Objectives/Hypothesis:
Systematically review the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). Such surgical innovation is likely to be reported in case ...series, retrospective cohorts, or case‐control studies rather than higher level evidence.
Study Design:
Systematic review and meta‐analysis.
Methods:
Embase (1980–December 7, 2010) and MEDLINE (1950–November 14, 2010) were searched using a search strategy designed to include any publication on endoscopic endonasal reconstruction of the skull base. A title search selected those articles relevant to the clinical or basic science of an endoscopic approach. A subsequent search selected articles of any defect other than simple cerebrospinal fluid (CSF) fistula, sella only, meningoceles, or simple case reports. The articles selected were subject to full‐text review to extract data on perioperative outcomes for ESBR. Surgical technique was used for subgroup analysis.
Results:
There were 4,770 articles selected initially, and full‐text analysis produced 38 studies with extractable data regarding ESBR. Of these articles, 12 described a vascularized reconstruction, 17 described free graft, and nine were mixed reconstructions. Three had mixed data in clearly defined patient groups that could be used for meta‐analysis. The overall CSF leak rate was 11.5% (70/609). This was represented as a 15.6% leak rate (51/326) for free grafts and a 6.7% leak rate (19/283) for the vascularized reconstructions (χ2 = 11.88, P = .001).
Conclusions:
Current evidence suggests that ESBR with vascularized tissue is associated with a lower rate of CSF leaks compared to free tissue graft and is similar to reported closure rates in open surgical repair.
Endoscopic skull base surgery continues to rapidly evolve, requiring comparable advances in reconstructive techniques. While smaller skull base defects with low intraoperative CSF flow have been ...successfully managed with a variety of avascular and/or noncellular techniques, larger defects with high CSF flow require more robust repairs often in the form of vascularized flaps, which confer excellent success rates in this setting. Despite these successful outcomes, a paucity of data describing specific patient and operative characteristics and their effects on repair exist. Therefore, a retrospective, consecutive chart review was performed on patients who underwent endoscopic skull base reconstruction with a vascularized flap in the setting of intraoperative CSF leaks. In this series, 151 patients with a mean age of 51 years underwent 152 vascularized flap skull base reconstructions for an array of benign and malignant pathologies. These vascularized flaps included 144 nasoseptal flaps, 6 endoscopic-assisted pericranial flaps, 1 facial artery buccinator flap, and 1 inferior turbinate flap that were used throughout all regions of the skull base. Perioperative (< 3 months) and postoperative (> 3 months) flap complications were assessed and revealed 3 perioperative flap defects (2.0%) defined as a visualized defect within the substrate of the flap and a total of 5 perioperative CSF leaks (3.3%). No patient experienced flap death/complete flap loss in the cohort. Assessed postoperative flap complications included 1 case (0.7%) of mucocele formation, 8 cases (5.3%) of prolonged skull base crusting, and 2 cases (1.3%) of donor-site complication, specifically septal perforation secondary to nasoseptal flap harvest. Among the 152 cases identified, 37 patients received radiation therapy while 114 patients did not undergo radiation therapy as part of the treatment profile. No significant association was found between perioperative complication rates and radiation therapy (p = 0.634). However, a significant association was found between postoperative complication rates and radiation therapy, primarily accounted for by an increased risk for prolonged (> 6 months) skull base crusting (p = 0.025). It is clear that larger skull base defects with high intraoperative CSF flow require thoughtful approach and strong consideration for vascularized repair.
Objectives:
One of the major challenges of cranial base surgery is reconstruction of the dural defect. Following a craniofacial resection, the standard reconstructive technique is direct suture ...repair of the dural defect with a fascial graft and rotation of an anteriorly based pericranial scalp flap to cover the dura. The introduction of endoscopic techniques and an endonasal approach to the ventral skull base has created new challenges for reconstruction. The nasoseptal flap has become the workhorse for vascularized endoscopic skull base reconstruction; however at times, the septal mucosal flap may be unavailable for reconstruction. This can be due to prior surgical resection or involvement of the nasal septum by sinonasal cancer. We have developed a minimally invasive endoscopic pericranial flap for endoscopic skull base reconstruction. The use of a pericranial scalp flap for reconstruction during endonasal skull base surgery using minimally invasive techniques has not been previously reported.
