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1.
Neurosurg Focus ; 55(6): E10, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38039538

RESUMO

OBJECTIVE: The aim of this study was to report the authors' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations. METHODS: Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke's cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022). RESULTS: Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498. CONCLUSIONS: CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.


Assuntos
Adenoma , Craniofaringioma , Neoplasias Hipofisárias , Adulto , Humanos , Melhoria de Qualidade , Neoplasias Hipofisárias/cirurgia , Hipófise/patologia , Nariz/cirurgia , Endoscopia , Adenoma/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias
2.
J Neurol Surg Rep ; 84(4): e156-e162, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-38124781

RESUMO

Introduction Clival tumors are rare and heterogeneous. Although some benign prototypical sellar lesions may present as clival tumors, the likelihood of malignant disease is higher. Here we define a novel algorithm for the workup and management of clival masses through an illustrative case of colorectal adenocarcinoma metastasis to the clivus. Methods In this case report, the best practice guidelines for managing clival masses are described through a literature review and refined by senior author consensus. We conducted a focused systematic review to characterize the present case in the context of clival metastasis from gastrointestinal malignancy. Results An 83-year-old woman presented with 4 weeks of headaches and blurry vision. Examination revealed partial right abducens and left oculomotor palsies. Magnetic resonance imaging (MRI) identified a large, weakly enhancing sellar and clival mass with sphenoid sinus extension. An aggressive subtotal endoscopic endonasal resection was performed with removal of all sphenoid, clival, and sellar disease without cavernous sinus wall resection. Pathology confirmed colorectal adenocarcinoma; computed tomography (CT) imaging identified an ascending colon mass with metastases to the liver and mesenteric nodes. Palliative oncologic therapies were recommended, but she elected hospice, and died 3 months after initial presentation. Gastrointestinal clival metastases are exceedingly rare among sellar and clival pathologies, with eight prior cases reported, most of which presented with diplopia from abducens nerve involvement. Conclusion Clival masses are uncommon skull base lesions that are associated with more aggressive diseases. We present a consolidated framework for decision-making in these challenging patients, alongside an unusual case example that illustrates the importance of increased suspicion for malignant clinical entities in this setting.

3.
J Neurosurg Case Lessons ; 5(14)2023 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-37014007

RESUMO

BACKGROUND: Skull base chordomas are typically extradural and present with cranial nerve deficits, headache, and visual disturbances. Clival chordoma involving the dura and presenting as a spontaneous cerebrospinal fluid (CSF) leak is extremely rare and can be mistaken for other skull base lesions. Here the authors present a case of chordoma with an unusual presentation. OBSERVATIONS: A 43-year-old female who presented with clear nasal drainage was diagnosed with CSF rhinorrhea secondary to a clival defect previously thought to be ecchordosis physaliphora. The patient subsequently developed bacterial meningitis and underwent endoscopic, endonasal, transclival gross-total resection of the lesion with repair of the dural defect. Pathology revealed brachyury-positive chordoma. She received adjuvant proton beam radiotherapy and has remained stable for 2 years. LESSONS: Spontaneous CSF rhinorrhea can occur as a rare primary presentation of clival chordoma, requiring careful radiological interpretation and a high index of suspicion for diagnosis. Chordoma cannot be reliably differentiated from benign notochordal lesions based on imaging alone; thus, intraoperative exploration and immunohistochemistry play key roles. Clival lesions presenting with CSF rhinorrhea should undergo prompt resection to facilitate diagnosis and prevent complications. Future studies on connections between chordoma and benign notochordal lesions may help to establish management guidelines.

