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de Andrade EJ, Recinos PF. Exoscopic supraorbital approach for a tuberculum sellae meningioma. Clin Neurol Neurosurg 2023; 231:107830. [PMID: 37356198 DOI: 10.1016/j.clineuro.2023.107830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/24/2023] [Accepted: 05/27/2023] [Indexed: 06/27/2023]
Abstract
Tuberculum sellae meningiomas are midline anterior skull base tumors and account for approximately 10-15% of all intracranial meningiomas. Clinical presentation of tuberculum sellae meningiomas is mainly characterized by visual deficits due to optic chiasm compression or optic canal invasion. Treatment options for TSM typically involve surgical resection of the tumor. The relevant microsurgical anatomy of the suprasellar region was discussed. (1,2). Tumor size, anatomical variations can affect the best approach for these tumors, with several approaches been described to access the suprasellar region as pterional, endoscopic endonasal and supraorbital approach that was the choice for this case (3). Besides the surgical corridor, minimally invasive techniques that preserve the surrounding tissue are becoming increasingly popular and are perfectly suited to deep seated lesions. In this article, we present a surgical video of an exoscopic supraorbital approach for resection of a tuberculum sellae meningioma. This is a case of a 42-year-old right-handed female who presented with headaches and progressive vision loss. Patient presented with tumor growth and surgery was indicated. We chose the minimally invasive supraorbital approach and then used the exoscope as magnification tool visualization tool. Gross total resection and decompression of the optic canals was achieved with improvement of visual field deficits.
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Affiliation(s)
- Erion Júnior de Andrade
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pablo F Recinos
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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3
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Potter T, Soni P, Krywyj M, Petitt J, Jarmula J, Obiri-Yeboah D, Oyem P, Momin A, Easley K, Sindwani R, Woodard T, Recinos PF, Kshettry VR. Predictive Factors for Postoperative Opioid Use in Elective Endoscopic Endonasal Skull Base Surgery. Laryngoscope 2023; 133:494-499. [PMID: 35353373 DOI: 10.1002/lary.30116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE In 2017, the United States opioid epidemic was declared a public health emergency. Increased efforts have been made to understand and reduce patient opioid use in neurosurgery. However, the factors associated with postoperative opioid use remain understudied in endoscopic endonasal skull base surgery (EESBS). We identified the demographic and surgical factors associated with postoperative opioid use in EESBS. METHODS A retrospective review was conducted of patients who underwent elective EESBS between January 2015 and December 2020. Patient demographics, relevant clinical history, and operative data were collected and analyzed. Total opioid use was calculated 24, 48, and 72 hours postoperatively. Multivariable linear regression analyses were performed to identify factors associated with opioid use. RESULTS There were 454 patients included. A history of anxiety/depression and younger patient age were associated with a significant increase in opioid use at 24 (28.2 MME, p < 0.001), 48 (53.4 MME, p < 0.001), and 72 (89.4 MME, p < 0.001) hours after surgery. Nasoseptal flap use was significantly associated with increased opioid use at 24 (12.8 MME, p < 0.49) and 48 (19.6 MME, p < 0.048) h postoperatively while controlling for intraoperative variables and surgical approach (trans-sellar vs. expanded). No significant association was observed for patient sex, history of migraines, preoperative opioid use, length of surgery, or surgical approach. CONCLUSION In patients undergoing EESBS, patient history of anxiety/depression, younger patient age, and nasoseptal flap use are associated with increased postoperative opioid use. Knowledge of these risk factors may guide perioperative prescribing patterns to both adequately control postoperative pain and reduce opioid use. LEVEL OF EVIDENCE 4 Laryngoscope, 133:494-499, 2023.
