Anterior endoscopic sublabial transmaxillary access to middle cranial base lesions

BACKGROUND

Anterior endoscopic access to middle cranial base lesions becomes feasible in the presence of infratemporal fossa (ITF) involvement. Various approaches, including endoscopic endonasal, transoral sublabial, and transorbital methods, have been described for accessing the ITF through a transmaxillary corridor. Among these approaches, endonasal access is the most commonly preferred, while the transorbital approach is a novel technique gaining popularity. The transoral sublabial approach is considered suitable for selected lesions.

METHODS

Patients who underwent the anterior endoscopic transoral/sublabial transmaxillary approach to middle cranial base lesions at a single institute from 2016 to 2023 were included in this retrospective study. Malignant lesions were excluded from the study. The sublabial approach was exclusively performed in all cases, with the exception of one patient who required a combined approach.

RESULTS

The anterior endoscopic transoral sublabial transmaxillary approach to the infratemporal fossa, upper parapharyngeal space, and middle cranial fossa was performed on 14 patients. The underlying conditions for these patients were as follows: trigeminal schwannomas (n = 8), meningiomas (n = 2), juvenile nasopharyngeal angiofibroma, osteochondroma, arachnoid cyst and encephalocele (n = 1 each). Gross total resection was achieved in 11 cases. The most common complication was numbness in the territory of the maxillary and mandibular nerves (n = 4). Two patients needed endoscopic maxillary antrostomy for persistent suppuration. No wound problems or CSF rhinorrhea occurred. The average follow-up time was 26.6 months.

CONCLUSION

The endoscopic sublabial transmaxillary approach provides direct access to the infratemporal fossa and middle cranial base, enhancing the surgical range of maneuverability while sparing the sinonasal cavity. This procedure is safe, less invasive, and could be used as an efficient corridor for the resection of selected infratemporal fossa lesions with or without extension to the middle cranial base and parapharyngeal space.

COVID-19 Associated Rhino-Orbital-Cerebral Mucormycosis: Clinical Features, Antifungal Susceptibility, Management and Outcome in a Tertiary Hospital in Iran

BACKGROUND

Despite the unprecedented surge in the incidence of mucormycosis in the COVID-19 era, the antifungal susceptibility patterns (ASPs) of COVID-19 associated mucormycosis (CAM) isolates have not been investigated so far and it is unclear if the high mortality rate associated with CAM is driven by decreased susceptibility of Mucorales to antifungal drugs.

OBJECTIVES

To describe the clinical, mycological, outcome and in vitro ASPs of CAM cases and their etiologies from Iran.

PATIENTS/METHODS

A prospective study from January 2020 to January 2022 at a referral tertiary hospital in Tehran, Iran was conducted for screening mucormycosis through histopathology and mycological methods. The identity of Mucorales isolates was revealed with ITS-panfungal PCR& sequencing and MALDI-TOF. The AS for amphotericin B, itraconazole, isavuconazole and posaconazole was cleared according to the EUCAST antifungal susceptibility testing protocol.

RESULT

A total of 150 individuals were diagnosed with CAM. Males constituted 60.7% of the population. The mean age was 54.9 years. Diabetes was the leading risk factor (74.7%). The median interval between diagnosis of COVID-19 and CAM was 31 days. The recovery rate of culture was as low as 41.3% with Rhizopus arrhizus being identified as the dominant (60; 96.7%) agent. Amphotericin B (MIC50 = 0.5 µg/ml) demonstrated the highest potency against Mucorales.

CONCLUSION

Majority of the cases had either diabetes, history of corticosteroid therapy or simultaneously both conditions. Accordingly, close monitoring of blood glucose should be considered. The indications for corticosteroids therapy are recommended to be optimized. Also, an anti Mucorales prophylaxis may be necessitated to be administrated in high risk individuals. Although amphotericin B was the most active agent, a higher rate of resistance to this antifungal was noted here in comparison with earlier studies on mucormycetes from non-CAM cases.

Pituitary metastasis from renal cell carcinoma presenting with significant hyperprolactinemia, case report

Key Clinical Message

Kidney metastasis to the pituitary gland can cause hyperprolactinemia even above 250 ng/mL. Although the treatment of metastasis is palliative, surgical decompression could play a major role in the recovery of symptoms and improve quality of life. Pituitary metastasis should be considered in the evaluation of an unusual pituitary mass.

