Contralateral Nasofrontal Trephination: A Novel Corridor for a "Dual Port" Approach to the Petrous Apex.

BACKGROUND AND OBJECTIVES: Expanded endonasal approaches (EEAs) have proven safe and effective in treating select petrous apex (PA) pathologies. Angled endoscopes and instruments have expanded indications for such approaches; however, the complex neurovascular anatomy surrounding the petrous region remains a significant challenge. This study evaluates the feasibility, anatomic aspects, and limitations of a contralateral nasofrontal trephination (CNT) route as a complementary corridor improving access to the PA. METHODS: Expanded endonasal and CNT approaches to the PA were carried out bilaterally in 15 cadaveric heads with endovascular latex injections. The distance to the PA, angle between instruments through the 2 approach portals, and surgical freedom were measured and compared. RESULTS: Three-dimensional DICOM-based modeling and visualization indicate that the CNT route reduces the distance to the target located within the contralateral PA by an average of 3.33 cm (19%) and affords a significant increase in the angle between instruments (15.60°; 54%). Furthermore, the vertical vector of approach is improved by 28.97° yielding a caudal reach advantage of 2 cm. The area of surgical freedom afforded by 3 different approaches (endonasal, endonasal with an endoscope in CNT portal, and endonasal with an instrument in CNT portal) was compared at 4 points: the dural exit point of the 6th cranial nerve, jugular foramen, foramen lacerum, and petroclival fissure. The mean area of surgical freedom provided by both approaches incorporating the CNT corridor was superior to EEA alone at each of the surgical targets (P = <.001). CONCLUSION: The addition of a CNT portal provides an additional avenue to expand on the classical EEA to the PA. This study provides insight into the anatomic nuances and potential clinical benefits of a dual-port approach to the PA.

A rare case of multifocal chordoma involving the lower clivus and multiple spine levels: illustrative case.

BACKGROUND: Chordomas are rare bone tumors originating from notochord remnants with a predilection for the median axis of the body, primarily in the sacrococcygeal spine, skull base, and cervical spine. This paper presents the first reported case of simultaneous multilevel chordomas with various enhancements. OBSERVATIONS: A 40-year-old woman presented with right-sided otalgia, headache, nasal obstruction, and facial pressure. The patient's head and spinal magnetic resonance imaging (MRI) demonstrated a midline lesion in the clivus, C2, and T1-5 spinal levels. All lesions were T1 isointense and T2 hyperintense, consistent with chordoma. Interestingly, the clivus lesion was enhancing, whereas the C2 lesion was only slightly enhancing, and the rest of the lesions showed no enhancement. The patient underwent endoscopic endonasal transclival approach surgery for the clival lesion, followed by radiation to the surgical bed and the C2 lesion. The remaining lesions were monitored. Follow-up imaging showed stable disease in the C2 lesion and other lower lesions. The patient's severe pain in the posterior cervical spine was managed with cervical fusion, pain management, and physical therapy. LESSONS: This case underscores the importance of comprehensive spinal MRI in patients with chordomas, as multiple concurrent primaries may be present. The article summarizes the fundamental distinctions between ecchordosis physaliphora and chordoma and casts doubt on the capacity to always differentiate them.

Endoscopic ultrasound guided resection of a Cushing's adenoma invading the medial cavernous sinus wall using the "interdural peeling" technique.

Cushing's adenoma invading the cavernous sinus requires aggressive resection to be cured. MRI is frequently inconclusive for identifying microadenomas, and visualizing the involvement of the medial cavernous sinus is even more challenging. In this video, the authors present a patient with an adrenocorticotropic hormone (ACTH)-producing microadenoma with doubtful left medial cavernous sinus involvement on MRI. She underwent an endoscopic endonasal exploration of the medial compartment of the cavernous sinus. The abnormally thickened wall, confirmed by intraoperative endoscopic endonasal ultrasound, was safely excised using the "interdural peeling" technique. Complete resection of the tumor resulted in normalization of her postoperative cortisol levels and disease remission with no complications. The video can be found here: https://stream.cadmore.media/r10.3171/2023.4.FOCVID22150.

Endoscopic Endonasal Transcavernous Posterior Clinoidectomy With Inferior Hypophyseal Artery Preservation for a Cavernous Sinus Hemangioma: Technical Case Report.

