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Abbasoglu B, Basak H, Mete B, Gokalp E, Zaimoglu M, Beton S, Meco C, Kahilogulları G. Effect of endoscopic endonasal skull base approaches on olfactory function and facial development in children. Childs Nerv Syst 2024:10.1007/s00381-024-06446-0. [PMID: 38850294 DOI: 10.1007/s00381-024-06446-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/01/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Endoscopic approaches for skull base pathologies are increasingly being performed, and the subsequent complications, especially in the long term, have also been partially clarified. However, there is no information on the effects of endoscopic endonasal skull base surgeries (EESBS) in children on odor and facial development in parallel with long-term development. We conducted this study to investigate postoperative olfactory function and facial development in pediatric patients who underwent skull base surgery using the endoscopic endonasal method. METHODS We evaluated the smell test, sinonasal symptoms, and facial development of pediatric patients who underwent endoscopic endonasal skull base surgery after long-term follow-up. Odor was evaluated using the "Sniffin' Sticks" test kit, which assessed the T (odor threshold), D (odor discrimination), and I (odor identification) parameters. Sinonasal symptoms were evaluated using the SNOT-22 (sinus-nose outcome test) questionnaire. SNA (sella-nasion-A point), SNB (sella-nasion-B point), and ANB (A point-nasion-B point) angles were calculated from maxillofacial tomography and magnetic resonance imaging) to evaluate facial development. Data were compared with those of the healthy control group. RESULTS We included 30 patients comprising 19 (63.3%) boys and 11 (36.7%) girls, with no age difference between case and control groups. The mean follow-up period was 7 years. Odor test data, cephalometric measurements, and SNOT-22 analysis results showed no statistically significant differences between the two groups. CONCLUSION To our knowledge, this is a comprehensive study with the longest follow-up period in terms of evaluation of facial development after EESBS in children to analyze odor using the Sniffin' Sticks test kit and the quality of life using SNOT-22. Olfactory function, facial development, and quality of life remained unaffected after long-term follow-up after EESBS in children. Although this surgical approach is minimally invasive, we recommend considering the possibility of complications, and the procedure should be performed by an experienced surgical team with adequate equipment.
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Affiliation(s)
- Bilal Abbasoglu
- Department of Neurosurgery, Ankara University Medical School, Ankara, Turkey
| | - Hazan Basak
- Department of Otorhinolaryngology - Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
| | - Bahir Mete
- Department of Neurosurgery, Ankara University Medical School, Ankara, Turkey
| | - Elif Gokalp
- Department of Neurosurgery, Ankara University Medical School, Ankara, Turkey
| | - Murat Zaimoglu
- Department of Neurosurgery, Ankara University Medical School, Ankara, Turkey
| | - Suha Beton
- Department of Otorhinolaryngology - Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
| | - Cem Meco
- Department of Otorhinolaryngology - Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
- Department of Otorhinolaryngology - Head and Neck Surgery, Salzburg Paracelsus Medical University, Salzburg, Austria
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Lubojacký J, Čábalová L, Mladoňová M, Hránková V, Krejčí T, Mičaník J, Miklošová M, Ličev L, Komínek P, Matoušek P. Transnasal Endoscopic Pituitary Surgery-The Role of a CT Scan in Individual Tailoring of Posterior Septum Size Resection. Tomography 2023; 9:2222-2232. [PMID: 38133076 PMCID: PMC10747678 DOI: 10.3390/tomography9060172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE This study was designed to evaluate the possibility of predicting the minimum size of septal resection for safe tumor extraction in transnasal paraseptal pituitary adenoma resection from preoperative computed tomography scans. METHODS A retrospective CT scan analysis was performed on 20 patients who underwent endoscopic pituitary surgery at the University Hospital in Ostrava. Virtual insertion of the straight instrument into the sphenoid cavity was simulated using a CT scan. The minimum septal resection size was predicted and compared to various diameters in the nasal cavity. The results were then compared with cadaveric dissections, in which septal resections were performed at 1 cm and 2 cm distances from the anterior sphenoid wall. The association between cadaver dissections and CT scan results was studied. RESULTS A total of 20 patients who underwent endoscopic transnasal surgery for pituitary adenoma between the years 2020 and 2021 were enrolled in the study. The mean virtual posterior septal size resection needed to reach the medial edge of the ICA with the straight instrument, without infracturing the nasal septum, was 13.2 mm. In cadavers with a 1 cm posterior septal resection, the medial edge of the ICA was reached with the straight instrument. In 2 cm resections, it was possible to reach beyond the lateral edge of the ICA. CONCLUSION There is no significant correlation between the minimum septal size resection and measured diameters in the nasal cavity. According to our study, a 1 cm resection is sufficient for a non-extended pituitary tumor extraction. More extensive septal resections allow for better maneuverability and overview in the surgical field.
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Affiliation(s)
- Jakub Lubojacký
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Lenka Čábalová
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Michaela Mladoňová
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Viktória Hránková
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
- Department of Anatomy, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Tomáš Krejčí
- Department of Neurosurgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Jakub Mičaník
- Department of Radiodiagnostics, Ostrava University Hospital, 70800 Ostrava, Czech Republic;
| | - Maria Miklošová
- Department of Anatomy, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Lačezar Ličev
- Faculty of Electrical Engineering and Computer Science, VŠB Technical University Ostrava, 70800 Ostrava, Czech Republic;
| | - Pavel Komínek
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
| | - Petr Matoušek
- Department of Otorhinolaryngology and Head and Neck Surgery, Ostrava University Hospital, 70800 Ostrava, Czech Republic
- Department of Craniofacial Sciences, Faculty of Medicine, University of Ostrava, 70103 Ostrava, Czech Republic
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Gstrein NA, Zwicky S, Serra C, Hugelshofer M, Regli L, Soyka MB, Holzmann D, Meerwein CM. Rhinologic outcome of endoscopic transnasal-transsphenoidal pituitary surgery: an institutional series, systematic review, and meta-analysis. Eur Arch Otorhinolaryngol 2023; 280:4091-4099. [PMID: 36988686 PMCID: PMC10382340 DOI: 10.1007/s00405-023-07934-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/17/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE We aimed to summarize the available data on the objective rhinologic outcome after endoscopic transnasal-transsphenoidal (ETT) surgery. METHODS Retrospective study on a consecutive cohort of treatment-naïve patients undergoing ETT pituitary gland surgery. Additionally, a systematic review and meta-analysis with focus on the rhinologic outcome, including postoperative smell function was performed. RESULTS The institutional series incorporated 168 patients. A concomitant endoscopic septoplasty was performed in 29/168 patients (17.3%). A nasoseptal flap was used for reconstruction of large skull-base defects or high-flow CSF leaks in 4/168 (2.4%) patients. Early postoperative rhinologic complications (< 4 weeks) included epistaxis (3%), acute rhinosinusitis (1.2%) and late postoperative complications (≥ 8 weeks) comprised prolonged crusting (15.6%), symptomatic synechiae (11.9%) and septal perforation (0.6%). Postoperative smell function was not impaired (Fisher's exact test, p = 1.0). The systematic review included 19 studies on 1533 patients with a median postoperative epistaxis rate of 1.4% (IQR 1.0-2.2), a postoperative acute rhinosinusitis rate of 2.3% (IQR 2.1-3.0), a postoperative synechiae rate of 7.5% (IQR 1.8-19.1) and a postoperative septal perforation rate of 2.2% (IQR 0.5-5.4). Seven studies including a total of 206 patients reported adequate outcome measures for smell function before and after ETT surgery. Only 2/7 studies reported an impairment of smell function postoperatively, especially in patients with nasoseptal flap harvesting. CONCLUSION Early and late postoperative rhinologic complication rates after ETT surgery for pituitary lesions seem to be low. A thorough evaluation of smell function, in particular in patients at risk for nasoseptal flap harvesting, may be an important factor in optimal postoperative care.
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Affiliation(s)
- Nathalie A Gstrein
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - Sebastian Zwicky
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland
| | - Christian M Meerwein
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland.
