Malleable registration mask: application of a novel registration method in image guided sinus surgery.

Image-guided systems are becoming more widely used in endoscopic sinus and skull base surgery. All systems require initial registration to correlate the CT scan images to the patient's anatomy. Multiple registration techniques can be used. The ideal technique is one that is easy, reproducible, and provides the most accurate registration in the least amount of time. This study used an optical-based image-guided system (LandmarX) to test a unique mask registration technique and (compared it to a previously used anatomic registration technique. Twenty-one patients were scanned with the mask and underwent surgery. Registration was performed using both the registration mask and the anatomic landmarks. Mean registration error and time were recorded. Results are reported for 20 patients. Mean registration error for the mask technique was 0.96 mm and took a mean of 41 seconds. Anatomic registration error using five or six points resulted in a mean initial error of 2.08 mm and took 31.2 seconds. Mean final anatomic registration error was 1.53 mm, requiring reregistration of a mean of 4.6 points, and took 106 seconds. Statistically significant differences were obtained between the two techniques with regard to registration error and time to final registration. We found that the registration mask technique is a more reliable technique in ease, accuracy, and time of registration. This technique should be especially beneficial to the less experienced image-guided surgeon.

Meningiomas of the paranasal sinuses.

Extracranial meningiomas are rare tumors, comprising approximately 2% of all meningiomas. Previously reported sites include the orbit, parapharyngeal space, and rarely, the paranasal sinuses. A retrospective chart review of patients with meningiomas was performed over the last 25 years, and three patients were identified with meningiomas involving the paranasal sinuses. The locations included the frontal sinus, the ethmoid sinus, and the sphenoid sinus. Presenting symptoms included facial pain and nasal obstruction; two patients noted facial swelling. Diagnosis was established via endoscopic transnasal biopsy in two patients. Computed tomographic (CT) guided biopsy was utilized to confirm the diagnosis in the third patient. Surgical extirpation was successfully performed with tumors arising from the ethmoid and frontal sinuses. The patient with neoplasm in the sphenoid sinus underwent radiation therapy. Extracranial meningiomas of the paranasal sinuses are rare tumors that may present a diagnostic and therapeutic challenge. We present three cases and discuss the clinical presentation, radiographic findings, diagnostic evaluation, and treatment options.

Endoscopic sinus surgery in patients with cystic fibrosis: an analysis of complications.

The application of endoscopic sinus surgery (ESS) for the management of paranasal sinus disease in patients with cystic fibrosis (CF) has been well described. Due to underlying medical issues such as acquired coagulopathies and advanced pulmonary disease, perioperative morbidity is assumed to be higher in this group. The incidence and type of complications associated with CF patients undergoing ESS has not been previously described. We reviewed 52 consecutive endoscopic procedures in 41 patients with CF performed by a single surgeon over a 34-month period. This review focused on perioperative and postoperative complications. Additional clinical data gathered included estimated blood loss, length of procedure, coagulation laboratory studies, the presence of nasal polyposis, the use of nasal packing, pulmonary function status, and average hospitalization time. A total of six complications were identified--four immediate and two delayed. The perioperative or immediate complications included two cases of epistaxis, one case of periorbital ecchymosis, and one case of pulmonary hemorrhage. Delayed complications include one case of epistaxis and one case of intranasal scarring. In two of these six patients, length of hospitalization was prolonged for management of the associated complications. No study has specifically addressed complications of ESS in the CF patient. Our review demonstrates a complication rate of 11.5%, which compares favorably with the non-CF ESS complication rates of 0-17% reported in the literature. Critical to successful management of these patients is coordinated care delivered by the pediatrician or internist, the pulmonary specialist, the anesthesia team, and the otolaryngologist. In addition to a review of current literature, we discuss the overall management approach adopted at our institution and highlight elements thought to minimize morbidity.

Management of thyroid carcinoma invading the aerodigestive tract.