4.
Front Oncol ; 13: 1117865, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36937407

RESUMO

Introduction: We investigated the clinicopathological features and prognoses of the new molecularly defined entities in latest edition of the World Health Organization (WHO) classification of sinonasal carcinoma (SNC). Methods: Integrated data were combined into an individual patient data (IPD) meta-analysis. Results: We included 61 studies with 278 SNCs including 25 IDH2-mutant, 41 NUT carcinoma, 187 SWI/SNF loss, and 25 triple negative SNCs (without IDH2 mutation, NUTM1 rearrangement, and SWI/SNF inactivation) for analyses. Compared to other molecular groups, NUT carcinoma was associated with a younger age at presentation and an inferior disease-specific survival. Among SNCs with SWI/SNF inactivation, SMARCB1-deficient tumors presented later in life and were associated with a higher rate of radiotherapy administration. SMARCA4-deficiency was mostly found in teratocarcinosarcoma while SMARCB1-deficient tumors were associated with undifferentiated carcinoma and non-keratinizing squamous cell carcinoma. Conclusion: Our study facilitates our current understanding of this developing molecular-defined spectrum of tumors and their prognoses.

5.
Int Forum Allergy Rhinol ; 13(10): 1852-1863, 2023 10.
Artigo em Inglês | MEDLINE | ID: mdl-36808854

RESUMO

BACKGROUND: The Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system has become the gold standard for outcomes reporting in endoscopic orbital surgery for orbital cavernous hemangiomas (OCHs). A recent systematic review demonstrated similar outcomes between OCHs and other primary benign orbital tumors (PBOTs). Therefore, we hypothesized that a simplified and more comprehensive classification system could be developed to predict surgical outcomes of other PBOTs. METHODS: Patient and tumor characteristics as well as surgical outcomes from 11 international centers were recorded. All tumors were retrospectively assigned an Orbital Resection by Intranasal Technique (ORBIT) class and stratified based on surgical approach as either exclusively endoscopic or combined (endoscopic and open). Outcomes based on approach were compared using chi-squared or Fisher's exact tests. The Cochrane-Armitage test for trend was used to analyze outcomes by class. RESULTS: Findings from 110 PBOTs from 110 patients (age 49.0 ± 15.0 years, 51.9% female) were included in the analysis. Higher ORBIT class was associated with a lower likelihood of gross total resection (GTR). GTR was more likely to be achieved when an exclusively endoscopic approach was utilized (p < 0.05). Tumors resected using a combined approach tended to be larger, to present with diplopia, and to have an immediate postoperative cranial nerve palsy (p < 0.05). CONCLUSION: Endoscopic treatment of PBOTs is an effective approach, with favorable short-term and long-term postoperative outcomes as well as low rate of adverse events. The ORBIT classification system is an anatomic-based framework that effectively facilitates high-quality outcomes reporting for all PBOTs.


Assuntos
Hemangioma Cavernoso , Neoplasias Orbitárias , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Masculino , Neoplasias Orbitárias/cirurgia , Neoplasias Orbitárias/patologia , Estudos Retrospectivos , Resultado do Tratamento , Nariz/cirurgia , Endoscopia , Hemangioma Cavernoso/cirurgia
6.
ORL J Otorhinolaryngol Relat Spec ; 85(2): 109-111, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36657411

RESUMO

Nasal septal perforation is a full-thickness defect of the nasal septum. There are many described etiologies of nasal septal perforation, including trauma, infectious, neoplastic, iatrogenic, and autoimmune. Graft-versus-host disease (GVHD) is a common and potentially life-threatening complication that can occur after an allogenic transplant. GVHD can result in the development of autoantibodies that lead to granulomatous inflammation with necrotizing vasculitis, causing perforation of the nasal septum. In this report, we describe a patient with nasal septal perforation secondary to GVHD and hope to provide novel insights into the association of GVHD and nasal septal perforation.


Assuntos
Doença Enxerto-Hospedeiro , Perfuração do Septo Nasal , Humanos , Perfuração do Septo Nasal/etiologia , Septo Nasal/cirurgia , Doença Enxerto-Hospedeiro/complicações
7.
Br J Neurosurg ; 37(5): 976-981, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33783287

RESUMO

BACKGROUND: Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus. OBJECTIVE: The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment. METHODS: A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed. RESULTS: Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%). CONCLUSION: Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.


