Endoscopic Transnasal Management of Meningoceles and Encephaloceles in Children: A Systematic Review.

OBJECTIVE: To review surgical techniques used in the endoscopic transnasal repair of pediatric basal meningoencephaloceles and compare perioperative outcomes in children <2 and ≥2 years old. DATA SOURCES: MEDLINE, EMBASE, and CENTRAL. REVIEW METHODS: Data sources were searched from inception to August 22, 2022, using search terms relevant to endoscopic transnasal meningoencephalocele repair in children. Reviews and Meta-analyses were excluded. Primary outcomes were the incidence of intraoperative and postoperative complications, including cerebrospinal fluid leak, recurrence, and reintervention. Quality assessments were performed using Newcastle-Ottawa Scale, ROBIN-I, and NIH. RESULTS: Overall, 217 patients across 61 studies were identified. The median age at surgery was 4 years (0-18 years). Fifty percent were female; 31% were <2 years. Most defects were meningoencephaloceles (56%), located transethmoidal (80%), and of congenital origin (83%). Seventy-five percent of repairs were multilayered. Children ≥2 years underwent multilayer repairs more frequently than those <2 years (P = 0.004). Children <2 years more frequently experienced postoperative cerebrospinal fluid leaks (P = 0.02), meningoencephalocele recurrence (P < 0.0001), and surgical reintervention (P = 0.005). Following multilayer repair, children <2 years were more likely to experience recurrence (P = 0.0001) and reintervention (P = 0.006). CONCLUSION: Younger children with basal meningoencephaloceles appear to be at greater risk of postoperative complications following endoscopic endonasal repair, although the quality of available evidence is weakened by incomplete reporting. In the absence of preoperative cerebrospinal fluid leak or meningitis, it may be preferable to delay surgery as access is more conducive to successful repair in older children.

Facilitation of Definitive Cancer Diagnosis With Quantitative Molecular Assays of BRAF V600E and TERT Promoter Variants in Patients With Thyroid Nodules.

Importance: Molecular testing of the presence of pathogenic genomic variants in a tumor without quantifying the variant allele fraction (VAF) does not differentiate the variation extent among tumors, often resulting in an inconclusive diagnosis because of interpatient variability. Objective: To examine the association between the quantification of VAFs of BRAF V600E and TERT promoter variants and a definitive cancer diagnosis of thyroid tumors. Design, Setting, and Participants: This diagnostic study analyzed a cohort of 378 surgically resected thyroid tumors with a maximum dimension of 1 cm or larger between March 15, 2016, and March 16, 2020, and a separate cohort of 217 residual thyroid fine-needle aspiration (FNA) biopsy specimens obtained from January 22, 2020, to March 2, 2021, at Mount Sinai Hospital, Toronto, Ontario, Canada. Data analysis was conducted between February 1, 2021, and February 1, 2023. Exposures: Quantitative VAF assays of BRAF V600E and TERT promoter variants (C228T and C250T) were performed by digital polymerase chain reaction molecular assays. Main Outcomes and Measures: The VAFs of BRAF V600E and TERT promoter variants were correlated with tumor histologic diagnoses and histopathologic features to delineate the association of VAF assays with tumor malignancy. The receiver operating characteristic curve analysis, sensitivity, specificity, positive predictive value, negative predictive value, and logistic regression analysis based on follow-up histopathologic types were used to determine the diagnostic utility of the quantitative molecular assays. Results: A total of 595 specimens, including 378 surgically resected thyroid tumors and 217 thyroid nodule FNA biopsy specimens, were collected from 580 patients (436 [75.2%] female with a mean [SD] age of 50 [16] years and 144 [24.8%] male with a mean [SD] age of 55 [14] years). Sensitive VAF assays of 378 thyroid tumors revealed the presence of the BRAF V600E variant in 162 tumors (42.9%), with 26 (16.0%) at a low VAF of 1% or less and 136 (84.0%) at a high VAF of greater than 1%, and the presence of TERT promoter variants in 49 tumors (13.0%), including 45 C228T variants (91.8%), 15 (33.3%) of which were quantified as having a low VAF (≤1%) and 30 (66.7%) as having a high VAF (>1%), and 4 C250T variants (8.2%) with VAFs between 40.0% and 47.0%. All tumors detected with BRAF V600E and/or TERT promoter variants, whether at low or high VAFs, received a definitive cancer diagnosis. Further analysis delineated a significant association between high VAFs of either variant individually or different VAF levels for both variants in coexistence and aggressive histopathologic features of tumors. Excluding low VAFs assisted in identifying patients at an intermediate-to-high risk of recurrence (odds ratio, 5.3; 95% CI, 1.9-14.6; P = .001). The VAF assays on the residual FNA biopsy specimens showed a high agreement to those on surgical tissues (κ = 0.793, P < .001) and stratified malignancy in 40 of 183 indeterminate FNA cases (21.9%), with a sensitivity of 93.8% (95% CI, 67.7%-99.7%), specificity of 90.0% (95% CI, 75.4%-96.7%), positive predictive value of 78.9% (95% CI, 53.9%-93.0%), and negative predictive value of 97.3% (95% CI, 84.2%-99.9%). Conclusions and Relevance: This diagnostic study suggests that sensitive quantitative VAF assays of BRAF V600E and TERT promoter variants can elucidate the interpatient variability in tumors and facilitate a definitive cancer diagnosis of thyroid nodules by differentiating the variation extent of genomic variants, even at low VAFs.

