Leonardo Balsalobre

The Endoscopic Endonasal Approach for Extradural and Intradural Clivus Lesions

OBJECTIVE To report the use of the endoscopic transnasal transclival approach to treat tumors involving the clivus region. METHODS The clinical records of 38 patients with clivus lesions were retrospectively reviewed to determine the surgical technique used. All patients were surgically treated using any of the options of the endoscopic transnasal transclival approach at the São Paulo Skull Base Center from 2000-2011. A transsphenoidal, transpterygoidal, retropharyngeal, or a combination of approaches was chosen based on the tumor topography. RESULTS Chordomas were the most frequent tumor (26 of 38), followed by chondrosarcoma (2 of 38). Biopsy only was performed in 6 patients with metastasis to the clivus, and 1 patient with fibrous dysplasia underwent a planned partial resection. Gross total resection (GTR) was achieved in 15 of 31 (48%) patients with indications for GTR. For centrally located tumors, GTR was achieved in 75% (15 of 20 patients). Fistula was the most frequent complication (6 of 31; 19%) but was much lower in the most recent series using the nasoseptal flap (1 of 16; 6%). Tumors with lateral extensions or with previous treatment had the worst results. The presence of intradural extension was not a limiting factor for GTR. CONCLUSION Endoscopic transnasal surgery is an alternative approach to treatment of clivus lesions, and, in expert hands, this technique can obtain good results. Lateral extension and previous treatment were factors that could make the surgery more difficult. Intradural extension did not limit the radicality of the removal.

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.

Primary spontaneous cerebrospinal fluid leaks located at the clivus.

Transclival meningoceles and primary spontaneous cerebrospinal fluid (CSF) leaks at the clivus are extremely rare lesions and only few of them have been reported in the literature. We report here six cases of transclival primary spontaneous CSF leaks through the clivus. A retrospective case study was performed. We reviewed six cases involving sinonasal CSF leaks located at the clivus treated between 1997 and 2009. Presenting symptoms, duration of symptoms, defect size, site of defect, surgical approach and technique of defect closure, intraoperative complications, postoperative complications, and recurrences are discussed. All CSF leaks were located in the upper central part of the clivus. two of six patients showed signs of increased intracranial pressure (ICP) including arachnoid pits and/or empty sella. For three patients a purely transnasal approach was used with multilayer reconstruction using a nonvascularized graft, and three patients underwent a transnasal transseptal approach with a multilayer reconstruction, with nasoseptal flap. No recurrences of CSF leaks at clivus or other sites were observed to date with a mean follow-up of 10.3 years (range, 3–15 years). Spontaneous CSF rhinorrhea located at the clivus is an extremely rare condition. To date, only eight cases have been described. Here, we report the largest group of six consecutive cases. Irrespective of the used reconstruction technique in all cases a 100% closure rate was achieved. However, identification of increased ICP is an essential aspect and this condition should be treated either medically or surgically.

Convergence of two major pathophysiologic mechanisms in nasal polyposis: immune response to Staphylococcus aureus and airway remodeling

This review is addressed two pathophysiologic mechanisms implicated in the pathogenesis of nasal polyposis: the unique remodeling process found in nasal polyp tissue and the immune response of patients with nasal polyposis to Staphylococcus aureus.These two theories converge to the same direction in different aspects, including decreased extracellular matrix production, impaired T regulation and favoring of a Th2 immune response.In patients with nasal polyposis, an exaggerated immune response to Staphylococcus aureus may aggravate the airway remodeling process.

Epithelium and stroma from nasal polyp mucosa exhibits inverse expression of TGF-β1 as compared with healthy nasal mucosa

ObjectiveTo evaluate TGF-β1 expression in polypoid mucosa (epithelium and stroma) of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).MethodsCross-sectional study with two groups: 17 patients with nasal polyposis and 11 controls. Polyps and normal nasal mucosa were processed by immunohistochemical methods for TGF-β1 visualization. Then, the percentage of TGF-β1 expression in stroma and epithelium was objectively quantified using UT Morph software.ResultsA lower percentage of positive expression was found in the epithelium of CRSwNP patients (32.44%) versus normal controls (55.91%) (p < 0.05), and a higher percentage of positive expression in the stroma of CRSwNP patients (23.24%) versus controls (5.88%) (p < 0.05).ConclusionThe lower percentage of TGF-β1 expression in the nasal epithelium of CRSwNP patients may have an impact on epithelium-directed topical treatments employed in this patient population.

