Contralateral Nasofrontal Trephination: A Novel Corridor for a "Dual Port" Approach to the Petrous Apex

BACKGROUND AND OBJECTIVES

Expanded endonasal approaches (EEAs) have proven safe and effective in treating select petrous apex (PA) pathologies. Angled endoscopes and instruments have expanded indications for such approaches; however, the complex neurovascular anatomy surrounding the petrous region remains a significant challenge. This study evaluates the feasibility, anatomic aspects, and limitations of a contralateral nasofrontal trephination (CNT) route as a complementary corridor improving access to the PA.

METHODS

Expanded endonasal and CNT approaches to the PA were carried out bilaterally in 15 cadaveric heads with endovascular latex injections. The distance to the PA, angle between instruments through the 2 approach portals, and surgical freedom were measured and compared.

RESULTS

Three-dimensional DICOM-based modeling and visualization indicate that the CNT route reduces the distance to the target located within the contralateral PA by an average of 3.33 cm (19%) and affords a significant increase in the angle between instruments (15.60°; 54%). Furthermore, the vertical vector of approach is improved by 28.97° yielding a caudal reach advantage of 2 cm. The area of surgical freedom afforded by 3 different approaches (endonasal, endonasal with an endoscope in CNT portal, and endonasal with an instrument in CNT portal) was compared at 4 points: the dural exit point of the 6th cranial nerve, jugular foramen, foramen lacerum, and petroclival fissure. The mean area of surgical freedom provided by both approaches incorporating the CNT corridor was superior to EEA alone at each of the surgical targets (P = <.001).

CONCLUSION

The addition of a CNT portal provides an additional avenue to expand on the classical EEA to the PA. This study provides insight into the anatomic nuances and potential clinical benefits of a dual-port approach to the PA.

A rare case of multifocal chordoma involving the lower clivus and multiple spine levels: illustrative case

BACKGROUND

Chordomas are rare bone tumors originating from notochord remnants with a predilection for the median axis of the body, primarily in the sacrococcygeal spine, skull base, and cervical spine. This paper presents the first reported case of simultaneous multilevel chordomas with various enhancements.

OBSERVATIONS

A 40-year-old woman presented with right-sided otalgia, headache, nasal obstruction, and facial pressure. The patient's head and spinal magnetic resonance imaging (MRI) demonstrated a midline lesion in the clivus, C2, and T1-5 spinal levels. All lesions were T1 isointense and T2 hyperintense, consistent with chordoma. Interestingly, the clivus lesion was enhancing, whereas the C2 lesion was only slightly enhancing, and the rest of the lesions showed no enhancement. The patient underwent endoscopic endonasal transclival approach surgery for the clival lesion, followed by radiation to the surgical bed and the C2 lesion. The remaining lesions were monitored. Follow-up imaging showed stable disease in the C2 lesion and other lower lesions. The patient's severe pain in the posterior cervical spine was managed with cervical fusion, pain management, and physical therapy.

LESSONS

This case underscores the importance of comprehensive spinal MRI in patients with chordomas, as multiple concurrent primaries may be present. The article summarizes the fundamental distinctions between ecchordosis physaliphora and chordoma and casts doubt on the capacity to always differentiate them.

Sternocleidomastoid Tendon as a Consistent Landmark for Identifying the Spinal Accessory Nerve: A Case Series

Objective

We propose a standardized approach of using the tendon of the sternocleidomastoid (SCM) muscle to locate the spinal accessory nerve (SAN) in neck dissection.

Study Design

Cross-sectional anatomic study.

Setting

Tertiary academic medical center.

Methods

Adult patients aged ≥18 years undergoing primary neck dissection for head and neck cancer were included. Anatomic measurements included the length of the SCM tendon, the distance from the mastoid tip to the entrance of the SAN into the SCM, the distance from the SAN to the distal edge of the SCM tendon, and the perpendicular distance from the anterior edge of the SCM to the SAN. Five cadaveric specimens also underwent bilateral modified radical neck dissections with the same anatomic measurements taken.