Postoperative opioid use following head and neck endocrine surgery: A multi-center prospective study.

Background: Opioid abuse is widespread in North America and the over-prescription of opioids are a contributing factor. The goal of this prospective study was to quantify over-prescription rates, evaluate postoperative experiences of pain, and understand the impact of peri-operative factors such as adequate pain counseling and use of non-opioid analgesia. Methods: Consecutive recruitment of patients undergoing head and neck endocrine surgery was undertaken from January 1st 2020 to December 31st 2021 at four Canadian hospitals in Ontario and Nova Scotia. Postoperative tracking of pain levels and analgesic requirements were employed. Chart review and preoperative and postoperative surveys provided information on counseling, use of local anesthesia, and disposal plans. Results: A total of 125 adult patients were included in the final analysis. Total thyroidectomy was the most common procedure (40.8%). Median use of opioid tablets was 2 (IQR 0-4), with 79.5% of prescribed tablets unused. Patients who reported inadequate counseling (n = 35, 28.0%) were more likely to use opioids (57.2% vs. 37.8%, p < .05) and less likely to use non-opioid analgesia in the early postoperative course (42.9% vs. 63.3%, p < .05). Patients who received local anesthesia peri-operatively (46.4%, n = 58) reported less severe pain on average [2.86 (2.13) vs. 4.86 (2.19), p < .05] and used less analgesia on postoperative day one [0 MME (IQR 0-4) vs. 4 MME (IQR 0-8), p < .05]. Conclusion: Over-prescription of opioid analgesia following head and neck endocrine surgery is common. Patient counseling, use of non-opioid analgesia, and peri-operative local anesthesia were important factors in narcotic use reduction. Level of evidence: Level 3.

Murine model for chronic rhinosinusitis: an interventional study.

BACKGROUND: Chronic rhinosinusitis (CRS) is a complex inflammatory disease of the sinonasal tract. To understand this disease entity and develop targeted treatments, a reproducible animal model is paramount. AIMS/OBJECTIVES: To optimize a murine model of eosinophilic CRS by establishing benchmark histological markers and validate its fidelity in evaluating intranasal treatments. MATERIAL AND METHODS: Forty-five Balb/c mice were included in the 7-week protocol. Experimental animals (n = 20) were induced a CRS disease state upon receiving intraperitoneal sensitization with ovalbumin (OVA), followed by intranasal OVA with Aspergillus oryzae protease. Analysis of complete blood count with differential, peripheral blood smear, and histological markers from the nasal cavity mucosa were performed. CRS mice were additionally treated with intranasal saline (n = 5) or mometasone (n = 10) and compared with control groups of untreated CRS (n = 5) and healthy (n = 5) mice after week 7. RESULTS: Histological analysis of experimental animal nasal mucosa revealed significantly higher levels of eosinophilic tissue infiltration/degranulation, hyaline droplets, Charcot-Leyden crystals, and respiratory epithelial thickness compared to healthy controls. Treatment with mometasone significantly reversed the histopathological changes observed in CRS mice. CONCLUSION AND SIGNIFICANCE: This murine model induced substantial local eosinophilic inflammation within sinonasal mucosa, that was reversible with mometasone. This model may be used to evaluate the efficacy of therapeutics designed to target CRS.

