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De Jesus O. Complications After Open Skull Base Surgery for Brain Tumors: A 26-Year Experience. Cureus 2023; 15:e50312. [PMID: 38205474 PMCID: PMC10776455 DOI: 10.7759/cureus.50312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Open skull base surgery carries the risk of significant complications. It is important to inform patients and family members clearly of the details of these complications. This study aimed to present the numerous complications encountered with open skull base surgery for brain tumors. This report analyzed the complications experienced by patients treated with open skull base surgery by a single skull base surgeon at a single tertiary center over 26 years. METHODS A retrospective study was performed using the University of Puerto Rico Neurosurgery database to identify patients who were managed using open skull base procedures from 1995 to 2020. The neurosurgical database for each patient had been prospectively recorded. Patients with skull base tumors under the author's care during the study period were included in the investigation. Exclusions include patients with non-tumoral conditions and non-skull base tumors and those operated using a microscopic transsphenoidal route. Patients who experienced an intraoperative or postoperative complication within 30 days of the surgery were further analyzed. RESULTS In the cohort, 141 patients with brain tumors underwent open skull base surgery. The cohort had a median age of 48 (range 3-79). It consisted of 101 (71.6%) females and 40 (28.4%) males, with a female-to-male ratio of 2.5:1. The approach most frequently used was an orbitofrontal craniotomy (with or without zygomatic osteotomy) in 79 patients (56%). A petrosal approach was utilized in 26 patients (18%). Forty-six patients (33%) developed an intraoperative or postoperative complication. Twenty-four percent of the complications occurred in the 30-day postoperative period. Five patients had more than one complication. The median age of the patients who experienced a complication was 44.5 (range 22-79), with a female-to-male ratio similar to the entire cohort. Cranial nerve injury was the most frequent complication. Worsening or loss of vision in the affected eye occurred in 5.7% of the patients. A cerebrospinal fluid leak occurred in 2% of the patients. Six patients died, two of them after a massive myocardial infarction. CONCLUSIONS The results of this study showed that approximately one-third of the patients undergoing open skull base surgery can develop a complication. The most frequent complication was injury to a cranial nerve. A large number of complications occurred intraoperatively. The majority of the complications in patients with tumors in the posterior fossa were associated with injury to a cranial nerve. At the middle fossa, damage to the optic nerves is a noteworthy complication. Complications at the anterior fossa involved worsening of vision or myocardial infarction. Less aggressive surgery near the cavernous sinus and the petroclival region may reduce complications. Understanding the complications can help counsel patients and family members.
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Affiliation(s)
- Orlando De Jesus
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
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Ryan JF, Tanavde VA, Gallia GL, Boahene KDO, London NR, Desai SC. Reconstruction in open anterior skull base surgery: A review and algorithmic approach. Am J Otolaryngol 2023; 44:103700. [PMID: 36473261 DOI: 10.1016/j.amjoto.2022.103700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/25/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Defects resulting from open resection of anterior skull base neoplasms are difficult to reconstruct. Our objective was to review the literature and describe an evidence-based algorithm that can guide surgeons reconstructing anterior skull base defects. METHODS A research librarian designed database search strategies. Two investigators independently reviewed the resulting abstracts and full text articles. Studies on reconstruction after open anterior skull base resection were included. Studies of lateral and posterior skull base reconstruction, endoscopic endonasal surgery, traumatic and congenital reconstruction were excluded. Based on the review, a reconstructive algorithm was proposed. RESULTS The search strategy identified 603 unique abstracts. 53 articles were included. Adjacent subsites resected, defect size, radiotherapy history, and contraindications to free tissue transfer were identified as key factors influencing decision making and were used to develop the algorithm. Discussion of the reconstructive ladder as it applies to skull base reconstruction and consideration of patient specific factors are reviewed. Patients with a prior history of radiotherapy or with simultaneous resection of multiple anatomic subsites adjacent to the anterior skull base will likely benefit from free tissue transfer. CONCLUSIONS Reconstruction of anterior skull base defects requires knowledge of the available reconstructive techniques and consideration of defect-specific and patient-specific factors.
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Affiliation(s)
- John F Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ved A Tanavde
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kofi D O Boahene
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaun C Desai
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Plou P, Boccalatte L, Padilla-Lichtenberger F, Figari M, Ajler P, Larrañaga J. Microsurgical free flaps for skull base reconstruction following tumor resection: Available techniques and complications. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:22-31. [PMID: 36623890 DOI: 10.1016/j.neucie.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/25/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Resection of malignant tumors located in the anterior and middle fossae of the skull base requires thorough anatomical knowledge, as well as experience regarding the possible reconstructive options to resolve the resulting defects. The anatomical and functional relevance of the region, the complexity of the defects requiring reconstruction and the potential complications that can occur, represent a true challenge for the surgical team. The goal of this study is to describe the microsurgical reconstructive techniques available, their usefulness and postoperative complications, in patients with malignant tumors involving the skull base. MATERIALS AND METHOD This observational, retrospective study, included all patients who underwent surgery for malignant craniofacial tumors from January 1st, 2009 to January 1st, 2019 at a University Hospital in Argentina. Only patients who required reconstruction of the resulting defect with a free flap were included. RESULTS Twenty-four patients required reconstruction with FF; 14 were male (58.3%) and mean age was 54.9 years. Sarcoma was the most frequent tumor histology. Free flaps used were the following: anterolateral thigh, rectus abdominis, radial, latissimus dorsi, iliac crest and fibular. Complications occurred in 6 cases and no deaths were reported in the study group. CONCLUSION Free flaps are considered one of the preferable choices of treatment for large skull base defects. In spite of the complexity of the technique and the learning curve required, free flaps have shown to be safe, with a low rate of serious complications. For these patients, the surgical resolution should be performed by a multidisciplinary team.
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Affiliation(s)
- Pedro Plou
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina.
| | - Luis Boccalatte
- Section of Head and Neck Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina
| | | | - Marcelo Figari
- Section of Head and Neck Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina
| | - Pablo Ajler
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
| | - Juan Larrañaga
- Section of Head and Neck Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina; Section of Reconstructive Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Argentina
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López F, Shah JP, Beitler JJ, Snyderman CH, Lund V, Piazza C, Mäkitie AA, Guntinas-Lichius O, Rodrigo JP, Kowalski LP, Quer M, Shaha A, Homma A, Sanabria A, Ferrarotto R, Lee AWM, Lee VHF, Rinaldo A, Ferlito A. The Selective Role of Open and Endoscopic Approaches for Sinonasal Malignant Tumours. Adv Ther 2022; 39:2379-2397. [PMID: 35352310 PMCID: PMC9122878 DOI: 10.1007/s12325-022-02080-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/07/2022] [Indexed: 11/26/2022]
Abstract
Endoscopic endonasal surgery has been demonstrated to be effective in the treatment of selected cases of sinonasal cancers. However, in cases of locally advanced neoplasms, as well as recurrences, the most appropriate approach is still debated. The present review aims to summarize the current state of knowledge on the utility of open approaches to resect sinonasal malignant tumours. Published comparative studies and meta-analyses suggest comparable oncological results with lower morbidity for the endoscopic approaches, but selection biases cannot be excluded. After a critical analysis of the available literature, it can be concluded that endoscopic surgery for selected lesions allows for oncologically safe resections with decreased morbidity. However, when endoscopic endonasal surgery is contraindicated and definitive chemoradiotherapy is not appropriate, craniofacial and transfacial approaches remain the best therapeutic option.
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Affiliation(s)
- Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain.
- Instituto Universitario de Oncología del Principado de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias and CIBERONC, ISCIII, University of Oviedo, Oviedo, Spain.