Endoscopic sinus surgery dissection courses using a real simulator: the benefits of this training

INTRODUCTION Endonasal surgeries are among the most common procedures performed in otolaryngology. Due to difficulty in cadaver acquisition and the intrinsic risks of training residents during operations on real patients, nasosinusal endoscopic dissection courses utilizing real simulators, such as the Sinus Model Otorhino Neuro Trainer are being developed as a new technique to facilitate the acquisition of better anatomical knowledge and surgical skill. OBJECTIVE To evaluate the efficacy of nasosinusal endoscopic dissection courses with the Sinus Model Otorhino Neuro Trainer simulator in the training of otolaryngology surgeons. METHODS A prospective, longitudinal cohort study was conducted with 111 otolaryngologists who participated in a theoretical and practical course of endoscopic surgery dissection using the Sinus Model Otorhino Neuro Trainer simulator, with application of questionnaires during and after the course. RESULTS From the ten procedures performed utilizing the simulator, the evaluation revealed mean scores from 3.1 to 4.1 (maximum of 5). Seventy-seven participants answered the questionnaire six months after the end of the course. 93% of them reported that they could perform the procedures more safely following the course, 98% reported an improvement in their anatomical and clinical knowledge, and 85% related an improvement in their surgical ability. After the course, the number of endoscopic surgeries increased in 40% of the respondents. CONCLUSION Endoscopic sinus dissection courses using the Sinus Model Otorhino Neuro Trainer simulator proved to be useful in the training of otolaryngologists.

Acute impact of continuous positive airway pressure on nasal patency: Acute impact of CPAP on nasal patency

Continuous airflow in the upper airway can cause discomfort, leading to nasopharyngeal complaints. The aim of the present study is to evaluate the acute effects of continuous positive upper‐airway pressure on nasal patency in awake normal subjects.

Effectiveness of balloon sinuplasty in patients with chronic rhinosinusitis without polyposis

INTRODUCTION Balloon sinuplasty is a minimally invasive endoscopic procedure, developed with the aim of restoring patency of the paranasal sinuses ostia with minimal damage to the mucosa. OBJECTIVE To evaluate the effectiveness of balloon sinuplasty in patients with chronic rhinosinusitis. METHODS This was a prospective cohort study comprising 18 patients with chronic rhinosinusitis without polyposis who underwent balloon sinuplasty. Patients were evaluated for clinical criteria, quality of life (Sino-Nasal Outcome Questionnaire Test-20 [SNOT-20]), and computed tomography of the sinuses (Lund-Mackay staging) preoperatively and three to six months after the procedure. RESULTS Out of 18 patients assessed, 13 were included, with a mean age of 39.9±15.6 years. Ostia sinuplasty was performed in 24 ostia (four sphenoid, ten frontal, and ten maxillary sinus). At the follow-up, 22 (92%) ostia were patent and there was no major complication. There was symptomatic improvement (SNOT-20), with Cronbach coefficients for consistency of the questionnaire items of 0.86 (95% CI: 0.73-0.94) preoperatively and of 0.88 (95% CI: 0.77-0.95) postoperatively, the difference being statistically significant (p<0.001). In addition, there was marked reduction of the computed tomography signs, an average of 4.2 point score (p<0.001). CONCLUSION Sinuplasty is effective in reducing symptoms and improving quality of life as a treatment option for chronic rhinosinusitis in selected patients.

Endoscopic Endonasal Approach in Skull Base Chondrosarcoma Associated with Maffucci Syndrome: Case Series and Literature Review.

BACKGROUND Maffucci syndrome is a nonhereditary disorder in which patients develop multiple enchondromas and cutaneous, visceral, or soft tissue hemangiomas. The potential malignant progression of enchondroma into a secondary chondrosarcoma is a well-known fact. Nevertheless, chondrosarcoma located at the skull base in patients with Maffuci syndrome is a very rare condition, with only 18 cases reported in the literature. CASE DESCRIPTION We report 2 other cases successfully treated through an expanded endoscopic endonasal approach and discuss the condition based on the literature review. CONCLUSIONS Skull base chondrosarcoma associated with Maffucci syndrome is a rare condition. The disease cannot be cured, therefore surgical treatment should be performed in symptomatic patients aiming for maximal tumor resection with function preservation. The endoscopic endonasal approach is a safe and reliable alternative for the management of these tumors.

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.