Faculty Bibliography

BACKGROUND: Successful reconstruction of large anterior skull base (ASB) defects after craniofacial resection of malignant skull base tumors is paramount for preventing cerebrospinal fluid (CSF) fistulas. The vascularized pedicled pericranial flap (PCF) has been the gold standard for repairing ASB defects after transbasal transcranial approaches. However, flap necrosis and delayed CSF leaks can occur after adjuvant radiation therapy. We describe a "double flap" reconstruction technique in which the PCF is augmented inferiorly by a secondary vascularized pedicled nasoseptal flap (NSF) that is harvested and rotated using an endoscopic endonasal approach. METHODS: This technique is illustrated in 2 patients who underwent a combined cranionasal (transbasal and endoscopic endonasal) approach for large sinonasal malignancies with significant intracranial extension (1 esthesioneuroblastoma, 1 sinonasal teratocarcinosarcoma). After tumor removal via a combined cranionasal approach, primary repair of the ASB dural defect was performed with a free patch graft. The ASB defect was then repaired using the double flap technique with a vascularized PCF from above and augmented with a vascularized NSF from below. RESULTS: Postoperatively, there were no complications of CSF leakage, meningitis, or tension pneumocephalus in both patients. After subsequent radiation therapy, the double flap repair remained intact at 2 years postoperatively in both patients. CONCLUSION: The double flap skull base reconstruction technique provides an additional barrier of vascularized tissue to prevent CSF leakage, meningitis, tension pneumocephalus, and postradiation necrosis. This technique is a viable option if a combined transcranial and transnasal endoscopic tumor resection is performed and postoperative radiation is anticipated.

Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement is usually performed as a primary procedure for severe stenosis or obstruction of both upper and lower canaliculi of the lacrimal drainage pathway, or occasionally, after unsuccessful dacryocystorhinostomy (DCR). Jones tube obstruction is quite common, and often requires removal of the obstructed tube and replacement or exchange of the tube in the operating room. This procedure is typically performed under general anesthesia, and is associated with the risks of general anesthesia, a significant investment of time, and the cost of the operating suite. Recently, there has been a movement toward in-office procedures in otolaryngology and ophthalmology due to greater patient satisfaction and savings in time and money for patients and physicians. In this report, we describe a novel in-office method to exchange an obstructed Jones tube that provides the aforementioned benefits while preserving patient comfort. No similar case has been previously reported in the literature.

PURPOSE: Identification and exposure of the frontal sinus recess (FSR) during endoscopic sinus surgery (ESS) are challenging due to the variable anatomy, the narrow opening of the frontal sinus ostium (FSO), and the proximity of vital anatomic structures. Hence, a strong understanding of frontal sinus anatomy is required to prevent intracranial entry. Consistent and easily identifiable landmarks and measurements could assist safe entry into the FSO. In this study, we determine the distances from the columella and anterior nasal spine (ANS) to the nasofrontal beak (NFB) and anterior skull base (ASB) using high-resolution computed tomography (HRCT) scans. METHODS: A radiographic analysis was performed at a tertiary care medical center. Measurements from the ANS to the NFB and ASB, and from the columella to the NFB and ASB were made using sagittal HRCT. Thirty-two HRCT scans were analyzed by three observers, and the mean distances and standard deviations were calculated. RESULTS: The mean distance from the ANS to the NFB was 52.3+/-3.4mm in men and 47.7+/-3.5mm in women (p<0.0001). Mean distance from the ANS to the ASB was 61.8+/-4.1mm in men and 56.5+/-4.1mm in women (p<0.0001). Mean distance from the columella to the NFB was 58.9+/-2.3mm in men and 53.0+/-3.3mm in women (p<0.0001), and from the columella to the ASB was 67.9+/-3.7mm in men and 61.3+/-4.1mm in women (p<0.0001). CONCLUSION: While performing FSR exposure in ESS, it is recommended to stay a distance of less than 66.9mm in men and 60.6mm in women from the columella to minimize intracranial complications.

