Brian D. Thorp

Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak.

Endoscopic skull base surgery continues to rapidly evolve, requiring comparable advances in reconstructive techniques. While smaller skull base defects with low intraoperative CSF flow have been successfully managed with a variety of avascular and/or noncellular techniques, larger defects with high CSF flow require more robust repairs often in the form of vascularized flaps, which confer excellent success rates in this setting. Despite these successful outcomes, a paucity of data describing specific patient and operative characteristics and their effects on repair exist. Therefore, a retrospective, consecutive chart review was performed on patients who underwent endoscopic skull base reconstruction with a vascularized flap in the setting of intraoperative CSF leaks. In this series, 151 patients with a mean age of 51 years underwent 152 vascularized flap skull base reconstructions for an array of benign and malignant pathologies. These vascularized flaps included 144 nasoseptal flaps, 6 endoscopic-assisted pericranial flaps, 1 facial artery buccinator flap, and 1 inferior turbinate flap that were used throughout all regions of the skull base. Perioperative (< 3 months) and postoperative (> 3 months) flap complications were assessed and revealed 3 perioperative flap defects (2.0%) defined as a visualized defect within the substrate of the flap and a total of 5 perioperative CSF leaks (3.3%). No patient experienced flap death/complete flap loss in the cohort. Assessed postoperative flap complications included 1 case (0.7%) of mucocele formation, 8 cases (5.3%) of prolonged skull base crusting, and 2 cases (1.3%) of donor-site complication, specifically septal perforation secondary to nasoseptal flap harvest. Among the 152 cases identified, 37 patients received radiation therapy while 114 patients did not undergo radiation therapy as part of the treatment profile. No significant association was found between perioperative complication rates and radiation therapy (p = 0.634). However, a significant association was found between postoperative complication rates and radiation therapy, primarily accounted for by an increased risk for prolonged (> 6 months) skull base crusting (p = 0.025). It is clear that larger skull base defects with high intraoperative CSF flow require thoughtful approach and strong consideration for vascularized repair.

Reconstructive options for endoscopic skull base surgery

This review describes the sequential learning from initial free tissue grafting reconstructive techniques to the current use of vascularized flaps. Outcomes and limitations of current endoscopic reconstructive techniques are discussed, including a systematic review of the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). The various endoscopic techniques for local and regional flaps in skull base reconstruction are described. Additionally, EMBASE (1980-December 7, 2010) and Medline (1950 - November 14, 2010) were searched using a search strategy designed to include any endoscopic endonasal reconstruction of the skull base. The manuscripts selected were subject to full text review to extract data on perioperative outcomes for ESBR. Surgical technique was used for sub-group analysis.

Outcome results of endoscopic vs craniofacial resection of sinonasal malignancies: a systematic review and pooled-data analysis†

Endoscopic approaches of sinonasal malignancies are now being described. This study aims to conduct a systematic review with a pooled‐data analysis to compare outcomes of endoscopic vs craniofacial resection of sinonasal malignancies.

Single‐blind randomized controlled trial of surfactant vs hypertonic saline irrigation following endoscopic endonasal surgery

Recent discussion has revolved around formulations of irrigation in the postoperative functional endoscopic sinus surgery patient, specifically the efficacy of emulsion based nasal irrigations.

Comparison of Socioeconomic and Demographic Factors in Patients with Chronic Rhinosinusitis and Allergic Fungal Rhinosinusitis

