Publications by authors named "Ashutosh Kacker"

102 Publications

Primary and Revision Anterior Cervical Discectomy and Fusion: A Study of Otolaryngologic Outcomes in a Large Cohort.

Spine (Phila Pa 1976) 2021 Dec;46(24):1677-1682

Weill Cornell Medicine Department of Otolaryngology Head and Neck Surgery, New York, New York.

Study Design: Retrospective chart review.

Objective: To determine risk factors for postoperative otolaryngologic complications among patients who undergo primary and revision anterior cervical discectomy and fusion (ACDF).

Summary Of Background Data: Swallowing and voice dysfunction are frequent postoperative complaints after ACDF surgery with a published incidence varying between 1.2% and 60%. A thorough understanding of the incidence and risk factors for these complications is needed.

Methods: Electronic medical records of adults who underwent ACDF with predicted difficult surgical site exposure performed by two-surgeon approach between 2008 and 2018 were reviewed. Patients were categorized by primary or revision ACDF status and by the number of levels addressed during the operation. Associations with postoperative otolaryngologic symptoms were assessed using simple and multivariable logistic regression.

Results: Participants included 718 adults with an average age of 55.8 years and 45% female sex. One hundred seventy-five patients (27%) underwent revision ACDF; ACDF status was unidentifiable for 74 patients. Seventy-nine cases (12%) involved one spinal level. New postoperative otolaryngologic symptoms among those who underwent primary and revision ACDF were 12.6% and 10.9% respectively. No evidence was found of an association between postoperative otolaryngologic symptoms and revision ACDF (OR, 0.84 [95% CI, 0.48-1.49]; P  = 0.55), but evidence was found of an association with prior thyroidectomy (aOR, 3.8 [95% CI, 1.53-8.94], P  = 0.0003). Significant evidence was found of increased odds for new postoperative dysphagia with increasing number of surgical levels (aOR, 1.5 [95% CI, 1.09-2.07]; P = 0.01).

Conclusion: Prior thyroidectomy and number of spinal levels addressed during ACDF were identified as risk factors for postoperative otolaryngologic complications including dysphagia. Revision ACDF was not associated with increased odds of postoperative otolaryngologic symptoms or dysphagia.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000004089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8613446PMC
December 2021

The critical importance of a vascularized flap in preventing recurrence after endoscopic repair of spontaneous cerebrospinal fluid leaks and meningoencephaloceles.

J Neurosurg 2021 Nov 12:1-8. Epub 2021 Nov 12.

Departments of1Neurological Surgery.

Objective: Spontaneous CSF leaks into the anterior skull base nasal sinuses are often associated with meningoencephaloceles and occur in patients with idiopathic intracranial hypertension (IIH). Endonasal endoscopic repair has become the primary method of choice for repair. The authors sought to evaluate the success rate of endoscopic closure and to identify predictive factors for CSF leak recurrence.

Methods: A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele.

Results: From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9-38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher's exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred.

Conclusions: Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.
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http://dx.doi.org/10.3171/2021.7.JNS211427DOI Listing
November 2021

Evaluation of the aerosol generating potential of endoscopic dacryocystorhinostomy.

Laryngoscope Investig Otolaryngol 2021 Oct 17;6(5):948-951. Epub 2021 Aug 17.

Weill Cornell Medicine Otolaryngology New York New York USA.

Purpose: The COVID-19 pandemic gave rise to renewed concerns of the transmission risks posed by surgeries on sites of high viral colonization such as the nasopharynx. Endoscopic dacryocystorhinostomy (DCR) involves the creation of a new tear duct from the lacrimal sac to the nasal cavity. The purpose of this project is to determine if endoscopic DCR is an aerosol generating procedure (AGP).

Methods: An optical particle sizer (OPS) was used to intraoperatively quantify aerosol concentrations during four cases of endoscopic DCR. The OPS sampled the air once every 60 seconds throughout the operations. The time of important operative steps were documented and correlated with OPS readings. Particle concentrations during each major surgical step were compared to baseline readings by the Mann Whitney Test.

Results: There were statistically significant increases in median particle concentrations during laryngeal mask airway intubations for both particles 0.3 to 5.0 μm and >5.0 μm ( < .001 and  = .023, respectively). Median particle concentrations during nasolacrimal duct probing, middle meatal debridement, drilling, balloon insertion, tube insertion, and Posisef insertion were not statistically different from baseline.

Conclusions: Endoscopic DCR in itself does not appear to be an AGP. It is, however, associated with other aerosol generating events such as laryngeal mask intubation, and thus requires appropriate personal protective equipment. Cautious interpretation of the results is encouraged given the limitations of OPS.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8513416PMC
October 2021

Long-term tumor control after endoscopic endonasal resection of craniopharyngiomas: comparison of gross-total resection versus subtotal resection with radiation therapy.

J Neurosurg 2021 Oct 15:1-9. Epub 2021 Oct 15.

1Department of Neurosurgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York.

Objective: Surgical management of craniopharyngiomas (CPAs) is challenging. Controversy exists regarding the optimal goals of surgery. The purpose of this study was to compare the long-term outcomes of patients who underwent gross-total resection with the outcomes of those who underwent subtotal resection of their CPA via an endoscopic endonasal approach.

Methods: From a prospectively maintained database of all endoscopic endonasal approaches performed at Weill Cornell Medicine, only patients with CPAs with > 3 years of follow-up after surgery were included. The primary endpoint was radiographic progression. Data were collected on baseline demographics, imaging, endocrine function, visual function, and extent of resection.