BACKGROUND: Advances in endoscopic sinus surgery have led to a greater number of in-office procedures away from the traditional operating room setting. Rhinologists acting independently of anesthesiologists must be prepared for potential complications, such as vasovagal response (VVR), that may arise during in-office rhinologic manipulations. In this study, we review our experience with this condition and discuss risk factors and a management algorithm for in-office VVR. METHODS: A retrospective analysis at a large tertiary referral center was performed on all patients undergoing in-office endoscopic procedures with rhinologic manipulation between July 2008 and June 2012. A total of 4973 patients underwent in-office endoscopic procedures and 8 patients with VVR were identified. Demographic data, diagnosis, procedure performed, and outcomes were reviewed. RESULTS: Eight patients out of 4973 (0.16%) experienced VVR during in-office endoscopic procedures. Seven (87.5%) of these 8 patients recovered from the VVR within 30 minutes and subsequently completed their scheduled procedure. One (12.5%) of the 8 patients did not fully recover after 30 minutes and was sent to the Emergency Department, where he was stabilized and subsequently discharged. The most common comorbidities in these 8 patients with VVR were hypercholesterolemia in 3 patients (37.5%), and hypertension and benign prostatic hyperplasia, each found in 2 patients (25.0%). CONCLUSION: Although the incidence of VVR during rhinologic procedures is low, rhinologists should be familiar with this condition and be prepared for its management.

PURPOSE: The vascularized pedicled nasoseptal flap (PNSF) represents a successful option for reconstruction of large skull base defects after expanded endoscopic endonasal approaches (EEA). This vascularized flap can be harvested early or late in the operation depending on the anticipation of high-flow CSF leaks. Each harvesting technique (early vs. late) is associated with different advantages and disadvantages. In this study, we evaluate our experience with early harvesting of the PNSF for repair of large skull base defects after EEA. METHODS: A retrospective review was performed at a tertiary care medical center on patients who underwent early PNSF harvesting during reconstruction of intraoperative high-flow CSF leaks after EEA between December 2008 and March 2012. Demographic data, repair materials, surgical approach, and incidence of PNSF usage were collected. RESULTS: Eighty-seven patients meeting the inclusion criteria were identified. In 86 procedures (98.9%), the PNSF harvested at the beginning of the operation was used. In 1 case (1.1%), the PNSF was not used because a high-flow intraoperative CSF leak was not encountered. This patient had recurrence of intradural disease 8months later, and the previously elevated PNSF was subsequent used after tumor resection. CONCLUSION: Based on our data, a high-flow CSF leak and need for a PNSF can be accurately anticipated in patients undergoing EEA for skull base lesions. Because of the advantages of early harvesting of the PNSF and the high preoperative predictive value of CSF leak anticipations, this technique represents a feasible harvesting practice for EEA surgeries.

BACKGROUND: Hemangiopericytomas are typically found in soft-tissue, but only rarely found in the sinonasal tract. Sinonasal hemangiopericytomas have been reported mostly through case studies, and optimal treatment is considered surgical excision. Classically, open surgical methods of tumor extirpation have been considered standard of care. With the wider use of endoscopic methods, an updated systematic review in terms of treatment is warranted. METHODS: Cases were identified using a MEDLINE and PubMed search. Relevant studies were identified, and data was extracted regarding patient demographics, presenting symptoms, tumor characteristics, treatment, and outcomes. RESULTS: A total of 128 cases were collected from 56 articles, consisting of case reports and series. The most common presenting symptoms were epistaxis, nasal obstruction, and facial pain/swelling/pressure. Computed tomography (CT) and X-ray were the most common modes of imaging during diagnosis and operative planning. The tumor often occupied multiple locations in the sinonasal tract at initial presentation. Surgical resection was the mainstay of treatment in 126 of the 128 cases (98.4%), either through open resection or endoscopic techniques. Surgical removal resulted in no recurrence in 79.7% of the cases. The use of endoscopic techniques increased significantly in the past decade. This review found no significant difference in terms of recurrence between endoscopic and open treatment groups, age, gender, and unilocality vs multilocality of tumor. CONCLUSION: Surgical management remains the mainstay of treatment for hemangiopericytomas. Endoscopic resection of these lesions has increased over the last few decades and has become a safe, viable, and reasonable alternative to open resection.

