Oshri Wasserzug

Association between cerebrospinal fluid leak and meningitis after skull base surgery.

Background. Meningitis and cerebrospinal fluid (CSF) leak are serious complications of skull base surgery, but whether postoperative CSF leak increases the risk of meningitis is unknown. Objective. To evaluate any association between meningitis and CSF leak after open or endoscopic skull base resection. Study Design and Setting. A retrospective case series with chart review in a tertiary care university-affiliated medical center. Methods. A total of 156 patients underwent intradural tumor resection in our institution between 1994 and 2009, 135 (86%) via the subcranial approach and 21 (14%) through the expanded endonasal approach. All occurrences of meningitis, brain abscess, and CSF leak had been recorded and were available for analysis. Results. Nine patients (5.7%) had postoperative meningitis, and 3 patients had postoperative CSF leak (1.9%). The risk of meningitis in patients without CSF leak was 4.5% (7/153) compared to 66% (2/3) in those with CSF leak. A statistical analysis revealed a significant association between CSF leak and meningitis, with a relative risk of 14.6 (95% confidence interval, 4.95-42; P = .008). Conclusion. Postoperative CSF leak significantly increases the risk of meningitis. Most cases of meningitis after skull base operation are probably associated with lumbar drainage infection or from an obscure leak.

Utility of a Three-Dimensional Endoscopic System in Skull Base Surgery

We evaluated the utility of a three-dimensional (3-D) endoscopic system for skull base surgery. We performed a retrospective case series in a tertiary care medical center. Thirty-six patients underwent skull base (nonpituitary) resections via 3-D endoscopic system. Fifteen patients (42%) were operated for excision of malignant tumors, 19 (53%) for excision of benign lesions, and 3 (8.3%) for skull base reconstruction. The tumors involved the cribriform plate (n = 13), sphenoid sinus and planum (n = 17), clivus (n = 7), and sella (n = 7). Complete tumor resection was achieved in 31 patients and subtotal resection in two. Five patients (14%) had postoperative complications. There was one case of meningitis, and there were no cases of cerebrospinal fluid leak. The surgeons ability to recognize anatomic structures at the skull base was evaluated using the 3-D and two-dimensional systems. The 3-D technique was superior to the conventional technique for identification of the sella, carotid prominence, optic prominence, cribriform plate, sphenoid, and fovea ethmoidalis. The two systems were equal for detection of the turbinates, clivus, maxillary, ethmoids, and frontal sinuses. Endoscopic skull base surgery with stereoscopic viewing is feasible and safe. Further studies are required to evaluate the advantage of binocular vision in skull base surgery.

Surgical treatment of juvenile nasopharyngeal angiofibroma with intracranial extension. Clinical article.

OBJECT The purpose of this study was to describe the surgical treatment and outcomes of patients with intracranial extension of juvenile nasopharyngeal angiofibroma (JNA). METHODS Twenty-one patients who underwent operations for JNAs between 1994 and 2008 were enrolled in the study. Seven patients (33%) had intracranial tumor extension. The middle cranial fossa and cavernous sinus were involved in 4 patients who underwent operations via the combined infratemporal fossa-midfacial degloving approach. The anterior skull base was involved in 3 patients who underwent the subcranialmidfacial degloving approach. RESULTS Complete tumor removal was achieved in all patients. Postoperative complications included 1 case of soft-tissue infection. None of the patients had tumor recurrence after a mean follow-up of 42 months (range 29-85 months). No adjuvant therapy was required in any patient. CONCLUSIONS Combined approaches can be used effectively for treatment of JNAs with intracranial extension without the need for adjuvant therapy.

Incidence of retropharyngeal calcific tendinitis (longus colli tendinitis) in the general population.

