Rounak B. Rawal

Pre-operative simulation of pediatric mastoid surgery with 3D-printed temporal bone models

OBJECTIVES As the process of additive manufacturing, or three-dimensional (3D) printing, has become more practical and affordable, a number of applications for the technology in the field of pediatric otolaryngology have been considered. One area of promise is temporal bone surgical simulation. Having previously developed a model for temporal bone surgical training using 3D printing, we sought to produce a patient-specific model for pre-operative simulation in pediatric otologic surgery. Our hypothesis was that the creation and pre-operative dissection of such a model was possible, and would demonstrate potential benefits in cases of abnormal temporal bone anatomy. METHODS In the case presented, an 11-year-old boy underwent a planned canal-wall-down (CWD) tympano-mastoidectomy for recurrent cholesteatoma preceded by a pre-operative surgical simulation using 3D-printed models of the temporal bone. The models were based on the childs pre-operative clinical CT scan and printed using multiple materials to simulate both bone and soft tissue structures. To help confirm the models as accurate representations of the childs anatomy, distances between various anatomic landmarks were measured and compared to the temporal bone CT scan and the 3D model. RESULTS The simulation allowed the surgical team to appreciate the childs unusual temporal bone anatomy as well as any challenges that might arise in the safety of the temporal bone laboratory, prior to actual surgery in the operating room (OR). There was minimal variability, in terms of absolute distance (mm) and relative distance (%), in measurements between anatomic landmarks obtained from the patient intra-operatively, the pre-operative CT scan and the 3D-printed models. CONCLUSIONS Accurate 3D temporal bone models can be rapidly produced based on clinical CT scans for pre-operative simulation of specific challenging otologic cases in children, potentially reducing medical errors and improving patient safety.

Minimizing Morbidity in Endoscopic Pituitary Surgery Outcomes of the Novel Nasoseptal Rescue Flap Technique

Objective The novel nasoseptal rescue flap has been proven to provide complete coverage of dural defects that may be encountered during endoscopic pituitary surgery through cadaveric studies. In this case series, the authors report outcomes from the first cohort of patients who had a nasoseptal rescue flap raised prior to surgery. Study Design Case series with chart review. Setting University of North Carolina–Chapel Hill. Subjects and Methods Patients requiring nasoseptal rescue flaps were identified from the senior author’s database. Results Nasoseptal rescue flaps were harvested in 26 consecutive patients, with only 7 (27%) patients actually requiring use of the rescue flap for skull base reconstruction due to intraoperative cerebrospinal fluid (CSF) leak. Six patients had low-flow CSF leaks, whereas 1 patient had a high-flow CSF leak. Nineteen patients had pituitary adenomas, whereas 7 patients had Rathke cleft cyst. Mean follow-up time was 6 months (range, 1-16 months). Since surgery, no patients have presented with CSF leak or septal perforation. The success rate in those 7 patients with rescue flap utilization was 100%. Conclusion The nasoseptal rescue flap is an effective surgical technique for patients undergoing pituitary surgery without a planned nasoseptal flap. It allows for vascularized skull base reconstruction if an intraoperative CSF leak is encountered and minimizes donor site morbidity if a leak is not encountered.

Endoscopic Resection of Sinonasal Malignancy A Systematic Review and Meta-analysis

Objectives The use of endoscopic approaches for sinonasal malignancy resection has increased, but survival data are limited secondary to disease rarity and new surgical technique. Here we present a systematic review and meta-analysis of endoscopic endonasal resection of sinonasal malignancy. Data Sources MEDLINE, PubMed Central, NCBI Bookshelf, Cochrane Library, clinicaltrials.gov, National Guideline Clearinghouse. Review Methods PRISMA/MOOSE guidelines were followed. MeSH terms were “endoscopic” AND (“esthesioneuroblastoma” OR “sinonasal adenocarcinoma” OR “squamous cell carcinoma” OR “sinonasal undifferentiated carcinoma”). For studies in which individual-level data were available, results were obtained by direct pooling. For studies in which only summary Kaplan-Meier curves were available, numerical data were extracted, traced, and aggregated by fitting a Weibull model. Results Of 320 studies identified, 35 case series were included (n = 952 patients), with 15 studies analyzed via aggregate modeling and 20 studies analyzed via direct pooling. Two- and 5-year survival rates for patients in aggregate modeling were 87.5% and 72.3%, respectively (mean follow-up: 32.9 months). Two- and 5-year survival for patients in direct pooling were 85.8% and 83.5%, respectively (mean follow-up: 43.0 ± 19.5 months). Significant overall survival difference was found between low- and high-grade cancers (P = .015) but not between low- and high-stage cancers (P = .79). Conclusion Overall 2- and 5-year survival rates are comparable and sometimes greater than those from open craniofacial resection. Survival rates significantly differ by cancer grade but not stage. Journals and investigators should be encouraged to publish retrospective and prospective case series with staged survival updates based on established guidelines.

Obstructive sleep apnea in patients undergoing endoscopic surgical repair of cerebrospinal fluid rhinorrhea

To examine the relationship between cerebrospinal fluid (CSF) rhinorrhea and obstructive sleep apnea (OSA).

