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1.
J Neurol Surg Rep ; 83(1): e8-e12, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-35028278

RESUMO

This report describes a case of pituitary apoplexy with rapidly evolving hemorrhage in a 74-year-old female with coronavirus disease 2019 (COVID-19) disease. The patient presented with severe headache and mild respiratory symptoms, with laboratories concerning for pituitary hypofunction. Brain imaging demonstrated a sellar mass concerning for a pituitary adenoma with ischemic apoplexy. She subsequently developed visual deficits within 24 hours of presentation, and repeat imaging demonstrated evolving hemorrhage and new mass effect on the optic chiasm. She was successfully managed with urgent endoscopic endonasal surgery despite her COVID-19 positive status by taking special intraoperative precautions to mitigate SARS-CoV2 transmission risk. Only a handful of cases of pituitary apoplexy have been reported in association with COVID-19 disease, and even fewer reports exist of endonasal procedures in such cases. We discuss the potential implication of COVID-19 in the occurrence of pituitary apoplexy, in addition to the safety and success of endonasal surgery in this population.

2.
Head Neck ; 2022 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-35020252

RESUMO

BACKGROUND: We ascertain the role of a low cervical paraspinal skeletal muscle index (CPSMI) as a biomarker for poor treatment tolerance in patients with operable mucosal head and neck squamous cell carcinoma (HNSCC). METHODS: A prospective cohort of patients with operable HNSCC requiring microvascular reconstruction was evaluated. Low CPSMI was calculated using preoperative CT neck imaging. Poor treatment tolerance, a composite measure of incomplete therapy or severe morbidity/mortality during treatment, was the primary outcome. RESULTS: One hundred and twenty-seven patients underwent extirpative surgery with a mean age was 60.5. Poor treatment tolerance occurred in 71 (56%) patients with 21 not completing recommended adjuvant therapy and 66 having severe treatment-related morbidity. A low CPSMI was independently associated with poor treatment tolerance (OR 2.49, 95%CI 1.10-5.93) and delay to adjuvant therapy (OR 4.48, 95%CI 1.07-27.6) after adjusting for multiple confounders. CONCLUSION: Low CPSMI was independently associated with poor treatment tolerance in patients with operable HNSCC.

3.
J Neurosurg ; (1): 9, 2021 10 22.
Artigo em Inglês | MEDLINE | ID: mdl-34874673

RESUMO

OBJECTIVE: Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas. METHODS: Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument. RESULTS: Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO. CONCLUSIONS: The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach. ABBREVIATIONS: EEA = endoscopic endonasal approach; GTR = gross-total resection; PRO = patient-reported outcome; PROMIS29 = Patient-Reported Outcomes Measurement Information System-29; QOL = quality of life; SMPRO = Suprasellar Meningioma Patient-Reported Outcome Survey; TCA = transcranial approach.

4.
Microsurgery ; 2021 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-34935198

RESUMO

OBJECTIVE: Sarcopenia is increasingly being recognized as a negative prognostic factor in patients with head and neck cancer (HNC). We associate a sarcopenia biomarker measured radiographically from computed tomography (CT) of the neck to postoperative adverse events in patients with operable HNC. PATIENTS AND METHODS: A prospective cohort of treatment-naïve HNC patients undergoing surgery with microvascular reconstruction was performed. Cervical paraspinal skeletal muscle index (CPSMI) was calculated using preoperative CT neck imaging and adjusted for height and sex. Postoperative adverse events, including Clavien-Dindo Grade 3+ complications and fistula, were recorded within 30-days of the index surgery. Multivariate logistic regression was used to evaluate the association between CPSMI and postoperative complications. The modified frailty index (mFI) and Risk Assessment Index (RAI) were compared with CPSMI outcomes. RESULTS: A total of 127 patients with mucosal HNC were included in the study. The mean age was 60.5 years, and 87 (68.5%) patients were male. Sixty Clavien-Dindo grade 3+ events occurred; 17 patients developed an oro/pharyngocutaneous fistula. Low CPSMI was independently associated with Clavien-Dindo Grade 3+ events (OR 2.80, 95% CI of 1.18-6.99) and fistula (OR of 6.10, 95% CI of 1.53-24.3) when adjusted for multiple factors. CPSMI outperformed the mFI and RAI frailty indices to predict postoperative adverse events (p < .05). CONCLUSION: Low CPSMI is independently associated with postoperative adverse events and outperforms current frailty indices inoperable HNC with microvascular reconstruction.

