Septal transposition: a novel technique for preservation of the nasal septum during endoscopic endonasal resection of olfactory groove meningiomas.

Endonasal resection of olfactory groove meningiomas allows for several advantages over transcranial routes, including a direct approach to the bilateral anterior cranial base and dura mater, early tumor devascularization, and avoidance of brain retraction. Although considered minimally invasive, the endoscopic approach to the cribriform plate typically requires resection of the superior nasal septum, resulting in a large superior septal perforation. The septal transposition technique improves preservation of sinonasal anatomy through the elimination of a septal perforation while allowing for wide exposure to the midline anterior cranial base and harvest of a nasal septal flap. Herein, the authors describe a 39-year-old female who presented with a progressively enlarging olfactory groove meningioma. An endoscopic endonasal resection with a septal transposition technique was performed. On follow-up, the nasal cavity had completely normal anatomy with preservation of the turbinates and nasal septum. The authors conclude that septal transposition is a useful technique that allows wide exposure of the anterior cranial base with maximal preservation of normal nasal anatomy and avoidance of a large septal perforation.

Development of an optimized preoperative computed tomography imaging checklist for endoscopic sinus surgery utilizing a systematic review of the literature and the modified Delphi method.

BACKGROUND: Critical review of computed tomography (CT) imaging is essential in preoperative planning for endoscopic sinus surgery. In this study, we used a systematic review and a modified Delphi method to develop a comprehensive checklist that facilitates preoperative review of sinus CT imaging. METHODS: We performed a systematic review of PubMed, Embase, CINAHL, Cochrane, and Web of Science databases to identify existing checklists developed to evaluate sinus CT imaging. An inclusive list of items from these checklists was compiled and a modified Delphi methodology was used to assign ranked priority. The Delphi process involved 14 rhinologists and had three phases: an initial survey with Likert priority (scale of 1-9) and two rounds of live discussions followed by survey to confirm consensus. RESULTS: Ninety-seven possible checklist items were identified from a systematic review and panelist input. On initial survey, 63 items reached a consensus score of 7+, and 13 items had near consensus scores between 6 and 7; two of these 13 borderline items were retained after subsequent panelist discussion. The resulting items were consolidated into an 11-item disease checklist and a 24-item anatomical checklist; the anatomical checklist was further divided into six subsections: nasal cavity, maxillary, ethmoid, sphenoid, frontal, skull base, and orbit. Additionally, panelists identified six core aspects of patient history to consider prior to surgery. CONCLUSIONS: After establishing content validity through a systematic literature review and a modified Delphi method, we developed a comprehensive checklist for preoperative sinus CT imaging review; implementation and evaluation of validity among trainees will suggest overall utility.

Endoscopic endonasal craniopharyngioma resection.

The authors present the case of a 21-year-old female with a progressive bitemporal hemianopsia. Cranial MR imaging revealed a large cystic suprasellar, retrochiasmatic lesion consistent with craniopharyngioma. The lesion was fully resected through an endoscopic endonasal transsphenoidal and transplanum approach. Closure of the resultant dural defect was performed with a bilayer fascia lata button and autologous mucoperichondrial nasoseptal flap. Each portion of this procedure was recorded and is presented in an edited high-definition format. The video can be found here: http://youtu.be/i3-qieLlbVk .

Quality of life outcomes after endoscopic approaches to intracranial tumors.

PURPOSE OF REVIEW: To review the literature on quality of life (QOL) in endoscopic approaches to anterior and central intracranial skull-base disease. As endoscopic surgical techniques have gained widespread acceptance and complications and morbidity remain low and comparable with microscopic and open approaches, a shift to focusing on patients' perception of their own well being as an important outcome parameter has been made. In addition to the traditional measurements of surgical outcomes (extent of resection, recurrence rate, morbidity, survival, and complication rate), the success of a surgery can now be assessed using QOL measures. RECENT FINDINGS: The main tools for assessing QOL in endoscopic skull-base surgery (anterior skull-base questionnaire and 22-item sinonasal outcome test) were not specifically designed for endoscopic skull-base approaches, and recently, a new tool was introduced and validated, the skull-base inventory, adding to our armamentarium, but it has not yet been widely employed. Endoscopic skull-base surgery leads to improved or sustained long-term QOL overall but it is significantly influenced by tumor disease. Specific endoscopic surgical technique (such as nasoseptal flap closure) appears to have less impact on QOL. SUMMARY: It is becoming critical to assess therapeutic interventions in terms of impact on a patient's QOL. QOL can be useful in comparing efficacy of surgical interventions, and in the future, it will likely become a reportable indicator of surgical outcome and guide our surgical technique recommendations. Large-scale prospective multicenter trials would be beneficial.

