Endoscopic endonasal obliteration of the frontal recess and anterior skull base.

BACKGROUND: Although endoscopic techniques have become more widespread in repair of frontal sinus (FS) defects, certain pathologies still require open approach (extensive trauma or tumors). Under certain circumstances even multiple complex open reconstructive procedures might fail to resolve persistent pneumocephalus or CSF leak and subsequently surgeons tend to escalate the invasiveness and employ even more complex and aggressive approaches. We present our experience treating persistent pneumocephalus or CSF leak after previously failed transcranial reconstruction utilizing an endoscopic endonasal approach (EEA). METHODS: We retrospectively reviewed a prospectively maintained database of all patients undergoing an EEA for repair of persistent pneumocephalus or CSF leak following FS cranialization between 2016 and 2020. RESULTS: Six patients who underwent cranialization of the FS with subsequent persistent pneumocephalus or CSF leak were identified; two patients suffered a traumatic fracture of the FS, remaining four patients had undergone previous cranial surgery. Clear violation of the FS was not recognized in one patient. All patients underwent cranialization of the FS either directly following initial craniotomy or during open repair of a FS fracture. Two patients underwent multiple transcranial surgeries including using vascularized free tissue transfer. Complete cessation of pneumocephalus/CSF leak was achieved in 83.3% (5/6) after the first and 100% (6/6) after two endoscopic procedures. No morbidity or mortality resulted from the endoscopic procedure. CONCLUSIONS: Skull base defects following a failed cranialization of FS are usually located in or in close proximity to the frontal recess. These defects can be safely and effectively repaired via an EEA.

Nasofrontal meningiomas: retrospective series and review of literature.

INTRODUCTION: Lesions affecting the anterior skull base and involving the paranasal sinuses (PNS), nasal cavity (NC), and orbit are infrequent and include predominantly a wide variety of sinonasal malignancies. Less than 3% of intracranial meningiomas extend extracranially and involve PNS and NC. Given their relatively low incidence, little is known about the treatment outcome of this subset of meningiomas. METHODS: Systematic literature and retrospective review of own institutional series of midline anterior skull base meningiomas with significant PNS and NC involvement were performed. RESULTS: Overall, 21 patients-16 in the literature review group and 5 of our institutional series-were included. Eleven (52.4%) patients had had a prior surgery for midline anterior skull base meningioma. Of patients having reported WHO grade, two were WHO II. Gross total resection was achieved in 16 (76.2%) of patients, utilizing solely transcranial approach in 15 patients, combined endoscopic and transcranial in five patients and purely endoscopic in one patient. Postoperative radiotherapy was administered in three (14.3%) patients, all after total resection via transcranial route, without a history of prior treatment. A postoperative cerebrospinal fluid leak was reported in four (10%) patients, requiring surgical repair in two. There were no reports of postoperative meningitis. No neurological complications were observed except of a reported worsening of vision in one patient. CONCLUSION: Midline anterior skull base meningiomas infrequently extend significantly into the PNS and NC. Despite their significant involvement, along with concomitant involvement of orbit, gross total resection is possible in the majority of cases with low morbidity using either purely transcranial or combined endoscopic/transcranial approach.

Correlation between CT imaging and symptom scores in cystic fibrosis associated chronic sinusitis.

PURPOSE: There are limited guidelines for diagnosing and managing chronic rhinosinusitis (CRS) in the cystic fibrosis (CF) population. While CF patients are known to have significant opacification on paranasal computed tomography (CT), limited evidence suggests that CT findings are not indicative of patients' symptom burden and therefore not a reliable indicator for surgical intervention. This provides a diagnostic challenge for otolaryngologists taking care of this patient population. The purpose of this study is to better define the relationship between objective imaging findings and patients' symptom severity in the CF-CRS population with the goal of providing more selective and effective patient care. MATERIALS AND METHODS: In this retrospective cohort study, 67 patients with CF CRS had their CT scans scored according to a modified Lund Mackay CT score (LMCTS), which was compared to their Sinonasal Outcome Test scores (SNOT-22). Total SNOT-22 and individual domains were evaluated. Pearson's correlation was performed. RESULTS: The overall mean SNOT-22 score was 32.3. The mean LMCTS was 17.6. These metrics correlate with relatively low subjective symptom scores in comparison to the high objective presence of sinus disease. While patients had high LMCTS, there was no correlation found between LMCTS and total SNOT-22 or individual SNOT-22 domains. CONCLUSIONS: CT findings in CF CRS patients do not accurately reflect patients' symptom burden and should not be used as a primary driver in the clinical management of these patients.

