Measurement of the intersiphon distance for normal skull base development and estimation of the surgical window for the endoscopic transtuberculum approach in children

OBJECTIVE

Due to the underdeveloped skull base in children, it is crucial to predict whether a sufficient surgical window for an endoscopic endonasal approach can be achieved. This study aimed to analyze the presumed surgical window through measurement of the intersiphon distance (ISD) and the planum-sella height (PSH) on the basis of age and its correlation with the actual surgical window for the endoscopic transtuberculum approach.

METHODS

Twenty patients of each age from 3 to 18 years were included as the normal skull base population. ISD and PSH were measured and compared among consecutive ages. Additionally, 42 children with craniopharyngiomas or Rathke's cleft cysts who underwent treatment via the endoscopic transtuberculum approach were included. ISD and PSH were measured on preoperative images and then correlated with the dimensions of the surgical window on postoperative CT scans. The intraoperative endoscopic view was classified as narrow, intermediate, or wide based on operative photographs or videos, and relevant clinical factors were analyzed.

RESULTS

In the normal skull base population, both ISD and the estimated area of the surgical window increased with age, particularly at 8 and 11 years old. On the other hand, PSH did not show an incremental pattern with age. Among the 42 children who underwent surgery, 24 had craniopharyngioma and 18 had Rathke's cleft cysts. ISD showed the strongest correlation with the actual area of the surgical window [r(40) = 0.69, p < 0.001] rather than with age or PSH. The visual grade of the intraoperative endoscopic view was narrow in 17 patients, intermediate in 21, and wide in 4. Preoperative ISD was 14.58 ± 1.29 mm in the narrow group, 16.13 ± 2.30 mm in the intermediate group, and 18.09 ± 3.43 mm in the wide group (p < 0.01). There were no differences in terms of extent of resection (p = 0.41); however, 2 patients in the narrow group had postoperative complications.

CONCLUSIONS

Normal skull base development exhibited age-related growth. However, in children with suprasellar lesions, the measurement of the ISD showed a better correlation than age for predicting the surgical window for the endoscopic transtuberculum approach. Children with a small ISD should be approached with caution due to the limited surgical window.

Endoscopic endonasal pituitary sacrifice for select tumors with retrochiasmatic and/or retrosellar extension: surgical anatomy, operative technique, and case series

OBJECTIVE

Tumors located in the retrochiasmatic region with extension to the third ventricle might be difficult to access when the pituitary-chiasmatic corridor is narrow. Similarly, tumor extension into the interpeduncular and retrosellar space poses a major surgical challenge. Pituitary transposition techniques have been developed to gain additional access. However, when preoperative pituitary function is already impaired or the risk of postoperative panhypopituitarism (PH) is considered to be particularly high, removal of the pituitary gland (PG) might be the preferred option to increase the working corridor. The aim of this study was to describe the relevant surgical anatomy, operative steps, and clinical experience with the endoscopic endonasal pituitary sacrifice (EEPS) and transsellar approach.

METHODS

This study comprised anatomical dissections to highlight the relevant surgical steps and a retrospective case series reporting clinical characteristics, indications, and outcomes of patients who underwent EEPS. The surgical technique is as follows: both lateral opticocarotid recesses are exposed laterally, the limbus sphenoidale superiorly, and the sellar floor inferiorly. After opening the dura, the PG is detached circumferentially and mobilized off the medial walls of the cavernous sinuses. The descending branches of the superior hypophyseal artery are coagulated, and the stalk is transected. After removal of the PG, drilling of the dorsum sellae and bilateral posterior clinoidectomies are performed to gain access to the hypothalamic region, interpeduncular, and prepontine cisterns.

RESULTS

From 2018 to 2023, 11 patients underwent EEPS. The cohort comprised mostly tuberoinfundibular craniopharyngiomas (n = 8, 73%). Seven (64%) patients had partial or complete anterior PG dysfunction preoperatively, while 4 (36%) had preoperative diabetes insipidus. Because of the specific tumor configuration, the chance of preserving endocrine function was estimated to be very low in patients with intact function. The main reasons for pituitary sacrifice were impaired visibility and surgical accessibility to the retrochiasmatic and retrosellar spaces. Gross-total tumor resection was achieved in 10 (91%) patients and near-total resection in 1 (9%) patient. Two (18%) patients experienced a postoperative CSF leak, requiring surgical revision.

CONCLUSIONS

When preoperative pituitary function is already impaired or the risk for postoperative PH is considered particularly high, the EEPS and transsellar approach appears to be a feasible surgical option to improve visibility and accessibility to the retrochiasmatic hypothalamic and retrosellar spaces, thus increasing tumor resectability.

Management Approaches and Patient Outcomes for Giant Pituitary Neuroendocrine Tumors Classified as Knosp Grade 3 and 4

Background Treatment of patients with a giant pituitary neuroendocrine tumor (GPitNET) is challenging. Here, we present the methods used for the clinical management of patients who underwent GPitNET resection mainly via endoscopic endonasal surgery along with multimodal support to avoid surgical complications, which can affect the outcomes. Methodology The medical records of 25 patients with a GPitNET who underwent endonasal endoscopic surgery were retrospectively reviewed. Complications were analyzed and factors affecting the extent of resection were evaluated. Results Gross total resection was achieved in six (24%), near-total resection (>90%) in nine (36%), and partial resection in 10 (40%) patients. Multivariate analyses revealed that tumors invading the middle fossa had negative effects on the extent of resection (odds ratio = 0.092, p = 0.047). Postoperative vision improved or normalized in 16 (64%), remained stable in eight (32%), and worsened in one (4%), while a new hormonal deficit was noted in seven (28%) patients. Complications included permanent oculomotor nerve palsy in one (4%) and transient oculomotor palsy in one (4%), apoplexy of the residual tumor resulting in ischemic stroke in one (4%), postoperative cerebrospinal fluid leakage in one (4%), and permanent diabetes insipidus in six (24%) patients. Conclusions For GPitNETs that extend into the middle fossa, our study underscored the difficulties in surgical extraction and the necessity for tailored treatment approaches. To ensure the safest and most complete removal possible, the surgical strategy must be specifically adapted to each case. Additionally, employing a comprehensive support approach is essential to reduce the chance of complications in patients impacted by this condition.

Improved optic nerve visualization and treatment planning through a dedicated optic nerve MRI protocol

OBJECTIVE

This study describes an innovative optic nerve MRI protocol for better delineating optic nerve anatomy from neighboring pathology.

METHODS

Twenty-two patients undergoing MRI examination of the optic nerve with the dedicated protocol were identified and included for analysis of imaging, surgical strategy, and outcomes. T2-weighted and fat-suppressed T1-weighted gadolinium-enhanced images were acquired perpendicular and parallel to the long axis of the optic nerve to achieve en face and in-line views along the course of the nerve.

RESULTS

Dedicated optic nerve MRI sequences provided enhanced visualization of the nerve, CSF within the nerve sheath, and local pathology. Optic nerve sequences leveraged the "CSF ring" within the optic nerve sheath to create contrast between pathology and normal tissue, highlighting areas of compression. Tumor was readily tracked along the longitudinal axis of the nerve by images obtained parallel to the nerve. The findings augmented treatment planning.

CONCLUSIONS

The authors present a dedicated optic nerve MRI protocol that is simple to use and affords improved cross-sectional and longitudinal visualization of the nerve, surrounding CSF, and pathology. This improved visualization enhances radiological evaluation and treatment planning for optic nerve lesions.

Incidence of and risk factors for chronic subdural hematoma after endoscopic endonasal surgery: quantitative analysis of pneumocephalus

OBJECTIVE

Chronic subdural hematoma (CSDH) is known to occur after endoscopic endonasal surgery (EES); however, the detailed clinical picture remains unclear. In this study, the authors aimed to examine the incidence of and risk factors for post-EES CSDH, with a focus on the quantitative evaluation of postoperative pneumocephalus.

METHODS

The authors retrospectively collected data on consecutive patients who, between November 2016 and December 2022, had undergone EES during which intraoperative cerebrospinal fluid (CSF) leakage occurred. Using CT images obtained immediately after surgery (CT0), the authors measured the extent of pneumocephalus in detail. The locations of pneumocephalus were divided into two groups: remote and local. Remote pneumocephalus was further subdivided into convexity and ventricular. The incidence of post-EES CSDH was calculated, and its risk factors were analyzed.

RESULTS

Among the 159 EES patients included in the study, Esposito grade 1, 2, and 3 intraoperative CSF leakage was confirmed in 22 (14%), 27 (17%), and 110 (69%) patients, respectively. CSDH occurred in 6 patients (3.8%). One patient (0.6%) required unilateral burr hole surgery, whereas the hematomas spontaneously disappeared in the others. All CSDHs occurred in patients with Esposito grade 3 CSF leakage and convexity pneumocephalus on CT0. In the multivariate analysis of 149 sides with convexity pneumocephalus on CT0, the product of the diameter and the thickness of convexity pneumocephalus on CT0 was significantly associated with subsequent CSDH (OR 1.21, 95% CI 1.06-1.38, p = 0.004). Using a cutoff value of 10 cm2, CSDH development could be predicted with a sensitivity of 0.82 and specificity of 0.74.

CONCLUSIONS

The incidence of post-EES CSDH is acceptably low, and surgery is rarely required. Patients with extensive convexity pneumocephalus on immediate postoperative CT are prone to develop CSDH and thus should be carefully monitored.