Cerebrospinal fluid leak after anterior cervical disc fusion: an unusual cause of dysphagia and neck mass.

OBJECTIVE: Dysphagia after anterior cervical disc fusion (ACDF) is a common complaint. We present two cases of dysphagia caused by a rare complication after ACDF: cerebrospinal fluid (CSF) leak into the neck. STUDY DESIGN: A case series of two patients. METHODS: Both patients underwent a chart review, comprehensive history, physical examination, flexible nasolaryngoscopy, and radiographic imaging. A literature review of the MEDLINE database (1966-2006), using key words "dysphagia" and "anterior discectomy," was performed. RESULTS: We present two patients with persistent dysphagia after ACDF surgery caused by CSF leak into the neck. Their clinical presentation, physical and radiographic examination findings, and hospital course will be discussed. CONCLUSIONS: CSF collection presenting as dysphagia and neck mass after ACDF must be included in the differential diagnosis because incision and drainage is contraindicated, and fine needle aspiration (FNA) must be performed under sterile conditions. Treatment including lumbar drain or re-exploration is appropriate.

Impact of educational intervention on the interrater agreement of nasal endoscopy interpretation.

OBJECTIVE: Nasal endoscopy is integral to the evaluation of sinonasal disorders. However, prior studies have shown significant variability in the interrater agreement of nasal endoscopy interpretation among practicing rhinologists. The objective of the current study is to evaluate the interrater agreement of nasal endoscopy among otolaryngology residents from a single training program at baseline and following an educational intervention. METHODS: Eleven otolaryngology residents completed nasal endoscopy grading forms for eight digitally recorded nasal endoscopic examinations. An instructional lecture reviewing nasal endoscopy interpretation was subsequently provided. The residents then completed grading forms for eight different nasal endoscopic examinations. Interrater agreement among residents for the pre- and postlecture videos was calculated using the unweighted Fleiss' kappa (Kf) statistic and intraclass correlation agreement (ICC). RESULTS: Interrater agreement improved from a baseline level of fair (Kf range 0.268-0.383) to a posteducational level of moderate (Kf range 0.401-0.547) for nasal endoscopy findings of middle meatus mucosa, middle turbinate mucosa, middle meatus discharge, sphenoethmoid recess mucosa, sphenoethmoid recess discharge, and atypical lesions (ICC, P < 0.001). The baseline level of agreement for evaluation of nasal septum deviation was poor/fair and did not improve following educational intervention. CONCLUSIONS: This study demonstrates a limited baseline level of interrater agreement of nasal endoscopy interpretation among otolaryngology residents. The interrater agreement for the majority of the characteristics that were evaluated improved after educational intervention. Further study is needed to improve nasal endoscopy interpretation. LEVEL OF EVIDENCE: N/A.

Endoscopic Endonasal Transsphenoidal Treatment of Pituitary Apoplexy: Outcomes in a Series of 20 Patients.

OBJECTIVE: Pituitary apoplexy is a rare clinical entity and few cases treated with an endonasal endoscopic approach (EEA) have been reported. We report our experience of treating pituitary apoplexy using an EEA approach. METHODS: We performed a retrospective chart review on all the patients who underwent EEA skull base and pituitary surgery between December 2003 and March 2012 performed by the senior authors (THS and VKA) and identified patients with pituitary apoplexy. The extent of resection was determined volumetrically and the visual and endocrine outcome was evaluated.  RESULTS: From a total of 488 skull base surgeries, there were 241 pituitary cases, of which 20 had apoplexy. The most common presenting symptoms included headaches (80%), endocrinopathy (95%), and visual symptoms (60%). Surgery was performed within 24 hours in 15% of patients, and > one month after ictus in 40% due to late referral. Gross-total resection (GTR) was achieved in 18 (90%) patients. There was one (5%) postoperative cerebrospinal fluid (CSF) leak treated with lumbar drainage. Of 12 patients with preoperative visual disturbances, seven had improvements. For those patients with visual field cuts, only 33.3% showed improvement. There was no postoperative visual deterioration. Two patients developed new transient postoperative diabetes insipidus (DI) but there was no new permanent DI. The mean duration of follow-up was 22 months (range: 6 days - 72 months). CONCLUSION: The endoscopic endonasal transsphenoidal approach is an effective modality to treat pituitary apoplexy with a high rate of GTR and minimal risk. Delayed surgery may result in lower rates of visual field defect improvement.

Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery.

OBJECTIVE: To describe the effect on postoperative cerebrospinal fluid (CSF) leak after anterior skull base (ASB) surgery and complications associated with the addition of the vascularized nasoseptal flap (NSF) to an existing reconstruction protocol. METHODS: A prospective database of all patients undergoing endoscopic ASB approaches was reviewed. Patients were divided into three groups based on the date the use of the NSF was adopted. Group A included patients with high-volume CSF leak closed using the NSF in addition to a multilayer closure. Group B included patients operated on during the same time period with no high-volume leak and no NSF. Group C included patients operated on before the adoption of the NSF with all types of CSF leak. Rates of intraoperative and postoperative CSF leak were analyzed for statistical significance. RESULTS: Of 415 consecutive patients undergoing endoscopic ASB surgery, there were 96 in group A, 114 in group B, and 205 in group C. CSF leak rates in group A (3.1%) and group B (2.6%) were significantly lower than in group C (5.9%; P < 0.05). Lumbar drains and the gasket seal closure were performed more frequently in group A (75% and 32%) compared with group B (21% and 12%) and group C (28% and 11%). NSF carried a 2% risk of postoperative mucocele. CONCLUSIONS: The addition of NSF to an algorithm for multilayer closure can decrease the rate of postoperative CSF leak.

Concomitant transsphenoidal approach to the anterior skull base and endoscopic sinus surgery in patients with chronic rhinosinusitis.

Objectives To describe outcomes of endoscopic resection of sellar tumors with concomitant endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS). Design Retrospective chart review. Setting Tertiary care medical center. Participants Patients who underwent endoscopic transsphenoidal surgery for excision of anterior skull base lesions and simultaneous functional endoscopic sinus surgery (FESS) for CRS between January 2006 and January 2011 by senior authors (MRR and JJE). Main Outcomes Measured Short- and long-term postoperative complications. Results Fourteen patients were identified. Average follow-up was 27 months. All patients had preoperative symptoms consistent with CRS. No patients were treated with preoperative antibiotics. Surgical pathology revealed chronic sinusitis in all specimens. Pathology of the intracranial lesions included 11 pituitary macroadenomas, one craniopharyngioma, one chondrosarcoma, and one cholesterol granuloma. Short-term postoperative morbidities included a sphenoid polyp, one adhesion, and one case of pharyngitis. Long-term outcomes included one frontoethmoidal mucocele, one recurrence of nasal polyps, and three cases of acute sinusitis. There were no intracranial complications for the entire follow-up period. Conclusions Transsphenoidal surgery can safely be performed in the setting of CRS without increased risk of intracranial complications.

Methicillin-resistant Staphylococcus aureus sinusitis in nonhospitalized patients: a systematic review of prevalence and treatment outcomes.

OBJECTIVES/HYPOTHESIS: Methicillin-resistant Staphylococcus aureus (MRSA) has been isolated from patients with acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS), although the exact prevalence is unknown. Similarly, the optimal treatment regimen for MRSA sinusitis has not been determined. The aim of this study was to summarize the existing data on prevalence and treatment outcomes for MRSA sinusitis in nonhospitalized patients. STUDY DESIGN: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS: MEDLINE, Embase, and Cochrane databases were queried for English-language studies published between 1942 and 2012. Studies were excluded that did not provide quantitative data on the prevalence or treatment of ARS or CRS with MRSA-positive cultures. An itemized assessment of the risk of bias was conducted for each included study. RESULTS: Of 409 studies identified during systematic review, 12 studies met the criteria for analysis. The level of evidence and freedom from bias of these studies were generally low. The prevalence of MRSA among all culture isolates ranged from 0% to 15.9% for ARS and 1.8% to 20.7% for CRS. Six studies reported quantitative treatment outcomes using variable measures, in which resolution of infection ranged from 58.3% to 100%. The treatment regimens were heterogeneous and included single- and multiple-agent therapy with oral, topical, and parental antibiotics. CONCLUSIONS: MRSA-positive cultures are found in a small but significant number of cases of ARS and CRS. Treatment of MRSA sinusitis may be effective, although treatment regimens and outcome measures are variable. Prospective studies utilizing standardized parameters are warranted.

Endoscopic endonasal craniopharyngioma resection.

