Faculty Bibliography

Direct access through the sinuses and nasopharyngeal mucosa in the endoscopic endonasal approach (EEA) raises concern for a contaminated operative environment and subsequent infection. The reported rate of meningitis in endoscopic endonasal skull base surgery in the literature ranges from 0.7 to 3.0% [1, 2]. The only factor identified as being independently associated with meningitis in a statistically significant manner is cerebrospinal fluid (CSF) leak [1-5]. However, many centers performing high volume of EEAs use postoperative antibiotic coverage independent of the presence intraoperative or postoperative CSF leak. Furthermore, while meningitis remains a severe concern, most centers use postoperative gram-positive coverage to prevent toxic shock syndrome caused by Staphylococcus aureus infection in the setting of prolonged nasal packing. There are currently a multitude of approaches regarding perioperative antibiotic coverage in EEAs [1-4]. Given the lack of consensus in the literature and our experience regarding the benefit of discontinuation of prolonged prophylactic antibiotics throughout the breadth of neurosurgical procedures, we sought to analyze the need for postoperative antibiotics in EEAs further. As such, we performed a prospective analysis compared with a retrospective cohort to delineate whether discontinuation of postoperative antibiotics leads to a change in the rate of postoperative infections. The retrospective cohort consisted of patients who underwent an EEA from January 1, 2013 to May 31, 2019. These patients all received postoperative antibiotics while nasal packing was in place (median 7 days). Starting on April 1, 2019 until August 1, 2019, we discontinued postoperative antibiotic use. Patients from this group made up the prospective cohort. The retrospective cohort had 315 patients (66% pituitary macroadenomas vs. 7% microadenomas, 4% meningiomas, 4% craniopharyngiomas, 4% chordomas, and 15% others) while the prospective group had 23 patients (57% pituitary macroadenomas, 30% craniopharyngiomas, 8% meningiomas/chordomas, and 5% others). The primary endpoint was rate of postoperative infections and specifically, meningitis and multidrug resistant organism (MDRO) infections. There was no statistically significant difference in the use of nasal packing (p = 0.085), intraoperative CSF leak (p = 0.133), and postoperative CSF leak (p = 0.507) between the two groups. There was also no significant difference in the number of patients with positive preoperative MSSA and MRSA nasal swabs (p = 0.622). There was a significant decrease in the number of patients discharged with antibiotics (55.1% in the retrospective and 4.5% in the prospective group, p = 0.000). The number of patients with positive blood cultures (p = 0.701) and positive urine cultures (p = 0.691) did not differ significantly between the two groups. Finally, there was no statistically significant difference in postoperative CSF infections (p = 0.34) or MDRO infections (0.786) between the two groups. We describe promising preliminary results that demonstrate that discontinuation of postoperative antibiotics in EEAs do not lead to a statistically significant increase in the rate of postoperative CSF or MDRO infections. The previous algorithm for postoperative antibiotic coverage in our center, like many centers, called for gram-positive coverage, which may have contributed to the overall preponderance of gram-negative meningitis cases in this cohort

OBJECTIVES/UNASSIGNED:To examine the frequency in which angled endoscopes are necessary to visualize the true maxillary ostium (TMO) following uncinectomy and prior to maxillary antrostomy. Additionally, to identify preoperative computed tomography (CT) measures that predict need for an angled endoscope to visualize the TMO. STUDY DESIGN/UNASSIGNED:Retrospective study. SETTING/UNASSIGNED:Tertiary academic hospital. PATIENTS AND METHODS/UNASSIGNED:Patients who underwent endoscopic sinus surgery (ESS) between December of 2017 and August of 2018 were retrospectively identified. Cases were reviewed if they were primary ESS cases for chronic rhinosinusitis without polyposis and if they were at least 18 years of age. RESULTS/UNASSIGNED:Sixty-three maxillary antrostomies were reviewed (82.5% were from bilateral cases). Thirty-five cases (55.6%) required an angled endoscope in order to visualize the TMO. Of the preoperative CT measures examined, a smaller sphenoid keel-caudal septum-nasolacrimal duct (SK-CS-NL) angle was significantly associated with need for an angled endoscope intraoperatively to visualize the TMO (17.1° SD ± 3.2 vs 15.0° SD ± 2.9; P = .010). CONCLUSION/UNASSIGNED:Angled endoscopes are likely required in the majority of maxillary antrostomies to visualize the TMO. This is important to recognize in order to prevent iatrogenic recirculation. The SK-CS-NL angle may help to identify cases preoperatively which require an angled endoscope to identify the TMO during surgery.