Age-Related Increase of Collagen/Fibrin Deposition and High PAI-1 Production in Human Nasal Polyps.

Objective: Our previous studies showed an age-related increased prevalence of nasal polyps (NP) and reduced production of S100A8/9 in elderly patients with chronic rhinosinusitis with NP (CRSwNP). In this study, we investigated an unbiased age-related gene expression profile in CRSwNP subjects and healthy controls, and further identified the differences in their tissue remodeling. Methods: Microarrays using NP and uncinate tissues from health controls (elderly, age ≥65 vs. non-elderly, age 18-49) were performed, and differentially regulated genes were analyzed. Quantitative real-time PCR (qPCR), Immunostaining, Periodic acid-Schiff (PAS), trichrome staining, Western blot, and ELISA were performed for further investigation. Results: Microarrays identified differentially expressed genes according to disease and age; 278 in NP vs. controls, 75 in non-elderly NP vs. non-elderly controls, and 32 in elderly NP vs. elderly controls. qPCR confirmed that the PLAT gene was downregulated and the SERPINB2 gene upregulated in NP vs. controls. The serous glandular cell-derived antimicrobial protein/peptide-related genes such as BPIFB3, BPIFB2, LPO, and MUC7 were remarkably reduced in NP, regardless of age. SERPINE1 gene (plasminogen activator inhibitor-1, PAI-1) expression was significantly increased in elderly NP versus elderly controls. IHC and western blot confirmed significantly decreased production of MUC7 and LPO in NP versus controls. There was a trend of age-related reduction of submucosal gland cells in normal controls. Trichrome and immunofluorescence staining demonstrated an age-related increase of collagen and fibrin deposition in NP, consistent with increased PAI-1 production. Conclusion: This study demonstrated age-related differential glandular remodeling patterns and fibrosis in NP and normal controls. PAI-1 expression was significantly increased in elderly NP versus elderly controls, suggesting PAI-1 as a potential treatment target in elderly NP.

Systematic review of outcomes for endoscopic sinus surgery and subsequent aspirin desensitization in aspirin-exacerbated respiratory disease.

OBJECTIVE: To review and evaluate outcomes of patients with aspirin-exacerbated respiratory disease (AERD) following endoscopic sinus surgery and subsequent aspirin desensitization. METHODS: Electronic searches of OVID MEDLINE (1948 to September 10, 2019), EMBASE (1980 to September 10, 2019), and PubMed were performed on September 10, 2019. A systematic review of the literature was performed using the 2009 PRISMA guidelines. Studies with both preoperative and postoperative data for patients with AERD who underwent sinus surgery and aspirin desensitization were considered appropriate for inclusion. Publications were written in English and included patients aged 18 years or older. RESULTS: Six studies met inclusion criteria for this systematic review. The primary outcome measure was change in symptom profile measured by patient-reported quality of life scores. The results demonstrate statistically significant improvement in symptoms following endoscopic sinus surgery, with sustained improvement following aspirin desensitization. Revision surgery rates were significantly lower in patients maintained on aspirin therapy. CONCLUSION: This review suggests that surgery followed by aspirin desensitization results in improvement in both subjective and objective outcome measures. The adjunctive use of aspirin desensitization allows for long-term stability in symptom scores. Recurrence of polyps and worsening symptoms requiring revision surgery occurs when aspirin maintenance therapy is interrupted.

Endoscopic endonasal resection of a medullary cavernoma: a novel case.

Brainstem cavernomas can present very challenging operative problems. Endoscopic endonasal approaches to these lesions in the mesencephalon and pons have been described. In this article the authors present the first case of a medullary cavernoma resected by an endoscopic transclival approach. A 26 year-old woman with a 1.5 cm medullary cavernoma presented with imbalance, swallowing difficulty, and right hemibody weakness. She was taken to the operating room for endoscopic endonasal transclival resection. Her pre-existing neurologic deficits worsened initially after surgery, but at three-month follow-up she had made a full neurologic recovery.

Powered irrigation with suction evacuation for chronic rhinosinusitis in the office setting: A pilot study.