BACKGROUND AND IMPORTANCE: Unilateral inferior hypophyseal artery (IHA) sacrifice is routinely performed during endoscopic endonasal transcavernous interdural posterior clinoidectomy. However, unilateral IHA sacrifice presents the risk of temporary postoperative diabetes insipidus. We present a case demonstrating the feasibility of endoscopic endonasal transcavernous posterior clinoidectomy without IHA sacrifice. CLINICAL PRESENTATION: A 62-year-old man presented with progressive weakness of his left oculomotor and abducens nerves. MRI of the brain revealed a small lesion suspicious for hemangioma in the posterior compartment of the left cavernous sinus. Following an endoscopic endonasal transcavernous approach using the interdural peeling technique, an IHA-sparing posterior clinoidectomy was performed to provide access to the tumor in the posterior cavernous sinus. After complete resection, the patient's symptoms improved and a diagnosis of cavernous sinus hemangioma was confirmed by histopathology. CONCLUSION: Unilateral IHA preservation may be performed safely when performing a transcavernous interdural posterior clinoidectomy. IHA preservation can be readily achieved if the artery is redundant, the lesion is small and located in the posterior cavernous sinus, and there is a short posterior clinoid, ultimately avoiding the risk of transient postoperative diabetes insipidus.

Real-time ultrasound guidance in the endoscopic endonasal resection of a retro-odontoid pannus: Technical note and case illustration.

Background and Objectives: Odontoidectomy is a surgical procedure indicated in the setting of various pathologies, with the main goal of decompressing the ventral brain stem and spinal cord as a result of irreducible compression at the craniovertebral junction. The endoscopic endonasal approach has been increasingly used as an alternative to the transoral approach as it provides a straightforward, panoramic, and direct approach to the odontoid process. In addition, intraoperative ultrasound (US) guidance is a technique that can optimize safety and surgical outcomes in this context. It is used as an adjunct to neuronavigation and provides intraoperative confirmation of decompression of craniovertebral junction structures in real time. The authors aim to present the use and safe application of real-time intraoperative US guidance during endonasal endoscopic resection of a retro-odontoid pannus. Methods: A retrospective chart review of a single case was performed and presented herein as a case report and narrated operative video. Results: A minimally invasive US transducer was used intraoperatively to guide the resection of a retro-odontoid pannus and confirm spinal cord decompression in real time. Postoperative examination of the patient revealed immediate neurological improvement. Conclusions: Intraoperative ultrasonography is a well described and useful modality in neurosurgery. However, the use of intraoperative US guidance during endonasal endoscopic approaches to the craniovertebral junction has not been previously described. As demonstrated in this technical note, the authors show that this imaging modality can be added to the ever-evolving armamentarium of neurosurgeons to safely guide the decompression of neural structures within the craniocervical junction with good surgical outcomes.

Clinical considerations for open versus endoscopic approaches in skull base surgery.

PURPOSE OF REVIEW: We aim to distill the current body of evidence to consider when selecting an endoscopic versus open approach to address cranial base disease. We evaluate the evolution of modern surgical techniques and their respective limitations. RECENT FINDINGS: Greater understanding of the role of tumor biology in relation to patient outcomes has led to increasingly sophisticated treatment algorithms. This combined with further development of advanced instrumentation and technique has led to the adoption of new surgical corridors previously unapproachable via traditional surgery. SUMMARY: Endoscopic and open craniofacial approaches both remain important surgical techniques in the management of cranial base tumors. The modern skull base surgeon may employ a combination of approaches to optimize tumor extirpation while preserving functional outcomes. Patient history, anatomic tumor extent, histology, and functional goals should be considered thoroughly when planning any surgical intervention.

Sternocleidomastoid Tendon as a Consistent Landmark for Identifying the Spinal Accessory Nerve: A Case Series.

Objective: We propose a standardized approach of using the tendon of the sternocleidomastoid (SCM) muscle to locate the spinal accessory nerve (SAN) in neck dissection. Study Design: Cross-sectional anatomic study. Setting: Tertiary academic medical center. Methods: Adult patients aged ≥18 years undergoing primary neck dissection for head and neck cancer were included. Anatomic measurements included the length of the SCM tendon, the distance from the mastoid tip to the entrance of the SAN into the SCM, the distance from the SAN to the distal edge of the SCM tendon, and the perpendicular distance from the anterior edge of the SCM to the SAN. Five cadaveric specimens also underwent bilateral modified radical neck dissections with the same anatomic measurements taken. Results: Twenty-two living subjects and 5 cadavers were included. No statistical correlation was noted between patient demographics and any measurement. The mean (SD) length of the SCM tendon was 63.7 mm (11.8) in living subjects and 61.5 mm (10.4) in cadaveric specimens. The average distance from the mastoid tip to the entrance of SAN into the SCM was 51.6 mm (12.2) in living subjects and 51.6 mm (7.1) in cadaveric subjects. The distance of the SAN insertion into the SCM muscle from the anterior edge was 8.9 mm (3.4) in living subjects and 16.2 mm (7.2) in cadaver specimens. Laterality was compared in the cadaveric specimens; there was no statistically significant difference in any of the measurements between sides. Conclusion: This study demonstrates the SCM tendon to be a reliable and safe surgical landmark to identify and preserve the SAN during neck dissection.