Methods:
We performed cadaveric studies to illustrate feasibility of an endoscopic pericranial flap for endonasal skull base reconstruction, then applied this novel technique to an elderly patient after endonasal skull base and dural resection of an esthesioneuroblastoma.
Results:
The technical report of the minimally invasive pericranial flap is outlined and the advantages and limitations during endonasal skull base reconstruction are discussed. The patient had excellent healing of her skull base and had no evidence of any postoperative cerebrospinal fluid leak.
Conclusions:
The minimally invasive endoscopic pericranial flap provides another option for endonasal reconstruction of cranial base defects. There is minimal donor site morbidity, and it provides a large flap that can cover the entire ventral skull base. The issues of intranasal tissue tumor involvement and the need for radiotherapy make the endoscopic pericranial flap an ideal reconstruction for anterior cranial base defects resulting from endonasal sinonasal and skull base cancer resections. Laryngoscope, 119:13–18, 2009
There have been no studies undertaken on the effect of the multidisciplinary head and neck tumor board on treatment planning. The objective of this study was to determine the efficacy of the ...multidisciplinary tumor board in altering diagnosis, stage, and treatment plan in patients with head and neck tumors.
Case series with planned data collection.
Comprehensive cancer center and tertiary academic hospital.
A prospective study of the discussions concerning 120 consecutive patients presented at a multidisciplinary head and neck tumor board was performed. As each patient was presented, a record was made of the "pre-conference" diagnosis, stage, and treatment plan. After case discussion, the "post-conference" diagnosis, stage, and treatment plan were recorded. Results are compared between malignant and benign tumor cohorts.
The study population comprised 120 patients with new presentations of head and neck tumors: 84 malignancies and 36 benign tumors. Approximately 27 percent of patients had some change in tumor diagnosis, stage, or treatment plan. Change in treatment was significantly more common in cases of malignancy, occurring in 24 percent of patients versus six percent of benign tumors (P = 0.0199). Changes in treatment were also noted to be largely escalations in management (P = 0.0084), adding multi-modality care.
A multidisciplinary tumor board affects diagnostic and treatment decisions in a significant number of patients with newly diagnosed head and neck tumors. The multidisciplinary approach to patient care may be particularly effective in managing malignant tumors, in which treatment plans are most frequently altered.
Objectives
To determine whether subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT) better improves patient outcomes and quality of life for adults with allergic rhinitis or ...rhinoconjunctivitis (AR/C) with or without mild to moderate asthma.
Methods
Systematic review methodology was based on the Cochrane Collaboration handbook and Preferred Reporting Items for Systematic Reviews and Meta‐analyses. Four databases (PubMed, Cochrane Library, EMBASE, and Web of Science) were queried from inception to July 30, 2020. Two independent reviewers screened potentially relevant studies and assessed risk of bias. Outcomes of interest were symptom score (SS), medication score (MS), combined symptom medication score (CSMS), and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ). Meta‐analyses with an adjusted indirect comparison were conducted in RevMan 5.4.1.
Results
Seven SCIT versus SLIT randomized controlled trials (RCTs) demonstrated no significant differences for any outcomes, but insufficient data precluded direct meta‐analysis. For the adjusted indirect comparison, 46 RCTs over 39 studies were included for SCIT versus placebo (n = 13) and SLIT versus placebo (n = 33). Statistically significant results favoring SCIT were found for SS (standardized mean difference SMD = 0.40; 95% confidence interval CI = 0.31–0.49), MS (SMD = 0.26; 95% CI = 0.14–0.39), CSMS (SMD = 0.42; 95% CI = 0.17–0.67), and RQLQ (MD = 0.24; 95% CI = 0.04–0.44). Statistically significant results favoring SLIT were found for SS (SMD = 0.42; 95% CI = 0.32–0.53), MS (SMD = 0.40; 95% CI = 0.28–0.53), CSMS (SMD = 0.37; 95% CI = 0.29–0.45), and RQLQ (MD = 0.32; 95% CI = 0.20–0.43). No significant differences were found between SCIT and SLIT for SS (SMD = −0.02; 95% CI = −0.15 to 0.11), MS (SMD = −0.14; 95% CI = −0.31 to 0.03), CSMS (SMD = 0.05; 95% CI = −0.21 to 0.31), or RQLQ (MD = −0.08; 95% CI = −0.31 to 0.15).