Bacterial infections in the form of adherent biofilms are frequently implicated in the pathogenesis and recalcitrance of chronic rhinosinusitis. The Hydrodebrider, a disposable powered irrigation and suction device, has been developed specifically to remove biofilm from the paranasal sinuses. We conducted a prospective study to evaluate the tolerability and efficacy of the Hydrodebrider in the office setting with the use of local anesthesia. Of the original 13 adults we recruited, 10 completed the entire study protocol. All enrolled patients had previously undergone sinus surgery that involved the creation of a maxillary antrostomy large enough to allow placement of a Hydrodebrider device, and the endoscopic findings in all patients were consistent with chronic sinusitis. The standard visual analog scale for pain (range: 0 to 10) was used to measure tolerability. The 20-Item Sino-Nasal Outcome Test (SNOT-20) for symptoms was completed at baseline and at 1 and 8 weeks after the procedure. The mean pain score obtained immediately after the procedure was only 2.3, indicating that the procedure was well tolerated. The mean SNOT-20 score trended toward improvement during the first week, but then returned to near-preprocedure levels at 8 weeks. In conclusion, powered irrigation with suction is a well-tolerated procedure in the office setting and might be a useful short-term adjunct in the management of recalcitrant chronic sinusitis.

Endoscopic Corneal Neurotization: Cadaver Feasibility Study.

PURPOSE: The authors describe a cadaver feasibility study investigating a minimally invasive technique for corneal neurotization with the supraorbital nerve harvested endoscopically. METHODS: A cadaver study was performed to investigate the technical feasibility of corneal neurotization via endoscopic supraorbital nerve transfer to the corneoscleral limbus. RESULTS: Endoscopic corneal neurotization was successfully performed on each cadaveric hemiface. CONCLUSION: The use of an endoscope allows for a minimally invasive approach to corneal neurotization with the supraorbital nerve.

Endoscopic Corneal Neurotization: Technique and Initial Experience.

PURPOSE: The authors describe a minimally invasive surgical technique to re-establish corneal sensibility in a patient with neurotrophic keratopathy with the supraorbital nerve harvested endoscopically. METHODS: Pedicled contralateral supraorbital nerve was harvested endoscopically through small eyelid crease and scalp incisions and transferred to the affected eye. RESULTS: Endoscopic corneal neurotization was successfully performed with restoration of corneal sensibility and corneal epithelial integrity. CONCLUSIONS: The use of an endoscope allows for a minimally invasive approach to successful corneal neurotization with the supraorbital nerve.

Pneumatization Patterns of the Petrous Apex and Lateral Sphenoid Recess.

Introduction The petrous apex poses a challenge for surgical intervention due to poor access. As intraoperative image guidance and surgical instrumentation improve, newer endoscopic approaches are increasingly favored. This study aims to provide normative data on the anatomy of the lateral sphenoid sinus recess and petrous apex. These normative data could assist in determining the efficacy of a transnasal transsphenoidal approach to lesions of the anteroinferior petrous apex. Methods This is a retrospective study investigating normative data on all maxillofacial computed tomography (CT) scans performed at a level I trauma center over a 6-month period. All appropriate images had the pneumatization pattern of the petrous apex and lateral recess of the sphenoid sinus reviewed by a single otologist and graded bilaterally. These were then analyzed in SPSS; Pearson correlation analyses and χ 2 test were used. Results A total of 481 patients were identified, yielding a total of 962 temporal bones and sphenoid sinuses for analysis. Eighty-eight percent of sides analyzed had a nonpneumatized lateral recess. The petrous apex was nonpneumatized in 54% of sides analyzed. There was a correlation noted between the degree of pneumatization of the petrous apex and pneumatization of the lateral recess of the sphenoid. Conclusion This study is the first to provide normative data comparing pneumatization of the petrous apex and sphenoid sinus. These data may support future work evaluating the utility of an endonasal approach to the petrous apex.

Anterior inferior petrosectomy: defining the role of endonasal endoscopic techniques for petrous apex approaches.

