Zoukaa Sargi

Endoscopic endonasal resection of esthesioneuroblastoma : A multicenter study

Background This study reports the combined experience of the University of Miami and University of Pittsburgh with endoscopic endonasal resection of esthesioneuroblastoma (ENB). A retrospective case series review was performed in a tertiary care university hospital. Methods Twenty-three patients, 16 men and 7 women, were reviewed. Mean age was 56.6 years (15-79 years). Nineteen patients received primary endoscopic endonasal anterior skull base resection. Of these, the modified Kadish stage at presentation was A in 2 patients, B in 11 patients, C in 5 patients, and D in 1 patient. Three patients had revision surgeries for recurrent tumors. The main outcome measures were complete resection and margin assessment, short-term and long-term complications, and recurrence rate. Results Complete resection and negative intraoperative resection margins were achieved endoscopically in 17 of the primarily treated cases. The two other cases had one patient that required an additional craniotomy approach to complete the resection of a positive lateral dual margin, another patient had positive margins at the orbital apex. All patients tolerated the endoscopic procedure very well with no meningitis. There were four cerebral spinal fluid leaks. Mean follow-up period for the primarily treated cases was 45.2 months (11-152 months), all were disease free at the most recent available follow-up. Conclusion In experienced hands and carefully selected patients, endoscopic resection of ENB respects the principles of oncologic surgery, providing an adequate exposure for margin assessment as well as reliable reconstruction of the anterior skull defect with a relatively low morbidity.

Tadalafil Reduces Myeloid-Derived Suppressor Cells and Regulatory T Cells and Promotes Tumor Immunity in Patients with Head and Neck Squamous Cell Carcinoma

Purpose: Myeloid-derived suppressor cells (MDSC) and regulatory T cells (Treg) play a key role in the progression of head and neck squamous cell carcinoma (HNSCC). On the basis of our preclinical data demonstrating that phosphodiesterase-5 (PDE5) inhibition can modulate these cell populations, we evaluated whether the PDE5 inhibitor tadalafil can revert tumor-induced immunosuppression and promote tumor immunity in patients with HNSCC. Experimental Design: First, we functionally and phenotypically characterized MDSCs in HNSCCs and determined, retrospectively, whether their presence at the tumor site correlates with recurrence. Then, we performed a prospective single-center, double-blinded, randomized, three-arm study in which patients with HNSCC undergoing definitive surgical resection of oral and oropharyngeal tumors were treated with tadalafil 10 mg/day, 20 mg/day, or placebo for at least 20 days preoperatively. Blood and tumor MDSC and Treg presence and CD8+ T-cell reactivity to tumor antigens were evaluated before and after treatment. Results: MDSCs were characterized in HNSCC and their intratumoral presence significantly correlates with recurrence. Tadalafil treatment was well tolerated and significantly reduced both MDSCs and Treg concentrations in the blood and in the tumor (P < 0.05). In addition, the concentration of blood CD8+ T cells reactive to autologous tumor antigens significantly increased after treatment (P < 0.05). Tadalafil immunomodulatory activity was maximized at an intermediate dose but not at higher doses. Mechanistic analysis suggests a possible off-target effect on PDE11 at high dosages that, by increasing intracellular cAMP, may negatively affect antitumor immunity. Conclusions: Tadalafil seems to beneficially modulate the tumor micro- and macro-environment in patients with HNSCC by lowering MDSCs and Tregs and increasing tumor-specific CD8+ T cells in a dose-dependent fashion. Clin Cancer Res; 21(1); 39–48. ©2014 AACR.

Efficacy of transnasal endoscopic resection for malignant anterior skull-base tumors†

Craniofacial resection (CFR) has been the standard of care for malignant tumors of the anterior skull base (ASB). However, during the past 2 decades, transnasal endoscopic resection (TER) has gained significant popularity. The purpose of this study is to compare CFR and TER with respect to perioperative and oncologic outcomes.