Further investigation of the lateral approach for the resection of Knosp grade 4 pituitary adenomas in endoscopic endonasal surgery

OBJECTIVE

The authors performed a further in-depth study of the lateral compartment of the cavernous sinus (LCCS) by the endoscopic endonasal approach to improve the safety and efficacy of the lateral approach for the removal of Knosp grade 4 pituitary adenomas (KG4PAs).

METHODS

Twenty-three cadaveric specimens were used for endoscopic endonasal dissection, and the LCCS was exposed to observe the neurovascular and fibrous structures within. A subclassification of the lateral approach based on further knowledge of the LCCS was proposed and used to resect 86 KG4PAs, and the surgical outcomes of these cases were reviewed. Type A KG4PAs represent tumor that was mainly distributed in the posterosuperior and superolateral compartments, type B KG4PAs represent tumor that was mainly distributed in the anteroinferior compartments, and type AB KG4PAs represent tumor that extended into each compartment with characteristics of types 4A and 4B.

RESULTS

The authors identified multiple fibers that anchored the horizontal segment of the internal carotid artery (ICA) to the abducens nerve. The fibers, the sympathetic nerve, and the inferior lateral trunk form a partition-like structure in the LCCS named the abducens nerve-ICA complex (AIC), and the LCCS can be divided into the superolateral and inferolateral compartments by the AIC. Accordingly, the lateral approach was subclassified into the lateral superior (LS) approach and the anterior inferior (AI) approach. The LS approach was mainly used to resect type A KG4PAs, whereas the AI approach was used to resect type B KG4PAs, and a combination of the two was used to resect type AB KG4PAs. The gross-total, subtotal, and partial resection rates were 81.4%, 12.8%, and 5.8%, respectively. The numbers of cases of postoperative transient cranial nerve palsy, postoperative permanent cranial nerve palsy, ICA injury, and CSF leakage were 6 (6.9%), 2 (2.3%), 1 (1.2%), and 1 (1.2%), respectively.

CONCLUSIONS

This study revealed that the LCCS is divided by the AIC into the superolateral and inferolateral compartments, avoiding the misconception that the LCCS has vertical communication. Therefore, the lateral approach was subclassified into the LS approach and the AI approach for the resection of KG4PAs, which allowed a high gross-total resection rate with acceptable safety in the surgical treatment of KG4PAs.

Endoscopic endonasal transsphenoidal surgery for unusual sellar lesions: eight cases and review of the literature

Background

Preoperative imaging for some unusual lesions in the sellar region can pose challenges in establishing a definitive diagnosis, impacting treatment strategies.

Methods

This study is a retrospective analysis of eight cases involving unusual sellar region lesions, all treated with endoscopic endonasal transsphenoidal surgery (EETS). We present the clinical, endocrine, and radiological characteristics, along with the outcomes of these cases.

Results

Among the eight cases, the lesions were identified as follows: Solitary fibrous tumor (SFT) in one case, Lymphocytic hypophysitis (LYH) in one case, Cavernous sinus hemangiomas (CSH) in one case, Ossifying fibroma (OF) in two cases; Sphenoid sinus mucocele (SSM) in one case, Pituitary abscess (PA) in two cases. All patients underwent successful EETS, and their diagnoses were confirmed through pathological examination. Postoperatively, all patients had uneventful recoveries without occurrences of diabetes insipidus or visual impairment.

Conclusion

Our study retrospectively analyzed eight unusual lesions of the sellar region. Some lesions exhibit specific imaging characteristics and clinical details that can aid in preoperative diagnosis and inform treatment strategies for these unusual sellar diseases.

Sphenoid Meningoencephalocele Correction Through a Transpterygoid Approach

Sphenoid meningoencephaloceles are rare, and their treatment is challenging. In this report, we describe two clinical cases of sphenoid meningoencephalocele, in which one patient presented with a cerebrospinal fluid leak after repeated head trauma, while in the other, sphenoid meningoencephalocele was detected during the study of memory impairment as the patient was otherwise asymptomatic. The CT scans showed bony dehiscence on the lateral wall of the sphenoid sinus filled with soft tissue that was confirmed by MRI as being herniated brain tissue. A transpterygoid endoscopic endonasal approach was performed with a multilayer reconstruction of the defect with success in both cases without perioperative complications. Imaging techniques are fundamental for diagnosis and surgical planning. Treatment using an endoscopic endonasal approach is efficient with very low morbidity.

[Bacterial contamination of autologous blood in reinfusion in neurosurgery: a phenomenon or a problem?]

There is a problem of bacterial contamination of autologous blood despite long-term experience of intraoperative blood salvage and reinfusion.

OBJECTIVE

To analyze safety of blood reinfusion with white blood cell filtration and X-ray irradiation for blood decontamination in neurosurgery.

MATERIAL AND METHODS

The study included 57 patients with various neurosurgical diseases. We used intraoperative blood reinfusion in all patients considering high predictable risk of major blood loss due to neurosurgical diseases, features of neoplasm topography, anamnesis and examination data. Microbiological examination of autologous blood was carried out at different stages before reinfusion.

RESULTS

Bacterial contamination of autologous blood samples was observed in 42% of patients. Enlargement of surgical access to paranasal sinuses in patients with craniofacial lesions poses a potential risk of bacterial contamination of autologous blood. Additional methods of decontamination including white blood cell filtration and X-ray irradiation reduced bacterial load. The above-mentioned methods were less effective for decontamination of microflora not typical for human skin compared to saprophytic ones. There were no postoperative infectious complications.

CONCLUSION

Combination of white blood cell filtration and X-ray irradiation reduces bacterial contamination and increases safety of reinfusion although these methods do not completely free autologous blood from opportunistic microorganisms. Decontamination quality significantly depended on microflora and surgical approach.

Surgical indication of pediatric Rathke's cleft cyst based on a 20-year retrospective cohort

OBJECTIVE

Rathke's cleft cyst (RCC) is the most commonly encountered pituitary incidentaloma in children. Because RCC is not frequently diagnosed in children, there are few reports on pediatric RCCs. The natural course of the disease and appropriate treatments are still obscure. The present study aimed to elucidate the natural history and surgical indications of RCCs in children.

METHODS

The authors retrospectively reviewed the clinical presentations, imaging features, ophthalmological evaluations, endocrine evaluations, and surgical outcomes of pediatric RCCs at a single institution from January 2000 to October 2022. Clinical outcomes between the surgery and observation groups were compared.

RESULTS

Among 93 patients, there were 41 patients in the surgery group and 52 patients in the observation group. The mean age at diagnosis was 10.9 years, and the mean follow-up period was 5.6 years. Headache fully or partially improved after surgery (86.2%), but the rate of improvement was not different from that of the observation group (70.0%). Ophthalmological abnormalities were effectively improved by surgical treatment (93.3%). Both the improvement and deterioration rates of endocrine abnormalities were significantly higher in the surgery group (p = 0.026 and p < 0.001, respectively), but the deterioration rate (43.9%) was higher than the improvement rate (14.6%). In the surgery group, the recurrence rate was 17.1% and the reoperation rate was 4.9%. Compared with total cyst wall resection, cyst fenestration with partial wall resection was associated with a higher recurrence rate (26.9%, p = 0.035) but a lower rate of endocrine abnormalities (30.8%, p = 0.049).

CONCLUSIONS

Pediatric RCCs of ≥ 10 mm in size were analyzed. Ophthalmological abnormalities are the major surgical indications for pediatric RCCs. Headache and partial endocrine abnormalities may be improved with surgery, but they are not absolute indications for surgery. Cyst fenestration with partial wall resection via an endoscopic endonasal approach is the most recommended surgical method. Follow-up is essential to monitor for the occurrence of visual field defects and the recurrence of cysts.

Portable MRI to assess optic chiasm decompression after endoscopic endonasal resection of sellar and suprasellar lesions

OBJECTIVE

Low-field portable MRI (pMRI) is a recent technological advancement with potential for broad applications. Compared with conventional MRI, pMRI is less resource-intensive with regard to operational costs and scan time. The application of pMRI in neurosurgical oncology has not been previously described. The goal of this study was to demonstrate the efficacy of pMRI in assessing optic nerve decompression after endoscopic endonasal surgery for sellar and suprasellar pathologies.

METHODS

Patients who underwent endoscopic endonasal surgery for sellar and suprasellar lesions at a single institution and for whom pMRI and routine MRI were performed postoperatively were retrospectively reviewed to compare the two imaging systems. To assess the relative resolution of pMRI compared with MRI, the distance from the optic chiasm to the top of the third ventricle was measured, and the measurements were compared between paired equivalent slices on T2-weighted coronal images. The inter- and intrarater correlations were analyzed.

RESULTS

Twelve patients were included in this study (10 with pituitary adenomas and 2 with craniopharyngiomas) with varying degrees of optic chiasm compression on preoperative imaging. Measurements were averaged across raters before calculating agreement between pMRI and MRI, which demonstrated significant interrater reliability (intraclass correlation coefficient [ICC] = 0.78, p < 0.01). Agreement between raters within the pMRI measurements was also significantly reliable (ICC = 0.93, p < 0.01). Finally, a linear mixed-effects model was specified to demonstrate that MRI measurement could be predicted using the pMRI measurement with the patient and rater set as random effects (pMRI β coefficient = 0.80, p < 0.01).

CONCLUSIONS

The results of this study suggest that resolution of pMRI is comparable to that of conventional MRI in assessing the optic chiasm position in relation to the third ventricle. Portable MRI sufficiently demonstrates decompression of the optic chiasm after endoscopic endonasal surgery. It can be an alternative strategy in cases in which cost, scan-time considerations, or lack of intraoperative MRI availability may preclude the ability to assess adequate optic nerve decompression after endoscopic endonasal surgery for sellar and suprasellar lesions.

