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ABSTRACT: OBJECTIVE: The introduction of the vascularized nasoseptal flap (NSF) has reduced the incidence of postoperative cerebrospinal fluid (CSF) leak following anterior skull base (ASB) surgery. The aim of this study was to describe the effect on CSF leak and complications associated with the addition of the NSF to an existing reconstruction protocol. METHODS: We reviewed a prospective database of all patients undergoing endoscopic ASB approaches. Patients were divided into 3 groups based on the date we adopted the use of the NSF. Group A included high-volume CSF leak closed using a NSF in addition to a multilayer closure. Group B included patients operated on during the same time period with no high-volume leak and no NSF. Group C included patients operated on before the adoption of the NSF with all types of CSF leak. Rates of intraoperative and post-operative CSF leak were analyzed for statistical significance. RESULTS: Of 415 consecutive patients undergoing endoscopic ASB surgery, there were 96 in Group A, 114 in Group B and 205 in Group C. CSF leak rates in Group A (3.1%) and Group B (2.6%) were significantly lower than in Group C (5.9%; p<0.05). Lumbar drains and the "gasket seal" closure were performed more frequently in Group A (75% and 32%) compared with Group B (21% and 12%) and Group C (28% and 11%). NSF carried a 2% risk of postoperative mucocele. CONCLUSION: The addition of NSF to an algorithm for multilayer closure can decrease the rate of post-operative CSF leak rate.
World Neurosurgery 09/2012; · 0.68 Impact Factor
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ABSTRACT: Endoscopic endonasal skull base surgery is a growing field in which the nasal corridors are used to address skull base lesions. Whether the middle turbinates must be removed for adequate exposure is controversial and not well addressed in the literature. This is a prospective, observational study of 163 consecutive cases of purely endoscopic endonasal transsphenoidal surgeries performed at a single tertiary care institution. The primary study outcome measurement is the feasibility of middle turbinate preservation in endoscopic transsphenoidal skull base surgery. The pathologies included 99 pituitary tumors, 15 craniopharyngiomas, 11 meningiomas, 11 Rathke's cleft cysts, 7 encephaloceles, 5 cerebrospinal fluid leak repairs, 9 clival chordomas, and 6 other pathologies of the sella. In patients undergoing surgery for a neoplasm, the average tumor size was 2.3 cm. The middle turbinate was preserved in 160/163 cases (98%). One hundred and twenty magnetic resonance imaging (MRI) studies were reviewed at a median of 16 months postoperatively and no patients (0%) developed frontal sinusitis. The middle turbinate can be preserved in nearly every endonasal, endoscopic transsphenoidal skull base case while still providing good exposure for successful tumor resection and skull base reconstruction. Postoperative sinonasal function may be better preserved with this technique.
Skull Base 09/2010; 20(5):343-7. · 0.66 Impact Factor
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ABSTRACT: The endoscopic endonasal transclival approach is a novel minimal-access method of managing clival pathology. Limited cases have been published.
To summarize our clinical experience with this approach and discuss technical nuances.
We retrospectively reviewed a prospective database of 250 endoscopic, endonasal skull base surgeries. Patients in whom a transclival approach was performed were identified. Extent of resection, complications, and clinical outcome were analyzed.
Seventeen patients underwent 21 procedures. Pathology included chordoma, meningioma, hemangiopericytoma, enterogenous cyst, epidermoid, and metastasis. Lumbar drain was placed intraoperatively in 9 cases and maintained for approximately 2 days postoperatively. Mean operative time was 252.8 minutes. Intraoperative cerebrospinal fluid (CSF) leak occurred in 10 cases. Greater than 95% resection was achieved in 11 of 12 cases (92%) in which it was the surgical goal. The risk of postoperative CSF leak was 4.8% for all procedures, 9.1% for procedures with large skull base defect, and 0% if a gasket-seal closure was achieved. A nasoseptal flap was used in 2 patients. There was one perioperative infarct, one case of deep vein thrombosis, and one postoperative pulmonary embolus. Mean follow-up was 8.5 months. All but one patient with preoperative cranial nerve deficits improved at last follow-up. All patients were free of disease progression at last follow-up.
The endonasal endoscopic transclival approach provides a minimal-access approach to the ventral midline posterior fossa skull base. The risk of CSF leak is low if appropriate closure techniques are applied.
Neurosurgery 09/2010; 67(3 Suppl Operative):ons150-8; discussion ons158. · 2.79 Impact Factor
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ABSTRACT: Large dural defects after extended endoscopic endonasal skull base resections require meticulous reconstruction to prevent a cerebrospinal fluid leak postoperatively. The nasoseptal flap is a vascularized tissue graft developed to aid in the multilayer reconstruction of the skull base. The purpose of this study is to describe the first experiences with bilateral nasoseptal flaps for reconstruction of very large skull base defects.
Prospective, observational study.
Large tertiary referral center (New York Presbyterian Hospital).
