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1.
Artigo em Inglês | MEDLINE | ID: mdl-32567798

RESUMO

BACKGROUND: Post-viral olfactory dysfunction (PVOD) is one of the most common causes of olfactory loss. Despite its prevalence, optimal treatment strategies remain unclear. This article provides a comprehensive review of PVOD treatment options and provides evidence-based recommendations for their use. METHODS: A systematic review of the Medline, Embase, Cochrane, Web of Science, Scopus, and Google Scholar databases was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies with defined olfactory outcomes of patients treated for PVOD following medical, surgical, acupuncture, or olfactory training interventions were included. The Clinical Practice Guideline Development Manual and Conference on Guideline Standardization (COGS) instrument recommendations were followed in accordance with a previously described, rigorous, iterative process to create an evidence-based review with recommendations. RESULTS: From 552 initial candidate articles, 36 studies with data for 2183 patients with PVOD were ultimately included. The most common method to assess olfactory outcomes was Sniffin' Sticks. Broad treatment categories included: olfactory training, systemic steroids, topical therapies, a variety of heterogeneous non-steroidal oral medications, and acupuncture. CONCLUSION: Based on the available evidence, olfactory training is a recommendation for the treatment of PVOD. The use of short-term systemic and/or topical steroids is an option in select patients after careful consideration of potential risks of oral steroids. Though some pharmacological investigations offer promising preliminary results for systemic and topical medications alike, a paucity of high-quality studies limits the ability to make meaningful evidence-based recommendations for the use of these therapies for the treatment of PVOD.

2.
J Neurol Surg B Skull Base ; 80(4): 392-398, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31316885

RESUMO

Background There is little data regarding postoperative outcomes of patients with obstructive sleep apnea (OSA) undergoing skull base surgery. The purpose of this study is to determine an association between risk factors and proximity of cerebrospinal fluid (CSF) leak to surgery in patients with OSA undergoing endoscopic skull base surgery. Methods A retrospective review of neurosurgical inpatients, with and without OSA, at a tertiary care institution from 2002 to 2015 that experienced a postoperative CSF leak after undergoing endoscopic skull base surgery. Results Forty patients met inclusion criteria, 12 (30%) with OSA. OSA patients had significantly higher body mass index (BMI; median 39.4 vs. 31.7, p < 0.01) and were more likely to have diabetes (41.7 vs. 10.7%, p = 0.04) than non-OSA patients; otherwise there were no significant differences in clinical comorbidities. No patients restarted positive pressure ventilation (PPV) in the inpatient setting. The type of repair was not a significant predictor of the time from surgery to leak. Patients with OSA experienced postoperative CSF leak 49% sooner than non-OSA patients (Hazard Ratio 1.49, median 2 vs. 6 days, log-rank p = 0.20). Conclusion Patients with OSA trended toward leaking earlier than those without OSA, and no OSA patients repaired with a nasoseptal flap (NSF) had a leak after postoperative day 5. Due to a small sample size this trend did not reach significance. Future studies will help to determine the appropriate timing for restarting PPV in this high risk population. This is important given PPV's significant benefit to the patient's overall health and its ability to lower intracranial pressure.

