Faculty Bibliography

OBJECTIVES/OBJECTIVE:To perform a radio-anatomical evaluation of the nasal cavity floor free mucosal graft (endonasal extended mucoplasty, EEM) to repair mucosal defects after an extended ethmoid-sphenoidotomy. METHODS:A human cadaveric study (radiological and anatomical dissection) and an in vivo study in surgical patients with CRSwNP were performed. The EEM areas were compared between 3D reconstruction from CT scans and anatomical/surgical dissections, both in cadaver specimens and in patients. Feasibility was assessed by correlation between the EEM area on CT scans and when harvested in cadavers and when grafted in patients. Usefulness was assessed by the degree of coverage of the EEM in the surface exposed after an extended ethmoid-sphenoidotomy. Both feasibility and usefulness were assessed in cadaveric specimens (n = 15) and patients (n = 4). RESULTS:, respectively. The coverage of the ethmoidal roof in the cadaveric dissection study was 100%, from the anterior ethmoidal artery to the posterior ethmoidal artery, covering the planun sphenoidale up to 75% in the case series. In 87.5% of the cases, up to 50% of the papiracea lamina was covered. CONCLUSION/CONCLUSIONS:The EEM have shown to be a feasible and useful grafting technique to repair skull base defects after performing an extended ethmoid-sphenoidotomy during surgery for CRSwNP. LEVEL OF EVIDENCE/METHODS:NA.

Hypothalamic hamartomas are benign tumors known to cause gelastic or dacrystic seizures, precocious puberty, developmental delay, and medically refractory epilepsy. These tumors are most often sporadic but rarely can be associated with Pallister-Hall syndrome, an autosomal dominant familial syndrome caused by truncation of glioblastoma transcription factor 3, a downstream effector in the sonic hedgehog pathway. In this clinical report, the authors describe two brothers with a different familial syndrome. To the best of the authors' knowledge, this is the first report in the literature describing a familial syndrome caused by germline mutations in the Smoothened (SMO) gene and the first familial syndrome associated with hypothalamic hamartomas other than Pallister-Hall syndrome. The authors discuss the endoscopic endonasal biopsy and subtotal resection of a large hypothalamic hamartoma in one of the patients as well as the histopathological findings encountered. Integral to this discussion is the understanding of the hedgehog pathway; therefore, the underpinnings of this pathway and its clinical associations to date are also reviewed.

BACKGROUND:The nasoseptal flap is the main pedicled flap used for endoscopic cranial base reconstruction. For large anterior cranial base defects, the anterior edge is a concern for the nasoseptal flap reach. OBJECTIVE:To present a surgical technique that completely releases the vascular pedicle of the nasoseptal flap from the sphenopalatine artery (SPA) foramen improving considerably the reach of the flap. METHODS:A patient with left anterior cranial base fracture involving the posterior table of the frontal sinus, who presented with cerebrospinal fluid leak and contused brain herniation to the ethmoid and frontal sinuses. Unilateral endoscopic endonasal anterior cranial base reconstruction was performed with left sided nasoseptal flap. The nasoseptal flap pedicle was dissected and completely released from the SPA foramen. The flap was left attached only to the internal maxillary artery (IMAX) vascular bundle. RESULTS:The flap covered the entire left anterior cranial base, from the planum sphenoidale to the posterior table of the frontal sinus. There was complete obliteration of the cerebrospinal fluid fistula postoperatively with resolution of the radiographic pneumocephalus and the patient's rhinorrhea. CONCLUSION:The complete release of the nasoseptal flap pedicle from the SPA foramen is feasible and remarkably improves the reach of the flap. It also increases the reconstructive area of the flap since the entire septal mucosa can be used for reconstruction and the pedicle length is based exclusively upon the SPA/IMAX.

BACKGROUND:Cerebrospinal fluid (CSF) leak is a common complication after surgeries involving sellar reconstruction. Various techniques, including the nasoseptal flap, have been developed to limit postoperative CSF leak. However, the nasoseptal flap causes complications owing to donor site morbidity. A free mucosal graft may be just as effective in reducing CSF leaks as well as reducing postoperative nasal discomfort. This study aimed to assess operative outcomes of free mucosal graft after pituitary resection. METHODS:A retrospective chart review was performed for patients who underwent endoscopic endonasal resection of pituitary adenomas. The following data were collected: demographic data, intraoperative CSF leak, postoperative CSF leak, other complications, and mucosal graft healing at 1 month. Also, the Sinonasal Outcome Test-22 was administered preoperatively and 1 month and 3 months postoperatively. RESULTS:Charts of 158 patients were reviewed, including patients who underwent no mucosal reconstruction, free mucosal graft reconstruction, and nasoseptal flap reconstruction. There was a 7.4% postoperative CSF leak rate in patients who underwent no reconstruction (n = 27), whereas postoperative CSF leak rate was 0.82% in patients undergoing free mucosal graft reconstruction (n = 122) (P < 0.05). Sinonasal Outcome Test-22 scores for patients with free mucosal graft reconstruction showed no significant worsening postoperatively. CONCLUSIONS:The free mucosal graft is a simple and effective means of sellar reconstruction in patients undergoing endonasal endoscopic pituitary resection, and its efficacy is similar to nasoseptal flaps. The free mucosal graft technique does not worsen sinonasal morbidity postoperatively.