Results: A total of 44 patients with a mean follow-up of 5.7 ± 2.6 years were included. Of these patients, 14 (31.8%) had prior surgery. GTR was achieved in 77.3% (34/44) of all patients and 89.5% (34/38) of patients in whom it was the goal of surgery. Preoperative tumor volume < 10 cm3 was highly predictive of GTR (p < 0.001). Radiation therapy was administered within the first 3 months after surgery in 1 (2.9%) of 34 patients with GTR and 7 (70%) of 10 patients with STR (p < 0.001). The 5-year recurrence-free/progression-free survival rate was 75.0% after GTR and 25.0% after STR (45% in subgroup with STR plus radiotherapy; p < 0.001). The time to recurrence after GTR was 30.2 months versus 13 months after STR (5.8 months in subgroup with STR plus radiotherapy; p < 0.001). Patients with GTR had a lower rate of visual deterioration and higher rate of return to work or school compared with those with STR (p = 0.02). Patients with GTR compared to STR had a lower rate of CSF leakage (0.0% vs 30%, p = 0.001) but a higher rate of diabetes insipidus (85.3% vs 50%, p = 0.02).

Conclusions: GTR, which is possible to achieve in smaller tumors, resulted in improved tumor control, better visual outcome, and better functional recovery but a higher rate of diabetes insipidus compared with STR, even when the latter was supplemented with postoperative radiation therapy. GTR should be the goal of craniopharyngioma surgery, when achievable with minimal morbidity.
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http://dx.doi.org/10.3171/2021.5.JNS202011DOI Listing
October 2021

A Novel Negative Pressure, Face-Mounted Antechamber to Minimize Aerosolization of Particles During Endoscopic Skull Base Surgery.

Oper Neurosurg (Hagerstown) 2021 08;21(3):131-136

Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA.

Background: The COVID-19 pandemic has revealed deficiencies in the adequacy of personal protective equipment (PPE) for healthcare workers. Endoscopic endonasal skull base surgery is thought to be among the highest-risk aerosol-generating procedures for surgeons and operating room personnel.

Objective: To validate the efficacy and clinical feasibility of a novel surgical device.

Methods: A low-cost, modifiable, and easily producible negative pressure, face-mounted antechamber was developed utilizing 3D printing and silicone molding. Efficacy was evaluated using an optical particle sizer to quantify aerosols generated during both cadaver and intraoperative human use with high-speed drilling.

Results: Particle counts in the cadaver showed that drilling led to a 2.49-fold increase in particles 0.3 to 5 μm (P = .001) and that the chamber was effective at reducing particles to levels not significantly different than baseline. In humans, drilling led to a 37-fold increase in particles 0.3 to 5 μm (P < .001), and the chamber was effective at reducing particles to a level not significantly different than baseline. Use of the antechamber in 6 complex cases did not interfere with the ability to perform surgery. Patients did not report any facial discomfort after surgery related to antechamber use.

Conclusion: The use of a negative pressure facial antechamber can effectively reduce aerosolization from endoscopic drilling without disturbing the flow of the operation. The antechamber, in conjunction with appropriate PPE, will be useful during the COVID-19 pandemic, as well as during flu season and any future viral outbreaks.
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http://dx.doi.org/10.1093/ons/opab173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194582PMC
August 2021

Development and validation of a patient face-mounted, negative-pressure antechamber for reducing exposure of healthcare workers to aerosolized particles during endonasal surgery.

J Neurosurg 2021 May 14:1-8. Epub 2021 May 14.

5Department of Neurosurgery, Weill Cornell Medicine, New York, New York.

Objective: The authors developed a negative-pressure, patient face-mounted antechamber and tested its efficacy as a tool for sequestering aerated particles and improving the safety of endonasal surgical procedures.

Methods: Antechamber prototyping was performed with 3D printing and silicone-elastomer molding. The lowest vacuum settings needed to meet specifications for class I biosafety cabinets (flow rate ≥ 0.38 m/sec) were determined using an anemometer. A cross-validation approach with two different techniques, optical particle sizing and high-speed videography/shadowgraphy, was used to identify the minimum pressures required to sequester aerosolized materials. At the minimum vacuum settings identified, physical parameters were quantified, including flow rate, antechamber pressure, and time to clearance.

Results: The minimum tube pressures needed to meet specifications for class I biosafety cabinets were -1.0 and -14.5 mm Hg for the surgical chambers with ("closed face") and without ("open face") the silicone diaphragm covering the operative port, respectively. Optical particle sizing did not detect aerosol generation from surgical drilling at these vacuum settings; however, videography estimated higher thresholds required to contain aerosols, at -6 and -35 mm Hg. Simulation of surgical movement disrupted aerosol containment visualized by shadowgraphy in the open-faced but not the closed-faced version of the mask; however, the closed-face version of the mask required increased negative pressure (-15 mm Hg) to contain aerosols during surgical simulation.

Conclusions: Portable, negative-pressure surgical compartments can contain aerosols from surgical drilling with pressures attainable by standard hospital and clinic vacuums. Future studies are needed to carefully consider the reliability of different techniques for detecting aerosols.
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http://dx.doi.org/10.3171/2020.10.JNS202745DOI Listing
May 2021

Frontal Sinus Fractures: 10-Year Contemporary Experience at a Level 1 Urban Trauma Center.

J Craniofac Surg 2021 Jan 12. Epub 2021 Jan 12.

*Department of Otolaryngology-Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY †Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL.

Frontal sinus fractures account for 5% to 15% of all facial fractures, and have traditionally been associated with high kinetic energy blunt injury. Surgical management is largely focused on minimizing potentially serious sequelae including frontal sinus dysfunction, CSF leak, and significant cosmetic deformity. An institutional database of 1944 patients presenting with maxillofacial fractures over a 10-year period was queried. Demographics, mechanism of injury, yearly trends, surgical approaches, and follow-up data were examined. A total of 160 (8.3%) patients presented with at least 1 fracture of the frontal sinus anterior table, posterior table, or frontal sinus outflow tract during the study period. The average annual number of cases was 15.9 ± 5.7 per year with a peak of 21.5 ± 4.0 cases during the 2014 to 2015 period and a decline to 8.5 ± 1.5 cases/year from 2016 to 2017. Among those patients with falls, 61.5% (n = 40) were a result of tripping or fainting at a height of <6 ft. 55.6% of fracture types were isolated to the anterior table, but fracture location was not significantly associated with operative intervention. Cases of operative fracture type had a higher rate of both displacement and comminution compared to nonoperative fractures (P < 0.00001). Of all patients presenting with frontal sinus fractures, 75% of cases were managed nonoperatively. However, many patients presented with falls and other seemingly low energy injuries which are not traditionally associated with frontal sinus trauma. These results highlight the need for continued follow-up even in otherwise low-risk urban populations in order to avoid long term sinus dysfunction.
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http://dx.doi.org/10.1097/SCS.0000000000007426DOI Listing
January 2021

Injury Patterns in Pediatric Facial Fractures Unique to an Urban Environment.

