Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Postoperative Period following Pituitary and Ventral Skull Base Surgery.

Objective Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design Retrospective chart review. Setting Tertiary care center. Methods and Participants All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017 and March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intraoperative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures Specificity and safety of ITF. Results Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50 ± 11.89. There were six patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives, and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100 and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. ITF represents a specific and safe test with potential utility in the postoperative setting.

Postoperative antibiotic use in patients with unilateral purulent chronic rhinosinusitis.

OBJECTIVES: To describe our experience with the use of postoperative antibiotics in the management of unilateral chronic rhinosinusitis (CRS) patients with active infection at the time of surgery, and to evaluate the need for routine postoperative antibiotic administration in this population. METHODS: This retrospective chart review analyzed the medical records of all patients who underwent endoscopic sinus surgery for unilateral purulent CRS between November 2013 and September 2019 at a tertiary care center and who were not prescribed routine postoperative antibiotics. Duration of time until normalization of sinus cavities and whether antibiotics were ultimately prescribed for persistent infectious signs and symptoms were recorded. Patient characteristics and findings were analyzed to determine if any of the evaluated parameters were associated with the need for postoperative antibiotics. RESULTS: Sixty-nine patients were included in the study. Thirty-three (47.8%) did not require antibiotics during the postoperative period. The average time to sinus normalization was 8.1 weeks (range 1-24 weeks) for patients who received antibiotics and 5.7 weeks (range 1-16 weeks) for those who did not receive antibiotics (P = .066). No evaluated variables were associated with antibiotic use on univariate or multivariate analysis. CONCLUSION: Postoperative antibiotics were not necessary to normalize infected sinus cavities for nearly half of patients with unilateral purulent CRS in this series. Further studies are needed to better delineate which patients would derive benefit from postoperative antibiotics. LEVEL OF EVIDENCE: Level IV.

Human papillomavirus and survival of patients with sinonasal squamous cell carcinoma.

BACKGROUND: To the authors' knowledge, the question of whether human papillomavirus (HPV) infection is associated with outcomes in patients with sinonasal squamous cell carcinoma (SNSCC) is not well studied at this time. In the current study, the authors investigated patterns of HPV testing and its association with survival in patients with SNSCC using the National Cancer Data Base. METHODS: The authors selected all SNSCC cases diagnosed between 2010 and 2016. HPV testing practices, clinicodemographic factors, treatments, and survival were analyzed. Multivariable Cox regression and propensity score-matched survival analyses were performed. RESULTS: A total of 6458 SNSCC cases were identified. Of these, only 1523 cases (23.6%) were tested for HPV and included in the current study. The median patient age was 64 years and the majority had advanced stage tumors (overall AJCC stage III-IV, 721 patients; 62.1%). HPV-positive SNSCC comprised 31.5% (447 of 1418 cases) of the final study cohort. Among 15 hospitals that routinely tested nonoropharyngeal SCCs for HPV, the percentage of HPV-positive SNSCCs was smaller (24.6%; P = .04). Patients with HPV-positive SNSCC were younger (aged 60 years vs 65 years; P < .001), with tumors that were more likely to be high grade (55.3% vs 41.7%; P < .001), and attributed to the nasal cavity (62.2% vs 44.0%; P < .001). HPV-positive SNSCC was associated with significantly improved overall survival in multivariable regression analysis (hazard ratio, 0.45; 95% CI, 0.28-0.72 [P = .001]) and propensity score-matched (hazard ratio, 0.61; 95% CI, 0.38-0.96 [P = .03]) analyses controlling for clinicodemographic and treatment factors. CONCLUSIONS: Currently, only a minority of patients with SNSCC are tested for HPV. However, a sizable percentage of SNSCC cases may be HPV related; furthermore, HPV-positive SNSCC is associated with improved overall survival. Routine HPV testing may be warranted in patients with SNSCC.

Endoscopic Visualization of the True Maxillary Ostium Following Uncinectomy.

OBJECTIVES: To examine the frequency in which angled endoscopes are necessary to visualize the true maxillary ostium (TMO) following uncinectomy and prior to maxillary antrostomy. Additionally, to identify preoperative computed tomography (CT) measures that predict need for an angled endoscope to visualize the TMO. STUDY DESIGN: Retrospective study. SETTING: Tertiary academic hospital. PATIENTS AND METHODS: Patients who underwent endoscopic sinus surgery (ESS) between December of 2017 and August of 2018 were retrospectively identified. Cases were reviewed if they were primary ESS cases for chronic rhinosinusitis without polyposis and if they were at least 18 years of age. RESULTS: Sixty-three maxillary antrostomies were reviewed (82.5% were from bilateral cases). Thirty-five cases (55.6%) required an angled endoscope in order to visualize the TMO. Of the preoperative CT measures examined, a smaller sphenoid keel-caudal septum-nasolacrimal duct (SK-CS-NL) angle was significantly associated with need for an angled endoscope intraoperatively to visualize the TMO (17.1° SD ± 3.2 vs 15.0° SD ± 2.9; P = .010). CONCLUSION: Angled endoscopes are likely required in the majority of maxillary antrostomies to visualize the TMO. This is important to recognize in order to prevent iatrogenic recirculation. The SK-CS-NL angle may help to identify cases preoperatively which require an angled endoscope to identify the TMO during surgery.

