Jessica W. Grayson

Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks

Spontaneous cerebrospinal fluid (CSF) leaks are associated with increased intracranial pressure (ICP) and considered a manifestation of idiopathic intracranial hypertension. Although postoperative acetazolamide and placement of CSF shunt systems are considered valuable interventions for elevated ICP, the impact on recurrence rate remains unclear. The objective of this study was to systematically review evidence from reported literature to evaluate whether postoperative ICP management reduces recurrence rates after primary endoscopic repair.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair

Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case‐series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques.

Effect of Overlapping Operations on Outcomes in Microvascular Reconstructions of the Head and Neck

Objective To compare outcomes after microvascular reconstructions of head and neck defects between overlapping and nonoverlapping operations. Study Design Retrospective cohort study. Setting Tertiary care center. Subjects and Methods Patients undergoing microvascular free tissue transfer operations between January 2010 and February 2015 at 2 tertiary care institutions were included (n = 1315). Patients were divided into 2 cohorts by whether the senior authors performed a single or consecutive microvascular reconstruction (nonoverlapping; n = 773, 59%) vs performing overlapping microvascular reconstructions (overlapping; n = 542, 41%). Variables reviewed were as follows: defect location, indication, T classification, surgical details, duration of the operation and hospitalization, and complications (major, minor, medical). Results Microvascular free tissue transfers performed included radial forearm (49%, n = 639), osteocutaneous radial forearm (14%, n = 182), anterior lateral thigh (12%, n = 153), fibula (10%, n = 135), rectus abdominis (7%, n = 92), latissimus dorsi (6%, n = 78), and scapula (<1%, n = 4). The mean duration of the overlapping operations was 21 minutes longer than nonoverlapping operations (P = .003). Mean duration of hospitalization was similar for nonoverlapping (9.5 days) and overlapping (9.1 days) cohorts (P = .39). There was no difference in complication rates when stratified by overlapping (45%, n = 241) and nonoverlapping (45%, n = 344) (P = .99). Subset analysis yielded similar results when minor, major, and medical complications between groups were assessed. The overall survival rate of free tissue transfers was 96%, and this was same for overlapping (96%) and nonoverlapping (96%) operations (P = .71). Conclusions Patients had similar complication rates and durations of hospitalization for overlapping and nonoverlapping operations.

Assessment of acquired mucociliary clearance defects using micro-optical coherence tomography

Dehydration of airway surface liquid (ASL) disrupts normal mucociliary clearance (MCC) in sinonasal epithelium, which may lead to chronic rhinosinusitis (CRS). Abnormal chloride (Cl−) transport is one such mechanism that contributes to this disorder and can be acquired secondary to environmental perturbations, such as hypoxia at the tissue surface. The objective of this study was to assess the technological feasibility of the novel micro‐optical coherence tomography (μOCT) imaging technique for investigating acquired MCC defects in cultured human sinonasal epithelial (HSNE) cells.

Management Strategies for Skull Base Inverted Papilloma

Objective Inverted papilloma attached to the ventral skull base presents a surgical dilemma because surgical removal of the bony pedicle is critical to decrease risk of recurrence. The objective of this study is to evaluate the effectiveness of endoscopic management of skull base inverted papilloma. Study Design Case series with planned data collection. Setting Tertiary medical center. Subjects Patients with skull base inverted papilloma. Methods Over 7 years, 49 patients with skull base inverted papilloma were referred for surgical resection. Demographics, operative technique, pathology, complications, recurrence, and postoperative follow-up were evaluated. Results Average age at presentation was 57 years. Twenty-six patients (53%) had prior attempts at resection elsewhere, and 5 had squamous cell carcinoma (SCCA) arising in an inverted papilloma. Six patients (12%) suffered major complications, including skull base osteomyelitis in 2 previously irradiated patients, cerebrospinal fluid leak with pneumocephalus (n = 1), meningitis (n = 1), invasive fungal sinusitis (n = 1), and cerebrovascular accident (n = 1). The mean disease-free interval was 29 months (range, 10-78 months). One patient with SCCA recurred in the nasopharynx (overall 2% recurrence rate). He is disease-free 3 years following endoscopic nasopharyngectomy. Three patients with SCCA had endoscopic resection of the skull base, while 1 subject with inverted papilloma pedicled on the superior orbital roof had an osteoplastic flap in conjunction with a Draf III procedure. All others received endoscopic resection. Conclusions Removal of the bony pedicle resulted in excellent local control of skull base inverted papillomas. Our experience demonstrates that disease eradication with limited morbidity is attainable with this approach.