Conclusion
SCIT and SLIT are comparably effective treatments for adults with AR/C. More RCTs analyzing SCIT versus SLIT are needed to directly compare the two. Laryngoscope, 132:499–508, 2022
Endoscopic skull-base surgery (ESBS) is a rapidly growing discipline that often combines the expertise of otolaryngology-head and neck surgeons and neurosurgeons to provide care for these challenging ...conditions. As the field has grown, so too has the literature evaluating this surgical approach and the challenges and complications associated with these interventions. An international, multidisciplinary effort to critically evaluate and grade the current literature on ESBS has resulted in the International Consensus Statement on Endoscopic Skull Base Surgery (ICAR:SB). This Executive Summary highlights the key findings of the ICAR:SB document.
Following the prior methodology of the ICAR statements, the ICAR:SB document consists of 98 topics in ESBS that underwent a systematic review. When sufficient evidence exists, an evidence-based review with recommendation (EBRR) or evidence-based review (EBR) was created and then underwent an iterative review process until consensus was achieved. This Executive Summary recapitulates these findings.
This summary complies the EBR and EBRR from the ICAR:SB document in the management of numerous skull-base pathologies including cerebrospinal fluid rhinorrhea, intradural tumors, sinonasal malignancies, and clival tumors, as well as the key issues of reconstruction after and the complications associated with ESBS.
The ICAR:SB Executive Summary recaps the evidenced-based recommendations concerning the advantages, limitations and challenges of ESBS in the management of diverse skull-base pathologies. Although multifactorial in nature, the overall level of evidence in ESBS is modest. This represents an opportunity to address these knowledge gaps moving forward.
Over the past 10 years, significant anatomic, technical, and instrumentation advances have facilitated the exposure and resection of intradural lesions via a fully endoscopic expanded endonasal ...approach (EEA). The vascularized nasoseptal flap (based on the posterior nasoseptal artery) has become our primary endoscopic reconstructive technique. The goals of this study are to prospectively evaluate the nasoseptal flap and high-risk cerebral spinal fluid (CSF) leak variables.
Prospective evaluation was performed of EEA patients with intraoperative high-flow leaks (either a cistern or ventricle open to nasal cavity during tumor dissection) who underwent nasoseptal flap reconstruction.
Seventy consecutive nasoseptal flaps for high-flow intraoperative leaks were evaluated prospectively by the primary author. Twelve risk factors were then graded at the time of the operations and correlated to CSF leak outcomes. The overall postoperative CSF leak rate was 5.7% (4/70). All four postoperative leaks were successfully managed with endoscopic repair and CSF diversion. A multivariate analysis of all 12 risk factors is detailed. Pediatric patients, large dural defects, and radiation therapy were noted to be factors in reconstructive failure. One flap death occurred in a patient with prior surgery and proton therapy, this leak was managed with a temporoparietal flap and endonasal repair.
The nasoseptal flap is an excellent anterior skull base reconstructive technique. Patients with high-flow intraoperative CSF leaks had a 94% successful reconstruction rate. Patients with skull base proton radiation therapy are at higher risk for flap failure and preparation for nonradiated tissue reconstruction should be discussed with the patient.
Objectives
Our objectives were to analyze the recent trends in applicants of otolaryngology‐head and neck surgery (Oto‐HNS) residency programs, including evolutions in sex and racial/ethnic ...distribution within the applicant pool and subsequent residency cohort.
Methods
Retrospective database and literature review. Data regarding applicants to Oto‐HNS programs as well as Oto‐HNS residents in the United States from 2008 to 2017 were analyzed from the Electronic Residency Application Service, National Resident Matching Program, and Journal of the American Medical Association.
