Simulation of Pediatric Anterior Skull Base Anatomy Using a 3D Printed Model

OBJECTIVE

The pediatric skull base may present anatomic challenges to the skull base surgeon, including limited sphenoid pneumatization and a narrow nasal corridor. The rare nature of pediatric skull base pathology makes it difficult to gain experience with these anatomic challenges. The objective of this study was to create a 3-dimensionally (3D) printed model of the pediatric skull base and assess its potential as a training tool.

METHODS

Twenty-eight participants at various stages of training and practice were included in our study. They completed a pre- and postdissection questionnaire assessing challenges with endoscopic endonasal skeletonization of the carotid arteries and sella face using the 3D printed model.

RESULTS

The majority of participants had completed a skull base surgery fellowship (60.7%), were <5 years into practice (60.7%), and had <10 cases of pediatric skull base experience (82.1%). Anticipated challenges included limitation of maneuverability of instruments (71.4%), narrow nasal corridor and nonpneumatized bone (57.1%). On a scale of 0-10, 10 being very difficult, the average participant expected level of difficulty with visualization was 6.89 and expected level of difficulty with instrumentation was 7.3. On postdissection assessment, there was a nonstatistically significant change to 6.93 and 7.5, respectively. Participants endorsed on a scale of 0-10, 10 being very realistic, an overall model realism of 7.0 and haptic realism of 7.1.

CONCLUSIONS

A 3D printed model of the pediatric skull base may provide a realistic model to help participants gain experience with anatomic limitations characteristic of the pediatric anterior skull base.

The otolaryngologist's and anesthesiologist's collaborative role in a pandemic: A large quaternary pediatric center's experience with COVID-19 preparation and simulation

There has been a rapid global spread of a novel coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which originated in Wuhan China in late 2019. A serious threat of nosocomial spread exists and as such, there is a critical necessity for well-planned and rehearsed processes during the care of the COVID-19 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be intimately familiar with strategies to mitigate the high-risk periods of viral contamination that are posed to the environment and healthcare personnel during tracheal intubation and extubation procedures. Since both the pediatric otolaryngologist and anesthesiologist are directly involved in emergency airway interventions, both specialties impact the safety of caring for COVID-19 patients and are a part of overall hospital pandemic preparedness. We describe our institutional approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital including operating room management and remote airway management. We outline our processes for the safe and effective care of these patients with emphasis on simulation and pathways necessary to protect healthcare workers and other personnel from exposure while still providing safe, effective, and rapid care.

Reconstruction of pediatric skull base defects: A retrospective analysis emphasizing the very young

INTRODUCTION

Pathology of the pediatric skull base is rare and ranges from congenital defects to malignancy and traumatic defects. Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic challenges for the skull base surgeon. The goal of this study was to retrospectively review our experience with reconstruction of pediatric skull base defects with particular emphasis on those ≤6 years of age.

METHODS

A retrospective chart review was conducted of patients ≤20 years of age who underwent endoscopic endonasal and combined endoscopic and open approaches to address cranial base pathology from 2007 to 2018. Patients were divided into two groups; those ≤6 years of age (group A) and those >6 years of age and ≤20 years of age (group B) and reconstructive techniques and outcomes were analyzed.

RESULTS

Intraoperative communication with the subarachnoid space (CSF leak) was created in 50% (3/6) of patients ≤ 6 years of age compared to 32.7% (16/49) in patients > 6 years and ≤20 years of age (P < 0.40) in management of their skull base disease. A vascularized flap was utilized for reconstruction in 66.7% (4/6) of patients ≤ 6 years of age and included a nasoseptal flap in 33.3% (2/6). A vascularized flap was utilized for reconstruction in 38.8% (19/49) of patients > 6 years and ≤20 years of age and most commonly included a nasoseptal flap (22.4%, 11/49). A lumbar drain was utilized in 50% (3/6) of patients ≤ 6 years of age compared to 18.4% (9/49) in patients > 6 and ≤20 years of age (P < 0.08). Post-operative CSF leaks were encountered in 16.7% (1/6) of patients ≤ 6 years of age compared to 10.2% (5/49) in patients > 6 and ≤20 years of age (P < 0.63). Behavioral issues were noted to potentially contribute to failed skull base reconstruction in patients <6 years of age.