Opioid Use After Elective Otolaryngologic Surgery at a Teaching Institution.

Background: Awareness of the opioid epidemic is promoting opioid stewardship in health care. For many commonly performed procedures in general surgery and gynecology, regimented opioid prescribing practices and/or multimodal nonopioid regimens are adequate for optimizing pain management and minimizing opioid dependence. We investigated opioid prescribing patterns for otolaryngology procedures at a tertiary hospital with the aim of characterizing postoperative pain and opioid use. Methods: This cross-sectional study with a patient survey was conducted in a tertiary care academic otolaryngology practice. Patients ≥18 years who underwent 1 of 41 common surgical procedures at an academic hospital between 2013 and 2017 were enrolled. Patients with any diagnosis of malignancy were excluded. Patients were analyzed according to surgery type (rhinoplasty, sinonasal surgery, tonsillectomy, parotidectomy, thyroidectomy, otologic surgery, and laryngoscopy), and those who had surgery in 2017 were surveyed via telephone interview using a standardized questionnaire. Results: A total of 3,152 patients met the study criteria, of whom 95.7% received an opioid prescription. Commonly prescribed opioid agents were hydrocodone-acetaminophen, oxycodone-acetaminophen, and acetaminophen-codeine. A median of 30 pills was prescribed per surgery, with little variation between different surgery types. Reported patient utilization was highest for parotid surgery and tonsillectomy and lowest for laryngoscopic, thyroid, and otologic surgery. Among all patients who received a prescription for opioids, 5.8% required a refill. Among the surveyed patients, 19.6% reported that they did not obtain the prescribed opioid, while 58.4% said they took half, less than half, or none of the prescribed opioid supply. Only 10.8% of surveyed patients disposed of the excess drugs in a recommended fashion. Conclusion: Our findings showed that the quantity of opioid prescriptions does not reflect actual patient analgesic use for elective surgeries in otolaryngology. Differential analgesic requirements for specific surgeries should be considered when prescribing postoperative analgesia.

Anterior cervical discectomy and fusion in the setting of kissing carotids: A technical report and literature review.

BACKGROUND: The "kissing carotids" (KCS) phenomenon refers to bilateral retropharyngeal displacement of the internal carotid arteries (ICA). This anomalous anatomy can impose a significant surgical challenge to spine surgeons. OBJECTIVE: In this report, we describe our approach for an anterior cervical discectomy and fusion in the setting of kissing carotids. METHODS: We discuss our case, surgical technique, rationale, and outcome. Additionally, we conducted a systematic review of the literature. CASE DESCRIPTION: An 82-year-old female presented to our service with progressive myelopathy. Cervical spinal imaging revealed a large disc herniation at C3-C4 and severe spinal canal stenosis. Vascular imaging showed anomalous ICAs bilaterally overlying the prevertebral fascia at the midline. The patient received aspirin preoperatively and underwent a multidisciplinary approach with neurosurgery and otolaryngology. A standard transcervical approach centered on the C5-C6 disc space, where the carotid arteries splayed most from midline, allowed for facilitated visualization and mobilization of the vessels. Prevertebral dissection was then performed rostrally to the C3-C4 disc space. The patient was put into burst suppression prior to retraction and underwent uncomplicated anterior discectomy and fusion. CONCLUSIONS: KCS is a rare but critical presentation of extreme medial displacement of bilateral ICAs. Few cases have been reported in the spinal surgery literature. Knowledge of this rare variant is important to avoid iatrogenic injury and complications.

SMARCB1-Deficient Sinonasal Carcinoma: Systematic Review and Case Report.

INTRODUCTION: To describe the current state of literature involving SMARCB1/INI-1 deficient sinonasal carcinoma (SDSC) and examine a case at our institution. METHODS: A systematic search was performed using the Population, Intervention, Comparator, Outcome, and Study Design approach. Search criteria included all occurrences in the title or abstract of the terms: "integrase interactor 1 deficient," "INI1 deficient," or "SMARCB1 deficient" and "sinonasal carcinoma." The main outcomes were disease-free survival, all-cause mortality, rates of recurrence, or metastases. RESULTS: Systematic search yielded 13 studies for final review. All studies were either case series or case reports with 82 cases of SDSC published since 2014. Age on presentation ranged from 19 to 75 years, with the majority of patients being male. Surgical resection was the primary modality of treatment with adjuvant radiation or chemoradiation therapy. Overall, the prognosis was poor, with most tumors presenting at advanced stages with an overall median (range) survival of 22 (12-44) months with an average (standard deviation) of 45.3% (33.1%) of patients dying of the disease. An average (standard deviation) of 38.2% (34.0%) of patients had no evidence of disease at follow-up. Studies comparing sinonasal undifferentiated carcinoma to SDSC reported worse prognosis for SDSC and increased risk for locoregional recurrence in the latter cohort. CONCLUSIONS: SDSC represents a highly aggressive tumor presenting at advanced stage with propensity of metastasis. More research is necessary to determine the optimal treatment modality and management.