Carolyn's Window Approach to Unilateral Frontal Sinus Surgery

OBJECTIVES

Due to the complexity and variety of the frontal recess and sinus anatomy, traditional Draf 2a frontal sinus surgery is challenging. The thickness of the nasofrontal beak and anterior-posterior dimensions of the frontal recess contribute to this complexity. Carolyn's window technique eliminates the limitation of anterior-posterior depth to facilitate a Draf 2a frontal sinusotomy. The approach is a 0° endoscope technique and provides an excellent view of the frontal sinus and recess. We describe Carolyn's window approach to frontal sinus surgery and the perioperative outcomes.

METHODS

Consecutive adult patients in whom Carolyn's window technique was applied for frontal sinus dissection as part of the endoscopic management of both inflammatory and neoplastic disease were assessed. The primary outcome was frontal sinus patency. Secondary outcomes were surgical morbidity, defined as early (<90 days) or late (>90 days).

RESULTS

Forty-five patients (49.1 ± 17.9 years, 48.9% Female) were assessed. All patients had successful frontal sinus patency (100% [95CI: 92.1%-100%]). Morbidities were adhesion (4.8%), crusting (2.4%), pain (1.2%), and bleeding (1.2%) in the early postoperative period. There were no other morbidities in the early and late postoperative periods.

CONCLUSION

Carolyn's window approach to frontal sinusotomy is a technique that evolves from previously described approaches. Successful frontal sinus patency with very low morbidities is achieved while still working with a 0° endoscope. The "axillectomy" performed simplifies frontal recess surgery by removing the anteroposterior diameter limitation and the dexterity required in angled endoscopy and instrumentation. The inferior-based lateral wall mucosal flap and free mucosal grafting expedite the mucosal healing process. Laryngoscope, 133:2496-2501, 2023.

Minimally invasive extraocular cranial nerve electromyography

OBJECTIVE

A reluctance to monitor extraocular cranial nerve (EOCN) function has restricted skull base surgery worldwide. Spontaneous and triggered electromyography (EMG) monitoring can be recorded intraoperatively to identify and assess potential cranial nerve injury. Determining the conductive function of EOCNs requires the collection of clear, reliable, and repeatable compound muscle action potentials (CMAPs) secondary to stimulation. EOCN EMG needle electrodes can, although infrequently, cause ocular morbidity including hematoma, edema, and scleral laceration. The aim of this study was to ascertain if minimally invasive 7-mm superficial needle electrodes would record CMAPs as well as standard 13-mm intraorbital electrodes.

METHODS

Conventionally, the authors have monitored EOCN function with intraorbital placement of paired 13-mm needle electrodes into three extraocular muscles: medial rectus, superior oblique, and lateral rectus. A prospective case-control study was performed using shorter (7-mm) needle electrodes. A single minimally invasive electrode was placed superficially near each extraocular muscle and coupled with a common reference. CMAPs were recorded from the minimally invasive electrodes and compared with CMAPs recorded from the paired intraorbital electrodes. The presence or absence of CMAPs was analyzed and compared among EMG recording techniques.

RESULTS

A total of 429 CMAPs were analyzed from 71 EOCNs in 25 patients. The experimental setup yielded 167 true-positive (39%), 106 false-positive (25%), 17 false-negative (4%), and 139 true-negative (32%) responses. These values were used to calculate the sensitivity (91%), specificity (57%), positive predictive value (61%), and negative predictive value (89%). EOCN electrodes were placed in 82 total eyes in 58 patients (CMAPs were obtained in 25 patients). Twenty-six eyes showed some degree of edema, bruising, or bleeding, which was transient and self-resolving. Three eyes in different patients had complications from needle placement or extraction including conjunctival hemorrhage, periorbital ecchymosis, and corneal abrasion, ptosis, and upper eyelid edema.

CONCLUSIONS

Because of artifact contamination, 106 false-positive responses (25%), and 17 false-negative responses (4%), the minimally invasive EMG technique cannot reliably record CMAP responses intraoperatively as well as the intraorbital technique. Less-invasive techniques can lead to an inaccurate EOCN assessment and potential postoperative morbidity. EOCN palsies can be debilitating and lifelong; therefore, the benefits of preserving EOCN function outweigh the potential risks of morbidity from electrode placement. EMG monitoring with intraorbital electrodes remains the most reliable method of intraoperative EOCN assessment.

Surgical strategy of pituitary and cavernous sinus exploration in MRI-Negative Cushing's disease after unsuccessful surgery

MRI-Negative Cushing's disease continues to be a challenging disease despite better imaging and techniques. The situation can be more complicated in the setting of prior surgery or failed surgery. Often, a narrow surgical corridor is encountered with robust cavernous or intercavernous sinuses. Controlling venous oozing properly is critical to achieving better outcomes. In this video, the authors present a case of MRI-Negative Cushing's disease after previous unsuccessful surgery. The pituitary tumor was detected on the left side of the gland, close to the cavernous sinus. Margin-plus resection is important if it can be achieved. Biochemical remission was achieved after surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.4.FOCVID2312.

Unique case of a GLI1 amplified biphasic mesenchymal tumor of the orbit

GLI1-altered mesenchymal tumors are an emerging entity in soft tissue pathology. In the head and neck region, they are most commonly in the tongue. Limited published data indicate a propensity for local recurrence, regional spread, and distant metastasis in both GLI1-rearranged and GLI1-amplified tumors. The purpose of this report is to present the rare case of a GLI1-amplified spindle cell tumor of the orbit and a focused review of the literature. A 54-year-old woman presented with proptosis, eye pain, and ocular motility restriction in the left eye. Imaging demonstrated a tumor occupying the superomedial intraconal orbit that was distinct from the extraocular muscles, optic nerve, and globe. The tumor was totally resected with a combined open transorbital and endoscopic, endonasal approach. Pathological analysis demonstrated a spindled and epithelioid mesenchymal tumor with diffuse nuclear GLI1 expression. PCR-based, next*-generation sarcoma fusion panel was negative for GLI1 fusions, including GLI1::ACTB fusions; however, DDIT3 breaks apart fluorescence in situ hybridization (FISH), which can be used as a surrogate for GLI1 alterations due to proximity to 12q13.3, showing amplification. Post-operatively, the patient had recovered visual acuity. She received adjuvant radiation therapy (60 Gy in 30 fractions). Surveillance for recurrence, regional spread, and distant metastasis has been negative at a 6-month follow-up. Ultimately, we report the first case of a GLI1-amplified mesenchymal neoplasm of the intraconal orbit managed with gross total resection via a combined approach followed by adjuvant radiation therapy.

The Impact of Endoscopic Endonasal Surgery on Quality of Life in Patients with Malignant Tumors of the Anterior Skull Base: A Prospective Study

Objective

To investigate the effects of endoscopic endonasal surgery (EES) on longitudinal quality of life (QoL) in patients with malignant tumors of the anterior skull base.

Methods

Eligible patients prospectively completed the Anterior Skull Base Surgery Questionnaire (ASBQ) and the 22-item Sino-Nasal Outcome Test (SNOT-22) questionnaires in referring to 3 different periods throughout their treatment and recovery.

Results

Forty patients were included. The median volume coronal maximum length of the tumor was 3.6 cm (95% CI 2.7-4.1cm). Overall QoL significantly worsened at 1 month postoperatively but returned to baseline after 1 year. Unrelieved symptoms in specific domains prompted further evaluation of individual items. Transient worsening of taste (p=0.011) and olfaction (p=0.004) lasted for 1 month but gradually relieved within the first postoperative year, but vision consistently worsened over the course of the treatment (p=0.126). Age>50 years (p<0.001), comorbidities (p<0.001), tumor necrosis (p<0.001) and recurrence (p=0.001) were associated with worse preoperative QoL. Poor long-term QoL was noted in those undergoing adjuvant therapy (p=0.032). Overall ASBQ scores (p=0.024), subdomain scores in specific symptoms (p=0.016), and vision scores (p=0.009) were worse only in patients with the greater coronal maximum diameter at 1-month postoperatively. Greater coronal maximum diameter was related to worse preoperative subdomain scores regarding specific symptoms (p=0.030) and decreased postoperative long-term decreased vision scores (p=0.014).

Conclusion

Long-term site-specific and sinonasal QoL eventually stabilized after EES. Greater coronal maximum diameter was significantly associated with worsened vision function. Temporarily worse olfactory, vision, and taste function may be tied to decreased short-term QoL.

Craniofacial Encephalocele: Updates on Management

Craniofacial encephaloceles are rare, yet highly debilitating neuroanatomical abnormalities that result from herniation of neural tissue through a bony defect and can lead to death, cognitive delay, seizures, and issues integrating socially. The etiology of encephaloceles is still being investigated, with evidence pointing towards the Sonic Hedgehog pathway, Wnt signaling, glioma-associated oncogene (GLI) transcription factors, and G protein-coupled receptors within primary cilia as some of the major genetic regulators that can contribute to improper mesenchymal migration and neural tube closure. Consensus on the proper approach to treating craniofacial encephaloceles is confounded by the abundance of surgical techniques and parameters to consider when determining the optimal timing and course of intervention. Minimally invasive approaches to encephalocele and temporal seizure treatment have increasingly shown evidence of successful intervention. Recent evidence suggests that a single, two-stage operation utilizing neurosurgeons to remove the encephalocele and plastic surgeons to reconstruct the surrounding tissue can be successful in many patients. The HULA procedure (H = hard-tissue sealant, U = undermine and excise encephalocele, L = lower supraorbital bar, A = augment nasal dorsum) and endoscopic endonasal surgery using vascularized nasoseptal flaps have surfaced as less invasive and equally successful approaches to surgical correction, compared to traditional craniotomies. Temporal encephaloceles can be a causative factor in drug-resistant temporal seizures and there has been success in curing patients of these seizures by temporal lobectomy and amygdalohippocampectomy, but magnetic resonance-guided laser interstitial thermal therapy has been introduced as a minimally invasive method that has shown success as well. Some of the major concerns postoperatively include infection, cerebrospinal fluid (CSF) leakage, infringement of craniofacial development, elevated intracranial pressure, wound dehiscence, and developmental delay. Depending on the severity of encephalocele prior to surgery, the surgical approach taken, any postoperative complications, and the age of the patient, rehabilitation approaches may vary.