Cribriform adenocarcinoma of the minor salivary glands: a case report.

BACKGROUND: Polymorphous adenocarcinoma is the third most common malignant salivary gland tumor. Within polymorphous adenocarcinoma, cribriform adenocarcinoma of salivary glands is a rare subtype and resembles papillary thyroid carcinoma histopathologically. Diagnostically, cribriform adenocarcinoma of salivary glands is challenging for pathologists and surgeons alike as initial presentation and cytologic nuclear features can be easily confused with papillary thyroid carcinoma arising from a thyroglossal duct remnant or lingual thyroid. CASE PRESENTATION: A healthy 64-year-old Caucasian woman presented to a community otolaryngologist with a 4-year history of progressive postnasal drip, globus sensation, and eventual dysphonia. Flexible fiberoptic laryngoscopy showed a large, smooth, vallecular lesion filling the oropharynx. Computed tomography imaging of the neck showed a rounded heterogeneous mass centered within the right aspect of the oropharynx measuring 4.2 × 4.4 × 4.5 cm. Fine needle aspiration biopsy was suspicious for papillary carcinoma due to microscopic findings of malignant cells, nuclear grooves, and a powdery chromatin pattern. In the operating room, the tumor was resected en bloc using a lateral pharyngotomy approach with partial resection of the right lateral hyoid. A limited cervical lymphadenectomy was performed to facilitate the lateral pharyngotomy approach and two out of three lymph nodes demonstrated regional metastatic disease. Nuclear grooves, nuclear membrane notching, and occasional intranuclear pseudoinclusions were identified, which are overlapping histopathological characteristics of papillary thyroid carcinoma and cribriform adenocarcinoma of salivary glands. It was negative for thyroglobulin and thyroid transcription factor-1, which was in keeping with cribriform adenocarcinoma of salivary glands rather than papillary thyroid carcinoma. CONCLUSION: It is difficult to distinguish cribriform adenocarcinoma of salivary glands from papillary thyroid carcinoma solely by cytology, and the distinct characteristics of regional lymph node metastasis coupled with nuanced histologic differences should be emphasized in the evaluation of patients presenting with neck lymphadenopathy and an unknown primary or tongue mass. If sufficient fine needle aspiration biopsy material is available, thyroid transcription factor-1, thyroglobulin, or molecular testing may prove useful in differentiating cribriform adenocarcinoma of salivary glands from papillary thyroid carcinoma. A misdiagnosis of papillary thyroid carcinoma may lead to inappropriate treatment including unnecessary thyroidectomy. Therefore, it is critical for both pathologists and surgeons to be aware of this uncommon entity to avoid misdiagnosis and subsequent mismanagement.

Battle of the axes: simulation-based assessment of fine needle aspiration biopsies for thyroid nodules.