BACKGROUND:We report a novel surgical technique based on an endonasal free mucosal graft (mucoplasty) for improving clinical results and local healing in chronic rhinosinusitis with nasal polyps (CRSwNP). METHODS:Patients diagnosed with bilateral CRSwNP scheduled for endoscopic sinus surgery were included. They underwent complete removal of anterior and posterior ethmoid cells, in addition to bilateral type III frontal sinusotomy. An endoscopic mucoplasty was performed in the left nasal cavity, whereas the right nasal cavity served as control. Patients were evaluated before surgery and 6 months after operation, including Sino-Nasal Outcome Test (SNOT-22), Visual Analogue Scale (VAS) for olfaction, endoscopic evaluation using the Modified und-Kennedy (MLK) scoring system and healing evaluation. RESULTS:Ten patients (mean age 53.6 years) were included. A significa t decrease of SNOT-22 score from 57.0 (21.1) to 20.3 (20.6) (P = 0.024) and a non-significa t decrease of VAS for olfaction score from 9.3 (0.5) to 4.6 (3.9) were found. Preoperative mean MLK score was 4.9 (0.7) in the right nostril and 4.8 (1.0) in the left one. After operation, there was a greater decrease of MLK score in the left nostril than in the right (1.9 [1.0] vs. 1.3 [0.8], P = 0.034). Better healing was proved in the nostril with the mucoplasty. CONCLUSION/CONCLUSIONS:Endonasal mucoplasty could be an effective, safe and feasible complementary surgical procedure in the treatment of CRSwNP. The reduced local edema associated with lower amount of secretions may confer a better control in the frontal recess, orbital wall and nasal roof.

OBJECTIVE:At our institution, skull base reconstruction using a free mucosal graft from the nasal cavity floor has been the standardized technique after pituitary adenoma resection via transsellar approach. In this study, the expected appearance of the reconstruction on postoperative magnetic resonance imaging (MRI) scans is described and its integrity and impact on the sinonasal cavity are assessed. METHODS:Fifty patients were selected, and their electronic medical records were reviewed for postoperative course, Sino-Nasal Outcome Test-22 (SNOT-22) scores, and nasal endoscopy reports. A total of 116 postoperative MRI scans were available to evaluate 1) the appearance and thickness of the graft, 2) the enhancement of the graft, and 3) the T2 signal in sphenoid sinus as a potential indication for inflammatory disease. RESULTS:There was no significant change in the thickness of the graft over time. Except for the 7 scans that were obtained without intravenous contrast, all scans showed enhancement of the graft. About half of the patients showed persistent T2 hyperintense signal at 12 and 24 months. However, this finding was not clinically significant, because postoperative SNOT-22 scores showed minimal sinonasal impact. CONCLUSIONS:Postoperative MRI surveillance scans showed a stable appearance of the graft that mimics the native mucosa, with enhancement through time, reflecting its robust vascularization and integration to the skull base. Although persistent T2 hyperintense signal was detected in the sphenoid sinus, clinical evidence based on nasal endoscopy reports and SNOT-22 scores indicated minimal sinonasal morbidity.

A young adult female originally presented with necrosis of the nasal cavity mucosa and septum after sniffing crushed acetaminophen. She underwent endoscopic sinus surgery and debridement but continued to use acetaminophen intranasally. Four months later, the destruction had extended to include the posterior pharyngeal wall and subglottis. The diagnosis was confirmed by polarizable talc found on biopsy of the subglottis. While nasal insufflation of cocaine and hydrocodone-acetaminophen has been well-documented, intranasal abuse of exclusively acetaminophen is not well understood. This case demonstrates the destructive potential of intranasal acetaminophen use and may help physicians recognize unusual signs and symptoms of intranasal drug abuse.

Extended endoscopic endonasal procedures are not unique among surgical interventions in carrying increased risk in the elderly population. There are, however, components of the procedure, namely high-flow cerebrospinal fluid leaks, that do result in the potential for increased perioperative morbidity for these patients. We present the case of a 77-year-old male with a large invasive pituitary macroadenoma resected through a transplanum-transtuberculum-transsellar endonasal approach. A gross total resection was obtained with resolution of the patient's preoperative ophthalmologic deficits. One month postoperatively, the patient developed progressive lethargy and cranial imaging demonstrated a left convexity subacute subdural hematoma. This was evacuated through a twist drill craniostomy. Despite measures to limit the operative time of the initial endonasal procedure as well as the absence of a postoperative cerebrospinal fluid fistula, the patient still developed this complication. Along with more typical potential causes of postoperative decline following extended endonasal procedures, problems from high-flow intraoperative cerebrospinal fluid leaks alone can result in morbidity in the elderly population. This should be acknowledged preoperatively and a high suspicion should exist for the presence of intracranial hemorrhage in these patients with any postoperative deficits. Additional intraoperative measures can be utilized to minimize such risks. The link to the video can be found at: https://youtu.be/EkLmt2T8_UE .