Peri-operative management of endoscopic endonasal cerebrospinal fluid leak repair: an international survey.

PURPOSE: Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts. METHODS: A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion. RESULTS: The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48 h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001). CONCLUSION: Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency.

Resident's preparedness for independent practice following Otorhinolaryngology-Head and Neck Surgery residency program: a cross-sectional survey.

PURPOSE: Evaluate perception of preparedness for independent practice following the Otorhinolaryngology-Head and Neck Surgery residency program of Université de Montréal. METHODS: Cross-sectional survey of graduates from the past 10 years. Participants were asked about their level of confidence at the end of their residency for various procedures using a 5-point Likert scale. RESULTS: 7 out of 27 procedures were mastered by most physicians at the end of residency. The highest confidence level was in head and neck surgery (4 out of 5 procedures with a mean confidence level of 4 or higher) and lowest in laryngology and otology (both having 3 procedures with a median confidence level of 2 or less). The lowest confidence level was seen in ossiculoplasty and thyroplasty, being the only procedures to have a mean confidence level below 2. The highest scores were seen in superficial parotidectomy, direct microlaryngoscopy and trans-oral drainage of an abscess. These latter were the only procedures in which 100% of the respondent had a confidence level of 4 or 5. DISCUSSION: It has recently been suspected that these fields were potential weaknesses, so adjustments were made. This study provides new information to improves the curriculum. Recent and incoming change's impact on resident's confidence will be assessed in the future. CONCLUSION: This study highlights procedures and Otorhinolaryngology-Head and Neck Surgery subspecialties in which more surgical exposure or curriculum changes could increase resident's confidence and skills as part of a comprehensive Otorhinolaryngology practice.

Sinus and anterior skull base surgery during the COVID-19 pandemic: systematic review, synthesis and YO-IFOS position.

PURPOSE: The COVID-19 pandemic has caused significant confusion about healthcare providers' and patients' pandemic-specific risks related to surgery. The aim of this systematic review is to summarize recommendations for sinus and anterior skull base surgery during the COVID-19 pandemic. METHODS: PubMed/MEDLINE, Google Scholar, Scopus and Embase were searched by two independent otolaryngologists from the Young Otolaryngologists of IFOS (YO-IFOS) for studies dealing with sinus and skull base surgery during COVID-19 pandemic. The review also included unpublished guidelines edited by Otolaryngology-Head and Neck Surgery or Neurosurgery societies. Perioperative factors were investigated including surgical indications, preoperative testing of patients, practical management in operating rooms, technical aspects of surgery and postoperative management. The literature review was performed according to PRISMA guidelines. The criteria for considering studies or guidelines for the review were based on the population, intervention, comparison, outcome, timing and setting (PICOTS) framework. RESULTS: 15 International publications met inclusion criteria. Five references were guidelines from national societies. All guidelines recommended postponing elective surgeries. An algorithm is proposed that classifies endonasal surgical procedures into three groups based on the risk of postponing surgery. Patients' COVID-19 status should be preoperatively assessed. Highest level of personal protective equipment (PPE) is recommended, and the use of high-speed powered devices should be avoided. Face-to-face postoperative visits must be limited. CONCLUSIONS: Sinus and skull base surgeries are high-risk procedures due to potential aerosolization of SARS-CoV-2 virus. Protection of health care workers by decreasing exposure and optimizing the use of PPE is essential with sinus and anterior skull base surgery.

Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study.