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Basak H, Beton S, Akyıldız S, Yücel L, Guliyev H, Meco C. Olfactory changes after endonasal endoscopic cerebrospinal fluid fistula repair: long-term outcomes. J Laryngol Otol 2023; 137:426-431. [PMID: 35673778 PMCID: PMC10040285 DOI: 10.1017/s0022215122001335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This study aimed to evaluate odour measurements after endoscopic repair of cerebrospinal fluid fistulas. METHOD Demographic characteristics, cerebrospinal fluid leak location, surgical procedure, aetiology and smell test results were retrospectively reviewed. RESULTS A total of 27 patients were included. The mean age was 43.52 years. The aetiology was spontaneous in 13 patients (48.1 per cent) and traumatic in 14 patients (51.9 per cent). The skull base defect was at the cribriform plate in 15 patients (55.6 per cent), the frontal sinus posterior wall in 4 patients (14.8 per cent), the sphenoid sinus posterior wall in 4 patients (14.8 per cent), around the anterior ethmoid artery in 2 patients (7.4 per cent), at the ethmoid roof in 1 patient (3.7 per cent) and at the sphenoid sinus posterolateral wall in 1 patient (3.7 per cent). After the comparison of pre-operative and post-operative values in identification, discrimination and threshold categories, a statistically significant difference was seen only in the threshold category (p = 0.014). CONCLUSION The results demonstrated that endoscopic repair of cerebrospinal fluid leak is safe in terms of olfactory functions.
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Affiliation(s)
- H Basak
- Department of Otorhinolaryngology, Ankara University School of Medicine, Turkey
| | - S Beton
- Department of Otorhinolaryngology, Ankara University School of Medicine, Turkey
| | - S Akyıldız
- Department of Otorhinolaryngology, Ankara University School of Medicine, Turkey
| | - L Yücel
- Department of Otorhinolaryngology, University of Health Sciences, Gülhane Training and Research, Ankara, Turkey
| | - H Guliyev
- Department of Otorhinolaryngology, Ankara University School of Medicine, Turkey
| | - C Meco
- Department of Otorhinolaryngology, Ankara University School of Medicine, Turkey
- Department of Otorhinolaryngology, Salzburg University Paracelsus Medical School, Austria
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Bengtsson OF, Sunnergren O, Segerhammar I, Förander P, Olsson M, Hulting AL, Stjärne P. Remission, complications, and overall survival in transsphenoidal pituitary surgery-a Swedish single-center experience of 578 patients. Acta Neurochir (Wien) 2023; 165:685-692. [PMID: 36662287 PMCID: PMC10006055 DOI: 10.1007/s00701-022-05456-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/12/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Surgical treatment of pituitary lesions causing hormonal overproduction or mass effect is standard procedure. There are few reports on the results and complications related to these surgeries from Northern Europe. Our aim was to evaluate the outcome and complications of a single tertiary surgical center over more than a decade. METHODS This was a retrospective study on all patients that underwent pituitary surgery from 1st of January 2005 to 31st of December 2017. The analysis included type of lesion, surgical method, pre- and postoperative need for hormonal substitution, hormonal outcome, complications to surgery, survival, need for revision surgery, or stereotactic radiation. Appropriate statistical analyses were made to evaluate surgical results, complications, and survival. RESULTS Five hundred seventy-eight patients were included in the study. Remission was achieved in 58% of patients with GH-producing and 94% of ACTH-releasing adenomas. Sixty-six percent had no preoperative hormonal substitution compared to 39% postoperatively. Rhinosinusitis (10%) was the most commonly reported postoperative complication followed by leakage of cerebrospinal fluid (8%) and meningitis (4%). Standardized mortality rate for the study population was higher (p = 0.18) when compared to the general population. CONCLUSION Our results regarding remission rates and complications are in comparison with previous studies. Surgery of pituitary lesion can be considered a safe and efficient surgery. We noted lower rates of CSF leakage in the later part of the study period and believe that this, in part, was an effect by the introduction of a multidisciplinary surgical skull base team and increased surgical experience.
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Affiliation(s)
- Ola Fridman Bengtsson
- Department of Otorhinolaryngology, Karolinska University Hospital, Eugeniavägen 3, 171 76, Stockholm, Sweden.
- Department of Clinical Sciences, Intervention and Technology, Division of Otorhinolaryngology, Karolinska Institute, Stockholm, Sweden.
| | - Ola Sunnergren
- Ear-, Nose-, and Throat Clinic, Jönköping County, Sweden
| | - Ivan Segerhammar
- Ear-, Nose-, and Throat Clinic, Örebro University Hospital, Örebro, Sweden
| | - Petter Förander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Olsson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anna-Lena Hulting
- Department of Molecular Medicine and Surgery, Patient Area Endocrinology and Nephrology, Inflammation and Infection Theme, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Pär Stjärne
- Department of Otorhinolaryngology, Karolinska University Hospital, Eugeniavägen 3, 171 76, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Division of Otorhinolaryngology, Karolinska Institute, Stockholm, Sweden
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Lee Y, Wang H, Yeh T, Yang S, Lin C, Huang P, Wang K, Lai D, Tseng H, Lin Y. Improved nasal recovery and intact olfactory function after a transseptal approach for endoscopic endonasal transsphenoidal adenomectomy: A retrospective analysis. Laryngoscope Investig Otolaryngol 2022; 7:1695-1703. [PMID: 36544964 PMCID: PMC9764772 DOI: 10.1002/lio2.931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/03/2022] [Accepted: 09/12/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives Endoscopic endonasal transsphenoidal adenomectomy (TSA) is the most frequently performed skull base surgery, and researchers have recently focused on preserving nasal function. The endoscopic transseptal approach is a promising procedure due to its reduced injury to the nasal mucosa; however, there are no studies comparing rhinological and neurosurgical outcomes concurrently with the standard endoscopic transnasal approach. Therefore, we conducted this study to investigate whether the transseptal approach could reduce nasal morbidities with comparable neurosurgical outcomes. Methods We retrospectively reviewed 25 patients who underwent endoscopic endonasal transseptal TSA for pituitary adenoma without encasement of internal carotid artery from January 2019 to December 2020. Another 25 patients who received transnasal approach from January 2017 to December 2018 were selected as controls. Patients with diseases affecting the nasal cavity/olfaction or usage of a nasoseptal flap were excluded for a better comparison of the two procedures. We collected data from radiological studies, endocrine studies, endoscopic evaluations, 22-item sinonasal outcome tests (SNOT-22) and Top International Biotech Smell Identification Test (TIBSIT) for comparison. Results Lower postoperative SNOT-22 and Lund-Kennedy endoscopic scores were observed in the transseptal group. The effect size of differences were classified as large effect (The absolute value of Cohen's d > 0.8). Nevertheless, the TIBSIT scores were not significantly different. The rates of gross total resection, recovery of hormonal abnormalities, and complications were not significantly different. After controlling possible confounding factors using multivariate analysis, the endoscopic transseptal approach remained an independent factor for lower SNOT-22 scores and Lund-Kennedy endoscopic scores. Conclusions The endoscopic transseptal approach provides improved recovery of nasal mucosa and intact olfaction without compromising neurosurgical outcomes. Level of Evidence 2b.
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Affiliation(s)
- Yen‐Hui Lee
- Department of OtolaryngologyNational Taiwan University HospitalTaipeiTaiwan
| | - Huan‐Chih Wang
- Department of NeurosurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Te‐Huei Yeh
- Department of OtolaryngologyNational Taiwan University HospitalTaipeiTaiwan
| | - Shih‐Hung Yang
- Department of NeurosurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Chih‐Feng Lin
- Department of OtolaryngologyNational Taiwan University HospitalTaipeiTaiwan
| | - Po‐Hao Huang
- Department of NeurosurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Kuo‐Chuan Wang
- Department of NeurosurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Dar‐Ming Lai
- Department of NeurosurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Ham‐Min Tseng
- Department of NeurosurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Yi‐Tsen Lin
- Department of OtolaryngologyNational Taiwan University HospitalTaipeiTaiwan
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Liu Z, Zhao L, Wang Y, Dai K, Lu A, Zhao P. Application of dural suturing in the endoscopic endonasal approach to the sellar region. Front Surg 2022; 9:944663. [PMID: 36061055 PMCID: PMC9433994 DOI: 10.3389/fsurg.2022.944663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThe endoscopic endonasal approach (EEA) is widely used in the treatment of cranial base tumors. Skull base reconstruction is a crucial part of EEA, which has a great impact on patients’ prognosis. In this study, we report our experience with sellar dural suturing in cranial base reconstruction and retrospectively analyze its effect.MethodsThe clinical data of 134 patients who suffered intraoperative CSF leakage and underwent EEA surgery in the Department of Neurosurgery of the First Affiliated Hospital of Nanjing Medical University from October 2018 to November 2020 were retrospectively collected and analyzed. According to whether sellar dural suturing was performed during the operation, they were divided into a suture group (55 cases) and a control group (79 cases).ResultsThe results showed that dural suturing of the sellar floor effectively reduced the postoperative hospitalization duration (p = 0.026) and the use rates of lumbar drainage (p = 0.047), autologous fat transplantation (p = 0.038), and pedicled nasoseptal flaps (p = 0.026).ConclusionSellar dural suturing under endoscopy is a promising and effective method for cranial base reconstruction in EEA surgery and is worthy of clinical application.