| | - Jatin P Shah
- Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
- Department of Oncology, Radiotherapy and Plastic Surgery, Sechenov University, Moscow, Russia
| | - Jonathan J Beitler
- Departments of Radiation Oncology, Maine General Hospital, Augusta, Maine, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Valerie Lund
- The Royal National Throat Nose and Ear Hospital, UCLH Foundation Trust, London, UK
| | - Cesare Piazza
- Department of Otorhinolaryngology - Head and Neck Surgery, ASST Spedali Civili di Brescia, University of Brescia, Italy, Brescia, Italy
| | - Antti A Mäkitie
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Orlando Guntinas-Lichius
- Department of Otorhinolaryngology, Institute of Phoniatry/Pedaudiology, Jena University Hospital, Jena, Germany
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto Universitario de Oncología del Principado de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias and CIBERONC, ISCIII, University of Oviedo, Oviedo, Spain
| | - Luiz P Kowalski
- Department of Otorhinolaryngology, Head and Neck Surgery, A.C. Camargo Cancer Center, São Paulo, Brazil
- Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Miquel Quer
- Department of Otolaryngology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Ashok Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Akihiro Homma
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia/Hospital Universitario San Vicente Fundación, Medellín, Colombia
- CEXCA Centro de Excelencia en Enfermedades de Cabeza y Cuello, Medellín, Colombia
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne W M Lee
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People's Republic of China
| | - Victor H F Lee
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, People's Republic of China
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Microsurgical free flaps for skull base reconstruction following tumor resection: Available techniques and complications. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Synchronized "One-Step" Resection and Cranio-Orbital Reconstruction for Spheno-Orbital Lesions With Custom Made Implant. J Craniofac Surg 2021; 32:1870-1873. [PMID: 33534310 DOI: 10.1097/scs.0000000000007385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In the last few years, skull base tumors involving the fronto-orbital region have been approached with complex, invasive, and time-consuming cranial reconstruction techniques. On the other hand, recent custom-made implants allow easier and faster procedures, with excellent aesthetic results. The authors propose an easy surgical-planned protocol with a synchronized "one-step" resection and reconstruction of these complex lesions, with a preformed poly-methyilmethacrylate (PMMA) cranioplasty. METHODS Our technique consists of a 2-phases procedure. In the first one, the so-called "virtual" phase, the authors get a tailored 3D-PMMA model based on high-resolution (HR) CT-scans of the patient's skull. Afterward, the authors perform the planned craniotomy on the 3D-PMMA model with the assistance of intraoperative navigation system. Therefore, a further CT-scan of the resected model is performed to develop the final implant. In the second phase, the "surgical phase," a single procedure consisting in a cranial resection and custom reconstruction is performed with the assistance of stealth-navigation. The authors describe 6 cases of complex fronto-orbital-sphenoidal benign tumors that required skull reconstruction. All patients were examined 3 months after surgery through cosmetic (facial and eyes symmetry and globe position) and ophthalmology tests (visual field, visual impairment, and diplopia). Postsurgical HR CT-scans of the head and MRI-scans of the brain documented a total resection of the tumor and an optimal accuracy of skull reconstruction. RESULTS In all cases, the authors obtained a highly accurate skull reconstruction following cranio-orbital tumor resection, with a less aggressive and faster procedure compared to autologous bone graft. Final cosmetic and functional results were excellent, with good results in cases of presurgical exophthalmos and orbital asymmetry. None of the patients developed implant-related complications. CONCLUSIONS The "one-step" resection and reconstruction of benign tumors involving the spheno-orbital region with neuronavigation assistance is a technique that allows an accurate tumor removal and a cranial-bone reconstruction within a single surgical procedure, with fewer complications and excellent cosmetic and functional results.
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Dodhia S, Fitzgerald CWR, McLean AT, Yuan A, Valero Mayor C, Adilbay D, Mimica X, Gupta P, Cracchiolo JR, Patel S, Wong RJ, Shah J, Ganly I, Cohen MA. Predictors of surgical complications in patients with sinonasal malignancy. J Surg Oncol 2021; 124:731-739. [PMID: 34236707 DOI: 10.1002/jso.26598] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 06/19/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Sinonasal and skull base tumors are rare, making it difficult to identify trends in surgical outcome. This study examines complications in a large cohort of patients undergoing surgery for sinonasal malignancy. METHODS Following IRB approval, an institutional database was reviewed to identify patients who underwent surgery for sinonasal or skull base malignancies from 1973 to 2016 at our institution. Charlson comorbidity index score and Clavien-Dindo grade were calculated. The main study endpoint was subgroup analysis of Clavien-Dindo Grade 0, Grades 1-2, and Grades 3-5 complications. An ordinal logistic regression model was constructed to assess the association between comorbidities, demographics, tumor characteristics, and surgical complications. RESULTS In total, 448 patients met inclusion criteria. Perioperative mortality rate at 30 days was 1.6% (n = 7). The rate of severe complications (Clavien-Dindo 3 or higher) was 13.6% (n = 61). Multivariate analysis using an ordinal logistic regression model showed no association between Charlson comorbidity index score and Clavien-Dindo grade of postoperative complication. Advanced T-stage was significantly associated with complications (p = 0.0014; odds ratio: 3.442 [95% confidence interval: 1.615, 7.338]). CONCLUSION Surgery for sinonasal and skull base tumors is safe with a low mortality rate. Advanced T-stage is associated with postoperative complications. These findings have implications for preoperative risk stratification. Key Points Surgery for sinonasal malignancy is safe with a 30 mortality of 1.6% and rate of severe complications of 12.8%. There is no association between patient comorbidity and post operative complication. On multivariate analysis, only advanced T stage was associated with increased rate of surgical complication.
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Affiliation(s)
- Sonam Dodhia
- Department of Otolaryngology, Head and Neck Surgery, New York-Presbyterian Hospital, New York, New York, USA
| | - Conall W R Fitzgerald
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew T McLean
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Avery Yuan
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cristina Valero Mayor
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dauren Adilbay
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ximena Mimica
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Piyush Gupta
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jennifer R Cracchiolo
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Snehal Patel
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard J Wong
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jatin Shah
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ian Ganly
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc A Cohen
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Antonelli V, Maimone G, D'Andrea M, Tomassini A, Bassi M, Tosatto L. "Single-step" resection and cranio-orbital reconstruction for spheno-orbital metastasis with custom made implant. A case report and review of the literature. Int J Surg Case Rep 2021; 81:105755. [PMID: 33752032 PMCID: PMC8010640 DOI: 10.1016/j.ijscr.2021.105755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 11/26/2022] Open
Abstract
Skull Base Metastases need multidisciplinary treatment. Surgical decompression has a decisive role in relieving neurological symptoms and improving Quality of Life. The virtual planning step consists of a phantom-base procedure with the aid of Stealth Navigation. New generations of custom-made PolyMethyl MethAcrylate (PMMA) cranioplasty allow a quick access to complementary therapies. Stealth navigation during the surgical step allows a precise tumor resection and drives to an accurate cranial reconstruction.
Introduction and importance Brain metastasis involving the skull base is a rare complication of malignant tumors. Besides radiotherapy, surgical treatment is a therapeutical option even though it may apply complex technical procedures that may delay complementary therapies. However, in recent days, the innovation of custom-made implants allows treating selected patients with fewer complications and better results. Case presentation We describe a single case of a complex fronto-orbital skull base metastasis requiring skull bone reconstruction that we treated with a single-step surgery and custom-made implant. Our procedure consists of two steps: in the first one, we perform a “virtual” craniotomy on a 3D phantom model previously built on a high-resolution bone CT scan. In the second step, the actual surgical procedure, the patient undergoes the resection and reconstruction of the cranial defect with an implant of PMMA custom-made cranioplasty. A three-month clinical and radiological follow-up is reported, which documented the extent of resection and good aesthetic results. Clinical discussion In our case, we performed a skull reconstruction of cranio-orbital region with macroscopic gross-total resection of the tumor. Complementary radiotherapy was obtained after one month. Three-month follow-up showed good esthetic results and progression-free disease. A recent review of the literature is provided to discuss different reconstruction techniques. Conclusion “Single-Step” resection and custom-made reconstruction is a relatively new technique that could be helpful not only for benign tumors, which remains its main application but also in selected cases of malignant tumors when immediate reconstruction and faster complementary treatments are needed.
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Affiliation(s)
- Vincenzo Antonelli
- Department of Neurosurgery, Hospital "M. Bufalini" - AUSL della Romagna, 286 Viale Ghirotti, 47521 Cesena, Italy
| | - Giuseppe Maimone
- Department of Neurosurgery, Hospital "M. Bufalini" - AUSL della Romagna, 286 Viale Ghirotti, 47521 Cesena, Italy.
| | - Marcello D'Andrea
- Department of Neurosurgery, Hospital "M. Bufalini" - AUSL della Romagna, 286 Viale Ghirotti, 47521 Cesena, Italy
| | - Alessia Tomassini
- Department of Neurosurgery, Hospital "M. Bufalini" - AUSL della Romagna, 286 Viale Ghirotti, 47521 Cesena, Italy
| | - Massimo Bassi
- Department of Maxillo-Facial Surgery, Hospital "M. Bufalini" - AUSL della Romagna, 286 Viale Ghirotti, 47521 Cesena, Italy
| | - Luigino Tosatto
- Department of Neurosurgery, Hospital "M. Bufalini" - AUSL della Romagna, 286 Viale Ghirotti, 47521 Cesena, Italy
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Silveira-Bertazzo G, Li R, Rejane-Heim TC, Martinez-Perez R, Albonette-Felicio T, Sholkamy Diab AG, Mahmoud Mady MS, Hardesty DA, Carrau RL, Prevedello DM. Endoscopic approaches to skull base malignancies affecting the anterior fossa. J Neurosurg Sci 2021; 65:169-180. [PMID: 33491349 DOI: 10.23736/s0390-5616.21.05170-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anterior skull base malignancies are rare and comprise distinct histological entities. Surgery encompasses the traditional craniofacial resections (CFR), and more recently, endoscopic endonasal approaches (EEA) or a hybrid cranioendoscopic (CEA) technique. Although the CFR is still considered the "gold-standard;" there is growing evidence supporting that EEA yield equivalent oncologic outcomes with less morbidity in well-selected cases. Therefore, this article aims to review the current state-of-art in addressing anterior cranial base malignancies using expanded endoscopic endonasal approaches (EEA) with particular references to surgical anatomy and nuances of hybrid cranioendoscopic techniques. Cadaveric dissections and illustrative cases are presented to detail our current surgical technique allied with tailored adjuvant therapies, and treatment strategies are further discussed based on tumor histology.
