Combined Minimally Invasive Supraciliary and Transfacial Approach for Large Tumors with Skull Base and Sinonasal Involvement.

BACKGROUND: Tumors invading both the anterior skull base and the sinonasal area have traditionally been accessed via largely invasive open craniofacial approaches. Minimally invasive extended endoscopic endonasal approaches have recently become increasingly available but have anatomical limitations and require incremental experience and thus high patient volume. Our objective was to assess the applicability of a novel combination of the minimally invasive supraciliary incision and the limited maxillofacial osteotomy as a combined surgical approach for large tumors invading both the anterior skull base and the sinonasal area. METHODS: The well-established technique of supraciliary incision with a 2.5 × 3.0-cm craniotomy was combined for the first time with limited facial translocation approach. RESULTS: This series involves 11 cases (female/male ratio 4:7; ranging in age from 6 to 61 years). Intracranial tumor propagation with intranasal and ethmoidal extension was detected in all patients. The pathologic diagnoses included adenocarcinomas, esthesioneuroblastoma, rhabdomyosarcoma, sinonasal papilloma, meningioma, and neurofibroma. The postoperative approach-related mortality rate was zero. No case of cerebrospinal fluid leak was detected. The 3-year survival rate was 70%. CONCLUSIONS: The limited transfacial approach in combination with a supraciliary extension is associated with minimal mortality and morbidity and facilitates gross total tumor removal. We highly recommend this approach for the surgical treatment of large tumors invading both the anterior skull base and the sinonasal area, especially for those being out of indication for extended endoscopic endonasal surgery.

[Endoscopic, posterior transseptal pituitary surgery--learning curve of the surgical technique and equipment in 61 operations]. / Endoszkópos posterior transseptalis hypophysismutét. A sebészi technika fejlodése a teljes endoszkópos tumoreltávolításig 61 eset elemzése alapján.

INTRODUCTION: The removal of hypophyseal tumor by transsphenoidal pituitary surgery using microsurgical instruments was first performed over 100 years ago. Operating techniques for this surgery are constantly being renewed, first by using a microscope and later on with the use of an endoscop. The authors provide an overview of the minimal invasive posterior transseptal-transsphenoidal aproach with the combined utilization of classical techniques with the assistance of the endoscop. METHOD: Sixty-one patients (33 female, 28 male, 21-84 yrs) were treated for sellar region tumor resection using an endonasal transsphenoidal aproach with the help of an endoscope. Follow ups were performed within 2-21 months. RESULTS: Total tumor resection was successful in 91.8%, and partial resection in 8.2% of the patients. The rate of complications using the endoscopic method was not higher compared to that of the classical microscopic method. There was no major bleeding in any of the cases. Adverse events such as minor epistaxis occurred in 4.9%, transitional diabetes insipidus in 6.5%, inraoperative CSF leak in 16.67%, postoperative CSF leak in 11.5% and meningitis in 8.2% of the patients. After the operation the pathological hormonal production stoped in all patients except in two patients who were acromegalic. However their GH level normalized and they did not require further treatment, the IGF-1 still remained high. CONCLUSION: The success of the surgical treatment is based on both, the proficient pre- and postoperative endocrinological care, and the minimal invasive surgical technique. The endoscope was used partially or continuously during the operation for better visualization of the operation field in multiple angles (30 degrees, 45 degrees). It was useful in differentiating between normal and tumorous glandular tissue, and also offered an enhanced view of the intrasellar (via hydroscopy) and parasellar region. Moreover the endoscopic method is able to decrease the operating time, reduce blood loss. In different stages of the surgery, depending on the anatomical and pathological situation, switching back and forth from microscope to endoscope technique, gives us the benefit of a clearer view in each situation.

Transoral CO2 laser management for selected supraglottic tumors and neck dissection.

This study aimed to evaluate transoral laser resection as a method of choice for conservation surgery for supraglottic laryngeal carcinoma in carefully selected patients. Between 1987 and 2006, 55 patients with early supraglottic carcinoma were selected for transoral laser surgery. The outcome of the endoscopic CO(2) laser resection and larynx-sparing functional results without tracheotomy was evaluated. Fifty-five patients with T1, T2 supraglottic carcinomas underwent transoral CO(2) laser resection and seven patients with manifest neck metastasis required a neck dissection at one session with additional postoperative radiation therapy. There was no need for tracheotomy; deglutition was moderately disturbed. Forty of the 55 (73%) patients had no signs of recurrence to date. Fifteen patients with local recurrences underwent salvage therapies: six repeated laser excisions, three radiotherapies, four supraglottic laryngectomies and two total laryngectomies. Laser-specific survival is 84% and larynx preservation is 96%. The overall 5-year-survival after salvage treatment is 98%. Development of late metastasis required five radical neck dissections (RND) and radiation therapy. The results indicated that transoral laser resection can control early supraglottic cancer in selected patients and can be combined with simultaneous neck dissection with less morbidity than "open surgery".

