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Lubojacký J, Čábalová L, Mladoňová M, Hránková V, Krejčí T, Mičaník J, Miklošová M, Ličev L, Komínek P, Matoušek P. Transnasal Endoscopic Pituitary Surgery-The Role of a CT Scan in Individual Tailoring of Posterior Septum Size Resection. Tomography 2023; 9:2222-2232. [PMID: 38133076 PMCID: PMC10747678 DOI: 10.3390/tomography9060172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE This study was designed to evaluate the possibility of predicting the minimum size of septal resection for safe tumor extraction in transnasal paraseptal pituitary adenoma resection from preoperative computed tomography scans. METHODS A retrospective CT scan analysis was performed on 20 patients who underwent endoscopic pituitary surgery at the University Hospital in Ostrava. Virtual insertion of the straight instrument into the sphenoid cavity was simulated using a CT scan. The minimum septal resection size was predicted and compared to various diameters in the nasal cavity. The results were then compared with cadaveric dissections, in which septal resections were performed at 1 cm and 2 cm distances from the anterior sphenoid wall. The association between cadaver dissections and CT scan results was studied. RESULTS A total of 20 patients who underwent endoscopic transnasal surgery for pituitary adenoma between the years 2020 and 2021 were enrolled in the study. The mean virtual posterior septal size resection needed to reach the medial edge of the ICA with the straight instrument, without infracturing the nasal septum, was 13.2 mm. In cadavers with a 1 cm posterior septal resection, the medial edge of the ICA was reached with the straight instrument. In 2 cm resections, it was possible to reach beyond the lateral edge of the ICA. CONCLUSION There is no significant correlation between the minimum septal size resection and measured diameters in the nasal cavity. According to our study, a 1 cm resection is sufficient for a non-extended pituitary tumor extraction. More extensive septal resections allow for better maneuverability and overview in the surgical field.
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Affiliation(s)
- Jakub Lubojacký
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Lenka Čábalová
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Michaela Mladoňová
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Viktória Hránková
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
- Department of Anatomy, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Tomáš Krejčí
- Department of Neurosurgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Jakub Mičaník
- Department of Radiodiagnostics, Ostrava University Hospital, 70800 Ostrava, Czech Republic;
| | - Maria Miklošová
- Department of Anatomy, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Lačezar Ličev
- Faculty of Electrical Engineering and Computer Science, VŠB Technical University Ostrava, 70800 Ostrava, Czech Republic;
| | - Pavel Komínek
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Petr Matoušek
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
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Albaharna H, Alqurashi A, Alshareef M, Alromaih S, Alrasheed AS, Alroqi A, Ajlan A, Alsaleh S. Impact of Concurrent Chronic Rhinosinusitis on Complication Rates after Endonasal Endoscopic Skull Base Surgery: A Single-Center Experience. J Neurol Surg B Skull Base 2023; 84:507-512. [PMID: 37671295 PMCID: PMC10477013 DOI: 10.1055/s-0042-1755602] [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: 10/23/2021] [Accepted: 06/20/2022] [Indexed: 10/15/2022] Open
Abstract
Objectives Preoperative planning of endoscopic skull base surgery (ESBS) is essential. The safety of performing surgery before managing sinus pathologies including concurrent chronic rhinosinusitis (CRS) in patients undergoing ESBS has been questioned. The current study aimed to evaluate and compare the complication rates between patients with and without CRS undergoing ESBS. Design This is a retrospective study. Setting Present study was conducted at tertiary referral center. Participants We included all patients who underwent ESBS between March 2015 and March 2021. However, patients who had surgical revision for remnant tumor, primary sinonasal tumor excision, and cerebrospinal fluid (CSF) leakage repair were excluded. The presence of concurrent CRS was determined according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020) criteria by reviewing electronic charts about the preoperative clinical assessment and CT scan images of the paranasal sinuses. Then, the incidence rates of postoperative meningitis, CSF leakage, and surgical site infection were compared between patients with and without concurrent CRS undergoing ESBS. Main Outcome Measures Postoperative complication rates in patients underwent ESBS with and without CRS. Results From a total of 130 ESBS cases, 99 patients were included in this study. Among them, 24 had concurrent CRS. One patient presented with postoperative meningitis, one with CSF leakage, and two with surgical site infections. The incidence rate of postoperative meningitis, CSF leakage, and surgical site infection did not significantly differ between patients with and without concurrent CRS. Conclusion Concurrent CRS is not a contraindication for ESBS. Moreover, simultaneous endoscopic sinus surgery can safely be performed without additional morbidity in ESBS.
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Affiliation(s)
- Hussain Albaharna
- Department of Otolaryngology, Head and Neck Surgery, Qatif Central Hospital, Qatif City, Saudi Arabia
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ashwag Alqurashi
- Department of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Alshareef
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Otolaryngology, Head and Neck Surgery, Khamis Mushait General Hospital, Khamis Mushait City, Saudi Arabia
| | - Saud Alromaih
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz S. Alrasheed
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Alroqi
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrazag Ajlan
- Department of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saad Alsaleh
- Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Revuelta Barbero JM, Soriano RM, Porto E, Bray DP, Barrow E, Henriquez O, Solares CA, Pradilla G. Purely nasal floor mucosa-free graft for reconstruction after endoscopic endonasal transellar approach: an anatomical and clinical analysis. Br J Neurosurg 2023:1-6. [PMID: 37082915 DOI: 10.1080/02688697.2023.2202233] [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: 04/22/2023]
Abstract
BACKGROUND/OBJECTIVE In this radioanatomical study with clinical correlate, we study a variation of the 'extended nasal floor mucosa' (ENFM) free-graft, the purely nasal floor mucosa (PuNFM) free-graft. The objectives of this study are to evaluate the coverage surface area provided by the PuNFM, study the adequacy of the PuNFM in the reconstruction of endoscopic endonasal approach (EEA) transsellar postoperative defects and compare and evaluate this reconstructive technique with current sellar region reconstruction practices. METHODS Dissections were performed on five cadaveric specimens. PuNFM were harvested bilaterally and the area provided for reconstruction was calculated. Twenty-five consecutive cases of pituitary adenomas resected through an EEA were analyzed to estimate the sellar defect surface area (SDSA) after a transsellar EEA and calculate the area of PuNFM bilaterally. RESULTS The median cadaveric SDSA was 4.77 cm2, with a median left and right side PuNFM area of 5.09 and 5.19 cm2, respectively. Clinically, the median SDSA was 5.36 cm2, and the total radiological PuNFM surface area was 5.46 cm2, with modified Knosp grade >2 tumors having larger SDSA than that of Knosp grade <2 tumors. The PuNFM graft proved to be most effective for covering modified Knosp <2 tumor defects. CONCLUSIONS The PuNFM represents a variation of the ENFM free-graft sellar defect reconstruction technique that provides sufficient surface area to reconstruct the majority of the sellar defects related to transsellar EAA for pituitary adenomas. This technique may positively impact sinonasal function and quality of life. Future prospective clinical studies are needed to verify these findings.