Abstract

Pituitary tumors are frequently encountered in the neurosurgical setting. Although the majority of them are pituitary adenomas, rare entities encompass pituitary metastasis. They should be differentiated from pituitary adenomas because their management and prognosis are different. We report a 53-year-old female who complained of headache and had remarkable hyperprolactinemia (271.1 ng/mL). Having considered macroprolactinoma as the initial diagnosis, medical treatment was initiated with Cabergoline. Subsequently, the patient's vision deteriorated which prompted us to perform endoscopic endonasal transsphenoidal surgery. Histologic examination of the resected tumor revealed metastatic renal cell carcinoma. Main treatment for these subjects is palliative; and unlike the pituitary adenoma, the prognosis is unfortunately poor. Pituitary metastasis should be considered in the evaluation of an unusual pituitary mass associated with hyperprolactinemia.

Internal carotid artery injury during endoscopic endonasal surgery for skull base pathologies: an institutional incidence, management, and outcome

BACKGROUND

Endoscopic endonasal surgery (EES) has become a popular approach to deal with skull base pathologies. The most catastrophic intra-operative complication of EES is internal carotid artery (ICA) injury. We aim to discuss and introduce our institutional experience with ICA injury during EES.

METHODS

A retrospective review of patients who underwent EES from 2013 to 2022 was performed to determine the incidence and outcomes of intraoperative ICA injuries.

RESULTS

There were six patients (0.56%) with intraoperative ICA injury in our institution during the last 10 years. Fortunately, there was no morbidity or mortality in our patients with intraoperative ICA injuries. The sites of injury were equally in paraclival, cavernous sinus, and preclinoidal segments of ICA.

CONCLUSION

Primary prevention is the best solution for this condition. Regarding our institutional experience, the best option for primary management just after an injury is packing the surgical site. In cases where packing is not enough for temporary control of bleeding, common carotid artery occlusion should be considered. We have presented our experience and reviewed previous studies regarding different treatments and suggested our intra and post-operative management algorithm.

Skull base osteomyelitis: A case report of Garcin syndrome due to mucormycosis in COVID pandemic

Garcin syndrome is characterized by progressive unilateral multiple cranial nerve palsy without the presence of intracranial hypertension. In this case, we present a patient who experienced lower cranial nerve (CN 9-12) involvement attributed to post-mucormycosis osteomyelitis of the skull base. The osteomyelitis resulting from mucormycosis led to the development of Garcin syndrome, which manifested as progressive paralysis of the cranial nerves. It is important to recognize this rare complication and consider it in the differential diagnosis when evaluating patients with lower cranial nerve palsy following mucormycosis-related skull base osteomyelitis.

Clinical Evaluation of Scout Accelerated Motion Estimation and Reduction Technique for 3D MR Imaging in the Inpatient and Emergency Department Settings

BACKGROUND AND PURPOSE

A scout accelerated motion estimation and reduction (SAMER) framework has been developed for efficient retrospective motion correction. The goal of this study was to perform an initial evaluation of SAMER in a series of clinical brain MR imaging examinations.

MATERIALS AND METHODS

Ninety-seven patients who underwent MR imaging in the inpatient and emergency department settings were included in the study. SAMER motion correction was retrospectively applied to an accelerated T1-weighted MPRAGE sequence that was included in brain MR imaging examinations performed with and without contrast. Two blinded neuroradiologists graded images with and without SAMER motion correction on a 5-tier motion severity scale (none = 1, minimal = 2, mild = 3, moderate = 4, severe = 5).

RESULTS

The median SAMER reconstruction time was 1 minute 47 seconds. SAMER motion correction significantly improved overall motion grades across all examinations (P < .005). Motion artifacts were reduced in 28% of cases, unchanged in 64% of cases, and increased in 8% of cases. SAMER improved motion grades in 100% of moderate motion cases and 75% of severe motion cases. Sixty-nine percent of nondiagnostic motion cases (grades 4 and 5) were considered diagnostic after SAMER motion correction. For cases with minimal or no motion, SAMER had negligible impact on the overall motion grade. For cases with mild, moderate, and severe motion, SAMER improved the motion grade by an average of 0.3 (SD, 0.5), 1.1 (SD, 0.3), and 1.1 (SD, 0.8) grades, respectively.

CONCLUSIONS

SAMER improved the diagnostic image quality of clinical brain MR imaging examinations with motion artifacts. The improvement was most pronounced for cases with moderate or severe motion.