The combined endonasal and transoral approach for the management of skull base and nasopharyngeal pathology: a case series

The posterior skull base and the nasopharynx have historically represented technically difficult regions to approach surgically given their central anatomical locations. Through continued improvements in endoscopic instrumentation and technology, the expanded endonasal approach (EEA) has introduced a new array of surgical options in the management of pathology involving these anatomically complex areas. Similarly, the transoral robotic surgical (TORS) approach was introduced as a minimally invasive surgical option to approach tongue base, nasopharyngeal, parapharyngeal, and laryngeal lesions. Although both the EEA and the TORS approach have been extensively described as viable surgical options in managing nasopharyngeal and centrally located head and neck pathology, both endonasal and transoral techniques have inherent limitations. Given these limitations, several institutions have published feasibility studies with the combined EEA and TORS approaches for a variety of skull base and nasopharyngeal pathologies. In this article, the authors present their clinical experience with the combined endonasal and transoral approach through a case series presentation, and discuss advantages and limitations of this approach for surgical management of the middle and posterior skull base and nasopharynx. In addition, a presentation is included of a unique, simultaneous endonasal and transoral dissection of the nasopharynx through an innovative intraoperative setup.

Endonasal odontoidectomy for basilar impression and brainstem compression due to radiation fibrosis.

INTRODUCTION Basilar invagination and basilar impression both refer to the displacement of the odontoid process into the foramen magnum, although the former is congenital and the latter is due to secondary etiology. Many etiologies for basilar impression exist, including trauma, Paget’s disease of the bone, osteogenesis imperfecta, rickets, and rheumatoid pannus. To our knowledge there have been no reports of basilar impression caused by radiation fibrosis of the odontoid process. We present this case with the subsequent novel indication for an endonasal transclival odontoidectomy. A 66-year-old female with a history of advanced tonsillar carcinoma treated with primary radiation therapy 6 years prior presented with neck pain and falls. She was significantly deconditioned, wheel-chair bound, with progressive wasting, fatigue, cervical instability, and pain. She also exhibited significant trismus (1 cm). Computed tomography (CT) imaging revealed basilar impression with severe narrowing of the spinal canal to 6 mm at the level of the foramen magnum along with brainstem compression (Fig. 1A,B). Given her significant trismus, a transoral approach to the odontoid was not a viable option without a mandibulotomy. The nasopalatine line showed that transnasal access to the odontoid process was feasible. We provide a detailed description and video of the surgical approach (Video 1).

Post-operative budesonide irrigations for patients with polyposis: A blinded, randomized controlled trial

OBJECTIVE To compare normal saline (NS) vs. NS+budesonide irrigations in post- functional endoscopic sinus surgery (FESS) patients with chronic rhinosinusitis with polyposis (CRSwNP). Currently, no evidence exists for NS+budesonide irrigation over NS irrigation alone. STUDY DESIGN Prospective, single-blind, randomized controlled trial. METHODS Subjects were prospectively enrolled to NS or NS+budesonide arms. Patients were evaluated at pre-operative and three post-operative visits (POV): POV1 (1-2 weeks post-op), POV2 (3-8 weeks post-op), and POV3 (3-6 months post-op). Patients were evaluated by three quality of life (QOL) questionnaires (SNOT-22, RSOM-31, and RSDI) and two olfaction scores (UPSIT and the PEA test). RESULTS Fifty patients were randomized, with 25 patients in the NS arm and 25 patients in the NS+budesonide arm. Two patients had unexpected pathology and were excluded from the study. By POV2 and POV3, patients experienced a significant improvement in all three QOL surveys, although the degree of improvement between arms was not significant up through POV3. Neither arm experienced significant olfactory improvement up through POV3. CONCLUSIONS While both NS and NS+budesonide treatments improve QOL for post-FESS patients, neither intervention significantly increases QOL as compared to the other. Olfaction was not significantly improved in either treatment group.

Evidence-Based Practice: Endoscopic Skull Base Resection for Malignancy

Successful outcomes of endoscopic approaches to benign sinonasal tumors have launched interest in expanding its use for sinonasal malignancy. Because of the heterogeneity and rarity of sinonasal malignancy, evidence for clinical outcomes of endoscopic approaches versus traditional craniofacial resection is low. Using the Oxford Center for Evidence-based Medicine guidelines, we present the existing evidence comparing both techniques for a variety of sinonasal malignancies.

Endoscopic Sinonasal Meningoencephalocele Repair A 13-Year Experience with Stratification by Defect and Reconstruction Type

Objective Sinonasal meningoencephalocele is a rare defect, with varying etiologies and treatment strategies. Here we present the largest published series from a single institution of patients with endoscopic repair. The primary goal is to examine rates of success with consideration to accompanying patient demographic data. The secondary goal is to report the results stratified by defect and reconstruction type. Design Retrospective consecutive case series. Setting Tertiary care academic center. Subjects and Methods Consecutive patients with CPT codes for skull base meningoencephalocele repair between May 2000 and March 2013 were reviewed. Patients who specifically had sinonasal defects were included. Results During the study period, 149 cases of sinonasal meningoencephaloceles were managed in 133 patients. Mean follow-up was 21.3 months (range, 0-116). There was a success rate of 88% for initial repair, with mean recurrence time of 8.3 months (range, 0-38), and a success rate of 93.8% for initial recurrence surgery, with 99.3% of ultimate successful repair. All cases were repaired endoscopically. Recurrence rate was not significantly related to location of defect (P = .682), size of defect (P = .434), particular reconstruction technique (P = .163), or etiology (trauma, P = .070). Overall complication rate was 11.3%. Conclusion Endoscopic sinonasal meningoencephalocele repair has excellent long-term results and may be considered as a primary approach. Surgeon comfort with a particular technique should be the most important factor used to guide choice of reconstruction.

A prospective randomized cohort study evaluating 3 weeks vs 6 weeks of oral antibiotic treatment in the setting of “maximal medical therapy” for chronic rhinosinusitis

Surprisingly, little literature exists evaluating the optimal duration of antibiotic treatment in “maximal medical therapy” for chronic rhinosinusitis (CRS). As such, we investigated whether 3 weeks vs 6 weeks of antibiotic therapy resulted in significant differences in clinical response.