Double Blinded Randomized Controlled Trial Comparing Budesonide and Saline Nasal Rinses in the Post-operative Management of Chronic Rhinosinusitis.

Post-operative management of chronic rhinosinusitis is very crucial for outcomes following surgery, Normal saline nasal irrigation and steroid spray form the standard treatment of care in this period. However nasal irrigation may not be adequate and spray is usually started after 2 weeks of surgery which in any case does not deliver optimum dosage of drug to the paranasal sinus mucosa. Budesonide nasal irrigation in a high-volume low-pressure system could be the solution for a better outcome. A double blinded randomized control trial with 88 patients in 2 groups of 44 each received normal saline or Budesonide nasal irrigation (0.5 mg in 200 ml) twice daily. Patients were followed up at 2 weeks post-operatively and 3 months, a SNOT 22 and Lund Kennedy Endoscopic scores were assessed for subjective and objective assessment. Subset analysis of only CRS patients (55) were done, and results presented. Patient reported subjective score at 3 months post operatively, SNOT22 was significantly (p < 0.0001) improved with the use of Budesonide irrigation (26.69 ± 2.92) as compared to Normal saline (30.54 ± 2.81) and objective assessment score, LKES was significantly (p = 0.0031) better in Budesonide group (4.06 + 0.74) in comparison to Normal saline in the saline (4.50 + 0.67) respectively. The mean scores 3 months post op visit was significantly lower for both subjective SNOT (p < 0.001) and objective score LKES (p < 0.0001) in Budesonide groups. Budesonide nasal irrigation with positive pressure high volume device has better patient benefits and wound healing when compared to normal saline irrigation in the post-operative management of chronic rhinosinusitis.

68 Ga-Citrate PET/CT Imaging in the Diagnosis of Skull Base Osteomyelitis and Its Usefulness in the Assessment of Treatment Response.

PURPOSE: 68 Ga-citrate PET/CT imaging in the diagnosis of skull base osteomyelitis (SBO) and its usefulness in the assessment of treatment response. METHODS: Eighteen patients underwent 68 Ga-citrate PET/CT scans for suspected SBO for diagnosis/assessment of treatment response. RESULTS: Of 18 patients, 16 patients had a positive study for SBO, and 2 patients had a negative study. Scan findings were correlated with clinical, biochemical, microbiological, and radiological parameters. CONCLUSION: 68 Ga-citrate PET/CT is a promising tool in the diagnosis and management of skull base osteomyelitis.

Clinico-Radiological Evaluation for Longitudinal Assessment in Central Skull Base Osteomyelitis: Proposal of Novel Scoring System.

This study aims to evaluate clinical, radiological and laboratory parameters for longitudinal assessment and prognostication in central skull base osteomyelitis (CSBO). Novel radiological score and cranial nerve assessment score (CNAS) have been proposed and analysed along with pain score (VAS), ESR, CRP, WBC count, and HbA1c for utility in disease-monitoring and predicting outcome in CSBO. CSBO cases managed in a tertiary care centre from January 2018 to November 2020, with a minimum follow-up of 6 months were included. The parameters were recorded at presentation, 3-month, 6-month postoperative follow-up, and at completion of therapy, for statistical analysis. Significant positive correlation was found amongst pain score, CNAS, radiological score, ESR, and CRP at different timelines. On longitudinal assessment, there was a statistically significant reduction in above-mentioned parameters, in the cases who recovered. Those with initial radiological score < 30, pain score ≤ 7, and CNAS < 10 showed early clinical improvement, required shorter duration of antimicrobial therapy, and exhibited higher probability of becoming disease-free at an earlier time, compared to those presenting with higher scores. We propose the use of pain score, a novel cranial nerve assessment score, and a novel radiological score for longitudinal assessment in CSBO. The trend in these parameters along with ESR and CRP are useful to monitor the disease process. The initial assessment scores can predict duration of antimicrobial therapy and probability of early recovery. WBC count and HbA1c were neither useful for disease-monitoring nor predicting outcome.

Tension Pneumocephalus: A Potentially Fatal Complication of Expanded Endoscopic Endonasal Approach.

While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications.

A Negative-Pressure Face-Mounted System Reduces Aerosol Spread during Endonasal Endoscopic Surgery.

