Free temporalis muscle fascia graft in dural reconstruction following surgical resection of intermediate and malignant skull base tumors: A 10-year experience from a single center.

BACKGROUND: Data from patients with post-ablative dural defects reconstructed using a free temporalis muscle fascia graft (FTFG) after resection of anterior or central skull base tumors were retrospectively analyzed. METHODS: The primary predictor and outcome variables were the reconstructive methods for dural repair and postoperative cerebrospinal fluid (CSF) leakage rate, respectively. RESULTS: Eighty patients were included, and 94 postoperative dural reconstructions were performed using FTFG. The postoperative CSF leakage rate was 3.19%. The postoperative CSF leakage rates did not significantly differ between open and endonasal endoscopic surgeries (1.92% vs. 4.88%; p > 0.05). In cases completed using the endonasal endoscopic approach, the postoperative CSF leakage rate was significantly associated with the intraoperative CSF leak flow (p < 0.05). CONCLUSIONS: Post-ablative dural defect reconstruction using FTFG resulted in low postoperative CSF leakage and complication rates comparable to those of free fascia lata graft from available literature.

Harmonic Scalpel-Assisted Endonasal Endoscopic Resection of the Vascular Tumors of the Anterior Skull Base.

Vascular tumors represent a challenging pathologic subset for surgical treatment as they show a propensity for profuse bleedings. This is especially applicable to the skull base region, where surgical access is difficult due to its complex anatomy. To overcome this problem, the authors introduced the use of a harmonic scalpel in endoscopic skull base surgery for vascular tumors. Here, the authors report the outcomes of endoscopic harmonic scalpel-assisted surgery in 6 juvenile angiofibromas and 2 hemangiomas. All surgeries were performed using Ethicon Endo-Surgery HARMONIC ACE 5 mm Diameter Shears. The median intraoperative blood loss was 400 mL (range: 200-1500 mL). The median length of hospital stay was 7 days (range: 5-10 days). Recurrence was recorded in 1 patient with juvenile angiofibroma, which was successfully resolved with revision surgery. In this institutional experience, ultrasonic technology showed precise cutting with minimal bleeding, resulting in reduced surgical morbidity compared with conventional endoscopic instruments.

Endoscopic, endoscopic-assisted and open approaches in the treatment of juvenile angiofibroma: what has been new in the past decade (and 1586 cases)?

PURPOSE: Juvenile angiofibroma (JA) is a benign, but locally invasive tumor of the nasopharynx. Surgical resection of JA is performed through endoscopic (EA), endoscopic-assisted (EAA), or open approaches (OA). The management of these tumors is constantly evolving. We aimed to compare the surgical efficiency and morbidity of EA, EAA, and OA in JA treatment by conducting a systematic review of the literature published over the last 10 years. METHODS: A systematic review of the English literature on surgical cases of JA published between 2012 and 2022 was performed. Eligible articles were analyzed for individual patient data (IPD) and aggregate patient data (APD). The primary predictor variable was the surgical approach. The primary outcome variable was recurrence rate. RESULTS: The search retrieved 75 articles reporting 1586 JA surgical cases; 129 in IPD, and 1457 in APD data sets. Within the IPD data set, recurrence rates were significantly lower in cases completed by EA than that by OA (p < 0.05). There was no significant difference in recurrence rates between the EA and EAA groups (p > 0.05). EAA had a lower recurrence rate than that of OA (p < 0.05). For the APD data set, the recurrence rate following EA was significantly lower than that following OA (p < 0.05). There was no significant difference in recurrence between the EA and EAA groups (p > 0.05), and between the EAA and OA groups (p > 0.05). CONCLUSIONS: EA represents the method of choice for mild and moderately advanced JA. EAA and OA still play important roles in the treatment of advanced-stage JA.

Poorly differentiated sarcoma of the maxillary sinus: a histopathology dilemma of a rare tumor.