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Affiliation(s)
- Giuliano Silveira-Bertazzo
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA.,Department of Pediatric Neuroendocrinology and Pediatric Endocrinology, Jeser Amarante Faria Children's Hospital, Neurological and Neurosurgical Clinic of Joinville, Joinville, Brazil
| | - Ruichun Li
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Thaïs C Rejane-Heim
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA.,Department of Pediatric Neuroendocrinology and Pediatric Endocrinology, Jeser Amarante Faria Children's Hospital, Neurological and Neurosurgical Clinic of Joinville, Joinville, Brazil
| | | | | | - Ahmed G Sholkamy Diab
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Assiut, Assiut, Egypt
| | - Mohammad S Mahmoud Mady
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA.,Department of Otolaryngology-Head and Neck Surgery, Ain Shams University, El Cairo, Egypt
| | - Douglas A Hardesty
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA.,Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA.,Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA - .,Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
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10
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Leite AKN, de Alvarenga GF, Gonçalves S, dos Santos AB, Sterman H, Cernea CR, Kulcsar MAV, Kowalski LP, Matos LL. Short-term survival in extensive craniofacial resections. Clinics (Sao Paulo) 2021; 76:e2836. [PMID: 34037072 PMCID: PMC8112106 DOI: 10.6061/clinics/2021/e2836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Craniofacial resection (CFR) procedures for craniofacial tumors with cranial extension are often extensive. Although CFRs may yield good oncological results, there are concerns about high perioperative morbidity and mortality. This study aimed to determine risk factors for perioperative mortality after open CFR in terms of deaths occurring during index hospitalizations. METHODS We conducted a retrospective analysis of CFRs conducted at a tertiary oncology hospital from May 2009 through December 2018. RESULTS Our analysis included data from the medical records of 102 patients, the majority of whom were male (n=74, 72.5%). The mean age was 61 years (±18.3 years). Skin malignancies (n=64, 63.4%) accounted for nearly two-thirds of the treated tumors, and most of these were squamous cell carcinoma. Postoperative medical complications occurred in 33 patients (33%), and surgical complications occurred in 48 (47%). Multivariate analysis revealed the only independent risk factors for perioperative deaths to be the presence of intracranial tumor extension on preoperative imaging (hazard ratio [HR]=4.56; 95% confidence interval [CI]: 1.74-11.97; p=0.002) and the unexpected emergence of postoperative neurological dysfunction (HR=10.9; 95% CI: 2.21-54.3; p=0.003). CONCLUSIONS In our study, factors related to tumor extension were associated with a higher risk of perioperative death.
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Affiliation(s)
- Ana Kober N. Leite
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Gustavo Fernandes de Alvarenga
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Sérgio Gonçalves
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alexandre Bezerra dos Santos
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Hugo Sterman
- Departamento de Neurocirurgia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Claudio R. Cernea
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marco Aurélio V. Kulcsar
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Paulo Kowalski
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Leandro Luongo Matos
- Departamento de Cirurgia de Cabeca e Pescoco, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, BR
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11
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Lim X, Rajagopal R, Silva P, Jeyaretna DS, Mykula R, Potter M. A Systematic Review on Outcomes of Anterior Skull Base Reconstruction. J Plast Reconstr Aesthet Surg 2020; 73:1940-1950. [PMID: 32546425 DOI: 10.1016/j.bjps.2020.05.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 04/21/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Anterior skull base resection often results in large defects that need to be reconstructed. This can be done using loco-regional, free flaps or both. OBJECTIVE The aim of this systematic review is to evaluate the surgical outcomes (mortality, complication rates and functional outcomes) for patients undergoing anterior skull base reconstruction. METHODS Electronic databases (MEDLINE, EMBASE and Scopus) were systematically searched for relevant articles from 1974 to March 2018. A total of 41 studies were included in this systematic review. No randomized controlled trials were identified; therefore, a meta-analysis was not performed. RESULTS Mortality from anterior skull base reconstruction were about 0-4% for loco-regional flaps while free flaps were around 0-7%. Overall complications ranged from 0% to 43% in loco-regional flaps, while rate of complications for free flaps ranged from 25% to 66.7%. Flap complications ranged from 0% to 14% for free flaps and 0% to 35% for local flaps. Quality-of-life measures did not differ significantly depending on surgical approach but were worse for patients with malignancies. CONCLUSION Due to varying standards of reporting of outcomes, lack of a standardized classification system for anterior skull base defects and absence of clinical trials, we were unable to perform a meta-analysis in this systematic review. Recommendations to guide future studies are proposed.
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Affiliation(s)
- Xuxin Lim
- Institute of Biomedical Engineering, The University of Oxford, Oxfordshire, UK.
| | - Rajini Rajagopal
- Department of Ear, Nose and Throat, John Radcliffe Hospital, Headington, Oxford, UK
| | - Priyamal Silva
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
| | - Deva Sanjeeva Jeyaretna
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
| | - Roman Mykula
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
| | - Matthew Potter
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
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12
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Adipofascial Radial Forearm Free Flap for Anterior Skull Base Reconstruction in Complicated Forebrain Oncological Surgery. J Craniofac Surg 2020; 30:1724-1729. [PMID: 31022131 DOI: 10.1097/scs.0000000000005559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Radical resections of ethmoidal tumors with intracranial extension present highly complex surgical and reconstructive problems. The purpose of report is to describe the authors' use of adipofascial radial forearm free flaps following unsuccessful anterior cranial fossa oncological surgery. METHODS Adipofascial radial forearm free flaps were used to treat 3 similar cases of cutaneous fistula following bone resorption with communication to anterior cranial fossa and nasal cavity. RESULTS No flap loss, no deaths, and no postoperative complications were observed. All patients underwent a nasal endoscopy, revealing adequate vitality and integration of the free flaps. One of the patients consented to additional surgery to improve outcome. CONCLUSIONS Meticulous preoperative selection and an experienced interdisciplinary team are required to achieve the best surgical outcomes in complex cases. Free adipofascial forearm flaps could be an excellent therapeutic option in the reconstruction of the anterior skull base, notably in cases involving major postoperative complications.
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13
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Surgical management of anterior skull-base malignancies (endoscopic vs. craniofacial resection). J Neurooncol 2020; 150:429-436. [DOI: 10.1007/s11060-020-03413-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/31/2022]
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14
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Patel J, Chitguppi C, Vimawala S, Epps G, Fastenberg J, Evans J, Rabinowitz M, Rosen M, Nyquist G. Treatment-related morbidity in patients treated for sinonasal malignancy. Int Forum Allergy Rhinol 2020; 10:526-532. [PMID: 31930702 DOI: 10.1002/alr.22509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Sinonasal malignancies are a rare, heterogeneous group of tumors that often present at an advanced stage and require multimodal therapy. The presence of high-grade toxicity and sinonasal complications after treatment can negatively impact quality of life. In this study we aim to describe posttreatment morbidity in patients with sinonasal malignancy. METHODS A retrospective analysis of all patients treated for sinonasal malignancy was conducted from 2005 to 2018 at a tertiary referral institution. A total of 129 patients met the inclusion criteria. Primary outcomes were treatment details, pathology, posttreatment complications, and radiation toxicity. Fisher's exact test, chi-square test, and Student t test were used for statistical analysis. RESULTS Mean age was 58.4 (median, 61; range, 19-94) years. After diagnosis, 24 patients had surgery alone, 46 had surgery with radiation alone, 47 had surgery with chemoradiation, and 14 received definitive chemoradiation. Overall, 10.4% (n = 12) of patients had postoperative complications, and 21.0% (n = 22) had high-grade (grade 3-5) radiation toxicity. After radiation, 20% (n = 21) of patients had chronic sinusitis requiring functional endoscopic sinus surgery and 20% (n = 21) had symptomatic nasal obstruction requiring operative debridement. CONCLUSION Sinonasal complications, including nasal obstruction and chronic sinusitis, occur frequently after definitive treatment of sinonasal malignancy and should be addressed when considering quality of life in survivors. These complications occur more frequently in patients who undergo chemoradiation as opposed to surgery alone.
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Affiliation(s)
- Jena Patel
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Chandala Chitguppi
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Swar Vimawala
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Gregory Epps
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Judd Fastenberg
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - James Evans
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Mindy Rabinowitz
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Marc Rosen
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Gurston Nyquist
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA
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15
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Ringel B, Abergel A, Horowitz G, Safadi A, Zaretski A, Yanko R, Margalit N, Fliss DM. Skull Base Reconstruction with Multilayered Fascia Lata: A Single-Center 17 Years Experience. J Neurol Surg B Skull Base 2020; 82:e217-e223. [PMID: 34306941 DOI: 10.1055/s-0039-3402013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022] Open
Abstract
Objective Reconstruction after open surgery of anterior skull base lesions is challenging. The fascia lata graft is our workhorse for achieving dural sealing and preventing cerebrospinal fluid leak and meningitis. This study seeks to analyze the donor and recipient site complication rates after fascia lata reconstruction. Methods This is a retrospective review of all open anterior skull base operations in which a double-layer fascia lata graft was used for the reconstruction of the defect from 2000 to 2016 at the Tel-Aviv Sourasky Medical Center, a tertiary referral center in Israel. Results Of the 369 patients operated for skull base lesions, 119 underwent open anterior skull base surgery and were reconstructed with a fascia lata graft. The patients' mean age was 47.1 years, and 68 (57.1%) were males. The overall postoperative early and late donor site complication rates were 6.7% ( n = 8) and 5.9% ( n = 7), respectively. Multivariate analysis found minor comorbidities and persistent/recurrent disease as being predictors for early-term complications. The overall postoperative early central nervous system (CNS) complication rate was 21.8% ( n = 26), while 12.6% ( n = 15) of the patients had late postoperative CNS complications. Conclusion Reconstruction of open anterior skull base lesions with fascia lata grafting is a safe procedure with acceptable complication and donor site morbidity rates.