3.
Int Forum Allergy Rhinol ; 9(5): 493-500, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30657649

RESUMO

BACKGROUND: Olfactory nerve fibers are at risk of injury during transnasal endoscopic skull-base approaches. Olfactory outcomes for various techniques have not been thoroughly investigated. This study aims to report long-term olfactory outcomes when a cold knife upper septal limb incision technique is used compared to monopolar cautery. METHODS: A prospective cohort study was performed at a tertiary referral center. Adult patients undergoing endoscopic approaches with septal incisions were randomized to cold knife or monopolar cautery groups. Patient demographics, clinical history, surgical data, and outcomes were collected. Preoperative, 3-month, and 12-month postoperative scores on the University of Pennsylvania Smell Inventory Test (UPSIT) and 22-item Sino-Nasal Outcome Test (SNOT-22) were measured. Fisher's exact tests were performed for categorical variables and t tests were performed for continuous variables. RESULTS: Twenty-two (22) patients (10 cold knife, 12 cautery) were enrolled between March 2016 and August 2017. The average age ± standard deviation was 50.2 ± 14.0 years (p = 0.59), 54% (p = 0.69) were female, and the primary pathology was pituitary adenoma (73%, p = 1.00). Preoperative, 3-month, and 12-month postoperative UPSIT scores were similar between the cold knife and cautery groups (32.8 vs 32.4, p = 0.80; 33.1 vs 33.0, p = 0.96; 33.6 vs 33.3, p = 0.84). On the "sense of smell/taste" question of the SNOT-22, there was also no difference at all time points (p > 0.22). CONCLUSION: There was no significant change in patient UPSIT scores 1 year after transnasal skull-base approaches, and no short-term or long-term differences between cold knife and cautery upper septal limb incision techniques. Our study supports an individualized approach based on surgeon preference.


Assuntos
Eletrocoagulação , Endoscopia , Septo Nasal/cirurgia , Procedimentos Cirúrgicos Nasais , Base do Crânio/cirurgia , Olfato , Adenoma/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/cirurgia , Estudos Prospectivos
4.
Int Forum Allergy Rhinol ; 8(10): 1162-1168, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29856526

RESUMO

BACKGROUND: To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing. METHODS: In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases. RESULTS: Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion. CONCLUSION: This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.


Assuntos
Mucosa Intestinal/transplante , Septo Nasal/cirurgia , Rinoplastia/métodos , Base do Crânio/cirurgia , Células-Tronco/citologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Septo Nasal/patologia , Estudos Prospectivos , Base do Crânio/patologia , Células-Tronco/metabolismo , Retalhos Cirúrgicos/patologia , Suínos , Resultado do Tratamento , Cicatrização
6.
Laryngoscope ; 128(2): 317-326, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28921539

RESUMO

OBJECTIVE: Since first described in the 1990s, the endoscopic modified Lothrop procedure (EMLP) has been the subject of a growing body of literature. We performed a review to compare indications and outcomes of EMLP in an early cohort of publications (1990-2008) versus a contemporary cohort (2009-2016) and compare outcomes associated with follow-up ≥2 years versus <2 years. DATA SOURCES: PubMed, SCOPUS and Cochrane databases. REVIEW METHODS: An English-language search of the PubMed and Ovid databases was conducted to identify publications from 1990 to 2016 reporting clinical outcomes of EMLP. Meta-analysis was performed using Statistical Analysis System 9.4. RESULTS: A total of 1,205 patients were abstracted from 29 articles with a mean follow-up of 29.1 ± 10.3 months. The overall rate of significant or complete symptom improvement was 86.5% (95% confidence interval [CI]: 84.2%-88.7%). The overall patency rate was 90.7% (95% CI: 89.1%-92.3%), with a revision rate of 12.6% (95% CI: 10.6%-14.3%). Compared to the early cohort, patients in the contemporary cohort underwent EMLP more often for tumors (P < .001), had higher rates of complete or significant symptom improvement (90.0% vs. 82.6 %, P < .001); and trended toward greater patency rates (92.1% vs. 88.6%, P = .052). Compared to the short-term follow-up cohort, the long-term cohort showed no differences in symptom improvement or patency, but the revision rate was higher (14.5% vs. 9.2%, P = .016). CONCLUSIONS: In the last decade, EMLP has been performed more frequently for tumors. Recent studies have demonstrated improved symptom outcomes and a trend toward improved patency rates. The revision rate increased significantly when follow-up exceeded 2 years. Laryngoscope, 128:317-326, 2018.