5.
Am J Otolaryngol ; 43(2): 103360, 2021 Dec 24.
Artigo em Inglês | MEDLINE | ID: mdl-34972004

RESUMO

BACKGROUND: Head and neck surgery encompasses major vessels, raising the concern of life-threatening complications such as stroke. METHODS: Databases at UPMC were queried to identify patients with both neck dissections and stroke from January 1st, 2004, to October 1st, 2020. A retrospective chart review was performed to identify patients who experienced a stroke within 30 days of a neck dissection. RESULTS: Search of a UPMC database for carotid artery stenosis (CAS), transient ischemic attack (TIA), and stroke identified 20,527 patients. After matching with the Head and Neck Tumor Registry patients, 41 of 4230 patients with a neck dissection also had a stroke, TIA, or CAS in their lifetime. One patient, with multiple risk factors, despite pre-operative precautions, had a stroke 2 days post neck dissection in the setting of carotid occlusion from hypercoagulability of malignancy and intraoperative vessel injury. The patient subsequently underwent a carotid thrombectomy and vein patch repair and has had no additional cerebrovascular accidents. CONCLUSION: Although the incidence of stroke post neck dissection is minimal, patients with multiple risk factors for stroke should be managed carefully to prevent deleterious outcomes.

6.
J Neurol Surg B Skull Base ; 82(6): 601-607, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34745826

RESUMO

Objective Previous work categorized skull base chordoma (SBC) into three genetic risk groups based on 1p36 and homozygous 9p21(p16) deletions, accounting for a wide variability in prognosis (A = low-risk, B = intermediate-risk, C = high-risk). However, it remains unclear how these groups could guide management. Study Design By integrating surgical outcome and adjuvant radiation (AdjXRT) information with genetic data on 152 tumors, we sought to develop an evidence-based management algorithm for SBC. Results Gross total resections (GTRs) were associated with improved progression free survival (PFS) in all genetic groups. For Group C tumors, GTR and AdjXRT independently contributed to PFS (multivariate Cox proportional hazard ratio [HR] = 0.14, p = 0.002, and HR = 0.40, p = 0.047, respectively). For Group B tumors, AdjXRT improved outcomes only when GTR was not feasible (log-rank p = 0.008), but not following GTR (log-rank p = 0.54). However, 24 of 25 Group A tumors underwent GTR, and AdjXRT for these did not confer any benefit (log-Rank p = 0.285). The high GTR rates in Group A could be explained by smaller tumor sizes (mean = 0.98cc/4.08cc/4.92cc for Group A/B/C, respectively, p = 0.031) and lack of invasiveness. Group A tumors were also more frequently diagnosed in young people ( p = 0.002) as asymptomatic lesions ( p = 0.001), suggesting that they could be precursors to tumors in higher risk groups. Conclusion Genotypic grouping by 1p36 and homozygous 9p21(p16) deletions can predict prognosis in SBC and guide management. GTR remains the cornerstone of SBC treatment and can be sufficient without AdjXRT in low and intermediate risk tumors. Low-risk tumors are associated with a less invasive phenotype, which makes them more amenable to GTR.