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Affiliation(s)
| | - Roberto M Soriano
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
| | - Edoardo Porto
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - David P Bray
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Emily Barrow
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
| | - Oswaldo Henriquez
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
| | - C Arturo Solares
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
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Curran K, Adepoju A, Pinheiro-Neto C, Peris-Celda M, Kenning T. Nasal Crust-Related Morbidity and Debridement After Endoscopic Skull Base Surgery. Int Arch Otorhinolaryngol 2023; 27:e336-e341. [PMID: 37125356 PMCID: PMC10147474 DOI: 10.1055/s-0042-1745853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/01/2022] [Indexed: 05/02/2023] Open
Abstract
Introduction: Nasal crust after endoscopic skull base surgery can cause nasal congestion, obstruction, and pain, which can affect quality of life. The use of debridement aims to provide symptomatic relief and improve quality of life. Generally, most adult patients tolerate office-based debridement, except in a few select patients that require further sedation in the operating room for a debridement. The study sought to determine the rate of symptomatic crust-related morbidity and the rate of debridement in both the office and the operating room. Methods: Premorbid, operative, and postoperative data of adult patients who had endoscopic skull base surgery in our institution from 2014 to 2018 were reviewed retrospectively. The characteristics of nasal symptoms in the postoperative period were determined and the number of debridements in the office and the operating room were analyzed. Results: Two hundred and thirty-four (234) patients with 244 surgeries were included in the study. The majority, 68.9%, had a sellar lesion and a free mucosa graft (FMG) was the most common skull base reconstruction at 53.5%. One hundred and twenty (49.0%) had crust-related symptoms during the postoperative period and 11 patients (4.5%) required the operating room for debridement. The use of a pedicled flap, anxiety, and preoperative radiotherapy were significantly associated with intolerance to in-office debridement ( p -value=0.05). Conclusions: The use of a pedicled flap or anxiety may predispose patients to require an OR debridement. Previous radiotherapy also influenced the tolerance to the in-office debridement.
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Affiliation(s)
- Kent Curran
- Department of Otolaryngology- Head and Neck Surgery, Albany Medical College, Albany Medical Center, Albany, New York, United States
- Address for correspondence Kent Curran, MD, MBA 43 New Scotland Avenue, Albany, New York, United States 12206-1043
| | - Adedamola Adepoju
- Department of Otolaryngology- Head and Neck Surgery, Albany Medical College, Albany Medical Center, Albany, New York, United States
| | - Carlos Pinheiro-Neto
- Department of Otolaryngology- Head and Neck Surgery, Albany Medical College, Albany Medical Center, Albany, New York, United States
| | - Maria Peris-Celda
- Department of Otolaryngology- Head and Neck Surgery, Albany Medical College, Albany Medical Center, Albany, New York, United States
| | - Tyler Kenning
- Department of Otolaryngology- Head and Neck Surgery, Albany Medical College, Albany Medical Center, Albany, New York, United States
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Conrad J, Blaese M, Becker S, Huppertz T, Ayyad A, Ringel F. Sinonasal Outcome After Endoscopic Transnasal Surgery-A Prospective Rhinological Study. Oper Neurosurg (Hagerstown) 2023; 24:223-231. [PMID: 36701557 DOI: 10.1227/ons.0000000000000532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/17/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The sinonasal outcome after transnasal skull base surgery has often been neglected aside from major outcome criteria as extent of tumor resection, ophthalmological, and endocrinological parameters. OBJECTIVE To analyze rhinological outcome after endoscopic transnasal neurosurgery. METHODS Patients were treated using a middle turbinate-preserving transnasal endoscopic approach for sellar/parasellar lesions. As major variables, olfactory function and nose breathing ability were assessed. The study participants were investigated by odor testing ("Sniffin' sticks"), rhinomanometry, and endoscopic inspection of the nasal cavity before and 6 months after surgery. Furthermore, sinonasal-associated quality of life was measured before, immediately and 6 months after surgery with a standardized questionnaire (SNOT-20-GAV). RESULTS Eighty-two patients (47 male, 35 female, median age 55 years) matched the inclusion criteria. Before surgery, the average odor was found to be 30.75 (≥31 = normosmia); in the postinterventional examination at 6 months, the average increased to 33.08 (n.s.). Rhinomanometric examination of binostril nasal airflow showed an average of 590.42 mL/s on inspiration before and an increase to 729.78 mL/s at 6 months after surgery. SNOT-20 symptom scores had a maximum score right after and no difference at 6 months after surgery (scores 23.76 and 14.91 vs 15.53 before surgery). CONCLUSION Based on the study, the endoscopic transnasal technique preserving the middle turbinate has no significant negative effects on the rhinological outcome.
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Affiliation(s)
- Jens Conrad
- Department of Neurosurgery, University Medical Center Mainz, Germany
| | - Marco Blaese
- Department of Neurosurgery, University Medical Center Mainz, Germany
| | - Sven Becker
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Mainz, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Tilman Huppertz
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Mainz, Germany
| | - Ali Ayyad
- Department of Neurosurgery, University Medical Center Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Germany
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Lemdani MS, Choudhry HS, Tseng CC, Fang CH, Sukyte-Raube D, Patel P, Eloy JA. Impact of Facility Volume on Patient Safety Indicator Events After Transsphenoidal Pituitary Surgery. Otolaryngol Head Neck Surg 2023; 168:227-233. [PMID: 35380889 DOI: 10.1177/01945998221089826] [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: 12/21/2021] [Accepted: 03/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To investigate the impact of facility volume on Patient Safety Indicator (PSI) events following transsphenoidal pituitary surgery (TSPS). STUDY DESIGN Retrospective database review. SETTING National Inpatient Sample database (2003-2011). METHODS The National Inpatient Sample was queried for TSPS cases from 2003 to 2011. Facility volume was defined by tertile of average annual number of TSPS procedures performed. PSIs, based on in-hospital complications identified by the Agency of Healthcare Research and Quality, and poor outcomes, such as mortality and tracheostomy, were analyzed. RESULTS An overall 16,039 cases were included: 804 had ≥1 PSI and 15,235 had none. A greater proportion of male to female (5.8% vs 4.3%) and Black to White (7.0% vs 4.5%) patients experienced PSIs. There was an increased likelihood of poor outcome (odds ratio [OR], 3.1 [95% CI, 2.5-3.7]; P < .001) and mortality (OR, 30.1 [95% CI, 18.5-48.8]; P < .001) with a PSI. The incidence rates of PSIs at low-, intermediate-, and high-volume facilities were 5.7%, 5.1%, and 4.2%, respectively. Odds of poor outcome with PSIs were greater at low-volume facilities (OR, 3.3 [95% CI, 2.4-4.4]; P < .001) vs intermediate (OR, 3.1 [95% CI, 2.1-4.2]; P < .001) and high (OR, 2.5 [95% CI, 1.7-3.8]; P < .001). Odds of mortality with PSIs were greater at high-volume facilities (OR, 43.0 [95% CI, 14.3-129.4]; P < .001) vs intermediate (OR, 40.0 [95% CI, 18.5-86.4]; P < .001) and low (OR, 17.3 [95% CI, 8.0-37.7]; P < .001). CONCLUSION PSIs were associated with a higher likelihood of poor outcome and mortality following TSPS. Patients who experienced PSIs had a lower risk of poor outcome but increased mortality at higher-volume facilities.