Assuntos
Endoscopia/métodos , Sinusite Frontal/cirurgia , Endoscopia/efeitos adversos , Feminino , Seio Frontal/cirurgia , Humanos , Masculino , Reoperação/estatística & dados numéricos , Resultado do Tratamento
7.
Artigo em Inglês | MEDLINE | ID: mdl-29204577

RESUMO

Clinical experience has suggested the existence of an intermediate form of fungal sinusitis between the categories of non-invasive fungal sinusitis (non-IFS) and invasive fungal sinusitis (IFS). This fungal sinusitis variant demonstrates unhealthy mucosa by endoscopy with fungal invasion, but lacks angioinvasion microscopically, representing what clinically behaves as a 'pre-invasive' subtype of fungal sinusitis. Unlike non-IFS disease, patients with pre-invasive fungal sinusitis were still felt to require anti-fungal medications due to histologic presence of invasive fungus. While sharing some clinical features of IFS, these 'intermediate' patients were successfully spared extended and repeated surgical debridements given the microscopic findings, and have been successfully treated with shorter courses of antifungal therapy. These select patients have had favorable outcomes when managed in a judicious and semi-aggressive manner, in an undefined zone between the treatments for routine fungal ball and aggressive IFS.

8.
Otolaryngol Clin North Am ; 50(3): 599-606, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28325634

RESUMO

Coblation is a technology that incorporates bipolar radiofrequency energy to ablate tissue at relatively low temperatures. Its use for sinonasal surgery is actively being investigated, including applications for turbinate reduction, sinus surgery, skull base surgery, and adenoidectomy. Potential benefits include reduction in blood loss, improved endoscopic surgical visualization, and reduction in postoperative pain. The main drawbacks are its relatively high cost, potential adverse effects on functional epithelium, and relative paucity of long-term outcomes.


Assuntos
Ablação por Cateter/métodos , Desbridamento/instrumentação , Equipamentos Cirúrgicos , Ablação por Cateter/economia , Temperatura Baixa , Desbridamento/métodos , Endoscopia , Humanos , Seios Paranasais/cirurgia , Hemorragia Pós-Operatória/terapia , Base do Crânio/cirurgia
9.
Head Neck ; 38(8): 1201-7, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27225507

RESUMO

BACKGROUND: The purpose of this study was to describe how the up-front transoral robotic surgery (TORS) approach could be used to individually tailor adjuvant therapy based on surgical pathology. METHODS: Between January 2009 and December 2013, 76 patients received TORS for oropharyngeal squamous cell carcinoma (OPSCC). Clinical predictors of adjuvant therapy were analyzed and comparisons were made between recommended treatment guidelines for up-front surgery versus definitive nonsurgical approaches. RESULTS: Advanced N classification, human papillomavirus (HPV)-positive tumor, extracapsular spread (ECS; 26 of 76), perineural invasion (PNI; 14 of 76), and positive margins (7 of 76) were significant predictors of adjuvant chemoradiotherapy (CRT) (p < .05). Up-front TORS deintensified adjuvant therapy; 76% of stage I/II and 46% of stage III/IV patients avoided CRT. Conversely, pathologic staging resulted in 33% of patients who would have received radiotherapy (RT) alone based on clinical staging, to be intensified to receive adjuvant CRT. CONCLUSION: The TORS approach deintensifies adjuvant therapy and provides valuable pathologic information to intensify treatment in select patients. TORS may be less effective in deintensification of adjuvant therapy in patients with clinically advanced N classification disease. © 2016 Wiley Periodicals, Inc. Head Neck 38:1201-1207, 2016.


Assuntos
Carcinoma de Células Escamosas/terapia , Quimiorradioterapia Adjuvante/métodos , Neoplasias de Cabeça e Pescoço/terapia , Neoplasias Orofaríngeas/terapia , Procedimentos Cirúrgicos Robóticos/métodos , Centros Médicos Acadêmicos , Adulto , Idoso , Análise de Variância , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Distribuição de Qui-Quadrado , Estudos de Coortes , Intervalo Livre de Doença , Feminino , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Estimativa de Kaplan-Meier , Laringectomia/métodos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Neoplasias Orofaríngeas/mortalidade , Neoplasias Orofaríngeas/patologia , Neoplasias Orofaríngeas/cirurgia , Planejamento de Assistência ao Paciente , Prognóstico , Radioterapia Adjuvante , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/mortalidade , Carcinoma de Células Escamosas de Cabeça e Pescoço , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos
10.
Head Neck ; 38 Suppl 1: E776-82, 2016 04.
Artigo em Inglês | MEDLINE | ID: mdl-25916790