9.
Ann Otol Rhinol Laryngol ; : 34894211045775, 2021 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-34628934

RESUMO

INTRODUCTION: The concept of a hospitalist has been well established. This model has been associated with reduced length of stay contributing to reduction in healthcare costs. Minimal literature is available assessing the effects of an otolaryngology (ENT) hospitalist at a tertiary medical center. The aim of this study is to assess the role of an ENT hospitalist on (1) performing tracheostomies and (2) providing care as part of the tracheostomy care team (TCT). METHODS: Retrospective chart review of all tracheostomies performed by the ENT service over 2 years (July 2015-June 2017), and prospective data collection of all tracheostomy care consults over 1 year (July 2016-June 2017). In year 1 (from July 2015 to June 2016), no ENT hospitalist was employed, and in year 2 (from July 2016 to June 2017), an ENT hospitalist was employed. RESULTS: Compared to other Ear, Nose, and Throat (ENT) surgeons, the ENT hospitalist performed tracheostomies with shorter patient wait times, and performed a greater proportion of percutaneous tracheostomies at the bedside versus open tracheostomies in the operating room. The tracheostomy care team (TCT) received 91 consults over the course of 1 year with an average of 1.1 billable procedures generated per consult. CONCLUSION: In this study, an ENT hospitalist was decreased patient wait time to tracheostomy and increased bedside percutaneous tracheostomies, which has positive implications for resource utilization and healthcare cost. The average wait time to receive a tracheostomy was reduced when calculated across the entire department due to the availability of the ENT hospitalist to see and perform tracheostomies. The TCT generated many billable bedside procedures in addition to encouraged decannulation of patients. This study highlights the fact that the ENT hospitalist contributes to providing expedient tracheostomies and provides valuable consulting services as part of a TCT at a high-volume tertiary care facility.

10.
J Neurol Surg B Skull Base ; 82(5): 540-546, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34513560

RESUMO

Background A nasal access guide (NAG) for endoscopic endonasal approaches (EEAs) to the skull-base has been developed and approved for clinical use but its utility has not been formally investigated. Objective The study aims to assess the effect of a NAG on endoscopic visualization during cadaveric dissection and to perform a workflow analysis with process-based performance measures in the operating room and their effect on clinical outcomes. Methods Skull-base course participants were observed during hands-on cadaveric dissection with and without NAG. Instances of endoscope withdrawal for lens cleaning and inadequate visualization due to lens soiling were tabulated. Participants completed a Likert-scale survey examining the NAG utility and provided an overall grading. Surgical workflow and process-based performance on patients undergoing EEA to the skull-base was analyzed. Passage of powered and dissecting instruments, removal of endoscopes for cleaning, and dislodgment or migration of the device were reviewed. Postoperative assessments included mucosal trauma and synechiae formation. Results Instances of endoscope soiling and manual cleaning were significantly reduced by 40% and 61% with the NAG during cadaveric dissection. The overall grading of the device was 2.75/3. Surgical workflow was observed in 35 patients. Average number of passes of endoscopes, instruments, and powered tools during a 10-minute observation period were 3,17, and 5 during the surgical approach, and 3, 18, and 1 during tumor dissection. Dislodgement of the device occurred in 25.7% and migration of the device in 2.8% of cases. Postoperative synechiae, exposed cartilage or septal perforation was not observed in follow up. Conclusion NAG can significantly reduce inadequate visualization during EEA to the skull-base and has the potential to reduce instances of nasal trauma. Participants assessed its overall utility as being "excellent."

11.
Pediatr Neurosurg ; 56(6): 519-528, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34518465

RESUMO

INTRODUCTION: Endoscopic endonasal surgery (EES) has been slower to gain popularity in early childhood due to anatomical challenges. We sought to describe the safety and efficacy of EES in early childhood. METHODS: All patients younger than 7 years who underwent EES at a large Cranial Base Center from 2002 to 2019 were reviewed as a retrospective cohort study. RESULTS: Thirty-six patients underwent EES before the age of 7 years. Four patients had two-stage EES. Two patients required combined transcranial and endonasal approaches. The mean age at the time of initial surgery was 4 years (range: 1-6). Twenty patients were male, and 16 were female. Of 21 tumors intended for resection, 11 patients had gross total resections, and 10 had near total (>95% tumor removed) resections. Nine patients (43%) had recurrences, of which 6 were craniopharyngiomas (p = 0.01). There was no difference in recurrence rates based on the degree of resection (p = 0.67). Three cerebrospinal fluid (CSF) leaks occurred following primary EES (8%). Following an increase in nasoseptal flap usage (31-52%) and CSF diversion (15-39%) in 2008, there was only one CSF leak out of 23 patients (4 vs. 15%; p = 0.54). Postoperatively, 1 patient developed a permanent new cranial neuropathy, and 1 patient developed a permanent visual field cut. Six patients developed permanent postoperative panhypopituitarism, of which all were craniopharyngiomas (p < 0.001). The mean follow-up was 64 months. CONCLUSIONS: Early childhood EES is both safe and technically feasible for a variety of pathologies.