Response to: Letter to the Editor regarding “Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair”

Thank you for the opportunity to respond to Shankar et al.’s letter to the editor regarding our article titled “Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair” (Int Forum Allergy Rhinol. 2017;7:441–449.). The authors suggest that the study is biased toward the success of the endoscopic approach due to the sample size of 48 patients, average fracture size of 1 cm, and average clinical follow up of 28 months. Current surgical dogma within the plastic surgery,1 oral maxillofacial,2 and otolaryngology3 literature dictates that frontal sinus posterior table fractures must be routinely obliterated or cranialized and anterior table fractures treated with open reduction; however, we clearly show that this is not the case for many of these fractures. We do not propose that transnasal endoscopic repair completely replace open approaches. As noted in our algorithm,4 there are patients that do not fit our criteria for the endoscopic approach (eg, intracranial injury requiring neurosurgical intervention). This approach is also solely under the purview of otolaryngologists—specifically those who are proficient at endoscopic frontal sinus surgery. The authors are also mistaken that larger frontal defects have not been included in the study. Fractures spanning the entire bilateral posterior table are in this series as noted in Figure 1C,F of the article. We have a wide range of clinical follow-up that is mostly attributed to our hospital being the only level 1 trauma center in our state (service to 7 million people). Some patients have limited follow-up due to distance and limitations to care, others have more pressing posttraumatic issues, or they are monitored by an otolaryngologist near their home. However, follow-up after obliteration or cranialization is similarly limited, and most reported literature has a similar range of follow-up—some as short as an average of 9 months.5 One of the reasons for obliterating a sinus is to prevent mucocele formation when, in fact, mucocele rates are suspected to be as high as 25%.6 When using modern techniques and expertise, frontal sinus closure after Draf 2b or Draf 37 is likely to be much lower than the rate of mucocele formation observed when an open approach is employed and the sinus obliterated.

Sinus hypoplasia in the cystic fibrosis rat resolves in the absence of chronic infection

Sinus hypoplasia is a hallmark characteristic in cystic fibrosis (CF). Chronic rhinosinusitis (CRS) is nearly universal from a young age, impaired sinus development could be secondary to loss of the cystic fibrosis transmembrane conductance regulator (CFTR) or consequences of chronic infection during maturation. The objective of this study was to assess sinus development relative to overall growth in a novel CF animal model.

In response to in reference to intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks : Letter to the Editor

Thank you for the chance to respond to MangussiGomes et al.’s letter concerning our article entitled “Intervention for Elevated Intracranial Pressure Improves Success Rate After Repair of Spontaneous Cerebrospinal Fluid Leaks.” Mangussi-Gomes et al. have brought up an important point in relation to our recent prospective case series and systematic review detailing the efficacy and importance of managing increased intracranial pressure (ICP) in patients with spontaneous cerebrospinal fluid (CSF) leaks. In reviewing the literature, we defined studies in which ICP was actively managed when the authors used lumbar puncture, lumbar drain, or ventriculostomy for the expressed purpose of measuring increased ICP and initiating some form of long-term therapy for control of intracranial hypertension either with acetazolamide or permanent CSF diversion (ventriculoperitoneal or lumboperitoneal shunt). We did not delineate between methods used for intracranial hypertension control when calculating success rates because the majority of studies in the active intervention cohort did not separate patient data and success rates by the method of ICP control. Therefore, it was not possible to evaluate success rates of each subclass of intervention. Furthermore, the method of ICP control was not standardized in many cohorts. Only one modality for ICP control was used in some series, whereas multiple modalities were utilized in others. In our prospective case series, the decision for acetazolamide or permanent shunt was based on general guidelines, but patient preference also guides decision making following discussion of risks and benefits regarding long-term medical therapy versus additional invasive surgical management. We typically shunt patients with higher risk factors (e.g., severely elevated ICP> 35 cm H2O, multiple skull base defects, and failure to reduce ICP with acetazolamide therapy). The majority of our patients (>80%) are placed on acetazolamide due to the noninvasive potential for control of ICP with a relatively mild side-effect profile and proven ability to significantly lower ICP. It is critical to note that no single form of therapy is a foolproof method for preventing future leaks. Indeed, several patients in our cohort previously had shunts elsewhere (including a lumboperitoneal shunt similar to the intervention of choice in your series of patients) and presented with new CSF leaks after their shunts became nonfunctional. Whereas numerous authors and centers may have their own algorithms for ICP intervention, our systematic review indicates there was a marked difference in the primary repair success rate of spontaneous CSF rhinorrhea when at least some form of active management was employed. We believe that our own center’s longterm success rate reflects our use of acetazolamide for most patients, while identifying higher-risk individuals for shunting. Importantly, your high success rate with lumboperitoneal shunts also supports our central argument that intervention for intracranial hypertension should be a routine part of the management of spontaneous CSF leak patients.

Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling: Upper airway wound healing through donor site grafting

To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo “Petri dishes” for active wound healing. The pedicled nasoseptal flap (NSF) for skull‐base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing.

Resveratrol and ivacaftor are additive G551D CFTR-channel potentiators: therapeutic implications for cystic fibrosis sinus disease: CFTR potentiation with ivacaftor and resveratrol

Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene result in defective Cl− transport and cause chronic bacterial infections in the upper and lower airways of cystic fibrosis (CF) patients. Ivacaftor is a CFTR potentiator that improves Cl− transport in CF patients with at least 1 copy of the G551D mutation. Resveratrol is also a potent CFTR potentiator that increases determinants of mucociliary transport. The objective of this study is to determine whether resveratrol and ivacaftor improve Cl− secretion in G551D CFTR over either agent alone.