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Douglas JE, Adappa ND, Choby G, Levine CG, Rabinowitz MR, Sindwani R, Wang EW, Woodworth BA, Kuan EC. American Rhinologic Society expert practice statement part 2: Postoperative precautions and management principles following endoscopic skull base surgery. Int Forum Allergy Rhinol 2024. [PMID: 38995330 DOI: 10.1002/alr.23406] [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: 05/19/2024] [Revised: 06/13/2024] [Accepted: 06/25/2024] [Indexed: 07/13/2024]
Abstract
The goal of this American Rhinologic Society expert practice statement (EPS) is to summarize the best available evidence regarding postoperative precautions for patients following endoscopic skull base surgery for intradural pathology. These topics include the administration of postoperative nasal hygiene; patient mobilization and activity level; the resumption of continuous positive airway pressure in patients with obstructive sleep apnea; and the timing and capacity with which a patient may be subjected to barotrauma, such as air travel postoperatively. This EPS was developed following the recommended methodology and approval process as previously outlined. Given the diverse practices and limited agreement on the accepted principles regarding postoperative precautions for patients following skull base surgery, this EPS seeks to summarize the existing literature and provide clinically relevant guidance to bring clarity to these differing practice patterns. Following a modified Delphi approach, four statements were developed, all of which reached consensus. Because of the paucity of literature on these topics, these statements represent a summation of the limited literature and the experts' opinions. These statements and the accompanying evidence are summarized below, along with an assessment of future needs.
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Affiliation(s)
- Jennifer E Douglas
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Garret Choby
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Corinna G Levine
- Department of Otolaryngology-Head & Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mindy R Rabinowitz
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Health System, Philadelphia, Pennsylvania, USA
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradford A Woodworth
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Edward C Kuan
- Departments of Otolaryngology-Head & Neck Surgery and Neurological Surgery, University of California, Irvine, California, USA
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Valencia-Sanchez BA, Kim JD, Zhou S, Chen S, Levy ML, Roxbury C, Patel VA, Polster SP. Special Considerations in Pediatric Endoscopic Skull Base Surgery. J Clin Med 2024; 13:1924. [PMID: 38610689 PMCID: PMC11013018 DOI: 10.3390/jcm13071924] [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: 02/16/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.
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Affiliation(s)
| | - Jeeho D. Kim
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Sheng Zhou
- USC Caruso Department of Otolaryngology-Head and Neck Surgery, Los Angeles, CA 90033, USA
| | - Sonja Chen
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
| | - Michael L. Levy
- Division of Pediatric Neurosurgery, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Neurosurgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology, University of Chicago Medicine, Chicago, IL 60637, USA;
| | - Vijay A. Patel
- Division of Pediatric Otolaryngology, Rady Children’s Hospital, San Diego, CA 92123, USA
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Sean P. Polster
- Department of Neurosurgery, University of Chicago, Chicago, IL 60637, USA (S.P.P.)
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Godse NR, Jarmula J, Kshettry VR, Woodard TD, Recinos PF, Sindwani R. Emergency department visits following endoscopic skull base surgery: An opportunity for improvement. Int Forum Allergy Rhinol 2024; 14:613-620. [PMID: 37422726 DOI: 10.1002/alr.23237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Readmissions are major healthcare expenditures, key hospital metrics, and are often preceded by an evaluation in the emergency department (ED). The purpose of this study was to analyze ED visits within 30 days of endoscopic skull base surgery (ESBS), risk factors for readmission once in the ED, and ED-related evaluation and outcomes. METHODS Retrospective review from January 2017 to December 2022 at a high-volume center of all ESBS patients who presented to the ED within 30 days of surgery. RESULTS Of 593 ESBS cases, 104 patients (17.5%) presented to the ED following surgery within 30 days, with a median presentation of 6 days post-discharge (IQR 5-14); 54 (51.9%) patients were discharged while 50 (48.1%) were readmitted. Readmitted patients were significantly older than discharged patients (median 60 years, IQR 50-68 vs. 48 years, 33-56; p < 0.01). Extent of ESBS was not associated with readmission or discharge from the ED. The most common discharge diagnoses were headache (n = 13, 24.1%) and epistaxis (n = 10, 18.5%); the most common readmitting diagnoses were serum abnormality (n = 15, 30.0%) and altered mental status (n = 5, 10.0%). Readmitted patients underwent significantly more laboratory testing than discharged patients (median 6, IQR 3-9 vs. 4, 1-6; p < 0.01). CONCLUSIONS Approximately half of patients who presented to the ED following ESBS were discharged home but underwent significant workup. Follow-up within 7 days of discharge, risk-stratified endocrine care pathways, and efforts to address the social determinants of health may be considered to optimize postoperative ESBS care.
