1
|
Godse NR, Jarmula J, Kshettry VR, Woodard TD, Recinos PF, Sindwani R. Emergency department visits following endoscopic skull base surgery: An opportunity for improvement. Int Forum Allergy Rhinol 2024; 14:613-620. [PMID: 37422726 DOI: 10.1002/alr.23237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Readmissions are major healthcare expenditures, key hospital metrics, and are often preceded by an evaluation in the emergency department (ED). The purpose of this study was to analyze ED visits within 30 days of endoscopic skull base surgery (ESBS), risk factors for readmission once in the ED, and ED-related evaluation and outcomes. METHODS Retrospective review from January 2017 to December 2022 at a high-volume center of all ESBS patients who presented to the ED within 30 days of surgery. RESULTS Of 593 ESBS cases, 104 patients (17.5%) presented to the ED following surgery within 30 days, with a median presentation of 6 days post-discharge (IQR 5-14); 54 (51.9%) patients were discharged while 50 (48.1%) were readmitted. Readmitted patients were significantly older than discharged patients (median 60 years, IQR 50-68 vs. 48 years, 33-56; p < 0.01). Extent of ESBS was not associated with readmission or discharge from the ED. The most common discharge diagnoses were headache (n = 13, 24.1%) and epistaxis (n = 10, 18.5%); the most common readmitting diagnoses were serum abnormality (n = 15, 30.0%) and altered mental status (n = 5, 10.0%). Readmitted patients underwent significantly more laboratory testing than discharged patients (median 6, IQR 3-9 vs. 4, 1-6; p < 0.01). CONCLUSIONS Approximately half of patients who presented to the ED following ESBS were discharged home but underwent significant workup. Follow-up within 7 days of discharge, risk-stratified endocrine care pathways, and efforts to address the social determinants of health may be considered to optimize postoperative ESBS care.
Collapse
Affiliation(s)
- Neal R Godse
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jakub Jarmula
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Troy D Woodard
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Raj Sindwani
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| |
Collapse
|
2
|
Merrill TB, Tyes J, Woodard TD. Is Elexacaftor/Tezacaftor/Ivacaftor Effective in Treating Sinonasal Disease in Patients with Cystic Fibrosis? Laryngoscope 2024; 134:501-503. [PMID: 37548273 DOI: 10.1002/lary.30937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/15/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Tyler B Merrill
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Jonathan Tyes
- University of Louisville School of Medicine, Louisville, Kentucky, U.S.A
| | - Troy D Woodard
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| |
Collapse
|
3
|
Godse NR, Sreenath SB, Sbeih F, Woodard TD, Kshettry VR, Recinos PF, Sindwani R. Fascia Lata: Another Workhorse for Complex Skull Base Reconstruction. Am J Rhinol Allergy 2023:19458924231170955. [PMID: 37081750 DOI: 10.1177/19458924231170955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Multiple methods exist for skull base reconstruction of defects created by expanded endonasal approaches. While the nasoseptal flap (NSF) has been well established as the workhorse of mucosal reconstruction in complex skull base defects in multi-layered closures, a variety of options exist for the inner layer of multilayer reconstruction, including fascia lata (FL). OBJECTIVE To present our experience and outcomes in utilizing FL in multiple ways to reconstruct a wide variety of complex skull base defects. METHODS Retrospective review was performed from May 2017 to February 2022 to identify 50 consecutive patients who underwent endoscopic skull base reconstruction using FL. RESULTS FL was employed for reconstruction in 50 patients included in the study: 37 undergoing primary expanded endonasal skull base surgery and 13 revision cases. A wide range of complex pathology was treated, with meningioma and craniopharyngioma being the two most common. FL was utilized as a "button" graft (34/50, 68.0%), free graft inlay/onlay (13/50, 26.0%), and as a button graft combined with onlay (3/50, 6.0%). Expanded surgery defects addressed included tuberculum sella/sphenoid planum (36/50, 72.0%), clivus (6/50, 12.0%), and cribriform/planum (8/50, 16.0%). Successful reconstruction with fascia lata was accomplished in 46/50 cases (92%), with only 4 cases (8%) requiring revision for post-op CSF leak. Donor-site complications were rare with only 1 case (2.0%) of post-op seroma. CONCLUSION FL, usually with NSF, offers a versatile option for the reconstruction of challenging defects with excellent outcomes and minimal morbidity. FL is emerging as a workhorse for reconstruction of the inner layer of complex skull base defects.
Collapse
Affiliation(s)
- Neal R Godse
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Satyan B Sreenath
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, IN, USA
| | - Firas Sbeih
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Troy D Woodard
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Pablo F Recinos
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Raj Sindwani
- Section of Rhinology and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
- Minimally Invasive Cranial Base and Pituitary Surgery Section, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
4
|
Sreenath SB, Grafmiller KT, Tang DM, Roof SA, Woodard TD, Kshettry VR, Recinos PF, Sindwani R, Fritz MA. Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era. Laryngoscope 2023; 133:562-568. [PMID: 35920134 DOI: 10.1002/lary.30315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/17/2022] [Accepted: 07/07/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi-modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic-assisted approach for the management of ORN of the skull base using fascia lata for MFTT. STUDY DESIGN Retrospective case series. METHODS Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long-term follow-up were reviewed. RESULTS Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post-op follow-up was 23 months. CONCLUSIONS With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity. LEVEL OF EVIDENCE 4 Laryngoscope, 133:562-568, 2023.
Collapse
Affiliation(s)
- Satyan B Sreenath
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Kevin T Grafmiller
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Dennis M Tang
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Scott A Roof
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mt. Sinai, New York, New York, U.S.A
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Varun R Kshettry
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Pablo F Recinos
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Michael A Fritz
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
| |
Collapse
|
5
|
Almeida JP, Sreenath SB, de Andrade EJ, Recinos PF, Woodard TD, Kshettry VR. Endoscopic Transpterygoid Transcavernous Approach for Resection of a Petroclival Chondrosarcoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e60-e61. [PMID: 35726942 DOI: 10.1227/ons.0000000000000222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida (Current Affiliation), USA
| | - Satyan B Sreenath
- Department of Otolaryngology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erion J de Andrade
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Troy D Woodard
- Department of Otolaryngology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
6
|
Tish S, Habboub G, Borghei-Razavi H, Woodard TD, Sindwani R, Kshettry VR, Recinos PF. Use of Radiofrequency Technology in Endonasal Skull Base and Transcranial Procedures. Skull Base Surg 2022; 83:312-316. [DOI: 10.1055/s-0040-1721820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/20/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objective Radiofrequency ablation is widely utilized in otorhinolaryngology. It is used for ablation, coagulation and resection, and hemostasis. It causes tissue destruction through a chemical interaction of ions. The potential benefit is to cause less thermal injury to surrounding tissues compared with other coagulative tools. In this article, we present novel uses of radiofrequency ablation in endoscopic endonasal, and transcranial surgery. This is the first study to describe its use in transcranial cases.
Design, Setting, and Participants This is a retrospective study of patients between 2016 and 2018 who underwent either endoscopic endonasal or transcranial surgery where radiofrequency ablation was used.
Main Outcome Measures We looked at indication for usage, blood loss, postoperative imaging to identify any stroke or edema, and clinical outcomes of these patients.
Results The radiofrequency device was used in eight endoscopic endonasal cases and four craniotomies. Four cases were for encephalocele repair and eight were for various intracranial pathologies. In endonasal encephalocele repair, the radiofrequency ablation helped in shrinking the herniated brain while minimizing thermal injury to the surrounding tissue. In tumors resection, the combination of ablation and coagulation effect was particularly effective for highly vascularized tumors. There were no vascular or major neurologic injuries. Postoperative periencephalocele edema was noted in one case.
Conclusion Initial experience with radiofrequency ablation showed that it was a safe technique to use in both endonasal skull-base and transcranial procedures. It seemed particularly useful for highly vascularized tumors but a greater experience is needed to further clarify its role in these procedures.
