João Mangussi-Gomes

Endoscopic Endonasal Management of Skull Base Chordomas: Surgical Technique, Nuances, and Pitfalls.

Chordoma is a rare primary bone tumor derived from transformed notochord remnants. It has a local aggressive behavior and high recurrence rates. Treatment of skull base chordomas is complex and challenging. Control of the disease relies mainly on surgical excision of the tumor, sometimes followed by high-dose radiation therapy. The main surgical goal is to achieve maximal tumor removal with minimal morbidity. Development of the expanded endoscopic endonasal approach has improved surgical and prognostic results of skull base chordomas. This article highlights important aspects of approach selection, technique, and nuances of surgical management of this tumor.

Localization of ectopic and supernumerary parathyroid glands in patients with secondary and tertiary hyperparathyroidism: surgical description and correlation with preoperative ultrasonography and Tc99m-Sestamibi scintigraphy

INTRODUCTION Hyperparathyroidism is an expected metabolic consequence of chronic kidney disease (CKD). Ectopic and/or supernumerary parathyroid glands (PT) may be the cause of surgical failure in patients undergoing total parathyroidectomy (PTX). AIM To define the locations of ectopic and supernumerary PT in patients with renal hyperparathyroidism and to correlate intraoperative findings with preoperative tests. MATERIALS AND METHODS A retrospective study was conducted with 166 patients submitted to PTX. The location of PT during surgery was recorded and classified as eutopic or ectopic. The preoperative localizations of PT found by ultrasonography (USG) and Tc99m-Sestamibi scintigraphy (MIBI) were subsequently compared with intraoperative findings. RESULTS In the 166 patients studied, 664 PT were found. Five-hundred-seventy-seven (86.4%) glands were classified as eutopic and 91(13.6%) as ectopic. Eight supernumerary PT were found. The most common sites of ectopic PT were in the retroesophageal and thymic regions. Taken together, USG and MIBI did not identify 56 (61.5%) ectopic glands. MIBI was positive for 69,7% of all ectopic glands located in the mediastinal and thymic regions. CONCLUSION The presence of ectopic and supernumerary PT in patients with renal hyperparathyroidism is significant. Although preoperative imaging tests did not locate most of ectopic glands, MIBI may be important for identifying ectopic PT in the mediastinal and thymic regions.

Corpo estranho em Otorrinolaringologia: perfil dos atendimentos em um pronto-socorro de referência

UNLABELLED Individuals often seek help with foreign bodies (FB) in their ears, noses, and throats. Proper recognition, study, and management of foreign bodies is required to prevent complications. OBJECTIVE To analyze the profile of the patients seen for FB at a reference otorhinolaryngology emergency care unit between February of 2010 and January of 2011. METHOD Cross-sectional retrospective historical cohort study based on digitized patient charts. RESULTS FB accounted for 827 cases and 5.3% of all patients seen in the ENT emergency unit. Children were affected more frequently, particularly when aged 8 and under. No statistically significant differences were seen between genders. Foreign bodies were mostly located in the ears (64.4%), followed by the nasal fossae (19.5%), and the oropharynx (8.9%). Complications were seen in 4.5% of the cases, and 4.4% required general anesthesia to have the FB removed. CONCLUSION In our ENT practice, foreign bodies were more commonly seen in children; the ears were the preferential site of occurrence. Complication rates and use of general anesthesia were low in our practice. It should be stressed that ENT foreign bodies need to be properly managed so as to avoid complications.

Is the occurrence of spontaneous epistaxis related to climatic variables? A retrospective clinical, epidemiological and meteorological study

Abstract Conclusion: Epistaxis has a bimodal age distribution. Anterior epistaxis of mild severity is more common in children; severe epistaxis occurs more often in adults and elderly patients. The occurrence of spontaneous epistaxis was shown to be weakly-to-moderately and inversely correlated to the mean monthly temperature, relative humidity and total rainfall. Objectives: To describe the clinical and epidemiological profiles of patients diagnosed with spontaneous epistaxis; to correlate its monthly occurrence with meteorological variables. Methods: A retrospective cross-sectional study was performed in a referral ENT service in São Paulo, Brazil. The study assessed the clinical and epidemiological features of 508 patients with spontaneous epistaxis treated between February 2010 and January 2011. The occurrence of epistaxis was associated with weather variables for the same study period. Results: Spontaneous epistaxis presented two age peaks of higher incidence (11–20 and 51–70 years). Children more frequently had localized bleeding (p = 0.003), in the anterior region of the nasal cavity (p = 0.0001), of absent-mild severity (p = 0.0082). Diffuse bleeding (p = 0.005), of moderate–severe intensity (p = 0.003), was more common in adults and elderly patients. The total number of visits because of epistaxis was inversely correlated to mean temperature (R = −0.489; p = 0.011), mean relative humidity (R = −0.364; p = 0.038), and total rainfall (R = −0.512; p = 0.009) during each month of the analyzed period.