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Affiliation(s)
- Neal R Godse
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jakub Jarmula
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Troy D Woodard
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Raj Sindwani
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Racette S, Tekumalla S, Agarwal A, Curry J, Beahm DD. Anterior Skull Base Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00072-5. [PMID: 37268516 DOI: 10.1016/j.otc.2023.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Anterior skull base reconstruction requires careful preoperative planning to use the most effective technique for the expected defect. Adherence to the principles of skull base reconstruction is imperative to minimize complications and improve patient outcomes.
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Affiliation(s)
- Samuel Racette
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Sruti Tekumalla
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Aarti Agarwal
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joseph Curry
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Donald David Beahm
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, KS, USA.
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Abiri A, Patel TR, Nguyen E, Birkenbeuel JL, Tajudeen BA, Choby G, Wang EW, Schlosser RJ, Palmer JN, Adappa ND, Kuan EC. Postoperative protocols following endoscopic skull base surgery: An evidence-based review with recommendations. Int Forum Allergy Rhinol 2023; 13:42-71. [PMID: 35678720 DOI: 10.1002/alr.23041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence-based guidance. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated. RESULTS A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction. CONCLUSION The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high-quality studies are needed in order to devise optimal postoperative ESBS protocols.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Tirth R Patel
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Emily Nguyen
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Bobby A Tajudeen
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Garret Choby
- Department of Otolaryngology, Head and Neck Surgery and Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric W Wang
- Department of Otolaryngology, Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rodney J Schlosser
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James N Palmer
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward C Kuan
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
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White A, Junior de Andrade E, Kshettry VR, Sindwani R, Recinos PF. Preoperative Workup for Patients with Pituitary Lesions. Otolaryngol Clin North Am 2022; 55:233-246. [DOI: 10.1016/j.otc.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Asmaro K, Yoo F, Yassin-Kassab A, Bazydlo M, Robin AM, Rock JP, Craig JR. Sinonasal Packing is Not a Requisite for Successful Cerebrospinal Fluid Leak Repair. Skull Base Surg 2021; 83:476-484. [DOI: 10.1055/s-0041-1740622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
Abstract
Background Numerous methods have been described to repair nasal cerebrospinal fluid (CSF) leaks. Most studies have focused on optimizing CSF leak repair success, leading to closure rates of 90 to 95%.
Objective This study aimed to determine if excellent reconstruction rates could be achieved without using sinonasal packing.
Methods A prospective case series of 73 consecutive patients with various CSF leak etiologies and skull base defects was conducted to evaluate reconstruction success without sinonasal packing. The primary outcome measure was postoperative CSF leak. Secondary outcome measures were postoperative epistaxis requiring intervention in operating room or emergency department, infectious sinusitis, and 22-item sinonasal outcome test (SNOT-22) changes.
Results Mean age was 54.5 years and 64% were female. Multilayered reconstructions were performed in 55.3% of cases, with collagen or bone epidural inlay grafts, and nasal mucosal grafts or nasoseptal flaps for onlay layers. Onlay-only reconstructions with mucosal grafts or nasoseptal flaps were performed in 44.7% of cases. Tissue sealants were used in all cases, and lumbar drains were used in 40.8% of cases. There were two initial failures (97.4% initial success), but both resolved with lumbar drains alone (no revision surgeries). There were no instances of postoperative epistaxis requiring intervention in the operating room or emergency department. Infectious sinusitis occurred in 2.7% of patients in the first 3 months postoperatively. SNOT-22 did not change significantly from preoperatively to first postoperative visits, then improved over time.
Conclusion Nasal CSF leaks from various etiologies and defect sites were successfully repaired without using sinonasal packing, and patients experienced minimal sinonasal morbidity.