Long-term effect of stenting after an endoscopic modified Lothrop procedure.

Background The aim of this study was to study the effect of stenting with a silastic sheet on the long-term patency of the common frontal ostium after an endoscopic modified Lothrop procedure (EMLP). Methods A retrospective analysis was performed of prospectively collected data at an academic tertiary referral center, where 72 patients underwent an EMLP between 1996 and 2003. Patency of the common frontal ostium was studied as an ordinal variable with three classes (patent, stenotic, and closed). Results A common ostium was endoscopically visualized in 94% of the patients (61.1% patent and 33.3% stenotic). Symptoms improved in 75% of the patients. A significant positive correlation was found between ostium patency and symptom improvement. Twenty-five patients were stented postoperatively. There was no statistical difference between the stented and the nonstented groups with regards to ostium patency and symptoms improvement. Conclusion Short-term stenting does not appear to reduce the rate of postoperative stenosis of the common frontal ostium after an EMLP.

The role of indeterminate fine-needle biopsy in the diagnosis of parotid malignancy

To examine the significance of indeterminate fine needle aspiration biopsy in the diagnosis of parotid gland malignancy.

Outcomes after surgical resection of head and neck paragangliomas: a review of 61 patients.

We reviewed the postoperative functional outcome following surgical resection of paragangliomas in patients with and without preoperative cranial nerve dysfunction. Patients who underwent surgical resections of head and neck paragangliomas were reviewed with functional outcomes defined as feeding tube and/or tracheostomy dependence, need for vocal cord medialization, and incidence of cerebral vascular accidents as primary end points. Secondary end points included pre- and postoperative function of lower cranial nerves and the impact of this dysfunction on long-term functional status. Sixty-one patients were identified: 27 with carotid paraganglioma (CP), 21 with jugular paraganglioma (JP), 8 with tympanic paragangliomas, 4 with vagal paragangliomas (VPs), and 1 with aortopulmonary paraganglioma. Following resection, 8 patients were feeding tube dependent, 14 patients required vocal cord medialization, 2 patients suffered strokes, but no patients required tracheostomy tubes. Twenty percent of patients (4/20) with JP and postoperative cranial neuropathies were feeding tube dependent, and 80% of patients (4/5) with CP and postoperative cranial nerve dysfunction were feeding tube dependent. Cranial nerve deficits were more common in patients with JP relative to those with CP. However, when cranial nerve dysfunction was present, our patients with CP had a higher incidence of temporary feeding tube dependence. Overall, 98% of patients were able to resume oral nutrition.

Pediatric Obstructive Sleep Apnea: Current Management

Obstructive sleep apnea syndrome (OSAS) is a condition frequently encountered in children, and belongs to a spectrum of diseases called sleep-disordered breathing. Its pathophysiology is related to decreased ventilation despite respiratory effort, leading to episodes of hypopnea and apnea. Left untreated, this condition could have a significant impact on both physical and mental health. Primary snoring is often the presenting symptom reported by parents, and should warrant careful screening for OSAS. Although overnight polysomnography remains the gold standard diagnostic test for OSAS, its feasibility in clinical practice is less obvious, and furthermore, interpretation of its results is not unanimously agreed on. This is why in clinical practice history and physical examination remain among the most useful diagnostic tools. Management of OSAS traditionally includes tonsillectomy and/or adenoidectomy to which most of the cases respond. However, other risk factors and coexisting conditions should be carefully investigated and treated prior to considering surgical treatment.

Tonsillectomy and Adenoidectomy Techniques: Past, Present and Future

Although the number of procedures has significantly decreased over the past century, tonsillectomy and adenoidectomy are commonly performed surgeries in the pediatric group, with obstructive sleep apnea being the most common indication. Despite the availability of newer technologies, tonsillectomy is still associated with a relatively high risk of postoperative morbidity. Pain and postoperative bleeding can have a significant impact on the child’s health and quality of life. This article reviews the currently available techniques for tonsillectomy and adenoidectomy, with their characteristics and potential benefits. No gold standard exists at this point, and further prospective clinical trials are needed in this perspective.