In reference to intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks

The distinguishing clinical-radiological features of idiopathic intracranial hypertension (IIH) are often found in patients with spontaneous cerebrospinal fluid (CSF) rhinorrhea. In such cases, CSF leak is probably a consequence of persistently increased intracranial pressure (ICP). In this context, it was with great delight that we read the study by Teachey et al. titled “Intervention for Elevated Intracranial Pressure Improves Success Rate After Repair of Spontaneous Cerebrospinal Fluid.” The authors presented a prospective case series of 108 patients with spontaneous CSF rhinorrhea who underwent endoscopic surgical repair and simultaneous evaluation and management of ICP over a period of 8 years. A surgical long-term success rate of 96.3% was reported. The authors also systematically reviewed the literature and collected the data of more 571 patients. The patients were then divided in two groups according to the treatment they had received for ICP: active (348) versus none (331). The groups presented significantly different long-term success rates after surgery (93% vs. 82%, respectively; P<.001). The authors concluded that correctly evaluating and treating ICP must be part of the optimal treatment of patients with spontaneous CSF rhinorrhea. Our group totally agrees and congratulates the authors for their meaningful work. It is interesting to note, however, that the active treatment group was quite heterogeneous and included all patients who 1) were prescribed acetazolamide, 2) had CSF diversion (vetriculoperitoneal or lumboperitoneal), or 3) had their ICP checked postoperatively, but did not require any further medical or surgical intervention. We were curious to know whether there were any differences in outcomes among these subgroups of patients. Possibly, better results were achieved with more aggressive and definitive CSF pressurelowering measures. With that in mind, since 1998 our team has advocated endoscopic repair and placement of permanent lumboperitoneal shunts (PLPS) for patients with spontaneous CSF rhinorrhea who are also suspected to have increased ICP. We have treated 18 patients meeting those criteria (16 females, 88.9%; 2 males, 77.8%; age average, 48.4 6 11.7 years). All of them underwent endoscopic surgery and placement of PLPS (follow-up: 129.8 6 68.7 months; minimum, 12 months; maximum, 226 months). None has presented recurrences to date (success rate5 100%), two (11.1%) presented symptoms of CSF hypotension, and one had transient abdominal discomfort (5.6%). None required revision surgery or shunt removal. Until now, there are no definitive guidelines for the treatment of IIH, with or without CSF leaks. Thus, beyond overstating that patients with spontaneous CSF rhinorrhea should also have their ICP addressed, it is time to take a step forward. We are anxious to see the best approach defined for patients with spontaneous CSF leaks and signs of IIH.

Efficacy of syringe-irrigation topical therapy and the influence of the middle turbinate in sinus penetration of solutions.

INTRODUCTION Topical therapies are the best postoperative treatment option for chronic rhinosinusitis, especially those with high volume and pressure, such as the squeeze bottles. However, they are not an available option in Brazil, where irrigation syringes are used. OBJECTIVE To investigate the efficacy of topical sinonasal therapy with syringe and the influence of the middle turbinate on this process METHODS: Intervention study in training models (S.I.M.O.N.T.). After standard dissection, three interventions were performed (Nasal Spray 4 puffs, 60-mL syringe and 240-mL Squeeze Bottle) with normal and Sutured Middle Turbinate. Images of each sinus were captured after the interventions, totalizing 144 images. The images were classified by 10 evaluators according to the amount of residual volume from zero to 3, with zero and 1 being considered poor penetration and 2 and 3, good penetration. The 1440 evaluations were used in this study. RESULTS Considering all middle turbinate situations, the amount of good penetrations were 8.1% for Spray; 68.3% for Syringe, and 78.3% for Squeeze (p<0.0001). Considering all types of interventions, the Normal Middle Turbinate group had 48.2% of good penetrations and the Sutured Middle Turbinate, 55% (p=0.01). Considering only the Sutured Middle Turbinates, there was no difference between the interventions with Syringe and Squeeze (76.3% vs. 80.4%; p=0.27). CONCLUSION Topical therapy of irrigation with a 60-mL syringe was more effective than that with nasal spray. The status of the middle turbinate proved to be fundamental and influenced topical therapy. Irrigation with syringe was as effective as the squeeze bottle when the middle turbinate was sutured to the nasal septum.