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Affiliation(s)
- Barak Ringel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avraham Abergel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gilad Horowitz
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ahmad Safadi
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arik Zaretski
- Department of Plastics and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ravit Yanko
- Department of Plastics and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nevo Margalit
- Department of Neurosurgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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16
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Wang W, Vincent A, Sokoya M, Kohlert S, Kadakia S, Ducic Y. Free-Flap Reconstruction of Skull Base and Orbital Defects. Semin Plast Surg 2019; 33:72-77. [PMID: 30863216 DOI: 10.1055/s-0039-1677881] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Orbital and anterior skull base defects present a significant challenge for reconstruction due to the complexity of the anatomy and the need for separation of intracranial and extracranial contents in this area. While endoscopic techniques have revolutionized the treatment of many anterior skull base defects, microvascular free tissue transfer is a viable option for large volume defects not suitable for traditional open approaches or for cases where endoscopic techniques have failed. The various free tissue transfer techniques for anterior skull base and orbit, as well as the advantages and disadvantages, are reviewed.
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Affiliation(s)
- Weitao Wang
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York
| | - Aurora Vincent
- Otolaryngology - Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Mofiyinfolu Sokoya
- Department of Facial Plastic and Reconstructive Surgery, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Scott Kohlert
- Department of Facial Plastic and Reconstructive Surgery, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Sameep Kadakia
- Division of Otolaryngology, Wright State University, Dayton, Ohio
| | - Yadranko Ducic
- Department of Facial Plastic and Reconstructive Surgery, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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17
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Ziai H, Yu E, Fu T, Muhanna N, Monteiro E, Vescan A, Zadeh G, Witterick IJ, Goldstein DP, Gentili F, de Almeida JR. Impact of Dural Resection on Sinonasal Malignancies with Skull Base Encroachment or Erosion. J Neurol Surg B Skull Base 2018; 79:419-426. [PMID: 30210968 PMCID: PMC6133664 DOI: 10.1055/s-0037-1612617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/13/2017] [Indexed: 02/03/2023] Open
Abstract
Objectives (1) To determine the occult rate of dural invasion in patients with tumors extending to and/or eroding the bony anterior skull base but without evidence of dural invasion on preoperative imaging. (2) To determine the impact of dural resection and of skull base erosion on survival outcomes in this group of patients (without evidence of dural invasion upon preoperative imaging). Study Design Retrospective study. Setting Tertiary care academic center. Participants Patients with sinonasal malignancies with anterior skull base encroachment/erosion without dural invasion on preoperative imaging treated surgically. Main Outcome Measures (1) Histopathologic disease in the dura in patients who had dural resection and (2) Oncologic outcomes (5-year local recurrence, dural recurrence, disease-specific survival, and overall survival) in patients with and without dural resection, and patients with and without skull base erosion. Results Thirty-seven patients were included. The occult rate of dural invasion was 54%. Patients with dural resection had improved margin control versus those without dural resection (90% vs 56%, p = 0.02). Dural resection improved 5-year overall survival only in patients with esthesioneuroblastoma compared with bony skull base resection alone (100% vs 75%, p = 0.03). Patients with skull base erosion had reduced local control versus those without erosion (63% vs 93%, p = 0.047). Conclusion This study suggests a substantial rate of occult dural invasion despite no overt imaging findings. Dural resection may be associated with improved margin control, but no oncologic benefit except for esthesioneuroblastomas, although treatment heterogeneity and small sample size may limit conclusions.
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Affiliation(s)
- Hedyeh Ziai
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Eugene Yu
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Terence Fu
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nidal Muhanna
- Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Eric Monteiro
- Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Allan Vescan
- Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Ian J. Witterick
- Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - David P. Goldstein
- Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada
| | - Fred Gentili
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - John R. de Almeida
- Department of Otolaryngology Head and Neck Surgery, University of Toronto, Toronto, Canada
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18
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Ringel B, Carmel-Neiderman NN, Peri A, Ben Ner D, Safadi A, Abergel A, Margalit N, Fliss DM. Continuous lumbar drainage and the postoperative complication rate of open anterior skull base surgery. Laryngoscope 2018; 128:2702-2706. [DOI: 10.1002/lary.27266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Barak Ringel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery; Tel Aviv Israel
| | | | - Aviyah Peri
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery; Tel Aviv Israel
| | - Daniel Ben Ner
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery; Tel Aviv Israel
| | - Ahmad Safadi
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery; Tel Aviv Israel
| | - Avraham Abergel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery; Tel Aviv Israel
| | - Nevo Margalit
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Dan M. Fliss
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery; Tel Aviv Israel
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19
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Batra PS, Citardi MJ, Worley S, Lee J, Lanza DC. Resection of Anterior Skull Base Tumors: Comparison of Combined Traditional and Endoscopic Techniques. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240501900517] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Traditional craniofacial resection (tCFR) has been used successfully for resection of anterior skull base (ASB) tumors. Minimally invasive endoscopic resection (MIER) also has been used recently; this strategy facilitates superior visualization, avoids facial incisions, and preserves local structures. The goal of this study was to compare the outcome for these two approaches. Methods Retrospective chart analysis was conducted to identify patients undergoing resection of ASB tumors between January 1995 and January 2003. Demographic data, tumor characteristics, and the surgical approach used were determined. The mean operative time, estimated blood loss, hospital stay, and complications were analyzed. Recurrence and mortality rates were calculated. Results Nine patients were managed with the MIER approach, and 16 patients were treated with the traditional open approach. No significant difference was observed between groups on operative time, estimated blood loss, or hospital stay. Major complications were encountered in 2/9 (22%) and 7/16 (44%) patients in the MIER and tCFR groups, respectively. Recurrence was observed in 3/9 (33%) and 5/14 (36%) of the patients in the MIER and tCFR groups, respectively. Mortality rates in the MIER and tCFR groups were 0/9 (0%) and 4/15 (27%), respectively. Conclusion In this preliminary study, MIER of ASB neoplasia did not differ significantly from tCFR in operative time, estimated blood loss, hospital stay, or complication rate. Survival and recurrence rates were similar also. This early experience suggests that MIER is a viable alternative for the surgical management of ASB lesions in appropriately selected patients.
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Affiliation(s)
| | | | - Sarah Worley
- Collaborative Biostatistics Center, Cleveland, Ohio
| | - Joung Lee
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Donald C. Lanza
- Sinus and Nasal Institute of Florida, St. Petersburg, Florida
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20
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Roh HJ, Batra PS, Citardi MJ, Lee J, Bolger WE, Lanza DC. Endoscopic Resection of Sinonasal Malignancies: A Preliminary Report. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240401800409] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background A minimally invasive endoscopic approach for the management of sinonasal malignancy offers several advantages including excellent illumination, maximal preservation of uninvolved vital structures, and sparing of facial incisions. The purpose of this study was to evaluate the outcome and morbidity of endoscopic resection with or without combined radiotherapy and/or chemotherapy. Methods Forty-seven patients with sinonasal malignancy were diagnosed and/or treated with an endoscopic approach at The Cleveland Clinic Foundation and The University of Pennsylvania Medical Center from 1996 to 2003. Nineteen patients fulfilled the study criteria and had a minimally invasive endoscopic resection. Fifteen patients were treated with curative intent and four patients underwent palliative resection. Results The mean age was 56.9 (9–78 years) years and the mean follow-up period was 26.4 months. Combined radiation with or without chemotherapy pre- or postoperatively was given to 15 of 19 (78.9%) patients. Thirteen patients were resected strictly with an endoscopic approach and six patients were resected in combination with neurosurgery. There were no peri- and postoperative deaths. The local recurrence (LR) rate was 26.3% (5/19) and the distant metastasis rate was 15.8% (3/19). Overall survival rate (OS) was 78.9% (15/19) at a mean follow-up duration of 32.1 (4–74 months) months. The disease-free survival (DFS) rate was 68.4% (13/19) by clinical, endoscopic, and radiographic surveillance at a mean follow-up duration of 33.1 months. Patients treated with curative intent had LR, OS, and DFS rates of 21.4, 85.7, and 85.7%, respectively, and the patients treated for palliation had LR, OS, and DFS rates of 40, 60, and 15%, respectively. Conclusion Minimally invasive endoscopic resection of sinonasal malignancy in combination with adjunctive therapies reduces treatment morbidity and yields LR, OS, and DFS rates that are comparable with traditional anterior craniofacial approaches.