OBJECTIVES: To evaluate approaches to thyroid carcinoma invading the aerodigestive tract, with particular attention to well-differentiated carcinomas. STUDY DESIGN: Retrospective review of experience with thyroid carcinoma invading the aerodigestive tract over a 20-year period at a tertiary referral hospital. METHODS: The medical records of all patients with a diagnosis of thyroid cancer treated at Emory University Hospital, Atlanta, Georgia, from 1977 through 1997 were reviewed. Multiple clinical variables were analyzed including treatment, development of recurrence, and survival. Survival and time to local recurrence were determined by Kaplan-Meier analysis, and statistical comparisons were made using log-rank analysis. RESULTS: Five hundred thirty-six cases were identified; 28 patients (5.2%) were identified with invasive disease involving the aerodigestive tract. Histologic findings at the time of invasion included 15 well-differentiated (WD) carcinomas and 13 poorly differentiated (PD) carcinomas. Eight of the 28 patients (5 WD, 3 PD) underwent surgical resection of some portion of the aerodigestive tract with curative intent. Ten patients (8 WD, 2 PD) underwent incomplete resection with tumor left adjacent to aerodigestive tract structures. All patients undergoing incomplete resection developed local recurrence. Six required salvage resection, as opposed to no recurrences in WD carcinomas following complete resection (P = .01). Survival at 5 years for WD carcinomas undergoing complete resection versus initial incomplete resection was 100% versus 50%, respectively (P = .27). CONCLUSION: Review of our experience shows that complete resection of thyroid carcinoma invading the aerodigestive tract can offer prolonged palliation, improved local control, and the opportunity for cure in selected patients.

Clinical characteristics and genotype analysis of patients with cystic fibrosis and nasal polyposis requiring surgery.

OBJECTIVE: To analyze the clinical characteristics and genotypes of patients with cystic fibrosis (CF) and nasal polyposis who require surgery. DESIGN: Cross-sectional analysis of a large patient database. SETTING: Data obtained from the National CF Patient Registry of the Cystic Fibrosis Foundation, Bethesda, Md. PATIENTS: Clinical and genotype data on 20198 patients with CF who were registered in 1992 and 1993 were analyzed. The study group (n = 815) consisted of patients with CF who had undergone surgical procedures for the treatment of nasal polyposis. The comparison group (n = 19383) comprised the remainder of the patients in the database. RESULTS: Statistical analysis revealed that patients with CF and nasal polyposis who required surgery had better pulmonary function (higher percent-predicted forced expiratory volume in 1 second and forced vital capacity), better nutritional status, a higher rate of Pseudomonas aeruginosa colonization, more office visits, more hospitalizations, and a higher rate of acute exacerbations per year (P < .001 for each) than did the comparison group. Among the patients who had mutation analysis performed, patients with nasal polyposis who required surgery were significantly associated with 2 specific genotypes: the delta-F508/delta-F508 (57.5% vs 49.9%, P = .01) and the delta-F508/G551D (12% vs 8%, P = .05) genotypes. CONCLUSIONS: Patients with CF and nasal polyposis who require surgery may constitute a clinical subgroup within the spectrum of the disease. These patients appear to have slightly better pulmonary function and nutritional status; yet, they seem to have a higher degree of health care utilization. The higher rate of P aeruginosa respiratory infection in this patient group suggests an association with the presence of nasal polyposis. Genotype analysis showed a higher prevalence of the delta-F508/delta-F508 and the delta-F508/G551D genotypes in this patient group.

Enhanced reliability and renewed applications of the deltopectoral flap in head and neck reconstruction.

Bakamjian introduced the deltopectoral skin flap in 1965, and thereafter it was used extensively for reconstructive surgery of the head and neck. Flap failure rates of 10% to 25% were reported, necessitating the development of alternative methods of reconstruction and eventually relegating the flap to historical references. Since 1991, we have used the deltopectoral flap in 24 patients for reconstruction after head and neck tumor surgery. Simple technical modifications have been used to enhance the reliability of this flap, with no observed failures or even partial flap loss. The deltopectoral flap remains a versatile and reliable tissue source that can be used simultaneously with the pectoralis major myocutaneous flap for a variety of complex head and neck reconstructions.