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Affiliation(s)
- Karam Asmaro
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Frederick Yoo
- Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, United States
| | | | - Michael Bazydlo
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Adam M. Robin
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Jack P. Rock
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - John R. Craig
- Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan, United States
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Saroul N, Rumeau C, Verillaud B, Patron V, Righini C, De Bonnecaze G, Daveau C, Mortuaire G, Mom T, Gilain L, Pereira B, Montrieul L. Failure of anterior skull base reconstruction for sinonasal carcinoma: consequence on the postoperative follow up. A multicentre evaluation of management. Acta Otolaryngol 2021; 141:630-634. [PMID: 33947299 DOI: 10.1080/00016489.2021.1914858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Numerous techniques for closure of the anterior skull base in cancer patients have a high success rate but management of failure is poorly documented. OBJECTIVES To standardize the post-operative follow-up after reconstruction surgery of the anterior skull base after removal for sinonasal carcinoma. MATERIALS AND METHODS Retrospective review of failure of anterior skull base reconstruction between 2005 and 2018 in a multicenter setting. RESULTS Twenty four patients were included. Reconstruction failure was detected by a cerebrospinal (CSF) leak in 79.2%, by an infectious complication without CSF leak (i.e. meningitis) in 12.5%, and in 8.3% by extensive pneumocephalus. Failure was observed during the first week after surgery in 75% of patients, in the second week in 21%, and in 4% after day 15. The delay in discovery of the failure was associated with multilayer reconstruction (p=.03). Failure was treated surgically in 54% of the patients and medically in 46%, with a similar success rate (85 vs. 100%). CONCLUSION AND SIGNIFICANCE After carcinologic resection of the anterior skull base, monitoring should be systematic during the first postoperative week. Surgical management of failure is not always necessary.
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Affiliation(s)
- Nicolas Saroul
- Otolaryngology Head and Neck Surgery Department, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Cécile Rumeau
- Otolaryngology Head and Neck Surgery Department, CHU de Nancy, Vandoeuvre les Nancy, France
| | - Benjamin Verillaud
- Otolaryngology Head and Neck Surgery Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Vincent Patron
- Otolaryngology Head and Neck Surgery Department, CHU de Caen, Caen, France
| | - Christian Righini
- Otolaryngology Head and Neck Surgery Department, CHU de Grenoble, Grenoble, France
| | | | - Clémentine Daveau
- Otolaryngology Head and Neck Surgery Department Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Geoffrey Mortuaire
- Otolaryngology Head and Neck Surgery Department, CHU de Lille, Lille, France
| | - Thierry Mom
- Otolaryngology Head and Neck Surgery Department, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurent Gilain
- Otolaryngology Head and Neck Surgery Department, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Department (DRCI), CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Laura Montrieul
- Otolaryngology Head and Neck Surgery Department, CHU de Clermont-Ferrand, Clermont-Ferrand, France
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Yang J, Wei R, Song X, Sun X, Wang H, Liu Q, Hu L, Yu H, Wang D. Risk of second primary malignancy after minor salivary gland cancer: A Surveillance, Epidemiology, and End Results database analysis. Head Neck 2021; 43:1769-1779. [PMID: 33590552 DOI: 10.1002/hed.26641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 12/20/2020] [Accepted: 02/02/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Minor salivary gland cancer (MiSGC) is a group of tumors with varied disease course in the head and neck. We evaluated the risk of a second primary malignancy (SPM) in MiSGC patients and identified possible prognostic factors for survival using a large population database. METHODS We used the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data to evaluate the risk and prognosis of SPM in patients diagnosed with MiSGC. RESULTS The risk of SPM increased in MiSGC patients compared with the endemic rate. The risk of SPM was slightly greater in female patients and who underwent radiotherapy. Age at primary diagnosis, sex, race, year of diagnosis, SEER stage, radiotherapy, SPM, histology, and tumor site were significant survival prognostic indicators of MiSGC patients. CONCLUSION Radiotherapy and female sex were risk factors for SPM after MiSGC. Long-term surveillance for SPM was important in MiSGC patients.