CONCLUSIONS

Pediatric patients, particularly those ≤6 years of age, present a unique set of anatomic and behavioral challenges for the skull base surgeon as highlighted in this study.

Management Patterns in Pediatric Complicated Sinusitis

OBJECTIVES

Sinusitis is a common pediatric illness that can be complicated by periorbital or intracranial extension. Patients can be managed with antimicrobials alone or in conjunction with surgical intervention. This article examines management patterns and outcomes in pediatric patients presenting with complicated sinusitis.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

An evaluation of 168 pediatric patients with complicated sinusitis with periorbital complications presenting at a single institution from 2008 to 2018 was performed. Demographics, disease characteristics, in-hospital management, and outcomes were recorded and analyzed.

RESULTS

The most common complication was orbital cellulitis, seen in 49% of children. Surgical intervention occurred in 49% of patients, with 36% receiving medical therapy followed by surgery (MTS). Chandler I patients underwent surgical intervention 30% of the time, Chandler II patients 29%, and Chandler III patients 83%. Nineteen percent of initially nonoperative patients started on ampicillin-sulbactam required MTS vs 57% of those started on other antibiotic regimens (P = .01). Twelve percent of initially nonoperative Chandler I to II patients started on ampicillin-sulbactam needed MTS vs 40% started on other antibiotic regimens. Hospital charges for operative patients were $45,056 vs $14,311 for nonoperative patients (P < .01). Hospital charges for patients with surgery followed by medical therapy (SMT) were $45,563 vs $44,393 for MTS (P = .92).

CONCLUSION

Nonoperative early stage patients started on ampicillin-sulbactam had a lower risk of MTS. MTS did not cost significantly more than SMT, and there were no significant outcome differences seen.

The expanded endonasal approach in pediatric skull base surgery: A review

OBJECTIVE

Surgery of the pediatric skull base has multiple unique challenges and has seen recent rapid advances. The objective of this review is to assess key issues in pediatric skull base surgery (SBS), including anatomic limitations, surgical approaches, reconstruction techniques, postoperative care, complications, and outcomes.

DATA SOURCES

PubMed literature review.

REVIEW METHODS

A review of the literature was conducted to assess the challenges, recent advances, and reported outcomes in pediatric SBS.

RESULTS

The pediatric skull base presents multiple anatomic challenges, including variable patterns of pneumatization, narrow piriform aperture width, and narrow intercarotid distance at the level of the cavernous sinus but not the superior clivus. These issues may be particularly challenging in patients less than 2 years of age. Endoscopic endonasal approaches in the sagittal and coronal plane have been applied to the pediatric skull base while open approaches may still be necessary in the setting of extensive intracranial or orbital disease, as well as disease lateral to critical neurovascular structures. While the nasoseptal flap was initially called into question for pediatric cases, it has been shown through multiple reports to be a feasible and robust reconstructive option. Complications and outcomes often depend upon the pathology. In children, response to noxious stimuli, ability to avoid Valsalva, and adherence to nasal precautions is variable. The use of lumbar drains is more common in pediatric than adult patients.

CONCLUSION

While the pediatric skull base presents unique challenges, outcomes data support that endoscopic endonasal approaches are a pertinent surgical technique in appropriately selected patients.

LEVEL OF EVIDENCE

3a.

Pediatric craniopharyngioma

BACKGROUND

Craniopharyngioma has historically been recognized to be a formidable pathology primarily due to its proximity to critical neurovascular structures and the challenging surgical corridors that surgeons have tried to reach this lesion.

