Impact of Reverse Septal Flap on Morbidity of Nasoseptal Flap Reconstruction of Skull Base Defects

BACKGROUND

The workhorse for endonasal reconstruction of skull base defects is the posteriorly-based nasoseptal flap (NSF). Postoperative nasal deformities and decreased olfaction are potential complications of NSF. The reverse septal flap (RSF) minimizes the donor site morbidity of the NSF by covering the exposed cartilage of the anterior septum. Currently, there are minimal data examining its effect on outcomes including nasal dorsum collapse and olfaction.

OBJECTIVE

Our study aims to clarify whether the RSF should be utilized when the option exists.

METHODS

Adult patients undergoing endoscopic endonasal approach (EEA) surgery of the skull base (transsellar/transplanum/transclival approaches) with NSF reconstruction were identified. Data from 2 separate cohorts, one retrospective and one prospective, were collected. Follow-up was at least 6 months. Patients were photographed preoperatively and postoperatively using standard rhinoplastic nasal views. Patients completed the University of Pennsylvania Smell Identification Test (UPSIT) and the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and postoperatively and were also queried regarding subjective changes in nasal appearance and plans for cosmetic surgery following EEA.

RESULTS

There were no statistically significant differences in the change in UPSIT and SNOT-22 scores between patients receiving RSF and other reconstructive groups (either NSF without RSF or no NSF). One of 25 patients who were reconstructed with an NSF with RSF reported a change in nasal appearance; none were considering reconstructive surgery. The proportion of patients reporting changes in appearance was significantly lower in the NSF with RSF group as compared to the NSF without RSF group (P = .012).

CONCLUSION

The use of an RSF to limit donor site morbidity of the NSF was shown to significantly decrease the proportion of patients who reported nasal deformities and did not show a significant difference in patient-reported sinonasal outcomes. Given these findings, RSF should be considered whenever an NSF is used for reconstruction.

Risk Factors in a Pediatric Population for Postoperative Intracranial Infection Following Endoscopic Endonasal Skull Base Surgery and the Role of Antibiotic Prophylaxis

BACKGROUND

Endoscopic endonasal skull base surgery (EESBS) is performed through a non-sterile corridor. Intracranial infection rates in a pediatric population have not been extensively studied and the exact effect of antibiotic prophylaxis on rates of infection after EESBS in pediatric patients remains unclear.

OBJECTIVE

The purpose of our study is to investigate risk factors for postoperative intracranial infection during EESBS in a pediatric population and help elucidate the role of antibiotic prophylaxis.

METHODS

We conducted a retrospective chart review of 99 consecutive patients under the age of 18 who underwent EESBS at our institution from 2013 to 2021. Centers for Disease Control and Prevention/National Healthcare Safety Network criteria for diagnosis of meningitis were used to identify postoperative intracranial infections.

RESULTS

The average age was 12.3 years (range 1.6-18) with 66 male patients and 33 female patients. 49 patients had an intraoperative cerebrospinal fluid (CSF) leak, of which 4 had a postoperative CSF leak. We identified 3 postoperative intracranial infections (3%), which were all meningitis cases. The infection rate was 6% (3/49) among those with intraoperative CSF leaks. All patients with meningitis had a postoperative CSF leak. All infections were transclival approaches (2 chordoma and 1 neurenteric cyst).

CONCLUSION

This investigation represents one of the largest pediatric endoscopic skull base surgery cohorts. EESBS is safe to perform in pediatric populations, but transclival approaches and postoperative CSF leaks are risk factors for postoperative meningitis.

Dural Sealants Do Not Reduce Postoperative Cerebrospinal Fluid Leak after Endoscopic Endonasal Skull Base Surgery

Introduction The application of cranial tissue sealants to assist with postoperative closure is widespread, but data are lacking regarding its utility in endoscopic endonasal surgery (EEA). A prospective study was conducted to assess the effect of sealant usage on postoperative cerebrospinal fluid (CSF) leak rate following standard reconstruction.

Methods A prospective trial of sealant usage after endoscopic endonasal skull base surgery was performed from May 2016 to June 2019 at a tertiary referral cranial base center. This study enrolled 300 consecutive adult and pediatric patients with skull base pathology who underwent EES in which an intraoperative CSF leak occurred. Patients were sequentially stratified into equally sized groups who did or did not receive sealant as part of their reconstruction.

