Tension Pneumocephalus Secondary to Positive Pressure Ventilation Following Endoscopic Endonasal Skull Base Surgery: Three-Year Follow-Up After Implementation of an Institutional Protocol.

BACKGROUND: Tension pneumocephalus (PMC) is a rare and feared complication following the endonasal endoscopic approach (EEA) to skull base procedures. This is a neurosurgical emergency that requires urgent decompression to avoid catastrophic neurologic damage or death. An avoidable cause is the application of positive pressure ventilation (PPV) in EEA patients for postoperative hypoxia. Our institution implemented a hospital-wide protocol in response to this to identify and manage at-risk patients; this paper aims to identify if this protocol was effective in lowering the rates of tension PMC secondary to PPV. RESULTS: In the 3 years following the implementation of the protocol, 110 patients underwent EEAs, from which 1 case of tension PMC (found to be not secondary to PPV) was identified. This is compared with 2 cases of tension PMC secondary to PPV over the preceding 5 years, out of 406 EEA patients. This constitutes a quantifiable reduction in PPV-related tension PMC in both standard and extended approach EEAs, signifying the effective uptake of the protocol. CONCLUSIONS: We found no cases of tension PMC after PPV following EEA skull base surgery in our institution since the implementation of an institution-wide guideline. This underscores the utility of our simple and cost-effective preventative protocol in reducing the overall rates of tension PMC following the inadvertent postoperative application of PPV. Further research is needed to study the comparative risks and benefits of PPV in the post-EEA patient and thus inform future iterations of the protocol.

The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery.

There is a paucity of high quality evidence regarding the routine placement of lumbar drain (LD) in reducing post-operative (op) cerebrospinal fluid (CSF) leak after extended endoscopic trans-sphenoidal resection of anterior skull base lesions. In this study, we sought to compare the incidence of post-op CSF leak between patients with upfront LD insertion and those without it. This was a prospective randomized controlled trial conducted over a period of 5 years with patients undergoing extended endoscopic trans-sphenoidal surgery randomly assigned to either LD insertion at the time of surgery, or no LD placement. Thirty-eight patients with anterior skull base tumors were accrued from three tertiary hospitals of Melbourne. Post-op leak was confirmed by ß2-transferrin-positive rhinorrhea, and/or worsening pneumocephalus on brain imaging. Skull base defect size and pedicled nasoseptal flap viability were assessed on post-op CT and MRI, respectively. There was no significant difference in post-op CSF leak incidence between the two subgroups (12.50% in LD arm vs. 9.10% in no LD arm). Patients with LD insertion however, demonstrated substantially raised complication rates, longer hospital lengths of stay and lower subjective quality of life measures at 12 months compared with those without LD. In conclusion, routine placement of LD at the time of surgery for extended anterior skull base trans-nasal approach did not reduce the risk of post-op CSF leak. Discretion is warranted when using LD as an adjunct due to its associated morbidities, prolonged hospital stay and adverse effect on patients' subjective outcome measures.

Closure of skull base defects after endoscopic endonasal transsphenoidal surgery: the role of the local sphenoid mucosal flap for low flow leaks.

A local sphenoid mucosal flap (SMF) is naturally raised during endonasal exposure of the sella. Typically, these flaps are repositioned; however, they could be used in place of a nasoseptal flap (NSF) for closure of low-grade CSF leaks. In this study, we aim to establish the safety and efficacy of SMF closure for low-grade CSF leaks and to assess the impact on sinonasal quality of life (QoL) compared to NSF closure. In a consecutive, prospective cohort of anterior skull base pathology, data regarding sellar and suprasellar extension (Hardy grade), cavernous sinus invasion (Knosp grade), intraoperative (Kelly grade) and postoperative CSF leak, and sino-nasal QoL data (SNOT-22) were analysed. Of 187 patients with no/low flow (Kelly 0-1) intraoperative CSF leak, 127 (67.9%) received a SMF and 60 (32.1%) received a NSF. A total of 141/187 (75.4%) had no intraoperative leak, while 46/187 (24.6%) had grade-1 leaks. SMF were used in 70.9% (100/141) of cases without intraoperative leak, and 58.7% (27/46) of cases with Kelly grade-1 leaks. Hardy grade 4, grade E and Knosp grade 4 lesions were all more commonly closed with a NSF (p < 0.05). Two patients (1.1%) had postoperative CSF leaks, both in the SMF group, and both after no discernible intraoperative leak. Sinonasal QoL was below baseline for up to 3 months postoperatively. SMF cases tended to have better sinonasal QoL for up to 6 weeks after surgery. Thus, in the largest cohort to date, SMF are a safe alternative to NSF for closure low-grade skull base defects. Sinonasal QoL was better in the first 6 weeks after SMF closure than NSF closure.