FOCUS OF REVIEW

In this work, we review the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to craniopharyngiomas. The management of craniopharyngiomas requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver the most comprehensive and safest surgical resection with minimal postoperative morbidity.

Pediatric pituitary adenomas

BACKGROUND

Pediatric pituitary adenomas are a rare medical entity that makes up a small portion of intracranial tumors in children and adolescents. Although benign, the majority of these lesions are secreting functional tumors with the potential for physiological sequela that can profoundly affect a child's development.

FOCUS OF REVIEW

In this review, we discuss the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to treat these tumors. The management of pituitary tumors requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver comprehensive care.

Effect of Drug Disposal Bag Provision on Proper Disposal of Unused Opioids by Families of Pediatric Surgical Patients: A Randomized Clinical Trial

IMPORTANCE

Although opioids are an important component of pain management for children recovering from surgery, postoperative opioid prescribing has contributed to the current opioid crisis in the United States because these medications are often prescribed in excess and are rarely properly disposed. One potential strategy to combat opioid misuse is to remove excess postoperative opioids from circulation by providing patients with drug disposal products that enable safe disposal of opioids in the home garbage.

OBJECTIVE

To determine whether the provision of a drug disposal bag increases proper opioid disposal among the families of pediatric patients undergoing ambulatory surgery.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled 202 parents or guardians of children 1 to 17 years of age who underwent otolaryngologic or urologic surgery at the outpatient surgery centers of a tertiary children's hospital in Columbus, Ohio, from June to December 2018 and who received an opioid prescription prior to discharge.

INTERVENTIONS

Families randomized to intervention were provided a drug disposal bag containing activated charcoal and instructions for use plus standard postoperative discharge instructions on opioid use, storage, and disposal. Families in standard care arm received standard postoperative discharge instructions only. All participants completed a baseline survey and a follow-up survey 2 to 4 weeks postoperatively.

MAIN OUTCOMES AND MEASURES

Primary outcome was proper opioid disposal, defined as disposal using a drug disposal bag or a disposal method recommended by the US Food and Drug Administration.

RESULTS

Of 202 parents or guardians enrolled, 181 completed follow-up (92 in intervention arm and 89 in standard care arm). Most patients in both groups were white (75 [73.5%] vs 79 [80.6%]) and male (63 [61.2%] vs 54 [54.6%]), and the median (interquartile range) age was 6 (5-9) years in the intervention arm and 7 (6-10) years in the standard care arm. For intention-to-treat analyses, 92 families receiving a disposal bag and 89 families not receiving a disposal bag were included. Among them, 66 families (71.7%) randomized to receive a disposal bag reported properly disposing of their child's opioids, whereas 50 parents (56.2%) who did not receive a disposal bag reported proper opioid disposal (difference in proportions, 15.5%; 95% CI, 1.7%-29.3%; P = .03). Among only those families who filled an opioid prescription and had leftover opioids after resolution of their child's pain, 66 of 77 parents or guardians (85.7%) who had received a disposal bag and 50 of 77 parents or guardians (64.9%) who had received standard care reported properly disposing of their child's opioids (difference in proportions, 20.8%; 95% CI, 7.6%-34.0%).

CONCLUSIONS AND RELEVANCE

Results of this study indicated that providing drug disposal bags to families of children receiving postoperative opioids increased the likelihood of excess opioid disposal. Greater availability of disposal products may complement ongoing prescribing reduction efforts aimed at decreasing opioid misuse.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03575377.

Multifocality in Sporadic Medullary Thyroid Carcinoma: An International Multicenter Study

BACKGROUND

Current surgical standard of care in sporadic medullary thyroid carcinoma (sMTC) consists of a minimum of total thyroidectomy with central neck dissection. Some have suggested thyroid lobectomy with isthmusectomy and central neck dissection for patients with sMTC, given their lower frequency of bilateral disease, although this topic has not been thoroughly studied. This study assessed the prevalence of multifocality in sMTC via a large international multi-institutional retrospective review to quantify this prevalence, including the impact of geography, to assess more accurately the risks associated with alternative surgical approaches.