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Takeda T, Omura K, Mori E, Mori R, Ishii Y, Otori N. Endoscopic modified transseptal bi-nostril approach for pituitary tumors. Efficacy of complex preservation of every turbinate and olfaction: A STROBE analysis. Eur Ann Otorhinolaryngol Head Neck Dis 2022; 139:337-342. [PMID: 35597759 DOI: 10.1016/j.anorl.2022.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/17/2022]
Abstract
AIMS Endoscopic modified transseptal bi-nostril approach minimizes turbinate and olfactory mucosal invasion and ensures preservation of the turbinates and bilateral olfaction. The main objective of this study was to investigate the pre- and postoperative variations in olfactory function in patients using this approach, and the secondary objective was to investigate the complications associated with the surgical procedure. MATERIAL AND METHODS This study is a single-center prospective cohort study using STROBE analysis. To completely protect the bilateral turbinates and olfactory epithelium, this procedure provided access to the sphenoid sinus by a transseptal approach via the left nasal cavity and by the olfactory cleft approach via the right nasal cavity without any turbinate resection. A T&T olfactometer was used to assess the mean recognition threshold of the left, right, and bilateral nasal passages before and after surgery, and complications associated with the surgical approach were investigated. OBJECTIVES We included 27 patients who underwent endoscopic modified transseptal pituitary surgery with an olfactory and turbinate preservation approach at our hospital between April 2018 and December 2019. RESULTS The mean postoperative recognition threshold of the right, left, and bilateral nasal cavities did not worsen (P<0.001 for all) relative to the preoperative values, and there was no difference in values between the right and left nasal cavities (P=0.85). The nasal turbinates were preserved in all patients during the study period, and no recurrence was observed. CONCLUSION Our modified EETSA could be implemented as an approach for turbinate and olfaction preservation.
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Affiliation(s)
- T Takeda
- Department of Otorhinolaryngology, The Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - K Omura
- Department of Otorhinolaryngology, The Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - E Mori
- Department of Otorhinolaryngology, The Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - R Mori
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Y Ishii
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - N Otori
- Department of Otorhinolaryngology, The Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
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Anstadt E, Chen W, O'Brien J, Ickow I, Chow I, Bruce MK, Goldstein J, Branstetter BF, Synderman CH, Wang EW, gardner P, Schuster L. Characterization of the Saddle Nose Deformity Following Endoscopic Endonasal Skull Base Surgery. Skull Base Surg 2022; 84:225-231. [PMID: 37180865 PMCID: PMC10171926 DOI: 10.1055/a-1796-7984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
Abstract
Objective: The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular.
Setting/Participants: This is a retrospective review of 20 adult patients with SND after endoscopic endonasal approach (EEA) for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center.
Outcome Measures: Fifteen measurements related to SND were obtained on pre-and post-operative imaging. Statistical analyses were performed to evaluate differences between pre- and post-operative anatomy.
Results: The most common EEA was transsellar. Reconstruction techniques included 9 free mucosal grafts alone, 8 vascularized nasoseptal flaps (NSF), 1 combined free mucosal graft/abdominal fat graft, and 1 combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection and nasolabial angle post-operatively. Sub-group analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2mm, p=0.039) and increased alar base width (1.2mm, p=0.046) post operatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on post-operative imaging, in contrast to those with functional adenomas who had no measurable significant changes.
Conclusions: Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests.
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Affiliation(s)
- Erin Anstadt
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - Wendy Chen
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - James O'Brien
- University of Pittsburgh School of Medicine, Pittsburgh, United States
| | - Ilana Ickow
- Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, United States
| | - Ian Chow
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - Madeleine K Bruce
- University of Pittsburgh Medical Center Health System, Pittsburgh, United States
| | - Jesse Goldstein
- Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
- Pediatric Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, United States
| | | | - Carl H Synderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - Eric W Wang
- Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, United States
| | - paul gardner
- neurosurgery, university of pittsburgh, pittsburgh, United States
| | - Lindsay Schuster
- Children's Hospital of Pittsburgh, Pediatric Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, United States
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Kılıç S, Sreenath SB, Grafmiller K, Woodard TD, Recinos PF, Kshettry VR, Sindwani R. Systematic Review of Olfactory Outcomes After Nasoseptal Flap Harvest for Endoscopic Skull Base Surgery: Does Using Cold Steel or Olfactory Strip Preservation Matter? Int Forum Allergy Rhinol 2021; 12:1043-1055. [PMID: 34910852 DOI: 10.1002/alr.22945] [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: 09/06/2021] [Revised: 11/12/2021] [Accepted: 12/12/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Several studies have described techniques aimed at mitigating olfactory dysfunction after nasoseptal flap (NSF) harvest for endoscopic skull base surgery (ESBS). No consensus exists as to whether popular methods including using cold-steel (CS) versus electrocautery (EC) or septal olfactory strip (SOS) preservation offer an advantage. This systematic review was performed to examine the impact of these two technical variations of NSF harvest on postoperative olfactory outcomes. METHODS Following PRISMA guidelines, Pubmed, Scopus, and Web of Science were searched for articles reporting olfactory outcomes in ESBS cases employing a NSF. Original articles focusing on technique variations of the NSF and reporting at least 1 objective olfactory measure were included. RESULTS Nine studies comprising 610 patients were included. Various, olfactory testing outcomes were reported, and post-op follow-up ranged from 6 weeks to 12 months. Three studies, including a randomized-controlled trial, compared the use of CS and EC for the superior incision of the NSF. No significant difference was found in objective olfactory function (p>0.05) when comparing these techniques. Five studies comprising 504 patients reported results from SOS sparing. SOS sparing technique in NSF harvest demonstrated smell preservation in the post-op setting when compared to pre-op measures (p>0.05), however, no direct comparison to non-SOS sparing techniques was made. CONCLUSION Use of CS as opposed to EC for the superior NSF incision does not appear to confer an advantage in preserving post-op olfactory function (grade B evidence). SOS preservation may be associated with better olfactory outcomes in NSF harvest (grade C evidence). This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suat Kılıç
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Satyan B Sreenath
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, IN
| | - Kevin Grafmiller
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Troy D Woodard
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Pablo F Recinos
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Varun R Kshettry
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Raj Sindwani
- Section of Sinus, Rhinology, & Skull Base Surgery, Head& Neck Institute, Cleveland Clinic, Cleveland, Ohio.,Section of Skull Base Surgery, Rose Ella Burkhardt Brain Tumor & Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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11
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Raikundalia MD, Huang RJ, Chan L, Truong T, Kuchibhatla M, Merchant J, Hachem RA, Codd PJ, Zomorodi AR, Teitelbaum JI, Goldstein BJ, Jang DW. Olfactory-Specific Quality of Life Outcomes after Endoscopic Endonasal Surgery of the Sella. ALLERGY & RHINOLOGY 2021; 12:21526567211045041. [PMID: 34733580 PMCID: PMC8558591 DOI: 10.1177/21526567211045041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objective To assess olfactory outcomes as measured by an olfactory-specific quality of life (QOL) questionnaire in patients undergoing EESBS for sellar lesions. Design Retrospective case series. Setting Tertiary academic medical center. Participants In total, 36 patients undergoing EESBS for lesions limited to the sella were evaluated. Main Outcome Measures The following were performed before and three months after surgery: 22-Item Sinonasal Outcomes Test (SNOT-22), University of Pennsylvania Smell Identification Test (UPSIT), and the Assessment of Self-reported Olfactory Functioning (ASOF), which has three domains: subjective olfactory capability scale (SOC), smell-related problems (SRP), and olfactory-related quality of life (ORQ). Results Median age at surgery was 52.5 years, with a median tumor size of 1.8 cm (range: 0.2 to 3.9 cm). Pre- and postoperative median scores were 35 [34, 36.2] and 34.5 [32, 36] for UPSIT, 21 [7.5, 33.5] and 21.5 [6.8, 35.7] for SNOT-22, 10 [9, 10] and 9 [8, 10] for ASOF-SOC, 5 [4.8, 5] and 4.5 [4, 5] for ASOF-SRP, and 5 [5, 5] and 5 [4.5, 5] for ASOF-ORQ. There was no significant change in the two of the three domains of the ASOF. Correlation between ASOF and UPSIT scores were weak. Older age and larger tumor size were associated with worsened olfaction after surgery. Conclusions Patients did not experience significant changes in olfactory-specific QOL three months after EESBS, as measured by two domains of the ASOF. The ASOF may serve as a useful adjunctive tool for assessing olfaction after surgery. The lack of correlation between UPSIT and ASOF suggests the need for more research in subjective olfactory-related quality of life after surgery.