Five patients underwent a multilayer reconstruction after an extended endoscopic transsphenoidal skull base surgery that included bilateral nasoseptal flaps. Pathologies consisted of two pituitary macroadenomas, one planum sphenoidale meningioma, one craniopharyngioma, and one cavernous sinus hemangioma.
All five patients underwent successful skull base reconstruction without a cerebrospinal fluid leak, complication at the reconstruction site, or anterior extension of the posterior septal perforation.
Bilateral nasoseptal flaps are a viable option for large dural defects of the anterior and ventral skull base when one nasoseptal flap may not completely seal the entire defect.
Otolaryngology Head and Neck Surgery 03/2010; 142(3):327-31. · 1.72 Impact Factor
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ABSTRACT: The endoscopic endonasal approach has become the preferred technique for CSF leak and encephalocele repair of the anterior skull base. The purpose of this study is to identify patient characteristics; review adjunctive perioperative treatments, reconstruction techniques, and outcomes; and identify risk factors for failure in patients undergoing endoscopic endonasal repair of anterior skull base CSF leaks and encephaloceles.
This is a prospective observational study of patients undergoing endoscopic endonasal repair of a CSF leak between October 2004 and May 2009. Twenty-eight consecutive patients underwent 32 procedures. Twenty-two of the patients were women, which represents a statistically significant trend toward the female sex (p < 0.05). The average body mass index (33.9) was significant for obesity. The origin of the skull base defect included the cribriform plate (in 9 cases), fovea ethmoidalis (in 7), combined fovea ethmoidalis/cribriform plate (in 2), lateral sphenoid sinus (in 6), sella (in 4), clivus (in 3), and frontal sinus (in 1).
The overall endonasal closure rate was 93.8% (30 of 32 procedures). One failure occurred due to overaggressive postoperative debridement, while the other recurred along the posterior wall of the frontal sinus, and endoscopic repair would have occluded the recess.
The endoscopic endonasal approach for the treatment of CSF leaks and encephaloceles of the anterior skull base is the preferred method of repair in the vast majority of cases. The authors' 93.8% closure rate in a variety of anatomical locations compares favorably with the transcranial approach and echoes the results of other endoscopic series.
Journal of Neurosurgery 11/2009; 113(5):961-6. · 2.96 Impact Factor
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ABSTRACT: Transcranial approaches to clival chordomas provide a circuitous route to the site of origin of the tumor often involving extensive bone drilling and brain retraction, which places critical neurovascular structures between the surgeon and pathology. For certain chordomas, the endonasal endoscopic transclival approach is a novel minimal access, but it is an equally aggressive alternative providing the most direct route to the tumor epicenter.
The authors present a consecutive series of patients undergoing endonasal endoscopic resection of clival chordomas. Extent of resection was determined by postoperative volumetric MR imaging and divided into > 95% and < 95%.
Seven patients underwent 10 operations. Preoperative cranial neuropathies were present in 4. The mean patient age was 52.0 years. The mean tumor volume was 34.9 cm3. Intraoperative lumbar drainage was used in 1 patient, and the tumors extended intradurally in 3. One patient underwent 2 intentionally palliative procedures for subtotal debulking. Greater than 95% resection was achieved in 7 of 8 operations in which radical resection was the goal (87%). All tumors with volumes < 50 cm3 had > 95% resection (p = 0.05). The overall mean follow-up was 18.0 months. Cranial neuropathies resolved in all 3 patients with cranial nerve VI palsies. One patient with recurrent nasopharyngeal chordoma died of disease progression; another experienced 2 recurrences before receiving radiation therapy. All surviving patients remain progression free. There were no intraoperative complications; however, 1 patient developed a pulmonary embolus postoperatively. There were no postoperative CSF leaks.
The endonasal endoscopic transclival approach represents a less invasive and more direct approach than a transcranial approach to treat certain moderate-sized midline skull base chordomas. Longer follow-up is necessary to determine comparability to transcranial approaches for long-term control. Large tumors with significant extension lateral to the carotid artery may not be suitable for this approach.
Journal of Neurosurgery 08/2009; 112(5):1061-9. · 2.96 Impact Factor
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ABSTRACT: To examine the role of core needle biopsy in the diagnosis of head and neck masses.
Prospective observational study.
The otolaryngology-head and neck surgery department outpatient clinic of a large managed care organization.
The study population comprised 40 consecutive patients referred for core needle biopsy of a cervicofacial lesion for which previous fine-needle aspiration biopsy had not provided the diagnosis.
Manually guided Delta Cut (Boston Scientific, Natick, Massachusetts) core needle biopsy was performed on neck masses larger than 1.5 cm.
Diagnosis was indicated by core needle biopsy results without excisional biopsy.
A core needle biopsy specimen sufficient for diagnosis and treatment was obtained from 36 of the 40 patients (90%). In 22 patients, subsequent excisional biopsy or curative surgery was performed after core needle biopsy, and pathologic examination confirmed the diagnosis for 19 of these 22 patients (86%). For 12 of the remaining 14 patients (86%), core needle biopsy was successfully used to diagnose lymphoma. No complications resulted from the core needle biopsy.
