Predictive factors for decreased baseline quality of life in patients with sinonasal malignancies.

BACKGROUND: The impact of sinonasal malignancies (SNMs) on quality of life (QOL) at presentation is poorly understood. The Sinonasal Outcome Test (SNOT-22) and University of Washington Quality of Life (UWQOL) are validated QOL instruments with distinctive subdomains. This study aims to identify factors impacting pretreatment QOL in SNM patients to personalize multidisciplinary management and counseling. METHODS: Patients with previously untreated SNMs were prospectively enrolled (2015-2022) in a multicenter observational study. Baseline pretreatment QOL instruments (SNOT-22, UWQOL) were obtained along with demographics, comorbidities, histopathology/staging, tumor involvement, and symptoms. Multivariable regression models identified factors associated with reduced baseline QOL. RESULTS: Among 204 patients, presenting baseline QOL was significantly reduced. Multivariable regression showed worse total SNOT-22 QOL in patients with skull base erosion (p = 0.02). SNOT-rhinologic QOL was worse in women (p = 0.009), patients with epistaxis (p = 0.036), and industrial exposure (p = 0.005). SNOT extranasal QOL was worse in patients with industrial exposure (p = 0.016); worse SNOT ear/facial QOL if perineural invasion (PNI) (p = 0.027). Squamous cell carcinoma pathology (p = 0.037), palate involvement (p = 0.012), and pain (p = 0.017) were associated with worse SNOT sleep QOL scores. SNOT psychological subdomain scores were significantly worse in patients with palate lesions (p = 0.022), skull base erosion (p = 0.025), and T1 staging (p = 0.023). Low QOL was more likely in the presence of PNI on UW health (p = 0.019) and orbital erosion on UW overall (p = 0.03). UW social QOL was worse if palatal involvement (p = 0.023) or PNI (p = 0.005). CONCLUSIONS: Our findings demonstrate a negative impact on baseline QOL in patients with SNMs and suggest sex-specific and symptom-related lower QOL scores, with minimal histopathology association. Anatomical tumor involvement may be more reflective of QOL than T-staging, as orbital and skull base erosion, PNI, and palate lesions are significantly associated with reduced baseline QOL.

Subcategorization of Perineural Invasion Stratifies Oral Cavity Squamous Cell Carcinoma Prognosis.

OBJECTIVE: To evaluate whether subcategorization of perineural invasion (PNI) improves the prognostic resolution of the American Joint Committee on Cancer, Eighth Edition (AJCC8) staging system in oral cavity squamous cell carcinoma (OCSCC). METHODS: OCSCC tumor specimens from patients seen at a tertiary care institution who underwent primary surgical resection between January 2019 and June 2021 were sorted into four PNI categories: negative, intratumoral, peripheral, and extratumoral. The prognostic effect of these PNI categories were assessed through Kaplan-Meier, Cox regression, and log-rank testing using recurrence-free survival (RFS) and overall survival (OS) as primary and secondary outcomes respectively. RESULTS: A total of 158 patients were examined. The median follow-up time was 21 months. PNI subcategorization further stratified RFS (p = 0.007) and OS (p = 0.002). Extratumoral PNI was associated with a 4.5-fold increase in recurrence risk (adjusted hazards ratio [aHR]: 4.53; 95% confidence interval [CI]: 1.1-18.66) and worse OS when compared with PNI negative disease (aHR: 5.71; 95% CI: 1.0-32.67). Peripheral PNI was associated with worse OS (aHR: 5.7; 95% CI: 1.35-24.08) but not worse RFS (p = 0.18) when compared with PNI negative disease. Interestingly, intratumoral PNI was not associated with significant differences in RFS (p = 0.087) or OS (p = 0.22) when compared with PNI negative disease. CONCLUSIONS: Subcategorization of OCSCC tumors into extratumoral, peripheral, and intratumoral PNI stratifies RFS and OS when compared with patients with PNI negative disease in an incremental fashion. This pilot study suggests that there may be added benefit in subcategorization of PNI in the prognostic evaluation of OCSCC. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1656-1662, 2024.

Long-term quality of life after treatment in sinonasal malignancy: A prospective, multicenter study.