IMPORTANCE: Ultrasound-guided fine-needle aspiration biopsies (UGFNA) play a crucial role in the diagnosis of thyroid nodules. There are two techniques for performing an UGFNA: short-axis technique and long-axis technique. There is sparsity in the literature regarding the differences between these two techniques. OBJECTIVE: To compare the efficiency between long-axis and short-axis thyroid UGFNA techniques in trainees. Our secondary outcomes were to define the comfort level and learning curves of trainees. DESIGN: A longitudinal prospective cohort study, completed from December 2018 to November 2019, using the Blue Phantom Thyroid Model© for UGFNA. Face and construct validity of the model were verified. Residents completed UGFNA on an assigned nodule using both long-axis and short-axis techniques, the order of which was sequentially allocated. The rate and time to successful biopsy were obtained for both techniques. Biopsy attempts were repeated to establish learning curves. SETTING: Single-center study. PARTICIPANTS: Fourteen Otolaryngology-Head & Neck Surgery residents at the University of Toronto. MAIN OUTCOME MEASURE: Biopsy success and efficiency for novice learners completing UGFNA on a simulated thyroid model using long-axis and short-axis techniques. RESULTS: A trend towards higher odds of successful biopsy using the long-axis technique with no difference in procedure duration was observed (OR = 2.2, p = 0.095, CI = 0.87-5.39). Learning curve graphs appeared heterogenous according to trainee level. Trainees found the long-axis technique easier to perform (10/14, 71%), and the simulator valuable for learning (12/14, 86%). CONCLUSION: Thyroid UGFNA using the long-axis technique may have an increased success rate and is generally favored by trainees for being easier to perform. Thyroid simulators have the potential to increase learner comfort and efficiency with UGFNA.

Development of a management protocol for internal carotid artery injury during endoscopic surgery: a modified Delphi method and single-center multidisciplinary working group.

BACKGROUND: Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported peri-operative mortality rate of 10%. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have been described as useful strategies for managing ICA bleeds. The objective of this study was to develop a formalized management protocol for intra-operative ICA injury through engagement with a multi-disciplinary panel. METHODS: A modified Delphi method including literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional neuroradiologists, anesthesiologists, and operating room nursing staff. RESULTS: After three rounds of stakeholder engagement with the expert panel, consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: Alert, Control, and Transfer. 'Alert' focusses on early communication with anesthesia and nursing staff. 'Control' focusses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, 'Transfer' describes the process of contacting neuro-interventional radiology and safely transferring the patient. A one-page handout of the protocol was developed for placement in operating theatres. CONCLUSION: Due to the life-threatening nature of ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed.

Endoscopic Treatment of Sellar Arachnoid Cysts via a Simple Cyst-Opening Technique: Long-Term Outcomes From a Single Center.

BACKGROUND: Sellar arachnoid cysts (SACs) are rare lesions that require treatment only if symptomatic. The endoscopic endonasal approach has been widely used. Despite their simple cystic appearance and the straight-forward surgical intervention, important associated risks exist, with cerebrospinal fluid (CSF) leak the prevalent risk. METHODS: A retrospective analysis of patients with pathologically confirmed SAC between January 2006 and December 2019 was conducted. A homogeneous simple cyst-opening technique and skull base reconstruction with nasoseptal flaps was used. RESULTS: A total of 10 patients were identified (7 women and 3 men; median age, 54.5 years; range, 20-77 years). Of the 10 patients, 8 had had newly diagnosed SACs and 2 patients had had recurrence from a previously microsurgically fenestrated SAC. Eight patients had presented with visual symptoms, one with visual symptoms and fatigue, and one with intractable headaches. Neuro-ophthalmological and endocrinological assessments had revealed visual field deficits in 6, visual acuity decline in 5, and hypopituitarism in 2 patients. The median calculated volume was 1.71 mL (range, 0.27-2.54 mL). Postoperatively, no CSF leak and no further surgical complications were noted. The visual field had improved in 4 of 6 patients and visual acuity had improved in 4 of 5 patients. Anterior pituitary function had improved in 1, worsened in 1, and remained stable in 8 patients. One patient had developed diabetes insipidus. One recurrence was recorded at 54 months postoperatively. CONCLUSIONS: The results from the present study have shown that SACs can be effectively treated using a simple cyst-opening technique. The routine use of nasoseptal flaps significantly reduced the risk of CSF leakage without compromising nasal quality of life in the long term or mandating additional incisions. Long-term follow-up is important to monitor for late recurrence.

Radiological Anatomy of the Olfactory Fossa: Is Skull Base Anatomy Really Ever "Safe"?