Facial Plast Surg 2021 Oct 23;37(5):564-570. Epub 2021 Feb 23.

Department of Otolaryngology, Head & Neck Surgery, Joan and Sanford I Weill Medical College of Cornell University, New York, New York.

This study aimed to define better the clinical presentation, fracture patterns, and features predictive of associated injuries and need for surgery in pediatric facial trauma patients in an urban setting. Charts of patients 18 years or younger with International Classification of Disease 9th and 10th revision (ICD-9/ICD-10) codes specific for facial fractures (excluding isolated nasal fractures) at NY-Presbyterian/Weill Cornell Medical Center between 2008 and 2017 were retrospectively reviewed. Of 204 patients, most were referred to the emergency department by a physician's office or self-presented. Children (age 0-6 years) were most likely to have been injured by falls, while more patients 7 to 12 years and 13 to 18 years were injured during sporting activities ( < 0.0001). Roughly half (50.5%) of the patients had a single fracture, and the likelihood of surgery increased with greater numbers of fractures. Older patients with either orbital or mandibular fractures were more likely to undergo surgery than younger ones ( = 0.0048 and  = 0.0053, respectively). Cranial bone fractures, CSF leaks, and intracranial injuries were more common in younger patients ( < 0.0001) than older patients and were more likely after high energy injuries; however, 16.2% of patients sustaining low energy injuries also sustained cranial bone, CSF leak, or intracranial injury. In an urban environment, significant pediatric facial fractures and associated injuries may occur after nonclassic low kinetic energy traumatic events. The age of the patient impacts both the injuries sustained and the treatment rendered. It is essential to maintain a high index of suspicion for associated injuries in all pediatric facial trauma patients.
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http://dx.doi.org/10.1055/s-0041-1724121DOI Listing
October 2021

Patterns of Facial Fractures in a Major Metropolitan Level 1 Trauma Center: A 10-year Experience.

Laryngoscope 2021 07 12;131(7):E2176-E2180. Epub 2021 Jan 12.

Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A.

Objective/hypothesis: To report characteristics and management of facial fractures in a major metropolitan center within the United States.

Study Design: Retrospective chart review.

Methods: Retrospective review at a level 1 trauma academic medical center of 3,946 facial fractures in 1,914 patients who presented from 2008 to 2017. Demographics, injury mechanism, associated injuries, and treatment information were collected. Logistic regression analyses were performed to determine factors associated with management.

Results: There were 1,280 males and 630 females with a median age of 42 years. Orbital fractures were the most common (41.4%) followed by maxilla fractures (21.9%). The most common mechanism was fall (43.6%). Surgical management was recommended for 38% of patients. The odds of surgical management were less for females (OR 0.59, 95% CI 0.48-0.73). Patients over 70 years were significantly less likely to undergo surgery compared to other age groups (OR 0.15-0.36, P < .001). The odds of surgical management were 1.69 times greater for patients with more than three fractures than for a single fracture (95% CI 1.18-2.42) and 2.23 times greater for traffic injuries compared to injuries from activities of daily living (95% CI 1.42-3.5).

Conclusions: This represents one of the largest comprehensive databases of facial fractures. Our patients were most frequently injured during activities of daily living, most commonly from falls. The majority of patients were managed conservatively. Gender, age, fracture number, and mechanism of injury were independently associated with the decision to treat surgically. Our data are in stark contrast to that from other populations in which assault or motor vehicle accidents predominate.

Level Of Evidence: 4 Laryngoscope, 131:E2176-E2180, 2021.
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http://dx.doi.org/10.1002/lary.29397DOI Listing
July 2021

Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data.

J Neurosurg 2020 Jul 24:1-13. Epub 2020 Jul 24.

Departments of1Neurosurgery and.

Objective: The endoscopic endonasal approach (EEA) has gained increasing popularity for the resection of suprasellar meningiomas (SSMs). Appropriate case selection is critical in optimizing patient outcome. Long-term outcome data are lacking. The authors systematically identified preoperative factors associated with extent of resection (EOR) and determined the relationship between EOR and long-term recurrence after EEA for SSMs.

Methods: In this retrospective cohort study, the authors identified preoperative clinical and imaging characteristics associated with EOR and built on the recently published University of California, San Francisco resectability score to propose a score more specific to the EEA. They then examined the relationship between gross-total resection (GTR; 100%), near-total resection (NTR; 95%-99%), and subtotal resection (STR; < 95%) and recurrence or progression with Kaplan-Meier survival analysis.

Results: A total of 51 patients were identified. Radiographic GTR was achieved in 40 of 47 (85%) patients in whom it was the surgical goal. Significant independent risk factors for incomplete resection were prior surgery (OR 25.94, 95% CI < 2.00 to 336.49, p = 0.013); tumor lateral to the optic nerve (OR 13.41, 95% CI 1.82-98.99, p = 0.011); and complete internal carotid artery (ICA) encasement (OR 15.12, 95% CI 1.17-194.08, p = 0.037). Tumor size and optic canal invasion were not significant risk factors after adjustment for other variables. A resectability score based on the multivariable model successfully predicted the likelihood of GTR; a score of 0 had a positive predictive value of 97% for GTR, whereas a score of 2 had a negative predictive value of 87.5% for incomplete resection. After a mean follow-up of 40.6 ± 32.4 months (mean ± SD), recurrence was 2.7% after GTR (1 patient with atypical histology), 44.4% after NTR, and 80% after STR (p < 0.0001). Vision was stable or improved in 93.5% and improved in 67.4% of patients with a preoperative deficit. There were 5 (9.8%) postoperative CSF leaks, of which 4 were managed with lumbar drains and 1 required a reoperation.

