Endoscopic endonasal approach for sinonasal and anterior skull base malignancies in the elderly

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Impact of Frailty on Postoperative Outcomes in Extended Endonasal Skull Base Surgery for Suprasellar Pathologies

OBJECTIVE

Frailty metrics estimate a patient's ability to tolerate physiologic stress and there are limited frailty data in patients undergoing expanded endonasal approaches (EEA) for suprasellar pathologies. Elevated frailty metrics have been associated with increased perioperative complications in patients undergoing craniotomies. We sought to examine this potential relationship in EEA.

STUDY DESIGN

Retrospective cohort study.

SETTING

Two tertiary academic skull base centers.

METHODS

Cases of patients undergoing EEA for suprasellar pathologies were reviewed. Demographic, treatment, survival, and postoperative outcomes data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, the modified 5-item frailty index (mFI-5), and the Charlson comorbidity index (CCI). Primary outcomes included 30-day medical and surgical complications.

RESULTS

A total of 88 patients were included, with 59 (67%) female patients and a mean age of 54 ± 15 years. The most common pathologies included 53 meningiomas (60.2%) and 21 craniopharyngiomas (23.9%). Most patients were ASA class 3 (54.5%) with mean mFI-5 0.82 ± 1.01 and CCI 4.18 ± 2.42. There was no association between increased frailty and 30-day medical or surgical outcomes (including postoperative cerebrospinal fluid leak), prolonged length of hospital stay, or mortality (all P > .05). Higher mFI-5 was associated with an increased risk for 30-day readmission (odds ratio: 2.35, 95% confidence Interval: 1.10-5.64, P = .04).

CONCLUSION

Despite the patient population being notably frail, we only identified an increased risk for 30-day readmission and observed no links with deteriorating surgical, medical, or mortality outcomes. This implies that conventional frailty metrics may not effectively align with EEA outcomes.

Management of Older Patients with Head and Neck Cancer: A Comprehensive Review

The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.

Safety of Endoscopic Sinus Surgery in the Elderly-Are Octogenarian Patients at a Higher Risk?

BACKGROUND

Surgeons are often faced with concerns regarding the risks versus benefits of endoscopic sinus surgery (ESS) in elderly patients.

OBJECTIVE

To analyze the risk for complications of ESS in the elderly (age ≥70 years) compared to younger patients, with emphasis on octogenarians.

METHODS

Retrospective review of medical charts of adult patients who underwent ESS at a tertiary referral center during the years 2014 to 2018.

RESULTS

We compared 128 elderly patients with 276 matched younger patients. In the elderly group mean age was 76 years (range, 70-91 years ). Thirty-one elderly patients were 80 years or older. Surgical complications in the elderly patients were 3.9%. Minor complications were 2.3% and major complications were 1.7%. The surgical complications rate was similar in the younger group (8%, P value: .127). Medical complications were observed in 2.3% comparing to 0.7% in younger patients. Interestingly, age, revision surgery, extent and duration of surgery, and modality of anesthesia were not identified as risk factors. Only ischemic heart disease (IHD) was identified as a risk factor for complications in a multivariate analysis in elderly patients. Comparison of elderly patients younger than 80 years with octogenarians revealed no difference in complication rate between these groups.

CONCLUSIONS

Overall, ESS was found to be a safe procedure in elderly patients compared to younger patients. Octogenarian patients should not be denied upfront surgery. IHD is a risk factor for complications in elderly patients.

Endoscopic Anatomy and a Safe Surgical Corridor to the Anterior Skull Base

OBJECTIVE

We describe the possibility to create precise preoperative planning for endonasal endoscopic approaches to the anterior skull base by overlapping endoscopic and radiologic anatomy. The important anatomic structures were marked. Morphometric measurements between these anatomic landmarks were performed endoscopically and compared with radiologic measurements of the same areas to ensure result compatibility.

METHODS

Seven cadaver heads injected intravascularly with colored silicone were used for this study. Thin-section brain and paranasal sinus computed tomography scans were obtained on all cadavers. Using 0-degree rigid endoscopes and endonasal endoscopic surgical instruments, the anterior skull base was examined binostrally in all cadavers. Bilateral middle turbinates were identified and preserved. Next, an inferior uncinectomy and middle meatal antrostomy were performed. After performing a frontal antrostomy, bilateral anterior and posterior ethmoidal cells were opened and the skull base was identified and followed to the posterior wall of the frontal sinus. A transnasal transethmoidal sphenoidotomy was done with full exposure to the entire anterior skull base.

RESULTS

The anatomic landmarks for endonasal endoscopic skull base approaches were distinguished and measurements were made. The anterior skull base was divided into 3 compartments: anterior (area between the posterior inferior border of the frontal sinus and the course of anterior ethmoidal artery), middle (area between the course of the anterior ethmoidal artery and that of the posterior ethmoidal artery [PEA]), and posterior (area between the course of the PEA and the attachment point of the anterior border of the sphenoid sinus to the skull base) compartments. The distances between important anatomic markers and endoscopic depth measurements of this area were measured.

CONCLUSION

During endonasal endoscopic anterior skull base surgery, the area between the anterior border of the sphenoid sinus and PEA artery was safe as the first dissection zone. Preoperative radiologic width and depth measurements facilitate orientation to the endoscopic anatomy during surgery and help predict the endonasal surgical corridor anatomy preoperatively.

Esthesioneuroblastoma: A Comprehensive Review of Diagnosis, Management, and Current Treatment Options

INTRODUCTION

Many controversies exist in the diagnosis and management of this aggressively malignant condition, mainly because of limited literature and lack of randomized control trials, resulting in nonstandardized treatment methods. We performed a comprehensive review of the literature to identify management approach and treatment options for esthesioneuroblastoma.

METHODS

An extensive review of the published literature was conducted in PubMed, OVID Medline, and EMBASE journals for studies of esthesioneuroblastoma. Terms for search included esthesioneuroblastoma (ENB) and olfactory neuroblastoma (ONB). No date restrictions were used.

RESULTS

The search yielded 3876 related articles. Cross-checking of articles led to exclusion of duplicate articles. The remaining 1170 articles were screened for their full text and English language availability. Of 609 full-text articles available, animal studies, irrelevant articles, and studies with mixed/confusing data were excluded. We finalized 149 articles pertaining to the topic, including 119 original research articles, 3 book chapters, 11 reviews, 9 case reports, and 7 case series.

CONCLUSIONS

Surgical resection followed by radiotherapy is the standard for treatment for higher-grade lesions. The endoscopic endonasal approach is gaining further recognition with more favorable outcomes and better survival than for open surgery. Postoperative radiotherapy is associated with the highest overall survival and shows benefit for patients with higher-stage disease and those who receive chemotherapy. Recurrence rates after treatment vary drastically in the literature and, therefore, prolonged follow-up with repeated imaging is recommended. Lifelong surveillance is recommended because of late recurrences associated with this tumor.