Anatomic Variation for the Endoscopic Endonasal Transsphenoidal Approach.

Knowledge of anatomy and its variations is the key to safe and efficient surgery. The endoscopic endonasal route to the sella has evolved to become the preferred route to access a wide variety of diseases. We describe the skeletal, vascular, and neural anatomic variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided.

Tension Pneumocephalus from Positive Pressure Ventilation Following Endoscopic Skull Base Surgery: Case Series and an Institutional Protocol for the Management of Postoperative Respiratory Distress.

BACKGROUND: Tension pneumocephalus (TP) is a rare but feared complication of endoscopic endonasal skull base surgery. In contrast to simple pneumocephalus, which is common after endoscopic transnasal approaches and managed conservatively, TP represents a neurosurgical emergency and mandates urgent decompression. CASE DESCRIPTION: Here we present 2 cases of TP as a consequence of positive pressure ventilation following endoscopic endonasal skull base surgery. Both occurred during resuscitation for postoperative hypoxia. These cases prompted the development of an institution-wide protocol to identify and manage patients at risk of TP after extended skull base approaches. CONCLUSIONS: To our knowledge, these are the only such cases of postoperative TP following positive pressure ventilation in the literature.

Patient Wellbeing and Quality of Life After Nasoseptal Flap Closure for Endoscopic Skull Base Reconstruction.

BACKGROUND: The endoscopic endonasal approach to the skull base avoids some of the surgical morbidity associated with a transcranial approach, however it often results in large skull-base defects requiring secure closure. The nasoseptal flap has become the preferred method for closure of such defects but may be associated with its own morbidity. METHODS: A consecutive cohort of patients with skull base pathology with prospectively collected quality of life data using ASBQ and SNOT was analysed. They were grouped into those who received a nasoseptal flap and those who did not. Pre-operative total ASBQ and SNOT scores, and their individual components, were compared to data collected at days 1, 3, and 7; six-weeks; and 3, 6, and 12-months postoperatively. RESULTS: Of 158 patients available for analysis, nasoseptal flaps were performed in 52 (33%). Average follow-up (±standard deviation) was 8.1 ± 3.9 months for ASBQ data and 8.2 ± 3.8 months for SNOT data. In the first post-operative week, nasal symptoms and otalgia were worse in the flap group. At six-weeks and beyond, there was no difference between groups in overall ASBQ or SNOT scores, or in the rate of clinically-significant improvement in SNOT or ASBQ scores or their components. CONCLUSION: In the largest cohort of patients to date, the use of a nasoseptal flap is associated with nasal symptoms and otalgia in the acute post-operative period, but is not associated with any long-term detriment to quality of life after endoscopic skull base surgery.

Glimpse into Pathophysiology of Sellar Arachnoid Cysts.

BACKGROUND: Sellar arachnoid cysts are a rare occurrence but may impinge on vital parasellar anatomy and thus are often symptomatic. The etiology of sellar arachnoid cysts is contentious, fueled by heterogeneity in cyst wall structure and contents between cases. The "ball-valve" mechanism is 1 of 2 predominant theories describing their formation, which contends that an aperture in the diaphragm allows cerebrospinal fluid to enter the cyst, propelled by pulsatile flow, but its egress is obscured by the pituitary during the ebb of the pressure wave. CASE DESCRIPTION: Here we present a case of a 51-year-old female with a symptomatic sellar arachnoid cyst. She underwent an endoscopic transsphenoidal fenestration which alleviated her symptoms. CONCLUSIONS: Intraoperative video evidence during arachnoid cyst fenestration supports the "ball-valve" theory of sellar arachnoid cyst development.

Co-occurrence of Pituitary Adenoma with Suprasellar and Olfactory Groove Meningiomas.

INTRODUCTION: The co-existence of pituitary adenoma and meningioma is extremely rare. It is even rarer in patients with no previous known risk factors for either tumour. Here, we present a case of synchronous non-functioning pituitary adenoma with suprasellar and olfactory groove meningiomas in a patient without previous irradiation. METHODS: The tumours were diagnosed on MRI in the 65-year-old patient who presented with patchy visual deficits. The decision was made to undergo surgery for resection of the suprasellar meningioma and the pituitary adenoma, leaving the small olfactory groove meningioma intact. Extended endoscopic transsphenoidal surgery was performed. RESULTS: Macroscopic clearance was achieved for pituitary macroadenoma and suprasellar meningioma. Postoperatively, visual field tsting and pituitary axis hormonal levels were normal. The pituitary macroadenoma was confirmed to be a non-functioning pituitary adenoma. The meningioma was diagnosed to be of WHO grade 1. CONCLUSION: The rationale for choosing such management option, including its risks and benefits in this challenging patient is discussed.

Image-guided surgery influences perioperative morbidity from endoscopic sinus surgery: a systematic review and meta-analysis.