Thyroid gland invasion in advanced squamous cell carcinoma of the larynx and hypopharynx.

INTRODUCTION Squamous cell carcinoma of the larynx and hypopharynx has the potential to invade the thyroid gland. Despite this risk, the proposition of either partial or total thyroidectomy as part of the surgical treatment of all such cases remains controversial. OBJECTIVES To evaluate the frequency of invasion of the thyroid gland in patients with advanced laryngeal or hypopharyngeal squamous cell carcinoma submitted to total laryngectomy or pharyngolaryngectomy and thyroidectomy; to determine whether clinic-pathological characteristics can predict glandular involvement. METHODS A retrospective case series with chart review, from January 1998 to July 2013, was undertaken in a tertiary care university medical center. An inception cohort of 83 patients with larynx/hypopharynx squamous cell carcinoma was considered. All patients had advanced stage disease (clinically T3-T4) and underwent total laryngectomy or total pharyngolaryngectomy in association with thyroidectomy. Adjuvant therapy was indicated when tumor or neck conditions required. Frequency of thyroid cartilage invasion was calculated; univariate and multivariate analysis of demographic, clinical and pathological characteristics associated with cartilage invasion were performed. RESULTS The overall frequency of invasion of the thyroid gland was 18.1%. Glandular involvement was associated with invasion of the following structures: anterior commissure (odds ratio=5.13; 95% confidence interval 1.07-24.5), subglottis (odds ratio=12.44; 95% confidence interval 1.55-100.00) and cricoid cartilage (odds ratio=15.95; 95% confidence interval 4.23-60.11). CONCLUSIONS Invasion of the thyroid gland is uncommon in the context of laryngopharyngeal squamous cell carcinoma. Clinical and pathological features such as invasion of the anterior commissure, subglottis and cricoid cartilage are more associated with glandular invasion.

Endoscopic Endonasal Transplanum Transtuberculum Approach for the Resection of a Large Suprasellar Craniopharyngioma

Objectives To demonstrate an endoscopic endonasal transplanum transtuberculum approach for the resection of a large suprasellar craniopharyngioma. Design Single‐case‐based operative video. Setting Tertiary center with dedicated skull base team. Participants A 72‐year‐old male patient diagnosed with a suprasellar craniopharyngioma. Main Outcomes Measured Surgical resection of the tumor and preservation of the normal surrounding neurovascular structures. Results A 72‐year‐old male patient presented with a 1‐year history of progressive bitemporal visual loss. He also referred symptoms suggestive of hypogonadism. Neurological examination was unremarkable and endocrine workup demonstrated mildly elevated prolactin levels. Magnetic resonance images demonstrated a large solid‐cystic suprasellar lesion, consistent with the diagnosis of craniopharyngioma. The lesion was retrochiasmatic, compressed the optic chiasm, and extended into the interpeduncular cistern (Fig. 1). Because of that, the patient underwent an endoscopic endonasal transplanum transtuberculum approach.1‐3 The nasal stage consisted of a transnasal transseptal approach, with complete preservation of the patients left nasal cavity.4 The cystic component of the tumor was decompressed and its solid part was resected. It was possible to preserve the surrounding normal neurovascular structures (Fig. 2). Skull base reconstruction was performed with a dural substitute, a fascia lata graft, and a right nasoseptal flap (Video 1). The patient did well after surgery and referred complete visual improvement. However, he also presented pan‐hypopituitarism on long‐term follow‐up. Fig. 1 Preoperative magnetic resonance images of a 72‐year‐old male patient with a large suprasellar craniopharyngioma. The lesion compressed was retrochiasmatic and compressed the optic chiasm from posterior to anterior. It also extended posteriorly into the interpeduncular cistern. (A) Coronal and (B) sagittal image. Fig. 2 An endoscopic endonasal transtuberculum transplanum approach was performed for the resection of the large suprasellar craniopharyngioma. Intraoperative picture demonstrating the relevant anatomy. Abbreviations: SHA, left superior hypophyseal artery; br., branch; ICA, left internal carotid artery; PCA, left posterior communicating artery. Conclusions The endoscopic endonasal route is a good alternative for the resection of suprasellar lesions. It permits tumor resection and preservation of the surrounding neurovascular structures while avoiding external incisions and brain retraction. The link to the video can be found at: https://youtu.be/zmgxQe8w‐JQ.