Complications in Endoscopic Endonasal Pitiuitary Adenoma surgery: An institution experience in 310 patients

Objective: Endoscopic Endonasal approaches (EEA) have shown excellent results for majority of hypophyseal tumors. The aim of this study was to evaluate and report the complications of EEA in patients with Pituitay Adenoma (PA) who underwent surgery between 2013 and 2018. Methods: We performed a retrospective review of 310 consecutive patients/325 procedures with PA treated with an Endoscopic Endonasal (EEA) approach from May 2013 to January 2018. Minor complications including transient diabetes insipidus (DI) or new anterior pituitary hormone insufficiency in one axis and major complications including CSF leakage, hematoma needing reoperation, vascular damage, brain infection, new pan-hypopituitarism permanent DI, new visual impairment, neurological deficits, and mortality were recorded. Results: We encountered 58 complications in 310 patients (18.7%) and in 325 procedures (17.7%). Minor complications were 43 (13.9% and 13.2%) in 310 patients and in 325 procedures respectively; whereas, major complications were 28 (9% and 8.6% respectively). Total complications were associated with diameter group 2 (>30 mm), diaphragm sella violation, suprasellar extension, paraselar involvement, nonfunctional secretory type, intraoperative arachnoid tearing Conclusion: EEA can be considered as a safe surgical treatment with acceptable complications in the management of pituitary adenomas.

Surgical complications of endoscopic approach to skull base: analysis of 584 consecutive patients

PURPOSE

Endoscopic techniques have been widely applied for challenging cranial base surgeries in recent years. In this study, we evaluated the safety and efficacy of using the endoscopic endo-nasal route for various skull base pathologies in terms of postoperative complications.

METHODS

A total of 584 consecutive patients who underwent endoscopic skull base surgery were studied. Peri- and post-operative complications and risk factors affecting the occurrence of these complications were evaluated.

RESULTS

648 endoscopic skull base surgical procedures were performed on 584 patients (47.8% females and 52.2% males) with the mean age of 41.2 years. Pituitary adenoma (69.3%) was the most common pathology. Post-operative mortality was 2.0%. The rates of post-operative permanent neurological deficit (one case of 6th nerve injury, two 12th nerve injuries and one hemiparesis) and visual deterioration were 0.6% and 1.5%, respectively. Ten patients (1.7%) were complicated with meningitis and it was the cause of death in 3. Systemic complications not directly attributable to skull base surgical access occurred in 2% (11 patients) with 5 mortalities. The rate of intra-operative vascular injury was 1% and among them one patient died due to PCA injury. The most common post-operative complications were diabetes insipidus (12.5%), anterior pituitary dysfunction (10.6%) and CSF leak (3.6%), respectively. In general, reoperation, malignant lesions, and level IV of surgical complexity were associated with a higher incidence of complications.

CONCLUSION

Endoscopic endo-nasal approach can be a safe and less-morbid first-line treatment of patients with various skull base lesions.

Endoscopic endonasal management of skull base defects in pediatric patients

PURPOSE

Skull base defects in children may be the result of congenital anomalies or trauma. They often present as cerebrospinal fluid (CSF) rhinorrhea, meningitis, brain abscess or nasal obstruction. Surgical intervention is predominantly the treatment of choice. Our goal is to assess the efficacy of endoscopic endonasal approach in treating skull base defects in pediatric patients.

MATERIAL AND METHODS

In this retrospective study we identified 38 patients (mean age 8.7 ± 5.6 years old, ranging 2 months-18 years) who underwent endoscopic endonasal repair of skull base defects, between March 2010 and February 2020. Patients who had skull base reconstruction after tumor resection, those who were lost to follow-up or did not sign the consent forms were excluded from the study.

RESULTS

The clinical indications for endoscopic endonasal repair were trauma (n = 24, 63.1%) and congenital defects (n = 14, 36.9%). Congenital skull base defects included basal meningoencephalocele (n = 5, 35.7%) and frontoethmoidal defects (n = 9, 64.3%). Mean follow up time was 32 ± 29.04 months, ranging 2-103 months. Fat graft (alone or in combination) was the most commonly used material to repair the skull base defects. Thirty-seven patients (97%) showed successful results after endoscopic endonasal surgery and were symptom free.

CONCLUSION

The endoscopic endonasal repair of CSF leak and skull base defects proved to be safe and feasible with 97% success rate.

Mucormycosis in patients with COVID-19: A cross-sectional descriptive multicentre study from Iran

PURPOSE

The aim of the study was to report clinical features, contributing factors and outcome of patients with coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM).

METHODS

A cross-sectional descriptive multicentre study was conducted on patients with biopsy-proven mucormycosis with RT-PCR-confirmed COVID-19 from April to September 2020. Demographics, the time interval between COVID-19 and mucormycosis, underlying systemic diseases, clinical features, course of disease and outcomes were collected and analysed.

