Porcine small intestine submucosal graft for endoscopic skull base reconstruction

Systematic review of errors on beta-2 transferrin gel electrophoresis testing of rhinorrhea and otorrhea

BACKGROUND

Beta-2 transferrin (B2-Tf) gel electrophoresis (GE) is the preferred non-invasive diagnostic modality for confirming cerebrospinal fluid (CSF) in body fluids. While B2-Tf GE testing is highly sensitive and specific for CSF, false-positive (FP) and false-negative (FN) results can lead to diagnostic and therapeutic dilemmas. Several series have demonstrated potential causes of false B2-Tf GE results, but few studies have reported reasons for these errors. The purpose of this systematic review was to describe sources of B2-Tf GE errors.

METHODS

A systematic review was performed by searching OVID, EMBASE, and Web of Science databases for B2-Tf GE studies. After applying exclusion criteria, original research studies directly addressing erroneous B2-Tf GE results underwent qualitative analysis.

RESULTS

Of the 243 abstracts screened, 71 underwent full-text review and 18 studies reporting B2-Tf GE errors were included for analysis. There were 15 potential FPs, 12 actual FPs, 12 potential FNs, 19 actual FNs, and 14 indeterminate results. There were also 246 potentially indeterminate results from in vitro studies. Reasons for B2-Tf GE errors included serum transferrin alterations (n = 17; all potential), infection related (n = 13; 9 potential), orbital or salivary contamination (n = 2; 1 potential), and collection related (n = 255; 246 potential). There were 31 false or indeterminate results with unspecified reasons. There were no reported errors due to laboratory processing.

CONCLUSIONS

Multiple potential or actual reasons for false or indeterminate results have been reported for B2-Tf GE testing of rhinorrhea and otorrhea. Future studies should explore reasons for B2-Tf testing errors and how these may affect clinical decision making.

Bioinspired polysaccharide-based nanocomposite membranes with robust wet mechanical properties for guided bone regeneration

Polysaccharide-based membranes with excellent mechanical properties are highly desired. However, severe mechanical deterioration under wet conditions limits their biomedical applications. Here, inspired by the structural heterogeneity of strong yet hydrated biological materials, we propose a strategy based on heterogeneous crosslink-and-hydration (HCH) of a molecule/nano dual-scale network to fabricate polysaccharide-based nanocomposites with robust wet mechanical properties. The heterogeneity lies in that the crosslink-and-hydration occurs in the molecule-network while the stress-bearing nanofiber-network remains unaffected. As one demonstration, a membrane assembled by bacterial cellulose nanofiber-network and Ca2+-crosslinked and hydrated sodium alginate molecule-network is designed. Studies show that the crosslinked-and-hydrated molecule-network restricts water invasion and boosts stress transfer of the nanofiber-network by serving as interfibrous bridge. Overall, the molecule-network makes the membrane hydrated and flexible; the nanofiber-network as stress-bearing component provides strength and toughness. The HCH dual-scale network featuring a cooperative effect stimulates the design of advanced biomaterials applied under wet conditions such as guided bone regeneration membranes.

Clinical outcomes of a novel porcine small intestinal submucosa patch for full-thickness hand skin defects: a retrospective investigation

OBJECTIVE

To investigate the clinical outcomes of a novel soft tissue repair patch (porcine small intestinal submucosa patch, SIS patch) in the treatment of full-thickness hand skin defects.

METHODS

From January 2017 to July 2019, 80 patients with hand soft tissue defects, who met the inclusion criteria, were retrospectively reviewed and divided into two groups. After debridement, patients in group A were treated with the novel SIS patch to cover the wound, and patients in group B were treated with autologous skin graft. The dimensions of skin defect area and healing outcome were evaluated and recorded. Scar assessment was carried out using Scar Cosmesis Assessment and Rating Scale (SCAR scale) at the last follow-up postoperation, and the recovery of wound sensation was assessed at the same time using British Medical Research Council (BMRC) grading of sensorimotor recovery. All the data were collected and statistically analyzed.

RESULTS

A total of 80 patients were enrolled in the study with 40 patients in each group. Four patients in group A and 5 patients in group B were excluded due to wound infection and lost to follow-up. There were 36 patients in group A and 35 patients in group B finally got follow-up postoperation with mean interval of 12.75 ± 5.61 months in group A and 14.11 ± 5.42 months in group B. The dimensions of skin defect area in group A ranged from 7.5 to 87.5 cm² (mean 25.97 ± 18.66 cm²) and in group B ranged from 7.5 to 86.25 cm² (mean 33.61 ± 19.27 cm²) which have no significant difference (P > 0.05). SCAR scale results of group A and group B were 10.98 ± 0.33 and 9.49 ± 0.35, respectively, and the difference was statistically significant (P < 0.05). BMRC grading results showed 6 cases of S4, 11 cases of S3+, 5 cases of S3, 6 cases of S2, 6 cases of S1 and 2 cases of S0 in group A, and 8 cases of S4, 10 cases of S3+, 7 cases of S3, 4 cases of S2, 5 cases of S1, and 1 case of S0 in group B, which had no significant difference between them (P > 0.05).