Results Three hundred consecutive adult and pediatric patients were enrolled in the study and had a confirmed intraoperative CSF leak. The intervention cohort with sealant (first 150 patients) had 21 postoperative CSF leaks (14% rate) compared with 9 postoperative CSF leaks (6% rate) in the control group without sealant (p = 0.02). On multivariate analysis, sealant usage was associated with a higher rate of postoperative CSF leak (odds ratio [OR] = 2.7; p = 0.025). Male gender (OR = 2.4; p = 0.04) and high-flow intraoperative CSF leak (OR = 3.1; p = 0.038) were also found to be associated with postoperative CSF leak.

Conclusion Among all patients undergoing EES with an intraoperative CSF leak, the addition of sealant to standard closure techniques did not reduce the rate of postoperative CSF leaks.

The Suprasellar Meningioma Patient-Reported Outcome Survey: a disease-specific patient-reported outcome measure for resection of suprasellar meningioma

OBJECTIVE

Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas.

METHODS

Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument.

RESULTS

Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO.

CONCLUSIONS

The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

ABBREVIATIONS

EEA = endoscopic endonasal approach; GTR = gross-total resection; PRO = patient-reported outcome; PROMIS29 = Patient-Reported Outcomes Measurement Information System-29; QOL = quality of life; SMPRO = Suprasellar Meningioma Patient-Reported Outcome Survey; TCA = transcranial approach.

QOLP-15. QUALITATIVE STUDY OF DIFFERENTIAL QUALITY OF LIFE (QOL) IN SUPRASELLAR MENINGIOMA PATIENTS TREATED VIA ENDOSCOPIC ENDONASAL APPROACH VERSUS OPEN CRANIOTOMY

BACKGROUND

The optimal surgical treatment of suprasellar meningiomas remains controversial. While successful surgery has historically been measured by extent of tumor resection (EOR), surgeons must also balance tumor- and patient-specific characteristics with quality of life (QoL) outcomes when considering either an open craniotomy or endoscopic endonasal approach (EEA).

METHODS

We conducted 28 in-depth individual interviews with patients diagnosed with suprasellar meningioma and treated via EEA (n=14) or craniotomy (n=14). We used a structured interview script and the transcribed interviews were independently coded by two researchers. Consensus was used to identify themes and domains of interest.

RESULTS

The overall sample (80% between 40-69 years old, 70% female, and 82% white) was largely similar between craniotomy and EEA cohorts. Tumor volumes were not different between both cohorts (p=0.2), with a combined average of 4.4 cm3 (standard error ± 0.7). Suprasellar meningiomas caused a wide range of symptoms with 21 concepts elicited. The most frequently endorsed concepts were “Vision” (n=22), “Headaches” (n=11), “Fatigue” (n=11), “Cognitive Symptoms” (n=10), “Pituitary Dysfunction – including Trouble Sleeping and Frequent Urination” (n=9), “Sinus Problems” (n=7), and “Personality Changes” (5). Both surgical approaches demonstrated improvements in vision (69.2% EEA, 66.7% craniotomy) and headaches (100% EEA, 80% craniotomy). Compared to EEA, craniotomy yielded a longer list of complications (3 vs.14) and surgery-specific symptoms (9 vs.16). More craniotomy patients reported having negative emotions (5 vs.1), new depression and anxiety (6 vs.1), financial difficulties (3 vs.1), and reduced desire/ability to pursue fun activities (12 vs.7) after surgery relative to EEA counterparts.

CONCLUSION

Suprasellar meningiomas can be debilitating with significantly impact on patients’ health and QoL. Our findings demonstrate differential effects upon patients’ post-operative QoL associated with type of surgery. Our findings support the need for measuring patient-centered, disease-specific QoL outcomes in patients undergoing craniotomy versus EEA for suprasellar meningioma resection.

The Effect of Nasoseptal Flap Elevation on Post-Operative Olfaction and Sinonasal Quality of Life: A Prospective Double-Blinded Randomized Controlled Trial

BACKGROUND

The use of nasoseptal flaps (NSF) for defect reconstruction in endoscopic endonasal approaches (EEA) to cranial base pathology has markedly reduced rates of cerebrospinal fluid leak. However, the effect of NSF use on post-operative olfaction remains unclear.

OBJECTIVE

To evaluate the impact of NSF use during EEA on binarial and uninarial olfaction, and sinonasal quality of life (QOL).