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Affiliation(s)
- Hwan-Jung Roh
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine, Pusan National University, Pusan, Korea
| | - Pete S. Batra
- Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland, Ohio
| | - Martin J. Citardi
- Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland, Ohio
| | - Joung Lee
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - William E. Bolger
- Department of Otolaryngology, Uniformed Services University of the Health Science University, Bethesda, Maryland
| | - Donald C. Lanza
- Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland, Ohio
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21
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Leong JL, Citardi MJ, Batra PS. Reconstruction of Skull Base Defects after Minimally Invasive Endoscopic Resection of Anterior Skull Base Neoplasms. ACTA ACUST UNITED AC 2018; 20:476-82. [PMID: 17063741 DOI: 10.2500/ajr.2006.20.2931] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The endoscopic resection of the cribriform plate during minimally invasive endoscopic resection (MIER) of the anterior skull base neoplasms may result in large anterior skull base defects. The objective of this study is to describe techniques for the management of skull base defects after MIER. Methods Retrospective analysis was performed on patients undergoing MIER and skull base reconstruction between April 2000 and August 2005. Results Fourteen patients underwent endoscopic resection of anterior skull base tumors and reconstruction during the study period. The mean age was 57.4 years (range, 26–84 years). The sex distribution was eight men and six women. The specific indications for resection included 11 malignant and 3 benign neoplasms. Ten patients received adjuvant therapy, and in two instances this occurred before surgery. In all instances, the dura was exposed; however, only 10 cerebrospinal fluid (CSF) leaks were encountered intraoperatively. Reconstruction of the skull base was successfully performed, most commonly in a multilayer fashion, using an array of materials including cartilage, fat, acellular dermal graft, and mucosal free grafts. Lumbar drain placement was used in seven cases for an average of 5.6 days. No postoperative CSF leaks occurred. The mean follow-up was 18.0 months (range, 1–56 months). Conclusion This report describes methods for the reconstruction of the skull base after MIER. Reconstitution of the skull base barrier can be achieved through application of principles for surgical repair of CSF rhinorrhea.
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Affiliation(s)
- Jern-Lin Leong
- Department of Otolaryngology, Singapore General Hospital, Singapore
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22
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Teshima M, Shinomiya H, Otsuki N, Kimura H, Taniguchi M, Hashikawa K, Kohmura E, Nibu KI. Complications in Salvage Surgery for Nasal and Paranasal Malignant Tumors Involving the Skull Base. J Neurol Surg B Skull Base 2017; 79:224-228. [PMID: 29765819 DOI: 10.1055/s-0037-1606382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 07/30/2017] [Indexed: 10/18/2022] Open
Abstract
Objective Nasal and paranasal malignant tumors invading the skull base are rare and poorly studied. We evaluated postoperative complications in patients undergoing salvage surgery for such tumors. Design Retrospective study. Setting Kobe University Hospital. Participants Among 48 patients who underwent surgery for tumors involving the skull base between 1993 and 2015, 21 patients had squamous cell carcinoma, 13 had olfactory neuroblastoma, 5 had adenocarcinoma, 2 had sarcoma, 2 had adenoid cystic carcinoma, and 1 each had malignant melanoma, poorly differentiated carcinoma, undifferentiated carcinoma, myoepithelial carcinoma, and malignant peripheral nerve sheath tumor. Prior to skull base surgery, radiotherapy, chemoradiotherapy (CRT), particle radiotherapy, chemotherapy, or surgery were applied in 3, 15, 4, 5, and 3 patients, respectively. Main Outcome Measures Main outcome measures were postoperative complications in patients who underwent skull base surgery after concomitant CRT and/or particle therapy. Results Major postoperative complications were observed in 14 surgical procedures (29%; 2 patients with cerebral herniation, 3 with cerebrospinal fluid leakages, 3 with meningitis, 1 with hydrocephalus, 6 with epidural abscesses, 2 with local infections, and 2 with partial flap necrosis). Four patients developed ≥2 complications. One patient died of postoperative lung infarction. Three (16.7%) of 18 patients without prior treatment and 9 (50%) of 18 patients who underwent preoperative radiotherapy/CRT had severe postoperative complications. Two (50%) of four patients treated with particle radiotherapy had postoperative complications. Conclusions CRT or particle radiotherapy were significantly associated with a high risk of severe postoperative complications after skull base surgery. Meticulous care should be taken in patients treated with radiotherapy/particle therapy prior to skull base surgery.
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Affiliation(s)
- Masanori Teshima
- Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirotaka Shinomiya
- Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Otsuki
- Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazunobu Hashikawa
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ken-Ichi Nibu
- Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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23
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Perkins EL, Brandon BM, Sreenath SB, Desai DD, Thorp BD, Ebert CS, Zanation AM. Transfacial and Craniofacial Approaches for Resection of Sinonasal and Ventral Skull Base Malignancies. Otolaryngol Clin North Am 2017; 50:287-300. [PMID: 28162241 DOI: 10.1016/j.otc.2016.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Malignancies of the paranasal sinuses and ventral skull base present unique challenges to physicians. A transfacial or craniofacial approach allows for wide, possibly en bloc, resection and is ideal for tumors that involve surrounding soft tissue, the palate, the orbit, anterolateral frontal sinus, and lateral dura. Transfacial approaches include a lateral rhinotomy often combined with a medial, subtotal, or total maxillectomy. Reconstruction is most commonly performed with a pericranial flap to separate the intranasal and intracranial compartments. These approaches have evolved and been refined but now are usually reserved for advanced tumors not amenable to endoscopic resection.
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Affiliation(s)
- Elizabeth L Perkins
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA
| | - Bryan M Brandon
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA
| | - Satyan B Sreenath
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA
| | - Dipan D Desai
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA
| | - Brian D Thorp
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA
| | - Charles S Ebert
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA; Department of Neurosurgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Physician's Office Building Room G-190, Chapel Hill, NC 27599, USA.
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Siddiqui F, Smith RV, Yom SS, Beitler JJ, Busse PM, Cooper JS, Hanna EY, Jones CU, Koyfman SA, Quon H, Ridge JA, Saba NF, Worden F, Yao M, Salama JK. ACR appropriateness criteria ® nasal cavity and paranasal sinus cancers. Head Neck 2016; 39:407-418. [PMID: 28032679 DOI: 10.1002/hed.24639] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/10/2016] [Indexed: 11/09/2022] Open
Abstract
The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Here, we present the Appropriateness Criteria for cancers arising in the nasal cavity and paranasal sinuses (maxillary, sphenoid, and ethmoid sinuses). This includes clinical presentation, prognostic factors, principles of management, and treatment outcomes. Controversies regarding management of cervical lymph nodes are discussed. Rare and unusual nasal cavity cancers, such as esthesioneuroblastoma and sinonasal undifferentiated carcinomas, are included. © 2016 American College of Radiology. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 407-418, 2017.
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Affiliation(s)
| | - Richard V Smith
- Montefiore Medical Center, American College of Surgeons, Bronx, New York
| | - Sue S Yom
- University of California San Francisco, San Francisco, California
| | | | - Paul M Busse
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ehab Y Hanna
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Harry Quon
- Johns Hopkins University, Baltimore, Maryland
| | - John A Ridge
- Fox Chase Cancer Center, American College of Surgeons, Philadelphia, Pennsylvania
| | - Nabil F Saba
- Emory University, American Society of Clinical Oncology, Atlanta, Georgia
| | - Francis Worden
- University of Michigan, American Society of Clinical Oncology, Ann Arbor, Michigan
| | - Min Yao
- University Hospitals Case Medical Center, Cleveland, Ohio
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Miller JD, Taylor RJ, Ambrose EC, Laux JP, Ebert CS, Zanation AM. Complications of Open Approaches to the Skull Base in the Endoscopic Era. J Neurol Surg B Skull Base 2016; 78:11-17. [PMID: 28180037 DOI: 10.1055/s-0036-1583948] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 03/27/2016] [Indexed: 10/21/2022] Open
Abstract
Objective It is important to characterize the developing complication profile of the open approach as it becomes reserved for more complex disease during the endoscopic era. Our objective was to characterize complication rates of current open skull base surgery. Design Retrospective chart review. Setting Tertiary care center. Participants The study group consisted of 103 patients and 117 open skull base surgeries were performed from 2008 to 2012. Main Outcome Measures Intraoperative/postoperative complications. Methods Fisher exact test and Wilcoxon rank sum test evaluated for associations of complications with potential risk factors. Results Postoperative complications occurred in 53 (45%) cases, of which 36 (31%) were major complications. Malignancy, dural grafting, age, and obesity were not associated with complications. Flap reconstruction was associated with increased complication rates (odds ratio = 2.27; 95% confidence interval: 1.03-5.04). Conclusion The open approach is increasingly utilized for only the most complex lesions, and selection bias cannot be overstated in comparative series. This study suggests that current open complication rates may be above those cited from prior studies, and patient and physician expectations should be adjusted accordingly.