Endoscopic-Modified Medial Maxillectomy for the Nonfunctioning Maxillary Sinus

BACKGROUND

Middle meatal antrostomy (MMA) is the traditional intervention for chronic maxillary sinusitis but often fails to correct a nonfunctioning maxillary sinus that has lost its capability for mucociliary clearance. Endoscopic-modified medial maxillectomy (EMMM) can reshape the maxillary sinus and avoid a "sumping" effect, preventing secondary bacterial colonization, encouraging dependent drainage, and promoting effective nasal irrigation.

OBJECTIVES

We describe a modification of the EMMM surgical technique in patients with recalcitrant maxillary sinusitis and perioperative outcomes.

METHODS

Consecutive adult patients with nonfunctioning maxillary sinuses managed with EMMM were assessed. Primary outcomes were the resolution of the presenting symptom and the absence of mucostasis. Secondary outcomes were early (<90 days) and late (>90 days) morbidity.

RESULTS

Fifty-seven patients (51.7  ±  17.5 years, 56.1% female) were assessed. Fifty-two patients had complete resolution of their presenting symptom (91.2% [95% CI: 80.7-97.1]) and 52 patients had an absence of mucostasis (91.2% [95% CI: 80.7-97.1]). Those with persistent crusting were also those with symptoms. Early morbidities included temporary dysesthesia (3.2%), bleeding (1.1%), and pain (3.2%), with no late morbidities.

CONCLUSION

EMMM is a robust approach for salvaging a nonfunctioning maxillary sinus. The procedure enhances nasal irrigation, supplants mucociliary clearance, and discourages dependent mucus retention.

Locally advanced sinonasal adenoid cystic carcinomas: endoscopic endonasal surgery-centered comprehensive treatment provides benefits

BACKGROUND

Sinonasal adenoid cystic carcinomas (SNACCs) are aggressive tumors that show massive expansion and are challenging to treat when locally advanced.

AIMS

To report our experiences with endoscopic endonasal surgery (EES) - centered comprehensive treatment and discuss the associated outcomes of these patients.

MATERIAL AND METHODS

A retrospective review of primary locally advanced SNACCs patients was conducted in a single center. EES combined with postoperative radiotherapy (PORT) was used as a comprehensive surgery-centered approach to treat these patients.

RESULTS

The study included 44 patients with Stage III/IV tumors. The median follow-up duration was 43 months (4-161 months). Forty-two patients underwent PORT. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 61.2% and 46%, respectively. Local recurrence occurred in 7 patients, and 19 patients had distant metastasis. No significant relationship was found between OS and postoperative local recurrence. The OS of patients with Stage IV or exhibiting distant postoperative metastases was shorter than that of other patients.

CONCLUSIONS AND SIGNIFICANCE

Locally advanced SNACCs are not a contraindication for EES. EES-centered comprehensive treatment can ensure satisfactory survival rates and reasonable local control. Function-preserving surgery using EES and PORT may represent an alternative strategy when vital structures are involved.

Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review

Cerebrospinal fluid leak (CSFL) is a rare pathological condition which requires prompt and adequate management due to the high rate of associated major complications. At present, CSFL can be successfully treated through endoscopic endonasal approaches with success rates higher than 90%. Despite this, CSFL recurrence may occur, and its management is critical and still represents a matter of debate. A systematic review of the literature on the management of recurrent CSFL was conducted. It included a cohort of 1,083 cases of CSFL treated with surgical or conservative approaches; 112 cases of recurrence were reported for an overall recurrence rate of 10.3%. Most of the leaks were localised in the anterior skull base (68.3%) and identification of recurrent CSFL may be troublesome. Therefore, the entire skull base must be meticulously examined and long-term follow-up is mandatory. The risk for CSFL recurrence is higher in patients affected by idiopathic intracranial hypertension (IIH), but its role in CSFL recurrence is yet to be understood. Recurrent CSFL must be repaired as soon as possible in order to reduce the risk of intracranial complications. The use of early post-operative CSF diversion by lumbar drain (LD) is currently a matter of debate even in case of CSFL recurrences.

Discontinuation of Postoperative Prophylactic Antibiotics for Endoscopic Endonasal Skull Base Surgery

Background  Postoperative prophylactic antibiotic usage for endoscopic skull base surgery varies based on the institution as evidence-based guidelines are lacking. The purpose of this study is to determine whether discontinuing postoperative prophylactic antibiotics in endoscopic endonasal cases led to a difference in central nervous system (CNS) infections, multi-drug resistant organism (MDRO) infections, or other postoperative infections. Methods  This quality improvement study compared outcomes between a retrospective cohort (from September 2013 to March 2019) and a prospective cohort (April 2019 to June 2019) after adopting a protocol to discontinue prophylactic postoperative antibiotics in patients who underwent endoscopic endonasal approaches (EEAs). Our primary end points of the study included the presence of postoperative CNS infection, Clostridium difficile ( C. diff ), and MDRO infections. Results  A total of 388 patients were analyzed, 313 in the pre-protocol group and 75 in the post-protocol group. There were similar rates of intraoperative cerebrospinal fluid leak (56.9 vs. 61.3%, p  = 0.946). There was a statistically significant decrease in the proportion of patients receiving IV antibiotics during their postoperative course ( p  = 0.001) and those discharged on antibiotics ( p  = 0.001). There was no significant increase in the rate of CNS infections in the post-protocol group despite the discontinuation of postoperative antibiotics (3.5 vs. 2.7%, p  = 0.714). There was no statistically significant difference in postoperative C. diff (0 vs. 0%, p  = 0.488) or development of MDRO infections (0.3 vs 0%, p  = 0.624). Conclusion  Discontinuation of postoperative antibiotics after EEA at our institution did not change the frequency of CNS infections. It appears that discontinuation of antibiotics after EEA is safe.

The "chameleon" sellar lesions: a case report of unexpected sellar lesions

Introduction

The sellar region and its boundaries represent a challenging area, harboring a variety of tissues of different linings. Therefore, a variety of diseases can arise or involve in this area (i.e., neoplastic or not). A total of three challenging cases of "chameleon" sellar lesions treated via EEA were described, and the lesions mimicked radiological features of common sellar masses such as craniopharyngiomas and/or pituitary adenomas, and we also report a literature review of similar cases.

Methods

A retrospective analysis of three primary cases was conducted at the Università degli Studi di Napoli Federico II, Naples, Italy. Clinical information, radiological examinations, and pathology reports were illustrated.

Results

A total of three cases of so-called "chameleon" sellar lesions comprising two men and one woman were reported. Based on the intraoperative finding and pathological examination, we noticed that case 1 had suprasellar glioblastoma, case 2 had a primary neuroendocrine tumor, and case 3 had cavernous malformation.

Conclusion

Neurosurgeons should consider "unexpected" lesions of the sellar/suprasellar region in the preoperative differential diagnosis. A multidisciplinary approach with the collaboration of neurosurgeons, neuroradiologists, and pathologists plays a fundamental role. The recognition of unusual sellar lesions can help surgeons with better preoperative planning; so an endoscopic endonasal approach may represent a valid surgical technique to obtain decompression of the optic apparatus and vascular structures and finally a pathological diagnosis.

[Autologous fibrin glue for endoscopic skull base repair in patients with cerebrospinal fluid leakage]

The main stages of endoscopic skull base repair in patients with cerebrospinal fluid (CSF) leakage are identification of bone boundaries of the fistula and its closure by auto- and allografts. Fibrin glue can be used to fix plastic materials and additionally seal skull base defect.

OBJECTIVE

To analyze efficacy and safety of Vivostat autologous fibrin glue for endoscopic skull base repair in patients with nasal CSF leakage and to compare postoperative outcomes after defect closure by Vivostat fibrin glue and allogeneic fibrin glue.

MATERIAL AND METHODS

A retro- and prospective analysis included 56 patients with nasal CSF leakage who were treated at the Burdenko Neurosurgery Center between January 2021 and June 2022. Patients were divided into 2 groups: Vivostat fibrin glue (n=27, 48.2%) and allogeneic fibrin glue (n=29, 51.8%). Demographic and clinical perioperative data were analyzed.

RESULTS

No early postoperative recurrence of CSF leakage was registered in both groups, whereas meningitis occurred in 2 cases in each group. Recurrent CSF leakage in delayed postoperative period occurred in 1 patient (3.4%) of the control group (p>0.05). Incidence of perioperative complications, subfebrile temperature in early postoperative period, surgery time and hospital-stay were similar.

CONCLUSION

Vivostat autologous fibrin glue is a safe and effective method for fixing the grafts in endoscopic skull base repair. The advantages of this approach are easy application, elimination of the risk of allergic, immunological and infectious complications, as well as acceleration of tissue regeneration.