Collapse
Affiliation(s)
- Shahed Tish
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
| | - Ghaith Habboub
- Department of Neurological Surgery, Section of Skull Base Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Hamid Borghei-Razavi
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
- Department of Neurological Surgery, Section of Skull Base Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Troy D. Woodard
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Raj Sindwani
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Varun R. Kshettry
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
- Department of Neurological Surgery, Section of Skull Base Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Pablo F. Recinos
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio, United States
- Department of Neurological Surgery, Section of Skull Base Surgery, Cleveland Clinic, Cleveland, Ohio, United States
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, United States
| |
Collapse
|
7
|
Kılıç S, Sreenath SB, Grafmiller K, Woodard TD, Recinos PF, Kshettry VR, Sindwani R. Systematic Review of Olfactory Outcomes After Nasoseptal Flap Harvest for Endoscopic Skull Base Surgery: Does Using Cold Steel or Olfactory Strip Preservation Matter? Int Forum Allergy Rhinol 2021; 12:1043-1055. [PMID: 34910852 DOI: 10.1002/alr.22945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/12/2021] [Accepted: 12/12/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Several studies have described techniques aimed at mitigating olfactory dysfunction after nasoseptal flap (NSF) harvest for endoscopic skull base surgery (ESBS). No consensus exists as to whether popular methods including using cold-steel (CS) versus electrocautery (EC) or septal olfactory strip (SOS) preservation offer an advantage. This systematic review was performed to examine the impact of these two technical variations of NSF harvest on postoperative olfactory outcomes. METHODS Following PRISMA guidelines, Pubmed, Scopus, and Web of Science were searched for articles reporting olfactory outcomes in ESBS cases employing a NSF. Original articles focusing on technique variations of the NSF and reporting at least 1 objective olfactory measure were included. RESULTS Nine studies comprising 610 patients were included. Various, olfactory testing outcomes were reported, and post-op follow-up ranged from 6 weeks to 12 months. Three studies, including a randomized-controlled trial, compared the use of CS and EC for the superior incision of the NSF. No significant difference was found in objective olfactory function (p>0.05) when comparing these techniques. Five studies comprising 504 patients reported results from SOS sparing. SOS sparing technique in NSF harvest demonstrated smell preservation in the post-op setting when compared to pre-op measures (p>0.05), however, no direct comparison to non-SOS sparing techniques was made. CONCLUSION Use of CS as opposed to EC for the superior NSF incision does not appear to confer an advantage in preserving post-op olfactory function (grade B evidence). SOS preservation may be associated with better olfactory outcomes in NSF harvest (grade C evidence). This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Suat Kılıç
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Satyan B Sreenath
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, IN
| | - Kevin Grafmiller
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Troy D Woodard
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Pablo F Recinos
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Varun R Kshettry
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Raj Sindwani
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
8
|
Little AS, Kshettry VR, Rosen MR, Rehl RM, Haegen TW, Rabinowitz MR, Nyquist GG, Recinos PF, Sindwani R, Woodard TD, Farrell CJ, Santarelli GD, Milligan J, Evans JJ. Postoperative Oral Antibiotics and Sinonasal Outcomes Following Endoscopic Transsphenoidal Surgery for Pituitary Tumors Study: A Multicenter, Prospective, Randomized, Double-Blinded, Placebo-Controlled Study. Neurosurgery 2021; 89:769-776. [PMID: 34411264 DOI: 10.1093/neuros/nyab301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 06/07/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Postoperative prophylactic antibiotics are commonly used in pituitary surgery, but evidence supporting their use is lacking, which has implications for antibiotic stewardship. OBJECTIVE To evaluate whether receipt of postoperative oral antibiotics results in superior sinonasal quality of life (QOL) compared with placebo among patients who undergo endoscopic endonasal transsphenoidal pituitary surgery. METHODS Patients were randomized to receive either oral placebo or cefdinir (trimethoprim-sulfamethoxazole in patients intolerant to cefdinir) for 7 d after surgery. They were monitored for 12 wk. The primary outcome measure was sinonasal QOL at 2 wk on the Anterior Skull Base Nasal Inventory-12. Supplementary end points included sinonasal QOL reported on the Sinonasal Outcome Test-22 and objective endoscopy scores to assess nasal healing according to the Lund-Kennedy method. RESULTS A total of 461 patients were screened, 131 were randomized, and 113 (placebo arm: 55; antibiotic arm: 58) were analyzed. There was no clinically meaningful or statistically significant difference in sinonasal QOL at any measured time point (P ≥ .24) using either instrument. Nasal cavity endoscopy scores were not significantly different at 1 to 2 wk after surgery (P = .25) or at 3 to 4 wk after surgery (P = .08). CONCLUSION Postoperative prophylactic oral antibiotics did not result in superior sinonasal QOL compared with placebo among patients who underwent standard endoscopic transsphenoidal surgery.
Collapse
Affiliation(s)
- Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Varun R Kshettry
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marc R Rosen
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan M Rehl
- Arizona Sinus Center, Valley ENT, Phoenix, Arizona, USA
| | | | - Mindy R Rabinowitz
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gurston G Nyquist
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pablo F Recinos
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raj Sindwani
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Troy D Woodard
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher J Farrell
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - John Milligan
- Arizona Otolaryngology Consultants, Phoenix, Arizona, USA
| | - James J Evans
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Parambil JG, Gossage JR, McCrae KR, Woodard TD, Menon KVN, Timmerman KL, Pederson DP, Sprecher DL, Al-Samkari H. Pazopanib for severe bleeding and transfusion-dependent anemia in hereditary hemorrhagic telangiectasia. Angiogenesis 2021; 25:87-97. [PMID: 34292451 PMCID: PMC8295629 DOI: 10.1007/s10456-021-09807-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare angiogenic disorder causing chronic gastrointestinal bleeding, epistaxis, and severe anemia. Pazopanib is an oral multi-kinase angiogenesis inhibitor with promise to treat bleeding in HHT. We analyzed outcomes of HHT patients with the most severe bleeding causing RBC transfusion dependence treated on a predefined institutional pazopanib treatment pathway (with data collected retrospectively). The primary endpoint was achievement of transfusion independence. Secondary endpoints included hemoglobin, epistaxis severity score, RBC transfusion and iron infusion requirements, number of local hemostatic procedures, ferritin and transferrin saturation, compared using paired and repeated measures mean tests. Thirteen transfusion-dependent HHT patients received pazopanib [median (range) dose 150 (25–300) mg daily)] for a median of 22 months. All patients achieved transfusion independence. Compared with pretreatment, pazopanib increased mean hemoglobin by 4.8 (95% CI, 3.6–5.9) g/dL (7.8 vs. 12.7 g/dL, P < 0.0001) and decreased mean epistaxis severity score by 4.77 (3.11–6.44) points (7.20 vs. 2.43 points, P < 0.0001) after 12 months of treatment. Compared with 3 months of pretreatment, RBC transfusions decreased by 93% (median of 16.0 vs. 0.0 units, P < 0.0001) and elemental iron infusion decreased by 92% (median of 4500 vs. 0 mg, P = 0.005) during the first 3 months of treatment; improvements were maintained over time. Pazopanib was well-tolerated: hypertension, lymphocytopenia, and fatigue were the most common TEAEs. In conclusion, pazopanib was safe and effective to manage severe bleeding in HHT, liberating all patients from transfusion dependence and normalizing hematologic parameters at doses lower than used to treat malignancies. These findings require confirmation in a randomized trial.
Collapse
Affiliation(s)
- Joseph G Parambil
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA.
| | - James R Gossage
- Division of Pulmonary, Critical Care and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - Keith R McCrae
- Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, USA
| | - Troy D Woodard
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA
| | | | - Kasi L Timmerman
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA
| | - Douglas P Pederson
- Cleveland Clinic, Respiratory Institute, 9500 Euclid Avenue A-90, Cleveland, OH, 44195, USA
| | | | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Zero Emerson Pl Suite 118, Office 112, Boston, MA, 02114, USA.
| |
Collapse
|
10
|
Sarris CE, Little AS, Kshettry VR, Rosen MR, Rehl RM, Haegen TW, Rabinowitz MR, Nyquist GG, Recinos PF, Sindwani R, Woodard TD, Farrell CJ, Santarelli GD, Milligan J, Evans JJ. Assessment of the Validity of the Sinonasal Outcomes Test-22 in Pituitary Surgery: A Multicenter Prospective Trial. Laryngoscope 2021; 131:E2757-E2763. [PMID: 34196397 DOI: 10.1002/lary.29711] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/24/2021] [Accepted: 06/15/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS Sinonasal Outcomes Test-22 (SNOT-22) is used widely as a patient-reported sinonasal quality-of-life (QOL) instrument for endoscopic endonasal pituitary surgery. However, it has never been validated in this population. This study explores the psychometric validity of SNOT-22 to determine if it is a valid scale in patients undergoing endoscopic pituitary surgery. STUDY DESIGN Multicenter prospective trial. METHODS Adult patients (n = 113) with pituitary tumors undergoing endoscopic surgery were enrolled in a multicenter study. Patient-reported QOL was assessed using SNOT-22 and the Anterior Skull Base Nasal Inventory-12. Face validity, internal consistency, responsiveness to clinical change, test-retest reliability, and concurrent validity were determined using standard statistical methods. RESULTS Internal consistency using Cronbach's alpha at baseline and 2 weeks postoperatively were 0.911 and 0.922, indicating SNOT-22 performed well as a single construct. Mean QOL scores were significantly worse at 2 weeks than baseline (16.4 ± 15.1 vs. 23.1 ± 16.4, P < .001), indicating the scale is responsive to clinical change. However, only 11/22 items demonstrated significant changes in mean scores at 2 weeks. Correlation between scores at 2 and 3 weeks was high, suggesting good test-retest reliability, r(107) = 0.75, P < .001. Factor analysis suggests the five-factor solution proposed for the SNOT-22 in rhinosinusitis patients is not valid in pituitary surgery patients. CONCLUSIONS The SNOT-22 is a valid QOL instrument in patients undergoing endoscopic pituitary surgery. However, because it includes 22 items, can be applied only as a single construct, 50% of the items do not demonstrate changes after surgery, and is not as sensitive to change as other scales, shorter instruments developed specifically for this patient population may be preferable. LEVEL OF EVIDENCE II Laryngoscope, 2021.