Conclusions: The EEA is a safe and effective approach to SSMs, with favorable visual outcomes in well-selected cases. The combination of postoperative MRI-based EOR with direct endoscopic inspection can be used in lieu of Simpson grade to predict recurrence. GTR dramatically reduces recurrence and can be achieved regardless of tumor size, proximity or encasement of the anterior cerebral artery, or medial optic canal invasion. Risk factors for incomplete resection include prior surgery, tumor lateral to the optic nerve, and complete ICA encasement.
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http://dx.doi.org/10.3171/2020.4.JNS20475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8111689PMC
July 2020

Pain and Opioid Analgesic Use After Otorhinolaryngologic Surgery.

Otolaryngol Head Neck Surg 2020 Dec 14;163(6):1178-1185. Epub 2020 Jul 14.

Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, New York, USA.

Objective: To quantify pain and opioid use after otorhinolaryngologic surgery. To determine the effect of patient and surgical factors on primary outcomes.

Study Design: Prospective cohort.

Setting: Tertiary academic hospital.

Subjects And Methods: Patients undergoing elective otorhinolaryngologic surgery were prospectively enrolled. Patients completed demographic surveys and psychometric questionnaires assessing attitudes toward pain and baseline anxiety and depression before surgery. After surgery, patients documented peak pain levels (0-100 mm, visual analog scale) and daily prescription and nonprescription analgesic requirements over a 2-week period. Average daily and cumulative pain and opioid use were calculated and compared among patient cohorts stratified by procedure and preoperative factors.

Results: A total of 134 patients were enrolled. Total tonsillectomy was associated with significantly higher pain scores and opioid consumption, as compared to all other procedures. There was moderate correlation between average cumulative pain and opioid use. Older patients required significantly fewer doses of opioids. There was no effect of sex, marital status, or education level on postoperative pain or opioid use. Psychometric instrument scores and chronic pain or analgesic use were not associated with significant differences in pain or opioid requirements. Most patients were prescribed substantially more opioids than they actually required.

Conclusion: Postoperative pain following elective otorhinolaryngologic surgery decreases dramatically within the first week and requires only few days of opioid analgesia, with the exception of tonsillectomy. Almost all patients required fewer than 15 doses of opioids.
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http://dx.doi.org/10.1177/0194599820933223DOI Listing
December 2020

The slope of the learning curve in 600 consecutive endoscopic transsphenoidal pituitary surgeries.

Acta Neurochir (Wien) 2020 10 1;162(10):2361-2370. Epub 2020 Jul 1.

Department of Neurosurgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA.

Background: Endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma has become a mainstay of treatment over the last two decades and it is generally accepted that once this learning curve is achieved, a plateau is reached with little incremental improvement.

Objective: The objective of this study was to assess the slope of the learning curve over a long period of time for a variety of outcomes measures.

Methods: We examined outcomes and complications in a consecutive series of 600 EETS for pituitary adenoma grouped into quartiles based on date of surgery.

Results: GTR significantly increased across quartiles from 55 to 79% in the last quartile (p < 0.005). The rate of intraoperative CSF leak significantly decreased from 60% in the first quartile to 33% in the last quartile and the rate of lumbar drain placement from 28% in the first quartile to 6% in the last quartile (p < 0.005). Hormonal remission for secreting adenomas increased from 68% in the first quartile to 90% in the last quartile (p < 0.05). The rate of post-operative CSF leak trended lower (3% in first quartile to 0.7% in last two quartiles). The greatest improvement in outcome occurred between the first and second quartiles (19.9%), but persistent improvement occurred between the second and third (6.7%) and third and fourth quartiles (8.0%).

Conclusion: Although the slope of the learning curve is steeper earlier in a surgeon's experience, the slope does not plateau and continues to increase even over more than a decade.
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http://dx.doi.org/10.1007/s00701-020-04471-xDOI Listing
October 2020

Endoscopic endonasal approaches to the craniovertebral junction: The Otolaryngologist's perspective.

World J Otorhinolaryngol Head Neck Surg 2020 Jun 16;6(2):94-99. Epub 2020 Mar 16.

Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College - New York, NY, USA.

Objective: To review indications and techniques for the endoscopic endonasal approach to the craniovertebral junction (CVJ), analyze postoperative outcomes, and discuss important technical considerations.

Methods: A retrospective analysis was performed on all patients undergoing endonasal endoscopic approaches to the CVJ from May 2007 to June 2017. Demographic information, presenting symptoms, imaging results, treatment course, postoperative functional status, and follow-up were recorded.

Results: There was a total of 30 patients in this series, with a mean follow-up of 11.7 months. The average age was 33.6 years (range, 5-75 years), with 18 females and 12 males. The majority of patients ( = 22, 73.3%) had Chiari malformation type 1 with basilar invagination and symptomatic cervicomedullary compression as the indication for surgery. Intraoperative cerebrospinal fluid leak (CSF) was noted in 3 cases of odontoid resection and a single case of skull base resection. There were no postoperative CSF leaks. Overall, 81% of patients resumed regular diet by post-operative day 2 (range, 0-8 days). Severe postoperative dysphagia occurred in two cases with one requiring gastrostomy tube placement and another utilizing total parenteral nutrition for support prior to eventual gastrostomy. On average, patients were extubated by postoperative day 0.93 (range 0-3 days), with 85% extubated by postoperative day 1. A tracheotomy was required in one patient.