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Affiliation(s)
- Mehdi S Lemdani
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Hannaan S Choudhry
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Christopher C Tseng
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Christina H Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, Bronx, New York, USA
| | - Donata Sukyte-Raube
- Center of Ear, Nose, and Throat Diseases, Vilnius University Hospital Santaros Clinics, Vilnius University, Vilnius, Lithuania
| | - Prayag Patel
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center-RWJBarnabas Health, Livingston, New Jersey, USA
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Quality of Life Considerations in Endoscopic Endonasal Management of Anterior Cranial Base Tumors. Cancers (Basel) 2022; 15:cancers15010195. [PMID: 36612191 PMCID: PMC9818735 DOI: 10.3390/cancers15010195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 12/24/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Considering quality of life (QOL) is critical when discussing treatment options for patients undergoing endoscopic endonasal skull base surgery (EESBS) for cancers at the base of the skull. Several questionnaires have been developed and validated in the last 20 years to explore QOL in this patient population, including the Anterior Skull Base Questionnaire, Skull Base Inventory, EESBS Questionnaire, and the Sino-Nasal Outcome Test for Neurosurgery. The Sino-Nasal Outcomes Test-22 and Anterior Skull Base Nasal Inventory-12 are other tools that have been used to measure sinonasal QOL in anterior cranial base surgery. In addition to pathology-related perturbations in QOL endoscopic surgical options (transsellar approaches, anterior cranial base surgery, and various reconstructive techniques) all have unique morbidities and QOL implications that should be considered. Finally, we look ahead to new and emerging techniques and tools aimed to help preserve and improve QOL for patients with anterior cranial base malignancies.
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Takroni R, Sharma S, Reddy K, Zagzoog N, Aljoghaiman M, Alotaibi M, Farrokhyar F. Randomized controlled trials in neurosurgery. Surg Neurol Int 2022; 13:379. [PMID: 36128088 PMCID: PMC9479513 DOI: 10.25259/sni_1032_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 08/04/2022] [Indexed: 11/04/2022] Open
Abstract
Randomized controlled trials (RCTs) have become the standard method of evaluating new interventions (whether medical or surgical), and the best evidence used to inform the development of new practice guidelines. When we review the history of medical versus surgical trials, surgical RCTs usually face more challenges and difficulties when conducted. These challenges can be in blinding, recruiting, funding, and even in certain ethical issues. Moreover, to add to the complexity, the field of neurosurgery has its own unique challenges when it comes to conducting an RCT. This paper aims to provide a comprehensive review of the history of neurosurgical RCTs, focusing on some of the most critical challenges and obstacles that face investigators. The main domains this review will address are: (1) Trial design: equipoise, blinding, sham surgery, expertise-based trials, reporting of outcomes, and pilot trials, (2) trial implementation: funding, recruitment, and retention, and (3) trial analysis: intention-to-treat versus as-treated and learning curve effect.
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Affiliation(s)
- Radwan Takroni
- Department of Neurosurgery, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Department of Neurosurgery, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kesava Reddy
- Department of Neurosurgery, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nirmeen Zagzoog
- Department of Neurosurgery, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Majid Aljoghaiman
- Department of Neurosurgery, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mazen Alotaibi
- Department of Neurosurgery, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Anstadt E, Chen W, O'Brien J, Ickow I, Chow I, Bruce MK, Goldstein J, Branstetter BF, Synderman CH, Wang EW, gardner P, Schuster L. Characterization of the Saddle Nose Deformity Following Endoscopic Endonasal Skull Base Surgery. Skull Base Surg 2022; 84:225-231. [PMID: 37180865 PMCID: PMC10171926 DOI: 10.1055/a-1796-7984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
Abstract
Objective: The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular.
Setting/Participants: This is a retrospective review of 20 adult patients with SND after endoscopic endonasal approach (EEA) for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center.
Outcome Measures: Fifteen measurements related to SND were obtained on pre-and post-operative imaging. Statistical analyses were performed to evaluate differences between pre- and post-operative anatomy.
Results: The most common EEA was transsellar. Reconstruction techniques included 9 free mucosal grafts alone, 8 vascularized nasoseptal flaps (NSF), 1 combined free mucosal graft/abdominal fat graft, and 1 combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection and nasolabial angle post-operatively. Sub-group analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2mm, p=0.039) and increased alar base width (1.2mm, p=0.046) post operatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on post-operative imaging, in contrast to those with functional adenomas who had no measurable significant changes.
Conclusions: Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests.
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Affiliation(s)
- Erin Anstadt
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - Wendy Chen
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - James O'Brien
- University of Pittsburgh School of Medicine, Pittsburgh, United States
| | - Ilana Ickow
- Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, United States
| | - Ian Chow
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - Madeleine K Bruce
- University of Pittsburgh Medical Center Health System, Pittsburgh, United States
| | - Jesse Goldstein
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
- Pediatric Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, United States
| | | | - Carl H Synderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - Eric W Wang
- Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - paul gardner
- neurosurgery, university of pittsburgh, pittsburgh, United States
| | - Lindsay Schuster
- Children's Hospital of Pittsburgh, Pediatric Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
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10
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Quality of Life and Morbidity after Endoscopic Endonasal Skull Base Surgeries Using the Sinonasal Outcomes Test (SNOT): A Tertiary Hospital Experience. Int J Otolaryngol 2021; 2021:6659221. [PMID: 34104196 PMCID: PMC8159648 DOI: 10.1155/2021/6659221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/28/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction Endoscopic endonasal skull base surgery (EESBS) has been associated with a minimally invasive and effective approach for pathology of the anterior skull base and associated with less overall morbidity compared with open approaches. However, it is associated with its own potential morbidity related to surgical manipulation or resection of normal and noninflamed intranasal structures to gain adequate access. The assessment of sinonasal QOL (quality of life) postsurgery is therefore a vital aspect in follow-up of these patients. Objectives To assess quality of life and morbidity after endoscopic endonasal skull base surgery using the Sinonasal Outcomes Test (SNOT-22). Methodology. A single-center retrospective cross-sectional review with a sample of 80-100 patients undergoing endoscopic endonasal transsphenoidal surgery was conducted at the ENT and Neurosurgery departments of King Fahad Specialist Hospital-Dammam (KFSH-D) for a period of 10 years from March 2010 to March 2020. Data were collected through hospital records and database, as well as from patients through phone call interviews. Records were reviewed for diagnosis, demographic features, and 22-item Sinonasal Outcomes Test (SNOT-22) scores noted at three points in time: prior to procedure and after, at 3 months and 6 months. Results Within the study cohort comprising 96 patients, the mean age of the participants was 39.5 ± 12.1 years, and diagnostic typing before and after histopathological investigations revealed maximum pituitary adenomas (46.9%) closely followed by CSF-related ailments (41.7%). The changes in the mean and standard deviation of the total SNOT-22 scores postoperatively at the 3rd month (9.5 ± 5.4) and the 6th month (8.8 ± 5.2) were statistically significant (p < 0.001) when compared to the preoperative score (10.8 ± 5.1). Conclusion Although there was a predicted passivity of symptoms in the post-EESBS period, several significant positive outcomes were seen. The increase in discomfort in the sleep domains postsurgery is an issue to pursue and reason out. The overall SNOT-22 scores noted preoperatively and 3 and 6 months postoperatively showed statistically significant improvements in QOL with no long-term effects.