Collapse
Affiliation(s)
- Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, U.S.A
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, U.S.A
| | - Varun R Kshettry
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
| | - Marc R Rosen
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Ryan M Rehl
- Arizona Sinus Center, Valley ENT, Phoenix, Arizona, U.S.A
| | | | - Mindy R Rabinowitz
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Gurston G Nyquist
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Pablo F Recinos
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.,Department of Otolaryngology, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
| | - Raj Sindwani
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.,Department of Otolaryngology, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
| | - Troy D Woodard
- Department of Neurosurgery and Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.,Department of Otolaryngology, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
| | - Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | | | - John Milligan
- Arizona Otolaryngology Consultants, Phoenix, Arizona, U.S.A
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| |
Collapse
|
11
|
Woodard TD, Yappel-Sinkko KB, Wang X, McCrae KR, Parambil JG. Sclerotherapy Versus Cautery/Laser Treatment for Epistaxis in Hereditary Hemorrhagic Telangiectasia. Laryngoscope 2021; 132:920-925. [PMID: 34160081 DOI: 10.1002/lary.29701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/21/2021] [Accepted: 06/13/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES/HYPOTHESIS Surgical interventions for epistaxis management in hereditary hemorrhagic telangiectasia (HHT) demonstrate short-term success and require repeated procedures for disease control. Although electrocautery and/or laser photocoagulation (C ± L) are most frequently performed, sodium tetradecyl sclerotherapy (STS) is emerging as a promising newer treatment. We hypothesized that in a 24-month time period, STS would require fewer treatments than C ± L to maintain epistaxis severity within the mild range. STUDY DESIGN Retrospective study. METHODS We retrospectively assessed 67 patients with HHT with moderate and severe epistaxis that were treated periodically with C ± L (34 patients) versus STS (33 patients). The primary outcome was the number of procedures needed to maintain the epistaxis severity score (ESS) as mild. Secondary outcomes assessed for differences in postoperative complications, hemoglobin levels, iron stores, hematologic support, and quality-of-life (QoL) scores. RESULTS To maintain ESS in the mild range, 1.6 STS procedures (range, 1-4) were performed versus 3.6 C ± L procedures (range, 1-8) (P = .003). Significant postoperative differences included reduction in nasal crusting (3% vs. 32%, P = .001), foul odor (3% vs. 35%, P < .001), and septal perforation (3% vs. 29%, P = .006) after STS. There were no significant differences between the two treatments in hemoglobin levels, iron stores, hematologic support, or QoL scores. CONCLUSION STS is able to attain satisfactory epistaxis control with significantly fewer procedures and lower postoperative complications than C ± L. STS should be considered as the initial surgical intervention for epistaxis in patients with HHT. LEVEL OF EVIDENCE IV Laryngoscope, 2021.
Collapse
Affiliation(s)
- Troy D Woodard
- Head and Neck Institute, Cleveland Clinic, Department of Otolaryngology-Head and Neck Surgery, Cleveland, Ohio, U.S.A
| | - Kathleen B Yappel-Sinkko
- Head and Neck Institute, Cleveland Clinic, Department of Otolaryngology-Head and Neck Surgery, Cleveland, Ohio, U.S.A
| | - Xiaofeng Wang
- Lerner Research Institute, Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, Ohio, U.S.A
| | - Keith R McCrae
- Taussig Cancer Institute, Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, Ohio, U.S.A
| | - Joseph G Parambil
- Respiratory Institute, Cleveland Clinic, Department of Pulmonary Medicine, Cleveland, Ohio, U.S.A
| |
Collapse
|
12
|
Sreenath SB, Tang DM, Ting JY, Illing EA, Recinos PF, Soni P, Kshettry VR, Cohen-Gadol A, Woodard TD, Sindwani R. Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide. Laryngoscope 2021; 131:2224-2230. [PMID: 34096616 DOI: 10.1002/lary.29672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/01/2021] [Accepted: 05/25/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Cerebrospinal fluid (CSF) leaks and meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be challenging. The traditional transpterygoid approach through the pterygopalatine fossa (PPF) is time consuming and places important structures at risk, which can lead to significant morbidity. We report a multi-institutional experience using a simplified, endoscopic modified transpterygoid approach (MTPA), which spares the PPF contents in the management of lateral sphenoid sinus meningoencephaloceles and CSF leaks. STUDY DESIGN Multi-Institutional, Retrospective Case Series. METHODS Patients with lateral sphenoid recess CSF leaks and meningoencephaloceles between 2014 and 2020 who underwent the MTPA at two academic medical centers were identified. Repair techniques and outcomes were evaluated. RESULTS Thirty-three patients underwent the MTPA for management. Skull base reconstruction was performed using a free mucosal graft (24/33, 72.7%), nasoseptal flap (4/33, 12.1%), bone grafts (3/33, 9.1%), and abdominal fat grafts (2/33, 6.1%). Lumbar drains and perioperative intracranial pressure measurements were routinely employed. Postoperative complications were uncommon and included three patients (9.7%) with temporary V2 anesthesia, one patient (3.2%) with prolonged V2 anesthesia, and one patient (3.2%) with subjective dry eye, all of which resolved at 9 months postoperatively. There were no recurrent CSF leaks resulting in a 100% success rate. Average follow-up was 13 months. CONCLUSION The MTPA reduces morbidity and greatly simplifies access to the lateral sphenoid sinus for the management of CSF leaks and meningoencephaloceles, without compromising exposure. This technique avoids the need for extensive PPF dissection and should be considered for the management of benign lesions involving the lateral sphenoid sinus. LEVEL OF EVIDENCE IV Laryngoscope, 2021.
Collapse
Affiliation(s)
| | - Dennis M Tang
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Jonathan Y Ting
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A.,Department of Neurosurgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Elisa A Illing
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A.,Department of Neurosurgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Pablo F Recinos
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Pranay Soni
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Varun R Kshettry
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Aaron Cohen-Gadol
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A.,Department of Neurosurgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| |
Collapse
|
13
|
Sreenath SB, Tang DM, Almeida JPD, Soni P, Woodard TD, Recinos PF, Kshettry VR, Sindwani R. Simplifying Access to the Lateral Sphenoid Recess: A Modification of the Transpterygoid Approach. Am J Rhinol Allergy 2021; 35:798-801. [PMID: 33761785 DOI: 10.1177/19458924211003813] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be difficult to access. Historically, the endoscopic transpterygoid approach was advocated, which carries additional morbidity given the dissection of the pterygopalatine fossa (PPF) contents to provide a direct line approach to the defect. Given our increased facility with angled endoscopes and instrumentation, we now approach this region in a less invasive manner. METHODS We describe the endoscopic modified transpterygoid approach (MTPA), a quicker approach to the lateral sphenoid recess which preserves the PPF contents through a single nostril corridor. RESULTS In the MTPA, the face of the sphenoid and anterior junction of the pterygoid plates are removed, allowing for mobilization of the PPF contents with the periosteum intact. Angled instrumentation is then used to resect the meningoencephalocele and repair the skull base defect in the lateral recess. If increased exposure is needed, this can be gained by sacrificing the sphenopalatine artery and even the vidian nerve, although this is rarely required. CONCLUSIONS The MTPA obviates the need for PPF dissection and simplifies access to the lateral sphenoid recess while minimizing postoperative morbidity. This approach should be considered for accessing meningoencephaloceles and other benign lesions in this challenging location.
Collapse
Affiliation(s)
| | - Dennis M Tang
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California
| | - João Paulo De Almeida
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Pranay Soni
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Pablo F Recinos
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Varun R Kshettry
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
14
|
Shah J, Cappello ZJ, Roxbury C, Tang D, Woodard TD, Kshettry VR, Recinos PF, Sindwani R. Prevalence and Clinical Significance of Radiographic Sinus Disease on Preoperative Computed Tomography Imaging in the Endoscopic Skull Base Surgery Population. Am J Rhinol Allergy 2020; 35:239-244. [PMID: 32781830 DOI: 10.1177/1945892420949130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Endoscopic skull base surgery (ESBS) provides a safe, minimally invasive approach to treat benign and malignant skull base lesions. The significance of concomitant sinonasal pathology on imaging in patients undergoing ESBS and its effect on perioperative management is not well described. We sought to identify the prevalence and clinical significance of incidentally found radiographic sinus disease on preoperative imaging in patients undergoing ESBS and provide a protocol for management of these patients. DESIGN A retrospective chart review was performed of consecutive patients who underwent ESBS from January 1, 2016 to June 30, 2018. Preoperative computed tomography (CT) scans were reviewed and scored using the Lund-Mackay (LM) staging system. Preoperative nasal endoscopy findings were analyzed. Any preoperative treatment based on these findings and changes in intraoperative management were examined. RESULTS A total of 156 patients (81 women, 74 men) who underwent ESBS were reviewed. The average LM score was 2 ± 2.7 (range: 0-12). A total of 94 patients (60.3%) had evidence of radiographic sinus disease (LM score > 0) and 23 patients (14.7%) had presence of sphenoid sinus disease. Seven patients (4.5%) were treated preoperatively based on CT and/or nasal endoscopy findings. All patients who received preoperative treatment had evidence of sinus disease on imaging with an average score of 4.7 and were evaluated and treated within 1-2 weeks prior to ESBS. One patient had ESBS postponed until endoscopic sinus surgery was performed for extensive chronic rhinosinusitis (CRS) findings on imaging. CONCLUSION A review of preoperative imaging in patients undergoing ESBS can help identify concurrent sinonasal disease, which has the potential to alter preoperative as well as intraoperative management in these patients. We report a diligent but conservative approach for the treatment of concomitant CRS in the ESBS population with decision for preoperative treatment guided by various factors.