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Affiliation(s)
- Milap D Raikundalia
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, USA
| | | | - Lyndon Chan
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, USA
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, USA
| | | | - James Merchant
- Department of Biostatistics and Bioinformatics, Duke University, Durham, USA
| | - Ralph Abi Hachem
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, USA.,Department of Neurosurgery, Duke University, Durham, USA
| | - Patrick J Codd
- Department of Neurosurgery, Duke University, Durham, USA
| | - Ali R Zomorodi
- Department of Neurosurgery, Duke University, Durham, USA
| | - Jordan I Teitelbaum
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, USA
| | - Bradley J Goldstein
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, USA
| | - David W Jang
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, USA.,Department of Neurosurgery, Duke University, Durham, USA
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12
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Chaskes MB, Khoury T, Chitguppi C, Lavergne P, Nyquist GG, Rabinowitz MR, Rosen MR, Evans JJ. A Single Layer Synthetic Dural Substitute Inlay is an Effective Sellar Reconstruction Technique in Endoscopic Transsphenoidal Pituitary Surgery. Skull Base Surg 2020; 83:291-295. [DOI: 10.1055/s-0040-1721822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/25/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives A variety of endonasal sellar repair techniques have been described; many are complex, multilayered, and carry potential morbidity. We propose an effective, technically simple single-layer repair for select sellar defects, including those with an intraoperative cerebrospinal fluid (CSF) leak. Our technique utilizes only a synthetic dural substitute inlay and dural sealant glue without packing or lumbar drainage.
Design This is a retrospective review-based study.
Setting This study was conducted at tertiary care center.
Participants Patients who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with the aforementioned inlay technique. Patients were selected for this technique if they had an identified intraoperative CSF leak, a patulous diaphragm (expanded and thinned diaphragma sella), or a comorbidity excluding them from a simpler onlay only reconstruction.
Outcome Measures Postoperative CSF leak and sinonasal morbidity included in the study
Results A total of 409 subjects were identified; 368 were initial resections. Gross total resection of the pituitary adenoma was achieved in 356 (87.0%) cases. Average tumor size was 2.6 ± 1.1 cm. Average tumor volume was 10.8 ± 12.1 cm3. There were 135 intraoperative CSF leaks and 196 patulous diaphragms. There were five postoperative CSF leaks (1.2%), all of which occurred in the first half of our series. Pre- and postoperative sino-nasal outcomes test-22 scores were 19.2 ± 18.2 and 18.8 ± 21.3 (p = 0.492), respectively.
Conclusion A synthetic dural substitute inlay and dural sealant glue is an excellent single-layer repair for sellar defects, even those with an intraoperative CSF leak. This technique is highly effective in preventing postoperative CSF leaks and does not utilize packing or lumbar drainage. It also avoids the potential cost and morbidity associated with more complex and multilayered closures.
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Affiliation(s)
- Mark B. Chaskes
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Tawfiq Khoury
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Chandala Chitguppi
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Pascal Lavergne
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia Pennsylvania, United States
| | - Gurston G. Nyquist
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Mindy R. Rabinowitz
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Marc R. Rosen
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - James J. Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia Pennsylvania, United States
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13
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Li P, Luo K, Zhang Q, Wang Z. Superior turbinate management and olfactory outcome after endoscopic endonasal transsphenoidal surgery for pituitary adenoma: a propensity score-matched cohort study. Int Forum Allergy Rhinol 2020; 10:1276-1284. [PMID: 32936520 PMCID: PMC7756434 DOI: 10.1002/alr.22694] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/27/2020] [Accepted: 08/27/2020] [Indexed: 12/12/2022]
Abstract
Background Surgical management of the superior turbinate (ST) is required to access the sella in endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenoma. Two common ST management techniques include partial resection of the ST (PRST) and intentional lateralization of the ST (ILST). Given the concentrated distribution of the olfactory nerve fibers on the medial surface of the ST, in this study we aimed to ascertain whether PRST worsens the objective olfactory outcome when compared with ILST. Methods A retrospective, propensity score‒matched cohort study was performed at a tertiary referral center. A total of 232 adult patients undergoing EETS for pituitary adenoma were analyzed. The threshold test (STT) and the 12‐item identification test (SIT‐12) from “Sniffin’ Sticks” were administered for separate nostrils preoperatively and 6 months postoperatively. Results Of 232 patients, 109 had right‐sided PRST and 123 received right‐sided ILST. Propensity score matching—controlling for olfactory‐related confounding factors, including gender, age, medical comorbidities, surgical technique, and preoperative olfaction—resulted in 74 matched pairs. When comparing the 6‐month postoperative olfactory performance of the right nostril, the STT score was significantly lower in the PRST group than the ILST group (p = 0.036, η2 for effect size estimate = 0.030), but the SIT‐12 scores were similar in the 2 groups (p = 0.325). Overall, the olfactory outcomes for the right nostril did not qualitatively differ between the PRST and ILST groups (p = 0.401). Conclusion Despite its association with threshold impairment, PRST in EETS does not seem to carry an additional risk of postoperative olfactory dysfunction.
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Affiliation(s)
- Pu Li
- Department of Otolaryngology-Head and Neck Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Kai Luo
- Department of Otolaryngology-Head and Neck Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Qiuhang Zhang
- Skull Base Center, Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Zhenlin Wang
- Department of Otolaryngology-Head and Neck Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
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14
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Chou CT, Valappil B, Mattos JL, Snyderman CH, Gardner PA, Fernandez-Miranda JC, Wang EW. The Effect of Nasoseptal Flap Elevation on Post-Operative Olfaction and Sinonasal Quality of Life: A Prospective Double-Blinded Randomized Controlled Trial. Am J Rhinol Allergy 2020; 35:353-360. [PMID: 32921136 DOI: 10.1177/1945892420957505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of nasoseptal flaps (NSF) for defect reconstruction in endoscopic endonasal approaches (EEA) to cranial base pathology has markedly reduced rates of cerebrospinal fluid leak. However, the effect of NSF use on post-operative olfaction remains unclear. OBJECTIVE To evaluate the impact of NSF use during EEA on binarial and uninarial olfaction, and sinonasal quality of life (QOL). METHODS This was a prospective double-blinded randomized controlled trial. Patients undergoing EEA for sellar pathology were recruited from the University of Pittsburgh Medical Center from December 2014 to May 2017. Subjects were randomized pre-operatively to a side of NSF harvest. Olfaction and QOL were assessed pre-operatively and 6 to 12 months post-operatively using the University of Pennsylvania Smell Identification Test, "Sniffin' Sticks," and Sinonasal Outcomes Test 22. The side of dominant uninarial olfaction was determined using "Sniffin' Sticks." RESULTS Thirty-one patients were enrolled. Sixteen underwent EEA without NSF (control group) and 15 with NSF. A dominant side of olfaction was identified in 14 patients with NSF; 8 patients were randomized to NSF harvest on the dominant side and the remaining 6 on the non-dominant side. NSF elevation resulted in a 4% decrease in University of Pennsylvania Smell Identification Test scores, but was not statistically significant compared to controls. Similarly, NSF elevation on the side of dominant olfaction resulted in a 6% decrease, but was not statistically significant when compared to the non-dominant elevation group. Change in rhinologic QOL as determined by the Sinonasal Outcomes Test 22 was not significantly different between any of the groups. CONCLUSIONS The use of NSF during EEA for sellar pathology does not have a significant effect on olfaction or rhinologic QOL. The presence of a dominant side of olfaction is not a primary consideration when deciding the side of NSF harvest.
