Socioeconomic differences between medically and surgically treated prolactinomas: a retrospective review of 598 patients.

OBJECTIVE: Socioeconomic status (SES) is known to affect presentations and outcomes in pituitary neuroendocrine tumor resections, but there is a paucity of literature examining its impact specifically on patients with prolactinomas, who may be treated medically or surgically. The authors sought to determine whether SES was associated with differences in treatment choice or outcomes for prolactinoma patients. METHODS: The authors retrospectively reviewed patient records at a high-volume academic pituitary center for prolactinoma diagnoses. Patients were split into medically and surgically treated cohorts. Race, ethnicity, insurance status, primary care physician (PCP) status, and zip code-based income data were collected and examined as socioeconomic covariates. Outcomes of interest included pretreatment likelihood of surgical cure, medical versus surgical treatment allocation, and posttreatment remission rates. RESULTS: The authors analyzed 568 prolactinoma patients (351 medically treated and 217 surgically treated). Patients receiving surgery were more likely to have Medicaid or private insurance (p < 0.001) and have lower incomes (p < 0.001) than medically treated patients. Lower-income surgical patients were more likely to require surgical intervention for an indication such as tumor decompression than higher-income patients (p = 0.023). Surgical patients with a PCP had a higher estimated likelihood of surgical cure (p = 0.008), while no SES-based differences in surgical remission likelihood existed in the medical cohort. After surgery, surgical patients who achieved remission had significantly higher income than those who did not (p < 0.001). Other SES factors were not associated with surgical remission, and among medically treated patients, remission rates were not affected by any SES factor. Income was inversely related to prolactinoma size in both cohorts (surgical, p < 0.001; medical, p = 0.005) but was associated more prominently in surgical patients (surgical, -0.65 mm per $10,000; medical, -0.37 mm per $10,000). CONCLUSIONS: While surgical prolactinoma patients were prone to income and PCP-related disparities, no SES disparities were found among medically treated patients. Income had a more pronounced association with tumor size in the surgical cohort and likely contributed to the increased need for surgical intervention seen in low-income surgical patients. Addressing socioeconomic healthcare disparities is needed among surgical prolactinoma patients to increase rates of early presentation and improve the outcomes of low-SES populations.

Facile Preparation of SrZr1-xTixO3 and SrTi1-xZrxO3 Fine Particles Assisted by Dehydration of Zr4+ and Ti4+ Gels under Hydrothermal Conditions.

In recent decades, perovskite-type compounds (ABB'O3) have been exhaustively studied due to their unique ferroelectric properties. In this work, a systematic study aiming to prepare fine particles in the binary system SrZrO3-SrTiO3 was conducted under hydrothermal conditions in a KOH (5 M) solution at 200 °C for 4 h under a constant stirring speed of 130 rpm. The precursors employed were SrSO4 powder (<38 µm size) and coprecipitated hydrous gels of Zr(OH)4•9.64 H2O (Zr-gel) and Ti(OH)4•4.5H2O (Ti-gel), which were mixed according to the stoichiometry of the SrZr1-xTixO3 in the compositional range of 0.0 > x > 100.0 mol% Ti4+. The XRD results revealed the formation of two crystalline phases rich in Zr4+, an orthorhombic structured SrZr0.93Ti0.07O3 and a cubic structured SrZr0.75Ti0.25O3 within the compositional range of 0.1-0.5 mol of Ti4+. A cubic perovskite structured solid solution, SrTi1-xZrxO3, was preferentially formed within the compositional range of 0.5 > x > 0.1 mol% Ti4+. The SrZrO3 and SrZr0.93Ti0.07O3-rich phases had particle sizes averaging 3 µm with a cubic morphology. However, a remarkable reduction in the particle size occurred on solid solutions prepared with hydrous Ti-gel over contents of 15 mol% Ti4+ in the reaction media, resulting in the formation of nanosized particle agglomerates with a cuboidal shape self-assembled via a 3D hierarchical architecture, and the sizes of these particles varied in the range between 141.0 and 175.5 nm. The limited coarsening of the particles is discussed based on the Zr-gel and Ti-gel dehydration capability differences that occurred under hydrothermal processing.