Collapse
Affiliation(s)
- Janki Shah
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zachary J Cappello
- Department of Otolaryngology-Head and Neck Surgery, Charlotte Eye, Ear, Nose and Throat, Charlotte, North Carolina
| | - Christopher Roxbury
- Rhinology and Endoscopic Skull Base Surgery, Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Dennis Tang
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Troy D Woodard
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Varun R Kshettry
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pablo F Recinos
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raj Sindwani
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
15
|
Cappello ZJ, Tang DM, Roxbury CR, Lobo BC, Borghei-Razavi H, Woodard TD, Kshettry VR, Recinos PF, Sindwani R. Utility of the Nasoseptal “Rescue” Flap Approach: Analysis of 125 Consecutive Patients and Implications for Routine Transsphenoidal Surgery. Am J Rhinol Allergy 2019; 34:269-275. [DOI: 10.1177/1945892419892164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The nasoseptal flap (NSF) is the reconstructive workhorse for endoscopic skull base surgery (ESBS). However, there is morbidity associated with its use and it is not always required for reconstruction. The bilateral nasoseptal “rescue” flap (NSRF) technique offers a quicker alternative to upfront NSF harvest, yet permits the use of a tailored NSF if needed after the defect has been created. The utility and implications of this strategy have not been well studied. Methods We retrospectively analyzed 125 consecutive transsphenoidal cases where an NSRF approach was used from January 2015 to October 2017 at the Cleveland Clinic. Records were analyzed for conversion to NSF, outcomes, and reconstruction-related complications. Results The mean age of patients included in the study was 51 years, with 51% females. NSRF was converted to full NSF in only 16% of cases. Rationale for conversion included an unanticipated high-flow (7) or low-flow (12) cerebrospinal fluid (CSF) leak and an exposed internal carotid artery (1). NSRF was utilized and converted to formal NSF in 3 patients who had previous remote transsphenoidal surgery. One patient who had an NSRF without a full NSF raised had a postoperative CSF leak; however, no CSF leaks or flap ischemia was noted for those who had full NSFs raised, even in revision surgery. Conclusion NSRF approach provides the reliability and flexibility of vascularized reconstruction, without the perioperative disadvantages of an upfront NSF harvest. The low and successful conversion rate to NSF demonstrates the utility of this strategy which should be incorporated into the standard approach for routine transsphenoidal surgery.
Collapse
Affiliation(s)
- Zachary J. Cappello
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Dennis M. Tang
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christopher R. Roxbury
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Brian C. Lobo
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Hamid Borghei-Razavi
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Troy D. Woodard
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Varun R. Kshettry
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Pablo F. Recinos
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Raj Sindwani
- Section of Rhinology, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| |
Collapse
|
16
|
Tish S, Habboub G, Prayson RA, Woodard TD, Kshettry VR, Recinos PF. Extraventricular neurocytoma with ganglioid differentiation of the sellar and parasellar regions in an elderly patient: A case report. Surg Neurol Int 2019; 10:82. [PMID: 31528420 PMCID: PMC6744785 DOI: 10.25259/sni-30-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/21/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Extraventricular neurocytoma (EVN) is a rare variant of central neurocytoma which arises outside of the ventricular system. Diffuse ganglioid differentiation is a characteristic seen in a subset of these tumors which has an uncertain prognostic significance. Typically, EVN presents in children and young adults. Given the rarity of this tumor, the natural history and response to treatments remain unclear. Case Description: We present a case of EVN with diffuse ganglioid differentiation in a 70-year-old male which arose in the midline parasellar region and extended into the third ventricle. This is the oldest such patient reported. Despite prior reports that extremes of age are associated with more aggressive behavior, the tumor in this case did not exhibit such an aggressive course. Conclusion: In this report, we review the natural history and clinical course of this patient and summarize the literature regarding this rare pathological entity. Our patient responded well to therapy despite older age, ganglioid differentiation, and higher mitotic index.
Collapse
Affiliation(s)
- Shahed Tish
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic Section of Skull Base Surgery, Ohio, United States
| | - Ghaith Habboub
- Section of Skull Base Surgery, Department of Neurological Surgery, Cleveland Clinic, Ohio, United States
| | - Richard A Prayson
- Department of Anatomic Pathology, Cleveland Clinic, Ohio, United States
| | - Troy D Woodard
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic Section of Skull Base Surgery, Ohio, United States.,Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Varun R Kshettry
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic Section of Skull Base Surgery, Ohio, United States.,Section of Skull Base Surgery, Department of Neurological Surgery, Cleveland Clinic, Ohio, United States
| | - Pablo F Recinos
- Minimally-Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic Section of Skull Base Surgery, Ohio, United States.,Section of Skull Base Surgery, Department of Neurological Surgery, Cleveland Clinic, Ohio, United States.,Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, United States
| |
Collapse
|
17
|
Roxbury CR, Qiu M, Shargorodsky J, Woodard TD, Sindwani R, Lin SY. Association Between Rhinitis and Depression in United States Adults. The Journal of Allergy and Clinical Immunology: In Practice 2019; 7:2013-2020. [DOI: 10.1016/j.jaip.2019.02.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/26/2019] [Accepted: 02/15/2019] [Indexed: 01/23/2023]
|
18
|
Tang DM, Roxbury CR, Sindwani R, Kshettry VR, Recinos P, Woodard TD. Multiple bioabsorbable corticosteroid-eluting stent placement with associated skull base injury. Laryngoscope 2018; 129:1494-1496. [PMID: 30597569 DOI: 10.1002/lary.27659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2018] [Indexed: 11/11/2022]
Abstract
Bioabsorbable corticosteroid-eluting sinus stents (BCES) are used to optimize healing after sinus surgery. We report a patient with BCES placed through a dural defect. A 70 year old underwent sinus surgery. Postoperatively, the patient developed mental status changes. The patient was taken to the operating room and eight BCES were identified, with one extending through the skull base. The stents were extracted and the defect was repaired. The patient recovered well. This is the first significant complication associated with BCES. Thorough review of preoperative imaging, understanding of skull base anatomy, and careful use of BCES are critical for safety. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1494-1496, 2019.