Objective Computed tomography (CT) is a powerful tool for delineating the anatomy of the anterior skull base. The goal of this study is to further characterize the relevant anatomical features of this area, along with other parameters important for endoscopic sinus surgery. Design Retrospective case review. Setting Tertiary care hospital. Participants Thirty patients who had CT scans of the paranasal sinuses. Main Outcome Measures The following features were assessed using image analysis software: olfactory fossa depth, the length and angle of the lateral lamella, fovea ethmoidalis length and shape, ethmoid roof height and slope, and the position and course of the anterior ethmoid artery. Statistical analysis was performed assessing for differences in the above parameters. Results The mean olfactory fossa depth of the anterior and posterior skull base was 3.4 ± 1.1 and 2.4 ± 0.9 mm, respectively ( p < 0.05). The mean lateral lamella length was 3.6 ± 0.9 mm, which did not demonstrate significant variability. The angle of the lateral lamella varied significantly by skull base position, measuring 63.1 ± 17.8 degrees anteriorly, and 39.1 ± 17.9 degrees posteriorly ( p < 0.05). In scans classified as a Keros type I, 25.3% had lateral lamellae longer than 4 mm. Furthermore, 43.7% had lateral lamellae with angles less than 45 degrees. Moving anteriorly, the posterior skull base sloped downward in 46.7% of patients. Conclusion Thorough preoperative assessment of CT scans is crucial to understanding the inherent variability of skull base anatomy. Even "safe" anatomy can still contain features such as long and acutely angled lateral lamella, which may predispose patients to iatrogenic injury.

Evaluating YouTube as a Source of Patient Information for Functional Endoscopic Sinus Surgery.

OBJECTIVE: To evaluate the quality of information presented on YouTube regarding functional endoscopic sinus surgery (FESS) for patients. METHODS: YouTube was searched using FESS-specific keywords under the setting of "relevance." The first 50 videos from each keyword were reviewed and analyzed by 2 independent physician reviewers. Videos not related to FESS and duplicates were excluded. Outcome measures included the modified DISCERN score (range 0-5), the Journal of the American Medical Association (JAMA) benchmark criteria (range: 0-4), a novel scoring checklist for FESS assessing usefulness (range: 0-16), and the Video Power Index (VPI). Intraclass correlation coefficient (ICC) was calculated. RESULTS: Of the 200 videos identified, 95 videos were analyzed after exclusions. Videos had an average VPI of 40.8 and SD 133.2. Average scores from the 3 objective checklists among all videos were low: modified DISCERN: 1.91, SD: 1.15; JAMA benchmark: 1.91, SD: 0.76; and FESS score: 3.54, SD: 1.77. The ICC between the 2 independent reviewers was excellent for all 3 checklists. We noted significant positive Pearson correlation between all 3 checklist scores (P < .001). In between-group comparisons of mean scores, there was significantly higher DISCERN and JAMA scores for videos from university/professional organizations, as compared to videos from medical advertising/for-profit companies and independent users. There were no significant differences in FESS scores noted between the 3 groups. CONCLUSION: There were overall low scores across the modified DISCERN, JAMA benchmark criteria, and FESS scoring checklists, reflecting the poor quality of YouTube videos as a source of patient information for FESS.

Association of the Implementation of a Standardized Thyroid Ultrasonography Reporting Program With Documentation of Nodule Characteristics.