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Affiliation(s)
- Tamia Potter
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Pranay Soni
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Maria Krywyj
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jordan Petitt
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jakub Jarmula
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Derrick Obiri-Yeboah
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Precious Oyem
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arbaz Momin
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kathryn Easley
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Raj Sindwani
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Troy Woodard
- Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.,Department of Otolaryngology-Head & Neck Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
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Salmon MK, Kshirsagar RS, Eide JG. Craniopharyngioma surgery for rhinologists. Curr Opin Otolaryngol Head Neck Surg 2023; 31:45-52. [PMID: 36730658 DOI: 10.1097/moo.0000000000000856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Craniopharyngiomas are rare tumors that that present with loss of pituitary function in most cases. They present in a bimodal age distribution and the most common treatment paradigms include gross total resection or subtotal resection followed by radiation. Endoscopic transnasal access to intradural tumors has become increasingly common due to improvements in equipment, increased familiarity with the surgical corridor and anatomy, and reconstruction techniques. As such, rhinologists play an increasingly important role in the management of craniopharyngiomas. RECENT FINDINGS Recent years have highlighted our growing experience with pediatric endonasal skull base surgery. Prior concerns including sphenoid pneumatization, midfacial growth restrictions, and intercarotid space limitations have been studied more extensively. It has been found that there are no increased complications with lack of sphenoid pneumatization, no changes to midfacial growth with endonasal techniques, and the inter-carotid distance is stable after around age 5. Advances in surgical and skull base reconstruction techniques and intraoperative monitoring have reduced the risks of complications from surgery. SUMMARY Rhinologists play an important role in craniopharyngioma surgery. The approach to and reconstruction after tumor removal are vital portions of the procedure that allow for resection and prevent postsurgical complications.
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Affiliation(s)
- Mandy K Salmon
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rijul S Kshirsagar
- Department of Head and Neck Surgery, Kaiser Permanente Redwood City Medical Center, Redwood City, California
| | - Jacob G Eide
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, USA
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Yu S, Taghvaei M, Reyes M, Collopy S, Piper K, Karsy M, Prashant GN, Kshettry VR, Rosen MR, Farrell CJ, Evans JJ. Evolution of Surgical Outcomes in Endoscopic Endonasal Resection of Craniopharyngiomas. J Neurol Surg B Skull Base 2022. [DOI: 10.1055/s-0042-1751291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Introduction Wide variations exist in the management of craniopharyngiomas, including pituitary stalk preservation/sacrifice. This study examines the practice patterns over 16 years using the endoscopic endonasal approach for the resection of craniopharyngiomas and it examines the effects of stalk preservation.
Methods Retrospective analysis was conducted for 66 patients who underwent endoscopic transsphenoidal surgery for resection of craniopharyngiomas. Patients were stratified into three epochs: 2005 to 2009 (N = 20), 2010 to 2015 (N = 23), and 2016 to 2020 (N = 20), to examine the evolution of surgical outcomes. Subgroup analysis between stalk preservation/stalk sacrifice was conducted for rate of gross total resection, anterior pituitary function preservation, and development of new permanent diabetes insipidus.
Results Gross total resection rates across the first, second, and third epochs were 20, 65, and 52%, respectively (p = 0.042). Stalk preservation across epochs were 100, 5.9, and 52.6% (p = 0.0001). New permanent diabetes insipidus did not significantly change across epochs (37.5, 68.4, 71.4%; p = 0.078). Preservation of normal endocrine function across epochs was 25, 0, and 23.8%; (p = 0.001). Postoperative cerebrospinal fluid (CSF) leaks significantly decreased over time (40, 4.5, and 0%; [p = 0.0001]). Stalk preservation group retained higher normal endocrine function (40.9 vs. 0%; p = 0.001) and less normal-preoperative to postoperative panhypopituitarism (18.4 vs. 56%; p = 0.001). Stalk sacrifice group achieved higher GTR (70.8 vs. 28%, p = 0.005). At last follow-up, there was no difference in recurrence/progression rates between the two groups.
Conclusion There is a continuous evolution in the management of craniopharyngiomas. Gross total resection, higher rates of pituitary stalk and hormonal preservation, and low rates of postoperative CSF leak can be achieved with increased surgical experience.
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Affiliation(s)
- Siyuan Yu
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Mohammad Taghvaei
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Maikerly Reyes
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Sarah Collopy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Keenan Piper
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Giyarpuram N. Prashant
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Varun R. Kshettry
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Marc R. Rosen
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Christopher J. Farrell
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - James J. Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
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