Results
Between 2008 and 2018, the number of Oto‐HNS residency programs and residency positions offered increased from 105 to 112 and from 273 to 315, respectively. There was no statistically significant difference between applicant sex in 2008 to 2012 compared to 2013 to 2018 (P > .05), but significantly more females made up the residency workforce from 2013 to 2018 compared to 2008 to 2012 (P < .001). However, the percentage increase in female residents from 2008 to 2017 was only 6.1% (29.8% to 35.9%). No statistically significant difference was present between applicant race in 2008 to 2012 compared to 2013 to 2018 (P > .05), but significantly more minority residents made up the residency workforce from 2013 to 2018 compared to 2008 to 2012 (P < .0001). However, the percentage increase in minority residents from 2008 to 2017 was only 4.9% (35.1% to 40%).
Conclusion
Women and minority racial and ethnic groups continue to be underrepresented among Oto‐HNS applicants. However, the presence of these groups among current residents has increased. Understanding and tracking these national trends yearly is critical for training a diverse future otolaryngology workforce.
Level of Evidence
VI Laryngoscope, 131:277–281, 2021
Although cisplatin plus radiotherapy is a standard treatment of locally advanced head and neck squamous cell carcinoma (LA-HNSCC), cisplatin contraindication is common. Radiation elicits and promotes ...tumor-directed immune stimulation, which may potentiate anti-PD-1 therapy. We provide the first efficacy report of combined pembrolizumab and definitive radiotherapy in LA-HNSCC.
This single-arm, multi-institution, phase II study (NCT02609503) enrolled 29 cisplatin-ineligible patients. Patients received radiotherapy concurrently with three cycles of pembrolizumab 200 mg every 3 weeks followed by three adjuvant cycles. The primary endpoint was a progression-free survival (PFS) of ≥16 months. Correlative studies included peripheral blood flow cytometry and Luminex cytokine profiling.
Reasons for cisplatin ineligibility included otopathy (69.0%), nephropathy (20.7%), and neuropathy (6.9%). With median follow-up of 21 months, estimated 24-month PFS and overall survival rates were 71% (95% confidence interval, 49%-84%) and 75% (51%-88%). The primary PFS endpoint has exceeded the hypothesis and its median has not been reached. Toxicities were typical of radiotherapy; however, high rates of grade 3/4 lymphopenia (58.6%) were observed. Flow cytometry revealed a relative decline in CD4 T cells and B cells, but not CD8 T cells. Upon treatment, frequencies of transitional B cells and tissue-like memory B cells increased, while resting memory B cells decreased. Patients with progression had greater percentages of baseline naïve B cells and fewer marginal zone B cells.
Pembrolizumab and radiotherapy is efficacious in LA-HNSCC and should be evaluated in a randomized trial. The observed changes in B-cell markers deserve further study both as potential biomarkers and as therapeutic targets.
Objectives/Hypothesis
Each year, the Triological Society awards several Research Career Development Awards (CDAs) to support early‐career otolaryngologists. The objective of this study was to ...evaluate academic outcomes of CDA recipients including National Institutes of Health (NIH) funding acquisition and h‐index. A secondary objective was to appraise gender differences in outcomes among awardees.
Study Design
Cross‐sectional study.
Methods
Recipients' practice setting, degree type, academic rank, and leadership titles were determined through review of academic and private practice profiles in October 2019. NIH funding was assessed using the NIH Research Portfolio Online Reporting Tool and the h‐index was calculated using the Scopus database.
Results
Between 2004 and 2019, 70 investigators received a CDA. Of the 65 awardees prior to 2019, 26 (40.0%) obtained NIH grants after the CDA. Having an MD/PhD or MD/master's was not associated with NIH funding attainment (P = .891) nor with higher funding total (P = .109). However, funding total was significantly higher for full professors compared to assistant professors (P = .022). The median h‐index among awardees was 16 (interquartile range = 11–21) and differed significantly by academic rank (P < .001). Moreover, 23 CDAs (32.9%) were awarded to women. However, fewer female recipients obtain NIH funding after the CDA compared to men (10.5% vs. 52.2%, P = .002), and they had significantly lower h‐indices than men (10 vs. 17, P < .001).
Conclusions
As a cohort, CDA awardees achieve higher academic success than academic otolaryngologists in general. However, female CDA recipients lag behind their male colleagues, highlighting the need for more research to uncover contributors to gender differences and ways to foster equity in research.
Level of Evidence
NA Laryngoscope, 131:288–293, 2021
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