo-Controlled Study

BACKGROUND

Postoperative prophylactic antibiotics are commonly used in pituitary surgery, but evidence supporting their use is lacking, which has implications for antibiotic stewardship.

OBJECTIVE

To evaluate whether receipt of postoperative oral antibiotics results in superior sinonasal quality of life (QOL) compared with placebo among patients who undergo endoscopic endonasal transsphenoidal pituitary surgery.

METHODS

Patients were randomized to receive either oral placebo or cefdinir (trimethoprim-sulfamethoxazole in patients intolerant to cefdinir) for 7 d after surgery. They were monitored for 12 wk. The primary outcome measure was sinonasal QOL at 2 wk on the Anterior Skull Base Nasal Inventory-12. Supplementary end points included sinonasal QOL reported on the Sinonasal Outcome Test-22 and objective endoscopy scores to assess nasal healing according to the Lund-Kennedy method.

RESULTS

A total of 461 patients were screened, 131 were randomized, and 113 (placebo arm: 55; antibiotic arm: 58) were analyzed. There was no clinically meaningful or statistically significant difference in sinonasal QOL at any measured time point (P ≥ .24) using either instrument. Nasal cavity endoscopy scores were not significantly different at 1 to 2 wk after surgery (P = .25) or at 3 to 4 wk after surgery (P = .08).

CONCLUSION

Postoperative prophylactic oral antibiotics did not result in superior sinonasal QOL compared with placebo among patients who underwent standard endoscopic transsphenoidal surgery.

Pazopanib for severe bleeding and transfusion-dependent anemia in hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) is a rare angiogenic disorder causing chronic gastrointestinal bleeding, epistaxis, and severe anemia. Pazopanib is an oral multi-kinase angiogenesis inhibitor with promise to treat bleeding in HHT. We analyzed outcomes of HHT patients with the most severe bleeding causing RBC transfusion dependence treated on a predefined institutional pazopanib treatment pathway (with data collected retrospectively). The primary endpoint was achievement of transfusion independence. Secondary endpoints included hemoglobin, epistaxis severity score, RBC transfusion and iron infusion requirements, number of local hemostatic procedures, ferritin and transferrin saturation, compared using paired and repeated measures mean tests. Thirteen transfusion-dependent HHT patients received pazopanib [median (range) dose 150 (25–300) mg daily)] for a median of 22 months. All patients achieved transfusion independence. Compared with pretreatment, pazopanib increased mean hemoglobin by 4.8 (95% CI, 3.6–5.9) g/dL (7.8 vs. 12.7 g/dL, P < 0.0001) and decreased mean epistaxis severity score by 4.77 (3.11–6.44) points (7.20 vs. 2.43 points, P < 0.0001) after 12 months of treatment. Compared with 3 months of pretreatment, RBC transfusions decreased by 93% (median of 16.0 vs. 0.0 units, P < 0.0001) and elemental iron infusion decreased by 92% (median of 4500 vs. 0 mg, P = 0.005) during the first 3 months of treatment; improvements were maintained over time. Pazopanib was well-tolerated: hypertension, lymphocytopenia, and fatigue were the most common TEAEs. In conclusion, pazopanib was safe and effective to manage severe bleeding in HHT, liberating all patients from transfusion dependence and normalizing hematologic parameters at doses lower than used to treat malignancies. These findings require confirmation in a randomized trial.

Assessment of the Validity of the Sinonasal Outcomes Test-22 in Pituitary Surgery: A Multicenter Prospective Trial

OBJECTIVES/HYPOTHESIS

Sinonasal Outcomes Test-22 (SNOT-22) is used widely as a patient-reported sinonasal quality-of-life (QOL) instrument for endoscopic endonasal pituitary surgery. However, it has never been validated in this population. This study explores the psychometric validity of SNOT-22 to determine if it is a valid scale in patients undergoing endoscopic pituitary surgery.

STUDY DESIGN

Multicenter prospective trial.

METHODS

Adult patients (n = 113) with pituitary tumors undergoing endoscopic surgery were enrolled in a multicenter study. Patient-reported QOL was assessed using SNOT-22 and the Anterior Skull Base Nasal Inventory-12. Face validity, internal consistency, responsiveness to clinical change, test-retest reliability, and concurrent validity were determined using standard statistical methods.