OBJECT: Historically, surgery to the petrous apex has been addressed via craniotomy and open microscopic anterior petrosectomy (OAP). However, with the popularization of endoscopic approaches, the petrous apex can further be approached endonasally by way of an endoscopic endonasal anterior petrosectomy (EAP). Endonasal anterior petrosectomy is a relatively new procedure and has not been compared anatomically with OAP. The authors hypothesized that the EAP and OAP techniques approach different portions of the petrous apex and therefore may have different applications. METHODS: Four cadaveric heads were used. An OAP was performed on one side and an EAP was performed on the contralateral side; the limits of bony resection were defined. The extent of bony resection was then evaluated using predissection and postdissection thin-slice CT scans. The comparative resection was then reconstructed using 3D modeling on Brainlab workstations. RESULTS: The average resection volumes for EAP and OAP were 0.297 cm(3) and 0.649 cm(3), respectively, representing a comparative percentage of 46% (EAP/OAP). An EAP and OAP achieved resection of 29% and 64% of the total petrous apex volume, respectively. Indeed, EAP addressed the inferior portion of the petrous apex located adjacent to the petroclival suture more completely than OAP, where 45% of the bone overlying the petroclival suture (petroclival angle to the jugular foramen) was resected with the EAP, while 0% was resected with the OAP. CONCLUSIONS: In anatomically normal cadavers, OAP achieved nearly a 50% larger volumetric resection than EAP. Furthermore, while OAP appears to completely address the superior portion of the petrous apex, EAP appears to have a niche in approaches to lesions in the inferior petrous apex. Given these results, the authors propose that OAP be redefined as the "superior anterior petrosectomy," while EAP be referred to as the "inferior anterior petrosectomy," which more clearly defines the role of each approach in anterior petrosectomy.

Field of view comparison between two-dimensional and three-dimensional endoscopy.

OBJECTIVES/HYPOTHESIS: Relative to microscopic transnasal surgery, endoscopic surgery provides improved visualization with an increased field of view. Advances such as high-definition (HD) and three-dimensional (3D) endoscopy have been introduced and clearly improve visualization. However, do both technologies maintain an increased field of view? We hypothesize that the field of view of 3D endoscopy is restricted relative to two-dimensional (2D) HD endoscopy. STUDY DESIGN: Laboratory investigation, prospective case series. METHODS: Standard measurements at 6-cm and 2-cm working distances where made to determine the comparative field of view utilizing Storz 0° 2D HD and Visionsense 3D endoscopes. Relative measurements were then made to determine field of view. Five clinical patients were then utilized to confirm laboratory studies and demonstrate the relative field of view change. RESULTS: 3D endoscopy demonstrates a 52% loss of field of view compared to 2D endoscopy in a controlled lab testing. This was confirmed in a small clinical patient series where a 55% ± 3% relative field of view reduction was observed. CONCLUSIONS: When working with 3D endoscopy in a currently available commercial product, the operator should be aware that relative to HD 2D endoscopy, there is a field of view restriction of 52%. LEVEL OF EVIDENCE: N/A.

Polyethylene glycol (PEG) hydrogel dural sealant and collagen dural graft matrix in transsphenoidal pituitary surgery for prevention of postoperative cerebrospinal fluid leaks.

Cerebrospinal fluid (CSF) rhinorrhea is the most common complication after transsphenoidal pituitary surgery. The authors compare their previous experience using an autologous fat graft and lumbar drain placement in 107 patients with their current technique of using a dural sealant and collagen matrix in 97 patients to prevent postoperative CSF leak after pituitary tumor resection. The failure rate for CSF leak repairs between the two groups was similar. The use of a dural sealant and collagen matrix, however, has the advantages of decreased length of hospital stay, decreased length of Intensive Care Unit stay, avoidance of the morbidity of an extra abdominal incision, and avoidance of the risks of lumbar CSF drainage.

Head and neck cancer stem cells: the side population.

OBJECTIVES/HYPOTHESIS: The cancer stem cell (CSC) theory concludes that a subpopulation of cancer cells, the cancer stem cells, can self-renew and are responsible for tumor growth. Previous studies have identified cells able to efflux Hoechst 33342 dye as the side population (SP). SP cells and CSCs share many characteristics, suggesting the SP isolated from malignant tumors contains CSCs. STUDY DESIGN: Experimental Study. METHODS: The SP was isolated from a head and neck cancer cell line and analyzed for CSC-like characteristics. RESULTS: The SP demonstrated the ability to reproduce both SP and non-side population (NSP) cells from as few as one cell. The SP had lower expression of active ß-catenin and more resistance to 5-fluorouracil; the SP also demonstrated greater expression of Bmi-1 (4.3-fold) and ABCG2 (1.4-fold). SP cells were able to produce tumors in an animal model, whereas NSP were not. SPs were identified in two primary human tumors. CONCLUSIONS: This work adds to the evidence that the SP in head and neck cancer represents cells with CSC properties and provides a method by which CSCs can be isolated and studied.