Superior Hypophyseal Artery Intraoperative Indocyanine Green Angiogram as a Predictor of Postoperative Visual Function After Endoscopic Endonasal Surgery.

BACKGROUND AND OBJECTIVES: To date, there are no tools to intraoperatively predict postoperative visual function after endoscopic endonasal surgery (EES) for suprasellar lesions. The objective of this study was to retrospectively evaluate the utility of indocyanine green (ICG) angiography as an intraoperative tool to measure optic chiasm perfusion and determine its relationship with postoperative visual function. METHODS: Videos of patients undergoing EES for resection of suprasellar lesions were reviewed, where 5 mg of ICG was diluted in 10 mL of saline and administered. Time between luminescence of the anterior cerebral artery and the superior hypophyseal artery branches supplying the optic chiasm was noted, and the percentage of optic chiasm vessels that luminesced was recorded. Postoperative examinations and imaging studies were used to assess visual function. Patients with and without new deficits were compared with examination of trends in ICG findings. RESULTS: A total of 7 trials were reviewed on 6 patients, with no complications occurring from ICG administration. Mean time to chiasm peak luminescence was 3.8 seconds, and 81.8% of chiasm vessels luminesced. Patients with stable or improved vision after resection demonstrated over 90% chiasm luminescence in every case, and mean chiasm time in these postresection ICG administrations was 4.0 seconds. One patient experienced new postoperative visual deficits; on review of their ICG administration, 11.5% of chiasm vessels luminesced, and the chiasm itself failed to display robust luminescence after 30 seconds of direct observation. CONCLUSION: This pilot study showed the capability of intraoperative ICG angiography to demonstrate perfusion of the optic chiasm during EES for resection of suprasellar lesions. While larger studies are required, preliminary results suggest chiasm times under 5 seconds and over 90% chiasm vessel illumination may reflect adequate chiasm perfusion, while those with delayed or absent chiasm luminescence may have compromised chiasm perfusion.

IL-13-associated epithelial remodeling correlates with clinical severity in nasal polyposis.

BACKGROUND: Epithelial remodeling is a histopathologic feature of chronic inflammatory airway diseases including chronic rhinosinusitis (CRS). Cell-type shifts and their relationship to CRS endotypes and severity are incompletely described. OBJECTIVE: We sought to understand the relationship of epithelial cell remodeling to inflammatory endotypes and disease outcomes in CRS. METHODS: Using cell-type transcriptional signatures derived from epithelial single-cell sequencing, we analyzed bulk RNA-sequencing data from sinus epithelial brushings obtained from patients with CRS with and without nasal polyps in comparison to healthy controls. RESULTS: The airway epithelium in nasal polyposis displayed increased tuft cell transcripts and decreased ciliated cell transcripts along with an IL-13 activation signature. In contrast, CRS without polyps showed an IL-17 activation signature. IL-13 activation scores were associated with increased tuft cell, goblet cell, and mast cell scores and decreased ciliated cell scores. Furthermore, the IL-13 score was strongly associated with a previously reported activated ("polyp") tuft cell score and a prostaglandin E2 activation signature. The Lund-Mackay score, a computed tomographic metric of sinus opacification, correlated positively with activated tuft cell, mast cell, prostaglandin E2, and IL-13 signatures and negatively with ciliated cell transcriptional signatures. CONCLUSIONS: These results demonstrate that cell-type alterations and prostaglandin E2 stimulation are key components of IL-13-induced epithelial remodeling in nasal polyposis, whereas IL-17 signaling is more prominent in CRS without polyps, and that clinical severity correlates with the degree of IL-13-driven epithelial remodeling.

Formal Closure of Endoscopic Endonasal Skull Base Defects With a "Bow Tie" Tri-Layer Graft.