Assuntos
Neoplasias Hipofisárias , Complicações Pós-Operatórias , Criança , Pré-Escolar , Endoscopia , Feminino , Humanos , Masculino , Recidiva Local de Neoplasia , Estudos Retrospectivos , Base do Crânio , Resultado do Tratamento
12.
J Med Case Rep ; 15(1): 446, 2021 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-34481512

RESUMO

BACKGROUND: Immunoglobulin-G4-related hypophysitis is a rare inflammatory disease that can present as a tumefactive pituitary lesion mimicking hypophyseal neoplasms such as pituitary adenoma or craniopharyngioma. The literature on this entity is sparse, with fewer than 100 cases reported across 19 publications; a recent review found only 24 cases published from 2007 to 2018. Previous reports have described demographic differences, with immunoglobulin-G4-related hypophysitis in females tending to present in the second and third decades in association with other autoimmune disease, while males tend to present in the fifth and sixth decades of life without an autoimmune history. CASE PRESENTATION: In contrast to the reported demographic trends, here we describe a unique case of immunoglobulin-G4-related hypophysitis in a 63-year-old white female with no history of autoimmune disease who presented with a rapidly enlarging sellar and hypothalamic mass causing headaches and cranial nerve palsies, prompting biopsy for diagnosis. The patient experienced rapid response to treatment with high-dose steroids and rituximab. CONCLUSION: The case contributes to the growing clinicopathologic description of immunoglobulin-G4-related hypophysitis and illustrates that this diagnosis should be a consideration even outside the conventional demographic setting.


Assuntos
Craniofaringioma , Hipofisite , Doenças da Hipófise , Feminino , Humanos , Hipofisite/diagnóstico , Imunoglobulina G , Masculino , Pessoa de Meia-Idade , Doenças da Hipófise/diagnóstico , Hipófise
13.
Oper Neurosurg (Hagerstown) ; 21(5): E421-E426, 2021 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-34392369

RESUMO

BACKGROUND: Chiari I malformations secondary to other causes represent a small subset of presenting symptomatic cases. Typically, the primary cause of the malformation is addressed first and results in resolution of the malformation and symptoms. However, in some cases, a patient may present with both a primary Chiari I malformation and another unrelated neurosurgical lesions. OBJECTIVE: To present a unique case in which resection of a ventral tumor allowed for spontaneous resolution of a simultaneously noted dorsal Chiari I malformation. METHODS: Pertinent data, including presenting symptoms, hospital course, surgical notes, preoperative images, and postoperative images, were collected using the electronic medical record. RESULTS: We present a case of a 46-yr-old man with a Chiari I malformation in conjunction with a ventral cranio-cervical junction chordoma. Endoscopic endonasal resection of the chordoma and ventral foramen magnum decompression resulted in radiographic resolution of the Chiari malformation and resolution of his symptoms. Our report represents a rare case of ventral foramen magnum decompression as a treatment for Chiari I malformation. CONCLUSION: It is felt that the chordoma mass effect was not the source of the Chiari I malformation. Thus, both ventral and dorsal decompressions of the posterior fossa may be considered for Chiari I decompression in select circumstances.


Assuntos
Malformação de Arnold-Chiari , Cordoma , Malformação de Arnold-Chiari/diagnóstico por imagem , Malformação de Arnold-Chiari/cirurgia , Cordoma/diagnóstico por imagem , Cordoma/cirurgia , Descompressão Cirúrgica , Forame Magno/diagnóstico por imagem , Forame Magno/cirurgia , Humanos , Masculino
14.
Oper Neurosurg (Hagerstown) ; 21(4): 207-216, 2021 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-34245152