OBJECTIVE/UNASSIGNED:To evaluate rates of epiphora after transection and marsupialization of the nasolacrimal duct (NLD) during endoscopic sinus and skull base surgery. INTRODUCTION/UNASSIGNED:The nasolacrimal canal forms part of the medial wall of the maxillary sinus. Transecting the NLD is sometimes necessary for tumor resection or surgical access to maxillary sinus and infratemporal fossa pathology. There is no consensus for the endoscopic management of the NLD when only the duct is transected without involving the nasolacrimal sac. METHODS/UNASSIGNED:Medical records of 29 patients from 2 academic institutions who underwent endoscopic sinus and skull base surgery with transection of the NLD were retrospectively reviewed. Whether the duct was marsupialized or simply transected was recorded, and the postoperative rate of epiphora was calculated. RESULTS/UNASSIGNED:Mean age was 59 years (range, 14-86 years). Mean follow-up was 10.5 months (range, 1-33 months). The NLD was marsupialized in 16 (55%) and simply transected in 13 (45%) patients. Six patients underwent postoperative radiation. No patients in the marsupialization group had epiphora postoperatively, all with Munk score of 0. One patient in the transection group developed postoperative epiphora with Munk score of 1. Pathology included inverted papilloma (8), acute on chronic inflammation (6), B-cell lymphoma (3), juvenile nasopharyngeal angiofibroma (2), squamous cell carcinoma (2), Schneiderian papilloma (2), metastatic melanoma (1), HPV-related carcinoma (1), adenocarcinoma (1), benign epithelial cyst (1), adenoid cystic carcinoma (1), and erosive chronic sinusitis without nasal polyposis (1). CONCLUSION/UNASSIGNED:Management after transection of the NLD varies widely. The duct may be simply transected or marsupialized, or a formal dacryocystorhinostomy can be performed. The surgeon must also choose whether to place a stent. Based on our small series and review of the literature, marsupialization or simple transection of the NLD results in a low rate of postoperative epiphora in the setting of endoscopic sinus and skull base surgery.

OBJECTIVES:/UNASSIGNED:Data on health care disparities by socioeconomic status for chronic rhinosinusitis (CRS) are lacking, and the available literature shows mixed results. The aim of this study was to evaluate several indicators of disease complexity in patients with CRS undergoing endoscopic sinus surgery between a private and a public hospital to determine if there are any disparities in the severity of disease presentation or in access to care. METHODS:/UNASSIGNED:Two hundred patients with CRS who underwent endoscopic sinus surgery from 2015 to 2017 were retrospectively reviewed. Demographics, disease-specific data, and pre- and postoperative management were collected. RESULTS:/UNASSIGNED:Public hospital patients (n = 100) were significantly more likely to be non-Caucasian (73.0% vs 25.0%, P < .0001) and to have Medicaid or no insurance (86.0% vs 4.0%, P < .0001). Patients from the public hospital were more likely to have CRS with nasal polyposis (85.0% vs 60.0%, P < .0001) and to have longer wait times for surgery (68 vs 45 days, P < .0001) and were more likely to be lost to follow-up (26.0% vs 16.0%, P = .031). Patients at the public hospital had CRS symptoms 21% longer ( P = .0206), and if a patient carried a diagnosis of asthma, he or she had on average more severe asthma ( P = .0021). CONCLUSIONS:/UNASSIGNED:This study suggests that patients of lower socioeconomic status had a longer duration of disease prior to surgery, more often had nasal polyposis, and had decreased access to care, as indicated by increased surgical wait times and being lost to follow-up. Acting as a foundation for further investigation, the ultimate intent of this study is to improve care for all patients.

Objectives  AlloDerm is an acellular dermal matrix often used for reconstruction throughout the body. AlloDerm has been shown to undergo revascularization when used to reconstruct soft tissue such as in abdominal wall reconstruction. In this study, the authors review the literature on revascularization of AlloDerm and demonstrate the histologic findings of AlloDerm after implantation during skull base reconstruction. Study Design  Literature review and case reports. Setting  Tertiary Care Institution Participants  Patients from a tertiary care institution Main Outcome Measures  Histologic slides are evaluated and compared with nonimplanted AlloDerm. Methods  The authors review a case of explanted AlloDerm that had been used for skull base reconstruction after endoscopic skull base surgery. Results  Upon reviewing the histologic slides of explanted AlloDerm to nonimplanted AlloDerm, we demonstrate revascularization of AlloDerm when used in skull base reconstruction. Representative slides will be included. Conclusions  AlloDerm undergoes revascularization when used for skull base reconstruction.