RESUMO

BACKGROUND: Transoral robotic-assisted surgery (TORS) carries a small, but not insignificant, risk of life-threatening postsurgical hemorrhage. The purpose of this study was to analyze all post-TORS hemorrhagic events at our institution to establish preventative recommendations. METHODS: We conducted a retrospective review of 224 consecutive patients who underwent TORS for any indication at a single tertiary care institution. RESULTS: Twenty-two patients (n = 22; 9.82%) had varying degrees of postoperative bleeding. An impaired ability to protect the airway at the time of hemorrhage increased the rate of severe complications. Prophylactic transcervical arterial ligation did not significantly decrease overall postoperative bleeding rates (9.1% vs 9.9%; p = 1.00); however, there was a trend toward decreased hemorrhage severity in prophylactically ligated patients (3.0% vs 7.3%; p = .7040). CONCLUSION: Prophylactic transcervical arterial ligation may reduce the incidence of severe bleeding following TORS. Post-TORS patients displaying an inability to protect the airway should be strongly considered for prophylactic tracheostomy to assist airway protection. © 2015 Wiley Periodicals, Inc. Head Neck 38: E776-E782, 2016.


Assuntos
Procedimentos Cirúrgicos Bucais/efeitos adversos , Hemorragia Pós-Operatória/epidemiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traqueostomia , Adulto Jovem
11.
Ear Nose Throat J ; 94(8): E43-7, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26322457

RESUMO

Papillary thyroid cancer (PTC) is the most common malignancy of the thyroid gland. It typically spreads via lymphatic extension. The rate of regional PTC metastasis to the neck is relatively high, while metastases outside the deep cervical chain are rare. Distant metastases are found in only 1% of patients with PTC at the time of surgery; the two most common sites are the lung and bone. We report 4 cases of PTC metastasis to unusual sites: (1) the occipital skull and internal jugular vein, (2) the parapharyngeal space, (3) the sternocleidomastoid muscle, and (4) the right atrium of the heart. It has been well documented that aggressive distant metastasis is a characteristic of PTC, and it is known to be an indicator of a poor prognosis. Some of our patients' sites of metastatic disease have not been previously reported. Patients in this series exhibited aggressive histologic findings, including columnar cell and follicular variants of papillary disease. In addition, all 4 patients demonstrated "PET-avid" disease with decreased iodine avidity.


Assuntos
Carcinoma Papilar/patologia , Neoplasias da Glândula Tireoide/patologia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/patologia , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/secundário , Humanos , Veias Jugulares/diagnóstico por imagem , Metástase Linfática , Neoplasias Musculares/diagnóstico por imagem , Neoplasias Musculares/secundário , Músculos do Pescoço/diagnóstico por imagem , Músculos do Pescoço/patologia , Osso Occipital/diagnóstico por imagem , Osso Occipital/patologia , Neoplasias Faríngeas/diagnóstico por imagem , Neoplasias Faríngeas/secundário , Neoplasias Cranianas/diagnóstico por imagem , Neoplasias Cranianas/secundário , Neoplasias Vasculares/diagnóstico por imagem , Neoplasias Vasculares/secundário
12.
Int Forum Allergy Rhinol ; 5 Suppl 1: S35-40, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26335835