Purpose Due to the potential risk of COVID-19 transmission during endonasal surgery, we studied methods to reduce droplet and aerosol generation during these procedures. Methods Droplet spread was assessed using ultraviolet light and a camera that detected fluorescence in the operative field and surgeon's personal protective equipment. Density of aerosols sized <10 µm was measured using a photometric particle counter. We designed a face-mounted negative-pressure mask placed on the patients' face during endoscopic endonasal surgery. Sixteen patients were recruited between October 2020 and March 2021 and randomly assigned to the mask and no-mask groups. We compared droplet spread and aerosols generated in both groups, with copious irrigation and continuous suction during drilling forming the mainstay of surgical technique in all cases. Results Droplet contamination due to direct spillage of fluorescein from the syringe was noted in two patients. Aerosol density rose during sphenoid drilling in both groups, with no significant difference when continuous suction and irrigation were employed (1.27 times vs. 1.07 times the baseline, p = 0 .248 ). Aerosol density rose significantly when suction and irrigation were interrupted in the no-mask group (44.9 times vs. 1.2 times, p = 0 .028) , which was not seen when the mask was used. Conclusion Aerosol generation increases during drilling in endonasal procedures and is a concern during this pandemic. The use of a rigid suction close to the drill along with copious irrigation is effective in reducing aerosol spread. The use of a negative pressure mask provides additional safety when inadvertent blockage of suction and inadequate irrigation occur.

Pharyngocutaneous Fistula Following Primary and Salvage Laryngectomy: Aetiology and Predictive Factors.

Laryngeal cancer treatment is often wrought with challenges, pharyngocutaneous fistula formation (PCF) in patients undergoing either primary or salvage laryngectomy for laryngeal and hypopharyngeal for squamous cell carcinoma is an important one. We aimed to study the factors before and at the surgery that are associated with PCF formation in a South Indian tertiary care hospital. A retrospective chart review of 127 patients who underwent total laryngectomy (TL) between May 2014 and April 2019 at our centre were done. Data was collected, including patient age and gender, comorbidities (Diabetes mellitus, COPD and hypothyroidism), smoking, tumor stage and site, prior tracheostomy, prior radiation, concurrent neck dissection and type of pharyngoplasty, Preoperative hemoglobin and albumin levels, surgical margin status and development of a PCF was also done. Further details specific to the development of a PCF were recorded for that subset of patients including the length of time to fistula, mode of closure, time of closure and modality of management. The overall incidence of PCF was 16.5% (21 of 127 patients), and the median time from TL to the diagnosis of PCF was 6 days (range, 3-20 days). The analysis was done separately for laryngectomies without any pharyngeal reconstruction (112/127 patients). In patients treated with a primary TL, the incidence of PCF was 12.20% (10 of 82) and 26.66% (8 of 30) after salvage TL. Subset analysis for type of pharyngoplasty repair showed 12% (15/127) underwent different types of vascularised/muscular flap for smaller residual pharyngeal mucosa, of which 20% (3/15) developed PCF and one patient developed haematoma needing exploration and re-suturing. The predictive factors for PCF were hypopharynx cancer (P < 0.05), surgical margin positivity (P < 0.0001), female gender (P < 0.05), absence of prior tracheostomy (P < 0.05) and tumor extension into pyriform sinus mucosa (P < 0.05). Preoperative patient factors of gender and site of primary along with histological margin positivity and extension of tumor to the pyriform sinus mucosa were significant risk factors for PCF formation. Pre-Op radiotherapy remains a strong clinical suspicion but not statistically significant.

Impact of Experience on Outcomes After Endoscopic Transsphenoidal Surgery for Acromegaly.

OBJECTIVE: Acromegaly is a syndrome of metabolic alterations secondary to increased growth hormone levels from a somatotroph pituitary adenoma. A multidisciplinary approach beginning with surgery, followed by adjuvant radiation or medical therapy for residual disease, is considered standard of care. Several factors affect the likelihood of remission after surgery, but the impact of surgical experience on remission rates has not been adequately assessed. METHODS: Retrospective review of 203 patients, divided into 2 eras (era 1, 102 patients; era 2, 101 patients) of patients who underwent transsphenoidal surgery for acromegaly by a single surgeon over 11 years, was performed, determining the effect of surgical experience on rates of remission and various complications. Remission was defined according to the 2014 Endocrine Society Clinical Practice Guideline. RESULTS: The rate of surgical remission was 40.6% (62.9% among noninvasive adenomas). Rates of surgical remission significantly improved in the latter half of this cohort (31.2% in the first half vs. 50% in the second half), despite other factors being comparable. On multivariate analysis, surgeon experience, cavernous sinus invasion, and preoperative growth hormone levels affected the rates of surgical remission. Rates of cerebrospinal fluid leak and hypopituitarism were lower in the second half, whereas resolution of acromegaly-associated comorbidities was increased. CONCLUSIONS: We report, in this large single-surgeon review of endoscopically operated acromegaly cases, increased rates of surgical remission and reduced complications with increasing surgeon experience. The overall experience of the treating team in dealing with perioperative and intraoperative factors also contributes to improved outcomes.