OBJECTIVE: Risk factors for a postoperative cerebrospinal fluid leak (CSF) after surgery include an intraoperative high flow of CSF, elevated body mass index, defect size, and defect site. In our prior series, a high postoperative CSF leak rate for tumors of the central skull base (planum, sella, and clivus) appeared to be due to graft migration. We changed our closure technique from a single layer of collagen +/- fat graft to a novel graft, termed a "Bow tie" (a tri-layer fat graft with two pieces of collagen matrix), and report our results in this study. METHODS: Retrospective temporal epoch study of a single otolaryngologist's experience of closing skull base defects in our skull base center from 2005 to 2017. RESULTS: One hundred and forty-nine patients met inclusion criteria in two time periods, pre- and post-introduction of the Bow tie technique. In epoch I, from 2005 to 2013, 79 patients had reconstruction with a single layer of dural graft (25 had additional free fat graft). In epoch II, from 2014 to 2017, 70 patients had reconstruction with the Bow tie. RESULTS: CSF leak rates were 8.7% overall: 15.2% in epoch I and 1.4% in epoch II (p = 0.01). After controlling the procedure, defects with a size greater than 2 cm had a 5.7 greater likelihood of failure. Epoch II had a lower incidence of major complications. CONCLUSION: Using a single surgeon's experience, the multilayer Bow tie has a significant reduction in postoperative CSF leak and associated major complications for defects of the central skull base. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1568-1575, 2023.

Correlation between tumor volume and serum prolactin and its effect on surgical outcomes in a cohort of 219 prolactinoma patients.

OBJECTIVE: Prolactinoma is the most common pituitary adenoma and can be managed medically or surgically. The authors assessed the correlation between tumor volume and prolactin level and its effect on surgical outcomes. METHODS: The authors reviewed 219 patients who underwent transsphenoidal prolactinoma resection at a single institution from 2012 to 2019. Outcomes were compared between patients with and without biochemical remission. Tumor volumes were quantified with BrainLab Smartbrush. Correlation analysis and linear regression were used to examine the association between tumor volume and serum prolactin level. Volume-adjusted prolactin level was defined as serum prolactin level divided by tumor volume. The authors utilized receiver operating characteristic (ROC) curve analysis to determine the thresholds for predicting biochemical remission status. RESULTS: The mean tumor volume was 5.66 cm3, and the mean preoperative prolactin level was 752.3 µg/L. Men had larger prolactinomas than women (mean volume 11.32 vs 2.54 cm3; p < 0.001), and women had a greater volume-adjusted prolactin level (mean 412.5 vs 175.9 µg/L/cm3, p < 0.001). In total, 66.7% of surgical patients achieved biochemical remission 6 weeks after surgery, whereas a similar cohort of medically treated patients during the same time frame demonstrated a 69.4% remission rate. Pearson correlation and linear regression analysis revealed a strong association between preoperative tumor volume and prolactin levels, with an increase in serum prolactin level of 101.31 µg/L per 1-cm3 increase in tumor volume (p < 0.001). This held true for men (R = 0.601, p < 0.001) and women (R = 0.935, p < 0.001), with women demonstrating a greater increase in prolactin level per 1-cm3 increase in volume (185.70 vs 79.77 µg/L, p < 0.001). Patients who achieved remission exhibited a 66.08-µg/L increase in preoperative prolactin level per 1 cm3 of preoperative tumor volume (p < 0.001), which was less than the 111.46-µg/L increase per 1 cm3 in patients without remission (p < 0.001). Patients who failed to achieve remission had residual tumors with a 77.77-µg/L increase in prolactin per 1 cm3 of remaining tumor volume after resection (p < 0.001). ROC curve analysis revealed significant thresholds that optimally predicted lack of postoperative remission on the basis of preoperative prolactin and tumor volume. These thresholds were rendered nonsignificant in patients with documented Knosp grade ≥ 3. CONCLUSIONS: Although the authors found a correlation between prolactinoma volume and serum prolactin level, patients without remission had a greater increase in serum prolactin level per increase in preoperative tumor volume than those who achieved remission, suggesting unique tumor composition. The authors also identified prolactin and tumor volume thresholds that optimally predicted biochemical remission status. The authors hope that their results can be used to identify prolactinomas for which surgery could achieve remission as an alternative to medical management.

IL-13-programmed airway tuft cells produce PGE2, which promotes CFTR-dependent mucociliary function.