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Affiliation(s)
- Jingyi Yang
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Ruoyan Wei
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Xiaole Song
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Xicai Sun
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Quan Liu
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Li Hu
- Department of Experimental Center, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
| | - Hongmeng Yu
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China.,Research Units of New Technologies of Endoscopic Surgery in Skull Base Tumor, Chinese Academy of Medical Sciences, Shanghai, China
| | - Dehui Wang
- Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Fudan University, Shanghai, China
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Shen SA, Jafari A, Qualliotine JR, DeConde AS. Incidence and Predictive Factors for Additional Opioid Prescription after Endoscopic Skull Base Surgery. J Neurol Surg B Skull Base 2020; 81:301-307. [PMID: 32500006 DOI: 10.1055/s-0039-1692473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/11/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Postoperative pain management and opioid use following endoscopic skull base surgery (ESBS) is not well understood. A subset of patients requires additional opioid prescription (AOP) in the postoperative period. The objective of this study is to describe the incidence of AOP, as well as evaluate patient and surgical characteristics that may predict additional pain management requirements following ESBS. Methods A retrospective review of cases undergoing ESBS between November 2016 and August 2018 was performed. We reviewed patients' sociodemographic and clinical data, and Controlled Substance Utilization Review and Evaluation System (CURES) records. Stepwise multivariable logistic regressions were performed to evaluate the factors associated with AOP within 60 days following surgery. Results A total of 42 patients were identified. Indications for ESBS included intracranial mass (64.2%), sinonasal malignancy (23.8%), and skull base reconstruction (9.5%). AOP were recorded in nine patients (21.4%). There were no significant differences in operative factors, including approach, lesion location, or perioperative analgesia between the two cohorts. On multivariable logistic regression, we found that younger age (odds ratio [OR]: 0.891, 95% confidence interval [CI]: 0.79-1.00, p = 0.050), comorbid depression (OR: 86.48, 95% CI: 1.40-5,379.07, p = 0.034), and preoperative opioid use (OR: 104.45, 95% CI: 1.41-7,751.10, p = 0.034) were associated with additional prescriptions postoperatively. Conclusion The requirement for extended postoperative opioid pain control is common after ESBS. Patient demographics including age and psychosocial factors, such as depression may predict the need for AOP after ESBS. These results suggest that patient-driven factors, rather than surgical characteristics, may determine the need for prolonged pain control requirements after ESBS.
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Affiliation(s)
- Sarek A Shen
- School of Medicine, University of California San Diego, La Jolla, California, United States
| | - Aria Jafari
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, United States
| | - Jesse R Qualliotine
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, United States
| | - Adam S DeConde
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California, United States
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Spock T, Kessler R, Lerner D, Filip P, Del Signore A, Colley P, Morgenstern P, Schaberg M, Bederson J, Govindaraj S, Iloreta AM, Shrivastava R. Endoscopic Skull Base Surgery Protocol From the Frontlines: Transnasal Surgery During the COVID-19 Pandemic. Otolaryngol Head Neck Surg 2020; 163:482-490. [DOI: 10.1177/0194599820931836] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective The coronavirus disease 2019 (COVID-19) pandemic disrupted the standard management paradigms for care of patients with sinus and skull base presentations due to concern for patient and health care provider safety, given the high aerosol-generating potential of endonasal procedures. Data Sources We reviewed the relevant literature complied from available sources, including PubMed, Google Scholar, and otolaryngology journals providing electronic manuscripts ahead of indexing or publication. Review Methods Incorporating available evidence and the projected infection control and resource limitations at our institution, we collectively authored a dynamic set of protocols guiding (1) case stratification, (2) preoperative assessment, (3) operative setup, and (4) postoperative care of patients with sinus or skull base presentations. Due to the rapidly evolving nature of COVID-19 publications, lack of rigorous data, and urgent necessity of standardized protocols, strict inclusion and exclusion criteria were not employed. Conclusions As scarce hospital resources are diverted to COVID-19 care and staff are redeployed to forward-facing roles, endonasal procedures have largely ceased, leaving patients with ongoing sinonasal and skull base complaints untreated. Skull base teams now weigh the urgency of surgery in this population with the regional availability of resources. Implications for Practice The COVID-19 pandemic will have an enduring and unpredictable impact on hospital operations and surgical skull base practices and will require a dynamic set of management protocols responsive to new evidence and changing resources. In the current resource-limited environment, clinicians may utilize these protocols to assist with stratifying patients by acuity, performing preoperative assessment, and guiding peri- and postoperative care.