Importance: Although most thyroid nodules are benign, the potential for malignant neoplasms is associated with unnecessary workup in the form of imaging, fine-needle aspiration, and diagnostic surgery. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is commonly used to assess the malignant neoplasm risk potential of thyroid nodules imaged by ultrasonography. However, standardized reporting of ACR TI-RADS descriptors is inconsistent. Objective: To increase the documentation rate of ACR TI-RADS thyroid nodule characteristics to 80% in 18 months. Design, Setting, and Participants: This prospective interrupted time series quality improvement study was conducted from December 1, 2018, to March 31, 2020, at a tertiary outpatient head and neck clinic among 229 patients who had at least 1 documented thyroid nodule identified on bedside clinic ultrasonography. Data analysis was performed throughout the entire study period because this was a quality improvement study with iterative small cycle changes; final analysis of the data was performed in April 2020. Main Outcomes and Measures: The primary outcome was the documentation rates of 6 ACR TI-RADS ultrasonographic descriptors. Secondary outcomes included nodule fine-needle aspiration biopsy rate and physician-reported clinic flow efficiency. Results: A total of 229 patients had at least 1 documented thyroid nodule and were included in the analysis. Size was the most frequently documented nodule characteristic (72 of 74 [97.3%]) at baseline, followed by echogenic foci (31 of 74 [41.9%]), composition (23 of 74 [31.1%]), echogenicity (17 of 74 [23.0%]), margin (6 of 74 [8.1%]), and shape (1 of 74 [1.4%]). After 3 Plan, Do, Study, Act (PDSA) cycles, the final intervention consisted of a standardized ultrasonography reporting form and educational initiatives for surgical trainees. After the third PDSA cycle (n = 36), reporting of nodule size, echogenic foci, and composition increased to 100%. Similarly, reporting of echogenicity (34 of 36 [94.4%]), shape (28 of 36 [77.8%]), and margin (25 of 36 [69.4%]) all increased. This represented a cumulative 90.3% documentation rate (195 of 216), a 56.5% increase from baseline (95% CI, 50.0%-61.9%). The standardized reporting form was used in 83.3% of eligible thyroid ultrasonography cases (30 of 36) after PDSA cycle 3, demonstrating good fidelity of implementation. There were no unintended consequences associated with clinic workflow, as a balancing measure, reported by staff surgeons. Conclusions and Relevance: This study suggests that implementation of an ACR TI-RADS-based reporting form in conjunction with educational initiatives improved documentation of ultrasonographic thyroid nodule characteristics, potentially allowing for improved bedside risk stratification and communication among clinicians.

Endoscopic Endonasal Pituitary Surgery For Nonfunctioning Pituitary Adenomas: Long-Term Outcomes and Management of Recurrent Tumors.

INTRODUCTION: Endoscopic endonasal approaches (EEAs) provide improved access and operative visualization for resection of pituitary adenomas. Although the technique has gained wide acceptance, there is a paucity of data regarding late recurrence. OBJECTIVE: We aim to assess long-term outcomes of patients with nonfunctioning pituitary adenomas (NFPAs) who underwent EEA. METHODS: We reviewed 269 patients operated on for an NFPA between 2005 and 2015. Clinical and radiologic factors including those potentially related to higher chances of recurrence were analyzed. Progression-free survival was analyzed using the Kaplan-Meier method, and univariate and multivariate survival were analyzed using a Cox regression model. RESULTS: The study included 269 patients. The gross total resection rate was 46.0% (n = 124) but cavernous sinus involvement was present in almost half the patients (n = 115). The probability of recurrence at 5 years and 10 years was 22.0% and 47.2%, respectively. The median time to recurrence was 10 years for patients without cavernous sinus involvement and 6 years for those with cavernous sinus involvement. Univariate and multivariate analysis showed that tumor size, cavernous sinus invasion, anterior skull base extensions, and residual tumor were significantly associated with recurrence. CONCLUSIONS: Recurrence rate of NFPA remains high despite the better visualization offered by EEA, especially in those tumors involving the cavernous sinus and/or previously operated on. Repeat surgery is adequate for tumor debulking and decompression of the optic apparatus but is unlikely to achieve gross total resection if a successful previous EEA has been performed. Radiation therapy is an effective option for management of recurrent tumors.

Surgical anatomy and technical nuances of the endoscopic endonasal approach to the anterior cranial fossa.

Endoscopic endonasal approaches (EEA) to the skull base have significantly impacted the management of lesions located in the cranial base. Specifically, lesions arising from the anterior cranial fossa, such as pituitary macroadenomas, craniopharyngiomas meningiomas and craniofacial malignancies have benefited from the development of such approaches. Understanding of the anatomy of the anterior fossa is of utmost importance for the successful selection of the approach and application of surgical techniques in EEA. In the current manuscript, we review the most relevant points of surgical anatomy and nuances of the surgical technique of EEA to the anterior fossa. Anatomical landmarks for the transtuberculum transplanum and transcribriform approaches are discussed and a step-by-step description for those approaches is presented. We reinforce that safe and effective application of such techniques follow the same principles of other skull base surgery techniques: mastering of surgical anatomy, adequate case selection, correct instrumentation and surgical experience.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic.