Objective The primary objective of this study is to evaluate the differences in socioeconomic, demographic, and disease severity factors between patients with chronic rhinosinusitis (CRS) and those with allergic fungal rhinosinusitis (AFRS). Study Design A retrospective cohort analysis was performed. Setting The study was conducted at the hospital of the University of North Carolina at Chapel Hill. Subjects and Methods A total of 186 patients were included (93 AFRS, 93 CRS with and without nasal polyps). Socio- economic and demographic data were obtained from the North Carolina State Data Center. Indicators of disease severity were measured by Lund-Mackay scores, serum immunoglobulin E (IgE) levels, diagnosis of asthma and/or allergic rhinitis, and the number of surgeries and computed tomography scans performed. Associations were analyzed with Fisher’s exact, Wilcoxon rank sum, and Pearson’s correlations tests. Results Compared with patients with AFRS, patients in both CRS groups were predominantly white (P < .0001), were older at the time of diagnosis (P < .0001), had higher county-based income per capita (P = .004), had lower quantitative serum IgE level (P < .001), and had lower Lund-Mackay scores (P < .0001). No associations between disease severity, socioeconomic status, and demographic factors were found within the CRS groups. Conclusion Within our cohort of patients residing in North Carolina, those with CRS have higher income, more access to primary care, and lower markers of disease severity than those with AFRS. These data continue to support the notion that AFRS merits classification as a distinct subtype of CRS.

Endoscopic Resection of Sinonasal Malignancy A Systematic Review and Meta-analysis

Objectives The use of endoscopic approaches for sinonasal malignancy resection has increased, but survival data are limited secondary to disease rarity and new surgical technique. Here we present a systematic review and meta-analysis of endoscopic endonasal resection of sinonasal malignancy. Data Sources MEDLINE, PubMed Central, NCBI Bookshelf, Cochrane Library, clinicaltrials.gov, National Guideline Clearinghouse. Review Methods PRISMA/MOOSE guidelines were followed. MeSH terms were “endoscopic” AND (“esthesioneuroblastoma” OR “sinonasal adenocarcinoma” OR “squamous cell carcinoma” OR “sinonasal undifferentiated carcinoma”). For studies in which individual-level data were available, results were obtained by direct pooling. For studies in which only summary Kaplan-Meier curves were available, numerical data were extracted, traced, and aggregated by fitting a Weibull model. Results Of 320 studies identified, 35 case series were included (n = 952 patients), with 15 studies analyzed via aggregate modeling and 20 studies analyzed via direct pooling. Two- and 5-year survival rates for patients in aggregate modeling were 87.5% and 72.3%, respectively (mean follow-up: 32.9 months). Two- and 5-year survival for patients in direct pooling were 85.8% and 83.5%, respectively (mean follow-up: 43.0 ± 19.5 months). Significant overall survival difference was found between low- and high-grade cancers (P = .015) but not between low- and high-stage cancers (P = .79). Conclusion Overall 2- and 5-year survival rates are comparable and sometimes greater than those from open craniofacial resection. Survival rates significantly differ by cancer grade but not stage. Journals and investigators should be encouraged to publish retrospective and prospective case series with staged survival updates based on established guidelines.

Expression of protease-activated receptors in allergic fungal rhinosinusitis

The etiology of the intense inflammatory response showed by patients with allergic fungal rhinosinusitis (AFRS) remains a mystery. Potential sources of this inflammation may include fungal proteases. Protease‐activated receptors (PARs) are components of the innate immune response that are modulated by proteolytic activity and are involved in potentiating T helper 2 (Th2) responses. The objective of the study was to determine whether there is differential expression of PARs in patients with AFRS compared to controls.

Markers of disease severity and socioeconomic factors in allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a refractory subtype of chronic rhinosinusitis. There is a paucity of data investigating the association of epidemiologic markers of disease severity. The primary objective of this study is to evaluate components of disease severity with socioeconomic status and health care access.

Chronic Rhinosinusitis in Children

Chronic rhinosinusitis (CRS) affects nearly 37 million people in the United States each year and accounts for approximately

Allergic fungal sinusitis in children.

6 billion in direct and indirect health care costs. Despite its prevalence and significant impact, little is known about its exact cause and pathophysiology, and significant controversy remains regarding appropriate treatment options. Basic science research, however, has shown recent promise toward improving understanding of the innate and environmental factors underlying the pathophysiology of CRS. The hope is that this will also lead to advances in treatment for children adversely affected by this common yet complicated disease.