METHODS

This was a prospective double-blinded randomized controlled trial. Patients undergoing EEA for sellar pathology were recruited from the University of Pittsburgh Medical Center from December 2014 to May 2017. Subjects were randomized pre-operatively to a side of NSF harvest. Olfaction and QOL were assessed pre-operatively and 6 to 12 months post-operatively using the University of Pennsylvania Smell Identification Test, "Sniffin' Sticks," and Sinonasal Outcomes Test 22. The side of dominant uninarial olfaction was determined using "Sniffin' Sticks."

RESULTS

Thirty-one patients were enrolled. Sixteen underwent EEA without NSF (control group) and 15 with NSF. A dominant side of olfaction was identified in 14 patients with NSF; 8 patients were randomized to NSF harvest on the dominant side and the remaining 6 on the non-dominant side. NSF elevation resulted in a 4% decrease in University of Pennsylvania Smell Identification Test scores, but was not statistically significant compared to controls. Similarly, NSF elevation on the side of dominant olfaction resulted in a 6% decrease, but was not statistically significant when compared to the non-dominant elevation group. Change in rhinologic QOL as determined by the Sinonasal Outcomes Test 22 was not significantly different between any of the groups.

CONCLUSIONS

The use of NSF during EEA for sellar pathology does not have a significant effect on olfaction or rhinologic QOL. The presence of a dominant side of olfaction is not a primary consideration when deciding the side of NSF harvest.

Experience With the Endoscopic Contralateral Transmaxillary Approach to the Petroclival Skull Base

OBJECTIVES/HYPOTHESIS

The contralateral transmaxillary (CTM) approach is a new surgical approach that improves the surgical trajectory relative to the petrous segment of the internal carotid artery (ICA). Here, we present our clinical experience with the CTM approach to the petroclival region of the skull base.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review of 29 patients who underwent a CTM approach for skull base pathology from 2015 to 2020 was performed. Assessment of gross total resection (GTR) was based on postoperative imaging.

RESULTS

The male:female ratio was 15:14, with an average age of 52 years (range = 19-78 years). Diagnoses included: 12 chondrosarcomas, 11 chordomas, two meningiomas, one schwannoma, one metastasis, one petrous apicitis, and one arachnoid cyst. CTM was performed in addition to a transclival approach and ipsilateral transpterygoid approach in all patients. Reconstruction of surgical defects included a vascularized flap in all but two patients: 24 nasoseptal flaps and three lateral nasal wall flaps. The reconstructive flap was on the same side as the CTM approach in 22 of 28 (79%) patients. There were no ICA injuries. In a subset of patients with chondromatous tumors, GTR of the targeted area was achieved in 16 of 22 (73%) evaluable chondromatous tumors. With a median follow-up of 13 months, 64% of these patients are without disease or dead of other causes; the remainder are alive with disease.

CONCLUSIONS

The CTM approach improves the degree of resection of skull base tumors involving the petroclival region using an endoscopic endonasal approach and may minimize risk to the ICA.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:294-298, 2021.

Variations in Surgical Outcomes of Carotid Body Tumors by Surgical Specialty

OBJECTIVES/HYPOTHESIS

A carotid body tumor (CBT) is a rare type of tumor that is divided among multiple surgical specialties. Individual surgeons may have limited experience in treating these tumors. We aim to compare different surgical specialties within a single healthcare system to detect variations in management and outcome.

STUDY DESIGN

Retrospective chart review.

METHODS

A chart review of all patients who underwent surgery for CBT at the University of Pittsburgh Medical Center (UPMC) from 2000 to 2019 was carried out. Univariate and multivariate analysis was used for descriptive statistics, comparison of outcomes, and identification of risk factors.

RESULTS

Fifty-eight CBT resection surgeries were performed at UPMC. Patients with advanced tumor were 6.7 (95% confidence interval [CI]: 1.36-32.7) times more likely to undergo preoperative embolization and 8.53 (95% CI: 2.011-36.19) times more likely to sustain carotid artery injury. Advanced-stage tumor resections were associated with greater blood loss (P = .03) and longer hospitalization (P = .02). Collaborative surgeries were associated with higher rates of carotid artery injury (P = .003), residual tumor (P < .001), and longer hospitalization (P = .003), as these combined cases were generally reserved for advanced-stage tumors (P = .02). There were no differences in outcomes between specialties. Of 22 surgeons, the median number of surgeries per surgeon was one (range = 1-12, 54.5%).