CONCLUSIONS

The novel SIS patch is an applicable biological material in the treatment of hand skin defect, which could achieve a better cosmetic appearance of the newborn skin tissue.

Diagnostic Value of Non-Contrast CT in Cerebrospinal Fluid Leakage After Endoscopic Transnasal Surgery for Sellar and Suprasellar Tumors

We aimed to study the relationship between pneumocephalus on non-contrast CT (NCCT) and post-operative cerebrospinal fluid leakage (p-CFL) after endoscopic transsphenoidal sellar and suprasellar tumor surgeries. Data from patients who underwent endoscopic treatment for sellar or suprasellar tumors from January 2018 to March 2020 were consecutively collected and reviewed. The NCCT pneumocephalus (NP) was measured the first day after operation and the first day after the expansive sponge was extracted. p-CFL was determined according to post-operative clinical symptoms, high resolution CT and glucose test, and expert consensus. Of the 253 patients enrolled in this study, 32 (12.6%) had p-CFL. Compared with patients without p-CFL, patients with p-CFL had a higher occurrence of intra-operative CFL, a longer operation time, a higher rate of pneumocephalus on first-day NCCT after operation (i.e., first-day NP), and a higher rate of NP volume change between two NCCT measurements (referred to as the NP change) (all p < 0.05). In multivariate regression analysis, first-day NP was independently associated with p-CFL occurrence [odds ratio (OR)=6.395, 95% confidence interval (CI)=2.236-18.290, p=0.001). After adding the NP change into the regression model, first-day NP was no longer independently associated with p-CFL, and NP change (OR = 19.457, 95% CI = 6.095–62.107, p<0.001) was independently associated with p-CFL. The receiver operating characteristic curve comparison analysis showed that NP change had a significantly better predicting value than first-day NP (area under the curve: 0.988 vs. 0.642, Z=6.451, p=0.001). NP is an effective imaging marker for predicting p-CFL after endoscopic sellar and suprasellar tumors operation, and the NP change has a better predicting value.

Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy

Objective  To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting  Set at the tertiary skull base center. Methods  This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results  Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases ( p  = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion  The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.

Porcine small intestine graft for reconstruction of oral defects

OBJECTIVE

To evaluate the feasibility and outcomes of porcine submucosal allograft (Biodesign Sinonasal Repair Graft [Cook Medical, Bloomington, IN]) in oral cavity and oropharynx reconstruction after ablative surgery.

METHODS

We conducted a prospective and retrospective review of patients who underwent Biodesign Sinonasal Repair Graft reconstruction for oral and oropharyngeal surgical defects at a single institution between 2018 and 2020. A total of 11 patients were included in the study. Data points included their perioperative medical and demographic data, immediate postoperative course, and follow-up visits at 10 days and at 2 months. The clinicopathologic characteristics of their disease, postoperative esthetic, and functional outcomes were recorded and analyzed.

RESULTS

Eleven procedures have been performed, and all patients received Biodesign reconstruction either immediately after ablation or after they failed a previous reconstruction. None of the patients had bone exposure. The subsites included oral tongue (n = 6), floor of the mouth (n = 3), buccal mucosa (n = 1), and soft palate (n = 1). In all cases, the operations and the postoperative course were uneventful. The mean defect size was 22 cm2. The median start of oral intake was at 2 days postoperatively. The Biodesign graft healed well in all patients with no total graft loss. There was one complication that required revision surgery due to obstruction of Wharton's duct by the Biodesign material.

CONCLUSIONS

Biodesign can be a viable option for small and medium-sized oral and oropharyngeal defects in patients who are medically unfit or do not want to undergo a free flap surgery.

LEVEL OF EVIDENCE

4.

Above and Beyond: Periorbital Suspension for Endoscopic Access to Difficult Frontal Sinus Pathology

OBJECTIVES/HYPOTHESIS

The periorbital suspension (PS) is an advanced adjunctive technique performed during endoscopic approaches to frontal sinus pathology that would be too far lateral or superior to address using traditional endoscopic transnasal approaches. The objectives of this study are to characterize the utility of this technique for frontal sinus pathology, determine anatomic limitations, and assess clinical outcomes following surgical treatment.

STUDY DESIGN

Prospective case series.

METHODS

Patient data including demographics, etiology, technique, complications, and clinical follow-up were collected. Preoperative computed tomography scans were reviewed for maximum lateral and superior extent of pathology, supraorbital recess height, anterio-posterior (AP) diameter of the frontal sinus, interorbital distance, and orbital-first olfactory neuron distance.