RESULTS

Fifteen patients with COVID-19 and rhino-orbital mucormycosis were observed. The median age of patients was 52 years (range 14-71), and 66% were male. The median interval time between COVID-19 disease and diagnosis of mucormycosis was seven (range: 1-37) days. Among all, 13 patients (86%) had diabetes mellitus, while 7 (46.6%) previously received intravenous corticosteroid therapy. Five patients (33%) underwent orbital exenteration, while seven (47%) patients died from mucormycosis. Six patients (40%) received combined antifungal therapy and none that received combined antifungal therapy died.

CONCLUSION

Clinicians should be aware that mucormycosis may be complication of COVID-19 in high-risk patients. Poor control of diabetes mellitus is an important predisposing factor for CAM. Systematic surveillance for control of diabetes mellitus and educating physician about the early diagnosis of CAM are suggested.

Mucormycosis in patients with COVID-19: A cross-sectional descriptive multicentre study from Iran

Purpose

The aim of the study was to report clinical features, contributing factors and outcome of patients with coronavirus disease 2019 (COVID‐19)‐associated mucormycosis (CAM).

Methods

A cross‐sectional descriptive multicentre study was conducted on patients with biopsy‐proven mucormycosis with RT‐PCR‐confirmed COVID‐19 from April to September 2020. Demographics, the time interval between COVID‐19 and mucormycosis, underlying systemic diseases, clinical features, course of disease and outcomes were collected and analysed.

Results

Fifteen patients with COVID‐19 and rhino‐orbital mucormycosis were observed. The median age of patients was 52 years (range 14–71), and 66% were male. The median interval time between COVID‐19 disease and diagnosis of mucormycosis was seven (range: 1–37) days. Among all, 13 patients (86%) had diabetes mellitus, while 7 (46.6%) previously received intravenous corticosteroid therapy. Five patients (33%) underwent orbital exenteration, while seven (47%) patients died from mucormycosis. Six patients (40%) received combined antifungal therapy and none that received combined antifungal therapy died.

Conclusion

Clinicians should be aware that mucormycosis may be complication of COVID‐19 in high‐risk patients. Poor control of diabetes mellitus is an important predisposing factor for CAM. Systematic surveillance for control of diabetes mellitus and educating physician about the early diagnosis of CAM are suggested.

Olfactory Dysfunction is Associated with More Severe Clinical Course in COVID-19

To perform a quantitative olfactory test in positive COVID19 RT-PCR admitted patients and asymptomatic ones, to evaluate the association between hyposmia and disease severity. This is a Cross sectional study. Ninety-one patients including 68 inpatients and 23 asymptomatic healthcare workers with positive COVID-19 RT-PCRs. Methods: Demographics and clinical characteristics were collected. Iran Smell Identification Test (IR-SIT), a highly accurate 6-odorant test was used to evaluate the reliability of self-reported hyposmia and determine the correlation of the measured olfactory dysfunction with disease severity. Twenty-two of 91 patients (24%) reported hyposmia, while 41/91 (45%) patients had measurable olfactory dysfunction (IR-SIT score 1–4, p < 0.05). Mean age of the 68 inpatients and 23 asymptomatic patients were 43.97 ± 16.13 years; M:F 43:25, and 43.87 ± 12.76 years; M:F 8:15 respectively. Of 68 patients, 20 were graded as severe, and 48/68 had mild course of disease. IR-SIT detected hyposmia in 80% of patients with severe disease, and 50% with mild disease, respectively. The risk of disease severity was significantly increased for patients with olfactory dysfunction and was detected 4 times higher when compared to patients with mild disease (OR 4, 95% CI: 1.166–13.728, p = 0.028). Olfactory Dysfunction was present in 80% of patients with severe course. The risk of disease severity is significantly increased with olfactory dysfunction in admitted patients.

The double-edged sword of systemic corticosteroid therapy in viral pneumonia: A case report and comparative review of influenza-associated mucormycosis versus COVID-19 associated mucormycosis

Acute respiratory distress syndrome is a common complication of severe viral pneumonia, such as influenza and COVID‐19, that requires critical care including ventilatory support, use of corticosteroids and other adjunctive therapies to arrest the attendant massive airways inflammation. Although recommended for the treatment of viral pneumonia, steroid therapy appears to be a double‐edged sword, predisposing patients to secondary bacterial and invasive fungal infections (IFIs) whereby impacting morbidity and mortality. Mucormycosis is a fungal emergency with a highly aggressive tendency for contiguous spread, associated with a poor prognosis if not promptly diagnosed and managed. Classically, uncontrolled diabetes mellitus (DM) and other immunosuppressive conditions including corticosteroid therapy are known risk factors for mucormycosis. Upon the background lung pathology, immune dysfunction and corticosteroid therapy, patients with severe viral pneumonia are likely to develop IFIs like aspergillosis and mucormycosis. Notably, the combination of steroid therapy and DM can augment immunosuppression and hyperglycaemia, increasing the risk of mucormycosis in a susceptible individual. Here, we report a case of sinonasal mucormycosis in a 44‐year‐old woman with hyperglycaemia secondary to poorly controlled diabetes following dexamethasone therapy on a background of influenza pneumonia and review 15 available literatures on reported cases of influenza and COVID‐19 associated mucormycosis.