Background: Large anterior skull base meningiomas with significant extension through the floor of the anterior fossa into the ethmoid and sphenoid sinuses pose a surgical dilemma. Radical resection of these tumors as well as the skull base and sinus component can be curative. This can be achieved through either a transcranial approach or a combined transcranial/endonasal approach depending on the involvement of the sinuses. However, in doing so, patients are at significant risk for postoperative cerebrospinal fluid leak as well as infection. Given these risks and the benign nature of these tumors, especially WHO grade I meningiomas, many surgeons will choose not to resect the portion going through the skull base. The residual tumor can then be observed or radiated if there are signs of growth.
Objective(s): We propose the use of a staged combined approach to maximize resection and minimize risk of CSF leak or infection. Case Presentation: We present the case of a 55-year-old male, BMI of 37, who presented with 3 weeks of left eye blurry vision, 2 years of anosmia, and personality changes. The patient was found to have a 7.3x5.9x4.6 cm anterior skull base meningioma with significant surrounding parenchymal edema in the bilateral frontal lobes as well as extension through the floor of the anterior skull base and into the ethmoid and sphenoid sinuses ([Fig. 1a], b). He was taken for a bifrontal craniotomy and resection of the intracranial component with planned amputation of the tumor at the skull base which was covered with a pericranial flap. He recovered well with return of his vision to normal. Pathology demonstrated a WHO grade II atypical meningioma. Follow-up imaging demonstrated persistent residual tumor within the ethmoid and sphenoid sinus ([Fig. 2]). We discussed an endoscopic endonasal resection of the residual tumor and anterior skull base in a delayed fashion once the pericranial graft healed versus radiation. The patient preferred to proceed with resection. He underwent an endoscopic endonasal resection of the residual tumor within the sinus and remaining anterior skull base. At the time of surgery the tumor was easily separated from the pericranial graft which was well healed. No CSF was observed but a nasoseptal flap was placed for protection. He was discharged on POD2. Postoperative imaging demonstrated gross total resection of the residual tumor ([Fig. 3]).
Conclusion(s): The use of a delayed combined transcranial and endoscopic endonasal approach for anterior skull base meningiomas with significant intracranial and sinus tumor component potentially maximizes surgical resection while reducing the risk of CSF leak and infection. (Figure Presented)

BACKGROUND: The presence of olfactory cleft polyps in chronic rhinosinusitis with nasal polyposis is well documented, but the effect of endoscopic olfactory cleft polyp surgery on olfaction, versus observation, has not been well studied. This analysis assessed if microdebridement of olfactory cleft polyps yields significant objective smell improvements in those with anosmia or hyposmia. METHODS: A randomized prospective single-blinded study was performed on patients undergoing bilateral endoscopic sinus surgery with profound bilateral nasal polyposis, excluding those younger than 18 years or without olfactory polyps. A preoperative University of Pennsylvania Smell Identification Test (UPSIT), visual analog scale (VAS), and sinonasal outcomes 20 score (SNOT-20), and a follow-up at 6 months was performed. Two cohorts were created, including one with cleft polyp removal (group A) and one with cleft polyps left in place (group B). RESULTS: There were 10 patients in group A and 7 in group B. By using the Wilcoxon signed rank test, the two groups were individually analyzed for changes in the preoperative UPSIT, VAS, and SNOT-20 versus the 6-month test results. In group A, the improvement in the UPSIT, VAS, and SNOT-20 were statistically significant at p < 0.05. For group B only the improvement in the VAS was statistically significant, at p < 0.05. There was a statistically significant difference in clinical smell improvement between group A and B at 6 months (p = 0.00512). CONCLUSIONS: Evidence exists that olfactory cleft polyp surgery improves olfactory function outcomes. Long-term data beyond 6 months is needed to further validate these early promising outcomes.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) leaks are caused by intracranial hypertension. Given this underlying etiology, patients may be at risk for developing multiple skull base defects. OBJECTIVE: The purpose of our study is to present the prevalence of multiple simultaneous skull base defects in patients with spontaneous CSF rhinorrhea. METHODS: We performed a retrospective chart review in a tertiary care practice of 44 consecutive patients with spontaneous CSF rhinorrhea who underwent endoscopic repair by the senior author (R.R.C.) to determine the prevalence of having multiple simultaneous skull base defects identified at the time of surgery. We defined this as two or more bony defects identified endoscopically with intact intervening bone with or without soft tissue prolapse into the nasal cavity or paranasal sinus cavity. RESULTS: Eight of 44 patients (18.2%) were found to have multiple simultaneous skull base defects. The average body mass index (BMI) of the study population was 34.5 (range, 22.7-59). CONCLUSION: A significant number of patients with spontaneous CSF rhinorrhea may have more than one skull base defect present at the time of presentation. The clinical significance of this finding in surgical and medical decision making is not clear at this time.