RESULTS

Internal consistency using Cronbach's alpha at baseline and 2 weeks postoperatively were 0.911 and 0.922, indicating SNOT-22 performed well as a single construct. Mean QOL scores were significantly worse at 2 weeks than baseline (16.4 ± 15.1 vs. 23.1 ± 16.4, P < .001), indicating the scale is responsive to clinical change. However, only 11/22 items demonstrated significant changes in mean scores at 2 weeks. Correlation between scores at 2 and 3 weeks was high, suggesting good test-retest reliability, r(107) = 0.75, P < .001. Factor analysis suggests the five-factor solution proposed for the SNOT-22 in rhinosinusitis patients is not valid in pituitary surgery patients.

CONCLUSIONS

The SNOT-22 is a valid QOL instrument in patients undergoing endoscopic pituitary surgery. However, because it includes 22 items, can be applied only as a single construct, 50% of the items do not demonstrate changes after surgery, and is not as sensitive to change as other scales, shorter instruments developed specifically for this patient population may be preferable.

LEVEL OF EVIDENCE

II Laryngoscope, 2021.

Sclerotherapy Versus Cautery/Laser Treatment for Epistaxis in Hereditary Hemorrhagic Telangiectasia

OBJECTIVES/HYPOTHESIS

Surgical interventions for epistaxis management in hereditary hemorrhagic telangiectasia (HHT) demonstrate short-term success and require repeated procedures for disease control. Although electrocautery and/or laser photocoagulation (C ± L) are most frequently performed, sodium tetradecyl sclerotherapy (STS) is emerging as a promising newer treatment. We hypothesized that in a 24-month time period, STS would require fewer treatments than C ± L to maintain epistaxis severity within the mild range.

STUDY DESIGN

Retrospective study.

METHODS

We retrospectively assessed 67 patients with HHT with moderate and severe epistaxis that were treated periodically with C ± L (34 patients) versus STS (33 patients). The primary outcome was the number of procedures needed to maintain the epistaxis severity score (ESS) as mild. Secondary outcomes assessed for differences in postoperative complications, hemoglobin levels, iron stores, hematologic support, and quality-of-life (QoL) scores.

RESULTS

To maintain ESS in the mild range, 1.6 STS procedures (range, 1-4) were performed versus 3.6 C ± L procedures (range, 1-8) (P = .003). Significant postoperative differences included reduction in nasal crusting (3% vs. 32%, P = .001), foul odor (3% vs. 35%, P < .001), and septal perforation (3% vs. 29%, P = .006) after STS. There were no significant differences between the two treatments in hemoglobin levels, iron stores, hematologic support, or QoL scores.

CONCLUSION

STS is able to attain satisfactory epistaxis control with significantly fewer procedures and lower postoperative complications than C ± L. STS should be considered as the initial surgical intervention for epistaxis in patients with HHT.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide

OBJECTIVES

Cerebrospinal fluid (CSF) leaks and meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be challenging. The traditional transpterygoid approach through the pterygopalatine fossa (PPF) is time consuming and places important structures at risk, which can lead to significant morbidity. We report a multi-institutional experience using a simplified, endoscopic modified transpterygoid approach (MTPA), which spares the PPF contents in the management of lateral sphenoid sinus meningoencephaloceles and CSF leaks.

STUDY DESIGN

Multi-Institutional, Retrospective Case Series.

METHODS

Patients with lateral sphenoid recess CSF leaks and meningoencephaloceles between 2014 and 2020 who underwent the MTPA at two academic medical centers were identified. Repair techniques and outcomes were evaluated.

RESULTS

Thirty-three patients underwent the MTPA for management. Skull base reconstruction was performed using a free mucosal graft (24/33, 72.7%), nasoseptal flap (4/33, 12.1%), bone grafts (3/33, 9.1%), and abdominal fat grafts (2/33, 6.1%). Lumbar drains and perioperative intracranial pressure measurements were routinely employed. Postoperative complications were uncommon and included three patients (9.7%) with temporary V2 anesthesia, one patient (3.2%) with prolonged V2 anesthesia, and one patient (3.2%) with subjective dry eye, all of which resolved at 9 months postoperatively. There were no recurrent CSF leaks resulting in a 100% success rate. Average follow-up was 13 months.

CONCLUSION

The MTPA reduces morbidity and greatly simplifies access to the lateral sphenoid sinus for the management of CSF leaks and meningoencephaloceles, without compromising exposure. This technique avoids the need for extensive PPF dissection and should be considered for the management of benign lesions involving the lateral sphenoid sinus.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Simplifying Access to the Lateral Sphenoid Recess: A Modification of the Transpterygoid Approach

BACKGROUND

Meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be difficult to access. Historically, the endoscopic transpterygoid approach was advocated, which carries additional morbidity given the dissection of the pterygopalatine fossa (PPF) contents to provide a direct line approach to the defect. Given our increased facility with angled endoscopes and instrumentation, we now approach this region in a less invasive manner.