For lesions that require immunohistochemical staining or that remain undiagnosed after fine-needle aspiration, use of core needle biopsy should be considered before excisional biopsy. Core needle biopsy is a safe, effective, time-efficient, inexpensive procedure that can be an important tool for diagnosing head and neck masses, especially when lymphoma is suspected.
Archives of Otolaryngology - Head and Neck Surgery 03/2008; 134(2):184-9. · 1.63 Impact Factor
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Gurston G Nyquist,
Christina Mumm,
Renee Grau,
A Neil Crowson,
Daniel L Shurman,
Paul Benedetto,
Pamela Allen,
Kelli Lovelace,
David W Smith,
Ilona Frieden,
C Patrick Hybarger,
Gabriele Richard
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ABSTRACT: We report on two young adults with KID syndrome and follicular hyperkeratosis, hidradenitis suppurativa of the groin, progressive development of proliferative pilar cysts and dissecting cellulitis of the scalp, who developed metastatic malignant pilar tumors. Based on our findings, we believe that cancer surveillance in patients with KID syndrome should include screening for pilar tumors and their early removal to avoid development of malignant proliferating pilar tumors with poor prognosis.
American Journal of Medical Genetics Part A 05/2007; 143(7):734-41. · 2.39 Impact Factor
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ABSTRACT: Free jejunal interposition has been one of the standard reconstructive options for patients undergoing total laryngopharyngoesophagectomy. Tracheoesophageal puncture (TEP) done primarily is a well-accepted means of voice restoration. The rapid recovery of swallowing and communication in patients who have advanced cancer of the upper aerodigestive tract is a valid goal. The objective of this study was to evaluate the functionality and complications of primary TEP in patients with a free jejunal interposition graft.
Twenty-four consecutive patients who had free jejunal interposition were studied. Thirteen of these patients had a primary TEP. Stricture was assessed through barium swallow, laryngoscopy, and CT scan.
A statistically significant greater number of patients had stricture develop after primary TEP (p < .0325). All these patients had stricture develop at the distal anastomosis. These patients also tended to have a poorer quality of diet. Moreover, speech with a TEP prosthesis in patients with a free jejunal interposition was less intelligible and functional than speech with a TEP prosthesis after simple laryngectomy.
This article recognizes an increased incidence of stricture formation after primary TEP as compared with non-TEP in patients undergoing pharyngolaryngectomy with free jejunal interposition. The morbidity and possible etiology of this complication are discussed. This clinical data have been translated into a change in clinical practice.
Head & Neck 03/2006; 28(3):205-9. · 2.40 Impact Factor
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Alexander Lin,
Siavash Jabbari,
Francis P Worden,
Carol R Bradford,
Douglas B Chepeha,
Theodoros N Teknos,
Jay J Liao, Gurston G Nyquist,
Christina Tsien,
Matthew J Schipper,
Susan Urba,
Gregory T Wolf,
Avraham Eisbruch
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ABSTRACT: Weight loss caused by acute mucositis and dysphagia is common during concurrent chemoirradiation (chemo-RT) of head-and-neck (HN) cancer. The metabolic consequences of weight loss during chemo-RT were investigated.
Ninety-six patients with locally advanced HN cancer were treated from 1995 to 2001 on protocols that consisted of 1 to 2 cycles of induction cisplatin/5-fluorouracil followed by irradiation (70 Gy over 7 weeks) concurrent with cisplatin (100 mg/m2 every 3 weeks). Body weights and metabolic evaluations were obtained before and during induction chemotherapy and chemo-RT. Greatest percent changes in weight and in the laboratory values were calculated for each phase of therapy.
During induction chemotherapy, significant changes were found in BUN, BUN:creatinine ratio, HCO3, Mg, and albumin, but not in creatinine, Na, K, or weight. During chemo-RT, significant additional changes were observed in all parameters measured, including increases in BUN, creatinine, BUN: creatinine ratio, and HCO3 and decreases in Mg, albumin, Na, K, and weight. The magnitude of most of these changes was significantly greater during chemo-RT than during induction chemotherapy. During chemo-RT, 35% of the patients had more than 10% body weight loss and 6 patients had an increase in creatinine of more than 100%, including 5 patients with Grade 2 nephrotoxicity, all of whom had weight loss 10% or more. Significant correlations were found between weight loss and creatinine (p < 0.0001) or BUN (p = 0.0002) rises, but not with BUN:creatinine ratio or other metabolic changes. Age, gender, tobacco history, hypertension, and diabetes mellitus were not significant predictors of nephrotoxicity.
Weight loss during cisplatin-containing chemo-RT was found to be associated with reduced kidney function. These findings do not establish cause-effect relationships; however, they highlight the importance of intensive supportive measures of nutrition and hydration beyond standard hydration during cisplatin administration. These intensive measures should be enacted before a 10% weight loss is reached.
International Journal of Radiation OncologyBiologyPhysics 12/2005; 63(5):1413-8. · 4.11 Impact Factor
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Otolaryngology Head and Neck Surgery 07/2003; 128(6):910-1. · 1.72 Impact Factor