Collapse
Affiliation(s)
- Dennis M Tang
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland, Ohio, U.S.A
| | - Christopher R Roxbury
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland, Ohio, U.S.A
| | - Raj Sindwani
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland, Ohio, U.S.A.,Minimal Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland, Ohio, U.S.A
| | - Varun R Kshettry
- Minimal Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland, Ohio, U.S.A.,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Pablos Recinos
- Minimal Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland, Ohio, U.S.A.,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Troy D Woodard
- Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland, Ohio, U.S.A.,Minimal Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland, Ohio, U.S.A
| |
Collapse
|
19
|
Roxbury CR, Shah J, Tang D, Kshettry VR, Recinos PF, Woodard TD, Taylor M, Sindwani R. Analysis of 24-hour surgical cancellations in an academic rhinology and skull base surgery practice. Int Forum Allergy Rhinol 2018; 9:298-304. [DOI: 10.1002/alr.22247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/18/2018] [Accepted: 10/25/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Christopher R. Roxbury
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Janki Shah
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Dennis Tang
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Varun R. Kshettry
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Pablo F. Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Troy D. Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Mark Taylor
- Department of Regional Anesthesiology, Anesthesia Institute; Cleveland Clinic Foundation; Cleveland OH
- Enterprise Surgical Operations; Cleveland Clinic Hospital System; Cleveland OH
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute; Cleveland Clinic Foundation; Cleveland OH
- Enterprise Surgical Operations; Cleveland Clinic Hospital System; Cleveland OH
| |
Collapse
|
20
|
Roxbury CR, Tang D, Shah J, McBride J, Woodard TD, Sindwani R. Size of septectomy does not affect distribution of nasal irrigation after endoscopic modified Lothrop procedure. Int Forum Allergy Rhinol 2018; 8:1127-1131. [PMID: 29883050 DOI: 10.1002/alr.22158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/08/2018] [Accepted: 05/15/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND The endoscopic modified Lothrop procedure (EMLP) is commonly performed in recalcitrant frontal sinusitis, in part to achieve better penetration of medicated irrigations postoperatively. Although EMLP requires a septectomy for exposure, it is unknown whether septectomy size affects delivery of irrigations. In this study we evaluated the role of septectomy in delivery of irrigations to the EMLP cavity. METHODS EMLP was performed on fresh human cadavers with sequentially increasing septectomy (minimal septectomy: drilling across septum to combine frontal sinuses; standard septectomy: 1.5 cm anterior to middle turbinate and inferiorly to the midlevel of the turbinate; large septectomy: extension to nasal floor). Irrigation with fluorescein-labeled water was performed with a 240-mL irrigation bottle in the vertex position and recorded with a 30° endoscope fixed in a 4-mm trephine in the paramedian EMLP cavity. Two blinded reviewers scored irrigation distribution recordings (0 = nasal cavity only; 1 = frontal recess; 2 = medial distribution; 3 = lateral distribution; 4 = entire sinus lavage). Distribution scores were assessed with Wilcoxon rank sum analysis. RESULTS Six specimens (mean age, 75.2 ± 2.4; 50% female) were assessed. Interobserver scores were highly concordant (Kendall's W = 0.86, p < 0.01), internally validating the experiment. Distribution scores did not vary significantly when comparing minimal septectomy with standard or large septectomy (Z = 0.55, p = 0.58, Z = 0.37, p = 0.71). CONCLUSION Increasing septectomy does not improve irrigation delivery in patients undergoing EMLP. These results suggest that a limited septectomy for access to the bilateral frontal sinuses is all that is required for effective drug delivery postoperatively. This strategy may reduce morbidity associated with larger septectomies.
Collapse
Affiliation(s)
- Christopher R Roxbury
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Dennis Tang
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Janki Shah
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, OH.,Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, OH
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute, Cleveland Clinic Foundation, Cleveland, OH.,Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, OH
| |
Collapse
|
21
|
Lobo BC, D'Anza B, Farlow JL, Tang D, Woodard TD, Ting JY, Sindwani R. Outcomes of sinonasal squamous cell carcinoma with and without association of inverted papilloma: A multi-institutional analysis. Am J Rhinol Allergy 2018; 31:305-309. [PMID: 28859706 DOI: 10.2500/ajra.2017.31.4470] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Sinonasal squamous cell carcinoma (SCC) accounts for <1% of all malignancies but represents 70% of sinonasal cancer. Up to 10% of SCCs are associated with inverted papilloma (IPSCC). Studies that compare patients, treatment, and outcomes of SCC and IPSCC are absent in the literature. METHODS A retrospective review of patients with SCC and those with IPSCC at Cleveland Clinic and Indiana University from 1995 to 2015. The records were analyzed for demographics, tumor characteristics, treatment, and outcomes. RESULTS The study comprised 117 patients with SCC, of whom, 29 had IPSCC. The mean age at diagnosis was similar: 63 and 64 years for patients with SCC and patients with IPSCC, respectively; with female patients representing 36% and 34%, respectively (p > 0.99).Smokers represented 64% of the patients with SCC and 55% of patients with IPSCC (p = 0.3); excessive alcohol intake was noted in 16% of the patients with SCC and 21% of the patients with IPSCC (p = 0.56).The maxillary sinus was most commonly involved, followed by the nasal cavity (51% versus 35% SCC, 45% versus 38% IPSCC). Frontal ethmoid and sphenoid sinuses contained primary tumors only in patients with SCC. Upfront treatment was surgery in 84% of patients with SCC and 97% of patients with IPSCC (p = 0.18); 68 and 55% received radiation, respectively, and 25 and 21% received chemotherapy, respectively.Overall survival averaged 5.5 and 3.4 years for patients with SCC and patients with IPSCC, respectively (p = 0.12); disease-free survival was 4.8 and 2.9 years, respectively (p = 0.18). Nodal metastasis was more likely in patients with SCC (18 versus 0%; p = 0.02). When divided into high- and low-stage disease: more common nodal metastases were demonstrated in high-stage SCC than in low-stage disease (p = 0.03). Overall survival was decreased between high- and low-grade disease but not when subdivided between SCC and IPSCC. CONCLUSION Although SCC with and without IP association are considered different diseases, their demographics and outcomes seem similar. Nodal metastasis was noted to be higher in the SCC cohort, which may indicate different tumor biology. Further study is warranted.
Collapse
Affiliation(s)
- Brian C Lobo
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | | | | | | | | | | |
Collapse
|
22
|
Lang M, Silva D, Dai L, Kshettry VR, Woodard TD, Sindwani R, Recinos PF. Superiority of constructive interference in steady-state MRI sequencing over T1-weighted MRI sequencing for evaluating cavernous sinus invasion by pituitary macroadenomas. J Neurosurg 2018; 130:1-8. [PMID: 29570007 DOI: 10.3171/2017.9.jns171699] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 09/11/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPreoperatively determining the extent of parasellar invasion of pituitary macroadenomas is useful for surgical planning and patient counseling. Here, the authors compared constructive interference in steady state (CISS), a T2-weighted gradient-echo MRI sequence, to volume-interpolated breath-hold examination (VIBE), a T1-weighted gradient-echo MRI sequence, for evaluation of cavernous sinus invasion (CSI) by pituitary macroadenomas.METHODSVIBE and CISS images of 98 patients with pituitary macroadenoma were retrospectively analyzed and graded using the modified Knosp classification. The Knosp grades were correlated to surgical findings of CSI, which were determined intraoperatively using 0° and 30° endoscopes. The predictive accuracies for CSI according to the Knosp grades derived from the CISS and VIBE images were compared using receiver operating characteristic (ROC) curves. Postoperative MRI was used to evaluate the gross-total resection (GTR) rates.RESULTSThe CSI rate by pituitary macroadenomas was 27.6% (27 of 98 cases). Of 196 assessments (left and right sides of 98 macroadenomas), 45 (23.0%) had different Knosp grades when scored using VIBE versus CISS images. For the VIBE images, 0% of Knosp grade 0, 4.5% of grade 1, 23.8% of grade 2, 42.1% of grade 3A, 100% of grade 3B, and 83.3% of grade 4 macroadenomas were found to have CSI intraoperatively. For the CISS images, 0% of Knosp grade 0, 2.1% of grade 1, 31.3% of grade 2, 56.3% of grade 3A, 100% of grade 3B, and 100% of grade 4 macroadenomas were found to have CSI intraoperatively. Two pituitary macroadenomas were classified as grade 4 on VIBE sequences but grades 3A and 2 on CISS sequences; CSI was not observed intraoperatively in both cases. The GTR rate was 64.3% and 60.0% for high-grade (3A, 3B, and 4) macroadenomas classified using VIBE and CISS sequences, respectively. The areas under the ROC curves were 0.94 and 0.97 for VIBE- and CISS-derived Knosp grades (p = 0.007), respectively.CONCLUSIONSKnosp grades determined using CISS sequence images are better correlated with intraoperative CSI than those determined using VIBE sequence images. CISS sequences may be valuable for the preoperative assessment of pituitary macroadenomas.
Collapse
Affiliation(s)
- Min Lang
- 1School of Medicine, Case Western Reserve University
- 3Department of Neurosurgery, Neurological Institute
| | - Danilo Silva
- 3Department of Neurosurgery, Neurological Institute
- 5Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lu Dai
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland Clinic
| | - Varun R Kshettry
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland Clinic
- 5Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Troy D Woodard
- 3Department of Neurosurgery, Neurological Institute
- 5Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raj Sindwani
- 3Department of Neurosurgery, Neurological Institute
- 5Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pablo F Recinos
- 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland Clinic
- 5Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
23
|
Parambil JG, Woodard TD, Koc ON. Pazopanib effective for bevacizumab-unresponsive epistaxis in hereditary hemorrhagic telangiectasia. Laryngoscope 2018; 128:2234-2236. [PMID: 29451965 DOI: 10.1002/lary.27129] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 12/30/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) most commonly manifests with nasal mucosal telangiectasias, and vascular endothelial growth factor (VEGF) plays a significant role in this angiodysplasia. We describe a patient with HHT with epistaxis recalcitrant to several endonasal procedures and six cycles of intravenous bevacizumab, for which he was dependent on iron infusions and packed red blood cells transfusions. He then started pazopanib at 100 mg with dramatic improvements in epistaxis and normalization of hemoglobin and iron levels, without replenishment needs for 12 months. This is the first report on the efficacy of pazopanib with high selectivity for abrogating VEGF receptor-2 signaling in HHT, and needs to be explored further. Laryngoscope, 128:2234-2236, 2018.