METHODS

A retrospective chart review of sMTC patients from 11 institutions over 29 years (1983-2011) was undertaken. Data regarding focality, extent of disease, RET germline analysis plus family and clinical history for multiple endocrine neoplasia type 2 (MEN2), and demographic data were collected and analyzed.

RESULTS

Patients from four continents and seven countries were included in the sample. Data for 313 patients with documented sMTC were collected. Of these, 81.2% were confirmed with negative RET germline testing, while the remaining 18.8% demonstrated a negative family history and no manifestations of MEN2 syndromes other than MTC. Bilateral disease was identified in 17/306 (5.6%) patients, while multifocal disease was noted in 50/312 (16.0%) sMTC patients. When only accounting for germline negative patients, these rates were not significantly different (5.6% and 17%, respectively). Among them, when disease was unifocal in the ipsilateral lobe and isthmus, bilateral disease was present in 6/212 (2.8%) cases. When disease was multifocal in the ipsilateral lobe or isthmus, then bilateral disease was present in 8/37 (21.6%) cases (p < 0.001). No geographic differences in focality were identified.

CONCLUSIONS

The 5.6% prevalence of bilateral foci in sMTC suggests that total thyroidectomy should remain the standard of care for initial surgery, as less complete thyroid surgery may fail to address fully the primary site of disease. Whether ipsilateral tumor focality should be an independent factor determining the need for completion thyroidectomy when sMTC is diagnosed after hemithyroidectomy remains to be determined.

Pediatric skull base reconstruction: case report of a tunneled temporoparietal fascia flap

The authors of this report present a pediatric case involving the use of a tunneled temporoparietal fascia flap to reconstruct a skull base defect for a multiply recurrent clival chordoma and cerebrospinal fluid leak, demonstrate the surgical technique through illustrations and intraoperative photos, and review the pertinent literature. A 9-year-old female patient underwent extensive clival chordoma resection via both the endoscopic and open approaches, which ultimately exhausted the bilateral nasoseptal flaps and other intranasal reconstructive options. Following proton beam radiation and initiation of chemotherapy, tumor recurrence was managed with further endoscopic resection, which was complicated by a recalcitrant cerebrospinal fluid leak. A tunneled temporoparietal fascia flap was used to provide vascular tissue to augment an endoscopic repair of the leak and reconstruction of the skull base. While the nasoseptal flap remains the workhorse for many pediatric and adult endoscopic skull base reconstructions, the tunneled temporoparietal fascia flap has a demonstrated efficacy in adults when the nasoseptal flap and other intranasal flaps are unavailable. This report documents a pediatric case, serving as a step toward establishing this technique in the pediatric population.

Prenatal diagnosis of obstructive head and neck masses and perinatal airway management: the ex utero intrapartum treatment procedure

Advances in prenatal imaging in the last 20 years have enabled prenatal diagnosis of obstructive head and neck masses. These advances, coupled with improvements in maternal-fetal anesthesia, have made possible the development of the ex utero intrapartum treatment (EXIT) procedure for management of obstructive head and neck masses, during which the airway is managed in a controlled fashion while maintaining fetal circulation for oxygenation. This review addresses the preoperative and perioperative assessment and management of patients with prenatally diagnosed airway obstruction, indications and contraindications for the EXIT procedure, technical details of the procedure, and outcomes.

Voice related quality of life in pediatric patients with a history of prematurity

OBJECTIVE

To determine incidence of dysphonia in patients with history of prematurity and evaluate the correlation between dysphonia and risk factors unique to premature infants. The aim of this study is to determine parent-perceived vocal quality in patients with history of prematurity and whether duration of intubation, number of intubations, and incidence of patent ductus arteriosus repair were correlated with these perceptions.

