Nevo Margalit

Integrated pet/ct system for staging and surveillance of skull base tumors

The utility of preoperative and postoperative whole body integrated positron emission tomography–computed tomography (PET‐CT) scanning for staging and follow‐up in patients with skull base tumors is undetermined.

Quality of life following endoscopic resection of skull base tumors.

The objective of the study is to evaluate patients quality of life (QOL) after endoscopic resection of skull base tumors. We estimated the QOL of 41 patients who underwent surgery for removal of skull base tumors via the expanded endonasal approach (EEA). The Anterior Skull Base Surgery Questionnaire (ASBS-Q), a multidimensional, disease-specific instrument containing 36 items was used. The rate of meningitis and cerebrospinal fluid leak was 1.4 and 0%, respectively. There was one case of uniocular visual impairment. The internal consistency of the instrument had a correlation coefficient (α-Cronbach score) of 0.8 to 0.92. Of 41 patients, 30 (75%) reported improvement or no change in overall QOL. Improved scores were reported in the physical function domain and worse scores in the specific symptoms domain. The most significant predictor of poor QOL was female gender, which led to a significant decrease in scores of all domains. Site of surgery, histology, age and comorbidity were not significant predictors of outcome. This paper further validates the use of the ASBS-Q for patients undergoing endoscopic skull base resection. The overall QOL of patients following endoscopic extirpation of skull base tumors is good. Female patients experience a significant decline in QOL compared with males.

Cranialization of the frontal sinus for secondary mucocele prevention following open surgery for benign frontal lesions.

Objective To compare frontal sinus cranialization to obliteration for future prevention of secondary mucocele formation following open surgery for benign lesions of the frontal sinus. Study Design Retrospective case series. Setting Tertiary academic medical center. Patients Sixty-nine patients operated for benign frontal sinus pathology between 1994 and 2011. Interventions Open excision of benign frontal sinus pathology followed by either frontal obliteration (nu200a=u200a41, 59%) or frontal cranialization (nu200a=u200a28, 41%). Main Outcome Measures The prevalence of post-surgical complications and secondary mucocele formation were compiled. Results Pathologies included osteoma (nu200a=u200a34, 49%), mucocele (nu200a=u200a27, 39%), fibrous dysplasia (nu200a=u200a6, 9%), and encephalocele (nu200a=u200a2, 3%). Complications included skin infections (nu200a=u200a6), postoperative cutaneous fistula (nu200a=u200a1), telecanthus (nu200a=u200a4), diplopia (nu200a=u200a3), nasal deformity (nu200a=u200a2) and epiphora (nu200a=u200a1). None of the patients suffered from postoperative CSF leak, meningitis or pneumocephalus. Six patients, all of whom had previously undergone frontal sinus obliteration, required revision surgery due to secondary mucocele formation. Statistical analysis using non-inferiority test reveal that cranialization of the frontal sinus is non-inferior to obliteration for preventing secondary mucocele formation (P<0.0001). Conclusion Cranialization of the frontal sinus appears to be a good option for prevention of secondary mucocele development after open excision of benign frontal sinus lesions.

Traumatic Facial Diplegia and Horner Syndrome: Case Report

Traumatic facial diplegia is an uncommon pathology, and is usually associated with bitemporal bone fractures. Traumatic Horner syndrome is mostly associated with carotid artery dissection. We present a case with traumatic facial diplegia and a unilateral Horner syndrome where the mechanisms of injury were unusual. The patient had developed his neurological deficits 9 days following trauma. We discuss the mechanisms of the facial palsy and Horner syndrome and the importance of their diagnosis.

Visual deterioration during pregnancy due to skull base tumors compressing the optic apparatus.

Intracranial tumors may rapidly enlarge during pregnancy. When the tumor abuts the optic apparatus, tumor growth may cause visual deterioration. The decisions regarding the management of these tumors should take into consideration visual function, fetal and maternal safety, and the ability for total resection of the tumor. The objective of the study was to describe our experience and to establish principles for management of intracranial tumors compressing the optic apparatus that present during pregnancy or in the early post partum period. A retrospective case-series review was conducted. Women who presented with visual deterioration either during pregnancy or in the early post partum period due to an intracranial tumor were included. Neurosurgical and obstetrical data were collected from the patients’ hospital files and outpatient clinic records. Between 2005 and 2011, nine pregnant women with visual deterioration were diagnosed and treated. Of them, four underwent a neurosurgical procedure during pregnancy. Of the five patients who underwent surgery for tumor resection after delivery, three required urgent cesarean section either due to acute visual deterioration or obstetrical reasons. There was no maternal or fetal mortality and a good overall neonatal outcome was achieved. Improvement in visual acuity and visual fields was achieved in all patients. Postoperative complications included two cases of CSF leak, which resolved after treatment. Visual deterioration during pregnancy due to tumors that compress the optic apparatus requires treatment by a multi-disciplinary team. Surgery is well tolerated by mother and fetus during early and midpregnancy; thus, in cases where visual deterioration is detected, delay of surgery is not justified.