Nasolacrimal Duct Management During Endoscopic Sinus and Skull Base Surgery.

OBJECTIVE: To evaluate rates of epiphora after transection and marsupialization of the nasolacrimal duct (NLD) during endoscopic sinus and skull base surgery. INTRODUCTION: The nasolacrimal canal forms part of the medial wall of the maxillary sinus. Transecting the NLD is sometimes necessary for tumor resection or surgical access to maxillary sinus and infratemporal fossa pathology. There is no consensus for the endoscopic management of the NLD when only the duct is transected without involving the nasolacrimal sac. METHODS: Medical records of 29 patients from 2 academic institutions who underwent endoscopic sinus and skull base surgery with transection of the NLD were retrospectively reviewed. Whether the duct was marsupialized or simply transected was recorded, and the postoperative rate of epiphora was calculated. RESULTS: Mean age was 59 years (range, 14-86 years). Mean follow-up was 10.5 months (range, 1-33 months). The NLD was marsupialized in 16 (55%) and simply transected in 13 (45%) patients. Six patients underwent postoperative radiation. No patients in the marsupialization group had epiphora postoperatively, all with Munk score of 0. One patient in the transection group developed postoperative epiphora with Munk score of 1. Pathology included inverted papilloma (8), acute on chronic inflammation (6), B-cell lymphoma (3), juvenile nasopharyngeal angiofibroma (2), squamous cell carcinoma (2), Schneiderian papilloma (2), metastatic melanoma (1), HPV-related carcinoma (1), adenocarcinoma (1), benign epithelial cyst (1), adenoid cystic carcinoma (1), and erosive chronic sinusitis without nasal polyposis (1). CONCLUSION: Management after transection of the NLD varies widely. The duct may be simply transected or marsupialized, or a formal dacryocystorhinostomy can be performed. The surgeon must also choose whether to place a stent. Based on our small series and review of the literature, marsupialization or simple transection of the NLD results in a low rate of postoperative epiphora in the setting of endoscopic sinus and skull base surgery.

Revascularization of AlloDerm Used during Endoscopic Skull Base Surgery.

Objectives AlloDerm is an acellular dermal matrix often used for reconstruction throughout the body. AlloDerm has been shown to undergo revascularization when used to reconstruct soft tissue such as in abdominal wall reconstruction. In this study, the authors review the literature on revascularization of AlloDerm and demonstrate the histologic findings of AlloDerm after implantation during skull base reconstruction. Study Design Literature review and case reports. Setting Tertiary Care Institution Participants Patients from a tertiary care institution Main Outcome Measures Histologic slides are evaluated and compared with nonimplanted AlloDerm. Methods The authors review a case of explanted AlloDerm that had been used for skull base reconstruction after endoscopic skull base surgery. Results Upon reviewing the histologic slides of explanted AlloDerm to nonimplanted AlloDerm, we demonstrate revascularization of AlloDerm when used in skull base reconstruction. Representative slides will be included. Conclusions AlloDerm undergoes revascularization when used for skull base reconstruction.

The effect of endoscopic olfactory cleft polyp removal on olfaction.

BACKGROUND: The presence of olfactory cleft polyps in chronic rhinosinusitis with nasal polyposis is well documented, but the effect of endoscopic olfactory cleft polyp surgery on olfaction, versus observation, has not been well studied. This analysis assessed if microdebridement of olfactory cleft polyps yields significant objective smell improvements in those with anosmia or hyposmia. METHODS: A randomized prospective single-blinded study was performed on patients undergoing bilateral endoscopic sinus surgery with profound bilateral nasal polyposis, excluding those younger than 18 years or without olfactory polyps. A preoperative University of Pennsylvania Smell Identification Test (UPSIT), visual analog scale (VAS), and sinonasal outcomes 20 score (SNOT-20), and a follow-up at 6 months was performed. Two cohorts were created, including one with cleft polyp removal (group A) and one with cleft polyps left in place (group B). RESULTS: There were 10 patients in group A and 7 in group B. By using the Wilcoxon signed rank test, the two groups were individually analyzed for changes in the preoperative UPSIT, VAS, and SNOT-20 versus the 6-month test results. In group A, the improvement in the UPSIT, VAS, and SNOT-20 were statistically significant at p < 0.05. For group B only the improvement in the VAS was statistically significant, at p < 0.05. There was a statistically significant difference in clinical smell improvement between group A and B at 6 months (p = 0.00512). CONCLUSIONS: Evidence exists that olfactory cleft polyp surgery improves olfactory function outcomes. Long-term data beyond 6 months is needed to further validate these early promising outcomes.