OBJECTIVE: To investigate the occurrence of olfactory and gustatory dysfunctions in patients with laboratory-confirmed COVID-19 infection. METHODS: Patients with laboratory-confirmed COVID-19 infection were recruited from 12 European hospitals. The following epidemiological and clinical outcomes have been studied: age, sex, ethnicity, comorbidities, and general and otolaryngological symptoms. Patients completed olfactory and gustatory questionnaires based on the smell and taste component of the National Health and Nutrition Examination Survey, and the short version of the Questionnaire of Olfactory Disorders-Negative Statements (sQOD-NS). RESULTS: A total of 417 mild-to-moderate COVID-19 patients completed the study (263 females). The most prevalent general symptoms consisted of cough, myalgia, and loss of appetite. Face pain and nasal obstruction were the most disease-related otolaryngological symptoms. 85.6% and 88.0% of patients reported olfactory and gustatory dysfunctions, respectively. There was a significant association between both disorders (p < 0.001). Olfactory dysfunction (OD) appeared before the other symptoms in 11.8% of cases. The sQO-NS scores were significantly lower in patients with anosmia compared with normosmic or hyposmic individuals (p = 0.001). Among the 18.2% of patients without nasal obstruction or rhinorrhea, 79.7% were hyposmic or anosmic. The early olfactory recovery rate was 44.0%. Females were significantly more affected by olfactory and gustatory dysfunctions than males (p = 0.001). CONCLUSION: Olfactory and gustatory disorders are prevalent symptoms in European COVID-19 patients, who may not have nasal symptoms. The sudden anosmia or ageusia need to be recognized by the international scientific community as important symptoms of the COVID-19 infection.

Effects of Fluticasone Furoate on Clinical and Immunological Outcomes (IL-17) for Patients With Nasal Polyposis Naive to Steroid Treatment.

OBJECTIVES: We investigated the effect of topical steroids on clinical outcomes and related immune response of chronic rhinosinusitis with nasal polyp (CRSwNP) patients and in eradicating some polyps. We want to explore a new potential mechanism linked to Th-17 cells. METHODS: Prospective, double-blind, placebo-controlled studies with 24 allergic and nonallergic patients were randomized to either placebo or fluticasone furoate for 12 weeks. Assessment of clinical response, endoscopic score with biopsies of the inferior turbinate, and polyps before and after treatment were performed. Biopsies were stained for T-cells, eosinophils, neutrophils, and IL-17A/F. RESULTS: Steroid treatment improved the mean symptoms scores from 7.12 to 4.02 (P < .01) and the polyp score from 5.13 to 3.31 (P < .05), but the comparison with placebo was not statistically significant in nonallergics due to insufficient study power. Steroid treatment decreased eosinophil counts on allergics but not neutrophils or T-cells. The IL-17A/F expression was higher in nonallergics with high neutrophil counts and was inclined by steroids. Compared to baselines, IL-17 cells were significantly less in allergic individuals and were not observed in allergics and with high neutrophil counts. CONCLUSION: Topical steroids were more effective on certain nasal polyp phenotypes. Identification of polyp phenotype might be essential to ensure a better therapeutic response to intranasal corticosteroids.

Intratympanic corticosteroids injections: a systematic review of literature.

The objective of the study was to determine the evidence of intratympanic steroids injections (ITSI) for efficacy in the management of the following inner ear diseases: Ménière's disease, tinnitus, noise-induced hearing loss (NIHL) and idiopathic sudden sensorineural hearing loss (ISSNHL). The data sources were literature review from 1946 to December 2014, PubMed and Medline. A systematic review of the existing literature was performed. Databases were searched for all human prospective randomized clinical trials using ITSI in at least one treatment group. The authors identified 29 prospective randomized clinical trials investigating the benefits of an intratympanic delivery of steroids. Six articles on Ménière's disease were identified, of which one favored ITSI over placebo in vertigo control. Of the five randomized clinical trials on tinnitus therapy, one study found better tinnitus control with ITSI. The only available trial on NIHL showed significant hearing recovery with combination therapy (ITSI and oral steroids therapy). Seventeen studies were identified on ISSNHL, of which 10 investigated ITSI as a first-line therapy and 7 as a salvage therapy. Studies analysis found benefits in hearing recovery in both settings. Due to heterogeneity in treatment protocols and follow-up, a meta-analysis was not performed. Given the low adverse effects rates of ITSI therapy and good patient tolerability, local delivery should be considered as an interesting adjunct to the therapy of the ISSNHL and NIHL. Only one article over six where ITSI therapy offers potential benefits to patients with Ménière's disease in the control of tinnitus and vertigo was found. ITSI does not seem to be effective in the treatment of tinnitus.

Anatomy of the craniocervical junction - A review.