Sarcomas are a rare heterogeneous group of neoplasms of mesenchymal origin. In the redistribution of all head and neck malignancies, sarcomas are represented by only 1%. Herein, we report a case of a 66-year-old patient with right maxillary sinus sarcoma that spread through the ostiomeatal complex, infiltrated the septum, all ethmoid cells, frontal sinus, involved the entire right nasal cavity and penetrated to the nasopharynx. Patient was treated with neoadjuvant chemotherapy, surgery and adjuvant radiotherapy. The histopathology indicated poorly differentiated sarcoma with elements of Ewing's sarcoma, but also with elements consistent with osteosarcoma. Molecular pathological analysis excluded Ewing's sarcoma. Samples were also sent for review to the other Pathology Clinics. They suggested poorly differentiated high-grade pleomorphic sarcoma with elements of osteosarcoma. The accurate diagnosis of the head and neck sarcoma type can be a histopathology dilemma posing a great challenge in the choice of therapeutic approach, and thus the treatment outcome.

Rare case of nasal cavity chondrosarcoma presenting only with unilateral decreased vision.

Chondrosarcomas comprise a heterogeneous group of malignant lesions characterized by production of cartilage matrix. Sinonasal involvement is extremely rare, with nasal congestion and obstruction being the leading symptoms. We present a rare case of large chondrosarcoma of the nasal cavity and paranasal sinuses, primarily presenting with ocular symptoms.

An unusual case of hyalinizing clear cell carcinoma in a sinonasal cavity and cranial base.

Hyalinizing clear cell carcinoma (HCCC) is a rare, predominantly minor salivary gland tumor. Most of these tumors occur in the oral cavity, mainly the palate and tongue. Primary localization of the tumor in the region of the nasal cavity and paranasal sinuses is extremely rare and, with only a few cases reported in the literature so far. We present an extremely rare case of a 61-year-old woman with hyalinizing clear cell carcinoma (HCCC), occupying the left posterior nasal and nasopharyngeal cavity, as a primary tumor location. The patient total recovery was uneventful, and she is now free of disease at three years postoperative follow-up.

Metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma.

OBJECTIVE: To investigate possible metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma (PTC) with lateral neck metastasis and to determine the reliability of preoperative ultrasound-guided fine-needle aspiration biopsy (FNAB) as a method of detecting positive lymph nodes in sublevel IIa in comparison with the finding of definitive pathohistological analysis. DESIGN: Prospective study with patients with proven lateral neck metastases from PTC at the time of initial diagnosis. All patients had total thyroidectomy, central neck dissection (level VI) and selective neck dissection (levels II-V). Potential predictive factors for the occurrence of metastasis in sublevel IIb were analysed. Sensitivity and specificity tests were used to determine the reliability of preoperative ultrasound-guided FNAB. Patients were monitored for recurrence for at least ten years. SETTING: Single-centre study. PARTICIPANTS: Study included 53 patients with proven lateral neck metastases from PTC at the time of initial diagnosis. RESULTS: Predictive factors for the occurrence of metastasis in sublevel IIb that have reached statistical significance are positive sublevel IIa, number of positive lymph nodes and positive levels IIa + III + IV + V. None of the patients who fulfilled predefined criterion for minimum 10-year follow-up had local recurrence in operated lateral levels. CONCLUSION: Highest clinical significance has positivity of sublevel IIa. Therefore, it is necessary to prove or exclude metastasis in sublevel IIa, preoperatively or intraoperatively, to decide whether to include sublevel IIb in dissection. Preoperative ultrasound-guided FNAB is a reliable method for the detection of positive lymph nodes in sublevel IIa in comparison with the definitive histopathological analysis.

Oral Mucormycosis and Aspergillosis in the Patient with Acute Leukemia.

A 54-year-old male patient with acute lymphoblastic leukemia was referred to the Department of Oral Medicine. He had a primary refractory disease and was treated according to HOVON71 and HAM protocol. Sixteen days after the start of the HAM protocol the patient developed palatal dark red/brownish lesion and maxillary vestibular exophytic lesion. Biopsy specimens from oral lesions were taken and microbiologic evaluation confirmed the presence of Aspergillus fumigatus and Rhizopus genus. The treatment of the patient consisted of the inferior maxillectomy and intravenous posaconazole and amphotericine B for the following 28 days. Since the coinfection with Aspergillus and Rhizopus is extremely rarely seen in the oral cavity, a diagnostic and therapeutic dilemma easily presents itself.