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Affiliation(s)
- Todd Spock
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Remi Kessler
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Lerner
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Filip
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Del Signore
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patrick Colley
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Morgenstern
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madeleine Schaberg
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Bederson
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Satish Govindaraj
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alfred Marc Iloreta
- Department of Otolaryngology–Head and Neck Surgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj Shrivastava
- Department of Neurosurgery, The Mount Sinai Hospital/Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Rezende GL, Neto ORM, Kückelhaus SAS. Morbidity in the postoperative follow-up of endoscopic anterior skull base surgery. Braz J Otorhinolaryngol 2020; 87:689-694. [PMID: 32327364 PMCID: PMC9422415 DOI: 10.1016/j.bjorl.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/25/2019] [Accepted: 02/25/2020] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Endoscopic access to the sellar region by videoendoscopy shows a low rate of surgical complications, with findings that indicate risk factors for reducing morbidities during and after the postoperative period. OBJECTIVE To evaluate, over a nine-year period, the acquisition of skills by the anterior skull base surgical team, according to the time of elimination of nasal crusts and/or the presence of morbidities in the postoperative follow-up of individuals treated in a tertiary public hospital. METHODS After confirming the diagnosis of skull base pathologies, the individuals in this study underwent endoscopic surgery according to the rostrocaudal or coronal axis. For the skull base reconstruction, the nasoseptal flap (associated or not with fascia lata with thigh fat) or free graft was used; clinical follow-up of individuals occurred for a minimum period of 12 months. To assess the impact of the surgical approach on patient clinical evolution, qualitative data related to smoking, post-nasal discharge, nasal flow, smell, taste, clinical symptoms of headache, cranial paresthesia, comorbidities and postoperative morbidities were obtained. RESULTS The most frequent diagnosis was pituitary macroadenoma (84.14%). The mean absence of crusts in this cohort was 124.45 days (confidence interval 95%=119.50-129.39). There was a low cerebrospinal fluid fistula rate (3%). Reconstruction with the nasoseptal flap with a fat graft was an independent variable that recorded the highest mean time for the elimination of nasal crusts (=145 days, confidence interval 95%=127.32-162.68). Allergic rhinitis and smoking were shown to be the most important and independent variables that increased the mean time to eliminate nasal crusts. CONCLUSION The mean time to eliminate nasal crusts did not change over the years during which the procedures were performed, demonstrating the adequate training of the surgical team. Debridement and nasal irrigation with saline solutions should be performed more frequently and effectively in patients with allergic rhinitis, smokers and those who received the nasoseptal flap and fascia lata graft with autologous fat.
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Affiliation(s)
- Gustavo Lara Rezende
- Hospital de Base do Distrito Federal, Brasília, DF, Brazil; Universidade de Brasília, Faculdade de Medicina, Departamento de Morfologia, Brasília, DF, Brazil.
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London NR, Rangel GG, Walz PC. The expanded endonasal approach in pediatric skull base surgery: A review. Laryngoscope Investig Otolaryngol 2020; 5:313-325. [PMID: 32337363 PMCID: PMC7178460 DOI: 10.1002/lio2.369] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Surgery of the pediatric skull base has multiple unique challenges and has seen recent rapid advances. The objective of this review is to assess key issues in pediatric skull base surgery (SBS), including anatomic limitations, surgical approaches, reconstruction techniques, postoperative care, complications, and outcomes. DATA SOURCES PubMed literature review. REVIEW METHODS A review of the literature was conducted to assess the challenges, recent advances, and reported outcomes in pediatric SBS. RESULTS The pediatric skull base presents multiple anatomic challenges, including variable patterns of pneumatization, narrow piriform aperture width, and narrow intercarotid distance at the level of the cavernous sinus but not the superior clivus. These issues may be particularly challenging in patients less than 2 years of age. Endoscopic endonasal approaches in the sagittal and coronal plane have been applied to the pediatric skull base while open approaches may still be necessary in the setting of extensive intracranial or orbital disease, as well as disease lateral to critical neurovascular structures. While the nasoseptal flap was initially called into question for pediatric cases, it has been shown through multiple reports to be a feasible and robust reconstructive option. Complications and outcomes often depend upon the pathology. In children, response to noxious stimuli, ability to avoid Valsalva, and adherence to nasal precautions is variable. The use of lumbar drains is more common in pediatric than adult patients. CONCLUSION While the pediatric skull base presents unique challenges, outcomes data support that endoscopic endonasal approaches are a pertinent surgical technique in appropriately selected patients. LEVEL OF EVIDENCE 3a.