Conclusion: The endonasal endoscopic approach is a valuable technique for access to the CVJ with minimal disruption of respiratory and alimentary function.
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http://dx.doi.org/10.1016/j.wjorl.2020.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296474PMC
June 2020

Low incidence of true Sternberg's canal defects among lateral sphenoid sinus encephaloceles.

Acta Neurochir (Wien) 2020 10 6;162(10):2413-2420. Epub 2020 May 6.

Departments of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA.

Background: Spontaneous sphenoid sinus cerebrospinal fluid (CSF) encephaloceles have been postulated to arise from a persistent Sternberg's canal. However, recent evidence has questioned this embryological etiology. We examined the anatomic location of a series of lateral sphenoid sinus encephaloceles to determine if they corresponded with the location of Sternberg's canal.

Methods: We queried a prospectively acquired database of surgically treated spontaneous CSF leaks and identified those arising from the sphenoidal sinus. Images were reviewed to characterize the leaks with respect to the foramen rotundum (FR) and the vidian canal (VC). Four leak types were classified of which Type I (medial to FR and VC entering nasopharynx) was theoretically located in the precise location of Sternberg's canal. Type II was medial to FR; Type III was lateral to FR; Type IV passed through an enlarged FR into sphenoid sinus. Demographic data were analyzed.

Results: Of 103 repaired CSF leaks, 17 arose from the lateral sphenoid sinus. There were no true Type I leaks, 3 Type II leaks, 12 Type III leaks, and 2 Type IV leaks. No differences were found with respect to sphenoid pneumatization, BMI, age, sex, arachnoid pits, or postoperative leak between different types.

Conclusions: No evidence was found to support the existence of a classic Sternberg canal CSF leak, supporting the hypothesis that most sphenoid spontaneous leaks likely occur secondary to chronically elevated ICP. Rare cases may be related to a weakness in the sphenoid wall in the region of Sternberg's canal.
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http://dx.doi.org/10.1007/s00701-020-04329-2DOI Listing
October 2020

Early experience with feasibility of balloon sinus dilation in complicated pediatric acute frontal rhinosinusitis.

Laryngoscope Investig Otolaryngol 2020 Apr 14;5(2):194-199. Epub 2020 Feb 14.

Department of Otolaryngology-Head and Neck Surgery Weill Cornell Medical College New York New York.

Background/objective: Complicated acute rhinosinusitis in the pediatric population is an uncommon problem that may affect the orbit or brain and is life-threatening. This condition requires surgical intervention with endoscopic sinus surgery for source control, and prior studies have demonstrated the safety of balloon sinuplasty in chronic frontal sinusitis.

Methods/results: We present our approach with a balloon sinus dilation hybrid procedure to resolve four distinct types of complicated acute frontal sinusitis in pediatric patients, including intracranial manifestations, intraorbital complications, and recurrent disease. All four patients were able to be managed operatively with frontal balloon sinuplasty.

Conclusions: Prior efficacy has been demonstrated for chronic frontal sinusitis in the pediatric population. We demonstrate that frontal balloon sinuplasty is also feasible in the proper clinical setting for acute frontal sinusitis, even in the presence of regional complications or recurrent disease.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178448PMC
April 2020

Acellular dermal matrix as an alternative to autologous fascia lata for skull base repair following extended endoscopic endonasal approaches.

Acta Neurochir (Wien) 2020 04 11;162(4):863-873. Epub 2020 Feb 11.

Department of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA.

Background: Skull base reconstruction after extended endoscopic endonasal approaches (EEAs) can be challenging. In addition to the nasoseptal flap, which has been adopted by most centers, autologous fascia lata is also often utilized. Harvesting of fascia lata requires a separate thigh incision, may prolong recovery, and results in a visible scar. In principal, the use of non-autologous materials would be preferable to avoid a second incision and maintain the minimally invasive nature of the approach, assuming the CSF leak rate is not compromised.

Objective: To assess the efficacy of acellular dermal matrix (ADM) as a non-autologous alternative to autologous fascia lata graft for watertight closure of the cranial base following EEAs.

Methods: A retrospective chart review of extended EEAs performed before and after the transition from fascia lata to ADM was performed. Cases were frequency matched for approach, pathology, BMI, use of lumbar drainage, and tumor volume. Power analysis was performed to estimate the sample size needed to demonstrate non-inferiority.

Results: ADM was used for watertight closure of the cranial base in 19 consecutive extended endoscopic endonasal approaches (16 gasket-seals and 3 buttons) with 1 postoperative CSF leak at the last follow-up (median 5.3, range 1.0-12.6 months). All patients had high-flow intraoperative leaks. The cohort included 8 meningiomas, 8 craniopharyngiomas, 2 chordomas, and 1 pituicytoma ranging in size from 0.2 to 37.2cm (median 5.5, IQR 2.8-13.3 cm). In 19 historical controls who received fascia lata, there were 2 postoperative CSF leaks.

Conclusions: Preliminary results suggest that ADM provides a non-inferior non-autologous alternative to fascia lata for watertight gasket-seal and button closures following extended EEAs, potentially reducing or eliminating the need to harvest autologous tissue.
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http://dx.doi.org/10.1007/s00701-019-04200-zDOI Listing
April 2020

How long is the tail end of the learning curve? Results from 1000 consecutive endoscopic endonasal skull base cases following the initial 200 cases.

J Neurosurg 2020 Feb 7;134(3):750-760. Epub 2020 Feb 7.

Departments of2Neurosurgery.

Objective: Endoscopic endonasal approaches (EEAs) to the skull base have evolved over the last 20 years to become an essential component of a comprehensive skull base practice. Many case series show a learning curve from the earliest cases, in which the authors were inexperienced or were not using advanced closure techniques. It is generally accepted that once this learning curve is achieved, a plateau is reached with little incremental improvement. Cases performed during the early steep learning curve were eliminated to examine whether the continued improvement exists over the "tail end" of the curve.