BACKGROUND: Quality of life (QOL) for individuals with sinonasal malignancy (SNM) is significantly under-studied, yet it is critical for counseling and may impact treatment. In this study we evaluated how patient, treatment, and disease factors impact sinonasal-specific and generalized QOL using validated metrics in a large cohort over a 5-year posttreatment time frame. METHODS: Patients with SNM who underwent definitive treatment with curative intent were enrolled in a prospective, multisite, longitudinal observational study. QOL was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) and University of Washington Quality of Life Questionnaire (UWQOL) instruments at pretreatment baseline and multiple follow-ups through 5 years posttreatment. Multivariable modeling was used to determine demographic, disease, and treatment factors associated with disease-specific and generalized physical and social/emotional function QOL. RESULTS: One hundred ninety-four patients with SNM were analyzed. All QOL indices were impaired at pretreatment baseline and improved after treatment. SNOT-22 scores improved 3 months and UWQOL scores improved 6 to 9 months posttreatment. Patients who underwent open compared with endoscopic tumor resection had worse generalized QOL (p < 0.001), adjusted for factors including T stage. Pterygopalatine fossa (PPF) involvement was associated with worse QOL (SNOT-22, p < 0.001; UWQOL Physical dimension, p = 0.02). Adjuvant radiation was associated with worse disease-specific QOL (p = 0.03). Neck dissection was associated with worse generalized physical function QOL (p = 0.01). Positive margins were associated with worse generalized social/emotional function QOL (p = 0.01). CONCLUSION: Disease-specific and generalized QOL is impaired at baseline in patients with SNM and improves after treatment. Endoscopic resection is associated with better QOL. PPF involvement, adjuvant radiation, neck dissection, and positive margins were associated with worse QOL posttreatment.

Role of Intraoperative Neurophysiological Monitoring in Preventing Stroke After Cardiac Surgery.

BACKGROUND: Perioperative stroke after cardiac surgical procedures carries significant morbidity. Dual intraoperative neurophysiological monitoring with electroencephalography (EEG) and somatosensory-evoked potentials detects cerebral hypoperfusion and predicts postoperative stroke in noncardiac procedures. We further evaluated preoperative risk factors and intraoperative neuromonitoring ability to predict postoperative stroke after cardiac operations. METHODS: All patients who underwent cardiac operations with intraoperative neurophysiological monitoring from 2009 to 2020 at a single academic medical center were retrospectively analyzed. Patients with circulatory arrest were excluded. Risks factors analyzed were sex, age, tobacco use, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, prior cerebrovascular accident, cerebrovascular disease, antiplatelet/anticoagulant use, abnormal somatosensory-evoked potentials and EEG baselines, and significant somatosensory-evoked potentials and EEG change as well as their permanence. Patients were divided into 2 groups by 30-day postoperative stroke occurrence. Univariate and multivariate logistical regressions were used for postoperative stroke significant predictors, and Kaplan-Meier curves estimated survival. RESULTS: The study included 620 patients (67.6% men), mean age 65.1 ± 14.1 years, with stroke in 5.32%. In univariate analysis, diabetes (odds ratio [OR], 2.62) and permanence of EEG change (OR, 5.35) were each associated with increased postoperative stroke odds. In multivariate analysis, diabetes (OR, 2.64) and permanent EEG change (OR, 4.22) were independently significantly associated with postoperative stroke. Overall survival was significantly better for patients with no intraoperative neurophysiological monitoring changes (P < .005). CONCLUSIONS: Permanent EEG change and diabetes were significant postoperative stroke predictors in cardiac operations. Furthermore, overall survival out to 10 years postoperatively was significantly higher in the group without intraoperative neurophysiological monitoring changes, emphasizing its important predictive role.

Intraoperative neurophysiologic monitoring during aortic arch surgery.

OBJECTIVE: To evaluate the ability of intraoperative neurophysiologic monitoring (IONM) during aortic arch reconstruction with hypothermic circulatory arrest (HCA) to predict early (<48 hours) adverse neurologic events (ANE; stroke or transient ischemic attack) and operative mortality. METHODS: This was an observational study of aortic arch surgeries requiring HCA from 2010 to 2018. Patients were monitored with electroencephalogram (EEG) and somatosensory evoked potentials (SSEP). Baseline characteristics and postoperative outcomes were compared according to presence or absence of IONM changes, which were defined as any acute variation in SSEP or EEG, compared with baseline. Multivariable logistic regression analysis was used to assess the association of IONM changes with operative mortality and early ANE. RESULTS: A total of 563 patients underwent aortic arch reconstruction with HCA and IONM. Of these, 119 (21.1%) patients had an IONM change, whereas 444 (78.9%) did not. Patients with IONM changes had increased operative mortality (22.7% vs 4.3%) and increased early ANE (10.9% vs 2.9%). In multivariable analysis, SSEP changes were correlated with early ANE (odds ratio [OR], 4.68; 95% confidence interval [CI], 1.51-14.56; P = .008), whereas EEG changes were not (P = .532). Permanent SSEP changes were correlated with early ANE (OR, 4.56; 95% CI, 1.51-13.77; P = .007), whereas temperature-related SSEP changes were not (P = .997). Finally, any IONM change (either SSEP or EEG) was correlated with operative mortality (OR, 5.82; 95% CI, 2.72-12.49; P < .001). CONCLUSIONS: Abnormal IONM events during aortic arch reconstruction with HCA portend worse neurologic outcomes and operative mortality and have a negative predictive value of 97.1%. SSEP might be more sensitive than EEG for predicting early ANE, especially when SSEP changes are permanent.

