Alfred Iloreta

The presentation and outcomes of mucosal melanoma in 695 patients

Most data on sinonasal mucosal melanoma come from small institutional studies, and therefore optimal treatment methods are not well understood. The purpose of this study was to analyze the association between treatment and survival in sinonasal mucosal melanoma.

Racial, ethnic, and socioeconomic disparities in pituitary surgery outcomes

To investigate the association of race, ethnicity, socioeconomic status, and hospital volume with outcomes in pituitary surgery.

Cost of management in epistaxis admission: Impact of patient and hospital characteristics.

To investigate patient and hospital characteristics associated with increased cost and length of stay in the inpatient management of epistaxis.

An evaluation of invasive fungal sinusitis outcomes with subsite analysis and use of frozen section analysis

Invasive fungal sinusitis (IFS) is an aggressive mycosis of the nasal cavity with frequent extension to adjacent structures. Occurring more commonly in immunocompromised individuals, prognosis is typically poor despite aggressive treatment. This study aims to examine postoperative outcomes and survival of a cohort of fungal sinusitis patients at an academic center, as well as identify causes of death in IFS patients.

Endoscopic‐assisted transmastoid decompression of petrous apex cholesterol granuloma

INTRODUCTION Cholesterol granuloma is one of the most common abnormalities of the petrous apex. It is a benign slowgrowing expanding cystic mass that contains fluid, lipid, and cholesterol crystals and is surrounded by a fibrous lining. The granuloma arises from a pneumatized petrous apex that becomes obstructed. It most commonly arises from the central petrous apex; however, it has been found at other subsites of the temporal bone. The obstruction creates a vacuum that causes blood to be drawn into the air cells. Cholesterol in the hemoglobin is released as red blood cells are broken down. The immune system reacts to the cholesterol as a foreign body producing an inflammatory response. Associated small blood vessels rupture as a result of the inflammation. Recurrent hemorrhaging causes the mass to expand. Most patients present with subtle symptoms of headache and pain; however, larger lesions can present with cranial neuropathies, tinnitus, and hearing loss. Asymptomatic patients in whom petrous apex cholesterol granuloma (PACG) is incidentally discovered do not need treatment. Treatment for symptomatic lesions is primarily surgical, with the goal of decompressing and draining the lesion, thereby providing aeration to the petrous apex while avoiding or minimizing destruction of normal structures. The traditional approaches to these tumors is via a corridor created by a surgical dissection through the temporal bone employing the infralabyrinthine, infracochlear, middle fossa, and/or retrolabyrinthine approaches. In severe cases, the translabyrinthine and/or transcochlear approaches may be employed. With the recent advancement in endoscopic anterior skull base surgery, medial approaches to the petrous apex via a transsphenoid or transpterygoid approach have been described. This is used when there is excellent pneumatization of the ipsilateral sphenoid sinus and the carotid artery is not between the sphenoid sinus and the lesion. Unlike cholesteatoma, PACGs only require drainage and do not need complete removal. The approach to these lesions is dependent on patient anatomy and the size and location of the cholesterol granuloma. Each approach carries its own set of risks, which can be as great as complete hearing loss, facial nerve palsy or paralysis, necessity for brain retraction, and cranial nerve or neurovascular injury. We describe a technique in which we approached the lesion via an infralabyrinthine approach through the temporal bone, and employed a 30-degree endoscope and angled instrumentation to access and drain the lesion.

Surgical pathway seeding of clivo-cervical chordomas.

Objective Clival chordomas are slow-growing aggressive tumors that originate from the extra-axial remnants of the notochord. Current management of these tumors use surgical resection combined with radiation therapy. Given the location and invasive nature of these tumors, complete resection is difficult. A variety of both open and endoscopic therapeutic approaches have evolved and combined with the improvements in proton therapy, long-term control of these tumors appears to be improving. However, in recent literature the relatively rare complication of surgical seeding or surgical pathway recurrence has been reported. We report a case of surgical seeding following primary resection and review the world literature regarding surgical pathway recurrence. Study Design Retrospective chart review and review of current literature. Methods We report a case of a patient with a large chordoma that required treatment with a staged endoscopic endonasal and external transcervical approach. The patient subsequently developed recurrent disease along the cervical skin incision due to surgical seeding. Literature review and case reports were identified by a comprehensive search of Medline for the years 1950 to 2012. Results The overall surgical pathway recurrence rate for clival chordoma resection based on analysis of the open nonendoscopic published case studies was 14 of 497 (2.8%). Conclusion Tumor seeding can occur anywhere along the operative route and is often outside the field of radiotherapy. Increased awareness of this rare occurrence is necessary. The use of novel techniques to minimize exposure to tumor including primary endoscopic resection and so-called clean oncologic technique may help limit tumor seeding. Level of evidence: 4.

Treatment modalities in sinonasal undifferentiated carcinoma: an analysis from the national cancer database.

Sinonasal undifferentiated carcinoma (SNUC) is a rare, aggressive malignancy of unknown etiology with a poor overall prognosis. Its relative rarity has made it difficult to determine the impact of different treatment modalities on survival.

Immersive virtual reality as a teaching tool for neuroanatomy

Three‐dimensional (3D) computer modeling and interactive virtual reality (VR) simulation are validated teaching techniques used throughout medical disciplines. Little objective data exists supporting its use in teaching clinical anatomy. Learner motivation is thought to limit the rate of utilization of such novel technologies. The purpose of this study is to evaluate the effectiveness, satisfaction, and motivation associated with immersive VR simulation in teaching medical students neuroanatomy.

Mandibular osteotomy for expanded transoral robotic surgery: A novel technique

Transoral Robotic Surgery (TORS) has revolutionized the surgical treatment of malignant lesions of the oropharyngeal region. Recent studies have shown that this approach is a very safe procedure and can provide favorable clinical and functional outcomes with respect to traditional approaches. However, a small minority of patients who present with lesions amenable to TORS resection may not be candidates due to anatomical access issues. Anatomic features such as a retrognathic mandible, macroglossia, trismus, dentition, and small oral aperture limit the ability to perform TORS with current technology. We propose a modified TORS approach in which transoral mandibular osteotomies are performed that can greatly improve exposure to oropharyngeal subsites and expand access to the larynx in selected patients.

Incentive Spirometry for the Tracheostomy Patient

Objective To determine the feasibility of developing and using a customized incentive spirometer device for patients who have undergone a tracheostomy procedure. Study Design The authors performed a prospective case series approved by the institutional review board. Setting Academic medical center. Subjects and Methods Patients were eligible for participation if they were older than 18 years and had a new tracheostomy. Spirometry exercises were performed using a protocol adapted from the American Academy of Respiratory Care guidelines. Patient data were recorded, including age, sex, tobacco use, surgical procedure, time under general anesthesia, length of hospital stay, and time until ambulation. The details of the spirometry exercises were also recorded along with any complications that occurred. Results An incentive spirometer was adapted for use with tracheostomy patients and received an investigational device exemption from the Food and Drug Administration. A total of 10 patients were enrolled (mean age 60 years). Sixty percent were current or former tobacco users, the mean anesthesia time was 9 hours, and 70% underwent a microvascular free flap reconstruction. Patients used the incentive spirometer for a mean of 1.6 days during the postoperative period, averaging 3.3 sessions per day and 6.8 breaths per session. The device was well tolerated by patients, and there were no complications associated with its use. Conclusion This study supports the feasibility of using a customized incentive spirometer for tracheostomy patients and establishes a safety profile for the device to be used in future studies.