Methods: A prospectively acquired database of all EEA cases performed by the senior authors at Weill Cornell Medicine/NewYork-Presbyterian Hospital was reviewed. The first 200 cases were eliminated and the next 1000 consecutive cases were examined to avoid the bias created by the early learning curve.

Results: Of the 1000 cases, the most common pathologies included pituitary adenoma (51%), meningoencephalocele or CSF leak repair (8.6%), meningioma (8.4%), craniopharyngioma (7.3%), basilar invagination (3.1%), Rathke's cleft cyst (2.8%), and chordoma (2.4%). Use of lumbar drains decreased from the first half to the second half of our series (p <0.05) as did the authors' use of fat alone (p <0.005) or gasket alone (p <0.005) for dural closure, while the use of a nasoseptal flap increased (p <0.005). Although mean tumor diameter was constant (on average), gross-total resection (GTR) increased from 60% in the first half to 73% in the second half (p <0.005). GTR increased for all pathologies but most significantly for chordoma (56% vs 100%, p <0.05), craniopharyngioma (47% vs 0.71%, p <0.05) and pituitary adenoma (67% vs 75%, p <0.05). Hormonal cure for secreting adenomas also increased from 83% in the first half to 89% in the second half (p <0.05). The rate of any complication was unchanged at 6.4% in the first half and 6.2% in the latter half of cases, and vascular injury occurred in only 0.6% of cases. Postoperative CSF leak occurred in 2% of cases and was unchanged between the first and second half of the series.

Conclusions: This study demonstrates that contrary to popular belief, the surgical learning curve does not plateau but can continue for several years depending on the complexity of the endpoints considered. These findings may have implications for clinical trial design, surgical education, and patient safety measures.
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http://dx.doi.org/10.3171/2019.12.JNS192600DOI Listing
February 2020

Long-term outcomes after endoscopic endonasal surgery for nonfunctioning pituitary macroadenomas.

J Neurosurg 2020 Jan 31:1-12. Epub 2020 Jan 31.

Departments of1Neurosurgery.

Objective: Nonfunctioning pituitary adenomas are benign, slow-growing tumors. After gross-total resection (GTR) or subtotal resection (STR), tumors can recur or progress and may ultimately require additional intervention. A greater understanding of long-term recurrence and progression rates following complete or partial resection and the need for further intervention will help clinicians provide meaningful counsel for their patients and assist data-driven decision-making.

Methods: The authors retrospectively analyzed their institutional database for patients undergoing endoscopic endonasal surgery (EES) for nonfunctioning pituitary macroadenomas (2003-2014). Only patients with follow-up of at least 5 years after surgery were included. Tumor volumes were measured on pre- and postoperative MRI. Tumor recurrence was defined as the presence of a 0.1-cm3 tumor volume after GTR, and tumor progression was defined as a 25.0% increase in residual tumor after STR.

Results: A total of 190 patients were included, with a mean age of 63.8 ± 13.2 years; 79 (41.6%) were female. The mean follow-up was 75.0 ± 18.0 months. GTR was achieved in 127 (66.8%) patients. In multivariate analysis, age (p = 0.04), preoperative tumor volume (p = 0.03), Knosp score (p < 0.001), and Ki-67 (p = 0.03) were significant predictors of STR. In patients with GTR, the probability of recurrence at 5 and 10 years was 3.9% and 4.7%, and the probability of requiring treatment for recurrence was 0.79% and 1.6%, respectively. In 63 patients who underwent STR, 6 (9.5%) received early postoperative radiation and did not experience progression, while the remaining 57 (90.5%) were observed. Of these, the probability of disease progression at 5 and 10 years was 21% and 24.5%, respectively, and the probability of requiring additional treatment for progression was 17.5% and 21%. Predictors of recurrence or progression in the entire group were Knosp score (p < 0.001) and elevated Ki-67 (p = 0.03). Significant predictors of progression after STR in those who did not receive early radiotherapy were cavernous sinus location (p < 0.05) and tumor size > 1.0 cm3 (p = 0.005).

Conclusions: Following GTR for nonfunctioning pituitary adenomas, the 10-year chance of recurrence is low and the need for treatment even lower. After STR, although upfront radiation therapy may prevent progression, even without radiotherapy, the need for intervention at 10 years is only approximately 20% and a period of observation may be warranted to prevent unnecessary prophylactic radiation therapy. Tumor volume > 1 cm3, Knosp score ≥ 3, and Ki-67 ≥ 3% may be useful metrics to prompt closer follow-up or justify early prophylactic radiation therapy.
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http://dx.doi.org/10.3171/2019.11.JNS192457DOI Listing
January 2020

Complication Rates Following Septoplasty With Inferior Turbinate Reduction.

Ochsner J 2019 ;19(4):353-356

Department of Otolaryngology, Weill Cornell Medical College, New York, NY.

Septoplasty with submucous resection of the inferior turbinate (SMRT) is a common correctional surgery performed in patients with deviated nasal septum resulting in nasal obstruction. Although complications are infrequent, studies examining long-term complications following septoplasty with SMRT are rare. We conducted a retrospective review of patients electing to undergo septoplasty with SMRT at a tertiary rhinology clinic from January 2007 to December 2015. Demographic data, intraoperative findings, duration of follow-up, and short-term and long-term complications were collected. Exclusion criteria included patients who underwent either septoplasty or turbinate reduction or any other nasal surgery, patients lost to follow-up within 1 year, and patients with incomplete medical records. A total of 359 patients met inclusion criteria. The majority were males (66.6%), and the average age of the cohort was 36.8 ± 12.3 years. The mean follow-up time was 23.3 months. Short-term complications were postoperative infection (n=12, 3.3%) and epistaxis that required intervention (n=16, 4.5%). Long-term complications occurred in 10 patients (2.8%): revision septoplasty (n=9, 2.5%) and hyposmia (n=1, 0.3%). No instances of synechiae, septal perforation, or saddle nose deformity occurred. Long-term complications following septoplasty with SMRT are infrequent. The most common long-term complication in this cohort was revision septoplasty.
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http://dx.doi.org/10.31486/toj.19.0002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928672PMC
January 2019

Endoscopic Endonasal Transclival Resection of a Pontine Metastasis: Case Report and Operative Video.