Assuntos
Rinorreia de Líquido Cefalorraquidiano , Neoplasias Hipofisárias , Prolactinoma , Humanos , Prolactinoma/diagnóstico por imagem , Prolactinoma/tratamento farmacológico , Prolactinoma/cirurgia , Agonistas de Dopamina/efeitos adversos , Rinorreia de Líquido Cefalorraquidiano/induzido quimicamente , Rinorreia de Líquido Cefalorraquidiano/diagnóstico por imagem , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/tratamento farmacológico , Neoplasias Hipofisárias/cirurgia , Resultado do Tratamento
8.
J Neurol Surg Rep ; 83(3): e105-e109, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-36110919

RESUMO

Introduction Biphenotypic sinonasal sarcoma (BSNS) is a recently found entity that first described by Lewis et al. It was then added to the 4th edition of the World Health Organization (WHO) of head and neck tumors in 2012. BSNS has been described as a rare low-grade sarcoma arising in the upper sinonasal tract. It is believed that in the past, BSNS was, likely, previously diagnosed as other low-grade or benign malignancies. Fibrosarcoma, leiomyosarcoma, and peripheral nerve sheath tumors, all fall within the differential diagnosis of BSNS. However, BSNS is unlike other mesenchymal sinonasal tumors, as it displays both neural and myogenic differentiation. BSNS has thus far been recognized in only a hand full of case reports, all of which have reported similar morphologic features of a low-grade soft tissue tumor with neural involvement arising from the nasal cavity or ethmoid air cells in middle aged individuals. In fact, being low-grade sarcoma became such a hallmark characteristic of this tumor that it even received the name low-grade sinonasal sarcoma with neural and myogenic features or LGSSNMF. Case Presentation We present, however, for the first time, a high-grade differentiation of BSNS in an otherwise healthy 72-year-old female. The patient was referred from an outside ENT (ear, nose, and throat) after pathology from a presumed polypectomy returned positive for a BSNS. Initial imaging revealed erosion through the bilateral lamina papyracea, anterior cranial fossa floor, and posterior table of the frontal sinus. She then underwent a combined endoscopic and bicoronal open approach for resection of the skull base lesion that was found to encompass the entirety of the sinonasal cavities bilaterally. Postoperatively, the patient underwent significant complications including infection of the pericranial flap, pneumocephalus, and eventually death. Discussion As BSNS is a fairly new entity, currently there has only been four case series conducted, each identifying features of a low-grade sarcoma with both myogenic and neural differentiation. Histologically, BSNS has monophasic spindle cells with uniform, elongated nuclei with scant cytoplasm between benign proliferations of surface-type respiratory epithelium, with a low mitotic rate. Our case, however, revealed pleomorphic hyperchromatic cells with high mitotic activity and necrosis with invasion of bone, staging it as high grade. Immunohistochemistry also differed from the previously reported standards. This case describes a new category for BSNS which may change the differential diagnosis, management, and surgical recommendations that are currently utilized for this skull base neoplasm.

9.
J Neurol Surg B Skull Base ; 83(2): 116-124, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35433178

RESUMO

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae. Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported. Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation. Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

10.
Otolaryngol Clin North Am ; 55(2): 343-350, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35365312

RESUMO

Nonfunctioning pituitary lesions represent a subset of pituitary adenomas that do not manifest with clinical features of hormone hypersecretion. Because of their indolent nature, their diagnosis is elusive, often resulting in presentation after the tumors have grown large enough to cause compressive symptoms. Although they are clinically silent, the various subtypes correspond to the predominant cell line of origin and therefore are biochemically distinct from one another. This article reviews the biochemical, clinical, and histopathologic features of each of these subtypes. A rubric is provided for diagnostic work-up of these lesions and the management options available to the treating clinician.


Assuntos
Adenoma , Neoplasias Hipofisárias , Adenoma/terapia , Humanos , Neoplasias Hipofisárias/diagnóstico , Neoplasias Hipofisárias/metabolismo , Neoplasias Hipofisárias/terapia
11.
Otolaryngol Head Neck Surg ; 166(6): 1169-1171, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35349362

RESUMO

David McDonogh, born into chattel slavery in Louisiana in the early 1800s, accomplished the unfathomable by becoming the first Black otolaryngologist in the United States of America. With tireless determination and profound intellect, Dr McDonogh surmounted immeasurable adversity along his improbable journey to freedom and success as an eye, ear, nose, and throat doctor in New York. His doctorate in medicine was posthumously awarded to his great-great-granddaughter in 2018 by the Columbia University Vagelos College of Physicians and Surgeons. In this History of Otolaryngology piece, we share his extraordinary story.