An in-depth understanding of the anatomy of the craniocervical junction (CCJ) is indispensable in skull base neurosurgery. In this paper, we discuss the osteology of the occipital bone, the atlas (C1) and axis (C2), the ligaments and the muscle anatomy of the CCJ region and their relationships with the vertebral artery. We will also discuss the trajectory of the vertebral artery and review the anatomy of the jugular foramen and lower cranial nerves (IX to XII). The most important surgical approaches to the CCJ, including the far lateral approach, the anterolateral approach of Bernard George and the endoscopic endonasal approach, will be discussed to review the surgical anatomy.

From Research to Clinical Practice: Long-Term Impact of Randomized Clinical Trial Examining the Effect of Lumbar Drains on Cerebrospinal Fluid Leak Rates Following Endonasal Skull Base Surgery.

Intraoperative cerebrospinal fluid (CSF) leaks are associated with increased risk of postoperative CSF leaks despite multilayered reconstruction with vascularized tissue. A recent randomized controlled trial (RCT) examining the use of perioperative lumbar drains (LD) in high-risk skull base defects identified a significant reduction in postoperative CSF leak incidence (21.2 vs. 8.2%; p = 0.017). This study was conducted to assess the efficacy of the selective use of CSF diversion, for patients with intraoperative CSF leaks involving endoscopic endonasal approaches (EEA) to the skull base. Method Consecutive endoscopic endonasal surgeries of the skull base from a pre-RCT cohort and post-RCT cohort were compared. The following case characteristics between the two cohorts were examined: patient age, body mass index (BMI), rate of revision surgery, tumor histology, use of CSF diversion, and vascularized reconstruction. The primary measured outcome was postoperative CSF leak. Results The pre-RCT cohort included 76 patients and the post-RCT cohort included 77 patients, with dural defects in either the anterior or posterior cranial fossa (pituitary and parasellar/suprasellar surgeries excluded). There was a significant reduction in the incidence of postoperative CSF leak in the post-RCT cohort (27.6 vs. 12.9%; p = 0.04). On subgroup analysis, there was a trend toward improvement in CSF leak rate of the anterior cranial fossa (19.2 vs. 10.5%; p = 0.27), whereas CSF leak rates of the posterior cranial fossa were significantly reduced compared with the pre-RCT cohort (41.4 vs. 12.8%; p = 0.02). Conclusion This study demonstrates that the integration of selective CSF diversion into the reconstructive algorithm improved postoperative CSF leak rates.

Features of Mild-to-Moderate COVID-19 Patients With Dysphonia.

INTRODUCTION: To explore the prevalence of dysphonia in European patients with mild-to-moderate COVID-19 and the clinical features of dysphonic patients. METHODS: The clinical and epidemiological data of 702 patients with mild-to-moderate COVID-19 were collected from 19 European Hospitals. The following data were extracted: age, sex, ethnicity, tobacco consumption, comorbidities, general, and otolaryngological symptoms. Dysphonia and otolaryngological symptoms were self-assessed through a 4-point scale. The prevalence of dysphonia, as part of the COVID-19 symptoms, was assessed. The outcomes were compared between dysphonic and nondysphonic patients. The association between dysphonia severity and outcomes was studied through Bayesian analysis. RESULTS: A total of 188 patients were dysphonic, accounting for 26.8% of cases. Females developed more frequently dysphonia than males (P = 0.022). The proportion of smokers was significantly higher in the dysphonic group (P = 0.042). The prevalence of the following symptoms was higher in dysphonic patients compared with nondysphonic patients: cough, chest pain, sticky sputum, arthralgia, diarrhea, headache, fatigue, nausea, and vomiting. The severity of dyspnea, dysphagia, ear pain, face pain, throat pain, and nasal obstruction was higher in dysphonic group compared with nondysphonic group. There were significant associations between the severity of dysphonia, dysphagia, and cough. CONCLUSION: Dysphonia may be encountered in a quarter of patients with mild-to-moderate COVID-19 and should be considered as a symptom list of the infection. Dysphonic COVID-19 patients are more symptomatic than nondysphonic individuals. Future studies are needed to investigate the relevance of dysphonia in the COVID-19 clinical presentation.