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Affiliation(s)
- Nyall R. London
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Otolaryngology‐Head and Neck SurgeryJohns Hopkins School of MedicineBaltimoreMarylandUSA
- National Institute on Deafness and Other Communication DisordersNIHBethesdaMarylandUSA
| | - Gustavo G. Rangel
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
| | - Patrick C. Walz
- Otolaryngology‐Head and Neck SurgeryThe Ohio State UniversityColumbusOhioUSA
- Pediatric Otolaryngology‐Head and Neck SurgeryNationwide Children's HospitalColumbusOhioUSA
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14
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Hussaini AS, Clark CM, DeKlotz TR. Perioperative Considerations in Endoscopic Skull Base Surgery. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020; 8:129-135. [PMID: 32421026 PMCID: PMC7223122 DOI: 10.1007/s40136-020-00278-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose of the Review Present an overview of perioperative considerations specific to endoscopic skull base surgery necessary to maximize successful outcomes. Recent Findings The majority of perioperative considerations for endoscopic skull base surgery lack strong supporting evidence and frequently have varied use or implementation amongst institutions. A notable exception comes from a recent randomized controlled trial demonstrating the benefit of lumbar drainage in high-risk cerebrospinal fluid leaks. Summary Skull base surgeons must consider a multitude of perioperative factors. While many components of perioperative management are extrapolated from related fields such as endoscopic sinus surgery or open cranial base surgery, additional high-quality studies are needed to delineate best practices specific to endoscopic skull base surgery.
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Affiliation(s)
- Adnan S Hussaini
- Department of Otolaryngology, Head and Neck Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Gorman Building, 1st Floor, Washington, DC, 20007 USA
| | - Christine M Clark
- Department of Otolaryngology, Head and Neck Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Gorman Building, 1st Floor, Washington, DC, 20007 USA
| | - Timothy R DeKlotz
- Department of Otolaryngology, Head and Neck Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Gorman Building, 1st Floor, Washington, DC, 20007 USA
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15
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Walz PC, Drapeau A, Shaikhouni A, Eide J, Rugino AJ, Mohyeldin A, Carrau R, Prevedello D. Pediatric pituitary adenomas. Childs Nerv Syst 2019; 35:2107-2118. [PMID: 31302729 DOI: 10.1007/s00381-019-04293-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pediatric pituitary adenomas are a rare medical entity that makes up a small portion of intracranial tumors in children and adolescents. Although benign, the majority of these lesions are secreting functional tumors with the potential for physiological sequela that can profoundly affect a child's development. FOCUS OF REVIEW In this review, we discuss the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to treat these tumors. The management of pituitary tumors requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver comprehensive care.
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Affiliation(s)
- Patrick C Walz
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Annie Drapeau
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ammar Shaikhouni
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jacob Eide
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Ahmed Mohyeldin
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA
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16
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Drapeau A, Walz PC, Eide JG, Rugino AJ, Shaikhouni A, Mohyeldin A, Carrau RL, Prevedello DM. Pediatric craniopharyngioma. Childs Nerv Syst 2019; 35:2133-2145. [PMID: 31385085 DOI: 10.1007/s00381-019-04300-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 07/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Craniopharyngioma has historically been recognized to be a formidable pathology primarily due to its proximity to critical neurovascular structures and the challenging surgical corridors that surgeons have tried to reach this lesion. FOCUS OF REVIEW In this work, we review the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to craniopharyngiomas. The management of craniopharyngiomas requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver the most comprehensive and safest surgical resection with minimal postoperative morbidity.
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Affiliation(s)
- Annie Drapeau
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Patrick C Walz
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, USA. .,Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, 43205, OH, USA.
| | - Jacob G Eide
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Ammar Shaikhouni
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ahmed Mohyeldin
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Daniel M Prevedello
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, USA
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17
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Rawlins KW, Governale LS, Leonard JR, Elmaraghy CA, Walz PC. Recurrent Cerebrospinal Leak After Endonasal Cranial Base Surgery in a 4-Year-Old Male: Challenges for Postoperative Management. EAR, NOSE & THROAT JOURNAL 2019; 100:472S-474S. [PMID: 31640409 DOI: 10.1177/0145561319880428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kasey W Rawlins
- Department of Otolaryngology, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lance S Governale
- Department of Neurosurgery, 3463University of Florida, Gainesville, FL, USA
| | - Jeffery R Leonard
- Department of Pediatric Neurosurgery, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Charles A Elmaraghy
- Department of Otolaryngology, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Otolaryngology, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Patrick C Walz
- Department of Otolaryngology, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Pediatric Otolaryngology, 2650Nationwide Children's Hospital, Columbus, OH, USA
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Choi DL, Reddy K, Weitzel EK, Rotenberg BW, Vescan A, Algird A, Sommer DD. Postoperative Continuous Positive Airway Pressure Use and Nasal Saline Rinses After Endonasal Endoscopic Skull Base Surgery in Patients With Obstructive Sleep Apnea: A Practice Pattern Survey. Am J Rhinol Allergy 2018; 33:51-55. [PMID: 30345806 DOI: 10.1177/1945892418804987] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. METHODS A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. RESULTS Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients' CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon's choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001). CONCLUSION Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.