Collapse
Affiliation(s)
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Omer N Koc
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| |
Collapse
|
24
|
Roxbury CR, Lobo BC, Kshettry VR, D'Anza B, Woodard TD, Recinos PF, Snyderman CH, Sindwani R. Perioperative management in endoscopic endonasal skull-base surgery: a survey of the North American Skull Base Society. Int Forum Allergy Rhinol 2017; 8:631-640. [DOI: 10.1002/alr.22066] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/07/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Christopher R. Roxbury
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Brian C. Lobo
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Varun R. Kshettry
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
| | - Brian D'Anza
- Section of Rhinology, Sinus and Skull Base Surgery; Case Western Reserve University; Cleveland OH
| | - Troy D. Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
| | - Pablo F. Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
| | - Carl H. Snyderman
- Center for Cranial Base Surgery; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head & Neck Institute; Cleveland Clinic Foundation; Cleveland OH
- Department of Neurosurgery, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center; Cleveland Clinic Foundation; Cleveland OH
| |
Collapse
|
25
|
|
26
|
|
27
|
Stokken JK, Halderman A, Recinos PF, Woodard TD, Sindwani R. Strategies for Improving Visualization During Endoscopic Skull Base Surgery. Otolaryngol Clin North Am 2016; 49:131-40. [PMID: 26614833 DOI: 10.1016/j.otc.2015.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The nasal cavity has a robust vascular supply, and bleeding is a primary obstacle to the minimally invasive skull base technique. Venous bleeding, including the cavernous sinus, can be managed with various techniques using hemostatic materials and pressure. A thorough understanding of the skull base vascular anatomy is vital for avoiding injury to major arteries and having confidence to control venous bleeding to optimize the endoscopic view and tumor resection.
Collapse
Affiliation(s)
- Janalee K Stokken
- Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Ashleigh Halderman
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| |
Collapse
|
28
|
Tien DA, Stokken JK, Recinos PF, Woodard TD, Sindwani R. Comprehensive Postoperative Management After Endoscopic Skull Base Surgery. Otolaryngol Clin North Am 2016; 49:253-63. [PMID: 26614842 DOI: 10.1016/j.otc.2015.09.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To maximize outcomes from endoscopic skull base surgery, careful early postoperative management is critically important. Standardized postoperative regimens are lacking. The type of reconstruction and presence and type of cerebrospinal fluid leak dictate management. If a leak is encountered intraoperatively, patients should avoid maneuvers that increase intracranial pressures for at least 1 month. Early postoperative care focuses on minimizing and managing nasal crusting. This article reviews the evidence in the literature on postoperative management, complications, and quality of life after surgery, and outlines our experience in the management of patients after endoscopic skull base surgery.
Collapse
Affiliation(s)
- Duc A Tien
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Janalee K Stokken
- Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
29
|
Affiliation(s)
- Raj Sindwani
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A-71, Cleveland, OH 44195, USA.
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A-71, Cleveland, OH 44195, USA.
| | - Pablo F Recinos
- Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, S-73, Cleveland, OH 44195, USA.
| |
Collapse
|
30
|
Abbassy M, Woodard TD, Sindwani R, Recinos PF. An Overview of Anterior Skull Base Meningiomas and the Endoscopic Endonasal Approach. Otolaryngol Clin North Am 2016; 49:141-52. [PMID: 26614834 DOI: 10.1016/j.otc.2015.08.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Meningiomas represent 30% of all primary brain tumors. Anterior skull base meningiomas represent 8.8% of all meningiomas. Surgical resection is a main treatment option for tumors that are symptomatic and/or growing. Recurrence is directly related to the extent of resection of the tumor, the dural attachment, and pathologic bone. Endoscopic endonasal approaches represent an important addition to the treatment armamentarium for skull base meningiomas. This article provides an overview of meningiomas, with a focus on those of the anterior skull base and their management.
Collapse
Affiliation(s)
- Mahmoud Abbassy
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH 44143, USA; Department of Neurosurgery, Faculty of Medicine, Alexandria University, Champlion Street, El-Azareeta, Alexandria, Egypt
| | - Troy D Woodard
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH 44143, USA; Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44143, USA
| | - Raj Sindwani
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH 44143, USA; Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44143, USA
| | - Pablo F Recinos
- Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Ave, S73, Cleveland, OH 44143, USA; Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Ave, A71, Cleveland, OH 44143, USA.
| |
Collapse
|
31
|
Abstract
The endoscopic endonasal approach provides a direct surgical trajectory to anteriorly located lesions at the craniovertebral junction. The inferior limit of surgical exposure is predicted by the nasopalatine line, and the lateral limit is demarcated by the lower cranial nerves. Endoscopic endonasal odontoidectomy allows preservation of the soft palate, and patients can restart an oral diet on the first postoperative day. Treating the condition at the craniovertebral junction using this approach requires careful preoperative planning and endoscopic endonasal surgical experience with a 2-surgeon 4-handed approach combining expertise in otolaryngology and neurosurgery.
Collapse
Affiliation(s)
- Varun R Kshettry
- Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA
| | - Brian D Thorp
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive #7070, Chapel Hill, NC 27599-7070, USA
| | - Michael F Shriver
- Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive #7070, Chapel Hill, NC 27599-7070, USA; Department of Neurosurgery, University of North Carolina at Chapel Hill, 170 Manning Drive #7060, Chapel Hill, NC 27599-7060, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Skull Base Surgery, Minimally Invasive Cranial Base and Pituitary Surgery Program, CCLCM, CWRU, 9500 Euclid Avenue, S-73, Cleveland, OH 44195, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Skull Base Surgery, Minimally Invasive Cranial Base and Pituitary Surgery Program, CCLCM, CWRU, 9500 Euclid Avenue, S-73, Cleveland, OH 44195, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Skull Base Surgery, Minimally Invasive Cranial Base and Pituitary Surgery Program, CCLCM, CWRU, 9500 Euclid Avenue, S-73, Cleveland, OH 44195, USA.
| |
Collapse
|
32
|
|
33
|
Shahangian A, Soler ZM, Baker A, Wise SK, Rereddy SK, Patel ZM, Oyesiku NM, DelGaudio JM, Hadjipanayis CG, Woodworth BA, Riley KO, Lee J, Cusimano MD, Govindaraj S, Khan MN, Psaltis A, Wormald PJ, Santoreneos S, Sindwani R, Trosman S, Stokken JK, Woodard TD, Recinos PF, Vandergrift WA, Boling C, Schlosser RJ. Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery. Int Forum Allergy Rhinol 2016; 7:80-86. [DOI: 10.1002/alr.21845] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Arash Shahangian
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Zachary M. Soler
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Andrew Baker
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Sarah K. Wise
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Shruthi K. Rereddy
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
- Department of Otorhinolaryngology-Head & Neck Surgery; University of Pennsylvania; Philadelphia PA
| | - Zara M. Patel
- Department of Otolaryngology-Head & Neck Surgery; Stanford University; Stanford CA
| | | | - John M. DelGaudio
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Constantinos G. Hadjipanayis
- Department of Neurosurgery; Emory University; Atlanta GA
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Beth Israel; New York City NY
| | - Bradford A. Woodworth
- Division of Otolaryngology-Head & Neck Surgery; University of Alabama at Birmingham; Birmingham AL
| | - Kristen O. Riley
- Department of Neurosurgery; University of Alabama at Birmingham; Birmingham AL
| | - John Lee
- Department of Otolaryngology-Head & Neck Surgery; University of Toronto; St. Michael's Hospital; Toronto ON Canada
| | - Michael D. Cusimano
- Department of Neurosurgery University of Toronto; St. Michael's Hospital; Toronto ON Canada
| | - Satish Govindaraj
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Hospital; New York City NY
| | - Mohemmed N. Khan
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Hospital; New York City NY
| | - Alkis Psaltis
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide SA Australia
| | - Peter J. Wormald
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide SA Australia
| | | | - Raj Sindwani
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | - Samuel Trosman
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | - Janalee K. Stokken
- Department of Otolaryngology-Head & Neck Surgery; Mayo Clinic; Rochester MN
| | - Troy D. Woodard
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | - Pablo F. Recinos
- Section of Rhinology; Head and Neck Institute and the Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center; Cleveland Clinic; Cleveland OH
| | | | - Caitlin Boling
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Rodney J. Schlosser
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| |
Collapse
|
34
|
Karnezis TT, Baker AB, Soler ZM, Wise SK, Rereddy SK, Patel ZM, Oyesiku NM, DelGaudio JM, Hadjipanayis CG, Woodworth BA, Riley KO, Lee J, Cusimano MD, Govindaraj S, Psaltis A, Wormald PJ, Santoreneos S, Sindwani R, Trosman S, Stokken JK, Woodard TD, Recinos PF, Vandergrift WA, Schlosser RJ. Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery. Int Forum Allergy Rhinol 2016; 6:1117-1125. [DOI: 10.1002/alr.21783] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 02/02/2016] [Accepted: 03/08/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Tom T. Karnezis
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Andrew B. Baker
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Zachary M. Soler
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Sarah K. Wise
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Shruthi K. Rereddy
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Zara M. Patel
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | | | - John M. DelGaudio
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | | | - Bradford A. Woodworth
- Division of Otolaryngology-Head & Neck Surgery; University of Alabama at Birmingham; Birmingham AL
| | - Kristen O. Riley
- Department of Neurosurgery; University of Alabama at Birmingham; Birmingham AL
| | - John Lee
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto; St. Michael's Hospital; Toronto ON Canada
| | - Michael D. Cusimano
- Department of Neurosurgery, St. Michael's Hospital; University of Toronto; Toronto ON Canada
| | - Satish Govindaraj
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Hospital; New York NY
| | - Alkis Psaltis
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide Australia
| | - Peter John Wormald
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide Australia
| | - Steve Santoreneos
- Department of Neurosurgery; Royal Adelaide Hospital; Adelaide Australia
| | - Raj Sindwani
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | - Samuel Trosman
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | - Janalee K. Stokken
- Department of Otolaryngology-Head & Neck Surgery; Mayo Clinic; Rochester MN
| | - Troy D. Woodard
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | - Pablo F. Recinos
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | | | - Rodney J. Schlosser
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| |
Collapse
|
35
|
D'Anza B, Stokken J, Greene JS, Kennedy T, Woodard TD, Sindwani R. Chronic invasive fungal sinusitis: characterization and shift in management of a rare disease. Int Forum Allergy Rhinol 2016; 6:1294-1300. [DOI: 10.1002/alr.21828] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/04/2016] [Accepted: 06/28/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Brian D'Anza
- Head and Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Janalee Stokken
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic; Rochester MN
| | - J. Scott Greene
- Department of Otolaryngology-Head and Neck Surgery, Facial Plastic Surgery; Geisinger Medical Center; Danville PA
| | - Thomas Kennedy
- Department of Otolaryngology-Head and Neck Surgery, Facial Plastic Surgery; Geisinger Medical Center; Danville PA
| | - Troy D. Woodard
- Head and Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| | - Raj Sindwani
- Head and Neck Institute; Cleveland Clinic Foundation; Cleveland OH
| |
Collapse
|
36
|
Abstract
Major complications during endoscopic sinus surgery are rare and occur in 0.36% to 3.1% of patients. Postoperative hemorrhage accounts for 23% to 39% of complications. Despite being rare, major hemorrhage can be serious for the patient. This article discusses hemorrhagic complications during and following endoscopic sinus surgery, focusing on a review of the surgical anatomy, common pitfalls to avoid, preventative measures, and management of certain catastrophic complications for which preparedness can mean the difference between life and death.