Utility of Nasal Access Guides in Endoscopic Endonasal Skull Base Surgery: Assessment of Use during Cadaveric Dissection and Workflow Analysis in Surgery.

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."

Benign Tumors of the Anterior Cranial Base.

Benign tumors of the anterior cranial base may originate from intracranial, cranial, or extracranial sites. Intracranial tumors such as meningiomas may secondarily involve the cranial base and extend into the sinuses or nasal cavity. Bony tumors arising from the cranium include benign fibro-osseous lesions such as osteoma, fibrous dysplasia, and ossifying fibroma. The most common extracranial tumors that may extend to the skull base include angiofibroma and inverted papilloma. Symptoms are nonspecific and diagnosis is often delayed. In most cases, a diagnosis can be established based on the clinical presentation and radiographic features. Some small asymptomatic tumors may be observed for growth (meningioma, osteoma), whereas others should be treated due to continued destructive growth (angiofibromas) or potential for malignancy (inverted papilloma). Surgery remains the predominant treatment modality for benign tumors of the anterior cranial base. The major advance in recent decades has been the adoption of endoscopic techniques. Advances in endoscopic transnasal surgery have dramatically altered the surgical landscape, enabling the removal of tumors of the anterior cranial base with minimal morbidity. Due to decreased morbidity in comparison to transfacial or transcranial approaches, endoscopic transnasal surgery has lowered the threshold for surgery for benign tumors and can be applied to adult as well as pediatric populations. Anatomical limits include the anterior cranial base from the frontal sinus to the sella and optic canals and laterally to the mid-plane of the orbital roofs. Large dural defects can be reliably reconstructed using local (nasoseptal) and regional (extracranial pericranial) vascularized flaps.

Endoscopic endonasal approach for clipping of a PICA aneurysm.

This video depicts the case of a 59-year-old woman that presented to the emergency department with the worst headache of her life. CT showed subarachnoid hemorrhage and digital subtraction angiogram demonstrated a right-side posterior inferior cerebellar artery (PICA) aneurysm. Given the medial and ventral position of the aneurysm, deep to the lower cranial nerves, which obviated distal control from an open approach, and the absence of an endovascular option able to reliably preserve the PICA, an endonasal approach was offered. A far medial approach was performed, and the aneurysm was successfully clipped. The patient developed a postoperative CSF leak with persistent posthemorrhagic hydrocephalus treated with reexploration and an eventual ventriculoperitoneal shunt. The patient was discharged without neurological deficits. The video can be found here: https://youtu.be/_9hsM2CaMow.

Lateral nasal wall flap for endoscopic reconstruction of the skull base: anatomical study and clinical series.

BACKGROUND: The lateral nasal wall (LNW) flap provides vascularized endonasal reconstruction primarily in revision surgery. Although the harvesting technique and reconstructive surface have been reported, the arterial supply to the LNW flap and its clinical implications is not well defined. This study presents anatomical dissections to clarify the vascular supply to this flap, and the associated clinical outcomes from this reconstructive technique. METHODS: The course and branching pattern of the sphenopalatine artery (SPA) to the LNW were studied in 6 vascular latex-injected heads (11 LNW flaps total). Patients undergoing an LNW flap since 2008 were identified and the underlying pathology, indication, flap viability, and clinical outcomes were retrospectively analyzed. RESULTS: The inferior turbinate artery arises from the LNW artery and divides into 2 branches at the most posterior aspect of the inferior turbinate bone. A smaller-caliber superficial branch travels anteriorly and branches to the LNW. A larger dominant branch travels into the inferior meatus and tangentially supplies the nasal floor. Twenty-four patients with sellar or posterior cranial fossa (PCF) defects were reconstructed with an LNW flap. Postoperative contrast enhancement of the LWN flap was identified in 95.5% of cases. Postoperative cerebrospinal fluid (CSF) leaks were identified in 6 cases. CONCLUSION: Blood supply to the nasal floor by the dominant inferior meatus branch is more robust than the supply to the anterior LNW by the superficial arterial branch. The LNW flap is the preferred vascularized reconstructive option to the PCF and sella in the absence of a nasoseptal flap (NSF).