Breaking paradigms in severe epistaxis: the importance of looking for the S‐point

INTRODUCTION Since the introduction of nasal endoscopy into the field of Otorhinolaryngology, the treatment paradigm for cases of severe epistaxis has shifted toward early and precise identification of the bleeding site. Although severe epistaxis is usually considered to arise from posterior bleeding, an arterial vascular pedicle in the superior portion of the nasal septum, around the axilla projection of the middle turbinate, posterior to the septal body, frequently has been observed. That vascular pedicle was named the Stamms S-point. OBJECTIVE The aim of this study was to describe the S-point and report cases of severe epistaxis originating from it. METHODS A retrospective case series study was conducted. Nine patients with spontaneous severe epistaxis, where the S-point was identified as the source of bleeding, were treated between March 2016 and March 2017. RESULTS Male predominance (77.8%) with age average of 59.3 years old were reported. Most cases presented comorbidities (88.9%) and were not taking acetylsalicylic acid (66.7%). A predominance of left sided involvement (55.6%) and anteroposterior bleeding being the principal initial presentation (77.8%) was seen. Six patients (66.7%) presented with hemoglobin levels below 10g/dL, and four (44.4%) required blood transfusion. Cauterization of S-point was performed in all patients, with complete resolution of bleeding. No patient experienced recurrence of severe epistaxis. CONCLUSION The Stamms S-point, a novel source of spontaneous severe epistaxis, is reported, and its cauterization was effective and safe. Otolaryngologists must actively seek this site of bleeding in cases of severe epistaxis.

Invasion of the Thyroid Gland in Advanced Laryngeal and Hypopharyngeal Squamous Cell Carcinoma

Objectives: (1) Evaluate the frequency of invasion of the thyroid gland in patients with laryngeal or hypopharyngeal squamous cell carcinoma (SCC) submitted to total laryngectomy (TL) or pharyngolaryngectomy (TPL) associated with thyroidectomy. (2) Determine whether clinico-pathological characteristics can predict glandular involvement. Methods: A retrospective study was conducted in an academically affiliated tertiary care referral center. Charts and anatomopathological reports of surgical specimens of 93 patients treated in the period from January 1998 to July 2013 were reviewed. All patients presented with laryngeal or hypopharyngeal SCC and underwent TL or TPL in association with thyroidectomy. Adjuvant therapy was indicated when tumor or neck conditions required it. Sociodemographic data, frequency of thyroid gland invasion, and other clinico-pathological variables were analyzed. Results: Tumor was staged as T2 in 10 patients, T3 in 26 patients, and T4 in 53 patients. Five patients had initial stage II and 88 had advanced stage III-IV disease. The overall frequency of invasion of the thyroid gland was 16.1%. Carcinomas that invaded the thyroid gland were more advanced (P = .005) and more frequently staged as T4a (P = .001). Glandular involvement was associated with invasion of the anterior commissure (odds ratio [OR] = 5.9; confidence interval [CI]–95% 1.2-27.7), subglottis (OR = 12.0; CI-95% 1.5-95.8), thyroid cartilage (OR = 4.2; CI-95% 1.1-16.1), and cricoid cartilage (OR = 18.7; CI-95% 5.0-70.2). Conclusions: Invasion of the thyroid gland is uncommon in the context of laryngopharyngeal SCC. Clinico-pathological features such as advanced tumors, T4a tumors, anterior commissure, subglottis, thyroid cartilage, and cricoid cartilage involvement are more associated with glandular invasion. Indications for thyroidectomy should be refined in order to reduce morbidity of the surgical treatment.