Initial clinical experience with high-pitch dual-source CT as a rapid technique for thoraco-abdominal evaluation in awake infants and young children

AIM

To evaluate dual-source high-pitch computed tomography (HPCT) imaging of the chest and abdomen as a rapid scanning technique to obtain diagnostic-quality imaging evaluation of infants and young children without sedation.

MATERIALS AND METHODS

Fifty-three paediatric patients (age 24.1±2 months) who underwent chest or abdomen HPCT (≥1.5) and standard pitch CT (SPCT, <1.5) on a dual-source 128-row multidetector CT system were included in the study. Image quality assessment was performed by two paediatric radiologists for diagnostic confidence, image artefacts, and image noise. Objective image noise was measured.

RESULTS

Most of the CT examinations were performed in children who were >1 year old (n=15 and n=20) followed by ≤1 year old (n=8 and n=10) in SPCT and HPCT, respectively. The mean radiation dose (SSDE) from HPCT was 1.96±1 mGy compared to 2.2±1 mGy for SPCT (p=0.3). No major artefacts were reported and overall image quality of all HPCT examinations was acceptable diagnostically. In addition, objective image noise values were not significantly different between HPCT compared with SPCT (11±3 versus 11±5, p=0.7).

CONCLUSION

Ultra-fast, HPCT can be performed without the need for sedation as a potential alternative to anaesthetised magnetic resonance imaging in infants and young children.

Crossed fused renal ectopia presenting as recurrent lower abdominal pain and urinary tract infection

BACKGROUND

Crossed fused renal ectopia is a relatively rare condition which may remain undiagnosed for a long time. Renal function is usually preserved. It usually involves the left kidney. It is usually associated with mal-rotation, and may be a cause of urinary tract infection, hydronephrosis and renal calculi.

MATERIAL AND METHOD

We report a case of a 15-year old boy who was referred to our clinic with complaints of abdominal pain, and an ultrasound report of "absent right kidney".

RESULTS

Urine examination indicated a partially treated infection, but the tests of kidney functions were normal. Intravenous urography confirmed crossed fused renal ectopia, and a flush aortogram showed two anomalous right renal arteries arising from the left side of aorta.

CONCLUSION

An "absent" kidney in its normal location should prompt further investigations. Recurrent chronic lower abdominal pain and urinary tract infection in a young person may be due to congenital renal abnormality. Evaluation of persistent urinary abnormalities in a child should include screening for congenital abnormalities.

Anterior mediastinal tracheostomy for malignancy: analysis of 12 cases

Introduction: Anterior mediastinal tracheostomy is indicated in extensive cervicothoracic malignancy with cervical mediastinal involvement of the trachea. This study was designed to assess the therapeutic outcome of anterior mediastinal tracheostomy.

Methods: From 2001 to 2010, 10 men and 2 women, with a median age of 64.5 years, underwent anterior mediastinal tracheostomy and were followed up for at least for 1 year. Seven patients had stomal recurrence following laryngectomy, 3 had carcinoma of the cervical esophagus, 1 had squamous cell carcinoma of the trachea invading the subglottic larynx, and 1 had adenoid cystic carcinoma of the trachea invading the subglottic larynx. They were evaluated in terms of etiology of the primary lesion, previous treatment, complications, hospital death, and Kaplan-Meier survival estimate.

Results: The tumor was completely resected in all cases. Postoperative complications included atelectasis (3 patients), stomal necrosis (1 patient), and anastomotic leak (1 patient). There were 2 (16.6%) postoperative hospital deaths. The mean duration of follow-up was 23 months, and the mean overall survival time was 25.59 months. Survival was calculated for 3 groups based on primary etiology: stomal recurrence of laryngeal carcinoma (12.85 months), cervical esophageal cancer (28 months), and primary malignancy of the trachea (29 months).

Conclusion: Because of the small number of patients, a definitive conclusion was difficult, but acceptable morbidity, mortality, and relative survival in selected patients, in whom an extensive cervicothoracic operation was performed by an experienced and skilled team of surgeons, demonstrated that anterior mediastinal tracheostomy can be a helpful procedure for patient survival.