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Affiliation(s)
- David L Choi
- 1 Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Kesava Reddy
- 2 Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Erik K Weitzel
- 3 US Army Institute of Surgical Research, Ft Sam Houston, San Antonio, Texas
| | - Brian W Rotenberg
- 4 Department of Otolaryngology-Head & Neck Surgery, Western University, London, Ontario, Canada
| | - Allan Vescan
- 5 Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Almunder Algird
- 2 Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Doron D Sommer
- 1 Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Endoscopic skull base surgery has become an established approach for the removal of tumors and cerebrospinal fluid fistulae repair. Compared with external approaches, it provides better aesthetic results and quality of life postoperatively. However, as it becomes popular and expands its indications possible complications should be reassessed in terms of incidence and variability in order to confirm its efficacy and safety. This article reviews the recent literature describing the main categories of possible complications suggesting strategies to minimize their incidence. RECENT FINDINGS Detailed preoperative planning based on imaging and histology can prevent major complications. Intraoperative use of image guidance and meticulous hemostasis provide the surgical field needed to avoid complications. Postoperative patient counseling, along with close and detailed nasal postoperative care are significant factors for an optimal outcome. SUMMARY Monitoring of complications after endoscopic skull base surgery is necessary in order to standardize protocols of management and improve our surgical techniques. The presence of late onset complications underlines the need of a special focus in postoperative care and follow-up.
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Wannemuehler TJ, Rabbani CC, Burgeson JE, Illing EA, Walgama ES, Wu AW, Ting JY. Survey of endoscopic skull base surgery practice patterns among otolaryngologists. Laryngoscope Investig Otolaryngol 2018; 3:143-155. [PMID: 30062128 PMCID: PMC6057222 DOI: 10.1002/lio2.149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/18/2018] [Accepted: 02/26/2018] [Indexed: 11/13/2022] Open
Abstract
Background Endoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences. Methods An anonymous 32‐item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi‐square, and Fisher exact tests. Results Seventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full‐time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice, P = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice (P = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high‐flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs (P < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2–8 weeks and positive airway pressure use for 2–6 weeks. Most respondents started saline irrigations 0–2 weeks postoperatively. Conclusions Based on responses from fellowship‐ and non‐fellowship‐trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS. Level of Evidence 5
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Affiliation(s)
- Todd J Wannemuehler
- Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A
| | - Cyrus C Rabbani
- Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A
| | - Jack E Burgeson
- Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A
| | - Elisa A Illing
- Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A
| | - Evan S Walgama
- Department of Otolaryngology-Head & Neck Surgery Cedars Sinai Medical Center Los Angeles California U.S.A
| | - Arthur W Wu
- Department of Otolaryngology-Head & Neck Surgery Cedars Sinai Medical Center Los Angeles California U.S.A
| | - Jonathan Y Ting
- Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A
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Roxbury CR, Lobo BC, Kshettry VR, D'Anza B, Woodard TD, Recinos PF, Snyderman CH, Sindwani R. Perioperative management in endoscopic endonasal skull-base surgery: a survey of the North American Skull Base Society. Int Forum Allergy Rhinol 2017; 8:631-640. [DOI: 10.1002/alr.22066] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/07/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Christopher R. Roxbury
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Brian C. Lobo
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Varun R. Kshettry
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
| | - Brian D'Anza
- Section of Rhinology, Sinus and Skull Base Surgery; Case Western Reserve University; Cleveland OH
| | - Troy D. Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
| | - Pablo F. Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
| | - Carl H. Snyderman
- Center for Cranial Base Surgery; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
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Krengli M. The management of skull base tumours: A challenge claiming for a multidisciplinary collaboration. Rep Pract Oncol Radiother 2016; 21:285-7. [DOI: 10.1016/j.rpor.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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