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Rupa V, Joy N. Management of coexistent sinonasal pathology in patients undergoing endoscopic cerebrospinal fluid rhinorrhea repair. Braz J Otorhinolaryngol 2020; 88:773-779. [PMID: 33408063 PMCID: PMC9483933 DOI: 10.1016/j.bjorl.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/27/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Patients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair. Objective To study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea Methods A retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period. Results Of a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%). Conclusion Patients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.
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Affiliation(s)
- Vedantam Rupa
- Christian Medical College Hospital, Department of ENT, Vellore, India.
| | - Nedha Joy
- Christian Medical College Hospital, Department of ENT, Vellore, India
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12
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Lee JJ, Thompson ZS, Piccirillo JF, Klatt-Cromwell CN, Orlowski HLP, Kallogjeri D, Pipkorn P, Schneider JS. Risk Factors for Patient-Reported Olfactory Dysfunction After Endoscopic Transsphenoidal Hypophysectomy. JAMA Otolaryngol Head Neck Surg 2020; 146:621-629. [PMID: 32379292 PMCID: PMC7206533 DOI: 10.1001/jamaoto.2020.0673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/23/2020] [Indexed: 12/11/2022]
Abstract
Importance Iatrogenic olfactory dysfunction after endoscopic transsphenoidal hypophysectomy (ETSH) is an overlooked complication without elucidated risk factors. Objective To assess the independent prognostic role of demographic, comorbidity, cephalometric, intraoperative, histological, and postoperative parameters in patient-reported postoperative olfactory dysfunction, and to explore the association between anatomical measurements of the skull base and sinonasal cavity and postoperative olfactory dysfunction. Design, Setting, and Participants This retrospective cohort study in a tertiary care medical center enrolled consecutive patients with primary sellar lesions who underwent ETSH between January 1, 2015, and January 31, 2019. Patients were excluded if they underwent multiple sinonasal surgical procedures, presented with a sellar malignant neoplasm, required an expanded transsphenoidal approach, had nasal polyposis or a neurodegenerative disease, or sustained traumatic brain injury. After undergoing medical record review and telephone screening, patients were asked to participate in a 3-item telephone survey. Main Outcomes and Measures The primary outcome was the Clinical Global Impressions change in smell rating, a validated transitional patient-reported outcome measure. Patients rated their change in smell before and after ETSH on a 7-point Likert scale, with the following response options: (1) much better, (2) somewhat better, (3) slightly better, (4) neither better nor worse, (5) slightly worse, (6) somewhat worse, or (7) much worse. Responses of slightly worse, somewhat worse, and much worse were surrogates for postoperative olfactory dysfunction status. Patient medical records, preoperative imaging scans, operative notes, and pathology reports were reviewed. Results Of the 147 patients (mean [SD] age, 54 [15] years; 79 women [54%]) who responded to the telephone survey, 42 (29%) reported olfactory dysfunction after ETSH. Median (interquartile range [IQR]) time between the ETSH completion and survey response was 31.1 (21-43) months. On multivariable analysis, abdominal fat grafting (adjusted relative risk [aRR], 2.95; 95% CI, 1.89-4.60) was associated with postoperative olfactory dysfunction, whereas smoking history (aRR, 1.54; 95% CI, 0.95-2.51) demonstrated a clinically meaningful but imprecise effect size. A more obtuse angle between the planum sphenoidale and face of the sella turcica on sagittal imaging was protective (aRR, 0.98; 95% CI, 0.96-0.99). Increased number of months after the ETSH was associated with patient-reported normosmia (aRR, 0.93; 95% CI, 0.91-0.95). In contrast, other comorbidities; intraoperative variables such as turbinate resection, nasoseptal flap, and mucosal or bone grafting; histological variables such as pathology and proliferative index; and postoperative variables such as adjuvant radiotherapy were not associated with postoperative olfactory dysfunction. Conclusions and Relevance This study found that abdominal fat grafting, acute skull base angle, and smoking history appeared to be clinically significant risk factors for patient-reported postoperative olfactory dysfunction. Increased time after ETSH may be associated with better olfactory outcomes.
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Affiliation(s)
- Jake J. Lee
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Zindzi S. Thompson
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
- School of Medicine, Meharry Medical College, Nashville, Tennessee
| | - Jay F. Piccirillo
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
- Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Cristine N. Klatt-Cromwell
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Hilary L. P. Orlowski
- Department of Radiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
- Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Patrik Pipkorn
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John S. Schneider
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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13
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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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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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15
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Hondronikos N, Alomari A, Schrader M, Knappe UJ. Rhinological Consequences of Microsurgical Endonasal-Transsphenoidal Surgery for Pituitary Tumors. Exp Clin Endocrinol Diabetes 2020; 129:157-162. [PMID: 32380562 DOI: 10.1055/a-1155-6269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Transsphenoidal surgery for sellar lesions may affect patency and function of the nasal airways, smell and sinonasal quality of life. Below is our report on otorhinolaryngological data garnered from patients undergoing endonasal transsphenoidal pituitary microsurgery. METHODS In a prospective study, 68 patients scheduled for transsphenoidal operations (32 female, 36 male, age 17-72 years) underwent otorhinolaryngological evaluation of their nasal morphology, a standardized smell test (sniffin' sticks) and rhinomanometry to analyse nasal breathing function preoperatively, 3-5 days postoperatively (without rhinomanometry), after 3-4 months and after 9 months. RESULTS Immediately after surgery, a reduction in smell sensation was detected in almost all patients. Within 3 months, this impairment resolved in all cases except one. In 2 patients (3%) with preoperative anosmia, improvement of smell function to>6 out of 12 sniffin' sticks was observed. At final visit no patient was noted to have new anosmia. Within 3 months, the results of the rhinomanometry revealed that all patients except one, regained their preoperative nasal breathing function. In 6 patients (8.8%) an improvement in their nose breathing abilities compared to the preoperative state was found. Three patients (4.4%) underwent a LASER transection of mucosal synechiae. In one case with persistent nasal obstruction (1.5%), secondary septoplasty had to be performed. There was no case in which perforation of the nasal septum, nasal tip deflection, or saddle nose deformity was observed. CONCLUSION Microsurgical resection of pituitary tumors via the endonasal transsphenoidal approach poses an acceptable risk with regards to sinonasal complications. The incidence of secondary rhinosurgical interventions is low. Standardized comparative studies between endoscopic and microsurgical transsphenoidal operations should be undertaken.