Predictive Value of Multimodality Intraoperative Neurophysiological Monitoring During Cardiac Surgery.

INTRODUCTION: This study aimed to determine the ability of multimodality intraoperative neurophysiologic monitoring, including somatosensory evoked potentials (SSEP) and EEG, to predict perioperative clinical stroke and stroke-related mortality after open-heart surgery in high-risk patients. METHODS: The records of all consecutive patients who underwent coronary artery bypass grafting, and cardiac valve repair/replacement with high risk for stroke who underwent both SSEP and EEG recording at the University of Pittsburgh Medical Center between 2009 and 2015 were reviewed. Sensitivity and specificity of these modalities to predict in-hospital clinical strokes and stroke-related mortality were calculated. RESULTS: A total of 531 patients underwent open cardiac procedures monitored using SSEP and EEG. One hundred thirty-one patients (24.67%) experienced significant changes in either modality. Fourteen patients (2.64%) suffered clinical strokes within 24 hours after surgery, and eight patients (1.50%) died during their hospitalization. The incidence of in-hospital clinical stroke and stroke-related mortality among patients who experienced a significant change in monitoring compared with those with no significant change was 11.45% versus 1.75%. The sensitivity and specificity of significant changes in either SSEP or EEG to predict in-hospital major stroke and stroke-related mortality were 0.93 and 0.77, respectively. CONCLUSIONS: Intraoperative neurophysiologic monitoring with SSEP and EEG has high sensitivity and specificity in predicting perioperative stroke and stroke-related mortality after open cardiac procedures. These results support the benefits of multimodality neuromonitoring during cardiac surgery.

Glucose metabolism outcomes in acromegaly patients on treatment with pasireotide-LAR or pasireotide-LAR plus Pegvisomant.

INTRODUCTION: Disorders of glucose metabolism are a serious acromegaly comorbidity and may be differently impacted by medical treatments of acromegaly. In this retrospective longitudinal multicenter study, we investigated the outcome of glucose metabolism and its predictors in patients treated with Pasireotide LAR (PAS-LAR) alone or in combination with Pegvisomant (PAS-LAR + Peg-V). SUBJECTS AND METHODS: Acromegaly patients treated continously with PAS-LAR or PAS-LAR + Peg-V for at least 6 months. RESULTS: Forty patients (25 females, 15 males) were enrolled. At last visit, 27/40 patients (67.5%) reached biochemical control of acromegaly. Overall, glucose metabolism improved in 3 (all in PAS-LAR + Peg-V; 7.5%), worsened in 26 (65%) and remained unchanged in 11 patients (27.5%). Glucose metabolism worsened in 25 patients (73.5%) treated with PAS-LAR and in a single patient (16.7%) treated with PAS-LAR + Peg-V (p < 0.001). Among patients treated with Pas-LAR alone, GH at baseline was higher in those with worsening of glucose metabolism (p = 0.04) as compared to those with stable glucose status. A significantly higher reduction of HbA1c was observed in patients treated with PAS-LAR + Peg-V, as compared with those treated with PAS-LAR alone (p = 0.005). CONCLUSIONS: Our data confirmed that glucose metabolism in patients treated with PAS-LAR is often worsened, and may be predicted by entity of baseline GH hypersecretion and by the dose of PAS-LAR. Moreover, our data, although limited by small numbers, may suggest that the combination treatment PAS-LAR + Peg-V can improve glucose homeostasis in selected patients.

Endoscopic transsphenoidal drainage of a petrous apex cholesterol granuloma using a frontal sinus nasal stent: a case report with long term follow up.