METHODS

We describe the endoscopic modified transpterygoid approach (MTPA), a quicker approach to the lateral sphenoid recess which preserves the PPF contents through a single nostril corridor.

RESULTS

In the MTPA, the face of the sphenoid and anterior junction of the pterygoid plates are removed, allowing for mobilization of the PPF contents with the periosteum intact. Angled instrumentation is then used to resect the meningoencephalocele and repair the skull base defect in the lateral recess. If increased exposure is needed, this can be gained by sacrificing the sphenopalatine artery and even the vidian nerve, although this is rarely required.

CONCLUSIONS

The MTPA obviates the need for PPF dissection and simplifies access to the lateral sphenoid recess while minimizing postoperative morbidity. This approach should be considered for accessing meningoencephaloceles and other benign lesions in this challenging location.

Prevalence and Clinical Significance of Radiographic Sinus Disease on Preoperative Computed Tomography Imaging in the Endoscopic Skull Base Surgery Population

INTRODUCTION

Endoscopic skull base surgery (ESBS) provides a safe, minimally invasive approach to treat benign and malignant skull base lesions. The significance of concomitant sinonasal pathology on imaging in patients undergoing ESBS and its effect on perioperative management is not well described. We sought to identify the prevalence and clinical significance of incidentally found radiographic sinus disease on preoperative imaging in patients undergoing ESBS and provide a protocol for management of these patients.

DESIGN

A retrospective chart review was performed of consecutive patients who underwent ESBS from January 1, 2016 to June 30, 2018. Preoperative computed tomography (CT) scans were reviewed and scored using the Lund-Mackay (LM) staging system. Preoperative nasal endoscopy findings were analyzed. Any preoperative treatment based on these findings and changes in intraoperative management were examined.

RESULTS

A total of 156 patients (81 women, 74 men) who underwent ESBS were reviewed. The average LM score was 2 ± 2.7 (range: 0-12). A total of 94 patients (60.3%) had evidence of radiographic sinus disease (LM score > 0) and 23 patients (14.7%) had presence of sphenoid sinus disease. Seven patients (4.5%) were treated preoperatively based on CT and/or nasal endoscopy findings. All patients who received preoperative treatment had evidence of sinus disease on imaging with an average score of 4.7 and were evaluated and treated within 1-2 weeks prior to ESBS. One patient had ESBS postponed until endoscopic sinus surgery was performed for extensive chronic rhinosinusitis (CRS) findings on imaging.

CONCLUSION

A review of preoperative imaging in patients undergoing ESBS can help identify concurrent sinonasal disease, which has the potential to alter preoperative as well as intraoperative management in these patients. We report a diligent but conservative approach for the treatment of concomitant CRS in the ESBS population with decision for preoperative treatment guided by various factors.

Utility of the Nasoseptal “Rescue” Flap Approach: Analysis of 125 Consecutive Patients and Implications for Routine Transsphenoidal Surgery

Introduction

The nasoseptal flap (NSF) is the reconstructive workhorse for endoscopic skull base surgery (ESBS). However, there is morbidity associated with its use and it is not always required for reconstruction. The bilateral nasoseptal “rescue” flap (NSRF) technique offers a quicker alternative to upfront NSF harvest, yet permits the use of a tailored NSF if needed after the defect has been created. The utility and implications of this strategy have not been well studied.

Methods

We retrospectively analyzed 125 consecutive transsphenoidal cases where an NSRF approach was used from January 2015 to October 2017 at the Cleveland Clinic. Records were analyzed for conversion to NSF, outcomes, and reconstruction-related complications.

Results

The mean age of patients included in the study was 51 years, with 51% females. NSRF was converted to full NSF in only 16% of cases. Rationale for conversion included an unanticipated high-flow (7) or low-flow (12) cerebrospinal fluid (CSF) leak and an exposed internal carotid artery (1). NSRF was utilized and converted to formal NSF in 3 patients who had previous remote transsphenoidal surgery. One patient who had an NSRF without a full NSF raised had a postoperative CSF leak; however, no CSF leaks or flap ischemia was noted for those who had full NSFs raised, even in revision surgery.

Conclusion

NSRF approach provides the reliability and flexibility of vascularized reconstruction, without the perioperative disadvantages of an upfront NSF harvest. The low and successful conversion rate to NSF demonstrates the utility of this strategy which should be incorporated into the standard approach for routine transsphenoidal surgery.