Biomechanical Comparison of the Temporalis Muscle Fascia, the Fascia Lata, and the Dura Mater.

The purpose of our research is to prove that elastic biomechanical characteristics of the temporalis muscle fascia are comparable to those of the fascia lata, which makes the temporalis muscle fascia adequate material for dural reconstruction in the region of the anterior cranial fossa. Fifteen fresh human cadavers, with age range from 33 to 83 years (median age: 64 years; mean age: 64.28 years), were included in the biomechanical study. Biomechanical stretching test with the comparison of elasticity among the tissues of the temporalis muscle fascia, the fascia lata, and the dura was performed. The samples were stretched up to the value of 6% of the total sample length and subsequently were further stretched to the maximum value of force. The value of extension at its elastic limit for the each sample was extrapolated from the force-extension curve and was 6.3% of the total sample length for the fascia lata (stress value of 14.61 MPa), 7.4% for the dura (stress value of 6.91 MPa), and 8% for the temporalis muscle fascia (stress value of 2.09 MPa). The dura and temporalis muscle fascia shared the same biomechanical behavior pattern up to the value of their elastic limit, just opposite to that of the fascia lata, which proved to be the stiffest among the three investigated tissues. There was a statistically significant difference in the extension of the samples at the value of the elastic limit for the fascia lata in comparison to the temporalis muscle fascia and the dura ( p = 0.002; Kruskal-Wallis test). Beyond the value of elastic limit, the temporalis muscle fascia proved to be by far the most elastic tissue in comparison to the fascia lata and the dura. The value of extension at its maximum value of force for the each sample was extrapolated from the force-extension curve and was 9.9% of the sample's total length for the dura (stress value of 10.02 MPa), 11.2% for the fascia lata (stress value of 23.03 MPa), and 18.5% (stress value of 3.88 MPa) for the temporalis muscle fascia. There was a statistically significant difference in stress values at the maximum value of force between the dura and the temporalis muscle fascia ( p = 0.001; Mann-Whitney U test) and between the dura and the fascia lata ( p < 0.001; Mann-Whitney U test). Because of its elasticity and similarity in its mechanical behavior to the dura, the temporalis muscle fascia can be considered the most suitable tissue for dural reconstruction.

Pectoralis major myocutaneous flap in the reconstructive surgery of the head and neck--our experience.

The goal of this retrospective study is the evaluation of pectoralis major myocutaneous pedicle flap (PMMPF) reliability in clinical practice based on the analysis of the leading indication and postoperative complications. In the period from 2005 to 2011 at the University Department of Otorhinolaryngology and Head and Neck Surgery, Zagreb University Hospital Center, a total number of 27 PMMPF were used in the treatment of 26 patients. Indications for flap use were upper aerodigestive tract and soft tissue defects following resection of head and neck cancer. One-stage reconstructive technique was used in all patients. Basic demographic data, clinical stage of malignant disease, indications, postoperative complications and management of flap-related complications were systematically analyzed. In 24 cases (89%) leading indication for flap use was primary defect reconstruction following head and neck carcinoma resection and in 3 cases (11%) "salvage" reconstruction following salivary fistula formation and flap-related complications. Tumor invaded skin in 2 (8%) cases, oral cavity in 1 (4%) case, oropharynx in 12 (46%) cases, larynx and/or hypopharynx in 10 (38%) cases and major salivary gland in 1 case (4%). Mucous defect occurred in 21 (81%), cutaneous defect in 3 (11%) and muco-cutaneous defect in 2 patients (8%), respectively. 16 postoperative complications (59.3%) were recorded but only one patient (4%) sustained total flap necrosis. Previously irradiated patients had significantly higher postoperative complication rate. The rate of complications requiring surgical treatment was 25%. Although the overall complication rate was substantially high, PMMPF achieved desired reconstructive goal in 96% cases. Functional and aesthetic assessment was difficult due to the small series of patients. In conclusion, pectoralis major myocutaneous pedicle flap is still safe and acceptable reconstructive method in surgical treatment of patients with head and neck tumors.

Composite platysmofascial flap in reconstruction following partial vertical laryngeal resections.