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Affiliation(s)
- Courtney T Chou
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Benita Valappil
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jose L Mattos
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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15
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Zhu J, Feng K, Tang C, Yang J, Cai X, Zhong C, Ma C. Olfactory outcomes after endonasal skull base surgery: a systematic review. Neurosurg Rev 2020; 44:1805-1814. [PMID: 32914235 DOI: 10.1007/s10143-020-01385-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/18/2020] [Accepted: 09/03/2020] [Indexed: 11/26/2022]
Abstract
For the last two decades, endonasal approach has been regularly applied to treat skull base lesions. However, postoperative olfactory dysfunction remains an unsolved problem. This systematic review aimed to identify factors that might affect postoperative olfactory prognosis of patients undergoing endonasal surgery for resection of sellar/parasellar lesions. The literature search was conducted comprehensively to exhaust studies which focused on patients' olfaction with objective olfactory assessments after endonasal skull base surgery. We sought to characterize the potential factors that might affect postoperative olfactory outcomes. Nineteen articles met inclusion criteria. We found that (1) endoscopic surgery was beneficial to patients' olfactory prognosis than microscopic surgery (incidence of postoperative decreased olfactory function: 18.48% (39/211) for the endoscopic group and 36.88% (52/141) for the microscopic group, P < 0.01); meta-analysis for single rate, 20% (95% CI 9-30%) for the endoscopic group and 35% (95% CI 0-72%) for the microscopic group); (2) harvesting septal flaps was an unfavorable factor for olfactory recovery and the rescue flap technique should be preferred compared with the HB flap; (3) no evidence showed that resection of the middle turbinate was detrimental to recovery of olfaction. Patients undergoing endoscopic endonasal surgery may have better olfactory outcomes than those undergoing microscopic endonasal surgery for resection of sellar/parasellar lesions. Special attention should be paid when using septal flaps is planned and the rescue flap technique should be the preferred choice. After resecting the middle turbinate, patients' olfaction still has a great chance of returning to the baseline. More homogeneous and high-quality studies are needed for further assessment.
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Affiliation(s)
- Junhao Zhu
- Jinling Hospital, School of Medicine, Nanjing Medical University, 104 Hanzhong Road, Nanjing, 210002, China
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Kaiyang Feng
- Arkansas College of Health Education, 7000 Chad Colley Blvd, Fort Smith, AR, 72916, USA
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Jin Yang
- Jinling Hospital, School of Medicine, Nanjing Medical University, 104 Hanzhong Road, Nanjing, 210002, China
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Xiangming Cai
- School of Medicine, Southeast University, Nanjing, 210009, China
| | - Chunyu Zhong
- Jinling Hospital, School of Medicine, Nanjing Medical University, 104 Hanzhong Road, Nanjing, 210002, China
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China
| | - Chiyuan Ma
- Jinling Hospital, School of Medicine, Nanjing Medical University, 104 Hanzhong Road, Nanjing, 210002, China.
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China.
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16
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Marx S, Tsavdaridou I, Paul S, Steveling A, Schirmer C, Eördögh M, Nowak S, Matthes M, El Refaee E, Fleck SK, Baldauf J, Lerch MM, Stahl A, Hosemann W, Schroeder HWS. Quality of life and olfactory function after suprasellar craniopharyngioma surgery-a single-center experience comparing transcranial and endoscopic endonasal approaches. Neurosurg Rev 2020; 44:1569-1582. [PMID: 32651708 PMCID: PMC8121742 DOI: 10.1007/s10143-020-01343-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/06/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Abstract
The endoscopic endonasal approach to suprasellar craniopharyngiomas has become popular as alternative to transcranial approaches. However, the literature lacks data regarding quality of life and olfactory function. The assessment of the long-term quality of life and olfactory function of all patients harboring a suprasellar craniopharyngioma who underwent surgery in our department has been done. Patient characteristics and perioperative data were gathered in a prospectively maintained database. At the last follow-up visit, the olfactory function and the quality of life (ASBQ, SNOT-22) as well as visual and pituitary function were assessed. Thirteen and 17 patients underwent surgery via a transcranial (T) and endonasal (E) route, respectively. No differences were seen in ASBQ, SNOT-22, and olfactory function between T and E, but in E were more full-time worker and less obesity. CSF leaks occurred in 15% of T and 29% of E (p = 0.43). Patients from group E had a superior visual outcome which was most pronounced in the visual field. The degree of new anterior and posterior pituitary gland deficiency after surgery and in the follow-up was lower in group E. The general and sinonasal quality of life and the olfactory function are equal in E and T. E is associated with a superior visual outcome, lower rates of diabetes insipidus, and lower rates of obesity, but has a higher risk for postoperative CSF leaks.
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Affiliation(s)
- Sascha Marx
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany.
| | | | - Sebastian Paul
- Department of ENT, University Medicine Greifswald, Greifswald, Germany.,Department of Ophthalmology, University Medicine Greifswald, Greifswald, Germany
| | - Antje Steveling
- Department of Internal Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Cornelia Schirmer
- Department of Internal Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Marton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Stephan Nowak
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Marc Matthes
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Ehab El Refaee
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany.,Department of Neurosurgery, Cairo University, Giza, Egypt
| | - Steffen K Fleck
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Joerg Baldauf
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Markus M Lerch
- Department of Internal Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Andreas Stahl
- Department of Ophthalmology, University Medicine Greifswald, Greifswald, Germany
| | - Werner Hosemann
- Department of ENT, University Medicine Greifswald, Greifswald, Germany
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Sauerbruchstraße, 17475, Greifswald, Germany
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17
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Lee JJ, Thompson ZS, Piccirillo JF, Klatt-Cromwell CN, Orlowski HLP, Kallogjeri D, Pipkorn P, Schneider JS. Risk Factors for Patient-Reported Olfactory Dysfunction After Endoscopic Transsphenoidal Hypophysectomy. JAMA Otolaryngol Head Neck Surg 2020; 146:621-629. [PMID: 32379292 PMCID: PMC7206533 DOI: 10.1001/jamaoto.2020.0673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/23/2020] [Indexed: 12/11/2022]
Abstract
Importance Iatrogenic olfactory dysfunction after endoscopic transsphenoidal hypophysectomy (ETSH) is an overlooked complication without elucidated risk factors. Objective To assess the independent prognostic role of demographic, comorbidity, cephalometric, intraoperative, histological, and postoperative parameters in patient-reported postoperative olfactory dysfunction, and to explore the association between anatomical measurements of the skull base and sinonasal cavity and postoperative olfactory dysfunction. Design, Setting, and Participants This retrospective cohort study in a tertiary care medical center enrolled consecutive patients with primary sellar lesions who underwent ETSH between January 1, 2015, and January 31, 2019. Patients were excluded if they underwent multiple sinonasal surgical procedures, presented with a sellar malignant neoplasm, required an expanded transsphenoidal approach, had nasal polyposis or a neurodegenerative disease, or sustained traumatic brain injury. After undergoing medical record review and telephone screening, patients were asked to participate in a 3-item telephone survey. Main Outcomes and Measures The primary outcome was the Clinical Global Impressions change in smell rating, a validated transitional patient-reported outcome measure. Patients rated their change in smell before and after ETSH on a 7-point Likert scale, with the following response options: (1) much better, (2) somewhat better, (3) slightly better, (4) neither better nor worse, (5) slightly worse, (6) somewhat worse, or (7) much worse. Responses of slightly worse, somewhat worse, and much worse were surrogates for postoperative olfactory dysfunction status. Patient medical records, preoperative imaging scans, operative notes, and pathology reports were reviewed. Results Of the 147 patients (mean [SD] age, 54 [15] years; 79 women [54%]) who responded to the telephone survey, 42 (29%) reported olfactory dysfunction after ETSH. Median (interquartile range [IQR]) time between the ETSH completion and survey response was 31.1 (21-43) months. On multivariable analysis, abdominal fat grafting (adjusted relative risk [aRR], 2.95; 95% CI, 1.89-4.60) was associated with postoperative olfactory dysfunction, whereas smoking history (aRR, 1.54; 95% CI, 0.95-2.51) demonstrated a clinically meaningful but imprecise effect size. A more obtuse angle between the planum sphenoidale and face of the sella turcica on sagittal imaging was protective (aRR, 0.98; 95% CI, 0.96-0.99). Increased number of months after the ETSH was associated with patient-reported normosmia (aRR, 0.93; 95% CI, 0.91-0.95). In contrast, other comorbidities; intraoperative variables such as turbinate resection, nasoseptal flap, and mucosal or bone grafting; histological variables such as pathology and proliferative index; and postoperative variables such as adjuvant radiotherapy were not associated with postoperative olfactory dysfunction. Conclusions and Relevance This study found that abdominal fat grafting, acute skull base angle, and smoking history appeared to be clinically significant risk factors for patient-reported postoperative olfactory dysfunction. Increased time after ETSH may be associated with better olfactory outcomes.