Extraventricular neurocytoma with ganglioid differentiation of the sellar and parasellar regions in an elderly patient: A case report

Background:

Extraventricular neurocytoma (EVN) is a rare variant of central neurocytoma which arises outside of the ventricular system. Diffuse ganglioid differentiation is a characteristic seen in a subset of these tumors which has an uncertain prognostic significance. Typically, EVN presents in children and young adults. Given the rarity of this tumor, the natural history and response to treatments remain unclear.

Case Description:

We present a case of EVN with diffuse ganglioid differentiation in a 70-year-old male which arose in the midline parasellar region and extended into the third ventricle. This is the oldest such patient reported. Despite prior reports that extremes of age are associated with more aggressive behavior, the tumor in this case did not exhibit such an aggressive course.

Conclusion:

In this report, we review the natural history and clinical course of this patient and summarize the literature regarding this rare pathological entity. Our patient responded well to therapy despite older age, ganglioid differentiation, and higher mitotic index.

Multiple bioabsorbable corticosteroid-eluting stent placement with associated skull base injury

Bioabsorbable corticosteroid-eluting sinus stents (BCES) are used to optimize healing after sinus surgery. We report a patient with BCES placed through a dural defect. A 70 year old underwent sinus surgery. Postoperatively, the patient developed mental status changes. The patient was taken to the operating room and eight BCES were identified, with one extending through the skull base. The stents were extracted and the defect was repaired. The patient recovered well. This is the first significant complication associated with BCES. Thorough review of preoperative imaging, understanding of skull base anatomy, and careful use of BCES are critical for safety. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1494-1496, 2019.

Size of septectomy does not affect distribution of nasal irrigation after endoscopic modified Lothrop procedure

BACKGROUND

The endoscopic modified Lothrop procedure (EMLP) is commonly performed in recalcitrant frontal sinusitis, in part to achieve better penetration of medicated irrigations postoperatively. Although EMLP requires a septectomy for exposure, it is unknown whether septectomy size affects delivery of irrigations. In this study we evaluated the role of septectomy in delivery of irrigations to the EMLP cavity.

METHODS

EMLP was performed on fresh human cadavers with sequentially increasing septectomy (minimal septectomy: drilling across septum to combine frontal sinuses; standard septectomy: 1.5 cm anterior to middle turbinate and inferiorly to the midlevel of the turbinate; large septectomy: extension to nasal floor). Irrigation with fluorescein-labeled water was performed with a 240-mL irrigation bottle in the vertex position and recorded with a 30° endoscope fixed in a 4-mm trephine in the paramedian EMLP cavity. Two blinded reviewers scored irrigation distribution recordings (0 = nasal cavity only; 1 = frontal recess; 2 = medial distribution; 3 = lateral distribution; 4 = entire sinus lavage). Distribution scores were assessed with Wilcoxon rank sum analysis.

RESULTS

Six specimens (mean age, 75.2 ± 2.4; 50% female) were assessed. Interobserver scores were highly concordant (Kendall's W = 0.86, p < 0.01), internally validating the experiment. Distribution scores did not vary significantly when comparing minimal septectomy with standard or large septectomy (Z = 0.55, p = 0.58, Z = 0.37, p = 0.71).

CONCLUSION

Increasing septectomy does not improve irrigation delivery in patients undergoing EMLP. These results suggest that a limited septectomy for access to the bilateral frontal sinuses is all that is required for effective drug delivery postoperatively. This strategy may reduce morbidity associated with larger septectomies.

Outcomes of sinonasal squamous cell carcinoma with and without association of inverted papilloma: A multi-institutional analysis

INTRODUCTION

Sinonasal squamous cell carcinoma (SCC) accounts for <1% of all malignancies but represents 70% of sinonasal cancer. Up to 10% of SCCs are associated with inverted papilloma (IPSCC). Studies that compare patients, treatment, and outcomes of SCC and IPSCC are absent in the literature.

METHODS

A retrospective review of patients with SCC and those with IPSCC at Cleveland Clinic and Indiana University from 1995 to 2015. The records were analyzed for demographics, tumor characteristics, treatment, and outcomes.