BACKGROUND: Cholesterol granulomas of the petrous apex are benign cysts affecting 0.6 patients per 1 million. The pathophysiology involves cholesterol crystals and lipids that are surrounded by giant cells. The cholesterol deposits induce an inflammatory response likely from acute hemorrhage leading to the formation of a fibrous capsule. The capsule expands over time compressing nearby cranial nerves (VI-VIII), which can cause worsening symptoms. Surgical resection has been shown to provide excellent improvement in symptoms. Historically, open approaches such as the infracochlear, infralabyrinthine, and middle fossa have been used. Herein we present a case showing the feasibility and clinical utility of using an endoscopic endonasal transclival approach for treatment of these tumors. CASE: A 44-year-old female presented with history of intermittent double vision, dizziness, nausea, and headaches for 3 years. She developed a partial left CN6 palsy with significant diplopia and episodes of left facial weakness. The worsening symptoms prompted presentation to the ED where MRI and CT scan revealed a left petrous apex lesion (1.8 × 1.7 cm) with hyperintensity on T1 and T2 imaging, suggestive of cholesterol granuloma. She underwent an endoscopic transclival resection of the lesion: drainage of left petrous apex cholesterol granuloma and stent placement from left petrous apex into sphenoid sinus (novel technique). This was done to allow continued communication and drainage of the tumor bed from the petrous apex into the sphenoid sinus with the intent to minimize the risk of recurrence. At the postop visit both 6th nerve palsy and diplopia had resolved. Imaging is stable 2 years after the surgery. DISCUSSION: The placement of the stent in this case was done to prevent symptom recurrence. 11% of patients that do not receive a stent will have symptom recurrence within one year. From the historical literature, only 4% of patients who had stent placement developed cyst recurrence or expansion on follow-up imaging. Stent placement has been shown to prevent cyst enlargement within the first few months after surgery. We demonstrate that the endoscopic endonasal transclival approach provided good visualization of the tumor, allowed for an adequate working window for resection, and provided a sufficient approach for stent placement.

Effects of Pegvisomant and Pasireotide LAR on Vertebral Fractures in Acromegaly Resistant to First-generation SRLs.

PURPOSE: Osteopathy is an emerging complication of acromegaly. In somatostatin receptor ligands (SRL)-resistant patients, pegvisomant (PegV) and pasireotide LAR (Pasi) are used for acromegaly treatment, but their effect on skeletal health is still not defined. METHODS: In a longitudinal retrospective international study, we evaluated incidence of radiological vertebral fractures (VFs) in 55 patients with acromegaly resistant to first-generation SRL. RESULTS: At study entry, prevalent VFs occurred in 23 patients (41.8%). Biochemical acromegaly control was reached in 66.7% of patients on PegV and in 66.7% of patients on Pasi. During the follow-up, incident VFs (iVFs) were detected in 16 patients (29.1%). Occurrence of iVFs was associated with prevalent VFs (P = .002), persistence of active acromegaly (P = .01) and higher value of insulin-like growth factor 1 (IGF-1) during follow-up (P = .03). Among patients with active disease at last visit, iVFs occurred less frequently in patients on treatment with Pasi (25%) compared to PegV (77.8% P = .04), independently of the IGF-1 values (P = .90). In patients who reached biochemical control, 22.7% on PegV and 12.5% on Pasi had iVFs (P = .40). Among both treatment groups, the presence of pre-existent VFs was the main determinant for iVFs. CONCLUSION: Our data show for the first time that patients with biochemically active disease treated with Pasi had lower risk of iVFs versus those treated with PegV. It also confirms that the presence of pre-existent VFs was the main determinant for iVFs. Additional studies on larger populations and with longer follow-up are needed to confirm our data and disclose the mechanisms underlying our findings.

Idiopathic Intracranial Hypertension After Surgical Treatment of Cushing Disease: Case Report and Review of Management Strategies.

BACKGROUND: Idiopathic intracranial hypertension (IIH) in patients with Cushing disease (CD), after treatment, is rarely described, in adults. The cause is believed to be multifactorial, potentially related to a relative decrease in cortisol after surgical resection or medical treatment of a corticotroph pituitary adenoma. We investigate our center's CD database (140 surgically and 60 medically [primary or adjunct] treated patients) for cases of IIH, describe our center's experience with symptomatic IIH, and review treatment strategies in adults with CD after transsphenoidal resection. CASE DESCRIPTION: We present the case of a 22-year-old woman who presented with worsening headache, nausea, vomiting, blurry vision, diplopia, visual loss, and facial numbness 14 weeks after surgical resection of adrenocorticotropic hormone-positive pituitary adenoma. Her CD had been in remission since surgery, with subsequent adrenal insufficiency (AI), which was initially treated with supraphysiologic glucocorticoid replacement, tapered down to physiologic doses at the time the IIH symptoms developed. CONCLUSIONS: Symptomatic IIH is rare in adult patients but can be severe and result in permanent vision loss. A high index of suspicion should be maintained and a fundus examination is necessary to exclude papilledema, whenever there are suggestive symptoms that initially may overlap with AI. It is possible that some cases of mild IIH are misdiagnosed as GC withdrawal or AI; however, further studies are needed. Treatment consists of reinitiation of higher steroid doses together with acetazolamide with or without cerebrospinal fluid diversion and the priority is to preserve vision and reverse any visual loss.