Oper Neurosurg (Hagerstown) 2020 07;19(1):E75-E81

Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.

Background And Importance: Brainstem lesions are challenging to manage, and surgical options have been controversial. Stereotactic radiosurgery (SRS) has been used for local control, but life-threatening toxicities from 0% to 9.5% have been reported. Several microsurgical approaches involving safe entry zones have been developed to optimize the exposure and minimize complications in different portions of the brainstem, but require extensive drilling and manipulation of neurovascular structures. With recent advancements, the endoscopic endonasal approach (EEA) can provide direct visualization of ventral brainstem. No case has been reported of EEA to remove a brainstem metastasis.

Clinical Presentation: We present an illustrative case of a 68-yr-old female with metastatic colon cancer who presented with 2.8 × 2.7 × 2.1 cm (7.9 cm3) heterogeneously enhancing, right ventral pontine lesion with extensive edema. She underwent endoscopic endonasal transclival approach, and gross total resection of the lesion was achieved.

Conclusion: The endoscopic approach may offer certain advantages for removal of ventral brainstem lesions, as it can provide direct visualization of important neurovascular structures, especially, if the lesion displaces the tracts and comes superficial to the pial surface.
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http://dx.doi.org/10.1093/ons/opz380DOI Listing
July 2020

Postoperative Bioresorbable Chitosan-Based Dressing for Endoscopic Middle Meatal Dacryocystorhinostomy With Balloon Dilation.

Ear Nose Throat J 2021 Jul 26;100(6):425-429. Epub 2019 Sep 26.

Department of Ophthalmology, 12295Weill Cornell Medicine, New York, NY, USA.

Purpose: To evaluate the improvement in epiphora and need for surgical revision in patients with acquired nasolacrimal duct obstruction following balloon-assisted, middle meatal endoscopic dacryocystorhinostomy with chitosan-based dressing versus bioresorbable polyurethane packing versus no packing.

Patients And Methods: This was a retrospective study of consecutive adult patients seen from 2015 to 2018 with follow-up evaluation of epiphora at least 3 months after balloon-assisted, middle meatal endoscopic dacryocystorhinostomy. Patients with a history of prior punctoplasty, septoplasty, sinus surgery, or dacryocystorhinostomy of any kind were excluded. Those meeting criteria were stratified by postoperative hemostatic intervention: no packing, bioresorbable packing, and chitosan-based dressing (groups 1, 2, and 3, respectively). Procedural outcomes were graded as successes or failures based on subjective report and anatomical findings at most recent visit within an 18-month postoperative window. Instances of recommendation for revision surgery were also recorded.

Results: Forty-three cases (36 patients) met the abovementioned criteria. Groups 1, 2, and 3 comprised 12, 17, and 14 cases each, respectively. Average patient age was 55.3 years old, and average duration of follow-up was 6.7 months. Significant variation in outcomes was detected across the 3 groups ( = .0495), particularly between groups 1 and 3 ( = .033). Use of chitosan-based dressing trended toward reduced rates of recommendation for surgical revision ( = .203, = .113).

Conclusions: Use of chitosan-based dressing after endoscopic dacryocystorhinostomy was associated with improved subjective and anatomical outcomes. It may also contribute to less frequent need for revision surgery. Further study in a larger prospective trial is recommended.
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http://dx.doi.org/10.1177/0145561319866822DOI Listing
July 2021

Solitary Mucus Cast at the Wharton Duct Orifice.

JAMA Otolaryngol Head Neck Surg 2019 Oct;145(10):969-970

Department of Otolaryngology-Head & Neck Surgery, Weill Cornell Medical College, New York, New York.

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http://dx.doi.org/10.1001/jamaoto.2019.2252DOI Listing
October 2019

Management strategies for recurrent acute rhinosinusitis.

Laryngoscope Investig Otolaryngol 2019 Aug 10;4(4):379-382. Epub 2019 Jul 10.

Department of Otolaryngology-Head and Neck Surgery Weill Cornell Medicine New York New York U.S.A.

Background: Management of patients with recurrent acute rhinosinusitis (RARS) is often challenging, and robust data in the literature is scant. The aim of this study is to better characterize the current treatment strategies for RARS used by otolaryngologists.

Methods: An online survey sent to all members of the American Rhinologic Society in a 1 month period evaluated demographics, practice characteristics, and management strategies for patients with RARS, subdivided into those with (RARSwD) and without (RARSsD) septal deviation. Eighty-eight practicing members responded, of whom 41% were fellowship-trained rhinologists.

Results: For most cases of RARSsD, 61% of otolaryngologists would primarily use medical management. Most would wait until patients had experienced 4-5 episodes to perform balloon sinuplasty (80%) or formal sinus surgery (79%). The sinus surgery procedure of choice was limited sinus surgery (62%). For RARSwD, 52% primarily chose medical management. Most would wait until patients had experienced 4-5 episodes to perform balloon sinuplasty (80%) or formal sinus surgery (78%). Nearly all fellowship-trained rhinologists (97%) would perform limited sinus surgery with septoplasty for RARSwD, compared to only 70% of other otolaryngologists who would do so and 24% who would perform complete sinus surgery with septoplasty. While 89% of practitioners in private practice would wait to perform balloon sinuplasty until patients had experienced 4-5 episodes, only 68% of those in academia would wait this long and 23% would do so after only 1-3 episodes.