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Affiliation(s)
- Justin D Miller
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Robert J Taylor
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Emily C Ambrose
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado, Denver, Colorado, United States
| | - Jeffrey P Laux
- Translational and Clinical Sciences Institute, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Charles S Ebert
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
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Chepeha DB, Wang SJ, Marentette LJ, Thompson BG, Prince ME, Teknos TN. Radial Forearm Free Tissue Transfer Reduces Complications in Salvage Skull Base Surgery. Otolaryngol Head Neck Surg 2016; 131:958-63. [PMID: 15577797 DOI: 10.1016/j.otohns.2004.05.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE: Patients who undergo skull base resection after prior surgery or radiation may be at high risk for complications when local flaps alone are used for reconstruction. To determine whether the complication rate could be reduced, fasciocutaneous free tissue transfer was used to reinforce the dural closure in patients who had prior skull base surgery or radiation. METHODS: This study is a case series of 20 patients (14 males, 6 females, aged 8–79 years of age with a mean of 47.7 years) from 1997 to 2001 who had prior skull base surgery or radiation, and underwent salvage skull base resection without large volume defects. All patients had a radial forearm free tissue transfer to reinforce the dural closure. Six patients had an osseous component to the forearm flap to provide vascularized bone to the orbital rim. RESULTS: The overall local complication rate was 35%. Three patients (15%) had major complications including 1 case of meningitis, 1 case of cerebrospinal fluid leak, and 1 case of a flap requiring venous salvage. There were no flap failures, 1 idiopathic median nerve palsy, and no pathologic radius bone fractures. CONCLUSION: Reconstruction with fasciocutaneous free tissue transfer for high-risk patients with low-volume dural defects following skull base resection can minimize the risk of major postoperative complications. EBM rating: C.
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Affiliation(s)
- Douglas B Chepeha
- Department of Otolaryngology--Head and Neck Surgery, University of Michigan Health System, Ann Arbor 48109-0312, USA.
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Rodrigues M, O'malley BW, Staecker H, Tamargo R. Extended pericranial flap and bone graft reconstruction in anterior skull base surgery. Otolaryngol Head Neck Surg 2016; 131:69-76. [PMID: 15243560 DOI: 10.1016/j.otohns.2004.02.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES: The objectives of this study was to establish a rationale for repairing large anterior skull base defects with an extended pericranial flap and split calvarial bone graft; to define large anterior skull base defects as those spanning the anterior cranial measuring at least 3.0 × 4.0 cm; and to describe the surgical technique and compare it with alternative strategies. STUDY DESIGN: Thirty-four patients underwent anterior craniofacial resection of anterior skull-based tumors of varying histology with reconstruction using an extended pericranial flap and split calvarial bone graft. RESULTS: The survival of the pericranial flap and bone graft was maintained in 33 of 34 patients. There was 1 episode of postoperative cerebrospinal fluid leak, 1 episode of osteomyelitis of the bone graft and an epidural abscess, and 1 episode of asymptomatic pneumocephalus. CONCLUSION: Split calvarial bone graft with an extended pericranial flap is an effective technique for reconstructing large anterior skull base defects.
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Affiliation(s)
- Michael Rodrigues
- University of Maryland School of Medicine, University of Maryland Hospital, Baltimore, MD, USA
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Use of Intraoperative Fluorescent Indocyanine Green Angiography for Real-Time Vascular Evaluation of Pericranial Flaps. Ann Plast Surg 2016; 76:198-204. [DOI: 10.1097/sap.0000000000000519] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ohno K, Tsunoda A, Ariizumi Y, Ohno K, Sumi T, Sugimoto T, Kishimoto S. [Combined Anterior Craniofacial Resection for Locally Advanced Ethmoid Carcinomas]. ACTA ACUST UNITED AC 2016; 118:1037-45. [PMID: 26548097 DOI: 10.3950/jibiinkoka.118.1037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Carcinoma of the ethmoid sinus is very rare, and treatment for locally advanced tumors remains as a formidable challenge to the clinician. We reviewed cases of ethmoid carcinoma in which anterior craniofacial resection had been undertaken and evaluated the safety and validity of the operative methods. METHODS We retrospectively reviewed 13 patients with ethmoid carcinoma who underwent combined anterior craniofacial resection. We evaluated the surgical procedures, complications, outcomes, local recurrence, and the survival rate. RESULTS Coronal incision and anterior craniotomy were performed in all cases. Four out of 13 cases underwent ipsilateral orbital exenteration due to involvement of the orbital contents. There were no potentially fatal complications, except for two cases of epidural abscesses which were successfully cured. Positive surgical margins were observed in 6 patients, and they received postoperative radiotherapy and/or chemotherapy. Local recurrences occurred in 4 cases, and 3 died at 9, 11, and 49 months after the surgery. Distant metastasis was not observed during the observation period. The overall 5-year survival rate was 75.2% (Kaplan-Meier method). CONCLUSION These tumors were safely removed without severe complications and postoperative mortality. Combined anterior craniofacial resection is an effective and safe option for treatment of locally advanced ethmoid carcinomas after various preoperative treatments.
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Kim YS, Moon KS, Kim GW, Lim SC, Lee KH, Jang WY, Jung TY, Kim IY, Jung S. Role of Craniofacial Resection for Malignant Tumors Involving the Anterior Skull Base: Surgical Experience in a Single Institution. Brain Tumor Res Treat 2015; 3:81-8. [PMID: 26605262 PMCID: PMC4656900 DOI: 10.14791/btrt.2015.3.2.81] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/24/2015] [Accepted: 07/13/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Craniofacial resection (CFR) has been regarded as a standard treatment for various tumors involving the anterior skull base. The purpose of this study was to evaluate the results of CFR for the patients with anterior skull base malignancies in our hospital. METHODS We retrospectively analyzed 17 patients with anterior skull base malignancies treated with CFR between 2001 and 2012. Mean follow-up duration was 41 months (range, 2-103 months). RESULTS Intracranial involvement was found in 11 patients (65%) and orbital extension in 6 patients (35%). Classical bifrontal craniotomy was combined with endoscopic endonasal approach in 14 patients and external approach in 3 patients. Vascularized flap was used for reconstruction of the anterior fossa floor in 16 patients (94%). The most common pathological type was squamous cell carcinoma (6 patients). Gross total resection was achieved in all cases. Postoperative complications developed in 4 patients (24%) and included local wound problem and brain abscess. One patient with liver cirrhosis died from unexpected varix bleeding after the operation. Although postoperative treatment, such as radiotherapy or chemotherapy, was performed in 14 patients, local recurrence was seen in 6 patients. The mean overall survival time after the operation was 69.0 months (95% confidence interval: 47.5-90.5 months) with a 1-, 2-, and 5-year survival rate of 82.3%, 76.5%, and 64.7%, respectively. Postoperative radiotherapy was found to be the powerful prognostic factor for favorable survival. CONCLUSION Considering the higher local control rate and acceptable complication or mortality rate, CFR with adjuvant radiotherapy is a gold standard treatment option for malignant tumors involving anterior skull base, especially with extensive intracranial involvement.
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Affiliation(s)
- You-Sub Kim
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Gun-Woo Kim
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sang Chul Lim
- Department of Otorhinolaryngology-Head and Neck Surgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Kyung-Hwa Lee
- Department of Pathology, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Woo-Youl Jang
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Research Institute of Medical Sciences, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Endoscopic endonasal resection of esthesioneuroblastoma: A single center experience of 24 patients. Clin Neurol Neurosurg 2015; 138:94-8. [PMID: 26310690 DOI: 10.1016/j.clineuro.2015.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/07/2015] [Accepted: 08/09/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Esthesioneuroblastoma (ENB) is an uncommon malignant tumor. During the past decade, endoscopic approaches have been gradually applied in treating skull base tumors. However, the experience in using this approach to treat ENB is still limited. Kadish staging and Dulguerov staging are common methods used for ENB staging, but it remains unclear as to which method is better. In this study, we reviewed our experiences with endoscopic surgeries for ENB and analyzed the prognostic roles of the two staging methods. METHODS A total of 24 patients with ENB treated with only endoscopic endonasal surgery between January 2001 and March 2012 were included. Overall survival (OS) and disease-free survival (DFS) were analyzed using the Kaplan-Meier method and early and advanced stages were compared using the log-rank test. The prognostic roles of the two staging methods were also analyzed. RESULTS Amongst the 24 patients, 19 patients presented with newly diagnosed ENB, and 5 patients presented with recurrent disease. The three-year OS and DFS rates were 82% and 70.8%, respectively. Four patients (16.6%) died from recurrence of the tumor. Dulguerov staging predicted OS with significant differences (P=0.042), whereas Kadish staging predicted DFS with significant differences (P=0.020) between the early and advanced stages. CONCLUSIONS The present study showed experiences that purely endoscopic endonasal surgery for ENB showed successful survival results with remarkably decreased complications. Dulguerov staging and Kadish staging play different prognostic roles in patients treated with purely endoscopic endonasal resection based on various end points.