RESULTS

The study comprised 117 patients with SCC, of whom, 29 had IPSCC. The mean age at diagnosis was similar: 63 and 64 years for patients with SCC and patients with IPSCC, respectively; with female patients representing 36% and 34%, respectively (p > 0.99).Smokers represented 64% of the patients with SCC and 55% of patients with IPSCC (p = 0.3); excessive alcohol intake was noted in 16% of the patients with SCC and 21% of the patients with IPSCC (p = 0.56).The maxillary sinus was most commonly involved, followed by the nasal cavity (51% versus 35% SCC, 45% versus 38% IPSCC). Frontal ethmoid and sphenoid sinuses contained primary tumors only in patients with SCC. Upfront treatment was surgery in 84% of patients with SCC and 97% of patients with IPSCC (p = 0.18); 68 and 55% received radiation, respectively, and 25 and 21% received chemotherapy, respectively.Overall survival averaged 5.5 and 3.4 years for patients with SCC and patients with IPSCC, respectively (p = 0.12); disease-free survival was 4.8 and 2.9 years, respectively (p = 0.18). Nodal metastasis was more likely in patients with SCC (18 versus 0%; p = 0.02). When divided into high- and low-stage disease: more common nodal metastases were demonstrated in high-stage SCC than in low-stage disease (p = 0.03). Overall survival was decreased between high- and low-grade disease but not when subdivided between SCC and IPSCC.

CONCLUSION

Although SCC with and without IP association are considered different diseases, their demographics and outcomes seem similar. Nodal metastasis was noted to be higher in the SCC cohort, which may indicate different tumor biology. Further study is warranted.

Superiority of constructive interference in steady-state MRI sequencing over T1-weighted MRI sequencing for evaluating cavernous sinus invasion by pituitary macroadenomas

OBJECTIVE

Preoperatively determining the extent of parasellar invasion of pituitary macroadenomas is useful for surgical planning and patient counseling. Here, the authors compared constructive interference in steady state (CISS), a T2-weighted gradient-echo MRI sequence, to volume-interpolated breath-hold examination (VIBE), a T1-weighted gradient-echo MRI sequence, for evaluation of cavernous sinus invasion (CSI) by pituitary macroadenomas.

METHODS

VIBE and CISS images of 98 patients with pituitary macroadenoma were retrospectively analyzed and graded using the modified Knosp classification. The Knosp grades were correlated to surgical findings of CSI, which were determined intraoperatively using 0° and 30° endoscopes. The predictive accuracies for CSI according to the Knosp grades derived from the CISS and VIBE images were compared using receiver operating characteristic (ROC) curves. Postoperative MRI was used to evaluate the gross-total resection (GTR) rates.

RESULTS

The CSI rate by pituitary macroadenomas was 27.6% (27 of 98 cases). Of 196 assessments (left and right sides of 98 macroadenomas), 45 (23.0%) had different Knosp grades when scored using VIBE versus CISS images. For the VIBE images, 0% of Knosp grade 0, 4.5% of grade 1, 23.8% of grade 2, 42.1% of grade 3A, 100% of grade 3B, and 83.3% of grade 4 macroadenomas were found to have CSI intraoperatively. For the CISS images, 0% of Knosp grade 0, 2.1% of grade 1, 31.3% of grade 2, 56.3% of grade 3A, 100% of grade 3B, and 100% of grade 4 macroadenomas were found to have CSI intraoperatively. Two pituitary macroadenomas were classified as grade 4 on VIBE sequences but grades 3A and 2 on CISS sequences; CSI was not observed intraoperatively in both cases. The GTR rate was 64.3% and 60.0% for high-grade (3A, 3B, and 4) macroadenomas classified using VIBE and CISS sequences, respectively. The areas under the ROC curves were 0.94 and 0.97 for VIBE- and CISS-derived Knosp grades (p = 0.007), respectively.

CONCLUSIONS

Knosp grades determined using CISS sequence images are better correlated with intraoperative CSI than those determined using VIBE sequence images. CISS sequences may be valuable for the preoperative assessment of pituitary macroadenomas.

Pazopanib effective for bevacizumab-unresponsive epistaxis in hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) most commonly manifests with nasal mucosal telangiectasias, and vascular endothelial growth factor (VEGF) plays a significant role in this angiodysplasia. We describe a patient with HHT with epistaxis recalcitrant to several endonasal procedures and six cycles of intravenous bevacizumab, for which he was dependent on iron infusions and packed red blood cells transfusions. He then started pazopanib at 100 mg with dramatic improvements in epistaxis and normalization of hemoglobin and iron levels, without replenishment needs for 12 months. This is the first report on the efficacy of pazopanib with high selectivity for abrogating VEGF receptor-2 signaling in HHT, and needs to be explored further. Laryngoscope, 128:2234-2236, 2018.