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Affiliation(s)
- Nikolaos Hondronikos
- Department of Otorhinolaryngology, Johannes Wesling Hospital Minden, Minden, Germany
| | - Ali Alomari
- Department of Neurosurgery, Johannes Wesling Klinikum, Universitätsklinikum der Ruhruniversität Bochum, Minden, Germany
| | - Martin Schrader
- Department of Otorhinolaryngology, Johannes Wesling Hospital Minden, Minden, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, Universitätsklinikum der Ruhruniversität Bochum, Minden, Germany
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16
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Quality of Life Outcomes and Approach-Specific Morbidities in Endoscopic Endonasal Skull Base Surgery. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00286-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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17
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Rowan NR, Valappil B, Chen J, Wang EW, Gardner PA, Snyderman CH. Prospective characterization of postoperative nasal deformities in patients undergoing endoscopic endonasal skull-base surgery. Int Forum Allergy Rhinol 2019; 10:256-264. [PMID: 31665569 DOI: 10.1002/alr.22466] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/28/2019] [Accepted: 10/08/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Surgeons have become increasingly aware of the impact of endoscopic endonasal surgery (EES) of the skull base on sinonasal-related quality of life. Prior retrospective investigation described a correlation between nasoseptal flap (NSF) reconstruction in EES with postoperative nasal deformities, such as nasal dorsum collapse. The primary objective of this study was to prospectively evaluate the incidence of, and contributing factors to, postoperative changes in nasal structure following EES. Secondary goals included assessing subjective changes in nasal appearance as well as objective nasal analysis. METHODS Clinical demographics and detailed perioperative information was prospectively collected for patients undergoing transsellar/suprasellar EES for skull-base tumors. Preoperatively, 1-month and 6-month photographs were completed for objective photographic nasal analysis and blinded assessment by surgeons. Subjective patient feedback was also solicited. RESULTS Overall, 14.7% (5/34) of patients subjectively reported postoperative nasal deformities, whereas both blinded-surgeon and objective nasal measurements identified deformities in 12.9% (4/31) of patients. Patients with postoperative deformities were more likely to have skull-base reconstruction with an NSF (p = 0.01) and trended toward an increased incidence in patients with nonpituitary neoplasms (p = 0.07). There were no other associations between clinical or operative characteristics and external deformities. No patients planned to undergo corrective repair. CONCLUSION External nasal deformities following EES are more frequent than previously acknowledged. Postoperative deformities appear to be associated with NSF reconstruction and may be associated with surgery for nonpituitary neoplasms. Patients should be counseled on this potential outcome, and future studies should investigate how to minimize postoperative sequela.
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Affiliation(s)
- Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benita Valappil
- Department of Otolaryngology, Eye & Ear Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonlin Chen
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric W Wang
- Department of Otolaryngology, Eye & Ear Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Carl H Snyderman
- Department of Otolaryngology, Eye & Ear Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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18
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Bhenswala PN, Schlosser RJ, Nguyen SA, Munawar S, Rowan NR. Sinonasal quality-of-life outcomes after endoscopic endonasal skull base surgery. Int Forum Allergy Rhinol 2019; 9:1105-1118. [PMID: 31356005 DOI: 10.1002/alr.22398] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/01/2019] [Accepted: 07/11/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND There are substantial gaps in our understanding of the influence of the endoscopic endonasal approach (EEA) for endoscopic skull base surgery on sinonasal-specific quality of life (QOL) as well as the instruments available for assessment. Our primary objective in this study was to characterize postoperative changes in sinonasal QOL, specifically using the 22-item Sino-Nasal Outcome Test (SNOT-22), with a secondary objective of delineating weaknesses in our current understanding of patient symptomatology after EEA for skull base surgery. METHODS A comprehensive literature review was conducted using PubMed, CINAHL, Cochrane Library, and SCOPUS for studies reporting SNOT-22 data pre- and postoperatively in patients who underwent EEA for skull base pathologies. Studies were limited to patients ≥18 years of age and excluded patients diagnosed with chronic rhinosinusitis (CRS). RESULTS Nineteen unique studies with 27 separate data sets and a total of 1025 patients were used in this meta-analysis. Overall SNOT-22 scores statistically improved at the 6-month (p = 0.0009) and 1-year (p = 0.002) time-points. Patients with preoperative SNOT-22 scores ≥20 achieved postoperative improvements at 12-week (p < 0.00001), 6-month (p < 0.0001), 1-year (p < 0.00001), and long-term follow-up (p < 0.0001). Patients with preoperative SNOT-22 scores <20 remained stable and did not worsen postoperatively. CONCLUSION Patients undergoing EEA for skull base pathologies who have impaired sinonasal QOL preoperatively demonstrated significant postoperative QOL improvements. Those patients with relatively normal preoperative sinonasal QOL remained asymptomatic postoperatively. This study supports the need for development of a contemporary disease- and approach-specific, validated QOL instrument for skull base pathologies.
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Affiliation(s)
- Prashant N Bhenswala
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC.,Department of Surgery, Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Suqrat Munawar
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Ogiwara T, Nagm A, Nakamura T, Mbadugha T, Horiuchi T, Hongo K. Significance and Indications of Surgery for Asymptomatic Nonfunctioning Pituitary Adenomas. World Neurosurg 2019; 128:e752-e759. [PMID: 31077893 DOI: 10.1016/j.wneu.2019.04.250] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/27/2019] [Accepted: 04/29/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The availability of magnetic resonance imaging (MRI) has led to an increase in the detection of pituitary incidentaloma (PI). However, there are no robust data on surgical treatment of PI on which to base therapeutic recommendations. This study was performed to investigate the significance of surgery for asymptomatic nonfunctioning pituitary adenoma (NFPA) among PIs. METHODS A total of 180 patients that underwent tumor resection of pituitary adenoma via the transsphenoidal approach between 2005 and 2017 were reviewed. Thirty-three consecutive patients with subjectively asymptomatic NFPA were included in this study. Our surgical indications for asymptomatic NFPAs were categorized as follows: macroadenoma with optic chiasma compression (group A, n = 14), solid tumor ≥2 cm in size (group B, n = 7), and tumor growth on follow-up MRI (group C, n = 12). The clinical outcomes were analyzed accordingly. RESULTS Seven patients (50%) in group A showed subjective improvement of visual function after tumor resection even though they had no complaints preoperatively. On the other hand, no changes occurred in any cases in group B or group C. Although there were no critical complications in this series, the incidence of nonnegligible nasal complications was relatively high (24.2%) and may decrease the patient's quality of life. CONCLUSIONS Surgery should be recommended for asymptomatic NFPA with optic chiasma compression to improve visual outcome. On the other hand, immediate intervention for other asymptomatic NFPA to reduce the likelihood of the appearance of tumor-related symptoms remains questionable considering its invasiveness to the nose.