Chronic type 2 (T2) inflammatory diseases of the respiratory tract are characterized by mucus overproduction and disordered mucociliary function, which are largely attributed to the effects of IL-13 on common epithelial cell types (mucus secretory and ciliated cells). The role of rare cells in airway T2 inflammation is less clear, though tuft cells have been shown to be critical in the initiation of T2 immunity in the intestine. Using bulk and single-cell RNA sequencing of airway epithelium and mouse modeling, we found that IL-13 expanded and programmed airway tuft cells toward eicosanoid metabolism and that tuft cell deficiency led to a reduction in airway prostaglandin E2 (PGE2) concentration. Allergic airway epithelia bore a signature of PGE2 activation, and PGE2 activation led to cystic fibrosis transmembrane receptor-dependent ion and fluid secretion and accelerated mucociliary transport. These data reveal a role for tuft cells in regulating epithelial mucociliary function in the allergic airway.

Socioeconomic predictors of case presentations and outcomes in 225 nonfunctional pituitary adenoma resections.

OBJECTIVE: Clinical presentations and outcomes of nonfunctional pituitary adenoma (NFPA) resections can vary widely, and very little prior research has analyzed this variance through a socioeconomic lens. This study sought to determine whether socioeconomic status (SES) influences NFPA presentations and postoperative outcomes, as these associations could aid physicians in understanding case prognoses and complications. METHODS: The authors retrospectively analyzed 225 NFPA resections from 2012 to 2019 at their institution. Race, ethnicity, insurance status, estimated income, and having a primary care provider (PCP) were collected as 5 markers of SES. These markers were correlated with presenting tumor burden, presenting symptoms, surgical outcomes, and long-term clinical outcomes. RESULTS: All 5 examined SES markers influenced variance in patient presentation or outcome. Insurance status's effects on patient presentations disappeared when examining only patients with PCPs. Having a PCP was associated with significantly smaller tumor size at diagnosis (effect size = 0.404, p < 0.0001). After surgery, patients with PCPs had shorter postoperative hospital lengths of stay (p = 0.043) and lower rates of readmission within 30 days of discharge (OR 0.256, p = 0.047). Despite continuing follow-up for longer durations (p = 0.0004), patients with PCPs also had lower rates of tumor recurrence (p < 0.0001). Higher estimated income was similarly associated with longer follow-up (p = 0.002) and lower rates of tumor recurrence (p = 0.013). Among patients with PCPs, income was not associated with recurrence. CONCLUSIONS: This study found that while all 5 variables (race, ethnicity, insurance, PCP status, and estimated income) affected NFPA presentations and outcomes, having a PCP was the single most important of these socioeconomic factors, impacting hospital lengths of stay, readmission rates, follow-up adherence, and tumor recurrence. Having a PCP even protected low-income patients from experiencing increased rates of tumor recurrence. These protective findings suggest that addressing socioeconomic disparities may lead to better NFPA presentations and outcomes.

Presentation and management of post-operative cerebrospinal fluid leaks after sphenoclival expanded endonasal surgery: A single institution experience.

While surgical approaches and techniques of expanded endonasal approach (EEA) surgery have been well described, little data exist regarding management of post-operative cerebrospinal fluid (CSF) leaks. In this study, we examined a surgeon's continuous 12-year experience with failed closure of sphenoclival skull base defects. We conducted a retrospective case series of patients identified with post-operative CSF leaks after EEA of the sphenoclival axis, managed by a single otolaryngologist at a minimally invasive skull base center. Ten out of 326 patients required therapeutic intervention for central skull base defect closure failure. Median time to presentation of CSF leak was 25 days (range 6-542 days). Symptoms included rhinorrhea (n = 7), meningitis (n = 6), and pneumocephalus (n = 1). The majority of patients (7 of 10) were first managed by lumbar drain placement - one of which had resolution of his/her CSF leak. Overall, 9 of 10 patients required endoscopic repair. The majority of the post-operative CSF leaks (9/13, 69.2%) were repaired using a vascularized mucosal flap. There were 3 patients who required a second revision surgery. All CSF leaks were repaired without completely deconstructing the initial repair. Failure sites most frequently occurred outside of the sella (80%), likely reflecting their direct relationship to the intracranial cisterns. Initial operative repair provided definitive treatment in most cases (70%). Correct placement of a vascularized local pedicle-based flap is essential for successful repair. Knowledge of alternative flaps is particularly important when the nasoseptal flap is no longer available.