The authors present the case of a 21-year-old female with a progressive bitemporal hemianopsia. Cranial MR imaging revealed a large cystic suprasellar, retrochiasmatic lesion consistent with craniopharyngioma. The lesion was fully resected through an endoscopic endonasal transsphenoidal and transplanum approach. Closure of the resultant dural defect was performed with a bilayer fascia lata button and autologous mucoperichondrial nasoseptal flap. Each portion of this procedure was recorded and is presented in an edited high-definition format. The video can be found here: http://youtu.be/i3-qieLlbVk.

Interrater agreement of nasal endoscopy for chronic rhinosinusitis.

BACKGROUND: Nasal endoscopy is a routine, important diagnostic tool in the evaluation of chronic rhinosinusitis (CRS). Although the procedure is ideally "objective," the subjective nature of endoscopy interpretation and lack of standardization are potential limitations. The goal of this study was to examine the interrater agreement of various categories of nasal endoscopy findings in patients undergoing evaluation for CRS. METHODS: Fourteen patients (28 sides) with CRS underwent clinical evaluation, SNOT-22, sinus computed tomography (CT), and digital video nasal endoscopy. Five academic rhinologists blindly reviewed the endoscopies for structural anatomic issues, inflammatory rhinosinusitis findings, and atypical lesions. Statistical comparison of the endoscopy interpretations was performed using the unweighted Fleiss' kappa statistic (K(f) ). RESULTS: The mean Lund-Mackay CT scan score was 7.8 (standard deviation [SD] 4.9) and the mean SNOT-22 score was 35.8 (SD 22.7). Significant variability was noted among the raters with respect to the various categories of nasal endoscopy findings. The overall levels of interrater agreement for the various categories were as follows: "almost perfect" for atypical lesions (K(f) = 0.912); "substantial" for nasal polyps (K(f) = 0.693); "moderate" for nasal discharge (K(f) = 0.422) and mucosal inflammatory changes of the middle turbinate (K(f) = 0.413); and "fair" for edema of the middle meatus (K(f) = 0.214), obstruction by nasal septum deviation (K(f) = 0.240), and obstruction by the middle turbinate (K(f) = 0.276). CONCLUSION: Significant variability was noted in the interrater agreement for nasal endoscopy findings in this study, with relatively limited agreement on some of the key findings of the procedure. Additional investigation and standardization of nasal endoscopy interpretation is required to improve the clinical utility of the procedure.

Hyperostotic chronic sinusitis as an indication for outpatient intravenous antibiotics.

OBJECTIVES: There is a subset of patients with chronic rhinosinusitis (CRS) that demonstrate osteitis of the sinuses. Osteitic bone is evident on computed tomography (CT) as hyperostosis. We propose treatment of this entity with a six week course of outpatient intravenous antibiotics in an approach similar to that used in the orthopedic literature for long bone osteomyelitis. This group of patients can be identified based on symptoms, unremitting course of disease, and imaging criteria. Although indications for the use of outpatient intravenous antibiotics must be determined judiciously in CRS we believe that hyperostotic sinusitis is an additional indication. STUDY DESIGN: A retrospective chart review. METHODS: A retrospective chart review of ten patient with hyperostotic sinusitis treated over a three year period (1/2007- 8/2009). RESULTS: Ten patients (age range, 25-85) with hyperostotic sinusitis were identified and quality of life was evaluated with SNOT-22. All patients underwent both pre- and post- treatment nasal endoscopy and CT. All patients underwent revision surgery by senior author (VKA). Five patients were treated with 6 weeks of intravenous antibiotics. Antibiotic choices were culture directed and antibiotics administered included Cefazolin, Clindamycin, Ertapenem, Maxipime, and Vancomycin. Minor complications encountered during therapy included: paresthesias and elevated liver enzymes. Five patients, (serving as the control group), were treated with traditional therapy involving intermittent and prolonged courses of oral antibiotics. CONCLUSIONS: Prolonged intravenous antibiotics may achieve adequate serum levels that cannot be achieved with oral antibiotics. Symptomatic relief in patients with hyperostotic sinusitis appears superior with intravenous antibiotics versus traditional oral therapy. Indications for intravenous antibiotics should include hyperostotic sinusitis.

10 pearls for safe endoscopic skull base surgery.

The introduction of the endoscopic endonasal approach for the management of lesions of the skull base has produced a paradigm shift in the way complicated lesions of this complex anatomic location are managed. The endonasal approach provides the most direct route to the anterior cranial base and adjacent skull base locations. This article presents the 10 most important tenets that have proved useful to the authors regarding postoperative patient management and surgical practice.

Radiation induced malignancy in retinoblastoma: new pathology in a case report.