Collapse
Affiliation(s)
- Ashleigh A Halderman
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA.
| |
Collapse
|
37
|
Tien DA, Stokken JK, Recinos PF, Woodard TD, Sindwani R. Cerebrospinal Fluid Diversion in Endoscopic Skull Base Reconstruction. Otolaryngol Clin North Am 2016; 49:119-29. [DOI: 10.1016/j.otc.2015.09.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
38
|
Abstract
Building an endoscopic cranial base practice can be challenging and is predicated on the right team. Successful outcomes stem from an efficient and talented team that improves its skills experientially in a supportive environment. As with most new endeavors that are beyond the traditional approach, there is a great deal of up-front effort and investment required. This article explores some of the key building blocks necessary for a successful endoscopic cranial base and pituitary program and highlights some of the lessons learned during the authors' journey at the Cleveland Clinic.
Collapse
Affiliation(s)
- Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA.
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA
| |
Collapse
|
39
|
Abbassy M, Kshettry VR, Hamrahian AH, Johnston PC, Dobri GA, Avitsian R, Woodard TD, Recinos PF. Surgical management of recurrent Cushing's disease in pregnancy: A case report. Surg Neurol Int 2015; 6:S640-5. [PMID: 26682090 PMCID: PMC4672578 DOI: 10.4103/2152-7806.170472] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/21/2015] [Indexed: 12/20/2022] Open
Abstract
Background: Cushing's disease is a condition rarely encountered during pregnancy. It is known that hypercortisolism is associated with increased maternal and fetal morbidity and mortality. When hypercortisolism from Cushing's disease does occur in pregnancy, the impact of achieving biochemical remission on fetal outcomes is unknown. We sought to clarify the impact of successful surgical treatment by presenting such a case report. Case Description: A 38-year-old pregnant woman with recurrent Cushing's disease after 8 years of remission. The patient had endoscopic transsphenoidal of her pituitary adenoma in her 18th week of pregnancy. The patient had postoperative biochemical remission and normal fetal outcome with no maternal complications. Conclusion: Transsphenoidal surgery for Cushing's disease can be performed safely during the second trimester of pregnancy.
Collapse
Affiliation(s)
- Mahmoud Abbassy
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amir H Hamrahian
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Philip C Johnston
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Georgianna A Dobri
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rafi Avitsian
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Troy D Woodard
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA ; Section of Skull Base Rhinology and Sinus Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA ; Section of Skull Base Rhinology and Sinus Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
40
|
Kharas GB, Ayman NJ, Calso R, Jordanovic L, Lane F, Lusciks J, Onofre J, Soto YL, Vega E, Voss MA, Woodard TD. Novel Copolymers of Styrene. 11. Ring-Substituted 2-Cyano-3-phenyl-2-propenamides. Journal of Macromolecular Science, Part A 2015. [DOI: 10.1080/10601325.2015.1029365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
41
|
Eytan DF, Kshettry VR, Sindwani R, Woodard TD, Recinos PF. Surgical outcomes after endoscopic management of cholesterol granulomas of the petrous apex: a systematic review. Neurosurg Focus 2015; 37:E14. [PMID: 25270133 DOI: 10.3171/2014.7.focus14344] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endoscopic endonasal treatment of petrous apex cholesterol granulomas allows for a natural drainage pathway into the nasopharynx. Because of the limited number of case series in the literature, there is limited evidence of recurrence rates and outcomes following endoscopic endonasal management. The purpose of this study was to determine the surgical outcomes of endoscopic endonasal approaches in the treatment of cholesterol granulomas of the petrous apex. METHODS A systematic literature review was performed using PubMed for articles published from January 1980 to April 2014 to identify all studies reporting outcomes for endoscopic endonasal surgical management of cholesterol granulomas of the petrous apex. Operative approach, use of a stent, symptom outcome, restenosis, cyst recurrence, reoperation, and complications were extracted from included studies. RESULTS A total of 53 patient cases were included from 22 relevant studies. The mean age was 41 years, and 26 patients (49%) were female. Stents were used in 45.1% of cases. Symptom resolution or improvement was seen in 98.6% of cases at follow-up (mean follow-up 20 months). Complications were reported in 13.2% of cases, with the most common complication being epistaxis. Restenosis on follow-up office endoscopic examination occurred in 9 of 45 cases (20.0%). Only 4 of these restenosis cases resulted in symptomatic cyst recurrence, resulting in an overall recurrence rate of 7.5%. The mean time from surgery to cyst recurrence was 13.5 months. The rate of symptomatic cyst recurrence was 10.7% in cases without the use of a stent compared with 4.3% in cases with stent placement (p = 0.6). CONCLUSIONS Based on current literature, endoscopic endonasal approaches result in a high rate of symptom improvement or resolution. Complication rates are lower than prior case series that have utilized open approaches. Asymptomatic restenosis can be managed conservatively, since it is associated with symptomatic cyst recurrence less than half of the time. This study revealed a nonsignificant trend toward a decrease in symptomatic cyst recurrence when a stent was used, but further work is needed to clarify its impact.
Collapse
|
42
|
Lachanas VA, Woodard TD, Antisdel JL, Kountakis SE. Sino-nasal outcome test tool assessment in patients with chronic rhinosinusitis and obstructive sleep apnea. ORL J Otorhinolaryngol Relat Spec 2012; 74:286-9. [PMID: 23235475 DOI: 10.1159/000343802] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 10/17/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The Sino-Nasal Outcome Test (SNOT-20) is a rhinosinusitis quality of life instrument. Nonrhinologic illnesses like obstructive sleep apnea (OSA) may elevate SNOT-20 scores. We compared SNOT-20 outcomes in patients with chronic rhinosinusitis (CRS) to those in patients with OSA. METHODS We analyzed prospectively collected data of patients with CRS and OSA. Pretreatment SNOT-20 and Lund-Kennedy endoscopy scores were obtained. Scores and patterns of SNOT-20 symptom distribution were compared. RESULTS Fifty-seven patients had CRS and 65 patients had OSA. Both groups had elevated mean total SNOT-20 scores (28 ± 12.2 and 29 ± 10.7, respectively). Higher scores were noticed for OSA patients on the wellness section of the SNOT-20 and for CRS patients on the sinonasal section of the SNOT-20 (p < 0.001). CONCLUSIONS CRS and OSA patients present with elevated total SNOT-20 scores but differ in their symptom distribution pattern. This study demonstrates that other disorders can elevate SNOT-20 scores and confirms the need for additional objective data to confirm CRS diagnosis.
