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.

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.

Complications in Endoscopic Endonasal Pituitary Adenoma Surgery: An Institution Experience in 310 Patients.

Objective Endoscopic endonasal approaches (EEAs) 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 pituitary 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 EEA 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 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, parasellar involvement, nonfunctional secretory type, and intraoperative arachnoid tearing. Conclusion EEA can be considered as a safe surgical treatment which has acceptable complications in the management of PAs.

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.

Can Preoperative Diffusion Tensor Imaging Tractography Predict the Visual Outcomes of Patients with Pituitary Macroadenomas? A Prospective Pilot Study.

OBJECTIVE: Visual impairment has been reported as the most common clinical manifestation of pituitary adenoma (PA) due to the compressive effect of the tumor. This prospective study aimed to evaluate the predictive role of diffusion tensor imaging (DTI) in the visual improvement of patients with PA, who were candidates for endoscopic endonasal surgery. METHODS: A total of 13 patients (male, 8; female, 5) with visual impairment due to pituitary macroadenoma were enrolled in this study. The DTI findings and visual parameters, including visual acuity (VA), visual field (VF), and visual evoked potential (VEP), were recorded for all participants before and 3 months after surgery. RESULTS: Significant recovery was reported in both VA and VF following PA surgery (P < 0.001). The results of perimetry indicated recovery in all quadrants, except for the lower nasal quadrant of the right eye. The tumor volume showed no significant association with the preoperative optic nerve, optic tract, and chiasm fractional anisotropy (FA) or mean diffusivity (MD). The VA and VF recoveries were more likely in patients with a lower preoperative optic nerve MD. Besides, increased preoperative FA of the optic nerve was associated with a higher probability of VA recovery. No significant correlation was found between the optic tract MD and FA values and visual improvement. Overall, MD values below 0.0021 and FA values above 0.1689 could predict a good prognosis of VA recovery after surgery. CONCLUSIONS: DTI may have a predictive value in estimating visual improvement in patients with PA preoperatively.

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.

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.

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.

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.

Surgical Outcomes of Endoscopic Endonasal Surgery in 29 Patients with Craniopharyngioma.

Background Recently the endoscopic endonasal surgery (EES) has been introduced as a modality for the treatment of patients with craniopharyngiomas. In this study, we describe our initial experience in treatment of 29 patients with craniopharyngiomas using this approach. Methods Twenty-nine consecutive patients with craniopharyngiomas who had undergone EES in a 5-year period were studied retrospectively. Patients underwent preoperative and postoperative endocrinologic and ophthalmologic evaluations. Radiologic characteristics of tumors and extent of resection were determined. The recurrence and complications were evaluated. Results Pituitary and visual dysfunction were observed preoperatively in 89.7 and 86% of patients, respectively. After EES, visual outcome either showed an improvement or else remained unchanged in 92.3% of the cases; however, pituitary function remained unchanged and even got worsened in 34.6% of the cases. Prevalence of diabetes insipidus before and after surgery was 58.6 and 69.2%. The rate of gross total resection was 62%. Moreover, 86.2% of the tumors were almost totally resected (more than 95% of the tumor size resected). After surgery, cerebrospinal fluid (CSF) leak and meningitis occurred in four (13.8%) and two (6.9%) patients, respectively. Perioperative mortality was seen in two of the cases (6.9%). The mean follow-up was 25 months and tumor recurrence was discovered in four patients (15.3%). Conclusion The EES with the goal of maximal and safe tumor resection could be used for the treatment of most craniopharyngiomas. Although the rates of visual improvement and gross tumor resection are high, CSF leak, pituitary dysfunction, and meningitis are serious concerns.

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.

Survivin gene polymorphism association with tongue squamous cell carcinoma.

SUBJECT: Survivin expression is correlated with tumor aggressiveness and severity in head and neck carcinoma. A polymorphism at position -31 (G/C) (rs 9904341) has been associated with cancer risk in several studies. We evaluated the correlation of this polymorphism with clinical manifestation of patients with tongue squamous cell carcinoma (SCC) in an Irananian population. METHODS: Paraffin-embedded tissue sections from patients with tongue SCC (n=91) were evaluated for association between the survivin -31 (G/C) polymorphism and tumor staging, pathological grade, lymph node metastasis, tumor size, and recurrence of tumor. RESULTS: There was a significant increase of presence of allele C in patients who were at stages III and IV compared to patients with lower stages [GC+CC vs. GG, p=0.025, odds ratio [OR] 2.76, 95% confidence interval [CI] [1.03-7.4]). In addition, presence of allele C was significantly decreased in patients with T1 tumor size compared to patients with larger tumor size (p=0.03, OR 0.6, 95% CI [0.2-2.03]). CONCLUSION: Presence of the C allele was significantly associated with tumor stage and size; therefore, survivin might be an important marker in the prognosis of tongue SCC that requires further investigation.