Septum submucosal glands exhibit aberrant morphology and reduced mucin production in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is characterized by significant accumulation and thickening of mucus in the sinonasal cavities. One contributor of aberrant mucus production and impaired mucociliary clearance (MCC) is altered function of the sinonasal submucosal glands (SMGs), yet contributions of SMGs to upper airway disease initiation and progression remain unknown. The objective of this study was to characterize the morphology and secretory cell identities of the nasal septum SMGs in both healthy and CRS adults. METHODS: Biopsies from adult participants with CRS without nasal polyps (CRSsNP, n = 4), CRS with nasal polyps (CRSwNP, n = 8), and non-CRS controls (n = 14) were collected from the posterior septum. Glandular morphology and mucus markers were investigated using histological techniques and high-resolution confocal microscopy. RESULTS: Analysis revealed a significant decrease in gland density in the posterior septum of CRSsNP (28% ± 6.15%) and CRSwNP (23% ± 3.09%) compared to control participants (53% ± 1.59%, p < 0.0001). Further analysis of the CRS SMG secretory function revealed an overall decrease in Mucin 5B+ gland mucus being produced. Dilated and cystic ductal structures filled with inspissated mucus were also common to CRS glands. CONCLUSION: Here, we describe a significant alteration in SMG structure and function in the adult CRS posterior septum suggesting reduced gland contribution to MCC. The SMGs of both the nose and sinuses may represent targets for future therapeutic approaches.

Use of Ultrasound for Navigating the Internal Carotid Artery in Revision Endoscopic Endonasal Skull Base Surgery.

While the use of image-guided navigation is an excellent adjunct to the use of anatomical landmarks, dynamic changes that may occur in the position of critical structures are not accounted for during and after tumor resection. Unlike navigation, Doppler ultrasonography provides real-time imaging of the anterior skull base and can be used to accurately identify the location of vital structures during skull base surgery. A 56-year-old female initially presented with new onset left eye visual deficits. She previously underwent sublabial transsphenoidal subtotal resection of the tumor, confirmed as clival chordoma. She subsequently presented to our institution. She was treated with an expanded endonasal resection of the remaining chordoma followed by CyberKnife radiosurgery. Two years later, surveillance imaging identified tumor recurrence within the right clivus posterior to the carotid artery. Intraoperatively, in the previously operated irradiated skull base, the normal bony architecture of the sella was absent, resulting in the inability to distinguish the anterior genu of the internal carotid artery (ICA) from the adjacent tumor. Using Doppler ultrasonography, the course of the ICA was imaged in real time, allowing for safe, gross total tumor resection. In the setting of prior operation, radiation, or extensive disease, the normal bony architecture of the sella may be disrupted, placing the cavernous ICA at risk. We report what we believe is the first use of intraoperative ultrasound during the endoscopic endonasal approach in the setting of a previously operated, radiated sella.

Short-term chemosensory distortions and phantoms in COVID-19.

Objective: To identify differentiation features of chemosensory dysfunction in COVID-19 infection and their primary drivers. Study Design: Cross-sectional cohort comparison. Methods: A national anonymous survey was used to query participants regarding nasal symptoms and chemosensory dysfunction including sensitivity levels, and presence or absence of distortions and phantoms within the 6-week time window surrounding their COVID-19 testing and survey completion. Results: Three-hundred and sixty-four respondents who reported COVID-19 positive (COVID+; n = 176) or COVID-19 negative (COVID-; n = 188) test results completed the survey. The COVID+ cohort had higher occurrence rates for: (a) chemosensory sensitivity impairments (67.0% vs 30.3%; P < .01), where the rate of complete loss of smell (anosmia) or taste (ageusia) was higher (35.8% vs 4.8%; P < .01), and (b) chemosensory distortions (39.8% vs 19.1%; P < .01), where the rate of anosmia or ageusia with distortions was also higher in the COVID+ cohort (19.9% vs 2.7%; P < .01). Occurrence rates in the two cohorts were similar for chemosensory phantoms (COVID+ 17.0%, COVID- 18.6%; P = .70) and nasal discharge or stuffiness in the presence of sensitivity impairment (COVID+ 63.6%, COVID- 52.6%; P = .17). Conclusion: Chemosensory dysfunction in COVID-19 is associated with higher rates of smell or taste sensitivity impairments and distortions. Higher rates of anosmia and ageusia drive these key findings. Chemosensory phantoms and nasal symptoms in the presence of sensitivity impairment occur at rates that should demand clinical attention, but they do not appear to be specific to COVID-19 positivity. Level of Evidence: 2b.

