Improving Tertiary Center Skull Base Cancer Outcomes: A Story of Missed Opportunity in Primary and Secondary Care

BACKGROUND: Mucocele is a true cystic expansile mass filled with mucus resulting from obstruction of the sinus ostia. Prompt diagnosis and management are needed to avoid complications due to the intracranial or intra-orbital extension. OBJECTIVES: To audit data of mucocele of the paranasal sinuses in a tertiary center, to review the literature regarding the clinical features and the management of mucocele in the paranasal sinus and to emphasize the iatrogenic causes of mucocele after the development of Endoscopic Skull Base Surgeries. MATERIALS AND METHODS: A retrospective analysis of etiology, clinical presentation, sinuses involved, operative technique, complication, recurrence were interpreted. RESULTS: The mean age of 16 patients managed is 49. Location:37% frontal,19% ethmoidal,19% frontoethmoidal,19% sphenoidal,6% maxillary. The iatrogenic cause was 44%. Symptoms included proptosis, external swelling, nasal block, and discharge, and vision loss. Complications were orbital abscess and skull base defect. 14 patients underwent endoscopic procedures-excision or marsupialization. One patient underwent craniotomy; one patient combined approach was performed. One patient had a recurrence. CONCLUSION: Mucocele of the paranasal sinuses is still a rare clinical scenario and it is imperative to note that any delay in diagnosis and management can lead to expansion and erosion of the bony wall of the sinuses and causing complications.

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Clinical Characteristics and Surgical Outcomes of Sinonasal Lesions Associated With Tumor-Induced Osteomalacia

Otolaryngology ◽

10.1177/0194599820975432 ◽

2020 ◽

pp. 019459982097543

Author(s):

Zhenzhen Zhu ◽

Weibo Xia ◽

Fang Qi ◽

Weiqing Wang ◽

Xiaowei Wang ◽

...

Keyword(s):

Skull Base ◽

Surgical Outcomes ◽

Recovery Rate ◽

Open Surgery ◽

Clinical Characteristics ◽

Clinical Symptoms ◽

Case Series ◽

Ethmoid Sinus ◽

Tertiary Center ◽

Significant Difference

Objective To investigate the clinical characteristics and surgical outcomes of sinonasal tumors associated with tumor-induced osteomalacia (TIO). Study Design Retrospective case series. Setting Single tertiary center. Methods We studied the clinical characteristics and surgical outcomes of 43 patients (22 male, 21 female) who had lesions in the nasal cavity and paranasal sinus associated with TIO and underwent surgery between August 2006 and November 2019. Results The mean ± SD duration between the onset of symptoms and surgery was 3.9 ± 2.6 years. The most common tumor site was the ethmoid sinus (76.7%), and the skull base was involved in 12 cases. Phosphaturic mesenchymal tumors were diagnosed in 41 patients, among whom there was 1 multifocal case. Another 2 cases involved odontogenic fibroma and hemangiofibroma, respectively. Serum phosphorus normalized in 39 cases within 4.4 ± 2.3 days, and serum fibroblastic growth factor 23 normalized within 1 day; clinical symptoms, however, gradually improved within several months after the first operation. There was no significant difference in the recovery rate between endoscopic and open surgery ( P = 0.639). Two patients with recurrent cases and 2 with nonremission cases recovered after a sinonasal reoperation. The patient with a multifocal case recovered after the resection of the tumors in the ethmoid sinus and mandible. The overall recovery rate was 97.7%. Conclusion Most sinonasal tumors associated with TIO are located in the ethmoid sinus, and the skull base is involved in some cases. Complete excision of the tumor leads to recovery, and endoscopic surgery could achieve recovery rates similar to those of open surgery.