METHODS

Cohort study of premature patients presenting to outpatient clinics from January 2010 to January 2013 in tertiary care center. Patients gestational age ≤37 weeks at birth without history of tracheostomy or known vocal fold pathology were eligible. A volunteer sample was obtained from patients presenting in Otolaryngology clinics from January 2010 to January 2013 whose parents agreed to complete surveys. Outcomes were assessed via parental completion of pediatric voice outcomes score (pVOS) and pediatric voice-related quality of life (pVRQOL) instruments. The primary outcome assessed was the incidence of dysphonia in infants with a history of prematurity without known vocal pathology. Additionally, patient factors associated with dysphonia were evaluated. The hypothesis tested was formulated prior to data collection.

RESULTS

Sixty-nine participants were included. Mean age at follow-up was 28 (3-197) months. Mean gestational age was 29 (23-37) weeks. Mean intubation duration was 3 (0-22) weeks and median number of intubations was 1 (range 0-5). Voice outcome scores varied widely with pVRQOL scores demonstrating a mean of 89.2±18.1 (25-100) and pVOS with a mean of 11.4±2.2 (0-13). Univariate analysis utilized Spearman correlation coefficients for continuous variables and Wilcoxon Two-sample test for categorical groups. Significance was set at p<0.05. All significant univariate associations were placed in a multivariate model. Duration of intubation ≥4 weeks was the only factor which correlated with dysphonia on multivariate analysis (p=0.0028, OR=6.4, 95% CI=1.9-21.6).

CONCLUSIONS

The data suggest that prolonged intubation is associated with poorer long term parent-perceived voice quality in premature patients. Further study is required to correlate parent perceptions with objective vocal quality data and physical findings of vocal pathology. These data may increase the clinician's suspicion for and evaluation of dysphonia in this population.

Comparison of Long-term Quality-of-Life Outcomes in Vestibular Schwannoma Patients

Objective

To compare long-term quality-of-life outcomes in vestibular schwannoma patients managed with observation, microsurgery, or stereotactic radiation.

Study Design

ross-sectional survey with retrospective chart review.

Setting

Tertiary care center.

Subjects and Methods

The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was mailed to 600 patients treated for vestibular schwannoma. Patients were separated by treatment and subsequently subdivided by years of follow-up (0-5, 6-10, and >10 years). Composite quality-of-life (cQOL) scores and subscores for hearing, balance, facial nerve, pain, anxiety, energy, and general health were calculated. Scores were compared among treatment groups as a whole, among treatment groups at each time interval, and within treatment groups over time using a 2-tailed analysis of variance and paired t test.

Results

The survey return rate was 49%, and the mean follow-up was 7.9 years. The only significant difference in cQOL occurred at 0 to 5 years, where stereotactic radiation scores were better than both microsurgery and observation ( P = .009). No significant differences were detected in cQOL after 5 years. Within the radiation group, cQOL was significantly lower at 6 to 10 years than at 0 to 5 years ( P = .013). At no point was cQOL for stereotactic radiation less than that for observation or microsurgery.

Conclusions

Long-term (>5 years) quality-of-life outcomes measured by the PANQOL in vestibular schwannoma patients show no significant differences between stereotactic radiation, observation, and microsurgical intervention. Studies are needed to fully evaluate very-long-term QOL for patients with vestibular schwannoma.

Fine needle aspiration and medullary thyroid carcinoma: the risk of inadequate preoperative evaluation and initial surgery when relying upon FNAB cytology alone

OBJECTIVES

To evaluate the diagnostic accuracy of fine-needle aspiration biopsy (FNAB) to preoperatively diagnose medullary thyroid cancer (MTC) among multiple international centers and evaluate how the cytological diagnosis alone could impact patient management.