RESUMO

BACKGROUND: Asthma is a prevalent disease characterized by chronic inflammatory changes of the airway and marked by airway hyperresponsiveness, edema, and excess mucus production. Management of the disease has focused upon reversing the early airway changes and limiting the late effects of airway remodeling. Several classes of medications are available for the effective treatment and long-term control of asthma and novel therapeutic options are in development that hold promise in improving patient outcome. METHODS: A review of updated guidelines and current literature was conducted to identify available pharmacologic treatments of asthma and determine future directions in development of novel therapeutic options. RESULTS: Inhaled corticosteroids are the most effective medications in long-term asthma control with adjunct medications such as ß2-agonists, which can provide symptomatic relief. Other classes of asthma control medications including anticholinergics, cromolyns, and leukotriene receptor modifiers can also be used to develop an effective management strategy based on asthma severity. CONCLUSION: Several classes of medications are available for the effective management of asthma. Inhaled corticosteroids play a central role in control of inflammation and several other adjuncts are available to tailor therapy to the patient's symptoms. New therapeutic options that target downstream inflammatory mediators can provide increased efficacy while limiting side effects.


Assuntos
Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Corticosteroides/uso terapêutico , Anti-Inflamatórios/uso terapêutico , Humanos
13.
JAMA Otolaryngol Head Neck Surg ; 141(6): 499-504, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25834991

RESUMO

IMPORTANCE: Few studies have examined quality-of-life (QOL) outcomes in patients who undergo transoral robotic surgery (TORS) alone (ie, without adjuvant radiotherapy or chemoradiotherapy). OBJECTIVE: To report QOL outcomes of patients with oropharyngeal squamous cell carcinoma who receive only TORS. DESIGN, SETTING, AND PARTICIPANTS: Medical records for all patients undergoing TORS for treatment of primary oropharyngeal squamous cell carcinoma from May 1, 2010, to March 31, 2014, at a tertiary care academic cancer center were examined from June through September 2014. Thirty-four patients who did not receive adjuvant therapy after TORS were included in the study. INTERVENTION: Primary surgical resection via TORS. MAIN OUTCOMES AND MEASURES: The University of Washington Quality of Life, version 4, questionnaire was completed by patients preoperatively and at 1-, 6-, 12-, and 24-month intervals after TORS. Demographic, clinicopathologic, and follow-up data were collected. RESULTS: Mean follow-up time was 14 months (May 1, 2010, to April 30, 2014). Most patients had T1 (20 [59%]) or T2 (13 [38%]) and N0 (13 [38%]) or N1 (16 [47%]) disease. Statistically significant improvement in QOL outcomes was noted in the following postoperative domains: chewing from 1 month (median, 50 [IQR, 50-100]) to 12 months (100 [IQR, 100-100]; P = .048), swallowing from 1 month (70 [IQR, 30-85]) to 6 months (100 [IQR, 70-100]; P = .047) and 1 to 24 months (100 [IQR, 70-100]; P = .048), pain from 1 month (38 [IQR, 25-75]) to 6 months (88 [IQR, 75-100]; P = .006) and 1 to 12 months after surgery (100 [IQR, 75-100]; P = .01), and activity from 1 month (63 [IQR, 50-88]) to 24 months (100 [IQR, 75-100]; P = .03). Two participants (6%) died during the follow-up period: 1 because of disease and 1 because of a myocardial infarction. Two patients (6%) required temporary gastrostomy tube placement, but none required tracheostomy. CONCLUSIONS AND RELEVANCE: Appropriately selected patients who undergo TORS alone for oropharyngeal squamous cell carcinoma experience acceptable short- and long-term QOL outcomes.


Assuntos
Carcinoma de Células Escamosas/psicologia , Carcinoma de Células Escamosas/cirurgia , Cirurgia Endoscópica por Orifício Natural/métodos , Neoplasias Orofaríngeas/psicologia , Neoplasias Orofaríngeas/cirurgia , Qualidade de Vida , Robótica , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/psicologia , Estadiamento de Neoplasias , Neoplasias Orofaríngeas/mortalidade , Neoplasias Orofaríngeas/patologia , Estudos Prospectivos , Estudos Retrospectivos , Inquéritos e Questionários , Taxa de Sobrevida , Resultado do Tratamento
14.
Am J Rhinol Allergy ; 29(2): 135-40, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25785755