Supratotal Resection of Residual Clival Chordoma With Combined Endoscopic Endonasal and Contralateral Transmaxillary Approaches: 2-Dimensional Operative Video.

The optimal treatment for skull base chordomas is gross total resection followed by radiotherapy and not radiation of partially resected tumors. Supratotal resection, defined as removal beyond all involved bone and dura, is ideal but difficult to achieve. In this video, we present the case of a 37-yr-old man with new onset of progressive cranial nerve sixth palsy and a skull base lesion compatible with clival chordoma. He underwent partial surgical resection at an outside institution via transcranial approach, with significant tumor residual at the clivus, dorsum sella, posterior clinoids, and petrous apex, extensive dural invasion, and intradural extension with attachment to the basilar artery and its long perforating branches. Supratotal surgical resection was achieved using an endoscopic endonasal transclival approach, ipsilateral transpteryoid approach to the foramen lacerum for carotid artery mobilization, bilateral interdural transcavernous approach with posterior clinoidectomies, and con-tralateral transmaxillary approach to the petrous apex. Reconstruction was performed in a multilayer fashion with fascia lata and fat grafts, extended nasoseptal flap, a lumbar drainage for 3 d. No cerebrospinal fluid leak occurred, and the abducens nerve palsy significantly improved at 3-mo follow-up. Proton therapy is planned. Recent advances in endoscopic endonasal surgery allow for very high rates of complete and even supratotal resection despite the challenging location. A long learning curve to acquire the technical skills and complex surgical anatomy is required to decrease complication rates and achieve maximal resection in chordomas. Reoperations are more challenging and risky; therefore, first attempt should have curative intent. The patient signed informed consent including the use of photographic and video material for educational or academic purposes.

Validation of training levels in endoscopic endonasal surgery of the skull base.

OBJECTIVE: A five-level training program was first proposed 10 years ago for surgeons learning endoscopic endonasal surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors. METHOD: A three-phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter-team validation (the classification applies to other surgical teams). Consecutive cases over a 1-year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid [CSF] leak and infection), estimated blood loss and duration of surgery. RESULTS: Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter-team validation demonstrated no difference between two teams of surgeons. CONCLUSION: This study provides a three-phase validation of training levels for endoscopic skull base surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:2253-2257, 2019.

Immunomodulators in chronic rhinosinusitis.

OBJECTIVE: To provide new insight into how chronic rhinosinusitis (CRS) is conceptualized and treated with a focus on immunomodulator therapy. DATA SOURCES: Pubmed, Medline, and Embase. METHODS: A current review of the evidence is provided for immunomodulators investigated for treatment of CRS with nasal polyps (CRSwNP). RESULTS: Biologic therapies targeting IgE, IL-4, IL-5, and IL-13 for the treatment of CRSwNP have shown promise and are currently in phase 3 trials. Anti-immunoglobin E (IgE) therapy with omalizumab was assessed in 6 studies, anti-interleukin (IL)-5 therapy in 3 studies (2 mepolizumab, 1 reslizumab) and anti IL-4/IL-13 (dupilumab) therapy in one study. Studied outcomes varied, but the majority of trials identified clinical benefit of therapy over placebo. Other potential targets include thymic stromal lymphopoetin (TSLP), IL-25, IL-33, and sialic acid-binding immunoglobulin-type lectin (Siglec)-8. Small molecule drugs that target the dysregulation of the immune system in CRS are also being investigated for their immunomodulatory effects on inflammation. CONCLUSION: Immunomodulator therapies for CRS currently in development will likely provide another therapeutic option for patients who have severe disease unresponsive to corticosteroids and surgery. Targeted monoclonal antibody therapies have shown encouraging results and phase 3 trials are underway. IL-4/IL-13 inhibition has shown the most promise to date. Further larger, well-designed trials are needed to improve understanding of these molecules and to offer endotype-driven therapies in the management of CRS. None of these therapeutics have shown long-term immunomodulation when discontinued and therefore further investigation into the pathomechanism of disease continues to be needed.