RESUMO

BACKGROUND: Endoscopic endonasal approaches (EEAs) to anterior skull base meningiomas have grown in popularity, though anatomic limitations remain unclear. OBJECTIVE: To show the anatomic limits of EEA for meningiomas. METHODS: Retrospective chart review for all patients that underwent EEA for anterior skull base meningiomas from 2005 to 2014. RESULTS: A total of 100 patients averaged follow-up of 46.9 mo (24-100 mo). A total of 35 patients (35%) had olfactory groove, 33 planum sphenoidale (33%), and 32 tuberculum sella (32%) meningiomas. The average diameter was 2.9 cm (0.5-8.1 cm). Vascular encasement was seen in 11 patients (11%) and calcification in 20 (20%). Simpson Grade 1 (SG1) resection was achieved in 64 patients (64%). Only calcification impacted degree of resection (40% SG1, P = .012). The most common residual was on the anterior clinoid dura (11 patients [11%]). Six (6%) had residual superior/lateral to the optic nerve. Residual tumor was adherent to the optic apparatus or arteries in 5 patients (5%) each, and 3 patients (3%) had residual lateral to the mid-orbit. Rates of residual decreased over time. A total of 11 patients (11%) had tumor recurrence (mean of 40 mo): 4 (4%) on the anterior clinoid, 2 (2%) each on the lateral orbital roof, adherent to optic apparatus and superolateral to the optic nerve, and 1 (1%) was at the anterior falx. CONCLUSION: Anterior skull base meningiomas can effectively be approached via EEA in most patients; tumors extending to the anterior clinoid, anterior falx, or superolateral to the optic nerve or orbital roof, especially if calcified, may be difficult to reach via EEA.


Assuntos
Neoplasias Meníngeas , Meningioma , Fossa Craniana Anterior/cirurgia , Humanos , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Recidiva Local de Neoplasia/cirurgia , Procedimentos Neurocirúrgicos , Estudos Retrospectivos , Resultado do Tratamento
15.
Am J Rhinol Allergy ; 35(6): 885-894, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34236268

RESUMO

BACKGROUND: Injury to the internal carotid artery (ICA) is a potentially devastating complication of endoscopic endonasal surgery (EES) that as many as 20% of skull base surgeons will experience at least once during their careers. Managing these injuries is difficult given the small operative field and poor visibility created by high-flow hemorrhage, and, at present, there is no consensus regarding best practices. OBJECTIVE: This study seeks to consolidate the practices and opinions of experienced skull base surgeons from high-volume tertiary care centers into a single consensus statement regarding the best practices for managing ICA injuries during EES. METHODS: A panel of 23 skull base surgeons (15 neurosurgeons and 8 otolaryngologists) completed a 3-round Delphi survey that assessed experiences and opinions regarding various aspects of ICA injury management. Mean (SD) years since fellowship completion was 15.6 (8.1) and all but 3 surgeons had experienced an ICA injury at least once. RESULTS: The final consensus statement included 36 guidelines all of which were grouped under 1 of 4 categories: 11 statements concerned preoperative management and equipment for high-risk patients; 14 statements concerned hemorrhage control; 4 statements concerned definitive management; 7 statements concerned pharmacologic treatment, blood pressure, and neurophysiologic monitoring. CONCLUSIONS: There are numerous decisions that a surgeon must make when facing a carotid artery injury. In our estimation, many questions can be grouped under 1 of the 4 categories outlined in our consensus statement and can be addressed by these findings.


Assuntos
Lesões das Artérias Carótidas , Artéria Carótida Interna , Lesões das Artérias Carótidas/etiologia , Lesões das Artérias Carótidas/cirurgia , Artéria Carótida Interna/cirurgia , Consenso , Endoscopia , Prova Pericial , Humanos , Base do Crânio/cirurgia
16.
Int Forum Allergy Rhinol ; 11(12): 1617-1625, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34176231