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Endoscopic Endonasal Transplanum Transtuberculum Approach for the Resection of a Large Suprasellar Craniopharyngioma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1625940 ◽

2018 ◽

Vol 79 (S 03) ◽

pp. S249-S250

Author(s):

João Mangussi-Gomes ◽

Eduardo Vellutini ◽

Huy Truong ◽

Felix Pahl ◽

Aldo Stamm

Keyword(s):

Skull Base ◽

Male Patient ◽

Single Case ◽

Tumor Resection ◽

Magnetic Resonance Images ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Cystic Component ◽

Tertiary Center ◽

Neurovascular Structures

Objectives To demonstrate an endoscopic endonasal transplanum transtuberculum approach for the resection of a large suprasellar craniopharyngioma. Design Single-case-based operative video. Setting Tertiary center with dedicated skull base team. Participants A 72-year-old male patient diagnosed with a suprasellar craniopharyngioma. Main Outcomes Measured Surgical resection of the tumor and preservation of the normal surrounding neurovascular structures. Results A 72-year-old male patient presented with a 1-year history of progressive bitemporal visual loss. He also referred symptoms suggestive of hypogonadism. Neurological examination was unremarkable and endocrine workup demonstrated mildly elevated prolactin levels. Magnetic resonance images demonstrated a large solid-cystic suprasellar lesion, consistent with the diagnosis of craniopharyngioma. The lesion was retrochiasmatic, compressed the optic chiasm, and extended into the interpeduncular cistern (Fig. 1). Because of that, the patient underwent an endoscopic endonasal transplanum transtuberculum approach.1 2 3 The nasal stage consisted of a transnasal transseptal approach, with complete preservation of the patient's left nasal cavity.4 The cystic component of the tumor was decompressed and its solid part was resected. It was possible to preserve the surrounding normal neurovascular structures (Fig. 2). Skull base reconstruction was performed with a dural substitute, a fascia lata graft, and a right nasoseptal flap (Video 1). The patient did well after surgery and referred complete visual improvement. However, he also presented pan-hypopituitarism on long-term follow-up. Conclusions The endoscopic endonasal route is a good alternative for the resection of suprasellar lesions. It permits tumor resection and preservation of the surrounding neurovascular structures while avoiding external incisions and brain retraction.The link to the video can be found at: https://youtu.be/zmgxQe8w-JQ.

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Endoscopic Transnasal Skull Base Surgery in Pediatric Patients

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1692641 ◽

2019 ◽

Vol 81 (05) ◽

pp. 515-525

Author(s):

Gokmen Kahilogullari ◽

Cem Meco ◽

Suha Beton ◽

Murat Zaimoglu ◽

Onur Ozgural ◽

...

Keyword(s):

Skull Base ◽

Pediatric Patients ◽

Skull Base Surgery ◽

Total Resection ◽

Visual Deficits ◽

Tertiary Center ◽

Before And After ◽

Effective Option ◽

Transnasal Surgery ◽

Visual Testing

Introduction In pediatric patients, endoscopic transnasal surgery (ETNS) poses challenges because of the small size of the developing skull and narrow endonasal corridors. Objective This study aimed to evaluate the efficacy of ETNS in children by assessing our experience of endoscopic skull base surgery. Materials and Methods All pediatric patients (n = 54) who were eligible for surgery using only the endonasal endoscopic approach at our tertiary center between 2012 and 2018 were included in this study. The surgeries were performed simultaneously by an endoscopic skull base team of neurosurgeons and otolaryngologists. Hormonal analyses were conducted before and after surgery in all patients with sellar/parasellar lesions. Patients older than 8 years underwent smell and visual testing. Results In the 54 patients aged 1 to 17 years who underwent surgery, craniopharyngioma was the most common pathology (29.6%), followed by pituitary adenoma (22.2%). Gross total resection was achieved in 33 (76.7%) of 41 patients who underwent surgery because of the presence of tumors. All visual deficits improved, although one patient sustained olfactory deterioration. Sixteen (29.6%) patients presented with complications such as transient diabetes insipidus and temporary visual loss. Conclusions Despite anatomy-related challenges in children, adequate results can be achieved with high rates of success, and the functional and anatomical integrity of the developing skull and nose of children can be preserved. In pediatric patients, ETNS is a safe and effective option for addressing various lesions along the skull base.