Nasoseptal Flap for Skull Base Reconstruction in Children

Objective The endoscopic endonasal approach is being increasingly used for the resection and reconstruction of anterior skull base (ASB) lesions. Vascularized nasoseptal flaps (NSF) have become the workhorse for the reconstruction of ASB defects, resulting in a significant decrease in the incidence of cerebrospinal fluid (CSF) leaks. The objective of this study was to investigate the efficacy and safety of NSF in children. Methods This is a retrospective analysis of the medical records of all patients under the age of 18 years who underwent endoscopic repair of ASB lesions with the use of NSF at our tertiary medical center between 1/2011 and 8/2016. Results Twelve children underwent ASB defect repair for both benign and malignant neoplasms using the endoscopic endonasal NSF technique. Four children had previously undergone ASB surgery. The male‐to‐female ratio was 1:1, the average age was 12.3 years, the average hospitalization time was 8.3 days, and the maximum follow‐up period was 24 months, during which craniofacial growth appeared to be unimpaired. A lumbar drain was used postoperatively in six cases. Crust formation and synechia were observed in two cases. There was one case of a major long‐term complication (a CSF leak followed by meningitis). Conclusions Endoscopic endonasal NSF was both an effective and a safe technique for ASB defect reconstruction in 12 children for both benign and malignant neoplasms. It had a high success rate and a low complication rate. No apparent negative influence on craniofacial growth was observed in our series.

Outcomes of Craniofacial Open Surgery in Octogenarians

Abstract Introduction The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80‐89), and the male‐to‐female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Continuous lumbar drainage and the postoperative complication rate of open anterior skull base surgery: Lumbar Drainage in Open Skull Base Surgery

Anterior skull base operations pose the risk for postoperative cerebrospinal fluid (CSF) leak. Routine lumbar continuous drainage catheter (LD) placement is intended to decrease CSF leaks and central nervous system (CNS) complications, but there are no sound evidence‐based data on its efficacy. The primary goal of this study was to review CNS complications following anterior open skull base surgery and their association with LD placement. The secondary goal was to define predictors for the development of early CNS complications.

Enhanced visualization of the surgical field in pediatric direct laryngoscopy using a three-dimensional endoscopic system

BACKGROUNDnDirect laryngoscopy and rigid bronchoscopy are currently performed using 2-dimensional endoscopic systems. Our objective was to determine whether a 3-dimensional endoscopic system can enhance visualization of the surgical field in pediatric direct laryngoscopy and rigid bronchoscopy.nnnMETHODSnA prospective cohort study was conducted. Thirty three children who underwent direct laryngoscopies in a tertiary referral childrens hospital were enrolled. Direct laryngoscopy was performed using both 2- and 3-dimensional endoscopic systems, after which the surgeons scored the quality of the images obtained with each system on a scale from 1 (low) to 5 (high). Comparison of the scores obtained with the 2 endoscopic systems was performed.nnnRESULTSnThe 33 study children (mean age 2.3u202fyears, M:F ratio 1:1.6) underwent 47 direct laryngoscopies. The mean score for visualization of the glottis was 4.8 for the three-dimensional system compared to 4.0 for the two-dimensional system (Pu202f=u202f.025), 4.7 vs. 3.8, respectively, (Pu202f=u202f.019) for the subglottis, and 4.6 vs. 3.9, respectively (Pu202f=u202f.031) for visualization of the proximal trachea. The mean score for visualization of the distal trachea was 3.0 vs. 3.7, respectively (Pu202f=u202f.020). In a child with recurrent type 3 laryngotracheal cleft a residual tracheo-esophageal fistula could not be detected using the 2D system, but was immediately detected using the 3D system.nnnCONCLUSIONSnVisualization of the glottis, subglottis and proximal trachea during direct laryngoscopy using a 3-dimensional endoscopic system was rated by the surgeons as being superior to the conventional 2-dimensional technique. Further outcome studies that will demonstrate the clinical advantage of the 3D technology are highly required.nnnLEVEL OF EVIDENCEn2b.

Vestibular Schwannoma—Management and Treatment Approaches

Vestibular schwannomas, more commonly known as acoustic neuromas (ANs), are benign, extra-axial tumours that originate from the schwann cells of the vestibular branches of the vestibulocochlear nerve (cranial nerve [CN] VIII). ANs account for 8–10 % of all intracranial tumours and 80 % of those involving the cerebellopontine angle (CPA). The incidence of ANs has been estimated to be 10–15 per one million people annually [1, 2]; the widespread and increasing use of MRI may lead to a more accurate, higher incidence because of the higher detection rate. The diagnosis of an AN is usually made in adults between the ages of 40–60 years, and the vast majority of these cases are sporadic, resulting from a somatic mutation. ANs are rarely diagnosed in teenagers in whom the tumour is associated with neurofibromatosis type 2 (NF2).