RESUMO

BACKGROUND: Management of sinonasal malignancy (SNM) often includes surgical resection as part of the multimodality treatment. Treatment-related surgical morbidity can occur, yet risk factors associated with complications in this population have not been sufficiently investigated. METHODS: Adult patients with histologically confirmed SNM whose primary treatment included surgical resection were prospectively enrolled into an observational, multi-institutional cohort study from 2015 to 2020. Sociodemographic, disease, and treatment data were collected. Complications assessed included cerebrospinal fluid leak, orbital injury, intracranial injury, diplopia, meningitis, osteoradionecrosis, hospitalization for neutropenia, and subsequent chronic rhinosinusitis. The surgical approach was categorized as endoscopic resection (ER) or open/combined resection (O/CR). Associations between factors and complications were analyzed using Student's t test, Fisher's exact test, and logistic regression modeling. RESULTS: Overall, 142 patients met the inclusion criteria. Twenty-three subjects had at least 1 complication (16.2%). On unadjusted analysis, adjuvant radiation therapy was associated with developing a complication (91.3% vs 65.5%, p = 0.013). Compared with the ER group (n = 98), the O/CR group (n = 44) had a greater percentage of higher T-stage lesions (p = 0.004) and more frequently received adjuvant radiation (84.1% vs 64.4%, p = 0.017) and chemotherapy (50.0% vs 30.6%, p = 0.038). Complication rates were similar between the ER and O/CR groups without controlling for other factors. Regression analysis that retained certain factors showed O/CR was associated with increased odds of experiencing a complication (odds ratio, 3.34; 95% confidence interval, 1.06-11.19). CONCLUSIONS: Prospective, multicenter evaluation of SNM treatment outcomes is feasible. Undergoing O/CR was associated with increased odds of developing a complication after accounting for radiation therapy. Further studies are warranted to build upon these findings.

17.
World Neurosurg ; 151: 118-123, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33940272

RESUMO

BACKGROUND: Preservation of the anterior arch of C1 in endoscopic endonasal odontoidectomy has been proposed as an alternative to complete C1 arch resections, potentially affording less destabilization of the craniocervical junction. Nonetheless, this approach may limit the decompression achieved. In this case, intraoperative repositioning allowed maximal decompression while preserving the anterior arch of C1. METHODS: A 79-year-old woman presented with suboccipital pain caused by an expansile and compressive mass centered on the dens. Notably, the mass occluded both vertebral arteries resulting in small cerebellar strokes. An endoscopic endonasal approach for diagnosis and decompression was performed followed by posterior fixation. RESULTS: Given the significant compression, the patient was initially positioned in slight cervical extension. After rhinopharyngeal flap harvest, the top half of the anterior arch of C1 was resected, maintaining its structural integrity. The odontoidectomy was completed flush to the superior border of the reduced C1 arch. After an intraoperative computed tomography (CT) scan, performed in a neutral position, the patient was then repositioned with cervical flexion. This maneuver presented the residual odontoid above the C1 arch, but, given the partial removal of the dens, it did not result in any change in neuromonitoring. Further odontoid resection was then completed and follow-up CT scan revealed maximal dens removal, extending below the C1 anterior arch in neutral position. CONCLUSIONS: In cases of odontoid/atlantoaxial pathology causing significant neural compression, staged intraoperative repositioning can safely maximize the odontoidectomy, while affording preservation of the structural integrity of the anterior arch of C1.


Assuntos
Artrite Reumatoide/cirurgia , Vértebras Cervicais/cirurgia , Descompressão , Processo Odontoide/cirurgia , Idoso , Descompressão/métodos , Descompressão Cirúrgica/métodos , Endoscopia/métodos , Feminino , Humanos , Nasofaringe/cirurgia , Processo Odontoide/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos
18.
Head Neck Pathol ; 15(4): 1185-1191, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33929681

RESUMO

Somatostatin receptor 2 (SSTR2) expression has previously been documented in olfactory neuroblastoma (ONB). Here, we fully characterize SSTR2 expression in ONB and correlate staining results with clinicopathologic parameters including Hyams grade. We also assess SSTR2 immunohistochemistry expression in various histologic mimics of ONB to assess its diagnostic functionality. 78 ONBs (51 primary biopsies/excisions and 27 recurrences/metastases) from 58 patients were stained for SSTR2. H-scores based on intensity (0-3 +) and percentage of tumor cells staining were assigned to all cases. 51 histologic mimics were stained and scored in an identical fashion. 77/78 (99%) ONB cases demonstrated SSTR2 staining (mean H-score: 189, range: 0-290). There were no significant differences in staining between primary tumors and recurrences/metastases (mean H-score: 185 vs 198). Primary low-grade ONB had somewhat stronger staining than high-grade tumors (mean H-score: 200 vs 174). SSTR2 expression had no prognostic value when considering disease-free or disease-specific survival. SSTR2 staining is significantly higher in ONB than its histologic mimics (mean H-score: 189 vs 12.9, p < 0.001) suggesting a potential use of the marker in diagnosis of ONB. In conclusion, SSTR2 is consistently expressed in ONB suggesting a role for somatostatin-analog based imaging and therapy in this disease. More generally, SSTR2 may be another marker of neuroendocrine differentiation in ONB.

