Endonasal endoscopic duraplasty: our experience.

OBJECTIVE: Endoscopic repair of cerebrospinal fluid (CSF) leaks is a recognized technique. We consider our experience and evaluate the outcomes in patients who underwent endoscopic repair of CSF leaks. METHODS: A retrospective case note review of 135 patients who underwent anterior cranial repairs of CSF leaks between August 1995 and December 2004 at a tertiary referral center. We describe the technical details and outcomes of care by purely endoscopic procedures. RESULTS: Thirteen patients had combined transcranial and endonasal repairs and 122 patients had their repairs using an endoscopic approach only. There were 64 males and 71 females with ages that ranged from 1 to 75 years (mean age 42 years, median age 44 years). The success rate for first attempt only was 93.4%. Eight of the 122 patients (6.6%) needed a second surgical repair. In one patient a bicoronal approach was necessary while in the other cases a revision endoscopic procedure was appropriate. The period of follow-up ranged from 2 months to 9 years (mean 5 years, median 39 months). CONCLUSIONS: Our experience confirmed that endoscopic surgery is an effective and safe method of treatment for most CSF leaks. A variety of different endoscopic techniques allowed CSF leaks to be repaired in almost every site of the anterior skull base with very few exceptions.

Cerebral vasoconstriction in neurally mediated syncope: relationship with type of head-up tilt test response.

BACKGROUND: The pathophysiology of neurally mediated syncope (NMS) is unclear. Cerebral vasoconstriction has been observed in NMS patients during tilt testing. To shed light on the pathophysiology of NMS, we attempted to establish whether the degree of cerebral vasoconstriction changes with the tilt test positivity type, scored in accordance with Sutton's classification. METHODS: Twenty-one patients (12 males and 9 females, mean age 41 +/- 15 years) consecutively admitted to tilt test evaluation were studied through simultaneous recordings of their electrocardiogram, blood pressure, electroencephalogram and transcranial Doppler sonography (TCD) of the middle cerebral artery. TCD allowed computation of the Gosling's pulsatility index [PI = (systolic velocity--diastolic velocity)/mean velocity], as an index of cerebrovascular resistance. RESULTS: In the 13 tilt-positive patients (62%), TCD revealed a significant PI increase at the onset of prodromic symptoms in comparison with baseline (2.01 +/- 0.94 vs 0.77 +/- 0.20, p < 0.001, paired-sample Student's t-test). No significant TCD alterations were seen in tilt-negative patients. Furthermore, the percentage change in the PI from baseline was significantly higher in cardioinhibitory types (254 +/- 51%, 5 patients) than in mixed and vasodepressor types (101 +/- 22%, 8 patients, p < 0.001, independent-sample Student's t-test). CONCLUSIONS: Our data show that the degree of cerebral vasoconstriction at the onset of prodromic symptoms changes with the tilt test positivity type. We suggest that in NMS patients the degree of cerebral vasoconstriction may depend on the amount of sympathetic activation. The sympathetic modulation of cerebral vasoconstriction may therefore be a turning point in the explanation of the pathophysiology of NMS.

Endoscopic endonasal transpterygoid transmaxillary approach to the infratemporal and upper parapharyngeal tumors.

OBJECTIVES: To describe the endoscopic transnasal approach to the infratemporal fossa (ITF) and upper parapharyngeal space (UPS) and to analyze the indications and outcomes of this surgical technique in the management of the tumors localized in this critical area. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care referral center. PATIENTS AND METHODS: Retrospective review of patients with benign and malignant tumors arising in or extending to the ITF and UPS, treated from 2002 to 2012 at a single institute. The tumors were surgically resected using an endoscopic endonasal transpterygoid transmaxillary approach. RESULTS: Thirty-seven consecutive patients with benign tumors (20 juvenile nasopharyngeal angiofibromas, 2 extracranial trigeminal Schwannomas, 2 meningiomas, 1 cavernous hemangioma) and nonmetastatic malignant tumors (2 adenoid-cystic carcinoma, 1 mucoepidermoid carcinoma, 1 squamous cell carcinoma, 1 adenocarcinoma, 1 recurrence of chondrosarcoma, and 6 recurrences of undifferentiated carcinoma of nasopharyngeal type) were treated with curative intent. A gross-total resection was achieved in 35 of 37 patients. Major complications were observed in 1 case (intraoperative internal carotid artery blowout). Postoperatively, 8 patients received some form of adjuvant treatment. Mean follow-up was 30 months for malignancies and 60 months for benign tumors. All patients are now alive without recurrences. Stable intracranial persistence of disease was reported in 2 cases (1 meningioma and 1 adenoid-cystic carcinoma). CONCLUSION: The purely endoscopic endonasal technique may provide a minimally invasive and safe approach to radically resect selected tumors involving the ITF and UPS. Larger case series and longer follow-up are needed to validate the reproducibility and efficacy of this technique.