Assuntos
Distinções e Prêmios , Otolaringologia , Cirurgiões , História do Século XX , Humanos , Louisiana , Otorrinolaringologistas , Estados Unidos
12.
Clin Case Rep ; 9(12): e05095, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34917361

RESUMO

Immunoglobin G4-related disease (IgG4-RD) is a chronic fibro-inflammatory condition that presents as a single or multiple tumefactive lesions affecting virtually any organ system. Here we report a case of recurrent sinonasal IgG4-RD and review the literature of this evolving entity.

14.
Int Forum Allergy Rhinol ; 11(11): 1557-1569, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34096200

RESUMO

BACKGROUND: Racial and ethnic disparities in cancer outcomes have been demonstrated for several different malignancies. In this study we aimed to quantify disease-specific survival (DSS) and the 5-year conditional disease-specific survival (CDSS, the change in life expectancy with increasing survivorship) for paranasal sinus cancer by race and ethnicity. METHODS: Patients with sinus cancer between 1973 and 2015 were extracted from the Surveillance, Epidemiology, End Results (SEER) registry. Kaplan-Meier analysis for DSS was stratified by race and ethnicity. Cox regression models of DSS were generated controlling for stage, age, race, and ethnicity. CDSS was calculated using Cox models. Logistic regression was conducted to identify risk factors for younger age at diagnosis, late-stage at diagnosis, and likelihood of receiving surgical intervention when recommended. RESULTS: The analysis included a total of 5202 patients. DSS was significantly different when stratified by race (p < 0.01). Compared with White patients, Black patients (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.13-1.45; p < 0.001) and American Indian/Alaskan Natives (HR, 1.94; 95% CI, 1.37-2.74, p < 0.001) exhibited increased mortality when controlling for other factors. Black patients had worse CDSS for regional and distant staged cancer compared with other races; American Indian/Alaskan Native patients had worse CDSS for cancers of all stages. Hispanic patients were more likely to present with advanced disease (odds ratio [OR], 1.47; 95% CI, 1.07-2.07; p = 0.020). American Indian/Alaskan Native patients were less likely than White patients to receive surgical intervention when recommended (OR, 0.42; 95% CI, 0.21-0.04; p = 0.024). Nonwhite patients were more likely to be diagnosed at a younger age. Variations in racial and ethnic disparities were observed over time. CONCLUSION: Race and ethnicity significantly impact paranasal sinus cancer outcome metrics. Disparities in outcomes are likely multifactorial.


Assuntos
Etnicidade , Neoplasias dos Seios Paranasais , Povo Asiático , Humanos , Estimativa de Kaplan-Meier , Neoplasias dos Seios Paranasais/epidemiologia , Estados Unidos/epidemiologia
15.
Laryngoscope ; 131(8): 1722-1728, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33493376

RESUMO

OBJECTIVE/HYPOTHESIS: The aim of this study is to assess the ethnic and racial demographics of patients enrolled in prospective chronic rhinosinusitis (CRS) studies relative to the corresponding geographic demographics of the United States (U.S.) census data. STUDY DESIGN: Systematic Review and Population analysis. METHODS: A systematic review was performed to identify CRS clinical trials, conducted in the U.S. and published between 2010 and 2020 in which patients were prospectively enrolled. Pooled racial and ethnicity data were compared to national and corresponding regional census data. RESULTS: Eighty-three studies were included, comprising 12,027 patients. 50.4% were male and the average age was 49.2 years. 8,810 patients underwent a surgical procedure. Of the 12,027 patients, 81.67% were identified as White, 5.35% as Black, 1.27% as Asian, 0.02% as Pacific Islander, 0.12% as American Indian, and 11.57% were classified as Other. The racial and ethnic composition of the pooled study population differs significantly from the national U.S. census data with the underrepresentation of each minority population (P ≤ .0002). Regional sub-analyses yield variable results. In the Northeast and West, there was an underrepresentation of all minority populations. In the South and Midwest, Black enrollment was similar to the U.S. census data, while all other minorities were underrepresented. CONCLUSIONS: The racial and ethnic composition of patients enrolled in prospective CRS clinical trials differs significantly from the demographics of the U.S. POPULATION: The generalizability and external validity of findings derived from studies comprised of demographically mismatched populations has not been established. Future efforts to enroll more representative populations should be emphasized by the research community, funding bodies, and editorial boards. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1722-1728, 2021.