Results

Twenty-two living subjects and 5 cadavers were included. No statistical correlation was noted between patient demographics and any measurement. The mean (SD) length of the SCM tendon was 63.7 mm (11.8) in living subjects and 61.5 mm (10.4) in cadaveric specimens. The average distance from the mastoid tip to the entrance of SAN into the SCM was 51.6 mm (12.2) in living subjects and 51.6 mm (7.1) in cadaveric subjects. The distance of the SAN insertion into the SCM muscle from the anterior edge was 8.9 mm (3.4) in living subjects and 16.2 mm (7.2) in cadaver specimens. Laterality was compared in the cadaveric specimens; there was no statistically significant difference in any of the measurements between sides.

Conclusion

This study demonstrates the SCM tendon to be a reliable and safe surgical landmark to identify and preserve the SAN during neck dissection.

Complications Associated with Medical Tourism for Facial Rejuvenation: A Systematic Review

BACKGROUND

Medical tourism for cosmetic surgery has become increasingly popular in recent years. The existing literature has identified poor outcomes associated with general cosmetic tourism; however, the complications associated with cosmetic tourism for facial rejuvenation remain poorly understood. The aims of this study are to delineate the risk profile associated with medical tourism for facial rejuvenation.

METHODS

A systematic review of PubMed, MEDLINE, and Embase was performed through January 2019 using the PRISMA guidelines. Search terms included combinations of keywords including medical tourism and plastic surgery and other related nomenclature. Articles published in English relevant to medical tourism for facial rejuvenation and its associated complications were examined.

RESULTS

We identified six retrospective studies including 31 patients who had obtained facial rejuvenation procedures abroad and experienced treatment-associated complications. Twenty-five of 26 listed patients (96%) were female (age range 33-62 years). Departure nations included the USA, Switzerland, England, Ireland, Australia, and Thailand. Destination nations included the Dominican Republic, Cyprus, the USA, Colombia, Thailand, India, and China. Procedures included blepharoplasty, facelift, rhinoplasty, chin lift, and injections with botulinum toxin and dermal fillers. Complications included abscess, poor cosmesis, facial nerve palsy, and death.

CONCLUSIONS

We present the first study to systematically review the complications associated with medical tourism for facial rejuvenation. No definitive conclusions can be made given the paucity of relevant data, its clinical and statistical heterogeneity, and small sample size. Additional research is warranted to help inform patients who seek facial rejuvenation procedures abroad and to better understand the health system implications associated with cosmetic tourism for facial rejuvenation.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Polypoid Change of the Middle Turbinate and Paranasal Sinus Polyposis Are Distinct Entities

Objectives

Polypoid change of the middle turbinate (PCMT) is a finding on intranasal examination whose significance is not well understood. We present a comparison of the clinical characteristics of PCMT with paranasal sinus polyposis (PSP), a common condition with potentially similar appearance.

Study Design

Parallel case series.

Setting

Tertiary rhinology clinic.

Subjects and Methods

Data were prospectively compiled from consecutive patients during a 12-month period with either PSP arising from the middle meatus or PCMT limited to the middle turbinate as identified on nasal endoscopy. Recorded data included comorbidities, the 22-item Sinonasal Outcome Test (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE), Lund-Mackay score from computed tomography (CT) imaging, and total eosinophil levels.

Results

Of 593 patients, 23 (3.9%) had PCMT and 44 (7.4%) had PSP. The PSP group was predominantly male (75% vs 52%, P < .001) with an older mean age (53.4 vs 35.4 years, P < .0001). PCMT was more often associated with allergic rhinitis (83% vs 34%, P < .001), whereas PCMT was rarely associated with chronic rhinosinusitis (10% vs 100%, P < .0001). Mean eosinophil count (7.1 vs 3.1, P = .096) was not significantly different between groups, whereas mean Lund-Mackay score was higher in PSP (14.9 vs 2.8, P < .0008). Mean NOSE score was greater in PSP (65.3 vs 46.8, P = .025), whereas SNOT-22 score was comparable between groups (40.6 vs 34.6, P = .29).

Conclusion

PCMT is a unique physical finding with clinical associations that distinguish it from PSP. PCMT has greater association with allergic rhinitis than chronic rhinosinusitis, and both PCMT and PSP are associated with impaired quality of life.