Collapse
Affiliation(s)
- Vasileios A Lachanas
- Department of Otolaryngology-Head and Neck Surgery, Georgia Health Science University, Augusta, GA 30912, USA
| | | | | | | |
Collapse
|
43
|
Haffey TM, Woodard TD. Atypical Skull Base Osteomyelitis in an Immunocompetent Patient. Otolaryngol Head Neck Surg 2011. [DOI: 10.1177/0194599811415823a386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: 1) Present an abnormal case presentation of an already rare and deadly disease process. 2) Critically review/summarize the literature as it pertained to this case. 3) Increase awareness of a diagnostically challenging reversible deadly disease process. 4) Review current treatment options/recommendations for atypical SBO. Method: This is an unusual case of atypical skull base osteomyelitis in an immunocompetent patient diagnosed in 2010 at the Cleveland Clinic Foundation (CCF). A literature review for “atypical” and “central skull base osteomyelitis” was performed using PubMed. Results: As with other published cases of atypical skull base osteomyelitis, this patient was an elderly male, had no preceding infective source, and presented initially with headache that progressed to multiple lower cranial neuropathies (CN 8, 9, 10, 12). However, our patient is unique because he was not diabetic and had no immunodeficiencies. His work-up initially centered on ruling out a primary headache disorder, temporal arteritis, and oncologic pathology. Biopsy, culture, and an indium tagged WBC scan were pivotal in proving an infectious etiology. Prolonged IV antibiotics were vital in clearing the infection. Conclusion: Skull base osteomyelitis should be considered even in immunocompetent patients presenting with headache and cranial neuropathies. When possible, culture, biopsy, and indium-tagged-WBC scan should be performed to help distinguish an infectious process over malignancy, and guide antibiotic therapy. Early diagnosis and treatment is imperative in managing this life-threatening disease.
Collapse
|
44
|
Affiliation(s)
- Helen Perakis
- Department of Otolaryngology-Head & Neck Surgery, Medical College of Georgia, GA, USA
| | | |
Collapse
|
45
|
Champagne JP, Antisdel JL, Woodard TD, Kountakis SE. Epidemiologic factors affect surgical outcomes in allergic fungal sinusitis. Laryngoscope 2010; 120:2322-4. [DOI: 10.1002/lary.21127] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
46
|
Abstract
OBJECTIVES To analyze postoperative clinical, functional, and quality-of-life (QOL) outcomes in patients after total laryngectomy (TL) and to determine the effect of preoperative variables (including age, sex, comorbidities, prior chemotherapy or radiation therapy, and tumor site and stage) on long-term survival and quality of life. DESIGN We performed a retrospective cohort follow-up study of patients who underwent TL for cancer between July 28, 1994, and August 11, 2005. SETTING University tertiary care facility. PATIENTS One hundred forty-three patients who underwent TL were identified, and their hospital medical records were reviewed. Ninety-one patients (63.6%) underwent TL for primary carcinoma and 52 (36.4%) for recurrent cancer. At follow-up, 58 patients (40.6%) were alive. MAIN OUTCOME MEASURES Baseline characteristics and preoperative clinical variables were collected. Follow-up data on function and QOL were collected from patients who were alive at the time of study via the Head and Neck Cancer Inventory, a previously validated questionnaire. Survival was estimated using the Kaplan-Meier method. Univariate and multivariate analysis was used to determine factors significant for survival. RESULTS The overall median survival for the cohort was 23.0 months (mean +/- SD, 50 +/- 29 months). On univariate analysis, the following 5 factors were significant predictors of long-term survival: cancer site in the larynx, T3 stage, N0 to N1 stage, presence of no more than 2 comorbidities, and absence of cardiovascular comorbidities at the time of cancer diagnosis (P<.05). On multivariate analysis, only T stage maintained significance as a predictor of survival (P =.04), while cancer site was nonsignificant at P =.07. For patients alive at the time of study, functional and QOL outcomes for 5 domains (speech, eating, social disruption, aesthetics, and overall QOL) ranged from intermediate (score, 31-69) to high (score, 70-100) categories. Pretreatment patient-related factors that correlated with notably better functional and QOL outcomes in at least 1 domain were age older than 65 years at diagnosis, presence of no more than 2 comorbidities, no history of previous chemoradiation therapy, and primary tracheoesophageal puncture placement. CONCLUSIONS Pretreatment clinical variables (including primary tumor site, tumor stage, regional metastases, and number and type of comorbidities) have an effect on long-term survival after TL. Despite common belief, many patients who have undergone TL maintain a good QOL overall. This study sheds light on which patient-related factors may affect health-related QOL outcomes after TL. These findings may be used to select patients who are good candidates for TL based on anticipated functional and QOL outcomes.
Collapse
Affiliation(s)
- Troy D Woodard
- Department of Otolaryngology--Head and Neck Surgery, Loyola University Medical Center, Maywood, IL, USA
| | | | | |
Collapse
|
47
|
Woodard TD, Yong S, Hotaling AJ. The Ex Utero Intrapartum Treatment (EXIT) procedure used for airway control in a newborn with cervical fetus in fetu: a rare case. Int J Pediatr Otorhinolaryngol 2006; 70:1989-94. [PMID: 16938354 DOI: 10.1016/j.ijporl.2006.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Accepted: 06/27/2006] [Indexed: 11/24/2022]
Abstract
Fetus in fetu is a condition in which there is a monozygotic diamniotic fetus encased within the body of its larger more developed twin. We report a case of airway obstruction in a full-term fetus caused by fetus in fetu. Prenatal ultrasound revealed a large cervical mass compressing the neonate's trachea and esophagus. The Ex Utero Intrapartum Treatment procedure was utilized to secure the fetus's airway. Upon resection, a fetiform structure, covered by skin with vertebral tissue and two appendages was appreciated. To our knowledge, this is the first reported case of cervical fetus in fetu in the literature.
Collapse
Affiliation(s)
- Troy D Woodard
- Department of Otolaryngology Head & Neck Surgery, Loyola University Medical Center, IL 60153, United States
| | | | | |
Collapse
|
48
|
Abstract
To test the contribution of bicarbonate (Bi) to hemodynamic stability during hemodialysis (HD), we compared the effects of ultrafiltration dialysis with bicarbonate and with acetate under conditions of high-sodium (141 mEq/liter) and low-sodium (130 mEq/liter) dialysate concentrations in 12 stable HD patients. Group 1 was patients (N = 5) who had normal findings on autonomic testing; group 2, patients (N = 7) who had abnormal findings on autonomic testing. All patients and staff were unaware of which dialysis was being used. During the high-sodium dialysate studies, changes in mean blood pressure (MBP), cardiac output (CO), and orthostatic tolerance to standing after HD were similar in both groups of patients with both acetate and bicarbonate dialysate. When the studies were repeated under low-sodium dialysate conditions, several differences emerged between acetate and bicarbonate HD. In group 1, the frequency of adverse symptoms upon standing after HD were reduced with bicarbonate (P less than 0.05). In group 2, bicarbonate HD prevented a significant decrease in orthostatic MBP after HD. These results suggest that bicarbonate affords no greater hemodynamic stability than does acetate if a dialysate sodium of 141 mEq/liter is used. With lower sodium dialysate, bicarbonate appears to provide a modest improvement in decreasing orthostatic symptoms and signs in patients with and without autonomic insufficiency.
Collapse
|
49
|
Henrich WL, Woodard TD, Meyer BD, Chappell TR, Rubin LJ. High sodium bicarbonate and acetate hemodialysis: double-blind crossover comparison of hemodynamic and ventilatory effects. Kidney Int 1983; 24:240-5. [PMID: 6314029 DOI: 10.1038/ki.1983.150] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The superiority of bicarbonate dialysis (Bi HD) over acetate dialysis (Ac HD) using a high sodium dialysate has not been established to our knowledge. We compared to Bi HD to Ac HD over 6 weeks each in ten stable patients using a double-blind crossover design and a dialysate sodium concentration of 140 mEq/liter. The dialyzer, delivery system, and disalysate constituents were identical except for the substitution of Bi or Ac. Interdialytic weight gain, pre- and post-HD blood pressures, and heart rates were also comparable in the two protocols. Beginning of the week pre-HD serum Bi was greater during Bi HD than Ac HD (19.1 +/- 0.9 vs. 15.1 +/- 0.8 mEq/liter, P less than 0.001); post-HD Bi values were also higher during Bi HD. Similarly, pre-HD pH was also greater with Bi HD 7.40 +/- 0.012 vs. 7.35 +/- 0.001 U, P less than 0.01). The number of adverse symptoms and signs were similar during each protocol (2.0 +/- 0.65 for Bi HD vs. 2.5 +/- 0.5 for Ac HD episodes/patient/6 weeks, NS). However, fewer therapeutic interventions were required during the Bi HD protocol (1.5 +/- 0.43 vs. 3.1 +/- 0.6 treatments/patient/6 weeks, P less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
50
|
|