Spontaneous CSF rhinorrhea: prevalence of multiple simultaneous skull base defects.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) leaks are caused by intracranial hypertension. Given this underlying etiology, patients may be at risk for developing multiple skull base defects. OBJECTIVE: The purpose of our study is to present the prevalence of multiple simultaneous skull base defects in patients with spontaneous CSF rhinorrhea. METHODS: We performed a retrospective chart review in a tertiary care practice of 44 consecutive patients with spontaneous CSF rhinorrhea who underwent endoscopic repair by the senior author (R.R.C.) to determine the prevalence of having multiple simultaneous skull base defects identified at the time of surgery. We defined this as two or more bony defects identified endoscopically with intact intervening bone with or without soft tissue prolapse into the nasal cavity or paranasal sinus cavity. RESULTS: Eight of 44 patients (18.2%) were found to have multiple simultaneous skull base defects. The average body mass index (BMI) of the study population was 34.5 (range, 22.7-59). CONCLUSION: A significant number of patients with spontaneous CSF rhinorrhea may have more than one skull base defect present at the time of presentation. The clinical significance of this finding in surgical and medical decision making is not clear at this time.

Distant pseudomeningoceles of the ventral skull base: a report of 2 cases.

BACKGROUND: The objective of this case series was to report what is to the best of our knowledge the first reports of nasopharyngeal and soft palate pseudomeningoceles tracking submucosally from the sphenoid sinus. METHODS: Analysis of cases through medical records. RESULTS: Two cases of middle-aged male patients presented to our tertiary care university teaching hospital for recurrent meningitis and a history of cerebrospinal fluid (CSF) rhinorrhea. Both were found to have pseudomeningoceles distant from the sphenoid sinus. One was tracking to the mucosa of the Eustachian tube, and the other to the dorsum of the soft palate. Both were found to be tracking submucosally from the sphenoid sinus, to the vidian canal, to the lateral nasopharyngeal wall, to their respective locations at the Eustachian tube and dorsum of the soft palate. CSF closure was performed with a transnasal endoscopic repair using the pedicled nasoseptal flap for 1 patient and Alloderm for the other, both with successful cessation of CSF rhinorrhea. CONCLUSION: We present these cases of distant spontaneous CSF leaks. We review the literature and discuss case management.

Measurement of mycotoxins in patients with chronic rhinosinusitis.

Mycotoxins are toxic secondary metabolites produced by a variety of fungi including Aspergillus, Alternaria, and Penicillium species. The presence of mycotoxins in sinonasal tissue and secretions and any possible link to chronic rhinosinusitis (CRS) or other diseases of the head and neck have not been reported. The authors performed an exploratory study to determine the presence and levels of mycotoxins in the sinonasal tissue and secretions of 18 subjects undergoing endoscopic sinus surgery for CRS. Using commercial enzyme-linked immunosorbent assay kits, samples were analyzed for the following mycotoxins: aflatoxin, deoxynivalenol, zearalenone, ochratoxin, and fumonisin. All specimens were negative for aflatoxin, deoxynivalenol, zearalenone, and fumonisin. Four (22%) of 18 specimens were positive for ochratoxin. The clinical significance of this finding remains to be determined.

First bite syndrome as a presenting symptom of a parapharyngeal space malignancy.

BACKGROUND: First bite syndrome is a known complication after parapharyngeal space surgery. This syndrome is usually encountered when the surgery is extensive but the parotid gland is preserved. A disruption in the balance between sympathetic and parasympathetic innervation to the parotid gland has been posited to play a role. METHODS: We report a 74-year-old woman with a parapharyngeal space malignancy who presented with first bite syndrome prior to any surgical intervention. The tumor and left parotid gland were resected via a transcervical approach. During the operation, the sympathetic chain was found to be directly involved with the tumor. RESULTS: The patient reported complete resolution of first bite syndrome immediately after the operation, and remained free of this symptom at 6 months' follow-up. CONCLUSION: To our knowledge, this is the first report of first bite syndrome presenting prior to any surgical intervention. Parotidectomy, if included in the surgical plan, may lead to the resolution of first bite syndrome.

Characteristics and outcomes of malpractice claims after tonsillectomy.

OBJECTIVE: To characterize the background and outcomes of tonsillectomy malpractice claims. METHODS: Review of 69 New York State insurance claims (Part I) and 87 national court trials (Part II) alleging injury after tonsillectomy. RESULTS: Part I. New York State insurance cases were most commonly discontinued (44%) or settled (42%) before trial. Compensations with a settlement or verdict were made in 48 percent of cases. Part II. Death or major injury occurred in 52 percent of insurance cases, with a mean award of $403,656 being made to plaintiffs. Of cases reaching trial, 60 percent of plaintiffs were compensated. Awards against anesthesiologists were more frequent and higher than against surgeons ($5 million vs $839,650). Death or major injury occurred in 52 percent of court cases, resulting in mean indemnity of $3.8 million. Most cases of death or major injury were attributable to airway complications. CONCLUSIONS: Approximately half of both New York state claims and court cases involved death or devastating morbidity, mostly related to airway complications, resulting in large awards. Tonsillectomy is a source of uncommon but potentially high-dollar-value litigation exposure to the surgeon, often attributable to non-surgical complications.