Recurrent bacterial meningitis after cochlear implantation in a patient with a newly described labyrinthine malformation.

Authors report on a so far undescribed bilateral inner ear malformation with congenital deafness where a defect of both the medial and lateral bony labyrinthine wall allowed the herniation of a cerebrospinal fluid-filled endosteum sac into the tympanic cavity. The story of cochlear implantation in this ear and the series of following meningitis demonstrates the dilemma of indicating implantation in labyrinthine dysplasia and the difficulties of treating postimplantation meningitis. Routes of bacterial invasion from inner ear to intracranium is discussed regarding normal, dysplastic and surgically "disturbed" inner ear anatomy.

Cochlear implantation for treatment-induced ototoxic deafness in Langerhans cell histiocytosis. A case report.

A case is presented where the authors carried out a cochlear implantation on a girl whose deafness was induced by cytostatic agents. The normally hearing child was diagnosed with Langerhans cell histiocytosis at the age of 3 years and received polychemotherapy for almost 2 years. By her 5th year, she started to develop a bilateral, progressive sensorineural hearing loss, necessitating a hearing aid in both ears. While her histiocytosis was cured, her hearing ultimately deteriorated to total deafness on the right and profound hearing loss on the left ear. After 3 years, her hearing aids no longer provided adequate hearing for the postlingually deafened girl. At the age of 14, a cochlear implantation was performed on her right ear with excellent results.

ALA (5-aminolevulinic acid)-induced protoporphyrin IX fluorescence in the endoscopic diagnostic and control of pharyngo-laryngeal cancer.

Photodynamic diagnosis is a modern method for the fluorescence imaging of superficial pharyngeal and laryngeal tumours. 5-aminolevulinic acid (ALA)-induced protoporphyrin IX fluorescence benefits the tumour selective accumulation of protoporphyrin; therefore, tumours can be differentiated from healthy tissue. ALA-induced fluorescence of laryngo-pharyngeal tumours and precancerous and benign lesions were evaluated by endoscopy. At the Department of Otorhinolaryngology, Head and Neck Surgery, Szeged, Hungary, 31 patients underwent ALA-induced protoporphyrin fluorescence imaging. After topical application of ALA, mesopharyngeal tumours were visualised by direct fluorescence endoscopy. Laryngeal and hypopharyngeal tumours were examined with a laryngomicroscope with the patients under general anaesthesia after inhalation of an ALA solution. Intensity of PPIX fluorescence was classified and compared with pathological findings. The examination of all 13 laryngeal and 12 pharyngeal tumours resulted in a middle or strong intensity of red fluorescence, but for one cancer, four precancerous and two benign lesions. Healthy tissues showed green autofluorescence. Margins of mesopharyngeal and vocal cord tumours were clearly outlined under fluorescent vision, giving a helpful contribution to diagnosis and therapy even in clinically non-visible tumours. Laryngomicroscopy combined with laser surgery also indicated PPIX fluorescence examination visualising margins of the tumour intermediately with the endoscope. The ALA-induced PPIX fluorescence imaging method revealed a sensitivity of 96%. This method is applicable for detecting early superficial tumours, margins of tumours and follow-up after surgery/radiation therapy in the laryngo-pharynx.

Successful cochlear implantation in a child after recovery from a head and neck malignancy: a case report.

We present the case of a successful pediatric cochlear implantation that was carried out following bilateral perilingual deafness caused by meningitis during the treatment of a childhood malignant tumor. A rhabdomyosarcoma localized in the frontobasal area was removed from the child at the age of 2 years. He then received 11 months of postoperative cytostatic treatment. A purulent meningitis developed at the end of the chemotherapy, resulting in a major-grade, bilateral sensorineural hearing loss (practically a perilingual deafness). After 6 tumor-free years and a meticulous preoperative assessment, a Nucleus 24 M cochlear implant was successfully implanted in the child's left ear. Two years after the operation, the child shows excellent hearing results and moderate speech development.

Glottic Cancer of the Free Margin and Ventricular Surface of Vocal Cord.

The authors differentiate cancer types of the glottis setting out from the free margin or the ventricular surface of the true vocal cord. The latter is considered to be a reliant clinicopathological unit starting from the dividing line of the stratified-ciliated epithelium margins, whereas the so called junctional tumor differs in its histogenesis and invasivity. They give a detailed description of intralaryngeal extension of these tumours on the basis of histopathological investigations.