RESUMO

OBJECTIVE: The objective of this systematic review was to evaluate synechiae formation in patients who underwent packing in the middle meatus at the completion of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis. DATA SOURCES: PubMed and Ovid. REVIEW METHODS: Prospective randomized controlled studies of ESS with the placement of middle meatal packing were reviewed and included for analysis. Metaanalysis of the pooled data was performed. RESULTS: Eighteen prospective, randomized, controlled trials met inclusion criteria, resulting in a total of 925 subjects. Although there was a trend toward decreased risk of synechiae formation in the patients who underwent placement of middle meatal packing postoperatively (RR = 0.544), this did not achieve statistical significance on metaanalysis (p = 0.052). CONCLUSIONS: This systematic review and metaanalysis suggests that use of middle meatal packing does not significantly reduce the risk of synechiae formation after ESS. There was, however, significant heterogeneity of the data analyzed, and the difference between groups was just short of statistical significance in our metaanalysis. Additional prospective randomized studies on this topic will further elucidate the utility of middle meatal packing.


Assuntos
Endoscopia , Seios Paranasais/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Aderências Teciduais/prevenção & controle , Animais , Bandagens , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Aderências Teciduais/etiologia
15.
Otolaryngol Head Neck Surg ; 152(2): 255-9, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25475502

RESUMO

OBJECTIVES: To assess delayed nasoseptal flaps as a viable reconstructive option for sellar defects, evaluate postoperative vascularity of delayed nasoseptal flaps, and compare cerebrospinal fluid leak and surgery-specific complication rates of primary to delayed nasoseptal flaps. STUDY DESIGN: Case series with chart review. SETTING: University of Pittsburgh Medical Center. SUBJECTS AND METHODS: All patients undergoing transsellar approaches for skull base tumors from 2009 to 2013 were evaluated. In cases where the necessity of a vascularized reconstructive flap was made evident only after tumor resection, the nasoseptal flap was raised after tumor resection and/or cerebrospinal fluid leak development, thus constituting a delayed nasoseptal flap. Outcome measures include postoperative magnetic resonance imaging (MRI) findings, cerebrospinal leak rates, and complication rates. RESULTS: During this timeframe, 437 patients underwent transsellar approaches. Primary nasoseptal flaps were used to reconstruct 179 patients while 32 patients had delayed flaps. All available postoperative MRI scans of delayed nasoseptal flap patients maintained vascularity on examination of T1 postcontrast images. There was no significant difference in cerebrospinal fluid leak rate between primary (3.4%) and delayed flaps (3.1%) (P = .95). There was no significant difference in surgery-specific complication rates between primary flaps (10.6%) and delayed flaps (3.1%; P = .14). Logistic regression analysis demonstrated no significant effect of flap type, age, or sex on cerebrospinal fluid leak rates. CONCLUSION: Delayed nasoseptal flaps are a viable reconstructive option for sellar skull base defects. They maintain vascularity as evidenced on postoperative MRI and are comparable to primary nasoseptal flaps with regard to cerebrospinal fluid leak rates and complication rates.


Assuntos
Endoscopia/métodos , Septo Nasal/transplante , Procedimentos Cirúrgicos Reconstrutivos/métodos , Neoplasias da Base do Crânio/cirurgia , Retalhos Cirúrgicos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Meios de Contraste , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Septo Nasal/irrigação sanguínea , Complicações Pós-Operatórias , Retalhos Cirúrgicos/irrigação sanguínea , Resultado do Tratamento
16.
Am J Rhinol Allergy ; 28(6): 502-7, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25514487