Complications of Nasoseptal Flap Reconstruction: A Systematic Review.

Objective The nasoseptal flap (NSF) is considered the primary vascularized flap for reconstruction of dural defects with endoscopic endonasal surgery (EES) of the skull base. However, the complications and morbidities associated with this reconstructive flap are poorly understood. This article presents a systematic review of the complications and morbidities related to the use of the NSF in skull base surgery. Method A systematic review of the literature based on published guidelines was performed to identify potential complications and morbidities related to the NSF. The MEDLINE and Embase databases were searched from January 1, 1950 to February 5, 2018. Results Twenty-seven articles were identified. Reported complications were as follows: NSF necrosis (4 studies; [0-1.3%]), mucocele formation (5 studies; [0-3.6%]), septal perforation (6 studies, [0-14.4%]), nasal dorsum collapse (2 studies, [0.7-5.8%]), effects on quality of life (QoL) (8 studies), and olfactory loss (11 studies). Conclusion Although complications associated with the NSF may be underreported in the literature, the NSF appears to be a safe and reliable reconstructive flap in EES of the skull base.

Diagnosis and endoscopic endonasal management of nontraumatic pseudoaneurysms of the cranial base.

BACKGROUND: Nontraumatic pseudoaneurysms of the cranial base are rare and present unique diagnostic and treatment dilemmas compared with both true aneurysms and pseudoaneurysms outside of the cranial base. There is a dearth of knowledge regarding the management of these complicated lesions. METHODS: Nontraumatic pseudoaneurysms of the cranial base internal carotid artery (ICA) were retrospectively identified at the University of Pittsburgh Medical Center through a key word search of cranial base cases from 2010 to 2017. RESULTS: Three cases were identified, demonstrating pseudoaneurysms of the cavernous and petrous ICA. Each patient underwent diagnostic work-up with computed tomography, magnetic resonance imaging, and angiography, followed by endovascular occlusion and endoscopic endonasal surgery, which resulted in relief of presenting complaints and ablation of the pseudoaneurysm. CONCLUSION: Symptomatic cranial base pseudoaneurysms should undergo treatment to obliterate the aneurysm and relieve the mass effect. First, formal angiography is necessary for accurate diagnosis and treatment planning. Next, endovascular occlusion is performed, with a preference for coiling or endoluminal reconstruction with a flow diverter. Last, endoscopic intervention follows in cases where: (1) decompression of vital structures is indicated; (2) diagnosis of the pseudoaneurysm cannot be definitively confirmed with angiography; or (3) the etiology of the confirmed pseudoaneurysm requires further investigation.

Sustained Inner Ear Steroid Delivery via Bioabsorbable Stent: A Tolerability and Feasibility Study on Guinea Pigs.

OBJECTIVE: To determine the feasibility and tolerability of a steroid-eluting middle ear device on an animal model. STUDY DESIGN: Prospective experimental. SETTING: Experimental animal study. SUBJECTS AND METHOD: Mometasone furoate (MF)-eluting miniature sticks were implanted through a myringotomy incision into the middle ear of 10 guinea pigs. Two additional ears of 2 animals served as controls. Fourteen days after implantation, perilymphatic fluid was collected through an endaural cochleostomy. MF concentrations were measured with high-performance liquid chromatography, and the middle ear mucosal inflammation was graded with hematoxylin and eosin colorations. RESULTS: Fourteen days after implantation, all tympanic membranes had fully healed. An average of 165 ng/mL of MF was detected in the perilymphatic fluid of the experimental ears, and none was measured in control ears. Microscopic residues of the ministicks were found in 90% of the samples, confirming the bioabsorbable properties of this device. Histologic analysis of the middle ear mucosa found similar inflammation profiles in both groups, thereby suggesting middle ear tolerability. CONCLUSION: MF-coated bioabsorbable miniature stick allows for prolonged delivery over 14 days without injuring the middle ear mucosa. Middle ear-sustained steroid delivery may prove to be beneficial in numerous neurotologic conditions.