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Affiliation(s)
- Jake J. Lee
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Zindzi S. Thompson
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
- School of Medicine, Meharry Medical College, Nashville, Tennessee
| | - Jay F. Piccirillo
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
- Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Cristine N. Klatt-Cromwell
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Hilary L. P. Orlowski
- Department of Radiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
- Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Patrik Pipkorn
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John S. Schneider
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
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18
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Serra C, Staartjes VE, Maldaner N, Holzmann D, Soyka MB, Gilone M, Schmid C, Tschopp O, Regli L. Assessing the surgical outcome of the "chopsticks" technique in endoscopic transsphenoidal adenoma surgery. Neurosurg Focus 2020; 48:E15. [PMID: 32480377 DOI: 10.3171/2020.3.focus2065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The "chopsticks" technique is a 3-instrument, 2-hand mononostril technique that has been recently introduced in endoscopic neurosurgery. It allows a dynamic surgical view controlled by one surgeon only while keeping bimanual dissection. Being a mononostril approach, it requires manipulation of the mucosa of one nasal cavity only. The rationale of the technique is to reduce nasal morbidity without compromising surgical results and complication rates. There are, however, no data available on its results in endoscopic surgery (transsphenoidal surgery [TSS]) for pituitary adenoma. METHODS The authors performed a cohort analysis of prospectively collected data on 144 patients (156 operations) undergoing TSS using the chopsticks technique with 3T intraoperative MRI. All patients had at least 3 months of postoperative neurosurgical, endocrinological, and rhinological follow-up (Sino-Nasal Outcome Test-20 [SNOT-20] and Sniffin' Sticks). The surgical technique is described, and the achieved gross-total resection (GTR) and extent of resection (EOR) together with patients' clinical outcomes and complications are descriptively reported. RESULTS On 3-month postoperative MRI, GTR was achieved in 71.2% of patients with a mean EOR of 96.7%. GTR was the surgical goal in 122 of 156 cases and was achieved in 106 of 122 (86.9%), with a mean EOR of 98.7% (median 100%, range 49%-100%). There was no surgical mortality. At a median follow-up of 15 months (range 3-70 months), there was 1 permanent neurological deficit. As of the last available follow-up, 11.5% of patients had a new pituitary single-axis deficit, whereas 26.3% had improvement in endocrinological function. Three patients had new postoperative hyposmia. One patient had severe impairment of sinonasal function (SNOT-20 score > 40). The operation resulted in endocrine remission in 81.1% of patients with secreting adenomas. CONCLUSIONS This study shows that the chopsticks technique confers resection and morbidity results that compare favorably with literature reports of TSS. This technique permits a single surgeon to perform effective endoscopic bimanual dissection through a single nostril, reducing manipulation of healthy tissue and thereby possibly minimizing surgical morbidity.
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Affiliation(s)
- Carlo Serra
- 1Department of Neurosurgery, Clinical Neuroscience Center
| | | | | | - David Holzmann
- 2Department of Otorhinolaryngology, Head and Neck Surgery; and
| | - Michael B Soyka
- 2Department of Otorhinolaryngology, Head and Neck Surgery; and
| | - Marco Gilone
- 3Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II," Naples, Italy
| | - Christoph Schmid
- 4Department of Endocrinology, Diabetes, and Clinical Nutrition, University Hospital of Zürich, University of Zürich, Switzerland; and
| | - Oliver Tschopp
- 3Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II," Naples, Italy
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center
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19
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Talmor G, Grube JG, Eloy JA, Liu JK, Hsueh WD. Nasoseptal Flap Necrosis After Endoscopic Skull Base Surgery in the Setting of COVID-19 Pandemic. World Neurosurg 2020; 140:374-377. [PMID: 32479908 PMCID: PMC7256530 DOI: 10.1016/j.wneu.2020.05.237] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 05/25/2020] [Indexed: 01/24/2023]
Abstract
Background A novel viral strain known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created a worldwide pandemic known as coronavirus 2019 (COVID-19). Early reports from China have highlighted the risks associated with performing endoscopic endonasal skull base surgery in patients with SARS-CoV-2. We present a rare complication of nasoseptal flap (NSF) necrosis associated with COVID-19, further emphasizing the challenges of performing these procedures in this era. Case Description A 78-year-old man underwent an extended endoscopic endonasal transplanum resection of a pituitary macroadenoma for decompression of the optic chiasm. The resulting skull base defect was repaired using a pedicled NSF. The patient developed meningitis and cerebrospinal fluid (CSF) leak on postoperative day 13, requiring revision repair of the defect. Twelve days later, he developed persistent fever and rhinorrhea. The patient was reexplored endoscopically, and the NSF was noted to be necrotic and devitalized with evident CSF leakage. At that time, the patient tested positive for SARS-CoV-2. Postoperatively, he developed acute respiratory distress syndrome complicated by hypoxic respiratory failure and death. Conclusions To our knowledge, this is the first reported case of NSF necrosis in a patient with COVID-19. We postulate that the thrombotic complications of COVID-19 may have contributed to vascular pedicle thrombosis and NSF necrosis. Although the pathophysiology of SARS-CoV-2 and its effect on the nasal tissues is still being elucidated, this case highlights some challenges of performing endoscopic skull base surgery in the era of COVID-19.
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Affiliation(s)
- Guy Talmor
- Department of Otolaryngology - Head & Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jordon G Grube
- Department of Otolaryngology - Head & Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head & Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - James K Liu
- Department of Otolaryngology - Head & Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
| | - Wayne D Hsueh
- Department of Otolaryngology - Head & Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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20
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Yamada H, Toda M, Fukumura M, Imai R, Ozawa H, Ogawa K, Yoshida K. Cerebrospinal fluid leakage due to nasoseptal flap partial necrosis: A pitfall for skull base reconstruction of endoscopic endonasal surgery. Surg Neurol Int 2020; 11:121. [PMID: 32494396 PMCID: PMC7265470 DOI: 10.25259/sni_117_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Vascularized nasoseptal flaps allow for the reconstruction of large dural defects and have remarkably reduced the incidence of postoperative complications during endoscopic endonasal skull base surgery. Nevertheless, some complications related to nasoseptal flap have been reported. Flap necrosis is a rare, but serious issue is associated with meningitis and cerebrospinal fluid (CSF) leak. Case Description: We performed endoscopic endonasal removal of the tuberculum sella meningioma in a 39-year-old woman with a history of Turner syndrome using abdominal fat, fascia, and a vascularized nasoseptal flap for dural and skull base defect reconstruction. After surgery, she developed CSF leak, and reoperation revealed partial necrosis of the septal flap that caused leakage. At this time, with a concern that removal of the necrotic part may lead to the insufficient size of the flap, we filled the gap tightly with fat pieces. However, the CSF leak recurred, and thus, we performed debridement of the necrotic region and reformed the multilayered reconstruction, following which she no longer experienced CSF leakage. Conclusion: Our case suggested that partial rather than total flap necrosis could occur, possibly due to variances of vascular anatomy, leading to focal ischemia. Debridement of the necrotic region may be an important solution for recurrent cerebrospinal leakage secondary to partial necrosis of a nasoseptal flap.