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The Role for Imaging in the Investigation of Isolated Objective Vestibular Weakness

Otolaryngology ◽

10.1177/0194599819877691 ◽

2019 ◽

Vol 161 (6) ◽

pp. 1027-1030

Author(s):

Deanna Gigliotti ◽

Brian Blakley ◽

Paige Moore ◽

Jordan Hochman

Keyword(s):

Hearing Loss ◽

Sensorineural Hearing Loss ◽

Skull Base ◽

Vestibular Schwannoma ◽

Brain Mri ◽

Internal Auditory Canal ◽

Retrospective Chart Review ◽

Sensorineural Hearing ◽

Lateral Skull Base ◽

Tertiary Center

Objective Unilateral vestibular weakness has considerable potential etiologies. One source is a vestibular schwannoma. This article evaluates, in the absence of other symptoms and signs, if unilateral vestibular weakness is an analogue to asymmetric sensorineural hearing loss and serves as an indication for lateral skull base imaging. Study Design Retrospective chart review. Setting Academic tertiary center. Subjects and Methods All patients undergoing caloric assessment between January 1, 2012, and June 30, 2018, were investigated. Patients with unilateral vestibular weakness (a left-right difference >25% on electronystagmography) were included in the study. A provincial encompassing image library was surveyed for potential adequate imaging (computed tomography internal auditory canal infused, magnetic resonance imaging [MRI] brain, MRI internal auditory canal) of the target population within the preceding 5 years. Presence/absence of vestibular schwannoma on imaging was determined. Results Of the 3531 electronystagmography reports reviewed during the period, 864 patients were identified with unilateral vestibular weakness. Of these, 542 had sufficient imaging, and 14 vestibular schwannomas were identified. Only 1 individual had a vestibular weakness in isolation, while the remaining 13 patients also suffered from documented sensorineural hearing loss that would have mandated MRI scanning. Conclusion The results of our study suggest that, in isolation, vestibular weakness is an insufficient indicator for lateral skull base imaging.

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Use of Salvage Surgery or Stereotactic Radiosurgery for Multiply Recurrent Skull Base Chordomas: A Single-Institution Experience and Review of the Literature

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-3402019 ◽

2020 ◽

Author(s):

Stella K. Yoo ◽

Ben A. Strickland ◽

Gabriel Zada ◽

Shelly X. Bian ◽

Adam Garsa ◽

...

Keyword(s):

Overall Survival ◽

Skull Base ◽

Stereotactic Radiosurgery ◽

Salvage Surgery ◽

Medical Center ◽

Academic Medical Center ◽

Univariate Analysis ◽

Recurrence Rates ◽

Tertiary Center ◽

Skull Base Chordomas

Abstract Introduction Chordomas are locally destructive neoplasms characterized by appreciable recurrence rates after initial multimodality treatment. We examined the outcome of salvage treatment in recurrent/progressive skull base chordomas. Methods This is a retrospective review of recurrent/progressive skull base chordomas at a tertiary urban academic medical center. The outcomes evaluated were overall survival, progression-free survival (PFS), and incidence of new toxicity. Results Eighteen consecutive patients who underwent ≥1 course of treatment (35.3% salvage surgery, 23.5% salvage radiation, and 41.2% both) were included. The median follow-up was 98.6 months (range 16–215 months). After initial treatment, the median PFS was 17.7 months (95% confidence interval [CI]: 4.9–22.6 months). Following initial therapy, age ≥ 40 had improved PFS on univariate analysis (p = 0.03). All patients had local recurrence, with 15 undergoing salvage surgical resections and 16 undergoing salvage radiation treatments (mostly stereotactic radiosurgery [SRS]). The median PFS was 59.2 months (95% CI: 4.0–99.3 months) after salvage surgery, 58.4 months (95% CI: 25.9–195 months) after salvage radiation, and 58.4 months (95% CI: 25.9.0–98.4 months) combined. Overall survival for the total cohort was 98.7% ± 1.7% at 2 years and 92.8% ± 5.5% at 5 years. Salvage treatments were well-tolerated with two patients (11%) reporting tinnitus and one patient each (6%) reporting headaches, visual field deficits, hearing loss, anosmia, dysphagia, or memory loss. Conclusion Refractory skull base chordomas present a challenging treatment dilemma. Repeat surgical resection or SRS seems to provide adequate salvage therapy that is well-tolerated when treated at a tertiary center offering multimodality care.

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