Transoral-transpharyngeal approach to the craniocervical junction.

The transoral-transpharyngeal approach is a reliable and technically sound method for gaining anterior extradural exposure to the craniocervical junction. We report 23 patients undergoing this approach for pathology lying between the inferior clivus and third cervical vertebra. Pathology included 6 patients with congenital malformations of the odontoid process, 4 patients with basilar invagination caused by rheumatoid arthritis, 2 patients with atlantoaxial subluxation caused by Down's syndrome, and 1 each with Chiari I malformation, pseudogout of C1/C2, ossification of the posterior longitudinal ligament, and chronic dens dislocation caused by trauma. Malignant tumors included 4 chordomas, 2 giant cell tumors of C1-C3, and 1 chondrosarcoma. Orotracheal intubation without tracheotomy was used in 22 patients. Sixteen of these 22 patients were extubated either immediately or within 24 hours. Six complications occurred in 5 patients and included a palatal dehiscence in 2, delayed oropharyngeal hemorrhage, prolonged endotracheal intubation because of severe tongue edema, and 1 case each of meningitis and aspiration pneumonia responsive to intravenous antibiotics. No deaths, local infections, or postoperative cerebrospinal fluid leaks occurred. Neurologic symptoms of cord compression improved or stabilized in all patients. The transoral-transpharyngeal approach is an effective means for extradural decompression of the anterior craniocervical junction and for exposure of selected tumors at this site.

Mucosal melanoma of the nasal cavity and paranasal sinuses.

BACKGROUND: Mucosal melanomas of the nasal cavity and paranasal sinuses are rare and do poorly. METHODS: Seventeen patients treated from 1981 to 1993 at a single referral center were retrospectively reviewed. RESULTS: Thirteen patients underwent surgical resection, with seven receiving postoperative radiotherapy. Eight had microscopically negative margins. The actuarial 2-year and 5-year survivals for this group of 13 were 67% (8 of 12) and 20% (2 of 10). The local recurrence rate was 85% (11 of 13) and distant metastases occurred in 31% (4 of 13) patients. In the absence of metastatic disease, resection of recurrent tumor correlated with disease-free intervals ranging from 3 months to 40 months. CONCLUSIONS: Those who received postoperative radiotherapy appeared to have done better with increased disease-free intervals and prolonged survival. Negative surgical margins were not predictive of a more favorable outcome. Surgical resection followed by postoperative radiotherapy is appropriate and resection of recurrent tumor should be considered.

Isolated metastatic melanoma of the cerebellopontine angle: case report.

Malignant melanoma is a common cause of central nervous system metastases. This report describes an extremely rare case of metastatic melanoma presenting as an isolated cerebellopontine angle tumor. Clinically and radiographically, the lesion mimicked an acoustic neuroma. The patient had neuro-otological symptoms, including tinnitus, vertigo, sensorineural hearing loss, facial nerve dysfunction, and prominent cerebellar dysfunction. Magnetic resonance images showed a lesion of the internal auditory canal and cerebellopontine angle that was hypointense on T1-weighted images, hyperintense on T2-weighted images, and enhanced after the administration of gadolinium. T2-weighted images showed significant cerebellar edema. Subtotal resection of the tumor through a suboccipital craniotomy palliated the symptoms, but the patient died of tumor progression 6 months later. In contrast to other metastatic tumors of the temporal bone, melanoma initially metastasizes to the internal auditory canal and is characterized by early neurovascular infiltration. This report highlights the pathophysiological characteristics, radiological findings, differential diagnosis, and treatment of metastatic melanoma of the internal auditory canal and cerebellopontine angle.