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Affiliation(s)
- Hiroki Yamada
- Departments of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, Japan
| | - Masahiro Toda
- Departments of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, Japan
| | - Mariko Fukumura
- Departments of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, Japan
| | - Ryotaro Imai
- Departments of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, Japan
| | - Hiroyuki Ozawa
- Departments of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, Japan
| | - Kaoru Ogawa
- Departments of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, Japan
| | - Kazunari Yoshida
- Departments of Neurosurgery, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, Japan
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21
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Chaskes MB, Fastenberg JH, Vimawala S, Nyquist GF, Rabinowitz MR, Chitguppi C, Falls M, Garzon-Muvdi T, Rosen MR, Evans JJ. A Simple Onlay Sellar Reconstruction Does Not Increase the Risk of Postoperative Cerebrospinal Fluid Leak in Well-Selected Patients. J Neurol Surg B Skull Base 2020; 82:e231-e235. [PMID: 34306943 DOI: 10.1055/s-0039-3402000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022] Open
Abstract
Objective A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting The present study was conducted at a tertiary care center. Participants In this study, pituitary adenoma patients were the participants. Outcome Measures Main outcome measure of the study is postoperative CSF leak. Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm 3 . No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 ( p = 0.796), respectively. Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.
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Affiliation(s)
- Mark B Chaskes
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Judd H Fastenberg
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Swar Vimawala
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Gurston F Nyquist
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Mindy R Rabinowitz
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Chandala Chitguppi
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Meagan Falls
- Sidney Kimmel Medical College of Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Tomas Garzon-Muvdi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Marc R Rosen
- Department of Otolaryngology Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
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22
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The Zurich Pituitary Score predicts utility of intraoperative high-field magnetic resonance imaging in transsphenoidal pituitary adenoma surgery. Acta Neurochir (Wien) 2019; 161:2107-2115. [PMID: 31392567 DOI: 10.1007/s00701-019-04018-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND It is currently unclear if there are subsets of patients undergoing transsphenoidal surgery (TSS) in which intraoperative high-field magnetic resonance imaging (3T-iMRI) is particularly advantageous. We aimed to investigate whether a radiological grading scale predicts the utility of 3T-iMRI in pituitary adenoma (PA) TSS. METHODS From a prospective registry, patients who underwent endoscopic TSS for PA using 3T-iMRI were identified. Adenomas were graded using the Zurich Pituitary Score (ZPS). We assessed improvement after 3T-iMRI in terms of gross total resection (GTR), residual volume (RV), and extent of resection (EOR). RESULTS Among 95 patients, rates of conversion to GTR after 3T-iMRI decreased steadily from 33% for grade I to 0% for grade IV adenomas, with a statistically significant conversion rate only for grade I (p = 0.008) and grade II (p < 0.001). All grade I adenomas were completely resected after 3T-iMRI. Median RV change was statistically significant for grades I to III, but not for grade IV (p = 0.625). EOR improvement ranged from a median change of 0.0% (IQR 0.0-4.5%) for grade I to 4.4% (IQR 0.0-9.0%) for grade IV, with a significant improvement only for grades I to III (p < 0.05). CONCLUSIONS Interestingly, this study shows that clinical utility of 3T-iMRI is highest in the more "simple" adenomas (ZPS grades I-II) than for the more "complex" ones (ZPS grade III-IV). Grade I adenomas are amenable to GTR if 3T-iMRI is implemented. In grade III adenomas, EOR and RV can be improved to clinically relevant levels. Conversely, in grade IV adenomas, 3T-iMRI may be of limited use.
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23
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Netuka D, Masopust V, Fundová P, Astl J, Školoudík D, Májovský M, Beneš V. Olfactory Results of Endoscopic Endonasal Surgery for Pituitary Adenoma: A Prospective Study of 143 Patients. World Neurosurg 2019; 129:e907-e914. [PMID: 31103759 DOI: 10.1016/j.wneu.2019.05.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clinical examination, including pre- and postoperative assessment of olfaction function, should be included in evaluating surgical outcomes in patients with pituitary adenomas. Most of the studies are lacking assessment of olfactory function. METHODS A prospective study of 143 patients who underwent surgical resection of pituitary adenomas from January 2014 to December 2017 was performed. Data on clinical presentation, pre- and postoperative neurologic, endocrinologic, and ophthalmologic examinations, complications, and follow-up outpatient examinations were recorded. Olfactory function was assessed using the Sniffin' Sticks odor identification test preoperatively, postoperatively (3 months), and 1 year after surgery. RESULTS Normosmia was present preoperatively in 93.7% of patients, postoperatively in 95.8% of patients, and in 95.1% 1 year postsurgery. Hyposmia was present preoperatively in 4.2% of patients, postoperatively in 2.1% of patients, and in 1.4% 1 year after surgery. Anosmia was present preoperatively in 2.1% of patients, postoperatively in 2.1% of patients, and in 3.5% 1 year after surgery. In patients with preoperative normosmia, postoperative hyposmia and anosmia were present in 1.5% of patients. There were no differences according to age, sex, size, or type of pituitary adenoma. CONCLUSIONS Assessment of olfactory function should be included in the analysis of pituitary adenoma surgery results. This prospective study showed low risk of olfaction deterioration if an endoscopic endonasal approach is used without any mucosal flaps for skull base reconstruction. Further studies that include objective olfaction assessment are warranted.
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Affiliation(s)
- David Netuka
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic.
| | - Václav Masopust
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Petra Fundová
- Department of Otorhinolaryngology and Maxillofacial Surgery, Third Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Jaromír Astl
- Department of Otorhinolaryngology and Maxillofacial Surgery, Third Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - David Školoudík
- Center for Science and Research, Faculty of Health Sciences, Palacký University Olomouc, Olomouc, Czech Republic
| | - Martin Májovský
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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24
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Yin LX, Low CM, Puccinelli CL, O'Brien EK, Stokken JK, Van Abel KM, Janus JR, Link MJ, Van Gompel JJ, Choby G. Olfactory outcomes after endoscopic skull base surgery: A systematic review and meta‐analysis. Laryngoscope 2019; 129:1998-2007. [DOI: 10.1002/lary.28003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 12/28/2022]
Affiliation(s)
- Linda X. Yin
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
| | | | | | - Erin K. O'Brien
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
| | | | | | - Jeffrey R. Janus
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
| | - Michael J. Link
- Department of NeurosurgeryMayo Clinic Rochester Minnesota U.S.A
| | | | - Garret Choby
- Department of OtorhinolaryngologyMayo Clinic Rochester Minnesota U.S.A
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25
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Majovsky M, Astl J, Kovar D, Masopust V, Benes V, Netuka D. Olfactory function in patients after transsphenoidal surgery for pituitary adenomas-a short review. Neurosurg Rev 2018; 42:395-401. [PMID: 30276575 DOI: 10.1007/s10143-018-1034-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/21/2018] [Accepted: 09/17/2018] [Indexed: 12/17/2022]
Abstract
Olfaction is an important sensory input that obviously affects many daily activities. However, olfactory dysfunction (hyposmia and anosmia) leads to a pronounced decrease in quality of life. Surprisingly, little attention has been paid to olfactory changes after transsphenoidal surgery for pituitary tumors. In this review, we summarize current knowledge of the effects of transsphenoidal pituitary surgery on olfaction and compare different surgical techniques. Based on selected studies, the endoscopic approach, in comparison with the microscopic approach, seems to be superior in terms of preservation of olfactory function, although the quality of data from these studies is generally poor. The best results were observed when the endoscopic approach was used without harvesting of the nasoseptal flap.
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Affiliation(s)
- Martin Majovsky
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, U Vojenske nemocnice 1200, 169 02, Prague, Czech Republic
| | - Jaromir Astl
- Department of Otorhinolaryngology and Maxillofacial Surgery, Third Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Daniel Kovar
- Department of Otorhinolaryngology and Maxillofacial Surgery, Third Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Vaclav Masopust
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, U Vojenske nemocnice 1200, 169 02, Prague, Czech Republic
| | - Vladimir Benes
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, U Vojenske nemocnice 1200, 169 02, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, U Vojenske nemocnice 1200, 169 02, Prague, Czech Republic.