Temporal Profile of Olfactory Dysfunction in COVID-19.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with olfactory dysfunction, but the evolution of the olfactory loss and timeline to recovery are largely unknown. This study examines changes in smell sensitivity in COVID-19-positive (COVID+) and COVID-19-negative (COVID-) viral illness during the initial weeks after infection. STUDY DESIGN: Cross-sectional cohort comparison. SETTING: National anonymous surveys. METHODS: Survey participants were queried about smell sensitivity and general health status at the time of COVID-19 testing and in the weeks that followed. RESULTS: In total, 375 (174 COVID+, 201 COVID-) participants completed the survey and 132 (62 COVID+, 70 COVID-) participants completed the 2-week follow-up survey. Normal smell in the COVID+ cohort was less frequent at the time of testing and at follow up (P < .05). Dynamic changes in smell sensitivity in the COVID+ cohort were more frequent in the initial weeks (P < .001). In those with normosmia at the start of infection, 38% of the COVID+ cohort reported worsening smell compared to only 8% in the COVID- cohort (P < .05). Recovery of overall health was associated with normosmia at the time of infection and improvement of smell sensitivity within weeks of infection. CONCLUSION: The COVID+ cohort showed greater dynamic change in smell sensitivity and a higher rate of persistent olfactory dysfunction in the weeks after infection. Normal smell at the time of COVID-19 infection may still worsen before recovery. Overall health recovery after viral illness is associated with improvement in smell sensitivity and the absence of initial anosmia or hyposmia.

Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma.

OBJECTIVE: Life expectancy has increased over the past century, causing a shift in the demographic distribution toward older age groups. Elderly patients comprise up to 14% of all patients with pituitary tumors, with most lesions being nonfunctioning pituitary adenomas (NFPAs). Here, the authors evaluated demographics, outcomes, and postoperative complications between nonelderly adult and elderly NFPA patients. METHODS: A retrospective review of 908 patients undergoing transsphenoidal surgery (TSS) for NFPA at a single institution from 2007 to 2019 was conducted. Clinical and surgical outcomes and postoperative complications were compared between nonelderly adult (age ≥ 18 and ≤ 65 years) and elderly patients (age > 65 years). RESULTS: There were 614 and 294 patients in the nonelderly and elderly groups, respectively. Both groups were similar in sex (57.3% vs 60.5% males; p = 0.4), tumor size (2.56 vs 2.46 cm; p = 0.2), and cavernous sinus invasion (35.8% vs 33.7%; p = 0.6). Regarding postoperative outcomes, length of stay (1 vs 2 days; p = 0.5), extent of resection (59.8% vs 64.8% gross-total resection; p = 0.2), CSF leak requiring surgical revision (4.3% vs 1.4%; p = 0.06), 30-day readmission (8.1% vs 7.3%; p = 0.7), infection (3.1% vs 2.0%; p = 0.5), and new hypopituitarism (13.9% vs 12.0%; p = 0.3) were similar between both groups. Elderly patients were less likely to receive adjuvant radiation (8.7% vs 16.3%; p = 0.009), undergo future reoperation (3.8% vs 9.5%; p = 0.003), and experience postoperative diabetes insipidus (DI) (3.7% vs 9.4%; p = 0.002), and more likely to have postoperative hyponatremia (26.7% vs 16.4%; p < 0.001) and new cranial nerve deficit (1.9% vs 0.0%; p = 0.01). Subanalysis of elderly patients showed that patients with higher Charlson Comorbidity Index scores had comparable outcomes other than higher DI rates (8.1% vs 0.0%; p = 0.006). Elderly patients' postoperative sodium peaked and troughed on postoperative day 3 (POD3) (mean 138.7 mEq/L) and POD9 (mean 130.8 mEq/L), respectively, compared with nonelderly patients (peak POD2: mean 139.9 mEq/L; trough POD8: mean 131.3 mEq/L). CONCLUSIONS: The authors' analysis revealed that TSS for NFPA in elderly patients is safe with low complication rates. In this cohort, more elderly patients experienced postoperative hyponatremia, while more nonelderly patients experienced postoperative DI. These findings, combined with the observation of higher DI in patients with more comorbidities and elderly patients experiencing later peaks and troughs in serum sodium, suggest age-related differences in sodium regulation after NFPA resection. The authors hope that their results will help guide discussions with elderly patients regarding risks and outcomes of TSS.