RESULTS

The PS approach was used in 30 surgeries (29 patients) for cerebrospinal fluid leaks (n = 5), benign tumors (n = 17), malignant tumors (n = 5), allergic fungal sinusitis (n = 2), and mucocele (n = 1) between 2018 and 2020. Approaches included 15 Draf IIB and 15 Draf III frontal sinusotomies. All pathology was surgically accessible using the PS approach and there were no intraoperative or postoperative complications. Postoperative follow-up was 11.7 ± 7.6 months. Mean recorded measurements (in mm) were as follows: maximum lateral extent -15.0 ± 7.7, superior extent 21.2 ± 7.7 in surgical plane and 20.9 ± 9.8 in the vertical plane, supraorbital recess height -2.6 ± 1.9, AP frontal sinus diameter -13.2 ± 4.7, interorbital distance -29.8 ± 5.4, and orbital-olfactory neuron distance -14.8 ± 2.9.

CONCLUSIONS

The PS technique can be safely and successfully utilized to provide endoscopic endonasal access to lateral and superior frontal sinus pathology.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Treatment of Frontal Sinus Osteomyelitis in the Age of Endoscopy

OBJECTIVE

Frontal sinus osteomyelitis is a severe complication which can result from chronic rhinosinusitis, trauma, or as a complication of reconstruction or obliteration of the frontal sinus. The objective of the current study is to evaluate the contemporary management of frontal sinus osteomyelitis in light of recent advancements in endoscopic surgical techniques.

METHODS

Review of a prospectively collected database of patients with frontal sinus pathology was performed from 2008-2020. Data from individuals with frontal sinus osteomyelitis was collected including demographics, etiology, surgical technique, adjunctive medical treatments, complications, and clinical follow up.

RESULTS

Sixteen patients (average age 48.3, range 8-84) were included in the study. An open approach was utilized in 6 patients (2 osteoplastic flaps, 3 Reidel procedures, 1 cranialization). Seven patients underwent completely endoscopic approaches (3 Draf IIB, 4 Draf III), while 3 individuals had combined procedures (Lynch with Draf III, osteoplastic flap + Draf III, fistula excision + Draf IIb). All patients received 6 weeks of antibiotics. Average clinical follow up was 24.4 months with no patients requiring revision procedures.

CONCLUSION

Endoscopic, endoscopic-assisted, and open approaches were utilized successfully in the current series of patients with osteomyelitis of the anterior table of the frontal sinus. While the progression of endoscopic techniques allows an additional surgical treatment option, it is important to select patients appropriately as open procedures continue to have an important role in the treatment algorithm.

Complications Are Rare From Middle Turbinate Resection: A Prospective Case Series

Background

When chronic rhinosinusitis with nasal polyps (CRSwNP) fails to respond to medical therapy, endoscopic sinus surgery (ESS) plays an integral role in management. Some studies have shown that middle turbinate resection (MTR) during ESS leads to decreased polyp recurrence and revision ESS rates. Other studies suggest MTR can lead to complications.

Objective

The purpose of this study was to assess the safety of MTR during ESS for CRSwNP by determining the incidences of intraoperative cerebrospinal fluid (CSF) leak, postoperative epistaxis requiring operative intervention, and postoperative complete frontal stenosis.

Methods

A multiinstitutional, prospective case series of 91 adult CRSwNP patients was conducted. Patients with medically refractory CRSwNP underwent primary or revision ESS plus MTR by 3 surgeons. Two of the surgeons performed partial MTRs, and one of the surgeons performed complete MTRs. Patients were evaluated for the following complications: intraoperative CSF leak during MTR, postoperative epistaxis requiring operative intervention, and postoperative complete frontal ostial stenosis. Secondary outcomes included changes from preoperative to postoperative 22-item Sinonasal Outcome Test (SNOT-22) scores and revision ESS rates.

Results

Unilateral or bilateral complete ESSs with MTRs were performed on 91 CRSwNP patients. In total, 173 MTRs were performed. Two surgeons performed 97 partial MTRs on 49 patients, and the third surgeon performed 76 complete MTRs on 42 patients. One CSF leak occurred during partial MTR (1/173, 0.57%). No patients suffered postoperative epistaxis requiring operative intervention, and no patients developed complete frontal stenosis. From preoperatively to postoperatively, mean SNOT-22 scores decreased from 53.7 to 13.1 ( P = .001). No revision ESS was needed during the follow-up period. Mean follow-up time was 7.5 ± 5.4 months.

Conclusions

Partial and complete MTR during ESS for CRSwNP in this cohort resulted in very low, acceptable intraoperative and short-term postoperative complication rates and no detriment to SNOT-22 scores.

Lateral nasal wall extension of the nasoseptal flap for skull-base and medial orbital wall defects

BACKGROUND

Sinonasal and skull-base tumors that previously required open resection can often be completely resected via an endonasal approach. The nasoseptal flap (NSF) is the workhorse vascularized tissue flap for the endoscopic reconstruction of large skull-base defects from tumor resections. The objective of the current article is to describe a novel modification of the NSF for simultaneous reconstruction of skull-base and medial orbital wall defects.

METHODS

An extension of the standard NSF to include mucosa of the lateral nasal wall was developed for closure of simultaneous skull-base and medial orbital wall defects. Outcomes including successful cerebrospinal fluid (CSF) leak closure, orbital edema, and postoperative cosmesis are reported. Eyelid edema was characterized according to the Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) scale.