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26
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Lavigne P, Faden DL, Wang EW, Snyderman CH. Complications of Nasoseptal Flap Reconstruction: A Systematic Review. J Neurol Surg B Skull Base 2018; 79:S291-S299. [PMID: 30210981 DOI: 10.1055/s-0038-1668158] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022] Open
Abstract
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.
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Affiliation(s)
- Philippe Lavigne
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Daniel L Faden
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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27
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Maldaner N, Serra C, Tschopp O, Schmid C, Bozinov O, Regli L. [Modern Management of Pituitary Adenomas - Current State of Diagnosis, Treatment and Follow-Up]. PRAXIS 2018; 107:825-835. [PMID: 30043702 DOI: 10.1024/1661-8157/a003035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Modern Management of Pituitary Adenomas - Current State of Diagnosis, Treatment and Follow-Up Abstract. Pituitary adenomas (PA) are benign neoplasms originating from parenchymal cells of the anterior pituitary. Tumor mass effect can cause headaches, visual deficits by compression of the optic chiasm, and partial or complete hypopituitarism. Hormone secreting PA can cause several forms of specific syndromes such as Cushing's disease or acromegaly depending on the type of hormone. Endoscopic transsphenoidal resection is the preferred treatment option for most symptomatic or growing PA. Nowadays techniques like high definition intraoperative MRI can assist the surgeon in his goal of maximal safe resection. An exception are prolactinomas which can usually be treated medically with dopamine agonists. Therapy of PA is complex and should be managed in a high-volume center with an interdisciplinary team approach including neurosurgeons and endocrinologists.
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Affiliation(s)
- Nicolai Maldaner
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Carlo Serra
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Oliver Tschopp
- 2 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
| | - Christoph Schmid
- 2 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
| | - Oliver Bozinov
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Luca Regli
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
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28
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Linsler S, Prokein B, Hendrix P, Oertel J. Sinonasal outcome after endoscopic mononostril transsphenoidal surgery: A single center cohort study. J Clin Neurosci 2018; 53:92-99. [PMID: 29680444 DOI: 10.1016/j.jocn.2018.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/09/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach has been well established for skull base surgery. However, there are only few studies pointing out nasal complaints after surgery. In this study, the authors evaluated postoperative nasal complaints and complications after mononostril endoscopic procedures. METHODS All patients operated on parasellar and sellar pathologies at our department via an endoscopic mononostril transnasal transsphenoidal approach from January 2011 to May 2015 were analyzed. To assess specific postoperative nasal pathological conditions and complaints, a questionnaire was established. Applicable data of 79 patients with additional ENT follow-up could be included. Endpoints were the quantitative evaluation of complications and correlation of these data. RESULTS There was no vascular injury or worsening of visual function. Two patients had persisting CSF fistula and one of them meningitis. There was a significant decrease of nasal complaints during follow up after 2 years (p < 0.001). Further surgical treatment by ENT physician was necessary in 11.4%. Resurgery significantly increased the risk of postsurgical complaints (p < 0.005). The use of a tamponade significantly reduced the risk of postsurgical reduced nasal airflow (p = 0.026) and sinusitis (p = 0.002). CONCLUSIONS Endoscopic endonasal procedures to skull base lesions achieve high radicality with low complication rates. However, they induce temporary and permanent nasal complaints and complications. Thereby, resurgeries increase the risk of nasal complaints and the use of nasal tamponades might increase the sinonasal outcome. Further prospective studies are necessary to objectify the evaluation of postsurgical nasal complications.
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Affiliation(s)
- Stefan Linsler
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, 66421 Homburg/Saar, Germany
| | - Benjamin Prokein
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, 66421 Homburg/Saar, Germany
| | - Philipp Hendrix
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, 66421 Homburg/Saar, Germany
| | - Joachim Oertel
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, 66421 Homburg/Saar, Germany.
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29
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Linsler S, Breuskin D, Tschernig T, Oertel J. Reaching the sellar region endonasally - One or both nostrils? A pilot study in body donors. Ann Anat 2018; 217:40-46. [PMID: 29501633 DOI: 10.1016/j.aanat.2018.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the effect of posterior septectomy size on surgical exposure and surgical freedom during the endoscopic transsphenoidal approach to the sellar and parasellar region. METHODS A mononostril and binostril approach to the sellar region was performed on 4 formalin-fixed cadaveric heads. Predefined anatomical structures were identified. Additionally, a millimeter gauge was introduced into the surgical site and the extent of dorsal septectomy was analyzed for both approaches. Surgical freedom was defined as the distance between the ipsilateral and contralateral limit of opening of the sphenoid sinus. RESULTS The mean extent of dorsal septectomy was 15.7±5.7mm using a binostril approach to achieve adequate visualization of all relevant anatomical structures. Superior results were obtained via binostril technique with respect to the ability to identify the contralateral internal carotid artery or opticocarotid recessus. No such advantage was found for all other landmarks. Surgical freedom between the ipsilateral and contralateral limit of exposure of the sphenoid sinus was measured with 15±0.8mm in the mononostril and 19.2±0.9mm in the binostril group. CONCLUSIONS The surgical exposure increased significantly with progressively larger posterior septectomy in binostril approaches until a 20-mm posterior septectomy. Bilateral lateral opticocarotid recesses were accessible with a mean of 15mm for posterior septectomy. In the mononostril group no dorsal septectomy was necessary. Thus, the nasal mucosa is more preserved by this technique. However, the lateral exposure is partially limited and the use of angled endoscopes is recommended when adopting a mononostril approach to the sellar region.
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Affiliation(s)
- Stefan Linsler
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - David Breuskin
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Thomas Tschernig
- Fachrichtung Anatomie und Zellbiologie, Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany.
| | - Joachim Oertel
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Germany
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Wu V, Cusimano MD, Lee JM. Extent of Surgery in Endoscopic Transsphenoidal Skull Base Approaches and the Effects on Sinonasal Morbidity. Am J Rhinol Allergy 2018; 32:52-56. [DOI: 10.2500/ajra.2018.32.4499] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Endoscopic transsphenoidal skull base surgery (ETSS) is now considered the criterion standard approach for resection of pituitary adenomas and other midline anterior skull base lesions. Normal sinonasal structures are resected during ETSS, which raises concerns for nasal morbidity and patient-based outcome. Objective To perform a surgical outcome assessment by examining whether the extent of ETSS approaches affected patient-specific sinonasal quality of life as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22). Methods A single-center prospective cohort study of patients operated on by the same skull base team between 2012 and 2016. Patients with completed pre- and postoperative SNOT-22 were included. The primary outcome was SNOT-22 scores at preoperative, 0–1 month, 2–4 months, >5 months follow-up. Age, sex, tumor pathology, surgical procedure, and intraoperative cerebral spinal fluid leak repair were also obtained. Results Of the 249 ETSS performed, 148 patients (59%) had at least one completed SNOT-22; 45 (18%) met the inclusion criteria. Sinonasal quality of life based on SNOT-22 at the 0–1-month follow-up was significantly worse than the presurgical levels (p < 0.05). However, there was a return of SNOT-22 scores to preoperative levels at 2–4 months (p > 0.05), which was sustained at >5 months (p > 0.05). Factors such as the extent of ETSS, a previous nasal surgery, repair of an intraoperative cerebral spinal fluid leak, and the tumor pathology did not affect SNOT-22 scores at any follow-up intervals (p > 0.05). Conclusion Sinonasal quality of life worsened after ETSS at 0–1 month follow-up but returned to preoperative levels at 2–4 months and remained at postoperative levels >5 months. Analysis of these data will allow us to educate our patients that the anticipated nasal morbidity after ETSS is usually only transient and should be expected to recover to preoperative levels.
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Affiliation(s)
- Vincent Wu
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Michael D. Cusimano
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John M. Lee
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Otolaryngology—Head and Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Laidlaw TM. Expanding Our Research Horizons. Am J Rhinol Allergy 2017. [DOI: 10.2500/ajra.2017.31.4475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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