OBJECTIVE: Patients with a genetic history of retinoblastoma have an increased risk of developing a second neoplasm. When these secondary malignancies occur in the previously irradiated field of the primary tumor they are most commonly osteosarcomas, fibrosarcomas, and squamous cell carcinomas. We present the first case of a radiation induced adenocarcinoma in a patient after treatment for retinoblastoma. STUDY DESIGN: A case report of one patient. METHODS: This case study underwent a chart review, comprehensive history, physical exam, rigid nasal endoscopy, and radiographic imaging. A literature review of the MEDLINE database 1966-2009 using key words, retinoblastoma, radiation, and second malignancy was performed. RESULTS: Our case is a 29 year old man with a past medical history significant for surgical resection followed by irradiation at age 1 for retinoblastoma who presented with right sided epistaxis and nasal obstruction. Endoscopy revealed a mass in the right nasal cavity. MRI and CT revealed a mass filling the right nasal cavity and ethmoids with erosion through the cribriform plate. The patient underwent surgical resection and pathology revealed an adenocarcinoma. CONCLUSIONS: Second malignancies in patients with retinoblastoma tend to occur in the previously irradiated field of the primary tumour and contribute significantly to long term morbidity and mortality rates. This is the first case of a sinonasal adenocarcinoma occurring in the previously irradiated field. The endoscopic skull base surgeon plays a vital role as patient survival depends on the diagnosis and surgical management.

Transoral resection of short segment Zenker's diverticulum and cricopharyngeal myotomy: an alternative minimally invasive approach.

OBJECTIVES/HYPOTHESIS: Transoral treatment of cricopharyngeal bar and small Zenker's diverticulum remains a challenge. We propose a new transoral approach for transoral cricopharyngeal myotomy (TOCPM) for patients with cricopharyngeal spasm and pharyngeal bar, and for transoral resection of diverticula (TORD) with cricopharyngeal myotomy in the patient with small (<3 cm) Zenker's diverticulum. METHODS: A retrospective review was conducted of 45 patients with cricopharyngeal spasm (21) and Zenker's diverticulum (24), where 14 patients were considered suitable for TORD and TOCPM. TOCPM used the Weerda laryngoscope (Karl Storz, Tuttlingen, Germany) to expose the cricopharyngeal bar using a microscope; the mucosa is cut and then the muscle is transected using monopolar cautery. A 0 degrees endoscope is inserted through the incision to ensure complete myotomy. Incision closure is by interrupted 4-0 Vicryl sutures (Ethicon Inc., Somerville, NJ) and fibrin glue. For the TORD procedure, the diverticular sac is everted and then resected using scissors. Through the sac opening, the TOCPM is completed. The sac opening is then closed as described in TOCPM. The patients are kept without food for 24 hours, followed by feeding and discharge. Modified barium swallow (MBS) evaluated functional results. RESULTS: Fourteen patients underwent TOCPM (eight), and TOCPM+TORD (six). There was one case of TOCPM that was aborted due to excessive bleeding, which prevented full myotomy. The rest did well. All were discharged the next day. Two poor results from the TOCPM and TOCPM+TORD group were due to poor esophageal motility. The remainder of patients had resolution of dysphagia and normalized MBS. No patient developed stricture or complications. CONCLUSIONS: Short segment Zenker's diverticulum and cricopharyngeal bar can now be addressed completely with a transoral approach. Because there is complete closure of the mucosal incision, prolonged hospitalization can be avoided.

Microscopic versus endoscopic transnasal pituitary surgery.

PURPOSE OF REVIEW: The transnasal endoscopic approach to the sella turcica is an alternative to the microscopic approach and over the last decade has come into prominence as a new technique. In the present article, we will analyze the current literature on outcomes between the two techniques. RECENT FINDINGS: The endoscopic approach to the pituitary has redefined visualization of the sella. The panoramic view afforded by the endoscope is unparalleled as compared with the traditional conical view of the microscope. This technique has been shown to have a statistically significant reduction in operative time and length of hospital stay. There is also a trend toward improved endocrine outcomes and rate of return of visual defects. These two approaches are equally efficacious in oncological outcomes and the complication rates are comparable. SUMMARY: With longer follow-up of this developing field it may be shown that complication rates are decreased, surgical reconstruction is less time consuming, and tumor resection is more complete due to improved visualization in the sellar and parasellar areas. In addition, the use of endoscopes facilitates extended approaches, reaching a myriad of skull base lesions that are suprasellar, retrosellar, and parasellar, which permits visualization beyond the abilities of the microscope.