Pituitary Stalk Stretch Predicts Postoperative Diabetes Insipidus After Pituitary Macroadenoma Transsphenoidal Resection.

BACKGROUND: Manipulation of the pituitary stalk, posterior pituitary gland, and hypothalamus during transsphenoidal pituitary adenoma resection can cause disruption of water electrolyte regulation leading to diabetes insipidus (DI). OBJECTIVE: To determine whether pituitary stalk stretch is an independent risk factor for postoperative DI after pituitary adenoma resection. METHODS: A retrospective review was performed of patients undergoing endoscopic endonasal resection of pituitary macroadenoma between July 2010 and December 2016 by a single neurosurgeon. We analyzed preoperative and postoperative imaging metrics to assess predictors for postoperative DI. RESULTS: Of the 234 patients undergoing resection, 41 (17.5%) developed postoperative DI. DI was permanent in 10 (4.3%) and transient in 31 (13.2%). The pituitary stalk stretch, measured as the change in stalk length from preoperative to postoperative imaging, was greater in the DI compared with the non-DI group (10.1 mm vs 5.9 mm, P < .0001). The pituitary stalk stretch was associated with DI with significant difference in mean pituitary stalk stretch between non-DI group vs DI group (5.9 mm vs 10.1 mm, P < .0001). Multivariate analysis revealed that pituitary stalk stretch >10 mm was a significant independent predictor of postoperative DI [odds ratios = 2.56 (1.10-5.96), P = .029]. When stratified into transient and permanent DI, multivariable analysis showed that pituitary stalk stretch >10 mm was a significant independent predictor of transient DI [odds ratios = 2.71 (1.0-7.1), P = .046] but not permanent DI. CONCLUSION: Postoperative pituitary stalk stretch after transsphenoidal pituitary adenoma surgery is an important factor for postoperative DI. We propose a reconstruction strategy to mitigate stalk stretch.

Pediatric pituitary adenomas.

BACKGROUND: Pediatric pituitary adenomas are a rare medical entity that makes up a small portion of intracranial tumors in children and adolescents. Although benign, the majority of these lesions are secreting functional tumors with the potential for physiological sequela that can profoundly affect a child's development. FOCUS OF REVIEW: In this review, we discuss the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to treat these tumors. The management of pituitary tumors requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver comprehensive care.

Risk Factors Associated With Postoperative Delirium in Patients Undergoing Head and Neck Free Flap Reconstruction.

IMPORTANCE: Postoperative delirium (POD) is associated with an increased rate of adverse events, higher health care costs, and longer hospital stays. At present, limited data are available regarding the risk factors for developing POD in patients undergoing head and neck free flap reconstruction. Identification of patients at high risk of developing POD will allow implementation of risk-mitigation strategies. OBJECTIVE: To determine the frequency of and risk factors associated with POD in patients undergoing free flap reconstruction secondary to head and neck disease. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included 515 patients undergoing free flap reconstruction from January 1, 2006, through December 31, 2012, at the James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Care Center, a tertiary care cancer hospital. Preoperative, intraoperative, and postoperative data were collected retrospectively. Data from January 1, 2006, through December 31, 2012, were analyzed, and the final date of data analysis was January 8, 2018. INTERVENTIONS: Head and neck free flap reconstruction. MAIN OUTCOMES AND MEASURES: The primary outcome was the development of POD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Univariable and multivariable logistic regression were used to identify risk factors associated with POD. RESULTS: Five hundred fifteen patients underwent free flap reconstruction during the study period (66.2% male; mean [SD] age, 60.1 [12.8] years). Of these, 56 patients (10.9%) developed POD. On multivariable analysis, risk factors associated with POD included increased age (odds ratio [OR], 1.06; 95% CI, 1.02-1.11), male sex (OR, 5.02; 95% CI, 1.47-17.20), increased operative time (OR for each 1-minute increase, 1.004 [95% CI, 1.001-1.006]; OR for each 1-hour increase, 1.26 [95% CI, 1.08-1.46]), advanced nodal disease (OR, 3.00; 95% CI, 1.39-6.46), and tobacco use (OR, 7.23; 95% CI, 1.43-36.60). Preoperative abstinence from alcohol was identified as a protective factor (OR, 0.24; 95% CI, 0.12-0.51). CONCLUSIONS AND RELEVANCE: This study identified variables associated with a higher risk of developing POD. Although many of these risk factors are nonmodifiable, they provide a target population for quality improvement initiatives. Furthermore, preoperative alcohol abstinence may be useful in preventing POD.

Esophageal-subarachnoid fistula: a case of spontaneous tension pneumocephalus in the setting of esophageal cancer.

BACKGROUND: Pneumocephalus occurs as a result of traumatic or iatrogenic violation of the dura. Tension pneumocephalus, whereby air continues to accumulate with no mechanism for escape, can cause significant morbidity and mortality. METHODS: This case report reviews the underlying pathophysiology, clinical presentation, diagnosis, and management of tension pneumocephalus. RESULTS: We present the case of a 68-year-old man who presented to the Emergency Department with headache thought to be the result of a newfound intracranial mass. After admission, he became obtunded and was found to have tension pneumocephalus requiring emergent evacuation. A cervical esophagus carcinoma caused an esophageal-subarachnoid fistula that resulted in tension pneumocephalus after a retching episode. CONCLUSION: This case illustrates the importance of considering alternative sources of pneumocephalus in the absence of more typical differential diagnosis.

Management of squamous cell carcinoma of the base of tongue with chemoradiation and brachytherapy.

BACKGROUND: Treatment of base of tongue (BOT) squamous cell carcinoma (SCC) has traditionally been associated with poor prognosis and significant morbidity. We report a program consisting of concurrent chemoradiation followed by brachytherapy for these patients. METHODS: We reviewed all patients in our institution with previously untreated BOT SCC (1996-2004) who received this treatment program. RESULTS: In 88 patients (median age, 60.2 years; 37 T1/T2; 51 T3/T4), cervical lymph node metastases were present in 71 patients (80.7%). Six patients had residual/subsequent cervical metastases requiring 7 neck dissections. Local recurrence occurred in 16 patients (18.2%) and distant metastases occurred in 9 patients (10.2%). Median follow-up time was 3.1 years (range, 0.5-7.8 years). Three-year overall survival was 80.9% (95% CI: 69.6% to 88.3%). Locoregional control rate was 79.9% and disease-specific survival was 69.5% at 3 years. CONCLUSIONS: Concurrent chemoradiotherapy followed with brachytherapy is a safe and effective method of treatment of SCC of the BOT.

Safety and cost-effectiveness of intra-office flexible videolaryngoscopy with transoral vocal fold injection in dysphagic patients.

SETTING: A tertiary care referral-based otolaryngology practice. OBJECTIVES: To evaluate the safety of office-based transoral oral vocal fold injection in an ambulatory dysphagic population and to evaluate cost-effectiveness in comparison with traditional injection laryngoplasty done under general anesthesia in the operating room. Dysphagia is a nonspecific and common symptom of many head and neck and systemic disease processes. In patients with glottal incompetence, the presenting complaint of dysphagia generally portends to more global oropharyngeal dysfunction than dysphonia alone. Although many authors have reported on and advocated the use of office injection technique in the management of dysphonia caused by glottal insufficiency, there is a paucity of literature regarding the use of this technique in a more medically compromised dysphagic patient population (Ann Otol Rhinol Laryngol 1997;106:778-83). We describe our experience with vocal fold injection in the office setting using a transoral technique under flexible videolaryngoscopy for the treatment of glottal insufficiency in dysphagic patients. The safety and cost-effectiveness of this approach are highlighted.