Meet the Lacrimal Sac: Endoscopic Surgeons' Road Map.

Knowledge of lateral nasal wall landmarks in relation to lacrimal apparatus is essential for successful endoscopic dacryocystorhinostomy. This descriptive study of right and left sagittally sectioned ten adult cadaver head specimens was done measuring various lateral nasal wall anatomical landmarks including lacrimal apparatus with digital calipers. Maxillary line was identified in 75%, majority overlapping lacrimal sac. Genu of middle turbinate was at or posterior to nasolacrimal duct. Mean distance of superior end of sac was 8.88 mm above axilla, between its anterior edge and axilla was 10.58 mm and its length was 11.72 mm. Considering above measurements, 'Rule of 10' can be applied for nasal mucosal incision. A "Three Tier Approach" to overcome mucosal (nasal), bony (lacrimal and frontal process of maxilla) and mucosal (sac) boundaries exposes lacrimal sac up to its inferior limit ensuring successful endonasal endoscopic dacryocystorhinostomy.

Ectomesenchymal chondromyxoid tumour: an uncommon characteristic tumour of the anterior tongue.

Ectomesenchymal chondromyxoid tumour (ECMT) is a rare benign tumour which classically presents in the anterior tongue. This tumour is grossly under-reported due to lack of immunohistochemical staining in many centres. We report a 46-year-old man who presented with mass in the anterior tongue and was diagnosed with ECMT. Further management of this lesion is explained with a review of the literature.

Feasibility of Transoral Approach to Accessory Parotid Tumors.

Tumors of the accessory parotid gland are very rare. Surgical removal of an accessory parotid tumor is usually accomplished by superficial parotidectomy through an external neck incision. However, this procedure inevitably results in a neck scar. In this case, we performed complete excision of a parotid tumor via an endoscopic-assisted transoral approach. Resection of such benign tumors can be achieved with less morbidity by endoscope-assisted surgery with a nerve monitoring system. The field of transoral surgery will continue to expand with technological advancements.

Langerhan's cell Histiocytosis of Sphenoid Sinus causing Vision Loss: A Case Report.

Langerhan's cell histiocytosis is an uncontrolled proliferation of dendritic cells. The involvement of skull base is rare. Variable clinical presentation and multi organ involvement often warrant a multidisciplinary approach for a successful diagnosis. We are reporting a case of 16-year-old male with sphenoid sinus Langerhan's cell histiocytosis which presented as a sudden and painless loss of vision. It is a rare entity in the diagnosis of blindness. Delayed diagnosis and treatment can result in serious complications. The radiological features and management options are discussed with a review of the pertinent literature. Keywords: : blindness; histiocytosis; langerhans-cell; sphenoid sinus.

A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.

BACKGROUND: Intraoperative cerebrospinal fluid (CSF) leaks are a frequent cause of morbidity in patients undergoing transsphenoidal surgery. This prospective study was performed to examine the impact of intraoperative lumbar subarachnoid drainage (LSAD) on the incidence of this complication and on the extent of resection in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. MATERIALS AND METHODS: This prospective study was conducted in a single large academic medical center. All patients with pituitary adenomas who had not undergone prior transsphenoidal surgery were eligible for inclusion in the study. Patients were randomly assigned to undergo transsphenoidal surgery with intraoperative lumbar drain insertion (LSAD group) or no lumbar drain insertion (no LSAD group). An otolaryngologist independently determined the occurrence of an intraoperative CSF leak. Extent of tumor resection was determined by volumetric analysis of postoperative magnetic resonance images in patients with nonfunctional tumors or functional adenomas with a large suprasellar component. RESULTS: Sixty patients were eligible for inclusion, of which 30 were assigned to the LSAD group and 30 to the no LSAD group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. The LSAD catheter was successfully inserted in all patients in the LSAD group. Intraoperative CSF drainage significantly reduced the incidence of CSF leak from 46.7% in the no LSAD group to 3.3% in the LSAD group (P < 0.001). However, there were no statistically significant differences in the incidence of postoperative CSF rhinorrhea between the two groups. There were no major catheter-related complications. There was no statistically significant difference in the extent of resection between the two groups. CONCLUSIONS: Controlled intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.