Complications Associated with Medical Tourism for Facial Rejuvenation: A Systematic Review.

BACKGROUND: Medical tourism for cosmetic surgery has become increasingly popular in recent years. The existing literature has identified poor outcomes associated with general cosmetic tourism; however, the complications associated with cosmetic tourism for facial rejuvenation remain poorly understood. The aims of this study are to delineate the risk profile associated with medical tourism for facial rejuvenation. METHODS: A systematic review of PubMed, MEDLINE, and Embase was performed through January 2019 using the PRISMA guidelines. Search terms included combinations of keywords including medical tourism and plastic surgery and other related nomenclature. Articles published in English relevant to medical tourism for facial rejuvenation and its associated complications were examined. RESULTS: We identified six retrospective studies including 31 patients who had obtained facial rejuvenation procedures abroad and experienced treatment-associated complications. Twenty-five of 26 listed patients (96%) were female (age range 33-62 years). Departure nations included the USA, Switzerland, England, Ireland, Australia, and Thailand. Destination nations included the Dominican Republic, Cyprus, the USA, Colombia, Thailand, India, and China. Procedures included blepharoplasty, facelift, rhinoplasty, chin lift, and injections with botulinum toxin and dermal fillers. Complications included abscess, poor cosmesis, facial nerve palsy, and death. CONCLUSIONS: We present the first study to systematically review the complications associated with medical tourism for facial rejuvenation. No definitive conclusions can be made given the paucity of relevant data, its clinical and statistical heterogeneity, and small sample size. Additional research is warranted to help inform patients who seek facial rejuvenation procedures abroad and to better understand the health system implications associated with cosmetic tourism for facial rejuvenation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Polypoid Change of the Middle Turbinate and Paranasal Sinus Polyposis Are Distinct Entities.

Objectives Polypoid change of the middle turbinate (PCMT) is a finding on intranasal examination whose significance is not well understood. We present a comparison of the clinical characteristics of PCMT with paranasal sinus polyposis (PSP), a common condition with potentially similar appearance. Study Design Parallel case series. Setting Tertiary rhinology clinic. Subjects and Methods Data were prospectively compiled from consecutive patients during a 12-month period with either PSP arising from the middle meatus or PCMT limited to the middle turbinate as identified on nasal endoscopy. Recorded data included comorbidities, the 22-item Sinonasal Outcome Test (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE), Lund-Mackay score from computed tomography (CT) imaging, and total eosinophil levels. Results Of 593 patients, 23 (3.9%) had PCMT and 44 (7.4%) had PSP. The PSP group was predominantly male (75% vs 52%, P < .001) with an older mean age (53.4 vs 35.4 years, P < .0001). PCMT was more often associated with allergic rhinitis (83% vs 34%, P < .001), whereas PCMT was rarely associated with chronic rhinosinusitis (10% vs 100%, P < .0001). Mean eosinophil count (7.1 vs 3.1, P = .096) was not significantly different between groups, whereas mean Lund-Mackay score was higher in PSP (14.9 vs 2.8, P < .0008). Mean NOSE score was greater in PSP (65.3 vs 46.8, P = .025), whereas SNOT-22 score was comparable between groups (40.6 vs 34.6, P = .29). Conclusion PCMT is a unique physical finding with clinical associations that distinguish it from PSP. PCMT has greater association with allergic rhinitis than chronic rhinosinusitis, and both PCMT and PSP are associated with impaired quality of life.

The Role of Transoral Robotic Surgery in the Management of HPV Negative Oropharyngeal Squamous Cell Carcinoma.

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is on the rise. This is largely due to the rapid increase in HPV positive OPSCC, which has been shown to confer a survival advantage. HPV negative OPSCC, however, has a more aggressive tumor biology and is a challenge to treat with standard current therapies. Chemoradiation has demonstrated poor locoregional control in HPV negative OPSCC, and open surgeries are associated with high morbidity. Transoral robotic surgery (TORS) has been proposed as an option to both intensify treatment and decrease surgical morbidity for patients with HPV negative OPSCC. TORS can be utilized as a primary treatment or in persistent, recurrent, or second primary OPSCC. There is emerging data showing improved functional outcomes with TORS versus open surgery or chemoradiation. Unfortunately, there have been no randomized trials comparing TORS to chemoradiation in HPV negative OPSCC. This article will review utility of TORS for HPV negative OPSCC.