The Cost Effectiveness of Implementation of a Postoperative Endocrinopathy Management Protocol after Resection of Pituitary Adenomas

Purpose  After developing a protocol for evaluating, diagnosing, and treating postoperative endocrinopathy both during the hospitalization and during the immediate discharge period following resection of pituitary adenomas, we sought to assess the impact of this protocol on quality outcomes. Methods  An IRB-exempt, quality improvement initiated, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective comparison of a pre-and-post-protocol cohort of all patients undergoing endoscopic endonasal resection of pituitary adenomas at NYU Langone Medical Center from January 2013 to December 2018. Demographic characteristics of the patients and their tumors with their postoperative outcomes were recorded. Quality outcomes regarding number of laboratory studies sent, rate of diabetes insipidus, length of stay, and readmission rate were also recorded. Statistical analysis was performed between the pre- and post-protocol groups. Results  There was a significant reduction in laboratory studies sent per patient (55.66 vs. 18.82, p <0.001). This corresponded with an overall cost reduction in laboratory studies of $255.95 per patient. There was a decrease in the overall number of patients treated with DDAVP (21.4% in the pre-protocol group vs. 8.9% in the post-protocol group, p  = 0.04). All post-protocol patients requiring DDAVP at discharge were identified by 48 hours. There was no significant change in length of stay or need for hydrocortisone supplementation postoperatively between the two groups. Length of stay was driven mostly by need for reoperation during initial hospitalization. There was no significant change in the rate of 30-day readmission. Conclusion  Implementation of a postoperative management protocol results in a more efficient diagnosis and management of endocrinopathy after pituitary adenoma surgery which translates to decreased cost.

Biphenotypic sinonasal sarcoma: European multicentre case-series and systematic literature review

Objective

Biphenotypic sinonasal sarcoma (BSNS) is a rare low-grade cancer that was included from the 4th edition of WHO classification of head and neck tumours. The purpose of this study is to analyse clinical behaviour, pattern of recurrences and survival outcomes of this neoplasm.

Methods

Retrospective review of patients affected by BSNS who were treated via an endoscopic-assisted approach in 6 European tertiary-care referral hospitals. Cases of BSNS described in literature since 2012 to date were fully reviewed, according to PRISMA guidelines.

Results

A total of 15 patients were included. Seven patients were treated via an endoscopic endonasal approach, 4 with endoscopic transnasal craniectomy, and 4 via a cranio-endoscopic approach. Adjuvant treatment was delivered in 2 cases. After a mean follow-up of 27.3 months, systemic metastasis was observed in 1 case; the 5-year overall survival and disease-free survival rates were 100% and 80 ± 17.9%, respectively.

Conclusions

BSNS is a locally aggressive tumour with a low recurrence rate and encouraging survival outcomes if properly treated with surgical resection and free margins followed by adjuvant radiotherapy for selected cases. Endoscopic-assisted surgery is safe and effective as an upfront treatment within a multidisciplinary care protocol.

Tumors Involving the Infratemporal Fossa: A Systematic Review of Clinical Characteristics and Treatment Outcomes

BACKGROUND

Infratemporal fossa (ITF) tumors represent various pathologies and are seldom described in the literature, reflecting their rarity. Here we review the literature on tumors invading ITF and describe patient characteristics, treatment strategies, and clinical outcomes.

METHODS

Relevant articles were retrieved from PubMed, Scopus, and Cochrane. A systematic review and meta-analysis were conducted on the clinical presentation, treatment protocols, and clinical outcomes.

RESULT

A total of 27 articles containing 106 patients with ITF tumors (median tumor size: 24.3 cm³ [interquartile range, 15.2-42 cm³]) were included (median age: 46 years [interquartile range, 32-55 years]; 59.4% were males]). Of the confirmed tumor pathology data, schwannomas (n = 24; 26.1%) and meningiomas (n = 13; 14.1%) were the most common tumors. Facial hypoesthesia (n = 22; 18.5%), auricular/preauricular pain (n = 20; 16.8%), and headaches (n = 11; 9.2%) were the most common presenting symptoms. Of patients who had surgical resection (n = 97; 95.1%), 70 (73.7%) had transcranial surgery (TCS) and 25 (26.3%) had endoscopic endonasal surgery (EES). Among available details on the extent of resection (n = 84), gross-total resection (GTR) was achieved in 62 (73.8%), and 5 (6.0%) had biopsy only. Thirty-five (33.0%) patients had postoperative complications. Among cases with available data on reconstruction techniques (n = 8), four (50%) had adipofascial antero-lateral thigh flap, three (37.5%) had latissimus dorsi free flap, and one (12.5%) had antero-lateral thigh flap. Fourteen (13.2%) patients had adjuvant chemotherapy, and sixteen (15.1%) had adjuvant radiotherapy. During a median follow-up time of 28 months (IQR, 12.25-45.75 months), 15 (14.2%) patients had recurrences, and 18 (17.0%) patients died. The median overall survival (OS) time was 36 months (95% confidence interval: 29-41 months), and the 5-year progression-free survival (PFS) rate was 61%.

CONCLUSION

Various tumor types with different biological characteristics invade the ITF. The present study describes patient demographics, clinical presentation, management, and outcomes. Depending on the tumor type and patient condition, patient-tailored management is recommended to optimize treatment outcomes.

Giant Non-Functioning Pituitary Adenomas: Treatment Considerations

Giant pituitary adenomas are a subgroup of pituitary adenomas defined by a diameter greater than 4 cm, and they account for 5–14% of adenomas in surgical series. Because of their growth patterns and locations, often involving critical neurovascular structures, they represent a true surgical challenge, and gross total resection is difficult to achieve. There is no consensus on the optimal surgical strategy for giant pituitary adenomas, and, often, integrated multi-staged treatment strategies have been considered. Transcranial or transsphenoidal approaches, alone or combined, according to tumor and patient features are the two main routes. Each of these strategies has pros and cons. The conventional transcranial approach has for a long time been considered the first choice for the removal of giant pituitary adenomas. Currently, with endoscopic techniques, it is also possible to remove lesions that involve the intradural compartment and the adjacent neurovascular structures with the use of extended approaches. Our policy for the management of these lesions is to adopt the endoscopic endonasal approach as the first choice unless the tumor presents significant intracranial extension that results in it being outside the visibility and maneuverability of the endoscopic endonasal route. In these latter cases, we agree that the transcranial approach is more appropriate. However, accurate preoperative evaluation and refined treatment plans for each patient are mandatory to define a proper strategy in order to achieve the most effective long-term result.

Differences in the length of postoperative care of endoscopic endonasal surgery in simple and complex surgical procedure groups

Background: The rapid development of endoscopic endonasal surgery has made the procedure widely used in nasal and sinus surgery. Endoscopic endonasal surgery is a minimally invasive procedure, but the possibility of postoperative damage to the sinonasal mucosa cannot be ruled out. The aim of this study was to analyze the difference in the length of postoperative care between complex and simple endoscopic endonasal surgeries which can be used as a reference in planning postoperative care.   Methods: This was a retrospective cross-sectional observational study. The participants were divided into two groups, i.e., simple, and complex surgical procedures groups. The simple procedure group consisted of middle meatal anstrostomy, frontal sinusotomy, sphenoidectomy, uncinectomy, endoscopic septoplasty, and endoscopic turbinoplasty. The complex procedure group included pansinus surgery and or at least total ethmoidectomy. The length of postoperative care between the two groups were measured and analyzed using the Chi-square test.   Results: The median length of care in the complex procedure group was significantly longer than that in the simple procedure group (p = 0.028), 12 weeks and 9 weeks, respectively. The number of postoperative outpatient visits was significantly less in the simple procedure group compared with the complex procedure group (Median 4 vs. 5; p=0.015). There was a significant correlation between length of care and the endonasal endoscopic surgical procedure group (p = 0.023).   Conclusions: The complex endoscopic endonasal surgery group required a longer length of care and more postoperative outpatient visit than the simple procedure group.

Does Endoscopic Transnasal Optic Nerve Decompression Followed by Radiosurgery Improve Outcomes in the Treatment of Parasellar Meningiomas?

Introduction: The clinical management of parasellar meningiomas (PM) is challenging due to their intimate association with critical neurovascular structures. Consensus regarding the recommended treatment protocol is lacking. This study will evaluate patients’ visual outcomes following endoscopic transnasal optic nerve decompression (ETOND) and will investigate the possibility of reducing the rate of complications associated with stereotactic radiosurgery (SRS). Methods: Retrospective analysis was conducted on all patients who underwent ETOND for PM between 2013 and 2020. The study comprised 12 patients (7 women and 5 men aged 36–75 years; mean, 55.2 years; median, 57.6 years) in which 14 optic nerve decompression procedures were carried out. Patients were followed up for 6 to 86 months (mean, 29.3 months; median, 25 months). There were five cases of spheno-orbital meningioma, four cases of cavernous sinus meningioma, and one case each of petro-clival meningioma, optic nerve sheath meningioma, and planum sphenoidale/tuberculum sellae meningioma. Visual outcome was evaluated and any postoperative complications noted. Results: Improvements in visual acuity were noted in 10 of 14 eyes (71.4%) 3 to 6 months postoperation. Visual acuity remained stable in the remaining four eyes. No deterioration of visual acuity was noted during the follow-up period. In total, 9 of the 12 patients underwent SRS. No tumor growth was determined, while reduction in tumor volume was noted in five patients following SRS. No complications associated with SRS or the surgical procedure were noted. Conclusions: ETOND appears to be a promising technique for increasing rates of improved visual function, while reducing the risk of post SRS-related complications. In combination with subsequent SRS, it is an ideal treatment modality in the management of parasellar meningiomas. Confirmation of our findings would require a larger, prospective multicenter study.

Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

Simple Summary

Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. Over time, several corridors have been proposed, each one carrying its own pros and cons. During the last decades, the endoscopic endonasal route has been asserted among the classic routes for a growing number of midline and paramedian lesions. Therefore, the aim of our paper is to present a comprehensive review of the indications and techniques for the management of skull base meningiomas, emphasizing the ambivalent and complementary role of the low and high routes.

Abstract

Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection.

Complications of Endoscopic Skull Base Surgery for Sellar and Parasellar Tumors in Pediatric Population; Neurosurgical Perspectives

Background

Advances in surgical techniques based on in-depth anatomical knowledge of the skull base have broadened the indications for endoscopic skull base surgery (ESS) with the advantage of wide and direct surgical exposure while minimizing invasiveness. However, the low incidence of the indicated diseases and narrow surgical corridors in children have limited the popularization of ESS. In addition, surgical complications and preventive interventions are not yet well known. Therefore, we retrospectively investigated the complications and prevention methods of ESS in children with a comprehensive review.

Methods

We retrospectively analyzed the medical records of pediatric patients who underwent ESS for sellar and parasellar tumors at Seoul National University Children's Hospital from July 2010 to December 2020. Visual and endocrine status, extent of resection, complications, and recurrences were investigated depending on the pathology of the tumor. In addition, a comprehensive literature review regarding the complications of pediatric ESS was performed.

Results

A total of 98 patients were enrolled. The median age of the patients was 12 years, and 52 patients were male. Preoperative visual disturbance was found in 53 patients, anterior pituitary function deficit in 69, and diabetes insipidus in 32. Gross total resection was attempted in 67 patients and achieved in 62 (93%). Biopsy and cyst fenestration were the goals of surgery in 26 patients, and all were achieved as planned. Regarding outcomes, visual disturbance worsened in two patients (2%), endocrine status was aggravated in 34 (35%) patients, and new-onset diabetes insipidus occurred in 27 (41%) patients. The overall surgical complication rate (other than aggravation of visual or endocrine status) was 17%. Postoperative meningitis (12%) was the most common complication, followed by cerebrospinal fluid leakage (2%), vasospasm, hemorrhage and infarction. By pathological diagnosis, craniopharyngioma had the highest complication rate of 29%. All but one patient with postoperative hemorrhage showed no permanent deficits.

Conclusion

ESS in children is feasible and relatively safe. More attention and different postoperative management protocols are required in children to avoid complications, especially in craniopharyngiomas. However, the complications can be mostly managed conservatively without permanent neurologic deficits.

Clinical Impact of Hydroxyapatite on the Outcome of Skull Base Reconstruction for Intraoperative High-Flow CSF Leak: A Propensity Score Matching Analysis

Background

Despite recent advances in skull base reconstructive techniques, including the multilayer technique during the last decade, complete reconstruction of grade 3 intraoperative high-flow cerebrospinal fluid (CSF) leak remains challenging. This study was designed to investigate the role of injectable hydroxyapatite (HXA) used in the multilayer technique on the clinical outcome of skull base reconstruction for intraoperative high-flow CSF leak.

Materials and Methods

This study enrolled 187 patients who experienced intraoperative high-flow CSF leak after endoscopic endonasal surgery for anterior skull base or suprasellar pathologies between January 2014 and July 2021. All skull base defects were reconstructed using the conventional multilayer technique including a vascularized naso-septal flap (NSF, n = 141) and the combined use of HXA with the conventional multilayer technique (HXA group, n = 46). We retrospectively evaluated the efficacy of the HXA group by 1:2 propensity score matching analysis.

Results

Overall, 17 of 187 patients (9.1%) showed postoperative CSF leaks, resulting in second reconstruction surgery. There were no statistical differences in patient age, sex, body mass index, tumor location, tumor type, and degree of resection, except for the follow-up period between the two groups. The HXA group showed a significantly lower incidence of postoperative CSF leak than the control group (0% vs. 12.1%, p < 0.05). Postoperative lumbar drain (LD) was performed in 8.7% of the HXA group compared to 46.1% of the control group (p < 0.01). CSF leak-related infection rates showed a decreasing tendency in the HXA group compared to the control group (0 vs. 7.1%, p = 0.06). A total of 46 patients in the HXA group were well matched with the control group (92 patients) at a 1:2 ratio. In the propensity score-matched control group, there were higher rates of postoperative CSF leaks than in the HXA group.

Conclusion

The use of HXA combined with the conventional multilayer technique completely reduced postoperative CSF leaks in this study. This technique resulted in reduced CSF leakage, even without postoperative LD, and decreased infection rates. Further randomized comparative studies are required to confirm our findings.

The use of augmented reality in transsphenoidal surgery: A systematic review

BACKGROUND

Augmented reality (AR) has become a promising tool in neurosurgery. It can minimise the anatomical challenges faced by conventional endoscopic or microscopic transsphenoidal reoperations and can assist in intraoperative guidance, preoperative planning, and surgical training.

OBJECTIVES

The aims of this systematic review are to describe, compare, and evaluate the use of AR in endoscopic and microscopic transsphenoidal surgery, incorporating the latest primary research.

METHODS

A systematic review was performed to explore and evaluate existing primary evidence for using AR in transsphenoidal surgery. A comprehensive search of MEDLINE and EMBASE was conducted from database inception to 11th August 2021 for primary data on the use of AR in microscopic and endoscopic endonasal skull base surgery. Additional articles were identified through searches on PubMed, Google Scholar, JSTOR, SCOPUS, Web of Science, Engineering Village, IEEE transactions, and HDAS. A synthesis without meta-analysis (SWiM) analysis was employed quantitatively and qualitatively on the impact of AR on landmark identification, intraoperative navigation, accuracy, time, surgeon experience, and patient outcomes.

RESULTS

In this systematic review, 17 studies were included in the final analysis. The main findings were that AR provides a convincing improvement to landmark identification, intraoperative navigation, and surgeon experience in transsphenoidal surgery, with a further positive effect on accuracy and time. It did not demonstrate a convincing positive effect on patient outcomes. No studies reported comparative mortalities, morbidities, or cost-benefit indications.

CONCLUSION

AR-guided transsphenoidal surgery, both endoscopic and microscopic, is associated with an overall improvement in the areas of intraoperative guidance and surgeon experience as compared with their conventional counterparts. However, literature on this area, particularly comparative data and evidence, is very limited. More studies with similar methodologies and quantitative outcomes are required to perform appropriate meta-analyses and to draw significant conclusions.

Endoscopic Endonasal Repair of the Orbital Medial Wall Fracture Utilising Nasal Septal Cartilage as the Reconstructive Material

BACKGROUND

To repair orbital medial wall fractures, otorhinolaryngologists often use the silicone sheet technique by inserting an inverted U-shaped silicone sheet into the middle meatus after the removal of fractured bones, and packing gauze inside the silicone sheet for several days to fix the shape of the medial wall. However, this method does not sufficiently reduce the orbital content.

OBJECTIVE

To describe the surgical procedure to repair medial wall fractures using nasal septal cartilage as the reconstructive material.

METHODS

First, endoscopic septoplasty is performed. Although the correction of the septal deviation is performed to secure the operative field, the nasal septal cartilage, except the L-strut is resected simultaneously. After septoplasty, the fractured bones of the lamina papyracea are removed from the herniated orbital contents, and then the orbital contents can be reduced without resistance by pushing laterally. Subsequently, the cartilage is inserted beneath the fracture edges of the orbital medial wall with great care to avoid entrapping the orbital soft tissue and extraocular muscles.

RESULTS

The cartilage can be placed appropriately along the medial wall of the orbit.

CONCLUSION

This technique enables to repair most cases of orbital medial wall fractures using the endoscopic endonasal approach alone without alloplastic implants.

Endoscopic treatment of sellar arachnoid cysts via a simple cyst-opening technique: Long-term outcomes from a single center

BACKGROUND

Sellar arachnoid cysts (SACs) are rare lesions that require treatment only if symptomatic. The endoscopic endonasal approach has been widely utilized. Despite their simple cystic appearance and the straight-forward surgical intervention there are important associated risks, with CSF leak being the prevalent one.

METHODS

A retrospective analysis of patients with pathologically confirmed SAC between January 2006 and December 2019 was conducted. A homogeneous simple cyst-opening technique and skull base reconstruction utilizing nasoseptal flaps was used.

RESULTS

Ten patients were identified (7 female and 3 male, median age was 54.5 years, range 20-77); 8 had newly diagnosed SACs whereas 2 recurrences from a previously microsurgically fenestrated SAC. Eight patients presented with visual symptoms (VS), 1 with VS and fatigue, and 1 with headaches. Neuro-ophthalmological and endocrinological assessments revealed visual field (VF) deficits in 6, visual acuity (VA) decline in 5 and hypopituitarism in 2 patients. Median calculated volume was 1.71 ml (range 0.27 - 2.54 ml). Postoperatively, no CSF leak and no further surgical complications were noted. VF improved in 4/6 while VA improved in 4/5 patients. Anterior pituitary function improved in 1, worsened in 1 and remained stable in 8 patients. One patient suffered diabetes insipidus. One recurrence was recorded 54 months postoperatively.

CONCLUSION

SACs can be effectively treated with a simple cyst-opening technique. The routine use of nasoseptal flaps significantly reduces the risk of CSF leak without compromising nasal quality of life in the long-term or mandating additional incisions. A long-term follow-up is important to monitor for late recurrences.