Clinical characteristics and outcomes of null-cell versus silent gonadotroph adenomas in a series of 1166 pituitary adenomas from a single institution.

OBJECTIVE: Nonfunctioning pituitary adenomas present without biochemical or clinical signs of hormone excess and are the second most common type of pituitary adenomas. The 2017 WHO classification scheme of pituitary adenomas differentiates null-cell adenomas (NCAs) and silent gonadotroph adenomas (SGAs). The present study sought to highlight the differences in patient characteristics and clinical outcomes between NCAs and SGAs. METHODS: The records of 1166 patients who underwent transsphenoidal surgery for pituitary adenoma between 2012 and 2019 at a single institution were retrospectively reviewed. Patient demographics and clinical outcomes were collected. RESULTS: Of the overall pituitary adenoma cohort, 12.8% (n = 149) were SGAs and 9.2% (n = 107) NCAs. NCAs were significantly more common in female patients than SGAs (61.7% vs 26.8%, p < 0.001). There were no differences in patient demographics, initial tumor size, or perioperative and short-term clinical outcomes. There was no significant difference in the amount of follow-up between patients with NCAs and those with SGAs (33.8 months vs 29.1 months, p = 0.237). Patients with NCAs had significantly higher recurrence (p = 0.021), adjuvant radiation therapy usage (p = 0.002), and postoperative diabetes insipidus (p = 0.028). NCA pathology was independently associated with tumor recurrence (HR 3.64, 95% CI 1.07-12.30; p = 0.038), as were cavernous sinus invasion (HR 3.97, 95% CI 1.04-15.14; p = 0.043) and anteroposterior dimension of the tumor (HR 2.23, 95% CI 1.09-4.59; p = 0.030). CONCLUSIONS: This study supports the definition of NCAs and SGAs as separate subgroups of nonfunctioning pituitary adenomas, and it highlights significant differences in long-term clinical outcomes, including tumor recurrence and the associated need for adjuvant radiation therapy, as well as postoperative diabetes insipidus. The authors also provide insight into independent risk factors for these outcomes in the adenoma population studied, providing clinicians with additional predictors of patient outcomes. Follow-up studies will hopefully uncover mechanisms of biological aggressiveness in NCAs and associated molecular targets.

Endoscopic skull base and transoral surgery during COVID-19 pandemic: Minimizing droplet spread with negative-pressure otolaryngology viral isolation drape.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has raised concern of transmission of infectious organisms through aerosols formation in endonasal and transoral surgery. METHODS: Retrospective review. We introduce the negative-pressure otolaryngology viral isolation drape (NOVID) system to reduce the risk of aerosol. NOVID consists of a plastic drape suspended above the patient's head and surgical field with a smoke evacuator suction placed inside the chamber. RESULTS: Four patients underwent endonasal (4) and endo-oral surgery (1). Fluorescein was applied to the surgical field. Black light examination of fluorescein-treated operative fields revealed minimal contamination distant to the surgical field. In two prolonged cases with high-speed drilling, droplets were identified under the barrier and on the tip of the smoke evacuator. Instruments and cottonoids appeared to be a greater contributor to field contamination. CONCLUSIONS: Negative-pressure aspiration of air under a chamber barrier, which appears to successfully keep aerosol and droplet contamination to a minimum.

Smell and taste symptom-based predictive model for COVID-19 diagnosis.