OBJECTIVE/HYPOTHESIS: The h-index is an objective and easily calculable measure that can be used to evaluate both the relevance and amount of scientific contributions of an individual author. Our objective was to examine how the h-index of academic otolaryngologists relates with academic rank. STUDY DESIGN: A descriptive and correlational design was used for analysis of academic otolaryngologists' h-indices using the Scopus database. METHODS: H-indices of faculty members from 50 otolaryngology residency programs were calculated using the Scopus database, and data was organized by academic rank. Additionally, an analysis of the h-indices of departmental chairpersons among different specialties was performed. RESULTS: H-index values of academic otolaryngologists were higher with increased academic rank among the levels of assistant professor, associate professor, and professor. There was no significant difference between the h-indices of professors and department chairpersons within otolaryngology. H-indices of chairpersons in different academic specialties were compared and were significantly different, suggesting that the use of this metric may not be appropriate for comparing different fields. CONCLUSIONS: The h-index is a reliable tool for quantifying academic productivity within otolaryngology. This measure is easily calculable and may be useful when evaluating decisions regarding advancement within academic otolaryngology departments. Comparison of this metric among faculty members from different fields, however, may not be reliable.

OBJECTIVES/HYPOTHESIS: Onodi cells are the posterior-most ethmoid air cells that lie superior to the sphenoid sinus. Identification of these cells is essential prior to endoscopic sinus and skull base surgery due to their intricate relationship with the optic nerves and carotid arteries, which may lead to deleterious complications. In this study, high-resolution computed tomography (HRCT) scans from 170 adult-patients were analyzed by two independent observers for the presence of Onodi cells. STUDY DESIGN: Radiographic analysis at a tertiary care medical center. METHODS: A retrospective analysis was performed on patients undergoing HRCT between July 2008 and September 2010. Incidence of Onodi cells and demographic data were collected. RESULTS: The overall prevalence of Onodi cells in this cohort was 65.3%. Subgroup analysis based on ethnicity showed a rate of Onodi cells of 83.3% in Asians, 73.1% in whites, 57.0% in African Americans, and 62.7% in Hispanics. The prevalence of Onodi cells was not significantly different among the different ethnicities (P > .05). However, this was limited by a small sample size in some ethnic groups. Onodi cell prevalence was equivalent among males and females: 62.2% and 63.5% respectively (P > .05). Overall, our results show a greater prevalence of Onodi cells than previously reported. CONCLUSIONS: We found a higher prevalence of Onodi cells in our cohort than previously reported in the literature. Therefore, it is important for surgeons to anticipate the presence of these cells during endoscopic sinus and skull base procedures to prevent potential complications.

Pituitary apoplexy in patients with adrenocorticotropic hormone (ACTH) producing tumors is a rare occurrence. We report four patients with Cushing's disease harboring ACTH-secreting macroadenomas who presented with pituitary apoplexy. We report the endocrinologic and visual outcomes of these patients after emergent transsphenoidal surgery. A retrospective chart review was performed in 4 patients who presented with pituitary apoplexy from hemorrhage into an ACTH-secreting pituitary adenoma. The patient charts were reviewed for clinical presentation, neuroimaging findings, intraoperative surgical findings, pathologic findings, and postoperative endocrinologic and visual outcomes. All patients presented with acute headaches, nausea, vomiting, and visual loss from optic compression. MR imaging demonstrated a hemorrhagic macroadenoma that was confirmed at surgery. All patients underwent emergent transsphenoidal decompression (within 24 h of presentation). One of these underwent an additional craniotomy to resect residual tumor. Postoperatively, all patients showed significant improvement in visual acuity and visual fields with biochemical remission confirmed on laboratory testing. Significant weight loss as well as resolution of diabetes and hypertension was noted in all cases. All four patients remained in biochemical remission at their most recent follow-up visit (mean 40 months, range: 24-72 months). Excellent endocrine and visual outcomes can be achieved after emergent transsphenoidal surgery in patients with Cushing's disease presenting with pituitary apoplexy. Although the cure rates of non-apoplectic ACTH macroadenomas are generally poor, higher rates of remission can be achieved in cases of pituitary apoplexy. This may be partly due to the effects of tumor infarction.