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

Expanded Endoscopic Endonasal Approach for Removal of a Tuberculum Sella Meningioma.

This 46-year-old female patient presented after a 6-month progressive right-sided visual loss, with a visual acuity of 20/60, a temporo/infranasal visual field deficit, and optic atrophy. The magnetic resonance imaging disclosed a tuberculum sella meningioma with minimal right medial canal invasion, however, no encasement of carotid arteries. Tuberculum sella meningiomas represent 5%-10% of intracranial meningiomas and are surgically challenging tumors that can severely hinder vision. The endoscopic approach allows for early coagulation of the tumor meningeal supply, and importantly, facilitates gross total removal without any manipulation of the optic nerve while preserving the superior hypophyseal arteries.1-9.

Surgical Nuances of Endoscopic Endonasal Resection of Craniopharyngiomas: 2-Dimensional Operative Video.

Understanding of the microsurgical anatomy of the sella and suprasellar space is necessary for successful selection of surgical approaches and resection of craniopharyngiomas. Endoscopic endonasal surgery provides excellent exposure of the suprasellar space and has become the approach of choice for most of those tumors. In this video, we discuss the anatomical and surgical nuances for resection of craniopharyngiomas via an endoscopic transtuberculum transplanum approach. Anatomical dissections and a clinical case are used to illustrate the technique. This is the case of a 52-yr-old woman who presented to our clinic with a history of progressive visual decline and headaches, but no hormonal deficiencies. Magnetic resonance imaging demonstrated the presence of a sella suprasellar solid cystic lesion suggestive of a craniopharyngioma. The lesion was mainly located anterior to the chiasm, preinfundibular and medial to the posterior-communicating artery. Considering the patient presented with no hormonal deficits, it was decided to proceed with an endoscopic extended approach for maximum tumor resection while attempting to preserve the pituitary stalk and gland and its function. The patient provided consent to undergo the procedure and for the surgical video. After a binostril approach and harvesting of vascularized flap, a large sphenoidotomy was performed, followed by a transtuberculum transplanum approach. The tumor was resected with blunt and sharp dissection with careful preservation of the branches of the superior hypophyseal and posterior-communicating arteries. Closure was performed in a multilayer fashion, with dura substitute, fascia lata, and vascularized flap. The patient had visual improvement after surgery and was discharged at postoperative day 5 with no complications. Anatomical dissection pictures © 2019 Joao Paulo Almeida, MD. Used with permission.

Expanded Endonasal Endoscopic Surgery in Suprasellar Craniopharyngiomas: A Retrospective Analysis of 43 Surgeries Including Recurrent Cases.

BACKGROUND: The role of expanded endonasal endoscopic surgery for primary and recurrent craniopharyngioma is not yet fully established. OBJECTIVE: To report and evaluate our experience with the endoscopic endonasal approach (EEA) for the resection of primary and recurrent craniopharyngiomas. METHODS: This is a retrospective cohort analysis of 43 consecutive EEA procedures in 40 patients operated from September 2006 to February 2012 for suprasellar craniopharyngiomas. In 21 patients (48.8%) the disease was recurrent. We have assessed the surgical results, visual, endocrinological, and functional outcomes and resection rates in this patient cohort. RESULTS: At presentation, 31 (72.1%) patients had visual deficits, 15 patients (34.9%) complained of headaches, 25 patients (58.1%) had anterior pituitary insufficiency, and 14 (32.5%) had diabetes insipidus. Total resection was achieved in 44.2% surgeries, of which 77.3% were in primary lesions and 9.5% in recurrent lesions (P < .001). Vision improved in 92.6% patients and worsened in 2.3%. Complications other than vision were encountered in 25.6% including 9/43 cerebrospinal fluid leak, 2/43 meningitis. A total of 51.9% of patients with preoperative residual anterior pituitary function had new anterior pituitary deficiencies and 42.8% had new diabetes insipidus. There was no mortality. Six patients (14%) had recurrence of disease during the follow-up period (mean 56.8 mo), 5 of which required repeat surgery. CONCLUSION: The EEA can be integrated in the overall management of both primary and recurrent craniopharyngiomas with good results; however, in our series recurrent surgery was associated with significantly lower rates of gross total resection.