BACKGROUND: The presentation of coronavirus 2019 (COVID-19) overlaps with common influenza symptoms. There is limited data on whether a specific symptom or collection of symptoms may be useful to predict test positivity. METHODS: An anonymous electronic survey was publicized through social media to query participants with COVID-19 testing. Respondents were questioned regarding 10 presenting symptoms, demographic information, comorbidities, and COVID-19 test results. Stepwise logistic regression was used to identify predictors for COVID-19 positivity. Selected classifiers were assessed for prediction performance using receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 145 participants with positive COVID-19 testing and 157 with negative results were included. Participants had a mean age of 39 years, and 214 (72%) were female. Smell or taste change, fever, and body ache were associated with COVID-19 positivity, and shortness of breath and sore throat were associated with a negative test result (p < 0.05). A model using all 5 diagnostic symptoms had the highest accuracy with a predictive ability of 82% in discriminating between COVID-19 results. To maximize sensitivity and maintain fair diagnostic accuracy, a combination of 2 symptoms, change in sense of smell or taste and fever was found to have a sensitivity of 70% and overall discrimination accuracy of 75%. CONCLUSION: Smell or taste change is a strong predictor for a COVID-19-positive test result. Using the presence of smell or taste change with fever, this parsimonious classifier correctly predicts 75% of COVID-19 test results. A larger cohort of respondents will be necessary to refine classifier performance.

The impact of frailty on perioperative outcomes and resource utilization in sinonasal cancer surgery.

OBJECTIVES/HYPOTHESIS: Frailty is a measure of decreased physiologic reserve that has been associated with adverse outcomes in older surgical patients. We aimed to measure the association of preoperative frailty with outcomes in patients undergoing sinonasal cancer surgery. STUDY DESIGN: Retrospective cohort study. METHODS: We identified 5,346 patients in the Nationwide Readmissions Database undergoing sinonasal cancer surgery from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multivariate regression was used to analyze the association of frailty with postoperative outcomes. RESULTS: Frailty was present in 7.4% of patients. Frailty was a significant independent predictor of intensive care unit-level complications (odds ratio [OR]: 4.83; 95% confidence interval [CI]: 2.95-7.93; P < .001) and nonhome discharge (OR: 3.07; 95% CI: 1.68-5.60; P < .001). Compared to nonfrail patients, frail patients had threefold longer median length of stay (12 days vs. 4 days; P < .001) and more than twofold higher median hospital costs ($44,408 vs. $18,660; P < .001). Frailty outperformed advanced comorbidity (defined as Charlson-Deyo score ≥3), age ≥80 years, and markers of surgical complexity (e.g., skull base/orbit involvement, flap reconstruction, neck dissection) in predicting serious complications, nonhome discharge, length of stay, and hospital costs. CONCLUSIONS: Frailty appears to have a stronger and more consistent association with adverse outcomes and increased resource utilization after sinonasal cancer surgery than age or comorbidity index. This information may be used in surgical risk stratification and can guide strategies to prevent or mitigate adverse events in this high-risk group. LEVEL OF EVIDENCE: NA Laryngoscope, 130:290-296, 2020.

Acquisition of Volumetric Models of Skull Base Anatomy Using Endoscopic Endonasal Approaches: 3D Scanning of Deep Corridors Via Photogrammetry.

OBJECTIVE: In this study we aim to evaluate the feasibility of creating volumetric models of highly intricate skull-base anatomy-previously not amenable to volumetric reconstruction-using endoscopic endonasal approaches. METHODS: Ten human cadaveric heads were dissected through the nasal corridor to expose anterior, middle, and posterior cranial fossi structures and the pterygopalatine and infratemporal fossi. A rigid endoscope with a 30° lens was used to capture the images. Subsequently, a photogrammetry software was used to align, smooth, and texturize the images into a complete 3-dimensional model. RESULTS: An average of 174 photographs were used to construct each model (n = 10). In the end, we achieved high-definition stereoscopic volumetric models of the nasal corridor; paranasal fossae; and anterior, middle and posterior fossae structures that preserved structural integrity. Strategic points of interests were labeled and animated for educational use. CONCLUSIONS: Endoscopic volumetric models represent a new way to depict the anatomy of the skull base; their use with 3-dimensional technologies could potentially improve the visuospatial understanding of narrow surgical corridors for education and surgical-planning purposes.