Oncocytic Schneiderian papillomas: Clinical behavior and outcomes of the endoscopic endonasal approach in 33 cases.

BACKGROUND: The purpose of this study was to evaluate the clinical behavior of oncocytic Schneiderian papillomas in relation to the rate of malignant transformation and recurrences and to report the long-term results of the endoscopic endonasal treatment. METHODS: A retrospective analysis was carried out on patients with oncocytic papilloma, endoscopically managed over the past 20 years, at 2 university centers following a uniform policy. RESULTS: Thirty-three patients were treated between November 1991 and December 2010. The mean follow-up period was 62 months. We observed 2 cases of persistence (6%) at the maxillary sinus level. Both of these patients underwent endoscopic surgical revision. Squamous cell carcinoma (SCC) was observed in 1 patient (3%). CONCLUSION: The endonasal endoscopic technique proved to be a safe and effective approach for the treatment of oncocytic papillomas. An oncocytic papilloma is not to be considered a negative prognostic factor in terms of malignant transformation or recurrence.

Growth hormone therapy and respiratory disorders: long-term follow-up in PWS children.

CONTEXT: Adenotonsillar tissue hypertrophy and obstructive sleep apnea have been reported during short-term GH treatment in children with Prader-Willi syndrome (PWS). OBJECTIVE: We conducted an observational study to evaluate the effects of long-term GH therapy on sleep-disordered breathing and adenotonsillar hypertrophy in children with PWS. DESIGN: This was a longitudinal observational study. PATIENTS AND METHODS: We evaluated 75 children with genetically confirmed PWS, of whom 50 fulfilled the criteria and were admitted to our study. The patients were evaluated before treatment (t0), after 6 weeks (t1), after 6 months (t2), after 12 months (t3), and yearly (t4-t6) thereafter, for up to 4 years of GH therapy. The central apnea index, obstructive apnea hypopnea index (OAHI), respiratory disturbance index, and minimal blood oxygen saturation were evaluated overnight using polysomnography. We evaluated the adenotonsillar size using a flexible fiberoptic endoscope. RESULTS: The percentage of patients with an OAHI of >1 increased from 3 to 22, 36, and 38 at t1, t4, and t6, respectively (χ(2) = 12.2; P < .05). We observed a decrease in the respiratory disturbance index from 1.4 (t0) to 0.8 (t3) (P < .05) and the central apnea index from 1.2 (t0) to 0.1 (t4) (P < .0001). We had to temporarily suspend treatment for 3 patients at t1, t4, and t5 because of severe obstructive sleep apnea. The percentage of patients with severe adenotonsillar hypertrophy was significantly higher at t4 and t5 than at t0. The OAHI directly correlated with the adenoid size (adjusted for age) (P < .01) but not with the tonsil size and IGF-1 levels. CONCLUSION: Long-term GH treatment in patients with PWS is safe; however, we recommend annual polysomnography and adenotonsillar evaluation.

Prevention and treatment of postoperative infections after sinus elevation surgery: clinical consensus and recommendations.

Introduction. Maxillary sinus surgery is a reliable and predictable treatment option for the prosthetic rehabilitation of the atrophic maxilla. Nevertheless, these interventions are not riskless of postoperative complications with respect to implant positioning in pristine bone. Aim. The aim of this paper is to report the results of a clinical consensus of experts (periodontists, implantologists, maxillofacial surgeons, ENT, and microbiology specialists) on several clinical questions and to give clinical recommendations on how to prevent, diagnose, and treat postoperative infections. Materials and Methods. A panel of experts in different fields of dentistry and medicine, after having reviewed the available literature on the topic and taking into account their long-standing clinical experience, gave their response to a series of clinical questions and reached a consensus. Results and Conclusion. The incidence of postop infections is relatively low (2%-5.6%). A multidisciplinary approach is advisable. A list of clinical recommendation are given.