RESULTS

Three patients underwent reconstruction using the modified NSF (average age 75 years). The average defect size of the skull base was 3.6 ± 0.1 cm by 2.3 ± 0.2 cm. The average defect size of the medial orbit was 2.7 ± 0.1 cm by 2.6 ± 0.1 cm. All defects were successfully covered intraoperatively using the lateral nasal wall extension of the NSF. Two patients developed mild eyelid edema, whereas 1 individual had no noticeable swelling (SPREE classification 2, 2, and 1). All patients were successfully sealed at last clinical follow up (average 28 weeks).

CONCLUSION

The modification of the NSF described here provides excellent coverage for reconstruction of large anterior skull-base defects and simultaneous medial orbital wall defects.

Predictors of Nasoseptal Flap Use After Endoscopic Transsphenoidal Pituitary Mass Resection

OBJECTIVE

The pedicled nasoseptal flap (NSF) is the widely accepted reconstructive technique of choice for repair of larger skull base defects after endoscopic endonasal approaches. There is a dearth of literature examining the decision-making process regarding flap harvest. The objective of this study is to evaluate preoperative characteristics that predict the use of NSF reconstruction after endoscopic transsphenoidal resection of pituitary tumors.

METHODS

In this retrospective case control study, demographic, clinical, imaging, and procedural details were gathered on all patients undergoing endoscopic transsphenoidal pituitary adenoma resection at a single academic center since January 2009. Characteristics were compared for patients receiving an NSF and those not undergoing NSF repair. A multivariate model that best predicted the use of an NSF was built and a risk score was developed.

RESULTS

Two hundred thirty-eight patients were included, and 39 underwent NSF placement. Tumor size and anatomic characteristics were the predominant factors that significantly differed between cases and controls. Patients with transsellar tumor extension had 6.3 higher odds of requiring NSF, each millimeter increase in tumor height on coronal T1 magnetic resonance imaging increased the odds of NSF use by 1.2. The flap risk score (FRS) is calculated by adding tumor height (mm) to 6 if there is transsellar extension. At an FRS of >35, the FRS is 87% specific and 85% sensitive for flap placement.

CONCLUSIONS

Preoperative imaging characteristics can predict NSF use. The FRS can be applied by surgical teams and referring physicians to determine which patients are more likely to undergo NSF repair.

Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling

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.

A Systematic Review of Secondary Cerebrospinal Fluid Leaks

Background

Secondary cerebrospinal leaks (CSF) are leaks that recur after an initial endoscopic repair of CSF leaks. Identification of characteristics that could predict secondary leaks may allow surgeons to plan repairs with the knowledge that these defects are more likely to fail.

Objective

To identify characteristics that could predict secondary CSF leaks.

Methods

A search of all studies that reported outcomes after endoscopic repair of CSF leaks was conducted by using medical literature data bases. Studies with the following criteria were included: written in the English language, secondary CSF leaks after primary repair, and assessment of success of fistula repair. Data extracted included the etiology of the leak, site of the leak, reconstructive materials used, and success of the repair.

Results

Ninety-four studies, from 1988 to 2015, with a total of 3149 primary CSF leaks were included. Sixty-three studies (67%) had a success rate of ≥80%; 77 studies (82%) had secondary leak rates of <40%. For 88 of the 94 studies (94%), the success rate after secondary repair improved to 81.0–100%. Of 48 studies that included leaks of more than one site, the sphenoid was the most common site of leak in 26 studies (55%), the ethmoid was the most common site in 16 studies (34%), and the cribriform was the most common site in 11 studies (23%).

Conclusion

The rate of secondary CSF leaks was low due to advances in endoscopic repair techniques. Spontaneous and iatrogenic CSF leaks were more likely to recur, especially without adequate control of underlying factors, such as increased intracranial pressure and obesity. Further studies with consistent reporting are required for more definitive conclusions about secondary CSF leaks.

Collagen matrix as an inlay in endoscopic skull base reconstruction

BACKGROUND

Multi-layer reconstruction has become standard in endoscopic skull base surgery. The inlay component used can vary among autografts, allografts, xenografts and synthetics, primarily based on surgeon preference. The short- and long-term outcomes of collagen matrix in skull base reconstruction are described.

METHODS

A case series of patients who underwent endoscopic skull base reconstruction with collagen matrix inlay were assessed. Immediate peri-operative outcomes (cerebrospinal fluid leak, meningitis, ventriculitis, intracranial bleeding, epistaxis, seizures) and delayed complications (delayed healing, meningoencephalocele, prolapse of reconstruction, delayed cerebrospinal fluid leak, ascending meningitis) were examined.

RESULTS

Of 120 patients (51.0 ± 17.5 years, 41.7 per cent female), peri-operative complications totalled 12.7 per cent (cerebrospinal fluid leak, 3.3 per cent; meningitis, 3.3 per cent; other intracranial infections, 2.5 per cent; intracranial bleeding, 1.7 per cent; epistaxis, 1.7 per cent; and seizures, 0 per cent). Delayed complications did not occur in any patients.