METHODS

We performed a retrospective chart review of sporadic MTC (sMTC) patients from 12 institutions over the last 29 years. FNAB cytology results were compared to final pathologic diagnoses to calculate FNAB sensitivity. To evaluate the impact of cytology sensitivity for MTC according to current practice and to avoid confounding results by local treatment protocols, changes in treatment patterns over time, and the influence of ancillary findings (e.g., serum calcitonin), therapeutic interventions based on FNAB cytology alone were projected into 1 of 4 treatment categories: total thyroidectomy (TT) and central neck dissection (CND), TT without CND, diagnostic hemithyroidectomy, or observation.

RESULTS

A total of 313 patients from 4 continents and 7 countries were included, 245 of whom underwent FNAB. FNAB cytology revealed MTC in 43.7% and possible MTC in an additional 2.4%. A total of 113 (46.1%) patients with surgical pathology revealing sMTC had FNAB findings that supported TT with CND, while 37 (15.1%) supported TT alone. In the remaining cases, diagnostic hemithyroidectomy and observation were projected in 32.7% and 6.1%, respectively.

CONCLUSION

FNAB is an important diagnostic tool in the evaluation of thyroid nodules, but the low sensitivity of cytological evaluation alone in sMTC limits its ability to command an optimal preoperative evaluation and initial surgery in over half of affected patients.

Pediatric polysomnography for sleep-disordered breathing prior to tonsillectomy: a guideline review

Snoring and other signs of sleep-disordered breathing (SDB) represent a common management challenge for the pediatrician, pulmonologist, anesthesiologist, and otolaryngologist. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery published a clinical practice guideline for the treatment of patients with SDB. This guideline provides indications for polysomnography use in patients with SDB. In this article, we discuss the management of SDB in pediatric patients, which relies on the accurate assessment of symptoms of SDB, identification of comorbidities known to increase the severity of SDB, and appropriate preoperative assessment of the patient.

Longitudinal Comparison of Quality-of-Life Outcomes in Vestibular Schwannoma Patients

Objectives:

1) Compare long-term quality of life (QOL) outcomes in vestibular schwannoma (VS) patients managed conservatively, with microsurgery, or with stereotactic radiation; 2) Evaluate factors contributing to their QOL.

Methods:

The Penn Acoustic Neuroma Quality of Life (PANQOL) survey was administered to 645 patients treated for VS at a tertiary care center over 24 years. Patients in each treatment group were sub-divided by years since diagnosis (0-5, 6-10, and >10). Composite QOL (cQOL) scores and sub-scores in hearing, balance, facial symptoms, pain, anxiety, and energy were compared by ANOVA at each time interval. Regression analysis correlated QOL with tumor size, speech recognition threshold, and reported symptoms.

Results:

Survey return rate was 49%. Mean follow-up was 7.6 years. The only significant difference in cQOL was at 1-5 years, where stereotactic radiation was best and conservative treatment was worst ( P = .009). No significant differences in cQOL were detected at 6-10 or >10 years. Significant differences between sub-scores were found in hearing, balance, and facial symptoms. Overall tumor size was inversely proportional to QOL (R = .54; P < .001); this correlation decreased with time (1-5 R = .61, P < .001 / 6-10 R = .40, P < .001 / >10 R = .16, P = .02).

Conclusions:

1) We found no significant difference in long-term QOL outcomes between treatment groups; however, patients treated by stereotactic radiation may experience better overall QOL up to 5 years post-treatment. 2) Tumor size at presentation is a good prognostic tool in VS patients but may be limited in predicting long-term QOL outcomes.