19.
Laryngoscope ; 131(9): E2513-E2517, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33559896

RESUMO

OBJECTIVES/HYPOTHESIS: The endoscopic endonasal approach (EEA) is increasingly utilized for management of petrous apex cholesterol granuloma (PACG). Surgical goals include drainage and marsupialization of the cyst. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of mucosal grafting on recurrence. STUDY DESIGN: Retrospective Cohort study. METHODS: Patients who underwent EEA for PACG at two tertiary care centers between 1999 and 2018 were identified and divided into two cohorts: Mucosal versus no mucosal reconstruction. Surgical approach, reconstructive method, and recurrence were recorded. Primary endpoint was symptomatic or radiographic recurrence. RESULTS: Thirty-four patients were identified undergoing 37 surgeries. Four patients developed recurrences of which three elected to undergo revision. Some form of mucosa was used to line the drainage tract in 20 cases. A free mucosal graft was used in 8, and a small customized nasal septal flap (miniflap) in 12. All four recurrences occurred in cases where no mucosa was used, demonstrating decreased recurrences with mucosal reconstruction (P < .05). There was no difference found between free mucosal grafts and miniflaps. CONCLUSIONS: Utilization of mucosa to partially line a circumferentially de-epithelialized drainage pathway after EEA for PACG reduce recurrence rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2513-E2517, 2021.


Assuntos
Granuloma/cirurgia , Membrana Mucosa/transplante , Osso Petroso/cirurgia , Retalhos Cirúrgicos , Adulto , Idoso , Colesterol , Drenagem/métodos , Endoscopia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Recidiva , Estudos Retrospectivos
20.
J Neurosurg ; : 1-9, 2021 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-33578381

RESUMO

OBJECTIVE: The endoscopic endonasal approach (EEA) to the lower clivus and craniovertebral junction (CVJ) has been traditionally performed via resection of the nasopharyngeal soft tissues. Alternatively, an inferiorly based rhinopharyngeal (RP) flap (RPF) can be dissected to help reconstruct the postoperative defect and separate it from the oropharynx. To date, there is no evidence regarding the viability and potential clinical impact of the RPF. The aim of this study was to assess RPF viability and its impact on clinical outcome. METHODS: A retrospective cohort of 60 patients who underwent EEA to the lower clivus and CVJ was studied. The RPF was used in 30 patients (RPF group), and the nasopharyngeal soft tissues were resected in 30 patients (control group). RESULTS: Chordoma was the most common surgical indication in both groups (47% in the RPF group vs 63% in the control group, p = 0.313), followed by odontoid pannus (20% in the RPF group vs 10%, p = 0.313). The two groups did not significantly differ in terms of extent of tumor (p = 0.271), intraoperative CSF leak (p = 0.438), and skull base reconstruction techniques other than the RPF (nasoseptal flap, p = 0.301; fascia lata, p = 0.791; inlay graft, p = 0.793; and prophylactic lumbar drain, p = 0.781). Postoperative soft-tissue enhancement covering the lower clivus and CVJ observed on MRI was significantly higher in the RPF group (100% vs 26%, p < 0.001). The RPF group had a significantly lower rate of nasoseptal flap necrosis (3% vs 20%, p = 0.044) and surgical site infection (3% vs 27%, p = 0.026) while having similar rates of postoperative CSF leakage (17% in the RPF group vs 20%, p = 0.739) and meningitis (7% in the RPF group vs 17%, p = 0.424). Oropharyngeal bacterial flora dominated the infections in the control group but not those in the RPF group, suggesting that the RPF acted as a barrier between the nasopharynx and oropharynx. CONCLUSIONS: The RPF provides viable vascularized tissue coverage to the lower clivus and CVJ. Its use was associated with decreased rates of nasoseptal flap necrosis and local infection, likely due to separation from the oropharynx.

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