Gilad Horowitz

Association between cerebrospinal fluid leak and meningitis after skull base surgery.

Background. Meningitis and cerebrospinal fluid (CSF) leak are serious complications of skull base surgery, but whether postoperative CSF leak increases the risk of meningitis is unknown. Objective. To evaluate any association between meningitis and CSF leak after open or endoscopic skull base resection. Study Design and Setting. A retrospective case series with chart review in a tertiary care university-affiliated medical center. Methods. A total of 156 patients underwent intradural tumor resection in our institution between 1994 and 2009, 135 (86%) via the subcranial approach and 21 (14%) through the expanded endonasal approach. All occurrences of meningitis, brain abscess, and CSF leak had been recorded and were available for analysis. Results. Nine patients (5.7%) had postoperative meningitis, and 3 patients had postoperative CSF leak (1.9%). The risk of meningitis in patients without CSF leak was 4.5% (7/153) compared to 66% (2/3) in those with CSF leak. A statistical analysis revealed a significant association between CSF leak and meningitis, with a relative risk of 14.6 (95% confidence interval, 4.95-42; P = .008). Conclusion. Postoperative CSF leak significantly increases the risk of meningitis. Most cases of meningitis after skull base operation are probably associated with lumbar drainage infection or from an obscure leak.

Reliability of a Transnasal Flexible Fiberoptic In-Office Laryngeal Biopsy

IMPORTANCE Transnasal fiberoptic laryngoscopy (TFL) has been used to guide various in-office procedures for the past 3 decades. Publications on in-office laryngeal biopsy have concurred that this procedure is safe, feasible, and easy to perform. However, the accuracy of in-office biopsy via TFL has not yet been established. The aim of this study was to examine this issue. OBJECTIVE To compare pathologic results obtained via in-office TFL with those of subsequent direct laryngoscopy to assess the accuracy of TFL as a diagnostic tool. DESIGN Prospective cohort study. SETTING Tertiary reference medical center. PARTICIPANTS One-hundred two patients with suspicious laryngeal lesions. INTERVENTION All patients underwent in-office biopsies. MAIN OUTCOME MEASURES All patients with malignant lesions were referred to appropriate services for treatment, and those with a diagnosis of a benign lesion or carcinoma in situ were referred for direct laryngoscopy for definitive diagnosis. The results of the pathologic testing on specimens from in-office and direct laryngoscopy were compared. RESULTS Adequate tissue for diagnostic purposes was obtained in 96 of 102 in-office TFL biopsies (94.1%). The biopsy results revealed invasive carcinoma in 34 patients (35.4%), carcinoma in situ in 17 patients (17.7%), and benign lesions in 45 patients (46.9%). All patients with benign lesions and carcinoma in situ were referred for biopsy of samples obtained using direct laryngoscopy, to which 57 patients agreed. The final pathologic results identified from the biopsies on direct laryngoscopy revealed that there was an underestimation of the TFL results in 30 of 91 patients (false-negative rate, 33.0%) and an overestimation in 1 patient (false-positive rate, 1.1%). The sensitivity of TFL biopsy compared with that of direct laryngoscopy biopsy was 69.2% and the specificity was 96.1%. CONCLUSIONS AND RELEVANCE Transnasal fiberoptic laryngoscopy yielded low sensitivity in assessing suspicious lesions of the larynx. These results may indicate that direct laryngoscopy represents the definitive pathologic diagnostic procedure whenever the pathologic results of an in-office TFL procedure are interpreted as benign or as carcinoma in situ.

Incidence of retropharyngeal calcific tendinitis (longus colli tendinitis) in the general population.

Objective To determine the incidence of retropharyngeal calcific tendinitis (longus colli tendinitis) in a general urban adult population. Study Design Observational study in a municipal medical center. Setting Single tertiary referral center. Methods All symptomatic patients with a differential diagnosis of retropharyngeal calcific tendinitis underwent fiber-optic assessment, laboratory studies, and imaging studies. The main outcome measure was the incidence of retropharyngeal calcific tendinitis. Results Thirteen patients with symptoms suggestive of retropharyngeal calcific tendinitis were evaluated in our institution between January 2008 and December 2011. Final diagnosis was made by means of a computed tomographic scan: 8 patients had retropharyngeal calcific tendinitis, 1 had retropharyngeal abscess, and the remaining 4 had other deep neck infections. The mean annual crude retropharyngeal calcific tendinitis incidence was 0.50 cases per 100,000 person-years, and the standardized incidence was 1.31 for the age-matched population. Conclusions Retropharyngeal calcific tendinitis is not a rare disease and is probably underdiagnosed because symptoms are nonspecific, treating physicians are often unfamiliar with this entity, and it is a self-limiting pathology.