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Affiliation(s)
- Toshihiro Ogiwara
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Alhusain Nagm
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan; Department of Neurosurgery, Al-Azhar University Faculty of Medicine-Nasr city, Cairo, Egypt
| | - Takuya Nakamura
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tobechi Mbadugha
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan; Unit of Neurosurgery, Memfys Hospital for Neurosurgery, Enugu, Nigeria
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
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Yin LX, Low CM, Puccinelli CL, O'Brien EK, Stokken JK, Van Abel KM, Janus JR, Link MJ, Van Gompel JJ, Choby G. Olfactory outcomes after endoscopic skull base surgery: A systematic review and meta‐analysis. Laryngoscope 2019; 129:1998-2007. [DOI: 10.1002/lary.28003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 12/28/2022]
Affiliation(s)
- Linda X. Yin
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
| | | | | | - Erin K. O'Brien
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
| | | | | | - Jeffrey R. Janus
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
| | - Michael J. Link
- Department of NeurosurgeryMayo Clinic Rochester Minnesota U.S.A
| | | | - Garret Choby
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
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21
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Tracy LF, Basu S, Shah PV, Frank-Ito DO, Das S, Zanation AM, Kimbell JS. Impact of endoscopic craniofacial resection on simulated nasal airflow and heat transport. Int Forum Allergy Rhinol 2019; 9:900-909. [PMID: 30861326 DOI: 10.1002/alr.22328] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 01/27/2019] [Accepted: 02/20/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Endoscopic craniofacial resections (CFR) are performed for extensive anterior skull base lesions. This surgery involves removal of multiple intranasal structures, potentially leading to empty nose syndrome (ENS). However, many patients remain asymptomatic postoperatively. Our objective was to analyze the impact of CFR on nasal physiology and airflow using computational fluid dynamics (CFD). This is the first CFD analysis of post-CFR patients. METHODS Three-dimensional sinonasal models were constructed from 3 postoperative images using MimicsTM . Hybrid computational meshes were created. Steady inspiratory airflow and heat transport were simulated at patient-specific flow rates using shear stress transport k-omega turbulent flow modeling in FluentTM . Simulated average heat flux (HF) and surface area where HF exceeded 50 W/m2 (SAHF50) were compared with laminar simulations in 9 radiographically normal adults. RESULTS Three adults underwent CFR without developing ENS. Average HF (W/m2 ) were 132.70, 134.84, and 142.60 in the CFR group, ranging from 156.24 to 234.95 in the nonoperative cohort. SAHF50 (m2 ) values were 0.0087, 0.0120, and 0.0110 in the CFR group, ranging from 0.0082 to 0.0114 in the radiographically normal cohort. SAHF50 was distributed throughout the CFR cavities, with increased HF at the roof and walls compared with the nonoperative cohort. CONCLUSION Average HF was low in the CFR group compared with the nonoperative group. However, absence of ENS in most CFR patients may be due to large stimulated mucosal surface area, commensurate with the nonoperative cohort. Diffuse distribution of stimulated area may result from turbulent mixing after CFR. To better understand heat transport post-CFR, a larger cohort is necessary.
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Affiliation(s)
- Lauren F Tracy
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Saikat Basu
- Department of Mechanical Engineering, South Dakota State University, Brookings, SD
| | - Parth V Shah
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Dennis O Frank-Ito
- Division of Otolaryngology, Head and Neck Surgery, Duke University Medical Center, Durham, NC
| | - Snigdha Das
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Adam M Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julia S Kimbell
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
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22
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Ogiwara T, Nagm A, Hasegawa T, Hanaoka Y, Ichinose S, Goto T, Hongo K. Pitfalls of skull base reconstruction in endoscopic endonasal approach. Neurosurg Rev 2018; 42:683-689. [PMID: 29982857 DOI: 10.1007/s10143-018-1006-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/26/2018] [Accepted: 06/29/2018] [Indexed: 11/24/2022]
Abstract
Various skull base reconstruction techniques have been developed in endoscopic endonasal approach (EEA) for skull base lesions to prevent postoperative cerebrospinal fluid (CSF) leakage. This study was performed to evaluate the efficacy and pitfalls of our method of skull base reconstruction after EEA. A total of 123 patients who underwent EEA (127 surgeries) between October 2014 and May 2017 were reviewed. Our algorithm for skull base reconstruction in EEA was categorized based on intraoperative CSF leakage graded as follows: grade 0 was excluded from this study; grade 1, dural suturing with abdominal fat graft or packing of gelatin sponge into the cavity; grade 2, method for grade 1 with addition of mucosal flap or nasoseptal flap (NSF); and grade 3, duraplasty in fascia patchwork closure with NSF. Bony reconstruction was not mandatory, and there was no postoperative bed rest or initial lumbar drainage (LD) insertion in any of the cases. Postoperative CSF leakage after EEA was mostly prevented (96.3%) by our algorithm without postoperative initial LD or bed rest. On the other hand, reconstruction surgery was required for postoperative CSF leakage in two cases-one with prior multitranssphenoidal surgery and radiotherapy and another patient with poor compliance due to communication difficulties. Both of the latter patients were obese. Greater care with regard to postoperative CSF leakage is required in patients with prior EEA with radiotherapy and obesity. In such high-risk patients, initial LD or bed rest may be required to prevent postoperative CSF leakage. It is also important to restrict activities that result in increased intracranial pressure.
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Affiliation(s)
- Toshihiro Ogiwara
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Alhusain Nagm
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.,Department of Neurosurgery, Al-Azhar University Faculty of Medicine, Nasr City, Cairo, Egypt
| | - Takatoshi Hasegawa
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yoshiki Hanaoka
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Shunsuke Ichinose
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Tetsuya Goto
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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23
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Roxbury CR, Magruder JT, Ramanathan M, Lim M, Gallia GL, Ishii M, Reh DD. Postoperative sinonasal morbidity in sellar reconstruction: mucosal autograft versus acellular dermal allograft. Int Forum Allergy Rhinol 2017; 7:1178-1185. [DOI: 10.1002/alr.22019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/25/2017] [Accepted: 09/03/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Christopher R. Roxbury
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore MD
| | - J. Trent Magruder
- Department of Surgery; Johns Hopkins Medical Institutions; Baltimore MD
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore MD
| | - Michael Lim
- Department of Neurosurgery; Johns Hopkins Medical Institutions; Baltimore MD
| | - Gary L. Gallia
- Department of Neurosurgery; Johns Hopkins Medical Institutions; Baltimore MD
| | - Masaru Ishii
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore MD
| | - Douglas D. Reh
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins Medical Institutions; Baltimore MD
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24
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Ten Dam E, Feijen RA, van den Berge MJC, Hoving EW, Kuijlen JM, van der Laan BFAM, Vermeulen KM, Krabbe PFM, Korsten-Meijer AGW. Development of the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire. Int Forum Allergy Rhinol 2017; 7:1076-1084. [PMID: 28834622 DOI: 10.1002/alr.22000] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/17/2017] [Accepted: 07/25/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND The patients' perspective of health outcomes has become important input for assessing treatment effects. However, existing endoscopic endonasal surgery (EES) instruments are not fully aligned with the concept of health-related quality of life (HRQoL). A prospective cohort study was therefore conducted to develop a suitable quality-of-life tool to assess nasal morbidity after EES: the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q). METHODS The study included 300 patients: 207 with sinus pathology and 93 with anterior skull base pathology. The EES-Q was administered prior to surgery and postoperatively (2 weeks, 3 months, and 1 year). Psychometric instrument properties were tested and relevant health domains were formulated. Seventy-two items were generated by the conventional psychometric approach. An exploratory factor analysis was used to test construct validity. The optimal number of factors to retain was determined by using the eigenvalues-greater-than-1 rule and scree plot. Orthogonal varimax rotation was used to enhance interpretability. Internal consistency was assessed using the Cronbach α. RESULTS The factor analysis yielded a 3-factor solution, representing physical, psychological, and social functioning. The final version of the instrument consisted of 30 items with a high internal consistency (>0.80) for all 3 HRQoL domains. CONCLUSIONS The EES-Q is a comprehensive, multidimensional, disease-specific instrument. A distinguishing characteristic is that, apart from the physical and psychological domains, the EES-Q also encompasses a social domain. Understanding different HRQoL aspects in patients undergoing EES may help caregivers restore, improve, or preserve the patient's health through individualized care, which depends on identifying their specific needs.