Objective To determine the incidence of retropharyngeal calcific tendinitis (longus colli tendinitis) in a general urban adult population. Study Design Observational study in a municipal medical center. Setting Single tertiary referral center. Methods All symptomatic patients with a differential diagnosis of retropharyngeal calcific tendinitis underwent fiber-optic assessment, laboratory studies, and imaging studies. The main outcome measure was the incidence of retropharyngeal calcific tendinitis. Results Thirteen patients with symptoms suggestive of retropharyngeal calcific tendinitis were evaluated in our institution between January 2008 and December 2011. Final diagnosis was made by means of a computed tomographic scan: 8 patients had retropharyngeal calcific tendinitis, 1 had retropharyngeal abscess, and the remaining 4 had other deep neck infections. The mean annual crude retropharyngeal calcific tendinitis incidence was 0.50 cases per 100,000 person-years, and the standardized incidence was 1.31 for the age-matched population. Conclusions Retropharyngeal calcific tendinitis is not a rare disease and is probably underdiagnosed because symptoms are nonspecific, treating physicians are often unfamiliar with this entity, and it is a self-limiting pathology.

Surgical Ablation and Free Flap Reconstruction in Children with Malignant Head and Neck Tumors

We assessed the feasibility and safety of free flap reconstruction in children undergoing extensive surgical excision of malignant head and neck tumors. We performed a retrospective review in a tertiary referral center of all patients aged 18 years or younger who underwent free flap reconstruction following resection of malignant head and neck tumors at our institution. Main outcome measures included complications at the primary and donor sites, functional and esthetic outcome, and tumor control. Eight of the 237 (3.4%) free flap reconstructions were performed on children. All tumors were malignant sarcomas. Ablative surgery was via a transfacial (n = 4) or a combined approach (n = 4). Transferred free flaps were the rectus abdominis (n = 3), gracilis (n = 3), fibula (n = 1), and anterolateral thigh (n = 1). The mean follow-up was 25.5 months. The overall early and late complication rates were 50% and 25%, respectively. There were no flap losses and no donor site complications. Functional outcome, including mastication, deglutition, and speech, was satisfactory. Local tumor control rate at last follow-up was 87.5%. Free flap reconstruction is an efficient and relatively safe technique for reconstructing surgical defects of the head and neck in children undergoing extensive surgery for malignant disease.

The Transcervical Approach for Parapharyngeal Space Pleomorphic Adenomas: Indications and Technique

Background Head and Neck Parapharyngeal space tumors are rare. Pleomorphic Adenomas are the most common Parapharyngeal space tumors. The purpose of this study was to define preoperative criteria for enabling full extirpation of parapharyngeal space pleomorphic adenomas via the transcervical approach while minimizing functional and cosmetic morbidity. Methods The surgical records and medical charts of 19 females and 10 males with parapharyngeal space pleomorphic adenomas operated between 1993 and 2012 were reviewed. Results Fifteen patients were operated by a simple transcervical approach, 13 by a transparotid transcervical approach, and one by a transmandibular transcervical approach. Complications included facial nerve paralysis, infection, hemorrhage and first bite syndrome. There were three recurrences, but neither recurrence nor complications were associated with the type of surgical approach. Conclusion A simple transcervical approach is preferred for parapharyngeal space pleomorphic adenomas with narrow attachments to the deep lobe of the parotid gland and for pleomorphic adenomas originating in a minor salivary gland within the parapharyngeal space.

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 (n = 41, 59%) or frontal cranialization (n = 28, 41%). Main Outcome Measures The prevalence of post-surgical complications and secondary mucocele formation were compiled. Results Pathologies included osteoma (n = 34, 49%), mucocele (n = 27, 39%), fibrous dysplasia (n = 6, 9%), and encephalocele (n = 2, 3%). Complications included skin infections (n = 6), postoperative cutaneous fistula (n = 1), telecanthus (n = 4), diplopia (n = 3), nasal deformity (n = 2) and epiphora (n = 1). 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.