CONCLUSION

Collagen matrix is an effective inlay material. It provides robust long-term separation between sinus and cranial cavities, and avoids donor site morbidity, but carries additional cost.

Management of Frontal Sinus Cerebrospinal Fluid Leaks and Encephaloceles

Encephaloceles and cerebrospinal fluid (CSF) leaks of the frontal sinus may result from congenital, traumatic, spontaneous, or neoplastic causes. Paramount to success is adequate preoperative planning with accurate history, physical exam, endoscopy, imaging, and testing to confirm location of the leak and origin of the disease. Generally, frontal sinus CSF leaks may be addressed endoscopically with favorable anatomy, proper surgical technique, and appropriate equipment. Open surgical approaches (eg, osteoplastic flap) are often required for superior/lateral defects or if the surgeon is not experienced with endoscopic frontal sinus techniques.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair

BACKGROUND

Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case-series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques.

METHODS

Prospective evaluation of patients undergoing surgery for frontal sinus fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of skull base defects, complications, and clinical follow-up.

RESULTS

Forty-six patients (average age, 42 years) with frontal sinus fractures were treated using endoscopic techniques from 2008 to 2016. Mean follow-up was 26 (range, 0.5 to 79) months. Patients were treated primarily with a Draf IIb frontal sinusotomies. Draf III was used in 8 patients. Average fracture defect (length vs width) was 17.1 × 9.1 mm, and the average length involving the posterior table was 13.1 mm. Skull base defects were covered with either nasoseptal flaps or free tissue grafts. One individual required Draf IIb revision, but all sinuses were patent on final examination and all closed reductions of anterior table defects resulted in cosmetically acceptable outcomes.

CONCLUSION

Frontal sinus trauma has traditionally been treated using open approaches. Our findings show that endoscopic management should become part of the management algorithm for frontal sinus trauma, which challenges current surgical dogma regarding mandatory open approaches.

Objective assessment of olfaction after transsphenoidal pituitary surgery

BACKGROUND

Transnasal endoscopic pituitary surgery has proven to be a safe and effective method for removing pituitary tumors. Direct and angled endoscopy at the site of dissection provides excellent visualization without external incisions. However, olfactory loss has been documented after surgical approaches to the pituitary and is accompanied by a significant detriment to quality of life.

STUDY DESIGN

A prospective cohort study.

METHODS

Subjects 19 years and older who were undergoing transnasal endoscopic pituitary surgery were recruited for this study. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and then at 3-4 months. Data regarding demographics, reconstructive technique, and complications were recorded. The patients had skull-base reconstruction with a Medpore implant or a vascularized nasoseptal flap.

RESULTS AND DISCUSSION

A total of 33 subjects were recruited, with 18 completing the study. The mean (SEM) age was 58.2 ± 2.4 years, with 12 females and 6 males. The majority of patients (89%) had nonfunctioning macroadenomas, and six individuals had reconstruction by using a vascularized nasoseptal flap. Matched mean (SEM) preoperative and postoperative UPSIT scores for this cohort were not significantly different (31.3 ± 0.4 versus 30.5 ± 0.5, respectively; p = 0.54). In addition, there was no significant difference between the mean preoperative and postoperative UPSIT scores of the patients who had nasoseptal flaps (29.4 ± 1.1 vs. 28.6 ± 1.3 respectively; p = 0.87).

CONCLUSIONS

In the current study, pre- and postoperative UPSIT scores were not significantly different in patients who underwent endoscopic transnasal pituitary surgery. The use of a nasoseptal flap also did not adversely affect postoperative UPSIT scores.

Management Strategies for Skull Base Inverted Papilloma

Objective

Inverted papilloma attached to the ventral skull base presents a surgical dilemma because surgical removal of the bony pedicle is critical to decrease risk of recurrence. The objective of this study is to evaluate the effectiveness of endoscopic management of skull base inverted papilloma.

Study Design

Case series with planned data collection.

Setting

Tertiary medical center.

Subjects

Patients with skull base inverted papilloma.

Methods

Over 7 years, 49 patients with skull base inverted papilloma were referred for surgical resection. Demographics, operative technique, pathology, complications, recurrence, and postoperative follow-up were evaluated.

Results

Average age at presentation was 57 years. Twenty-six patients (53%) had prior attempts at resection elsewhere, and 5 had squamous cell carcinoma (SCCA) arising in an inverted papilloma. Six patients (12%) suffered major complications, including skull base osteomyelitis in 2 previously irradiated patients, cerebrospinal fluid leak with pneumocephalus (n = 1), meningitis (n = 1), invasive fungal sinusitis (n = 1), and cerebrovascular accident (n = 1). The mean disease-free interval was 29 months (range, 10-78 months). One patient with SCCA recurred in the nasopharynx (overall 2% recurrence rate). He is disease-free 3 years following endoscopic nasopharyngectomy. Three patients with SCCA had endoscopic resection of the skull base, while 1 subject with inverted papilloma pedicled on the superior orbital roof had an osteoplastic flap in conjunction with a Draf III procedure. All others received endoscopic resection.