Microsurgical anatomy of the dorsal clinoidal space: implications for endoscopic endonasal parasellar surgery

OBJECTIVE

The clinoidal venous space dorsal to the internal carotid artery (ICA) has not been well studied given its inaccessibility due to obstruction by the ICA during transcranial surgery. The evolution of endoscopic endonasal surgery has provided a new perspective into the clinoidal space and a new route for paraclinoidal lesions. Understanding the dorsal clinoidal space (DCS) is vital in planning and performing endoscopic endonasal surgery in the parasellar region. A detailed and precise description of the DCS from the endonasal perspective has not yet been provided. The authors' goal in this study was to delineate the microsurgical anatomy of the DCS from an endoscopic endonasal perspective, emphasizing its surgical implications when treating invasive pituitary adenomas and other parasellar lesions.

METHODS

An endoscopic endonasal transsellar approach was performed in 15 silicone-injected postmortem heads. Afterward, the sellar region was dissected through a transcranial approach using magnification ×3 to ×40 microscopy. The osseous, dural, and arterial relationships of the DCS and its architecture were investigated. The DCS's length, width, and depth were measured and its anatomical variations recorded.

RESULTS

The DCS was identified in 90% of the specimens, and in most cases, its shape was a narrow rectangular pyramid, with its base oriented toward the sphenoid sinus and its apex toward the posterior clinoid process. It is delimited superiorly by the distal ring, inferiorly by the medial aspect of the proximal dural ring or caroticoclinoid ligament, laterally by the clinoidal ICA, and medially by the superior continuation of the medial wall of the cavernous sinus. The width, height, and length of the DCS were 4 ± 1, 4.5 ± 1.5, and 7 ± 2 mm, respectively. A fenestrated caroticoclinoid ligament is a potential route for tumor invasion from the cavernous sinus into the DCS.

CONCLUSIONS

This report provides important anatomical descriptions of the DCS from endoscopic endonasal and transcranial perspectives that may facilitate the space's safe exposure for the removal of invasive adenomas, increasing total resection rates and minimizing the risk of injury to neurovascular structures.

Angiomatous Nasal Polyp Diagnosed by Preoperative Imaging and Successfully Resected by Endonasal Endoscopic Surgery: A Case Report

Angiomatous polyp is a benign, nonneoplastic nasal polyp that accounts for 4-5% of all inflammatory nasal polyps but is rarely reported in the literature. It can grow rapidly and exhibit an aggressive clinical behavior that can simulate malignant sinonasal tumor. We herein report a case of a 13-year-old boy with a rapidly growing angiomatous polyp in the nasal cavity. We had followed up the patient without significant changes for two years, but the tumor had rapidly grown in the last six months. At first, the rapid growth of the tumor and the bone erosion of the maxilla were suggestive of a malignant tumor. However, with preoperative magnetic resonance imaging (MRI) and [18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography imaging findings, we established the corrective diagnosis of an angiomatous polyp. After the diagnostic imaging, we performed an endoscopic endonasal surgery and totally resected the tumor without unnecessary excessive surgery. Recognition of this disease that can mimic malignancy is important to avoid excessive surgery such as en bloc resection by craniofacial approach, and we believe that MRI findings can be helpful for the imaging diagnosis.

[Multiple skull base defects: features of pathogenesis, diagnosis and treatment]

OBJECTIVE

To determine the risk factors of multiple skull base defects, as well as features of diagnosis and treatment of this pathology.

MATERIAL AND METHODS

A retrospective analysis included 39 patients who underwent surgery for nasal CSF leakage at the Burdenko Neurosurgical Center in 2000-2019. The study recruited patients with multiple simultant skull base defects.

RESULTS

Traumatic defects were observed in 23 (59%) patients, spontaneous defects - in 16 (41%) cases. All patients underwent endoscopic endonasal closure of skull base defects with autografts.

CONCLUSION

Multiple defects are more common in severe traumatic brain injury. The main risk factors of multiple spontaneous defects are female sex and overweight. Adequate diagnosis implies high-resolution CT (slice width 0.5-1 mm), as well as intraoperative control of all suspicious and «weak» areas. Endoscopic endonasal technique is effective and safe for multiple skull base defects (efficiency 97%).

Critical review of multidisciplinary approaches for managing sinonasal tumors with orbital involvement

Orbital invasion is frequently observed in tumors involving the maxillary, ethmoid and frontal sinuses given the proximity of the orbit to the sinonasal tract and ventral skull base. The main objective of the present review is to determine the existing evidences on the frequency, treatment, and outcomes of orbital invasion in benign and malignant sinonasal tumors. A systematic review of the literature published from 1995 to 2020 was performed and data sources included PubMed, Cochrane library, NCBI Bookshelf, National Guideline Clearinghouse. Orbital invasion was reported in 2-4% of inverted papillomas, 12-15% of fibro-osseous lesions, 27-32% of juvenile angiofibromas, 35-45% of low-grade malignancies, and 50-80% of high-grade cancers. Surgical resection with negative margins represents the cornerstone of management for benign and low-grade malignant tumors. Histology-specific induction chemotherapy can be used for high-grade sinonasal cancers in order to downstage the tumor and increase the possibility of orbital preservation. When a significant response to induction chemotherapy is observed, exclusive chemoradiation should be offered to improve overall survival rates. Appropriate reconstruction of any surgical defects is essential in order to minimize complications and optimize functional and aesthetic outcomes. Orbital apex invasion represents a negative prognostic factor. In conclusion, a multidisciplinary teamwork is mandatory to maximize local control, minimize morbidity and improve orbital preservation rates.

Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010-2018

OBJECTIVE

The endoscopic endonasal approach (EEA) has evolved into a mainstay of skull base surgery over the last two decades, but publications examining the intraoperative and perioperative complications of this technique remain scarce. A prior landmark series of 800 patients reported complications during the first era of EEA (1998-2007), parallel to the development of many now-routine techniques and technologies. The authors examined a single-institution series of more than 1000 consecutive EEA neurosurgical procedures performed since 2010, to elucidate the safety and risk factors associated with surgical and postoperative complications in this modern era.

METHODS

After obtaining institutional review board approval, the authors retrospectively reviewed intraoperative and postoperative complications and their outcomes in patients who underwent EEA between July 2010 and June 2018 at a single institution.

RESULTS

The authors identified 1002 EEA operations that met the inclusion criteria. Pituitary adenoma was the most common pathology (n = 392 [39%]), followed by meningioma (n = 109 [11%]). No patients died intraoperatively. Two (0.2%) patients had an intraoperative carotid artery injury: 1 had no neurological sequelae, and 1 had permanent hemiplegia. Sixty-one (6.1%) cases of postoperative cerebrospinal fluid leak occurred, of which 45 occurred during the original surgical hospitalization. Transient postoperative sodium dysregulation was noted after 87 (8.7%) operations. Six (0.6%) patients were treated for meningitis, and 1 (0.1%) patient died of a fungal skull base infection. Three (0.3%) patients died of medical complications, thereby yielding a perioperative 90-day mortality rate of 0.4% (4 deaths). High-grade (Clavien-Dindo grade III-V) complications were identified after 103 (10%) EEA procedures, and multivariate analysis was performed to determine the associations between factors and these more serious complications. Extradural EEA was significantly associated with decreased rates of these high-grade complications (OR [95% CI] 0.323 [0.153-0.698], p = 0.0039), whereas meningioma pathology (OR [95% CI] 2.39 [1.30-4.40], p = 0.0053), expanded-approach intradural surgery (OR [95% CI] 2.54 [1.46-4.42], p = 0.0009), and chordoma pathology (OR [95% CI] 9.31 [3.87-22.4], p < 0.0001) were independently associated with significantly increased rates of high-grade complications.

CONCLUSIONS

The authors have reported a large 1002-operation cohort of EEA procedures and associated complications. Modern EEA surgery for skull base pathologies has an acceptable safety profile with low morbidity and mortality rates. Nevertheless, significant intraoperative and postoperative complications were correlated with complex intradural procedures and meningioma and chordoma pathologies.

Surgical outcomes and multidisciplinary management strategy of Cushing's disease: a single-center experience in China

OBJECTIVE

The primary aim of this study was to investigate the value of multidisciplinary team (MDT) management in treating patients with Cushing's disease (CD). The secondary aim was to assess the concordance of bilateral inferior petrosal sinus sampling (BIPSS) lateralization with intraoperative observations.

METHODS

The authors recruited 124 consecutive patients (128 procedures) who had undergone endoscopic endonasal resection of adrenocorticotropic hormone-secreting pituitary adenomas from May 2014 to April 2018 and assessed their clinical characteristics, surgical outcomes, and adjuvant therapies. The criteria for surgical remission were normalized serum and urinary cortisol levels, which could be suppressed by a low-dose dexamethasone suppression test at 3-months' follow-up without adjuvant treatment.

RESULTS

The remission rates of the 113 patients with long-term follow-up (20.3 ± 12.2 months) were 83.2% after surgery alone and 91.2% after adjuvant therapy. The surgical remission rates of macroadenomas, MRI-visible microadenomas, and MRI-negative tumors were 66.7% (12/18), 89.3% (67/75), and 75% (15/20), respectively (p = 0.039). The surgical remission rates had a trend of improvement during the study period (87.5% in 2017-2018 vs 76.5% in 2014, p = 0.517). Multivariate regression analysis showed that a history of previous pituitary surgery (OR 0.300, 95% CI 0.100-0.903; p = 0.032) and MRI-visible microadenoma (OR 3.048, 95% CI 1.030-9.019; p = 0.044) were independent factors influencing surgical remission. The recurrence rate was 3.2% after a mean of 18 months after surgery. The remission rate of postoperative MDT management in patients with persistent disease was higher than non-MDT management (66.7% vs 0%, p = 0.033). In cases with preoperative BIPSS lateralization, 84.6% (44/52) were concordant with intraoperative findings.