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Manjunath L, Derousseau T, Batra PS. Prognostic value of surgical margins during endoscopic resection of paranasal sinus malignancy. Int Forum Allergy Rhinol 2015; 5:454-9. [PMID: 25758938 DOI: 10.1002/alr.21463] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 09/29/2014] [Accepted: 10/21/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Complete tumor resection with intraoperative frozen section control remains a central tenet of head and neck surgical oncology. The purpose of this study was to evaluate the significance of margins in predicting recurrence and disease status following endoscopic resection of sinonasal malignancy. METHODS This single-institution observational cohort study was performed on 68 patients over a 5-year period who underwent curative minimally invasive endoscopic resection (MIER) for sinonasal malignancies. RESULTS The mean age was 58.8 years and 69.1% were male. The mean follow-up after definitive MIER was 15.9 months. A mean of 10.8 margins were taken per surgery (range, 2 to 27). False-negative frozen section analysis was 22.1% for the entire cohort, but slightly higher at 25.0% for T3 or T4 malignancies. At last follow-up, no evidence of disease (NED) status was noted in 60.0% of those with positive margins vs 83.0% in those with negative margins, respectively (p = 0.0795). Regional or distant recurrences were observed in 39.9% of patients with positive margins and 13.2% of those with negative margins, respectively (p = 0.0299). Disease-free survival (DFS) was 9.7 months for patients with positive margins, whereas it was 15.9 months for patients with negative margins. CONCLUSION Disease-free status as a function of residual microscopic disease did not prove to be statistically significant. However, positive margins were correlated with a statistically significant increase in regional or distant recurrence. This suggests that complete resection with clear margins can impact oncologic outcomes in patients managed by MIER for sinonasal cancers.
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Affiliation(s)
| | | | - Pete S Batra
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
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Krischek B, Carvalho FG, Godoy BL, Kiehl R, Zadeh G, Gentili F. From craniofacial resection to endonasal endoscopic removal of malignant tumors of the anterior skull base. World Neurosurg 2015; 82:S59-65. [PMID: 25496637 DOI: 10.1016/j.wneu.2014.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/25/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review the current literature and provide our institutional approach and opinion on the indications and limitations of traditional open craniofacial resection (CFR) and a minimally invasive pure endonasal endoscopic approach for anterior skull base tumors concentrating primarily on malignant lesions. METHODS Based on 3 decades of experience with both open and more recently endoscopic techniques, we examined our current practice in treating tumors and other lesions involving the skull base and our current indications and limitations in the use of these techniques. We conducted a retrospective chart analysis to see which operative techniques were used for malignant tumors of the anterior skull base in the last 10 years at our institution. RESULTS There were 30 cases identified. Traditional CFR was performed in 16, a pure endoscopic resection was performed in 9, and an endoscopic procedure combined with a frontal craniotomy was performed in 5. Gross total resection was achieved in 83.3% in the CFR group and 75% in the pure endoscopic resection group. Near-total resection was 10% in the CFR group and 33.3% in pure endoscopic resection group. Of the 5 patients who underwent a combined approach, 80% had gross total resection, and 20% had near-total resection. CONCLUSIONS Both traditional CFR and the endonasal endoscopic approach offer advantages and disadvantages. Both approaches can achieve good results with appropriate patient selection. Numerous important factors, including location and the extent of tumor, should be taken into consideration when considering either approach. The most important determinant of outcome is the ability to achieve gross total resection with microscopic negative margins rather than the type of approach used. In the future, skull base surgeons will need to be familiar with and capable of offering both techniques to the patient.
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Affiliation(s)
- Boris Krischek
- Department of Neurosurgery, University of Cologne, Germany; Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Felipe G Carvalho
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | | | - Rasmus Kiehl
- Department of Neuropathology, University Health Network, Toronto, Canada
| | - Gelareh Zadeh
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada.
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Analysis of Morbidity and Mortality in Patients Undergoing Skull Base Reconstruction. J Craniofac Surg 2015; 26:135-40. [DOI: 10.1097/scs.0000000000001399] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Wessell A, Singh A, Litvack Z. Preservation of olfaction after unilateral endoscopic approach for resection of esthesioneuroblastoma. J Neurol Surg Rep 2014; 75:e149-53. [PMID: 25083376 PMCID: PMC4110124 DOI: 10.1055/s-0034-1376427] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022] Open
Abstract
Objectives We present a case of olfactory preservation after a unilateral transcribriform transethmoidal endoscopic resection of esthesioneuroblastoma. We also discuss the oncologic results of endoscopic and transcranial approaches and describe the potential benefits and limitations of an endoscopic approach. Setting Single academic medical center. Participant and Design The clinical course of a 28-year-old patient who underwent endoscopic en bloc resection of esthesioneuroblastoma through a unilateral transcribriform transethmoidal approach was reviewed. Results Imaging demonstrated a left-sided nasal mass with cribriform plate involvement (Kadish C). Intraoperatively, the left olfactory bulb and epithelium were sacrificed. Negative frozen sections were obtained from the right olfactory epithelium and dura surrounding the right olfactory bulb. Reconstruction was performed using a multilayered closure of fascia, rigid buttress, and nasoseptal flap. Histology was consistent with esthesioneuroblastoma. Postoperative clinical evaluation, endoscopy, and magnetic resonance imaging demonstrated no evidence of residual or recurrent tumor at 18 months. The UPSIT smell testing revealed normal olfaction preoperatively, moderate microsomia at 3 months postoperatively, and mild microsomia at 18 months postoperatively. Conclusions Endoscopic resection of esthesioneuroblastoma has demonstrated similar oncologic control while reducing postoperative morbidity and mortality over transcranial approaches. This case reveals the potential to preserve olfaction while achieving en bloc endoscopic resection of early stage esthesioneuroblastoma.
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Affiliation(s)
- Aaron Wessell
- School of Medicine, The George Washington University Medical Center, Washington, District of Columbia, United States
| | - Ameet Singh
- Department of Surgery, Division of Otolaryngology, The George Washington University Medical Center, Washington, District of Columbia, United States
| | - Zachary Litvack
- Department of Neurosurgery, The George Washington University Medical Center, Washington, District of Columbia, United States
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Banu MA, Szentirmai O, Mascarenhas L, Salek AA, Anand VK, Schwartz TH. Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks. J Neurosurg 2014; 121:961-75. [PMID: 24995788 DOI: 10.3171/2014.5.jns132028] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS. METHODS The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1-10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0-4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak. RESULTS The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed "suspicious" pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as "benign" pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0-4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of "suspicious" pneumocephalus provides the best overall prediction for postoperative CSF leaks. CONCLUSIONS Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A "suspicious" pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of "suspicious" pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.
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Affiliation(s)
- Matei A Banu
- Departments of Neurological Surgery, Brain and Spine Center
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Abstract
Treatment of skull base tumors involves multiple specialities. The lesions are usually advanced and the treatment is often associated with unfavorable results, which may be functional and/or aesthetic. Here we have done an analysis for the complications and unfavorable results of 546 cases treated surgically by a single craniofacial surgeon over a period of 14 years. The major morbidity ranges from death to permanent impairment of vital organ functions (brain, eye, nose), infections, tissue losses, flap failures, treatment associated complications, psychosocial issues, and aesthesis besides others. This article is aimed at bringing forth these unfavorable results and how to avoid them.
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Affiliation(s)
- Hemen Jaju
- Consultant, Jaju Plastic Surgery Center, and Department of Plastic Surgery, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
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Gray ST, Lin A, Curry WT, Barker FG, Busse P, Sanan A, Deschler DG, Lin DT. Delayed complications after anterior craniofacial resection of malignant skull base tumors. J Neurol Surg B Skull Base 2013; 75:110-6. [PMID: 24719797 DOI: 10.1055/s-0033-1359306] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 09/18/2013] [Indexed: 10/25/2022] Open
Abstract
Objective To report complications occurring at least 6 months after completion of treatment for patients with anterior skull base malignancy undergoing anterior craniofacial resection (CFR). Design Retrospective review of medical records of all patients undergoing traditional CFR for treatment of anterior skull base malignancy from 2002 through 2011. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Thirty-one consecutive patients who had at least 18 months of follow-up for analysis were reviewed. All patients underwent traditional CFR. A total of 28 patients received postoperative proton beam radiation therapy. Eleven patients received adjuvant chemotherapy. Main Outcome Measures A delayed complication was any complication occurring at least 6 months after the completion of treatment. Results Seventeen patients had delayed complications. Orbital complications were the most common type (13 patients) followed by issues with wound healing (6 patients). The most common orbital complication was epiphora (7 patients). The most common wound complication was a nasocutaneous fistula (5 patients). Conclusions Patients with anterior skull malignancy can develop complications months to years after the completion of treatment. Therefore, it is important to continue to follow and report complications for several years when deciding on the optimal approach for treatment of these patients.