Assuntos
Etnicidade/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Rinite/cirurgia , Sinusite/cirurgia , Doença Crônica , Ensaios Clínicos como Assunto , Demografia , Feminino , Geografia , Humanos , Masculino , Pessoa de Meia-Idade , Grupos Minoritários , Estudos Prospectivos , Rinite/complicações , Rinite/etnologia , Sinusite/complicações , Sinusite/etnologia , Classe Social , Estados Unidos/etnologia
17.
Artigo em Inglês | MEDLINE | ID: mdl-32596656

RESUMO

This article presents a case of low-grade cribriform cystadenocarcinomas (LGCCC), a rare salivary gland tumor manifesting in the infratemporal fossa (ITF). The lesion in this case is unique in its location, histopathology, and management in that the tumor resection was performed using an exclusively endoscopic, endonasal approach. This case highlights the expanding application of endoscopic skull base techniques to address an indolent, slow-growing malignancy of the ITF.

18.
Med Sci (Basel) ; 7(4)2019 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-30934800

RESUMO

Asthma is a prevalent inflammatory condition of the lower airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchial hyperresponsiveness (BHR). Symptomatically, these patients may demonstrate wheezing, breathlessness, chest tightness, and coughing. This disease is a substantial burden to a growing population worldwide that currently exceeds 300 million individuals. This is a condition that is frequently encountered, but often overlooked in the field of otolaryngology. In asthma, comorbid conditions are routinely present and contribute to respiratory symptoms, decreased quality of life, and poorer asthma control. It is associated with otolaryngic diseases of the upper airways including allergic rhinitis (AR) and chronic rhinosinusitis (CRS). These conditions have been linked epidemiologically and pathophysiologically. Presently, they are considered in the context of the unified airway theory, which describes the upper and lower airways as a single functional unit. Thus, it is important for otolaryngologists to understand asthma and its complex relationships to comorbid diseases, in order to provide comprehensive care to these patients. In this article, we review key elements necessary for understanding the evaluation and management of asthma and its interrelatedness to CRS.

19.
JAMA Otolaryngol Head Neck Surg ; 141(10): 927-33, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26378612

RESUMO

IMPORTANCE: Improvements in endoscopic technology and reconstructive techniques have made the endoscopic endonasal approach (EEA) a viable option to approach ventromedial lesions in the region of the hypoglossal canal. Prior to contemplating this surgical corridor, a thorough understanding of anatomic relationships and landmarks is essential to safely approach this region of the posterior skull base through an EEA. OBJECTIVE: To describe the surgical technique and anatomic landmarks in the EEA to the hypoglossal canal through referencing nasopharyngeal and posterior skull base anatomy. DESIGN, SETTING, AND PARTICIPANTS: Study of latex-injected cadaveric heads at the North Carolina Eye Bank Multidisciplinary Surgical Skills Laboratory at the University of North Carolina. INTERVENTIONS: An EEA to the hypoglossal canal was carried out bilaterally in 5 embalmed, latex-injected cadaver heads. MAIN OUTCOMES AND MEASURES: Cadaveric measurements of anatomic landmarks and relationships in the approach were obtained using a 10-cm surgical ruler and were reported as mean distances. Additionally, high-quality endoscopic images demonstrating the operative technique and anatomic relationships were obtained. RESULTS: The distance between the lacerum segment of the internal carotid arteries, the superolateral boundary, was 23.6 mm (SD, 11.8 mm). The distance between the anterolateral edge of the occipital condyles, the inferolateral boundary, was 19 mm (SD, 0.80 mm). The supracondylar groove was identified in the same anteroposterior plane as the nasopharyngeal orifice of the eustachian tube, and the anterior-most edge of the occipital condyle was 14 mm (SD, 0.82 mm) from the posterosuperior edge of the salpingopharyngeal fold. Additionally, the transtubercular corridor was on the same plane as the superior edge of the torus tubarius in the anteroposterior axis. The distance to the hypoglossal canal from midline was 10 mm, which was found after completing drilling in the transcondylar and transtubercular corridors. Last, the hypoglossal nerve rootlets were identified entering the canal 6 mm inferiorly and 8 mm laterally from the vertebrobasilar junction. CONCLUSIONS AND RELEVANCE: The eustachian tube and other elements of nasopharyngeal anatomy are fixed landmarks that provide important points of reference when approaching the hypoglossal canal through an EEA. A thorough understanding of these anatomic relationships is vital in safely navigating this direct, surgical corridor to the posterior fossa.


