John Milligan

Comparison of sinonasal quality of life and health status in patients undergoing microscopic and endoscopic transsphenoidal surgery for pituitary lesions: a prospective cohort study.

OBJECT Despite the widespread adoption of endoscopic transsphenoidal surgery for pituitary adenomas, the sinonasal quality of life (QOL) and health status in patients who have undergone this technique have not been compared with these findings in patients who have undergone the traditional direct uninostril microsurgical technique. In this study, the authors compared the sinonasal QOL and patient-reported health status after use of these 2 surgical techniques. METHODS The study design was a nonblinded prospective cohort study. Adult patients with sellar pathology and planned transsphenoidal surgery were screened at 4 pituitary centers in the US between October 2011 and August 2013. The primary end point of the study was postoperative patient-reported sinonasal QOL as measured by the Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12). Supplementary end points included patient-reported health status estimated by the 8-Item Short Form Health Survey (SF-8) and EuroQol (EQ)-5D-5L instruments, and sinonasal complications. Patients were followed for 6 months after surgery. RESULTS A total of 301 patients were screened and 235 were enrolled in the study. Of these, 218 were analyzed (111 microsurgery patients, 107 endoscopic surgery patients). Demographic and tumor characteristics were similar between groups (p ≥ 0.12 for all comparisons). The most common complication in both groups was sinusitis (7% in the microsurgery group, 13% in the endoscopic surgery group; p = 0.15). Patients treated with the endoscopic technique were more likely to have postoperative nasal debridements (p < 0.001). The ASK Nasal-12 and SF-8 scores worsened substantially for both groups at 2 weeks after surgery, but then returned to baseline at 3 months. At 3 months after surgery, patients treated with endoscopy reported statistically better sinonasal QOL compared with patients treated using the microscopic technique (p = 0.02), but there were no significant differences at any of the other postoperative time points. CONCLUSIONS This is the first multicenter study to examine the effect of the transsphenoidal surgical technique on sinonasal QOL and health status. The study showed that surgical technique did not significantly impact these patient-reported measures when performed at high-volume centers. Clinical trial registration no.: NCT01504399 ( clinicaltrials.gov ).

Sinonasal leiomyosarcoma: review of literature and case report.

Objectives/Hypothesis: To determine prognosis of primary sinonasal leiomyosarcomas after treatment.

Endoscopic Endonasal Transmaxillary Approach and Endoscopic Sublabial Transmaxillary Approach: Surgical Decision-Making and Implications of the Nasolacrimal Duct

BACKGROUND The nasolacrimal duct resides in the wall of the medial nasal cavity and influences minimal access endoscopic transmaxillary approaches to the lateral skull base. We describe an algorithm for surgical approach selection on the basis of the relationship of the target lesion to a line drawn from the anterior nasal SEptum through the Nasolacrimal Duct to the lesion (i.e., SEND line). METHODS We use the SEND line to estimate the lateral extent in the endonasal middle meatal transmaxillary approach, where the surgeon has good surgical freedom without the use of angled instruments and endoscopes. Lesions with an epicenter lateral to the SEND line were addressed through a sublabial anterior antrostomy transmaxillary corridor. Tumors with a more medially located epicenter, such as those involving the lateral sphenoid sinus and pterygoid plates, were addressed through the endonasal middle meatal corridor. Extensive tumors involving both domains were addressed through a combination approach. RESULTS We describe three instructive cases in which the approach selection was determined in part by preoperative assessment of the location of the tumor relative to the SEND line. CONCLUSIONS The endoscopic sublabial transmaxillary and endoscopic endonasal middle meatal transmaxillary approaches are complementary corridors to the anterior skull base that can be used independently or in combination. The location of the target lesion relative to the SEND line as determined on preoperative imaging can serve as a guide for surgical decision making.

The Minimal Clinically Important Difference of the Anterior Skull Base Nasal Inventory-12

BACKGROUND The minimal clinically important difference (MCID) is defined as the smallest change in health‐related quality of life (QOL) that patients consider meaningful. The MCID is essential for determining clinically significant changes, rather than simply statistically significant changes, in QOL scores. The Anterior Skull Base Nasal Inventory‐12 (ASK Nasal‐12), a site‐specific sinonasal QOL instrument, has emerged as a standard instrument for assessing QOL in patients who have undergone endonasal transsphenoidal surgery. OBJECTIVE To determine the MCID for the ASK Nasal‐12. METHODS Distribution‐ and anchor‐based methods were used to determine the MCID for the ASK Nasal‐12 based on raw data from a multicenter prospective QOL study of 218 patients. RESULTS Two distribution‐based statistical methods, the one‐half standard deviation method and the effect‐size method, both yielded MCIDs of 0.37 (medium effect). The first anchor‐based method, using the 2‐wk postoperative overall nasal functioning item as the anchor, yielded an MCID of 0.31. The second anchor‐based method, using the 2‐wk postoperative Short Form Health Survey 8 bodily pain item as the anchor, yielded an MCID of 0.29. CONCLUSION The largest MCID obtained for the ASK Nasal‐12 using 4 statistical methods 2 wk postoperatively was 0.37. This information provides clinicians with an essential context for determining the clinical significance of changes in QOL scores after interventions. Our results will help clinicians better interpret QOL scores and design future studies that are powered to detect meaningful QOL changes.