Combination of pet imaging with viral vectors for identification of cancer metastases.

There are three main ways for dissemination of solid tumors: direct invasion, lymphatic spread and hematogenic spread. The presence of metastases is the most significant factor in predicting prognosis and therefore evidence of metastases will influence decision-making regarding treatment. Conventional imaging techniques are limited in the evaluation and localization of metastases due to their restricted ability to identify subcentimeter neoplastic disease. Hence, there is a need for an effective noninvasive modality that can accurately identify occult metastases in cancer patients. One such method is the combination of positron emission tomography (PET) with vectors designed for delivery of reporter genes into target cells. Vectors expressing the herpes simplex virus-1 thymidine kinase (HSV1-tk) reporter system have recently been shown to allow localization of micrometastases in animal models of cancer using non invasive imaging. Combination of HSV1-tk and PET imaging is based on the virtues of vectors which can carry and selectively express the HSV1-tk reporter gene in a variety of cancer cells but not in normal tissue. A radioactive tracer which is applied systemically is phosphorylated by the HSV1-tk enzyme, and as a consequence, the tracer accumulates in proportion to the level of HSV1-tk expression which can be imaged by PET. In this paper we review the recent developments in molecular imaging of micrometastases using replication-competent viral or nonviral vectors carrying the HSV1-tk gene using PET imaging. These diagnostic paradigms introduce an advantageous new concept in noninvasive molecular imaging with the potential benefits for improving patient care by providing guidance for therapy to patients with risk for metastases.

Elective neck irradiation versus observation in squamous cell carcinoma of the maxillary sinus with N0 neck: A meta-analysis and review of the literature

Elective neck irradiation of a clinical node‐negative (N0) neck in squamous cell carcinoma (SCC) of the maxillary sinus is a controversial issue.

Nasopharyngeal biopsy in adults: a large-scale study in a non endemic area.

BACKGROUND Limited data exist on the referral criteria for endoscopic-guided nasopharyngeal biopsy to rule out nasopharyngeal malignancy among adults in a non-endemic area. METHODS Retrospective study of all adult patients that had been referred to our outpatient clinic to undergo endoscopic-guided nasopharyngeal biopsy to exclude nasopharyngeal malignancy between 1/2006-10/2013. All medical consultation referral letters were reviewed, and statistical analyses were conducted to evaluate clinically significant predictors (demographics, clinical manife- stations, nasopharyngeal endoscopic findings) for nasopharyngeal malignancy. RESULTS A total of 470 patients (470 nasopharyngeal biopsies, 54.9% males and 66% smokers) were included. The most common pathological result was adenoid/lymphoid hyperplasia (76.2%). The overall negative rate of all biopsies for malignancy was 94.2%. Twenty-seven patients had nasopharyngeal malignancy: 22 had squamous cell carcinoma and 5 had non-Hodgkin`s lymphoma. Advanced age, cervical mass, and suspicious nasopharyngeal mass were independent risk factors for nasopharyngeal malignancy on univariate and multivariate analyses. CONCLUSIONS Nasopharyngeal biopsy may safely be avoided in adults living in a non-endemic area for NPC who are free of the risk factors of advanced age, the presence of a cervical mass, and suspicious nasopharyngeal mass.

