Arjuna B. Kuperan

Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks

The advances in endoscopic skull base surgery have led to the resection of increasingly larger cranial base lesions and the creation of larger skull base defects with the potential for increased postoperative high‐flow cerebrospinal fluid (CSF) leaks. These concerns led to the development of the vascularized pedicled nasoseptal flap (PNSF), which is now used as the mainstay for repair of large skull base defects in many academic centers. In this report, we review the incidence of postoperative CSF leaks in our institution in patients undergoing endoscopic skull base repair of high‐flow CSF leaks with a vascularized PNSF without concurrent CSF diversion.

Endoscopic nasoseptal flap repair of skull base defects: is addition of a dural sealant necessary?

Objective We compared the incidence of postoperative cerebrospinal fluid (CSF) leaks in patients undergoing endoscopic skull base repair with a pedicled nasoseptal flap (PNSF) with or without the addition of a dural sealant. Study Design and Setting Retrospective analysis at a tertiary care medical center. Methods A retrospective analysis was performed at our tertiary care medical center on patients who underwent endoscopic repair of high-flow CSF leaks using a PNSF between December 2008 and August 2011. Repair materials, incidence of postoperative CSF leaks, and demographic data were collected. Results Thirty-two high-flow CSF leaks were repaired with a PNSF alone without dural sealant (group A), and 42 were repaired with a PNSF with the addition of a dural sealant (group B). In group A, there were no postoperative CSF leaks (0%), whereas in group B, there was 1 delayed postoperative CSF leak, resulting in a 2.4% leak rate. The incidence of postoperative CSF leakage was not significantly different between the 2 groups (P = .38). The overall postoperative CSF leak rate was 1.4%. Conclusions The use of dural sealants when performing endoscopic PNSF repair of high-flow CSF leaks is not supported by our data. In addition, this practice may significantly increase surgical cost. We encountered no postoperative CSF leaks in patients with high-flow CSF leaks treated with PNSF alone without dural sealants. Meticulous surgical technique and proper positioning of the PNSF seem to obviate the need for dural sealants during endoscopic skull base reconstruction of high-flow CSF leaks.

Nasoseptal flap repair after endoscopic transsellar versus expanded endonasal approaches: Is there an increased risk of postoperative cerebrospinal fluid leak?†‡

The development of expanded endoscopic endonasal approaches (EEAs) has allowed resection of cranial‐base lesions beyond the sella. One major criticism is an increased risk of postoperative cerebrospinal fluid (CSF) leakage because of the larger skull base defect. We evaluated our experience with vascularized pedicled nasoseptal flap (PNSF) reconstruction and compared the postoperative CSF leak rates between patients undergoing endoscopic transsphenoidal (transsellar) approaches versus expanded EEA (transplanum‐transtuberculum, transcribriform, transclival).

Modified Hemi-Lothrop Procedure for Supraorbital Frontal Sinus Access: A Case Series

T he lateral recess or supraorbital region of the frontal sinus (FS; pneumatization of the FS over the orbit) is difficult to access endoscopically. Surgical intervention to this region is often limited to external approaches or advanced endoscopic techniques such as the endoscopic modified Lothrop procedure (EMLP). Recently, we described a modification of the EMLP termed the modified hemi-Lothrop procedure (MHLP), which limits the dissection of the EMLP to the ipsilateral diseased FS, thereby sparing the natural drainage pathway of the contralateral nondiseased FS. In this study, we investigate the effectiveness of the MHLP and provide our experience with 15 patients who underwent this technique.

Modified mini-Lothrop/extended Draf IIB procedure for contralateral frontal sinus disease: a cadaveric feasibility study.

T he endoscopic modified Lothrop procedure (EMLP) and Draf IIB are advanced endoscopic approaches used to access recalcitrant frontal sinus (FS) disease. However, in select cases, anatomic variations may hinder access using these traditional endoscopic approaches. In fact, neither of these techniques specifically addressed patients with unilateral inaccessible FS recesses. We propose a hybrid modification of the EMLP and Draf IIB techniques, which we titled the modified mini-Lothrop procedure (MMLP) or extended Draf IIB procedure to manage FS disease in patients with inaccessible ipsilateral FS recess through a contralateral approach. In contrast to external FS procedures or a combined external trephination and endoscopic approach demonstrated in previous literature, we offer a purely endoscopic means of addressing this select patient population.

Management of hyoid bone fractures: a systematic review.