The internet, adolescent males, and homemade blowgun darts: a recipe for foreign body aspiration

We describe our experience with blowgun dart aspiration via an illustrative case series and review the resources available to teach children how to construct these objects. A 15-year-old boy presented with cough, wheeze, and eventually admitted to aspiration of a homemade blowgun dart. This instance heightened the awareness of our experience with blowgun dart aspiration as 3 cases presented within a 3-month period. Patients uniformly presented with cough and reported aspiration, and wheezing was noted in 2 of the 3. Although all ultimately admitted their behavior, 2 were initially reluctant to admit aspirating the blowgun dart. Radiographic findings of a needle-shaped metallic airway foreign body were consistent in all patients. Each admitted to finding instructions for blowgun dart construction on the Internet. Emergent rigid bronchoscopy with blowgun dart removal resulted in symptom resolution in all without complication. This represents the largest series of blowgun dart aspiration to date. During deep inhalation, when preparing to propel a blowgun dart, the vocal folds maximally abduct, leading to increased risk for aspiration. Twenty websites were identified providing instructions for the construction of homemade blowgun darts. With the accessibility of the Internet and number of instructional websites, this clinical entity may become more common in the future. Unfortunately, only a few of the websites provide any safety warnings. Certainly, prompt treatment can result in good outcomes; however, serious potential complications, including death, could occur especially given the hesitance our patients showed in divulging the truth of the inciting event.

Three-Dimensional Segmented Volumetric Analysis of Sporadic Vestibular Schwannomas

Objective

To compare 3-D segmented volumetric analysis of vestibular schwannomas (VS) with traditional linear tumor measurement on serial magnetic resonance imaging (MRI) studies to assess volume and growth rates.

Study Design

Case series with retrospective chart review.

Setting

Tertiary care medical center.

Methods

This analysis identified 24 VS patients clinically followed with serial gadolinium enhanced images. Maximum linear dimensions (MLD) were obtained from gadolinium-contrasted T1 sequences from 3 serial MRI scans per RECIST guidelines. MLD was cubed (MLD3) and orthogonal analysis (OA) was carried out to provide volumetric estimates for comparison with segmented data. Segmented volumetric analysis (SVA) was performed with semi-automated 3-D conformal procedure. Tumor volume, percentage change in volume, and interval percentage change were compared using paired 2-tailed t tests.

Results

The average interval between MRIs was 2.6 years. Volume estimates differed significantly between SVA and OA and MLD3 at all intervals. Linear growth measurements averaged 0.5 mm/y (5.4%). Volumetric growth was 50 mm3/y (22.8%) with SVA, 110 mm3/y (19.6%) with OA, and 210 mm3/y (14.4%) with MLD3 estimates. Differences between MLD and both MLD3 and SVA were significant, but significance between MLD3 and SVA was only identified in interval analysis. Progression was identified in 75% more patients with SVA than OA, MLD3, or MLD.

Conclusions

VS assume complex configurations. Linear measurements inaccurately estimate tumor volume and growth compared with segmented analysis. SVA is a useful clinical tool that accurately assesses tumor volume. Use of outcomes such as tumor volume and percentage of volume change may be more sensitive in assessing tumor progression compared with linear measurements.

Ectopic mediastinal goiter successfully managed via cervical approach: case report and review of the literature

BACKGROUND

Ectopic mediastinal goiter is a rare entity that presents diagnostic and treatment challenges to the clinician.

METHODS

A case of primary ectopic mediastinal goiter is presented and use of a cervical approach for excision is described herein. Additionally, precedent literature highlighting surgical treatment approaches is reviewed.

RESULTS

The distinction between primary and secondary ectopic mediastinal goiter is significant as this indicates the vascular supply to the ectopic mass. Previous authors suggested open thoracic procedures for all primary mediastinal goiters to safely divide intrathoracic vascular supply, but favorably positioned anterior mediastinal goiter may be safely removed via cervical approach. This is the second case of primary ectopic mediastinal goiter successfully resected via cervical approach.

CONCLUSION

Select cases of primary mediastinal goiter may be amenable to excision via cervical approach, avoiding potential complications of open thoracic procedures. Additionally, CT-guided biopsy is an effective tool in preoperative diagnosis of anterior mediastinal masses.