The Transcervical Approach for Parapharyngeal Space Pleomorphic Adenomas: Indications and Technique

Background Head and Neck Parapharyngeal space tumors are rare. Pleomorphic Adenomas are the most common Parapharyngeal space tumors. The purpose of this study was to define preoperative criteria for enabling full extirpation of parapharyngeal space pleomorphic adenomas via the transcervical approach while minimizing functional and cosmetic morbidity. Methods The surgical records and medical charts of 19 females and 10 males with parapharyngeal space pleomorphic adenomas operated between 1993 and 2012 were reviewed. Results Fifteen patients were operated by a simple transcervical approach, 13 by a transparotid transcervical approach, and one by a transmandibular transcervical approach. Complications included facial nerve paralysis, infection, hemorrhage and first bite syndrome. There were three recurrences, but neither recurrence nor complications were associated with the type of surgical approach. Conclusion A simple transcervical approach is preferred for parapharyngeal space pleomorphic adenomas with narrow attachments to the deep lobe of the parotid gland and for pleomorphic adenomas originating in a minor salivary gland within the parapharyngeal space.

Cranialization of the frontal sinus for secondary mucocele prevention following open surgery for benign frontal lesions.

Objective To compare frontal sinus cranialization to obliteration for future prevention of secondary mucocele formation following open surgery for benign lesions of the frontal sinus. Study Design Retrospective case series. Setting Tertiary academic medical center. Patients Sixty-nine patients operated for benign frontal sinus pathology between 1994 and 2011. Interventions Open excision of benign frontal sinus pathology followed by either frontal obliteration (n = 41, 59%) or frontal cranialization (n = 28, 41%). Main Outcome Measures The prevalence of post-surgical complications and secondary mucocele formation were compiled. Results Pathologies included osteoma (n = 34, 49%), mucocele (n = 27, 39%), fibrous dysplasia (n = 6, 9%), and encephalocele (n = 2, 3%). Complications included skin infections (n = 6), postoperative cutaneous fistula (n = 1), telecanthus (n = 4), diplopia (n = 3), nasal deformity (n = 2) and epiphora (n = 1). None of the patients suffered from postoperative CSF leak, meningitis or pneumocephalus. Six patients, all of whom had previously undergone frontal sinus obliteration, required revision surgery due to secondary mucocele formation. Statistical analysis using non-inferiority test reveal that cranialization of the frontal sinus is non-inferior to obliteration for preventing secondary mucocele formation (P<0.0001). Conclusion Cranialization of the frontal sinus appears to be a good option for prevention of secondary mucocele development after open excision of benign frontal sinus lesions.

A Novel Radiographic Sign and a New Classifying System in Mastoiditis-Related Epidural Abscess.

Objective To describe a novel radiographic sign (“halo”) and a new classification method of an evolving perisigmoid epidural abscess and present its correlation with intraoperative findings. Study Design Retrospective and prospective cohort study in a tertiary academic children’s hospital. Methods The retrospective arm (15 children) was conducted between 1998 and 2007 and the prospective arm (11 children) between 2008 and 2013. The computerized tomographic appearance of the perisigmoid region was classified into four groups: Class I, normal; Class II, smooth halo; Class III, nodular halo 4 mm or less in diameter; and Class IV, gross nodular halo more than 4 mm in diameter. Intraoperative findings of the perisigmoid region were compared with the preoperative scan results. Results The correlation between preoperative imaging and intraoperative findings of the retrospective arm was highly significant (p = 0.007). The correlation between the preoperative imaging studies and intraoperative findings of the prospective arm was also highly significant (p = 0.005). The interobserver agreement for the proposed classification method was high (Cohen kappa score, 0.76; weighted kappa score, 0.84). Conclusion A novel radiographic sign (“halo”) and a new classification method for an evolving perisigmoid epidural abscess in acute mastoiditis are described. A thin and smooth halo sign is not indicative of a true abscess formation. Gross perisigmoid granular changes, however, are highly suggestive of an epidural abscess that warrants surgical intervention.

Symptoms, Signs and Physical Examination of Patients with Skull Base Tumours

The clinical presentation of skull base tumours (SBTs) varies greatly and relates directly to the location and growth rate of the lesion. Signs and symptoms can often be misleading and initially interpreted as being infectious or benign diseases. A major limiting factor in the treatment of SBTs is their close proximity to sensitive organs such as the brain stem, chiasm, optic nerves and spinal cord. Complete tumour resection is considered the primary treatment modality for most lesions [1]. Therefore, it is imperative to establish a diagnosis shortly after the appearance of symptoms, as late diagnosis can lead to a worsening prognosis.