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Affiliation(s)
- Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States ; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Alice Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States ; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - William T Curry
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Paul Busse
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Akshay Sanan
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States ; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Derrick T Lin
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States ; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
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The Reconstruction of the Spheno-Orbital Region Using Latissimus Dorsi Flap and Costal Graft. J Craniofac Surg 2013; 24:e379-83. [DOI: 10.1097/scs.0b013e31829031d6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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From craniofacial resection to the endonasal endoscopic approach in skull base surgery. World Neurosurg 2013; 80:56-8. [PMID: 23376383 DOI: 10.1016/j.wneu.2013.01.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 01/28/2013] [Indexed: 11/21/2022]
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Husain Q, Patel SK, Soni RS, Patel AA, Liu JK, Eloy JA. Celebrating the golden anniversary of anterior skull base surgery: reflections on the past 50 years and its historical evolution. Laryngoscope 2013; 123:64-72. [PMID: 23280942 DOI: 10.1002/lary.23687] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 06/29/2012] [Accepted: 07/25/2012] [Indexed: 01/18/2023]
Abstract
With its inception nearly half a century ago through the pioneering work of Dandy, McLean, and Smith, anterior skull base (ASB) surgery is a relatively young discipline. It became a distinct entity in 1963 when Ketcham popularized the combined transcranial transfacial approach for en bloc resection of tumors of the paranasal sinuses extending into the anterior cranial fossa. However, because these procedures resulted in major morbidities and mortalities, alternative modes of treatment were sought. Since the 1970s, the introduction and promotion of the surgical endoscope by Messerklinger, Stammberger, and Kennedy, commenced the era of endoscopic sinus surgery. Thaler and colleagues described the utility of the endoscope for ASB surgery at the turn of the century. This allowed direct visualization and safer, more accurate removal of tumors. In 2001, Casiano reported the first purely endoscopic endonasal ASB resection, a novel technique that has been adopted by major skull base centers. The success of ASB surgery can be attributed to both the development of the skull base team as well as improvements in surgical techniques, instrumentation, and visualization technology. In this article, we review the historical evolution of ASB surgery as we approach the 50th anniversary since its recognition as a distinct entity.
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Affiliation(s)
- Qasim Husain
- Department of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey 07103, USA
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Song CM, Won TB, Lee CH, Kim DY, Rhee CS. Treatment modalities and outcomes of olfactory neuroblastoma. Laryngoscope 2012; 122:2389-95. [PMID: 23070733 DOI: 10.1002/lary.23641] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 06/03/2012] [Accepted: 07/11/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To analyze the clinical features of olfactory neuroblastoma (ONB) and compare the treatment results according to various treatment modalities, and to validate various staging systems. STUDY DESIGN Retrospective analysis. METHODS This study included 35 patients with ONB. Treatment consisted of neoadjuvant chemotherapy and radiation therapy (seven patients), traditional craniofacial resection (TCFR, 12 patients), endoscopic craniofacial resection with craniotomy (ECFR, 11 patients), and transnasal endoscopic resection without craniotomy (five patients). The overall mean follow-up period was 64.9 months and mean disease-free survival (DFS) was 50.2 months. RESULTS Five-year overall survival and 5-year DFS rates were 76.0% and 61.8%, respectively. Five-year DFS rates for nonsurgical treatment, TCFR, ECFR, and transnasal endoscopic resection without craniotomy group were 35.7%, 41.7%, 80.8%, and 100%, respectively (P = .01). Neck metastasis negatively affected survival (P = .03). DFS rate of patients in the endoscopic surgery group was higher than the nonendoscopic surgery group on Cox multivariate regression analysis (P = .02). The modified Kadish classification system predicted DFS more accurately than the Biller and Dulguerov classification system (P = .04). Locoregional recurrence occurred in 23% (period of recurrence after treatment, mean 49 months; range, 3-143) of patients with ONB, and distant metastasis in 26%. ECRF group showed lesser perioperative bleeding amount and shorter operation time compared with TCFR. However, the admission period was not statistically different. CONCLUSIONS Endoscopic surgery for advanced ONB showed successful survival results compared with nonendoscopic surgery on multivariate analysis, and limited morbidities. Modified Kadish classification best predicted DFS for ONB. Long-term follow-up is necessary due to its late recurrence.
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Affiliation(s)
- Chang Myeon Song
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, South Korea
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Efficacy of transnasal endoscopic resection for malignant anterior skull-base tumors. Int Forum Allergy Rhinol 2012; 2:487-95. [DOI: 10.1002/alr.21062] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 03/01/2012] [Accepted: 04/17/2012] [Indexed: 11/07/2022]
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Mai JC, Sekhar LN. Modern Management of Anterior Skull Base Tumors. World Neurosurg 2012; 78:60-1. [DOI: 10.1016/j.wneu.2012.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/12/2012] [Indexed: 12/25/2022]
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Abstract
Skull base surgery has undergone a revolution in recent decades with the introduction and development of new surgical approaches correlated with many modifications in this anatomically and functionally complex area. The most important progress has been possible with the advent of microsurgical flaps, which allow for the movement of large masses and different tissue components, providing effective separation and coverage of the endocranial content, replacement of the composite craniofacial defects, and reconstruction of poorly vascularized areas. To reduce the incidence of complications in the treatment of frontal recurrent mucoceles, accurate planning of reconstruction is mandatory. We introduce 2 cases involving anterior cranial base repair after radical resection of chronically infected tissues in patients affected by frontal recurrent mucoceles. Reconstruction was accomplished through a forearm flap and a frontal bone reconstruction with custom-made prosthesis.
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Raza SM, Garzon-Muvdi T, Gallia GL, Tamargo RJ. Craniofacial resection of midline anterior skull base malignancies: a reassessment of outcomes in the modern era. World Neurosurg 2011; 78:128-36. [PMID: 22120268 DOI: 10.1016/j.wneu.2011.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 06/23/2011] [Accepted: 09/04/2011] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Craniofacial resection has been considered the gold standard in the management of malignancies involving the anterior skull base, where the goal of surgery is negative margins with minimal morbidity. In recent years, there has been growing enthusiasm for purely endoscopic techniques for craniofacial malignancies. Given recent advancements in open surgical approaches, there is a need to review the technique of open craniofacial resection in the modern surgical era. METHODS We review our experience of open craniofacial resection of midline anterior cranial fossa malignancies in the modern era. RESULTS Between 1995 and 2009, 41 patients underwent bifrontal craniotomy/craniofacial resection for malignancy. A subset of patients had undergone previous treatment, i.e., transfacial resection (34%), chemotherapy (5%), and radiation therapy (10%). Esthesioneuroblastoma (29%) was the most common pathology, followed by squamous cell carcinoma (27%) and the remaining patients presented with various histologic subtypes. All tumors invaded the cribriform plate; tumors invaded dura in 51%, parenchyma in 17% and orbit in 54% of patients. Negative margins were obtained in 85% of the cohort. Postoperative complications included seizure (one patient), cerebrospinal leak (one patient), and symptomatic pneumocephalus (two patients). CONCLUSION Since its introduction more than 50 years ago, craniofacial resection has undergone several important technical advancements concurrent to the introduction of endoscopy. With these improvements, our results indicate good oncologic disease control with minimal morbidity for extensive malignancies invading the intracranial cavity. With improvements in both open and endoscopic techniques, there is a need to reassess outcomes to determine relative indications.
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Affiliation(s)
- Shaan M Raza
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Abstract
One of the major challenges of cranial base surgery is reconstruction of basal dural defects. Ineffective reconstruction may result in potentially life-threatening complications such as cerebrospinal fluid leak, meningitis, and tension pneumocephalus. Goals of reconstructive procedures are to repair the dural defect and to separate intracranial contents from bacteria-laden secretion of the mouth, nose, and sinus. Different reconstructive techniques have been reported. Multiple factors may influence the surgical choice of reconstructive technique and its outcome. Regional pedicled flap and vascular free flaps represent the best reconstructive options because vascularized tissues promote fast and complete healing. A variety of endoscopic pedicled mucosal flaps within the nasal cavity have also been described. The different reconstruction techniques are described and discussed in terms of indications, advantages, and drawbacks.
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Terasaka S, Day JD, Fukushima T. Extended transbasal approach: anatomy, technique, and indications. Skull Base Surg 2011; 9:177-84. [PMID: 17171087 PMCID: PMC1656738 DOI: 10.1055/s-2008-1058144] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Appropriate indications for the transbasal approach have not been clearly established. The focus of this study is to determine the feasibility of maximal exposure of the clivus and surrounding regions via this strategy. Further, we sought to determine the key anatomical landmarks and morphometric data necessary for safe, radical exposure. In 20 injected cadaveric specimens, anatomical observations were made grossly and microscopically with 4-40 x magnification. The three basic variations of the transbasal craniotomy were compared with regard to surgical exposure. Maximum exposure of the ventral clivus could be obtained by total ethmoidectomy and sphenoidectomy through the extensive transbasal craniotomy. The lateral limits of exposure were found to be the optic nerves, intracavernous carotid arteries, and hypoglossal canals. Inferiorly, the foramen magnum is the limit of exposure. Morphometric measurements were determined between the key landmarks and were found helpful in subsequent dissections due to the lack of bony structures in relation to neural and vascular structures within the bone. The keys to optimizing the transbasal approach are beyond the simple initial steps of the craniotomy. Maximal exposure from the suprasellar compartment to the foramen magnum is possible via the extended transbasal approach.
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