Graft-Extended Nasoseptal Flap for Endoscopic Anterior Skull Base Reconstruction: A Novel Technique.

Reconstruction of the anterior part of the anterior skull base with a nasoseptal flap (NSF) is technically demanding. This challenge is mainly related to the real possible length of the flap. Herein, we describe a new technique for extending the NSF such that it can sufficiently cover the far anterior part of the anterior skull base. Three cadaveric heads were used for mucosal graft extension of the NSF. The graft was harvested from the other side, sutured to the NSF, then repositioned over the skull base after opening all the paranasal sinuses. Each head was operated by a rhinologist and a skull base surgeon. The study variables were the initial length of the NSF, the length of the graft harvested, the new length of the graft-extended NSF, and the length of the new graft-extended NSF from the nasal spine. The average length of the NSFs was 6.4 cm (± 0.2); that of the harvested grafts was 2.93 cm (± 0.1); that of the graft-extended NSF was 9.33 cm (± 0.4); and that of the graft-extended NSF from the nasal spine was 3.93 cm. The graft-extended NSF is an easy and extremely useful technique for the reconstruction of the far anterior parts of the skull base. However, further prospective studies on the clinical usefulness of this technique and its long-term results are yet to be performed. Level of evidence: IV.

Arteriovenous Malformation of the Upper Eyelid: A Case Report.

Arteriovenous malformations (AVMs) are rare lesions formed by direct connection of arteries and veins bypassing capillary beds. AVM locations can vary; however, extracranial AVMs remain the least common. The vast majority of these malformations are congenital and can be triggered by hormonal changes. A 49-year-old woman presented with a progressive right-sided upper eyelid swelling over the past 12 years. The patient had mechanical ptosis and mild impairment of the right visual field. The swelling was compressible with a thrill, and bruits were heard. The patient was diagnosed with AVM using cerebral angiography. Preoperative endovascular embolization was not possible; however, surgical excision was successfully done with no complications. AVMs and fistulas are high-flow vascular lesions that usually occur during childhood and progress with time. Only a few cases of face and eyelid AVMs have been reported in the literature. Diagnosis of these anomalies is mostly made based on clinical presentation and radiographic imaging such as angiography. Treatment options remain controversial, and management should be individualized for each patient. Endovascular embolization followed by surgical excision is advisable in many cases. Due to its rare entity, information regarding the best management options for AVMs is limited. Reducing the risk of bleeding and achieving total resection is the goal of treatment. Long-term follow-up is required in these patients because recurrent cases of AVMs have been reported.

Seeker Uncinectomy: A Randomized Controlled Cadaveric Trial.

BACKGROUND: Endoscopic sinus surgery is a common surgery, in which the uncinate process of the ethmoid is removed as the first surgical step. There are multiple techniques for uncinectomy. Herein we describe a new and simple uncinectomy technique. METHODS: We performed a randomised controlled trial with blinded assessors. Eight cadaveric heads were used to compare the new technique to the commonly used technique; retrograde uncinectomy. The procedures were performed by 2 rhinologists, and the findings were evaluated by 2 senior rhinologists blinded to the technique and the surgeon who did. They assessed the final view of the procedure and the complications. Thereafter, they assessed the procedure for the duration and ease of each technique for teaching purposes. RESULTS: Fifteen uncinectomies were performed, 7 using the retrograde technique, and 8 using the new technique. The mean durations were 5.64 min using the seeker uncinectomy and 7.57 min using the retrograde uncinectomy, p-value = 0.017. The completion was better in seeker uncinectomy; however, not significant statistically, p > 0.05. The complications with the new technique were inferior turbinate injury in 12.5% and natural ostium non-identification in 12.5%, p > 0.05. With retrograde uncinectomy, lacrimal injury occurred in 14.3%, p > 0.05. The ease of teaching scores was higher for the seeker uncinectomy. CONCLUSION: Based on this cadaveric trial, seeker uncinectomy seems to be a safe and easy to perform technique. However, injury to the inferior turbinate and missing the natural ostium must be taken into consideration. These warrant further studies on the clinical application of this procedure.

The Cox-2 Inhibitor Meloxicam Ameliorates Neuroinflammation and Depressive Behavior in Adult Mice after Splenectomy.

BACKGROUND: Peripheral surgical trauma may incite neuroinflammation that leads to neuronal dysfunction associated with both depression and cognitive deficits. In a previous study, we found that adult mice developed neuroinflammation and short-term working memory dysfunction in a delayed, transient manner after splenectomy that was ameliorated by the cyclooxygenase-2 inhibitor meloxicam. We tested the hypothesis that splenectomy in mice would also cause anhedonia, the diminished response to pleasure or rewarding stimuli that is a hallmark of depression, and that treatment with meloxicam would be ameliorative. METHODS: After Institutional Animal Care and Use Committee approval, Swiss-Webster mice underwent sucrose preference training before being randomized into groups on day 0, when they had either splenectomy and anesthesia or anesthesia alone. Within each group, half were randomized to receive intraperitoneal saline at 24 hours, while the other half received intraperitoneal meloxicam at 24 hours. Sucrose preference ratios were determined on days 1, 5, 9, and 14. Additional mice were randomized into groups for brain histochemistry. Specimens were stained for glial fibrillary acidic protein (GFAP), a marker of astrocytes, and CD45, a protein tyrosine phosphatase that identifies microglial activation. RESULTS: On day 5, mice receiving splenectomy and saline demonstrated diminished sucrose preference, which was not seen in mice receiving splenectomy and meloxicam. Semiquantitative analysis of histological slides taken from splenectomized mice treated with meloxicam revealed reduced microglial-based neuroinflammation and reactive astrocytosis compared to mice receiving saline. CONCLUSION: Splenectomy in mice is associated with neuroinflammation and anhedonia, as evidenced by reactive microgliosis, astrocytosis, and behavioral changes. Postsurgical treatment with meloxicam attenuates both neuroinflammation and anhedonia. These findings suggest that cyclooxygenase-2-dependent mechanisms may play a role in the development of postoperative mood disorders, possibly via modulation of peripheral effects on neuroinflammation.

The Role of TREM2 in Alzheimer's Disease and Other Neurological Disorders.

Alzheimer's disease (AD) is the leading cause of dementia worldwide. Late-onset AD (LOAD), is the most common form of Alzheimer's disease, representing about >95% of cases and early-onset AD represents <5% of cases. Several risk factors have been discovered that are associated with AD, with advancing age being the most prominent. Other environmental risk factors include diabetes mellitus, level of physical activity, educational status, hypertension and head injury. The most well known genetic risk factor for LOAD is inheritance of the apolipoprotein (apo) E4 allele. Recently, rare variants of TREM2 have been reported as a significant risk factor for LOAD, comparable to inheritance of apoE4. In this review we will focus on the role(s) of TREM2 in AD as well as in other neurodegenerative disorders.