Clinical applications of three-dimensional printing in otolaryngology-head and neck surgery: A systematic review.

OBJECTIVES: Medical three-dimensional (3D) printing, the fabrication of handheld models from medical images, has the potential to become an integral part of otolaryngology-head and neck surgery (Oto-HNS) with broad impact across its subspecialties. We review the basic principles of this technology and provide a comprehensive summary of reported clinical applications in the field. METHODS: Standard bibliographic databases (MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and The Cochrane Central Registry for Randomized Trials) were searched from their inception to May 2018 for the terms: "3D printing," "three-dimensional printing," "rapid prototyping," "additive manufacturing," "computer-aided design," "bioprinting," and "biofabrication" in various combinations with the terms: "ptolaryngology," "head and neck surgery," and "otology." Additional articles were identified from the references of retrieved articles. Only studies describing clinical applications of 3D printing were included. RESULTS: Of 5,532 records identified through database searching, 87 articles were included for qualitative synthesis. Widespread implementation of 3D printing in Oto-HNS is still at its infancy. Nonetheless, it is increasingly being utilized across all subspecialties from preoperative planning to design and fabrication of patient-specific implants and surgical guides. An emerging application considered highly valuable is its use as a teaching tool for medical education and surgical training. CONCLUSIONS: As technology and training standards evolve and as healthcare moves toward personalized medicine, 3D printing is emerging as a key technology in patient care in Oto-HNS. Treating physicians and surgeons who wish to stay abreast of these developments will benefit from a fundamental understanding of the principles and applications of this technology. Laryngoscope, 129:2045-2052, 2019.

Postoperative Continuous Positive Airway Pressure Use and Nasal Saline Rinses After Endonasal Endoscopic Skull Base Surgery in Patients With Obstructive Sleep Apnea: A Practice Pattern Survey.

BACKGROUND: Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. METHODS: A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. RESULTS: Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients' CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon's choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001). CONCLUSION: Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

Effectiveness of discovery learning using a mobile otoscopy simulator on knowledge acquisition and retention in medical students: a randomized controlled trial.

BACKGROUND: Portable educational technologies, like simulators, afford students the opportunity to learn independently. A key question in education, is how to pair self-regulated learning (SRL) with direct instruction. A cloud-based portable otoscopy simulator was employed to compare two curricula involving SRL. Pre-clerkship medical students used a prototype smartphone application, a 3D ear attachment and an otoscope to complete either otoscopy curriculum. METHODS: Pre-clerkship medical students were recruited and randomized to two curriculum designs. The "Discovery then Instruction" group received the simulator one week before a traditional lecture, while the "Instruction then Discovery" group received it after the lecture. To assess participants' ability to identify otoscopic pathology, we used a 100-item test at baseline, post-intervention and 2-week retention time points. Secondary outcomes included self-reported comfort, time spent using the device, and a survey on learning preferences. RESULTS: Thirty-four students completed the study. Analysis of knowledge acquisition and retention showed improvement in scores of both groups and no significant effects of group (F1,31 = 0.53, p = 0.47). An analysis of participants' self-reported comfort showed a significant group x test interaction (F1,36 = 4.61, p = 0.04), where only the discovery then instruction group's comfort improved significantly. Overall device usage was low, as the discovery then instruction group spent 21.47 ± 26.28 min, while the instruction then discovery group spent 13.84 ± 18.71 min. The discovery first group's time spent with the simulator correlated moderately with their post-test score (r = 0.42, p = 0.07). After the intervention, most participants in both groups (63-68%) stated that they would prefer the instruction then discovery sequence. CONCLUSIONS: Both curricular sequences led to improved knowledge scores with no statistically significant knowledge differences. When given minimal guidance, students engaged in discovery learning minimally. There is value in SRL in simulation education, and we plan to further improve our curricular design by considering learner behaviours identified in this study.