Conclusions

Removal of the bony pedicle resulted in excellent local control of skull base inverted papillomas. Our experience demonstrates that disease eradication with limited morbidity is attainable with this approach.

Endonasal Endoscopic Surgery in the Management of Sinonasal and Anterior Skull Base Malignancies

Sinonasal malignancies represent a rare subset of tumors with a wide variety of histopathologic diagnoses and overall poor prognosis. These tumors tend to have an insidious onset with non-specific symptoms which often leads to delayed diagnosis and advanced local disease at presentation. The principal goal of surgery is to obtain a negative margin resection. Open craniofacial techniques are well established in the management of sinonasal malignancies and remain the treatment of choice for many advanced tumors. Over the past couple of decades, there has been tremendous application of endoscopic techniques to skull base pathologies including sinonasal malignancies. For selected cases, endonasal endoscopic techniques can be performed with curative intent and reduced surgical morbidity and mortality. Here we discuss principles of surgical management of sinonasal malignancies, review the techniques of endonasal endoscopic resection of sinonasal malignancies, and highlight the importance of pathology in the multi-disciplinary management of patients with these complex lesions.

Draf III mucosal graft technique: long-term results

BACKGROUND

The Draf III procedure is an effective endoscopic approach to the treatment of frontal sinus disorders, but has a significant restenosis rate. The objective of the current study is to assess long-term success of the Draf III mucosal grafting technique.

METHODS

Patients undergoing Draf III with mucosal grafting technique were prospectively enrolled. Demographics, indication for surgery, anterior-posterior (AP) diameter of frontal ostium, and complications were recorded. Failure was defined a priori as closure ≥50% of the intraoperative AP diameter at last clinical follow-up.

RESULTS

Ninety-six patients requiring Draf III with mucosal grafting were enrolled, 67 of which (average age 54 years; range, 15-84 years) had at least 1 year of follow-up (average 34 months; range, 12-85 months) and were included in the analysis. Reasons for the procedure included chronic rhinosinusitis with frontal ostium stenosis (n = 37), tumor (n = 26), and cerebrospinal fluid leak (n = 4). Average preoperative Lund-Mackay score was 13.9 ± 7.8. Average intraoperative AP diameter was 11.0 ± 1.9 mm. The procedure was highly effective with 97% (65/67) of patients maintaining a patent frontal sinus ostium (>50% intraoperative AP diameter) for the duration of follow-up (average postoperative diameter 9.9 ± 2.2 mm). However, the 2 Draf III failures remained patent, did not need further intervention, and were considered clinically successful. Three patients required reoperation for reasons unrelated to closure of the Draf III.

CONCLUSION

Common causes of failure following Draf III procedures include osteoneogenesis and stenosis. This study provides long-term data demonstrating excellent outcomes using the mucosal grafting technique.

Endoscopic repair of cerebrospinal fluid rhinorrhoea

GOAL

The purpose of this review was to look at the success rate of transnasal endoscopic repair of CSF rhinorrhoea and the impact of patient factors, repair techniques and adjuvant treatment.

MATERIAL AND METHODS

A literature search was performed on PubMed, Medline and Cochrane Central databases, independently by two of the authors, of all studies reporting the outcomes of CSF rhinorrhoea repair, published until the 1st June 2014, using keywords Cerebrospinal fluid leak, CSF leak, CSF fistula, CSF leak or fistula repair, endoscopic sinus surgery or ESS complications. Sixty-seven papers were included for the review.

RESULT

The repair of CSF rhinorrhoea has rapidly evolved over the past 30 years. Prior to the advent of the endoscopic approach, craniotomy was used for repairs, which carried a variable success rate and morbidity. More recently, there have been several case series and reports that describe various endoscopic methods and materials for repair, with mean success rate of 90% (range: 60-100%). The most common site of CSF leak is the ethmoid roof/cribriform plate region. Traumatic CSF leak, in particular iatrogenic, is still the most common cause. Imaging with CT and MRI remains the gold standard for localisation of CSF leaks. The sphenoid sinus is the most common location for CSF leak repair failure. Lumbar drains and antibiotics are used as adjuvant therapy to endoscopic repair, but their benefits are not clear; intrathecal fluorescein can be used to aid location of CSF leak, but should be reserved for more complex cases. Further work into graft materials used and adjuvant treatment is needed to make any meaningful conclusions about their efficacy.

CONCLUSION

The literature demonstrates that endoscopic repair of CSF rhinorrhoea is safe and effective, with a very low complication rate. It has almost completely replaced the older open techniques.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations

BACKGROUND

Management strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely because of limited evidence-based guidance.

METHODS

A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014 to examine 5 endoscopic repair techniques and 8 perioperative management strategies for CSF rhinorrhea. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process.