Objective Fractures of the hyoid bone are rare occurrences. They are mainly caused by strangulation/asphyxiation injuries, trauma to the neck, and motor vehicle accidents (MVAs). As a result of their rarity, proper treatment guidelines are not in place for dealing with these injuries. In this study, a systematic literature review was conducted with the goal of identifying optimal management for patients with fracture of the hyoid bone. Data Sources MEDLINE and PubMed databases. Review Methods The MEDLINE and PubMed databases were searched for patients diagnosed with hyoid bone fracture. Further cases were obtained from the bibliographies of relevant articles. Full-text articles were obtained. Patient presentation, method of diagnosis, treatment regimen, and outcomes are discussed. Results Forty-six cases were collected from 36 articles. No randomized controlled trials regarding treatment of hyoid fractures were found. The most common etiologies were MVA, assault, and neck trauma during athletic activities. Most common presenting symptoms included dysphagia, odynophagia, and pain upon neck rotation. Most frequent presenting signs included anterior neck tenderness and swelling. Five cases out of 46 had surgical repair of the fractured hyoid bone. In the remaining 41 cases, 26 were treated with conservative management, which included rest/observation, diet changes, and analgesia, while the other 15 cases required tracheotomy or surgical treatment for related injuries. All patients survived and had excellent outcomes with resolution of symptoms. Conclusion This review shows that direct surgical treatment of hyoid fractures was performed in only 10.9% of cases. Both conservative and surgical management yielded positive outcomes.

Case report of a congenital lingual leiomyomatous hamartoma: new epidemiologic findings and a review of the literature.

We present an unusual case of a lingual leiomyomatous hamartoma, along with a current literature review of this previously under reported lesion. Described is a case of a 5 month-old male presenting with a posterior midline tongue mass and surgical excision yielded pathology consistent with a leiomyomatous hamartoma. A comprehensive literature review revealed thirty-nine cases of leiomyomatous hamartomas, a number much greater than previously reported. We conclude that these rare lesions are notably twice as common as previously reported and have equal gender predilection.

Thymopharyngeal duct cyst: a case presentation and literature review.

The differential diagnosis of a lateral cystic neck mass includes branchial cleft cysts and lymphangiomas. Cervical thymic cysts are rare, and thymopharyngeal duct cysts, which maintain a connection to the pharynx, are rarer still. We present an interesting case of a 6 year-old male who developed acute onset of a left-sided neck mass. CT and MRI findings revealed a multiloculated cyst closely associated with the left lobe of the thyroid gland with a tract extending up along the carotid sheath to the pyriform sinus. Complete surgical excision was performed. The anatomic location and pathology were consistent with a thymopharyngeal duct cyst. The embryology, clinical presentation, radiologic and pathologic findings, and surgical management of thymopharyngeal duct cysts will be discussed.

Utility of a rotation–suction microdebrider for tumor removal in endoscopic endonasal skull base surgery

The microdebrider is a common tool used in endoscopic sinus surgery for removing polypoid and sinonasal tissue. It uses rotating blades and an integrated suction device for controlled removal of tissue under video-endoscopic visualization. To our knowledge, the application of the microdebrider for endoscopic removal of skull base tumors has not been reported. This study aimed to investigate the utility of the rotation-suction microdebrider as a tool for endoscopic endonasal removal of solid and fibrous skull base tumors. Thirty-two patients underwent endoscopic endonasal skull base surgery where the rotation-suction microdebrider was used as the primary tool for tumor removal and debulking. Pathologies included a variety of anterior skull base meningiomas, sinonasal skull base malignancies, juvenile nasopharyngeal angiofibromas, schwannomas, and other skull base lesions. Gross total and near total removal was achieved in 87.5% (28/32) of patients, and subtotal removal was performed in 12.5% (4/32) of patients. The microdebrider allowed efficient debulking and removal of solid and fibrous tumors, such as meningiomas, that were not responsive to standard ultrasonic aspiration. There were no complications of orbital or neurovascular injury, or thermal injury to the nostril. The rotation-suction microdebrider is a useful tool for endoscopic endonasal removal of skull base tumors. This is particularly useful for solid and fibrous tumors that are not responsive to standard ultrasonic aspiration. For intracranial tumors, it is critical to remain inside the tumor capsule during debulking so as to avoid injury to the surrounding neurovascular structures.

Safety of cranial fixation in endoscopic brow lifts

INTRODUCTION The endoscopic brow lift technique relies on brow mobilization and often soft fixation to the underlying calvarium. While the endoscopic brow lift has been used safely, there are anecdotal reports of cerebrospinal fluid leak. We sought to measure calvarial thickness to improve the safety of cranial fixation. METHODS A retrospective review was performed of T2 weighted MRIs of the face of 28 patients. Calvarial thickness was measured on 10 coronal planes, from 3 centimeters (cm) anterior to 6 cm posterior to coronal suture. Fifteen points were measured on each coronal plane, starting in the midline and extending laterally for 7 cm. There were a total of 150 calvarial measurements per patient, covering the surface area used in endoscopic brow lifts. Statistical comparison was performed using analysis of variance. RESULTS Cranial thickness ranged from 1.1 to 13.6mm, with a mean of 6.1mm. The skull was thickest 2-4 cm posterior to the coronal suture, and thinnest 1cm anterior to the coronal suture. The cranium thins as it extends laterally, with an average thickness of 5.0mm at seven centimeters from midline. Average skull thickness for males was 5.96 versus 6.16 in females. There was no relationship between age and skull thickness. CONCLUSION Cranial thickness increases medially and posteriorly, and is larger for females compared with their male counterparts. Given the risk of CSF leak, surgeons need to be aware of how cranial thickness varies by location along the skull.