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Affiliation(s)
- Ellen Ten Dam
- Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Graduate School of Medical Sciences Institute for Drug Exploration, University of Groningen, Groningen, The Netherlands
| | - Robert A Feijen
- Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Minke J C van den Berge
- Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eelco W Hoving
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jos M Kuijlen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bernard F A M van der Laan
- Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karin M Vermeulen
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paul F M Krabbe
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Astrid G W Korsten-Meijer
- Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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25
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Greig SR, Cooper TJ, Sommer DD, Nair S, Wright ED. Objective sinonasal functional outcomes in endoscopic anterior skull-base surgery: an evidence-based review with recommendations. Int Forum Allergy Rhinol 2016; 6:1040-1046. [DOI: 10.1002/alr.21760] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 01/21/2016] [Accepted: 02/04/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Samuel R. Greig
- Department of Otolaryngology, Head and Neck Surgery, Department of Surgery; University of Alberta; Edmonton Canada
| | - Timothy J. Cooper
- Department of Otolaryngology, Head and Neck Surgery, Department of Surgery; University of Alberta; Edmonton Canada
| | - Doron D. Sommer
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery; McMaster University; Hamilton Ontario Canada
| | - Salil Nair
- Department of Otolaryngology, Head and Neck Surgery; Auckland District Health Board; Auckland New Zealand
| | - Erin D. Wright
- Department of Otolaryngology, Head and Neck Surgery, Department of Surgery; University of Alberta; Edmonton Canada
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26
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Schlüter A, Ahmadipour Y, Vogelsang T, Kreitschmann-Andermahr I, Kleist B, Weller P, Holtmann L, Mattheis S, Lang S, Bergmann C, Mueller O. Evaluation of the application of rhino-septal splints in endoscopic transsphenoidal skull base surgery. Eur Arch Otorhinolaryngol 2016; 273:4571-4578. [PMID: 27363406 DOI: 10.1007/s00405-016-4179-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
Abstract
The endoscopic transnasal route for the surgical removal of tumors in the sellar region is frequently associated with nasal complications such as synechiae or impaired nasal breathing. In this study, we investigated the impact of septal splints on avoiding surgery-related co-morbidities. 49 patients in whom endoscopic transnasal, transsphenoidal surgery for sellar tumors was performed between 2012 and 2014 were studied. In 30 of these, nasal septal splints were applied at the end of surgery to both sides of the septum and left in situ for 10 days (group 1), 19 patients received no splints (group 2). A standardized postsurgical follow-up investigation with endoscopic nasal examination, rhinomanometry and olfactory testing was performed on average 2 months postoperatively. Patients' subjective nose-related discomfort at follow-up was assessed descriptively using a set of standardized self-rating statements on nasal problems. Synechias occurred less likely with nasal septal splints (n = 15; 50 %) than without (n = 16; 84.2 %). Moreover, multiple synechiae were predominantly observed in the group without septal splints (n = 10 vs. n = 2). Rhinomanometry showed improved flow-V150-inspiration scores when splints were used (with significant differences between groups for the left nostril: p = 0.039 and p = 0.022, resp.). In accordance, impaired nasal breathing after surgery was reported more frequently by 76.9 % of patients without splints, but only 56 % of patients with splints. Our results provide support for the application of nasal septal splints when operating endoscopically on tumors in the sellar region to reduce postoperative synechias and to improve nasal breathing.
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Affiliation(s)
- Anke Schlüter
- Department of Oto-Rhino-Laryngology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Trutz Vogelsang
- Department of Oto-Rhino-Laryngology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | | | - Bernadette Kleist
- Department of Neurosurgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Patrick Weller
- Department of Oto-Rhino-Laryngology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Laura Holtmann
- Department of Oto-Rhino-Laryngology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Stefan Mattheis
- Department of Oto-Rhino-Laryngology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Stephan Lang
- Department of Oto-Rhino-Laryngology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Christoph Bergmann
- Department of Oto-Rhino-Laryngology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Oliver Mueller
- Department of Neurosurgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.
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27
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Postoperative otorhinolaryngologic complications in transnasal endoscopic surgery to access the skull base. Braz J Otorhinolaryngol 2016; 83:349-355. [PMID: 27320654 PMCID: PMC9444793 DOI: 10.1016/j.bjorl.2016.04.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 04/08/2016] [Accepted: 04/14/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction The large increase in the number of transnasal endoscopic skull base surgeries is a consequence of greater knowledge of the anatomic region, the development of specific materials and instruments, and especially the use of the nasoseptal flap as a barrier between the sinus tract (contaminated cavity) and the subarachnoid space (sterile area), reducing the high risk of contamination. Objective To assess the otorhinolaryngologic complications in patients undergoing endoscopic surgery of the skull base, in which a nasoseptal flap was used. Methods This was a retrospective study that included patients who underwent endoscopic skull base surgery with creation of a nasoseptal flap, assessing for the presence of the following post-surgical complications: cerebrospinal fluid leak, meningitis, mucocele formation, nasal synechia, septal perforation (prior to posterior septectomy), internal nasal valve failure, epistaxis, and olfactory alterations. Results The study assessed 41 patients undergoing surgery. Of these, 35 had pituitary adenomas (macro- or micro-adenomas; sellar and suprasellar extension), three had meningiomas (two tuberculum sellae and one olfactory groove), two had craniopharyngiomas, and one had an intracranial abscess. The complications were cerebrospinal fluid leak (three patients; 7.3%), meningitis (three patients; 7.3%), nasal fossa synechia (eight patients; 19.5%), internal nasal valve failure (six patients; 14.6%), and complaints of worsening of the sense of smell (16 patients; 39%). The olfactory test showed anosmia or hyposmia in ten patients (24.3%). No patient had mucocele, epistaxis, or septal perforation. Conclusion The use of the nasoseptal flap has revolutionized endoscopic skull base surgery, making the procedures more effective and with lower morbidity compared to the traditional route. However, although mainly transient nasal morbidities were observed, in some cases, permanent hyposmia and anosmia resulted. An improvement in this technique is therefore necessary to provide a better quality of life for the patient, reducing potential complications.
