Kristen S. Moe

Tension Pneumocephalus after Endoscopic Sinus Surgery

Objectives:Large skull base defects and cerebrospinal fluid (CSF) leak repairs are traditionally performed through a transnasal endoscopic approach or an open craniotomy approach. While this is often successful, when the defect is adjacent to the crista galli it can be very difficult to seal the medial portions of the defect. Our objective is to report our experience using a novel multiportal (transnasal and transorbital) endoscopic technique to repair large, bilateral anterior cranial fossae defects using an intracranial “brain sling.”Methods:Reviews of the literature and medical records were performed.Results:Endoscopic transnasal and transorbital repair of large bilateral anterior cranial fossae skull base defects was performed using acellular radiated cadaver dermis and collagen matrix through a multiportal approach. The visualization and surgical access through transorbital portals permitted an intracranial extradural/intradural repair using a single, large section of reconstruction material. It was ...

The use of negative-pressure therapy in the closure of complex head and neck wounds.

The evolution of wound care has seen much technological advancement over many decades. Most recently, negative-pressure therapy, by which a vacuum pressure is applied through a wound bed, has dramatically improved the surgical outcomes of complex wounds. Although initial studies focused on wounds to the abdomen, torso, and extremities, more publications are appearing that demonstrate the efficacy of negative-pressure wound therapy in the head and neck. This article reviews the history and evolution of negative-pressure therapy, highlights the current opinions on its mechanism of action, and summarizes its use in complex head and neck wounds.

Tension pneumocephalus after endoscopic sinus surgery: a technical report of multiportal endoscopic skull base repair.

Objectives: Large skull base defects and cerebrospinal fluid (CSF) leak repairs are traditionally performed through a transnasal endoscopic approach or an open craniotomy approach. While this is often successful, when the defect is adjacent to the crista galli it can be very difficult to seal the medial portions of the defect. Our objective is to report our experience using a novel multiportal (transnasal and transorbital) endoscopic technique to repair large, bilateral anterior cranial fossae defects using an intracranial “brain sling.” Methods: Reviews of the literature and medical records were performed. Results: Endoscopic transnasal and transorbital repair of large bilateral anterior cranial fossae skull base defects was performed using acellular radiated cadaver dermis and collagen matrix through a multiportal approach. The visualization and surgical access through transorbital portals permitted an intracranial extradural/intradural repair using a single, large section of reconstruction material. It was introduced through a portal distant to the site of injury to avoid enlarging the region of damage, and fashioned so that forces of gravity maintained its proper position. All leaks were repaired successfully with one surgical procedure, and there were no surgical complications in the cohort. Conclusions: The “brain sling” technique is applicable to the reconstruction of large skull base defects of any etiology and may be important for oncologic reconstruction. By using a multiportal approach, instrumentation could be performed without blocking the endoscopic view, and multiple viewing angles of the pathology could be used to improve the surgical efficacy.

Clival paragangliomas: a report of two cases involving the midline skull base and review of the literature

Head and neck paragangliomas are rare neuroendocrine tumors that arise from paraganglion cells of the parasympathetic nervous system. Paragangliomas arising from the midline skull base have only rarely been reported. Surgery is the mainstay of treatment and adjuvant radiation is often recommended. These tumors can rarely secrete metanephrines and normetanephrines which can complicate operative management. Here we present two cases of clival paragangliomas with unique clinical presentations and review the previous literature on skull base paragangliomas.

Periorbital Scar Correction

Periorbital scarring with eyelid retraction can have serious visual effects and can lead to loss of vision or even loss of the eye. Understanding of eyelid anatomy and the delicate balance of its structural supports is critical for the identification of the eyelid disorder responsible for the cicatrix and helps to guide treatment. The 2-finger test and lateral distraction of the lid can also be of significant help in proper diagnosis of the underlying disorder. Proper reconstruction with respect to the anterior and posterior lamellae helps to ensure a favorable outcome.

Pathology Quiz Case 1

PREVIOUSLY HEALTHY 2-year-old boy presented with a 7-month history of progressive obstructive sleep apnea and bilateral cervical lymphadenopathy despite intensive antibiotic therapy. His physical examination demonstrated enlarged tonsils and adenoids and bilateral cervical lymphadenopathy. His white blood cell count was in the upper range of normal, with slight lymphocytosis. He underwent a tonsillectomy, an adenoidectomy, and an excisional lymph node biopsy from the left posterior triangle. He tolerated surgery without incident and was discharged on postoperative day 1. He returned 3 days later and was admitted for persistent poor oral intake, pain, and refusal to voluntarily rotate his head. Physical examination revealed asymmetry of the posterior pharyngeal wall. The findings of microscopic analysis of all 3 surgical specimens are shown in Figure 1 and Figure 2. A pediatric infectious disease consultation was obtained; Bartonella and Tularemia titers were drawn; and purified protein derivative skin testing and radiography of the chest were performed. The results of all laboratory and radiologic examinations were normal. Empiric antibiotic therapy consisting of rifampin and clarithromycin was initiated. A cervical computed tomographic scan with contrast demonstrated a large retropharyngeal abscess (Figure 3). The patient returned to the operating room for transoral drainage and culture. Microscopic findings of the contents of the abscess were nearly identical to those found in the previous specimens (Figures 1 and 2). What is your diagnosis?