CONCLUSIONS

MRI-visible microadenoma and primary surgery were independent predictors of surgical remission in CD. The MDT management strategy helps to achieve a better overall outcome. BIPSS may help to lateralize the tumor in MRI-negative/equivocal microadenomas.

Machine learning-based prediction of outcomes of the endoscopic endonasal approach in Cushing disease: is the future coming?

OBJECTIVE

Machine learning (ML) is an innovative method to analyze large and complex data sets. The aim of this study was to evaluate the use of ML to identify predictors of early postsurgical and long-term outcomes in patients treated for Cushing disease (CD).

METHODS

All consecutive patients in our center who underwent surgery for CD through the endoscopic endonasal approach were retrospectively reviewed. Study endpoints were gross-tumor removal (GTR), postsurgical remission, and long-term control of disease. Several demographic, radiological, and histological factors were assessed as potential predictors. For ML-based modeling, data were randomly divided into 2 sets with an 80% to 20% ratio for bootstrapped training and testing, respectively. Several algorithms were tested and tuned for the area under the curve (AUC).

RESULTS

The study included 151 patients. GTR was achieved in 137 patients (91%), and postsurgical hypersecretion remission was achieved in 133 patients (88%). At last follow-up, 116 patients (77%) were still in remission after surgery and in 21 patients (14%), CD was controlled with complementary treatment (overall, of 131 cases, 87% were under control at follow-up). At internal validation, the endpoints were predicted with AUCs of 0.81-1.00, accuracy of 81%-100%, and Brier scores of 0.035-0.151. Tumor size and invasiveness and histological confirmation of adrenocorticotropic hormone (ACTH)-secreting cells were the main predictors for the 3 endpoints of interest.

CONCLUSIONS

ML algorithms were used to train and internally validate robust models for all the endpoints, giving accurate outcome predictions in CD cases. This analytical method seems promising for potentially improving future patient care and counseling; however, careful clinical interpretation of the results remains necessary before any clinical adoption of ML. Moreover, further studies and increased sample sizes are definitely required before the widespread adoption of ML to the study of CD.

Utility of 7 Tesla MRI for Preoperative Planning of Endoscopic Endonasal Surgery for Pituitary Adenomas

Objective  There is increasing interest in investigating the utility of 7 Tesla (7 T) magnetic resonance imaging (MRI) for imaging of skull base tumors. The present study quantifies visualization of tumor features and adjacent skull base anatomy in a homogenous cohort of pituitary adenoma patients. Methods  Eighteen pituitary adenoma patients were scanned at 7 T in this prospective study. All patients had reference standard-of-care clinical imaging at either 3 T (7/18, 39%) or 1.5 T (11/18, 61%). Visualization of tumor features and conspicuity of arteries and cranial nerves (CNs) was rated by an expert neuroradiologist on 7 T and clinical field strength MRI. Overall image quality and severity of image artifacts were also characterized and compared. Results  Ability to visualize tumor features did not differ between 7 T and lower field MRI. Cranial nerves III, IV, and VI were better detected at 7 T compared with clinical field strength scans. Cranial nerves III, IV, and VI were also better detected at 7 T compared with only 1.5 T, and CN III was better visualized at 7 T compared with 3 T MRI. The ophthalmic arteries and posterior communicating arteries (PCOM) were better detected at 7 T compared with clinical field strength imaging. The 7 T also provided better visualization of the ophthalmic arteries compared with 1.5 T scans. Conclusion  This study demonstrates that 7 T MRI is feasible at the skull base and identifies various CNs and branches of the internal carotid artery that were better visualized at 7 T. The 7 T MRI may offer important preoperative information that can help to guide resection of pituitary adenoma and reduce operative morbidity.

Long Term Outcomes of Nasoseptal Perforation Repair With an Anterior Ethmoidal Artery Flap

BACKGROUND

Nasoseptal perforation repair is a challenging condition with no standard technique for repair recognized.

METHODS

A case series of consecutive patients who underwent nasoseptal perforation repair with an anterior ethmoidal artery flap was conducted. Demographic data, preoperative features of the perforation and postoperative outcomes were analyzed. Closure rate, complications and persistence of nasal symptoms were documented.

RESULTS

Thirty-two patients were included in the study. The average perforation diameter was 1.48 cm (range: 0.4-3 cm). Iatrogenic trauma was the most common cause (56% of patients). Nine cases ended up being idiopathic. The overall closure rate was 81%, but 87.5% when perforation had a 2-cm diameter or less. Of the six failures, 2 were due to flap necrosis and 4 to a residual anterior perforation. Despite the persistence, 2 patients solved their symptoms. One patient underwent revision surgery.

CONCLUSION

The anterior ethmoidal artery flap is a reliable and minimal invasive technique for closure of symptomatic perforations. For defects larger than 2 cm, a lower success rate and additional reconstructive measures should be considered. Objective questionnaires are needed in order to evaluate functional outcomes.

Endoscopic Endonasal Surgery of a Large Vidian Nerve Schwannoma With Preparation for Avoiding Major Vascular Injury

Vidian nerve schwannomas are extremely rare, and their surgical management requires an awareness of the surrounding vascular and nervous systems, including the internal carotid artery. Herein, we report a case of a vidian nerve schwannoma that was successfully removed using an endoscopic endonasal approach in a 21-year-old patient who presented with lacrimal hyposecretion. Imaging revealed a large mass extending to the middle cranial fossa posteriorly, to the pterygopalatine fossa laterally, and to the sphenoid sinus medially. The paraclival and petrosal portions of the internal carotid artery were displaced posteriorly. Endoscopic observation of the right nose demonstrated anterior displacement of the inferior portion of the middle turbinate. Based on the above, we suspected a vidian nerve schwannoma, and endoscopic endonasal surgery was performed with particular attention to avoid vascular injuries. An endoscopic transmaxillary approach was used to expose the anterior surface of the tumor. After confirming the pathological diagnosis intraoperatively, intracapsular resection of the tumor was completed using an ultrasonic surgical aspirator with Doppler monitoring of the location of the internal carotid artery. Endoscopic management of the surgical field and preparation to avoid vascular injury are essential for safe and efficient tumor resection.

Preoperative Endovascular Embolization in an Easily Bleeding Respiratory Epithelial Adenomatoid Hamartoma of the Olfactory Cleft: A Case Report

Respiratory epithelial adenomatoid hamartomas (REAHs) are rare tumors occurring in the nasal cavity and sinuses, and their etiology is unknown. REAH is a relatively recently established lesion and is often misdiagnosed as nasal polyposis or other tumors. Preoperative endovascular embolization for sinonasal tumors is now widely accepted as an effective method to reduce blood loss, soften the tumor, and facilitate surgical procedures. However, to the best of our knowledge, there are no reports of the requirement for preoperative embolization in the management of REAH. Here, we present a 70-year-old man with an easily bleeding REAH of the olfactory cleft, vascularized by branches of the bilateral internal and external carotid arteries. We removed the tumor endoscopically after preoperative embolization of the bilateral sphenopalatine arteries. Histological investigation revealed an intratumoral hemorrhage accompanying the REAH, with no evidence of a residual or recurrent tumor during the last follow-up at 3 months. In conclusion, accurate preoperative diagnosis and proper preoperative interventions such as embolization are needed for safe and adequate treatment of REAHs that have an abundant blood flow.

[Airway support for endoscopic endonasal surgery in gerontology.]

Airway patency during ENT surgery in general anesthesia is a serious problem. It is important to manage the degree of intraoperative bleeding to improve the visibility of the surgical site and reduce the risk of complications. Airway management may affect the severity of intraoperative bleeding. We have shown that the use of a laryngeal mask during endoscopic endonasal rhinosinus surgery during general anesthesia reduces the severity of the hemodynamic response, which is expressed in an increase in heart rate, mean arterial pressure and intraoperative bleeding, and also reduces the risk of surgery.

Early practices in endonasal skull base surgery during the COVID-19 pandemic: a global survey

OBJECTIVE

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, endoscopic endonasal surgery (EES) is feared to be a high-risk procedure for the transmission of coronavirus disease 2019 (COVID-19). Nonetheless, data are lacking regarding the management of EES during the pandemic. The object of this study was to understand current worldwide practices pertaining to EES for skull base/pituitary tumors during the SARS-CoV-2 pandemic and provide a basis for the formulation of guidelines.

METHODS

The authors conducted a web-based survey of skull base surgeons worldwide. Different practices by geographic region and COVID-19 prevalence were analyzed.

RESULTS

One hundred thirty-five unique responses were collected. Regarding the use of personal protective equipment (PPE), North America reported using more powered air-purifying respirators (PAPRs), and Asia and Europe reported using more standard precautions. North America and Europe resorted more to reverse transcriptase-polymerase chain reaction (RT-PCR) for screening asymptomatic patients. High-prevalence countries showed a higher use of PAPRs. The medium-prevalence group reported lower RT-PCR testing for symptomatic cases, and the high-prevalence group used it significantly more in asymptomatic cases.Nineteen respondents reported transmission of COVID-19 to healthcare personnel during EES, with a higher rate of transmission among countries classified as having a medium prevalence of COVID-19. These specific respondents (medium prevalence) also reported a lower use of airborne PPE. In the cases of healthcare transmission, the patient was reportedly asymptomatic 32% of the time.

CONCLUSIONS

This survey gives an overview of EES practices during the SARS-CoV-2 pandemic. Intensified preoperative screening, even in asymptomatic patients, RT-PCR for all symptomatic cases, and an increased use of airborne PPE is associated with decreased reports of COVID-19 transmission during EES.