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Long-term outcomes of endoscopic endonasal approach for skull base surgery: a prospective study. Eur Arch Otorhinolaryngol 2015; 273:1809-17. [PMID: 26688432 DOI: 10.1007/s00405-015-3853-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Little is known about the long-term effects of either transnasal transsphenoidal endoscopic approach (TTEA) or expanded endonasal approach (EEA). This study assessed the long-term impact of endoscopic skull base surgery on olfaction, sinonasal symptoms, mucociliary clearance time (MCT), and quality of life (QoL). Patients with pituitary adenomas underwent TTEA (n = 38), while patients with other benign parasellar tumours who underwent an EEA with vascularised septal flap reconstruction (n = 17) were enrolled in this prospective study between 2009 and 2012. Sinonasal symptoms (Visual Analogue Scale), subjective olfactometry (Barcelona Smell Test-24, BAST-24), MCT (saccharin test), and QoL (short form SF-36, rhinosinusitis outcome measure/RSOM) were evaluated before, and 12 months after, surgery. At baseline, sinonasal symptoms, MCT, BAST-24, and QoL were similar between groups. Twelve months after surgery, both TTEA and EEA groups experienced smell impairment compared to baseline. Moreover, EEA (but not TTEA) patients reported increased posterior nasal discharge and longer MCTs compared to baseline. No significant changes in olfactometry or QoL were detected in either group 12 months after surgery. Over the long-term, expanded skull base surgery, using EEA, produced more sinonasal symptoms (including loss of smell) and longer MCTs than pituitary surgery (TTEA). EEA showed no long-term impact on smell test or QoL. LEVEL OF EVIDENCE IIb.
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29
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Reponen E, Tuominen H, Hernesniemi J, Korja M. Patient-Reported Outcomes in Elective Cranial Neurosurgery. World Neurosurg 2015; 84:1845-51. [DOI: 10.1016/j.wneu.2015.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/02/2015] [Accepted: 08/03/2015] [Indexed: 12/18/2022]
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30
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Naunheim MR, Sedaghat AR, Lin DT, Bleier BS, Holbrook EH, Curry WT, Gray ST. Immediate and Delayed Complications Following Endoscopic Skull Base Surgery. J Neurol Surg B Skull Base 2015; 76:390-6. [PMID: 26401482 DOI: 10.1055/s-0035-1549308] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/12/2015] [Indexed: 10/23/2022] Open
Abstract
Objectives To characterize the temporal distribution and resolution rate of postoperative complications from endoscopic skull base surgery. Design Retrospective review of patients undergoing endoscopic resection of paranasal sinus or skull base neoplasm from 2007 to 2013. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Fifty-eight consecutive patients. Main Outcome Measures Postoperative complications were categorized as cerebrospinal fluid (CSF) leak, pituitary, orbital, intracranial, or sinonasal. Complications were temporally categorized as "perioperative" (within 1 week), "early" (after 1 week and within 6 months), or "delayed" (after 6 months). Results The most common perioperative complications were diabetes insipidus (19.0%), CSF leak (5.2%), and meningitis (5.2%), with resolution rates of 75%, 100%, and 100%, respectively. Overall, CSF leak occurred in 13.8% of patients and resolved in all cases. A total of 53.8% of all complications were evident within 1 week of surgery. Chronic rhinosinusitis was the most common delayed complication (3.4%). Hypopituitarism and delayed complications were less likely to resolve (p = 0.014 and p = 0.080, respectively). Conclusions Monitoring of complications after endoscopic skull base surgery should focus on neurologic complications and CSF leak in the early postoperative period and development of chronic rhinosinusitis in the long term. Late-onset complications and hypopituitarism are less likely to resolve.
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Affiliation(s)
- Matthew R Naunheim
- 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
| | - Ahmad R Sedaghat
- 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
| | - Benjamin S Bleier
- 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
| | - Eric H Holbrook
- 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, Boston, Massachusetts, United States
| | - 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
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Shin M, Kondo K, Kin T, Suzukawa K, Saito N. Endoscopic transnasal interseptal approach for invasive clival tumors: development of an approach method regarding maximal preservation of the nasal anatomy. Neurol Med Chir (Tokyo) 2015; 55:336-44. [PMID: 25797777 PMCID: PMC4628181 DOI: 10.2176/nmc.oa.2014-0280] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Asian people frequently show small noses, narrow nasal apertures, and congestive mucosa on the turbinates and septum. To reduce the risk of nasal morbidity with increased radicality for skull base tumors in these patients, we developed endoscopic transnasal interseptal approach (ETISA) in transsphenoidal surgery for invasive clival tumors (ICTs). Indication for ETISA is radical resection for tumors occupying deep ventral skull base regions, confined posterior to the level of the middle turbinates. After removing ethmoidal air cells, the middle turbinates are laterally deflected. A linear incision is made vertically on each side of the septal mucosa, which is separated from the bony septum as far as the sphenoid rostrum. The blades of an adjustable speculum are inserted submucosally, and the bony septum is temporarily displaced. The surgical pathway is widely maintained from the entrance to the deep surgical field without sacrificing the nasal mucosa and turbinates. Thirty-two consecutive patients with clival tumors (18 chordomas, 11 chondrosarcomas, 3 others) were treated. Bilateral middle turbinectomy was routinely performed in the initial 3 patients, but in only 4 of the remaining 29 (3 unilaterally, 1 bilaterally). Tumor was sufficiently resected in 29 patients (90.6%; gross total removal n = 25, subtotal resection n = 4). As complications, 6 patients showed mild and transient worsening of cranial nerve symptoms. Nasal complications arose in 3 patients, persisting > 3 months in 2 (5.7%). This approach allows fine bimanual handling and swift delivery of surgical equipment while reasonably preserving the nasal anatomy, which is useful in endoscopic transsphenoidal surgery for ICT.
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Affiliation(s)
- Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital
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32
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Awad AJ, Mohyeldin A, El-Sayed IH, Aghi MK. Sinonasal morbidity following endoscopic endonasal skull base surgery. Clin Neurol Neurosurg 2015; 130:162-7. [PMID: 25621713 DOI: 10.1016/j.clineuro.2015.01.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 12/27/2014] [Accepted: 01/03/2015] [Indexed: 10/24/2022]
Abstract
Open transcranial surgery has long served as the traditional approach for resecting tumors and other lesions in the skull base. However, endoscopic endonasal skull base surgery (EESBS) has emerged as a credible alternative. This paper provides insight on the sinonasal morbidity in patients undergoing EESBS. A literature review was performed by searches of MEDLINE database to provide further insight on sinonasal morbidity associated with EESBS, with a particular focus on published incidence rates and patterns of complication. We identified only articles that reported the incidence of sinonasal morbidity and complications as the major outcome of the studies. The most common sinonasal morbidity symptoms are nasal crusting (50.8%), nasal discharge (40.4%), nasal airflow blockage (40.1%) followed by disturbances in olfaction (26.7%). The incidence of mucocele formation is 8%, and this is significantly increased in pediatric patients up to 25% (range, 14-50%). Epistaxis appears to be a rare event, often times not found in some case series. Some studies suggested less morbidity if the middle turbinate can be preserved, a finding that must be balanced with the need for sufficient exposure on larger cases. Sinonasal morbidity following endoscopic endonasal skull base surgery has the potential to adversely impact patient quality of life, with nasal crusting and discharge being the two most common symptoms. Morbidity signs and symptoms usually resolve within 3-4 months, however symptoms can persist for longer with more complex surgeries. The rate of mucocele formation is higher in pediatric patients, with special attention required in graft positioning for this population in particular.
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Affiliation(s)
- Ahmed J Awad
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, USA
| | - Manish K Aghi
- Department of Neurosurgery, University of California at San Francisco, San Francisco, USA.
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