CONCLUSIONS

Surgeons who completed only one surgery for CBT had a greater rate of hospital readmission and greater length of hospital stay. Collaborative surgeries had worse outcomes due to more advanced tumors requiring more complex surgeries.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E190-E195, 2021.

Prospective characterization of postoperative nasal deformities in patients undergoing endoscopic endonasal skull-base surgery

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.

Injury of the Carotid Artery during Endoscopic Endonasal Surgery: Surveys of Skull Base Surgeons

Objectives  This study aimed to review endoscopic skull base surgeon experience with internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) to provide an estimate of the incidence of ICA injury, the associated factors and identify the best training modalities for the management of this complication. Design  Anonymous electronic survey of past participants at a well-established endoscopic skull base surgery course and a global online community of skull base surgeons. Main Outcome Measures  Relative incidence of ICA injuries during EES, associated anatomic and intraoperative factors, and surgeon experience. Results  At least 20% of surgeons in each surveyed population experienced a carotid artery injury. Reported carotid artery injuries were most common during tumor exposure and removal (48%). The parasellar carotid artery was the most commonly injured segment (39%). Carotid artery injuries were more common in high-volume surgeons, but only statistically significant in one of the two populations. Attendance at a skull base course or courses did not change the incidence of carotid artery injury in either surveyed population. In both surveys, respondents preferred live surgeries or active (not computer simulated) training models. Conclusions  ICA injury is underreported and most common when manipulating the parasellar carotid artery for exposure and tumor dissection. Given the high morbidity and mortality associated with these injuries, vascular injury management should be prioritized and taught in a graduated approach by modern endoscopic skull base courses.

Development of an evidence-based decision pathway for vestibular schwannoma treatment options

OBJECTIVE

To integrate multiple sources of clinical information with patient feedback to build evidence-based decision support model to facilitate treatment selection for patients suffering from vestibular schwannomas (VS).

METHODS

This was a mixed methods study utilizing focus group and survey methodology to solicit feedback on factors important for making treatment decisions among patients. Two 90-minute focus groups were conducted by an experienced facilitator. Previously diagnosed VS patients were recruited by clinical investigators at the University of Pittsburgh Medical Center (UPMC). Classical content analysis was used for focus group data analysis. Providers were recruited from practices within the UPMC system and were surveyed using Delphi methods. This information can provide a basis for multi-criteria decision analysis (MCDA) framework to develop a treatment decision support system for patients with VS.

RESULTS

Eight themes were derived from these data (focus group + surveys): doctor/health care system, side effects, effectiveness of treatment, anxiety, mortality, family/other people, quality of life, and post-operative symptoms. These data, as well as feedback from physicians were utilized in building a multi-criteria decision model.

DISCUSSION

The study illustrated steps involved in the development of a decision support model that integrates evidence-based data and patient values to select treatment alternatives.

CONCLUSIONS

Studies focusing on the actual development of the decision support technology for this group of patients are needed, as decisions are highly multifactorial. Such tools have the potential to improve decision making for complex medical problems with alternate treatment pathways.

Sealants and dental caries: insight into dentists' behaviors regarding implementation of clinical practice recommendations

BACKGROUND

The authors conducted a qualitative study of private-practice dentists in their offices by using vignette-based interviews to assess barriers to the use of evidence-based clinical recommendations in the treatment of noncavitated carious lesions.

METHODS

The authors recruited 22 dentists as a convenience sample and presented them with two patient vignettes involving noncavitated carious lesions. Interviewers asked participants to articulate their thought processes as they described treatment recommendations. Participants compared their treatment plans with the American Dental Association's recommendations for sealing noncavitated carious lesions, and they described barriers to implementing these recommendations in their practices. The authors recorded and transcribed the sessions for accuracy and themes.

RESULTS

Personal clinical experience emerged as the determining factor in dentists' treatment decisions regarding noncavitated carious lesions. Additional factors were lack of reimbursement and mistrust of the recommendations. The authors found that knowledge of the recommendations did not lead to their adoption when the recommendation was incongruent with the dentist's personal experience.

CONCLUSIONS

The authors found that ingrained practice behavior based on personal clinical experience that differed substantially from evidence-based recommendations resulted in a rejection of these recommendations.

PRACTICAL IMPLICATIONS

Attempts to improve the adoption of evidence-based practice must involve more than simple dissemination of information to achieve a balance between personal clinical experience and scientific evidence.