RESULTS

We reviewed 67 studies examining 13 practices pertinent to the management of CSF rhinorrhea, reaching a highest aggregate grade of evidence of B. The literature does not support the routine use of prophylactic antibiotics or lumbar drainage. Various endoscopic repair materials show similar success rates; however, larger defects may benefit from vascularized grafts. There were no relevant studies to address postoperative activity restrictions.

CONCLUSION

Despite relatively low levels of evidence, recommendations for the management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal clinical management approaches.

Inferior turbinate reconstruction using porcine small intestine submucosal xenograft demonstrates improved quality of life outcomes in patients with empty nose syndrome

BACKGROUND

We describe the surgical technique for use of small intestine submucosal (SIS) xenograft implant for inferior turbinate reconstruction and report our early results in a pilot case series of patients suffering from symptoms consistent with empty nose syndrome (ENS).

METHODS

We report an observational prospective cohort study of ENS patients undergoing inferior turbinate reconstruction using porcine SIS xenograft. Effects of the procedure on quality of life (QOL) were assessed through serial 25-item Sino-Nasal Outcome Test (SNOT-25) scores and analyzed by 1-way analysis of variance (ANOVA) between the initial visit and 1, 4, and 12 weeks after surgery.

RESULTS

Three patients with ENS underwent inferior turbinate reconstruction. No unexpected complications were noted over the 12-week follow-up course. Despite mild partial reabsorption of the SIS implant, neoturbinates were maintained in all patients. The mean preoperative score SNOT-25 was 77.6 (maximum 125). The mean postoperative scores were 65 at 1 week, 57 at 4 weeks, and 55 at 12 weeks (p < 0.01). Furthermore, for the "difficulty with nasal breathing" and "nose is too open" subdomains, statistically significant improvement was also noted at weeks 4 and 12 postoperatively (p < 0.05 and p <0.01, respectively).

CONCLUSION

The use of porcine SIS xenograft for inferior turbinate reconstruction appears to be safe and effective in the treatment of patients diagnosed with ENS. This study demonstrates statistically significant improvement in global QOL metrics and nasal-specific subdomains following inferior turbinate reconstruction/neoturbinate creation for ENS as evaluated through serial SNOT-25 scores.

Inaccurate Assessments of Anterior Cranial Base Malignancy Following Nasoseptal Flap Reconstruction

Objective The nasoseptal flap (NSF) provides vascularized tissue for repair of skull base defects of various etiologies. However, the NSF repair after skull base resection for anterior cranial base malignancies may demonstrate radiologic findings confusing for recurrent or residual disease on postoperative surveillance imaging. The objective of the current study was to review neuroradiologic misinterpretations of NSF reconstruction following anterior cranial base malignancies. Methods A multicenter review of patients reconstructed with the NSF after endoscopic resection of anterior cranial base malignancies from 2008 to 2013 was performed. Data were collected regarding etiology, surgical technique, locoregional control, and postoperative radiologic assessments. Only patients with at least one postoperative surveillance scan with inaccurate assessment of residual or recurrent malignancy were included in the study. Results Over 5 years, 13 patients were identified who had erroneous reporting of malignancy due to NSF reconstruction. On average, two neuroradiologists interpreted the NSF as persistent or recurrent malignancy over this time period (range: 1-7). The key findings suspicious for recurrence were enhancement and soft tissue thickening of the NSF. These findings were present in at least one postoperative scan in all patients. Conclusion Neuroradiologists and rhinologists performing surveillance on patients with a history of skull base malignancy with NSF reconstruction should maintain collaborative efforts to accurately interpret radiologic findings of the NSF during postoperative imaging.

Updates in reconstruction of skull base defects

PURPOSE OF REVIEW

Skull base surgery has undergone a fundamental transformation with the development and rapid adoption of endoscopic endonasal expanded approaches. Defects created from these newer approaches have necessitated an evolution of novel reconstructive techniques, which are reviewed here.

RECENT FINDINGS

New reconstructive techniques continue to be developed for repairing surgical defects from endoscopic endonasal skull base resections. Improvisations also allow well known flaps to be used in these approaches. Long term outcomes from repair using some of these techniques are now becoming available.

SUMMARY

Endoscopic resection of previously unapproachable skull base lesions has become possible with advancements in technology, as well as reconstructive methods. These newer techniques may offer improved outcomes and lower morbidity over conventional surgery.

The use of image-guidance during transsphenoidal pituitary surgery in the United States

BACKGROUND

Intraoperative image guidance is a useful modality for transsphenoidal pituitary surgery. However, the outcomes associated with this technology have not been systematically evaluated.

OBJECTIVE

The purpose of the study was to quantify complication rates with and without the use of image guidance during transsphenoidal pituitary surgery using a nationwide database with broadly applicable results.

METHODS

A retrospective analysis of the Nationwide Inpatient Sample was performed from 2007 to 2011. Transsphenoidal pituitary resections for adenomas were identified by International Classification of Diseases-9th Revision, Clinical Modification code. The effect of image guidance on cerebrospinal fluid (CSF) leak complications and cost-benefit was analyzed.