RESUMO

BACKGROUND: The middle turbinate (MT) is a structure that is often carefully preserved during endoscopic sinus surgery (ESS) in an effort to preserve nasal physiology and serve as an anatomic landmark. However, resection is performed in select cases because of involvement of the MT in the inflammatory process, obstruction, or instability. Therefore, significant controversy exists among surgeons regarding the indications for proceeding with MT resection in ESS. This study evaluates clinical outcomes of MT resection after ESS. METHODS: An English language search of the PubMed and Ovid databases was conducted for publications examining clinical outcomes of MT resection after ESS performed for chronic rhinosinusitis. Two authors independently examined the articles to identify those meeting inclusion criteria. Any differences over which studies to include were resolved by discussion and consensus. Bias assessment was conducted using the Cochrane Collaboration bias tool for randomized controlled trials and the Newcastle-Ottawa bias tool for cohort and case-control studies. RESULTS: After initial screening, search results revealed 71 articles that warranted detailed evaluation. After applying inclusion criteria, 9 studies were selected. A total of 2123 patients were included among the studies. All studies were controlled. Within the limited available data, olfaction scores may be improved in the MT resection patients compared with MT preservation patients. No difference between the groups was noted for quality of life outcomes, nasal airway resistance, or rates of postoperative frontal sinusitis. In regard to postoperative endoscopic examinations, some studies note greater improvement in the MT resection group compared with the MT preservation group, while others were equivalent. CONCLUSION: Although some studies show outcome benefit in MT resection patients compared with MT preservation patients, several others show no difference. When MT resection was appropriately indicated, no studies showed detrimental effects compared with MT preservation in their designated outcomes. Additional more stringent studies are warranted.


Assuntos
Endoscopia , Seios Paranasais/cirurgia , Rinoplastia , Conchas Nasais/cirurgia , Animais , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Conchas Nasais/imunologia , Conchas Nasais/patologia
17.
J Neurol Surg B Skull Base ; 75(4): 225-30, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25093144

RESUMO

Objective When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design Cadaveric anatomical study. Participants Cadaveric specimens. Main Outcome Measures Flap size, arc of rotation, and reconstructive applications were assessed. Results The average width of the flap was 5.46 ± 0.58 cm (7.32 ± 0.59 cm with septal mucosa). The average length of the flap was 5.01 ± 0.58 cm (5.28 ± 0.37 cm with septal mucosa). The average surface area of the flap was ∼ 27.26 ± 3.65 cm(2) (40.53 ± 6.45 cm(2) with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable.

18.
Laryngoscope ; 124(10): 2297-304, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24913023

RESUMO

OBJECTIVES/HYPOTHESIS: To identify factors contributing to local tumor recurrence in oral cavity and laryngeal squamous cell carcinomas treated with surgery alone, to approximate tumor age from time to recurrence data by applying Collins' law, and to identify factors that may affect time to recurrence. STUDY DESIGN: Retrospective review. METHODS: A retrospective review of all patients treated for head and neck cancer from 1997 to 2013 at the University of Pittsburgh Medical Center was performed. RESULTS: A total of 517 patients treated with surgery alone qualified for the study, of which 84 had local recurrence, and 433 had no local recurrences. History of tobacco use (P = .017), pack-year cigarette history (P = .001), and T stage (P = .03) were associated with disease recurrence. Overall, never tobacco users, those with fewer pack-years of smoking history, and those with lower T stage were more likely to recur. Time to recurrence was significantly shorter for laryngeal tumors compared to oral cavity tumors (P = .027). Median time to recurrence for oral cavity tumors was 8.6 months and laryngeal tumors was 7.1 months. CONCLUSIONS: In this study, lower pack-year smoking history, lower T stage, and history of never tobacco use were associated with local tumor recurrence. Applying the concept of Collins' law to estimate the age of tumors at diagnosis, the median tumor age at diagnosis was estimated to be 8.6 months for oral cavity tumors and 7.1 months for laryngeal tumors.


Assuntos
Neoplasias Laríngeas/diagnóstico , Neoplasias Bucais/diagnóstico , Recidiva Local de Neoplasia/etiologia , Estadiamento de Neoplasias , Procedimentos Cirúrgicos Otorrinolaringológicos , Medição de Risco/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Incidência , Neoplasias Laríngeas/cirurgia , Masculino , Pessoa de Meia-Idade , Neoplasias Bucais/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Pennsylvania/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Adulto Jovem
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