Assuntos
Dissecação , Tuba Auditiva/patologia , Nervo Hipoglosso/patologia , Cirurgia Endoscópica por Orifício Natural , Base do Crânio/patologia , Base do Crânio/cirurgia , Pontos de Referência Anatômicos/patologia , Cadáver , Humanos , Cavidade Nasal
20.
Laryngoscope ; 124(11): 2443-50, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25513678

RESUMO

OBJECTIVES/HYPOTHESIS: To propose a clinically applicable anatomic classification system describing three progressive endoscopic endonasal approaches (EEAs) to the infratemporal fossa (ITF) and their potential sequelae. Overall feasibility and outcomes of these approaches are presented through a consecutive case series. STUDY DESIGN: Description of classification system for EEAs to the ITF and case series. METHODS: A classification system of EEAs to ITF tumors was created based on the senior author's clinical experience and cadaveric dissection. A retrospective chart review of 21 child and adult patients with primary ITF tumors treated by these approaches from 2008 to 2012 at a tertiary-care academic medical center was conducted. RESULTS: Three progressive EEAs to ITF tumors were defined: 1) a transpterygopalatine fossa approach, 2) a transmedial pterygoid plate approach, and 3) a translateral pterygoid plate approach. Twenty-one patients treated with these approaches were identified consecutively, with a mean age of 44.2 years (range, 11-79 years). Tumors primarily involving the pterygopalatine fossa and not the ITF were excluded. Pathology included three advanced juvenile nasopharyngeal angiofibromas, three adenoid cystic carcinomas, two recurrent inverted papillomas, two trigeminal schwannomas, and 11 other diverse skull base pathologies. No intraoperative or postoperative complications occurred, with a mean follow-up of 21.5 months (range, 1-55 months). Expected potential sequelae such as V2/palatal numbness, Eustachian tube dysfunction, and trismus occurred in 10/21 patients. CONCLUSIONS: EEAs to ITF tumors are technically feasible with low risk of complications for well-selected patients. The proposed classification system is useful for anticipating potential sequelae for each approach.


Assuntos
Endoscopia/métodos , Recidiva Local de Neoplasia/patologia , Fossa Pterigopalatina/cirurgia , Neoplasias da Base do Crânio/patologia , Neoplasias da Base do Crânio/cirurgia , Adolescente , Adulto , Idoso , Angiofibroma/patologia , Angiofibroma/cirurgia , Criança , Estudos de Coortes , Fossa Craniana Anterior/cirurgia , Feminino , Seguimentos , Humanos , Neoplasias Infratentoriais/patologia , Neoplasias Infratentoriais/cirurgia , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Cavidade Nasal/cirurgia , Recidiva Local de Neoplasia/cirurgia , Neurilemoma/patologia , Neurilemoma/cirurgia , Estudos Retrospectivos , Medição de Risco , Lobo Temporal/patologia , Lobo Temporal/cirurgia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Adulto Jovem
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