RESULTS

A total of 48,848 transsphenoidal pituitary resections were identified, of which 77.5% were partial resections and 22.5% were complete. Pathologic indications included benign (89.3%), malignant primary (0.6%), and malignant secondary (0.4%). Complications included same-stay death (0.4%), CSF leak (8.8%), postoperative CSF rhinorrhea (1.9%), diabetes insipidus (12.4%), and meningitis (0.4%). Image guidance was employed in 7% (n = 3401) of all cases. When analyzed by modality, computed tomography (CT)-assisted procedures had lower CSF rhinorrhea rates (1.1%) compared with cases with no image guidance (1.9%), whereas magnetic resonance (MR)-assisted procedures had the highest rates (2.7%, χ2 p < 0.001). Rates of CSF leak demonstrated a similar pattern (CT 6.4%, no image guidance 8.9%, MR 9.2%, χ2 p < 0.001). CT-assisted surgery had significantly shorter length of stay (2.9 days) versus no image guidance (3.7 days, p < 0.001), lower total charges ($47,589 versus $62,629, p < 0.001), and lower total cost ($16,748 versus $20,530, p < 0.001).

CONCLUSIONS

CT-assisted surgery is associated with a lower rate of CSF leak, shorter length of stay, and lower cost compared with patients without image guidance. Further studies that control for severity and extent of disease are warranted to confirm this finding.

Management of Lateral Frontal Sinus Pathology in the Endoscopic Era

OBJECTIVES

Considerable advances in endoscopic technique and experience have allowed an increasing number of patients with complex frontal sinus disease to be treated with endoscopic surgery. The objective of the current study was to evaluate management strategies and outcomes regarding treatment of lateral frontal sinus disease.

STUDY DESIGN

Prospective case series.

SETTING

Academic tertiary medical center.

SUBJECTS AND METHODS

Prospectively collected data concerning frontal sinus pathology located lateral to the plane of the lamina papyracea (lateral disease) were reviewed. Data were collected regarding demographics, etiology, surgical technique, revision rate, anatomic considerations, and clinical follow-up. Only patients with at least 24 weeks of clinical follow-up and pathology who required removal and dissection in this region were included in the study.

RESULTS

Over 5 years, 156 patients (mean age, 47.9 years; range, 14-84 years) with 183 lateral frontal sinus pathologies and an average clinical follow up of 76 weeks (range, 24-237 weeks) were evaluated. Endoscopic or open surgery was attempted in 84 patients (54%) prior to intervention at our institution. Primary pathologies included inflammatory/obstructive diseases (n = 119), skull base defects (n = 33), and tumors (n = 31). Initial interventions included endoscopic (Draf IIA, n = 76; Draf IIB, n = 52; Draf III, n = 23), extended (IIA + trephine, n = 1; III + trephine, n = 2; III + osteoplastic flap, n = 2), and open (osteoplastic flap, n = 3; Reidel, n = 1; cranialization, n = 1) procedures. Seven patients (4%) required a subsequent revision procedure.

CONCLUSION

The vast majority of lateral frontal sinus pathology was managed using endoscopic techniques with excellent outcomes and a low revision rate in the current study.

Porcine small intestine submucosal grafts for post-tumor resection orbital reconstruction

OBJECTIVES/HYPOTHESIS

Removal of the medial orbital wall for sinonasal tumor involvement is required to obtain complete oncologic resection. However, orbital fat herniation can produce significant morbidity, including enophthalmos and diplopia. The purpose of the current study was to evaluate outcomes following use of porcine small intestine submucosa (SIS) grafts for orbital reconstruction following extirpation of sinonasal malignancies.

STUDY DESIGN

Case series in a tertiary hospital setting.

METHODS

Review of prospectively collected data regarding orbital reconstruction using SIS was performed. Demographics, tumor histology, size of orbital defect, adjuvant treatment, clinical status, and complications were recorded.

RESULTS

Seventeen patients (average age, 58 years; range, 27-82 years) had SIS grafting of the medial orbital wall over a 5-year period at our tertiary academic institution. The average orbital wall defect size was 4.6 cm(2) (range, 1 cm(2)-24 cm(2)). Tumor histopathology included esthesioneuroblastoma (n = 5), squamous cell carcinoma (n = 4), adenocarcinoma (n = 2), sinonasal undifferentiated carcinoma (n = 2), melanoma (n = 3), and neuroendocrine carcinoma (n = 1). Surgical goals were curative intent in all patients. Ten patients had postoperative radiation therapy, whereas five individuals had surgical extirpation following neoadjuvant chemotherapy and radiation. All patients had complete locoregional control at last clinical follow-up (average, 16 months; range, 2-54 months), although three patients developed distant metastases. The only orbital complications noted were enophthalmos (n = 1), periorbital cellulitis (n = 1), and orbital wall crusting (n = 1).

CONCLUSIONS

SIS reconstruction of orbital wall defects was effective in the current series of patients, with only one patient developing noticeable enophthalmos and a low incidence of surgical complications.

LEVEL OF EVIDENCE

4.