A novel nasoseptal flap harvesting technique in revision expanded endoscopic transsphenoidal approaches.

OBJECTIVES: To describe the technique of harvesting the nasoseptal flap (NSF) in revision-expanded endoscopic approaches (EEA). STUDY DESIGN: We retrospectively analyzed four cases of endoscopic skull base reconstruction (ESBR) following revision EEA done for pituitary adenoma recurrence. The presence of an intact mucoperiosteum between the nasal septum and the roof of the choana as judged on a preoperative endoscopic and radiological assessment was considered to be sufficient for the presence of a viable pedicle. By strategic placement of the incisions, the entire bilateral posterior nasal septal mucoperiosteum was raised in the NSF containing the remnant vascular pedicle. ESBR was performed with multilayer grafting of the dural defect, and the NSF was placed onto the bony margins of the defect. RESULTS: All patients had successful skull base reconstruction with the NSF raised by this technique as none of them developed postoperative cerebrospinal fluid leak. CONCLUSION: Though the number of patients in this study is small, we would like to present the concept of harvesting the NSF in revision surgery, wherein neither measuring the surface area of the pedicle nor the acoustic Doppler assessment of the pedicle is required.

Endoscopic Transmaxillary Transposition of Temporalis Flap for Recurrent Cerebrospinal Fluid Leak Closure.

Objective To describe the technique of endoscopic transmaxillary temporalis muscle flap transposition for the repair of a persistent postoperative sphenoidal cerebrospinal fluid leak. Design The repair of a recurrent cerebrospinal fluid leak for a patient who had undergone endoscopic transsphenoidal excision of an invasive silent corticotroph Hardy C and Knosp Grade IV pituitary adenoma was undertaken. The patient had completed postoperative radiotherapy for the residual tumor and presented with cerebrospinal fluid leak, 1 year later. The initial two attempts to repair the cerebrospinal fluid leak with free grafts failed. Therefore, an endoscopic transmaxillary transposition of the temporalis muscle flap was attempted to stop the cerebrospinal fluid leak. Results The endoscopic transmaxillary transposition of the vascularized temporalis muscle flap onto the cerebrospinal fluid leak repair site resulted in successful closure of the cerebrospinal fluid leak. Conclusion Endoscopic transmaxillary transposition of the temporalis flap resulted in closure of recurrent cerebrospinal fluid leak in a patient with recurrent pituitary adenoma, who had undergone previous surgery and radiotherapy. This technique has advantages over the endoscopic transpterygoid transposition of the same flap and could be used as a complementary technique in selected patients.

Skull Base Osteomyelitis Caused by an Elegant Fungus.

Malignant otitIs externa (skull base osteomyelitis) is predominantly caused by bacteria while fungal etiology is rare. We report a middle aged diabetic gentleman who succumbed to invasive skull base infection due to Apophysomyces elegans a fungus belonging to Zygomycetes which causes only skin and soft tissue infections. Mortality and invasive infections due to this genus is rarely reported, especially in the ear.

Principles in Skull Base Reconstruction following Expanded Endoscopic Approaches.

OBJECTIVES: This study aims to describe the types of anterior skull base defects following expanded endoscopic approaches (EEA) and to outline the techniques involved in the repair of these defects. DESIGN: We retrospectively analyzed 63 cases of endoscopic skull base reconstruction (ESBR) following tumor excision, done from September 2011 to January 2015. These tumors consisted of 14 pituitary adenomas, 20 craniopharyngiomas, and 29 other miscellaneous tumors. The classification of skull base defects by Tabaee et al and the classification of cerebrospinal fluid (CSF) leaks by Esposito et al were considered during the ESBR. Recurrence of CSF leak was considered as failure of reconstruction. RESULTS: The 63 skull base defects included in this study occurred following EEA for tumor excision. Failure of reconstruction occurred in 6 six patients. All were successfully repaired, however, three patients in this series died due to tumor-related complications. CONCLUSION: The adherence to the general principles of reconstruction, appreciating the subtle differences in the nature of the various defects and the ability to adopt different strategies are the prerequisites for the successful closure of skull base defects.

A reclusive foreign body in the airway: a case report and a literature review.

A foreign body in the larynx is an airway emergency that requires urgent evaluation and treatment. Irregular foreign bodies tend to orient in a sagittal plane and may produce only partial obstruction, allowing adequate air movement, hence making them undetectable for a long period of time. We report a case of a laryngotracheal foreign body that remained reclusive for 9 years.