Extended maxillary sinusotomy in isolated refractory maxillary sinus disease

Many patients have refractory maxillary sinus disease despite optimal medical and surgical therapy. Endoscopic middle meatal maxillary sinusotomy with total uncinectomy is the surgical standard of care since the importance of restoring the physiologic pathway of mucociliary flow through the ostiomeatal complex was first suggested by Kennedy and Stammberger. However, dysfunctional mucociliary clearance resulting from prolonged inflammatory disease or iatrogenic mucosal stripping during previous sinus procedures may render middle meatal maxillary sinusotomy less effective in keeping the sinus free of disease. Patients with dysfunctional mucociliary clearance have benefited from facilitating drainage with hypertonic irrigations via gravity-dependent inferior antrostomies. In addition, an inferior meatal maxillary sinusotomy may provide further access to address mucopus and mucosal lesions in clinic without the need for further formal operative procedures. During the past few years, the senior author (R.R.C.) developed what we call an extended maxillary sinusotomy, which is defined as a combination revision middle meatal maxillary sinusotomy and an inferior meatal maxillary sinusotomy, with or without partial middle and inferior turbinoplasty. After approval was obtained from the institutional review board, a preexisting database of all surgeries performed by the senior author at the University of Miami/ Jackson Memorial Hospital, Department of Otolaryngology, from January 1997 through December 2004 was reviewed. Patients who underwent endoscopic, extended maxillary sinusotomy for persistent, symptomatic, chronic maxillary rhinosinusitis, despite appropriate medical management and previous endoscopic middle meatal maxillary sinusotomy with total uncinectomy, were considered for the study. Patients with involvement of other sinuses, fungal sinusitis, immotile cilia syndrome, immunodeficiency, neoplasm, persistent uncinate process, and recirculation phenomenon were excluded. All surgeries were performed under general anesthesia by one surgeon (R.R.C.), as an outpatient procedure, with the use of the following technique: After mucosal decongestion with Neo-Synephrine, the area of the sphenopalatine

Use of the Microdebrider in Selective Excision of Hereditary Hemorrhagic Telangiectasia: A New Approach

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is an autosomal dominant disease characterized by diffuse mucocutaneous telangiectasias and arteriovenous malformations. The nasal mucosa is the most common site for telangiectasias, with the most frequent symptom being chronic, recurrent epistaxis, occurring in approximately 93% of patients. The distribution of nasal telangiectasias in HHT occurs mostly in the periphery of large supplying nasal vessels in the anterior nasal cavity (Little’s area) and the lateral nasal wall (heads of the middle and inferior turbinates). With a mean age of onset of 12 years and a mean frequency of 18 bleeding episodes per month, HHT can have a major impact on everyday life. It also poses a significant challenge for otolaryngologists, who are often conflicted as to which treatment option to use. There has been no single treatment modality that has been proved to be superior to others in both ease of administration and long-term control of bleeding. Most recently, treatment has involved determining the severity of epistaxis, from mild to severe. Treatments range from nasal packing to laser photocoagulation with the CO2, KTP, Nd:YAG, or argon laser to embolization, septodermoplasty, and nasal closure (modified Young’s procedure). Recognizing the limitations of the above treatment options, a new technique was explored and developed in our institution. We have selectively been excising nasal telangiectasia in patients with HHT by using a microdebrider. The microdebrider is a relatively new tool in otolaryngology that allows for precise, less-traumatic tissue removal. This unique feature of the microdebrider allows for delicate and complete removal of lesions on the nasal mucosa. After obtaining institutional review board approval, patient records were retrospectively reviewed and only patients who were preoperatively diagnosed with HHT and were treated with the microdebrider were included in the study. Under general anesthesia, the telangiectasias were identified using the 30-degree telescope connected