The use of narrow band imaging in patients with benign disease: hereditary hemorrhagic telangiectasia.

SUMMARY: : Narrow band imaging (NBI) is a new type of imaging technology that enhances the visibility of blood vessels used in the detection of abnormal angiogenesis in preneoplastic and neoplastic lesions. This technique is used in the diagnosis and management of dysplastic and malignant endobronchial lesions. To our knowledge, this is the first description of the use of NBI to diagnose and manage benign lesions, hereditary hemorrhagic telangiectasia (HHT). The objective of this study was to implement NBI as a tool for use in the bronchoscopic visualization leading to the diagnosis and management of nonmalignant lesions in the tracheobronchial tree. This is including but not limited to HHT. NBI was used to detect the origin of significant hemoptysis in a patient with HHT. The patient had conventional white light (CWL) bronchoscopy, followed by NBI. NBI illuminated the abnormal blood vessels significantly better than CWL bronchoscopy. This led to a more effective diagnosis and management of the abnormal vessels causing the hemoptysis. NBI may provide a higher probability of locating abnormal endobronchial lesions in both benign and malignant diseases than CWL bronchoscopy. It can be used to treat these abnormal lesions as in our patient who presented with hemoptysis. A prospective study is needed to determine whether NMI and CWL are additive as in malignant disease. Furthermore, NBI can be used in lesions of the tracheobronchial tree and the gastrointestinal tract, and pleura, so that the appropriate management can be initiated.

Single-marker identification of head and neck squamous cell carcinoma cancer stem cells with aldehyde dehydrogenase.

BACKGROUND: In accord with the cancer stem cell (CSC) theory, only a small subset of cancer cells are capable of forming tumors. We previously reported that CD44 isolates tumorigenic cells from head and neck squamous cell cancer (HNSCC). Recent studies indicate that aldehyde dehydrogenase (ALDH) activity may represent a more specific marker of CSCs. METHODS: Six primary HNSCCs were collected. Cells with high and low ALDH activity (ALDH(high)/ALDH(low)) were isolated. ALDH(high) and ALDH(low) populations were implanted into NOD/SCID mice and monitored for tumor development. RESULTS: ALDH(high) cells represented a small percentage of the tumor cells (1% to 7.8%). ALDH(high) cells formed tumors from as few as 500 cells in 24/45 implantations, whereas only 3/37 implantations of ALDH(low) cells formed tumors. CONCLUSIONS: ALDH(high) cells comprise a subpopulation cells in HNSCCs that are tumorigenic and capable of producing tumors at very low numbers. This finding indicates that ALDH activity on its own is a highly selective marker for CSCs in HNSCC.

Probiotics as adjunctive treatment for chronic rhinosinusitis: a randomized controlled trial.

OBJECTIVE: To determine if oral probiotics as adjunctive treatment are more effective than placebo in improving quality of life in patients with chronic inflammatory rhinosinusitis. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. METHODS: A total of 77 patients with chronic inflammatory rhinosinusitis were randomly assigned to receive oral probiotic Lactobacillus rhamnosus R0011 strain (500 million active cells/tablet twice daily) (n = 39) or oral placebo treatment (n = 38) for 4 weeks. RESULTS: In the probiotic group, the mean change from baseline in the SNOT-20 scores was significant at 4 weeks (P = 0.002) but not at 8 weeks (P = 0.37). Rhinological domain improved by 9.3 percent (P = 0.004) in probiotics group but returned to baseline level at 8 weeks. No significant differences were found between the probiotic and placebo groups in mean changes from baseline to 4 weeks (P = 0.79) or from baseline to 8 weeks (P = 0.23). No changes in symptom frequency were noted, either within each group or between treatment groups at 4 and 8 weeks. There was no difference in medication use or side effects between the two study groups. CONCLUSION: Oral use of the probiotic strain L rhamnosus R0011 did not improve sinonasal quality-of-life scores in patients with chronic inflammatory rhinosinusitis compared with placebo.