Involvement of the Maxillary Sinus in Bisphosphonate-Related Osteonecrosis of the Jaw: Radiologic Aspects

Background The use of bisphosphonates is very common among patients with osteoporosis and multiple myeloma as well as those with bone metastases from various malignancies. The benefits of bisphosphonates are well recognized, but it became evident during the past decade that these medications portend the major adverse effect of osteonecrosis of the jaw, known as bisphosphonate-related osteonecrosis of the jaw. Objective Our aim was to evaluate the specific manifestations of bisphosphonate use on the maxillary sinus in patients with documented bisphosphonate-related osteonecrosis of the jaw. Methods A retrospective review of all the patients diagnosed between October 2003 to August 2014 as having bisphosphonate-related osteonecrosis of the jaw in a large university-affiliated tertiary care medical center. The records of 173 patients diagnosed as having bisphosphonate-related osteonecrosis of the jaw during the study period were retrieved. The available head and neck computed tomographic images were analyzed for cases of involvement of the maxilla. Main Outcome Measures Manifestations of bisphosphonate-related osteonecrosis of the jaw as observed on physical examination and on imaging studies. Results Seventy-one patients (41%) had involvement of the maxilla, 86 patients (49%) had involvement of the mandible, and 16 patients (9%) had involvement of both the maxilla and the mandible. Computerized tomography studies were available for 50 patients with involvement of the maxilla: 36 (72%) had evidence of maxillary sinus opacification (in comparison, the incidence of maxillary sinus opacification as an incidental finding in the general population is reported to be 19%, p < 0.0001). Sixteen patients (32%) had evidence of oroantral fistula, and five patients (10%) had oronasal fistula. Conclusion In addition to its well-established effects on the mandible and maxilla, bisphosphonate-related osteonecrosis of the jaw significantly affected the maxillary sinus. Its radiologic manifestations should be recognized by clinicians and especially by otolaryngologists.

Rapid onset of osteonecrosis of the jaw in patients switching from bisphosphonates to denosumab

OBJECTIVE The aim of this study was to determine whether osteonecrosis of the jaw (ONJ) developed more rapidly in patients who switched from bisphosphonates (BP) treatment to denosumab than in patients who received only denosumab. STUDY DESIGN This was a retrospective cohort study conducted at a tertiary referral center. Thirty-one patients with ONJ met the inclusion criteria. RESULTS Twenty-two patients who had been on BP were switched to denosumab (BP + D), whereas 9 patients received only denosumab. Both groups were similar for the known ONJ risk factors, that is, age, diabetes mellitus, and smoking. The number and cumulative doses of denosumab before the onset of ONJ symptoms were significantly lower among the BP + D group compared with the denosumab-only group (P = .025 and .018, respectively). In the BP + D group, ONJ symptoms developed in 9 patients (41%) following the administration of ≤3 denosumab doses compared with ONJ developing in only 1 patient (11%) who was naïve to BP. ONJ developed spontaneously without any known triggering event in 72.7% of patients in the BP + D group and in 77.8% of patients in the denosumab-only group. CONCLUSIONS Denosumab-induced ONJ might develop rapidly in patients previously treated with BP. ONJ developed spontaneously in most patients treated with denosumab. In light of our sample being small, there is need for further investigation on our conclusions.

One-Stage Decannulation Procedure for Patients Undergoing Oral and Oropharyngeal Oncological Surgeries and Prophylactic Tracheotomy~!2009-11-01~!2010-02-23~!2010-06-18~!

Objective: Decannulation of patients with tracheotomy usually requires decrease in tracheostomy tube size, capping for 24-48 hours and observation after tube removal. Delay in decannulation may increase cardiopulmonary load, prolong hospitalization and cause patient distress. We propose a one-stage procedure in an intensive care unit (ICU) setting for patients undergoing head and neck surgeries and temporary tracheotomy. Study Design and Setting: Patients undergoing resection of head and neck tumors involving the oral cavity or oropharynx in a tertiary cancer center were prospectively studied. Following clinical and laboratory assessments, the tracheostomy tube was removed under cardiopulmonary monitoring in the ICU. Results: All 24 study patients underwent successful decannulation and were discharged 24 hours later. Follow-up time was 5 months. None of them required reintubation or recannulation. Conclusion: A one-stage decannulation is feasible and safe for patients undergoing resection of head and neck tumors involving the oral cavity or oropharynx. This procedure may lessen hospitalization time and reduce patients distress.