OBJECTIVE: Although image-guided surgery (IGS) is considered a valuable tool, its impact on perioperative morbidity for endoscopic sinus surgery (ESS) remains unclear. The evidence from reported literature is systematically reviewed with meta-analysis. DATA SOURCES: MEDLINE (1946 to September 14, 2012, week 2) and EMBASE (1974 to September 14, 2012, week 37). REVIEW METHODS: MEDLINE and EMBASE were searched using a search strategy for publications on IGS during ESS that reported original data on perioperative morbidity. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed. Both comparative cohort studies with non-IGS cases and case series were included. Primary outcome was major and total complications. Secondary outcomes were specific orbital and intracranial injury, major hemorrhage, ability to complete the operation, and revision surgery. The incidence of these events was defined as dichotomous variables and expressed as a risk ratio (RR) in a fixed-effects model. RESULTS: In total, 2586 articles fulfilled the search, producing 55 included studies. Fourteen were comparative cohorts of IGS and non-IGS sinus surgical patient populations used for meta-analysis. Among the cohorts, major complications were more common in the non-IGS group (RR = 0.48; 95% confidence interval [CI], 0.28-0.82; P = .007). Total complications were greater in the non-IGS group (RR = 0.66; 95% CI, 0.47-0.94; P = .02). All other outcomes did not reach significance on meta-analysis. CONCLUSION: Contrary to current review articles on the topic of IGS use during ESS, there is evidence from published studies that the use of IGS for sinus surgery, within selected populations, is associated with a lower risk of major and total complications compared with non-IGS sinus surgery.

Nasal lavage with mupirocin for the treatment of surgically recalcitrant chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: To examine the efficacy and tolerability of topical mupirocin for the management of surgically recalcitrant chronic rhinosinusitis (CRS) associated with Staphylococcus aureus infection. STUDY DESIGN: Prospective open-label pilot study. METHODS: Patients with surgically recalcitrant CRS who had positive nasendoscopically guided cultures for Staphylococcus aureus were treated with twice daily nasal lavages containing 0.05% Mupirocin and lactated ringers salts. The duration of treatment was 3 weeks. Patients were assessed before and after treatment in terms of nasendoscopic findings, microbiology results, and Sinonasal Outcome Test (SNOT-20) and visual analogue scale questionnaires. RESULTS: Fifteen of 16 patients had improved nasendoscopic findings after treatment. Twelve of 16 patients noted overall symptom improvement. Fifteen of 16 patients had negative swab results for Staphylococcus aureus after treatment. Only minimal adverse effects were experienced. CONCLUSIONS: Nasal Lavage with 0.05% Mupirocin may represent an effective and well tolerated alternative treatment for postsurgical recalcitrant CRS.

Fully endoscopic transsphenoidal resection of pituitary tumors: technique and results.

BACKGROUND: The aim of this study was to describe our two-surgeon fully endoscopic approach to pituitary surgery and to report results in terms of tumor remission, improvement in vision, and complications. A retrospective chart review was performed. METHODS: Our prospectively recorded surgical database was searched for all endoscopic transsphenoidal procedures between January 2001 and December 2005. Those patients who had surgery had their medical charts reviewed and presenting symptoms and signs, lesion characteristics, endocrine investigations, operative details, complications, and treatment outcomes recorded. RESULTS: Thirty-two patients were included in the study. Twenty-three patients had macroadenomas, five patients had microadenomas, and four patients had other pathologies. Most patients with macroadenomas had significant supra- or parasellar extension. Of the 14 patients who had visual loss at presentation, 13 had postoperative improvement. Two patients had postoperative cerebrospinal fluid leaks, which were successfully treated endoscopically. Eight patients required some form of hormone replacement after surgery. After a mean follow-up of 31 months, the overall remission rate for patients with macroadenomas was 82% and for patients with microadenomas was 100%. CONCLUSION: The fully endoscopic transsphenoidal approach provides excellent visualization for tumor resection and results in acceptable remission rates.

Isolated inflammatory sphenoid sinus disease in children.

Isolated inflammatory disease of the sphenoid sinus is very uncommon in the pediatric population. A 10-year review of all patients at our institution 16 years of age or younger with inflammatory sphenoid sinus disease found 8 patients with isolated sphenoid sinusitis and 3 with sphenoid mucoceles. The most common symptoms were headache and visual disturbance. Five patients with uncomplicated sinusitis were successfully managed medically, while 3 with either complicated sinusitis or sinusitis not responding to antibiotics were treated by endoscopic sphenoidotomy. All patients with a mucocele were treated surgically. Isolated inflammatory sphenoid sinusitis should be considered in children age 7 years or older who present with headache that does not respond to simple analgesia. Delayed diagnosis and advanced disease may lead to life-threatening complications.