OBJECTIVES: The superficial layer of deep cervical fascia represents a valuable material for the reconstruction of defects secondary to partial vertical laryngeal resections. However, there are drawbacks to the use of this flap, which include possible weakness and subsequent instability of the laryngeal wall. METHODS: To overcome this problem, we included platysma along with the superficial layer of deep cervical fascia to form a composite soft tissue flap that will meet all reconstructive needs following partial vertical laryngeal resection. RESULTS: Inclusion of platysma yields more durable and adequately vascularized flap resistant to saliva, seroma formation, and infection. Because of segmental blood supply of strap muscles and their indirect perforating vessels, medially based horizontal composite flap is better supplied with blood in comparison with cranially based vertical flap. Medial insertion of the horizontal flap is much more convenient than lateral, due to ancillary blood supply from the contralateral side and easier pursuance of ipsilateral neck dissection. CONCLUSIONS: The method of our choice for laryngeal reconstruction after partial vertical laryngeal resections is paramedially based horizontal platysmofascial composite flap with the insertion opposite to the side of the primary laryngeal tumor.

Synchronous multicentric bilateral sinonasal inverted papilloma and frontal sinus osteoma.

Inverted papilloma is generally considered a benign unilateral sinonasal tumor. Its synchronous bilateral multicentric occurrence is extremely rare. A 22-year-old male patient presented with stage III inverted papilloma involving both ethmoid sinuses, both frontal sinuses, and cribriform area. The patient also had a large osteoma emanating from the basal part of the frontal sinus septum, which completely obstructed both nasofrontal recesses, leaving no communication between the sinuses and the nasal cavity. The frontal sinus septum was intact, so there was no communication between the 2 sides either. Following the era of aggressive surgical approaches dominated by lateral rhinotomy and medial maxillectomy, the advent of endoscopic techniques has dramatically improved visualization of sinus chambers and nasal cavity, resulting in lower morbidity and similar results to those achieved with open surgical procedures. In our patient, the concomitant presence of a huge frontal sinus osteoma posed an unacceptable risk for endoscopic resection due to the possible residual disease in the nasofrontal recess regions. Surgical resection remains the mainstay treatment and should be tailored in accordance with the localization and spread of disease. The surgeon should be ready to use different surgical approaches and, if intraoperatively needed, to modify them accordingly.

Large intracranial intradural mucocele as a complication of frontal sinus osteoma.

Paranasal sinus osteomas are mostly asymptomatic; however, secondary mucocele can develop if they impede the natural sinus drainage. Such a mucocele can destroy the bone and extend into the adjacent structures. We report on an unusual case of frontal sinus osteoma in a 27-year-old patient, complicated by large secondary mucocele that eroded the bone and extended into the frontal lobe of the brain. Unexpectedly, the patient did not report any visual or other symptoms attributable to central nervous system deficit. The mucocele was completely resected through bifrontobasal osteoplastic craniotomy, whereas osteoma was evacuated in its entirety by both drilling and mobilizing. Open surgical approach remains the main treatment for complicated paranasal sinus osteoma, and radical removal of intracranial mucocele is mandatory to prevent the development of life-threatening infections. Although intradural extension of a secondary mucocele is extremely unusual, head and neck surgery specialists should take this severe complication in consideration.

Correlation between the minimal cross-sectional area of the nasal cavity and body surface area: preliminary results in normal patients.

Nasal symptoms often are inconsistent with rhinoscopic findings. However, the proper diagnosis and treatment of nasal pathology requires an objective evaluation of the narrow segments of the anterior part of the nasal cavities (minimal cross-sectional area [MCSA]). The problem is that the value of MCSA is not a unique parameterfor the entire population, but rather it is a distinctive valuefor particular subject (or smaller groups of subjects). Consequently, there is a need for MCSA values to be standardized in a simple way that facilitates the comparison of results and the selection of our treatment regimens. We examined a group of 157 healthy subjects with normal nasal function. A statistically significant correlation was found between the body surface area and MCSA at the level of the nasal isthmus and the head of the inferior turbinate. The age of subjects was not found a statistically significant predictor for the value of MCSA. The results show that the expected value of MCSA can be calculated for every subject based on anthropometric data of height and weight.