Conclusions: Treatment of patients with RARS is complex, and the differences in strategies employed between groups of otolaryngologists may reflect their training backgrounds and different patient populations.

Level Of Evidence: V.
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http://dx.doi.org/10.1002/lio2.294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703111PMC
August 2019

A Dual Approach for the Management of Complex Craniovertebral Junction Abnormalities: Endoscopic Endonasal Odontoidectomy and Posterior Decompression with Fusion.

World Neurosurg X 2019 Apr 24;2:100010. Epub 2019 Jan 24.

Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA.

Background: Ventral brainstem compression secondary to complex craniovertebral junction abnormality is an infrequent cause of neurologic deterioration in pediatric patients. However, in cases of symptomatic, irreducible ventral compression, 360° decompression of the brainstem supported by posterior stabilization may provide the best opportunity for improvement in symptoms. More recently, the endoscopic endonasal corridor has been proposed as an alternative method of odontoidectomy associated with less morbidity. We report the largest single case series of pediatric patients using this dual-intervention surgical technique. The purpose of this study was to evaluate the surgical outcomes of pediatric patients who underwent posterior occipitocervical decompression and instrumentation followed by endoscopic endonasal odontoidectomy performed to relieve neurologic impingement involving the ventral brainstem and craniocervical junction.

Methods: Between January 2011 and February 2017, 7 patients underwent posterior instrumented fusion followed by endonasal endoscopic odontoidectomy at our unit. Standardized clinical and radiological parameters were assessed before and after surgery. A univariate analysis was performed to assess clinical and radiologic improvement after surgery.

Results: A total of 14 operations were performed on 7 pediatric patients. One patient had Ehlers-Danlos syndrome, 1 patient had a Chiari 1 malformation, and the remaining 5 patients had Chiari 1.5 malformations. Average extubation day was postoperative day 0.9. Average day of initiation of postoperative feeds was postoperative day 1.0.

Conclusions: The combined endoscopic endonasal odontoidectomy and posterior decompression and fusion for complex craniovertebral compression is a safe and effective procedure that appears to be well tolerated in the pediatric population.
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http://dx.doi.org/10.1016/j.wnsx.2019.100010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6580888PMC
April 2019

Postoperative pain and analgesic requirements after septoplasty and rhinoplasty.

Laryngoscope 2019 09 7;129(9):2020-2025. Epub 2019 Mar 7.

Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College and Weill Cornell Medicine, New York, New York, U.S.A.

Objectives/hypothesis: To assess and define the level of pain after rhinoplasty and septoplasty and to better define the strength and quantity of postoperative opioids needed.

Study Design: Prospective outcomes research.

Methods: Two groups of patients were enrolled. One group underwent septoplasty with/without turbinate reduction and the other group underwent functional and/or cosmetic rhinoplasty (with/without septoplasty). Patients completed a 15-day log (daily, beginning on the day of surgery) to record the analgesics used and the daily maximal level of pain using a visual analog scale. Level of pain, number of days of moderate or severe pain, total number of opioid pills used, and total morphine milligram equivalents (MMEs) of opioid used were assessed.

Results: Pain after septoplasty and rhinoplasty was generally mild. Average pain was moderate through postoperative day (POD) 2 after rhinoplasty and only on POD 0 after septoplasty. There was no statistically significant difference between the two groups in terms of number of opioid tablets consumed or total MMEs used. Patients undergoing rhinoplasty consumed more acetaminophen than septoplasty-only patients (7471 ± 1009 vs. 2781 ± 585, P = .0112). Ninety percent of patients would have received adequate analgesia with as few as 11 opioid tablets. All patients had excess opioid at the end of the study period.

Conclusions: Both septoplasty and rhinoplasty are associated with mostly mild pain, and postoperative opioid requirements are quite low. Surgeons can reliably reduce opioid prescription after septoplasty and rhinoplasty to as few as 11 tablets. Reducing opioid prescribing will not adversely affect the patient but will reduce the availability of opioids for misuse or diversion.

Level Of Evidence: 2c Laryngoscope, 129:2020-2025, 2019.
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http://dx.doi.org/10.1002/lary.27913DOI Listing
September 2019

Technological and Ideological Innovations in Endoscopic Skull Base Surgery.

World Neurosurg 2019 Jan 29. Epub 2019 Jan 29.

- Department of Otolaryngology - Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA; - Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA; - Department of Neuroscience, Weill Cornell Medical College, New York, NY, USA. Electronic address:

Background: Endoscopic skull base surgery has evolved over the last several decades due to technological advances and operative techniques. Several innovations that are not yet mainstream may have significant impact on the future of endoscopic skull base surgery.

Methods: Current literature pertaining to innovations in endoscopic skull base surgery was retrieved using PubMed, Embase, Web of Science, and Google Scholar.

Results: Several recent innovations may play an influential role in the advancement of endoscopic skull base surgery, including fluorescent dyes such as indocyanine green fluorescence, fluorescein, and 5-aminolevulinic acid, 3D endoscopes, robotic surgery, and intraoperative magnetic resonance imaging.

Conclusions: Several technologies are under current investigation with the hope to improve future outcomes in endoscopic skull base surgery. Additional research and evolution are necessary and will require intense scrutiny before becoming standard of care.
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http://dx.doi.org/10.1016/j.wneu.2019.01.120DOI Listing
January 2019

Opioid analgesic use and patient-reported pain outcomes after rhinologic surgery.

Int Forum Allergy Rhinol 2019 04 3;9(4):339-344. Epub 2018 Dec 3.

Department of Otolaryngology-Head and Neck Surgery, Department of Anesthesiology, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, NY.

Background: Opioid-based analgesics are routinely prescribed after elective rhinologic surgery. Balancing appropriate pain management while avoiding overprescription necessitates an evidence-based approach.

Methods: Patients undergoing elective rhinologic surgery, including endoscopic sinus surgery (ESS), septoplasty, or ESS with septoplasty, were prospectively enrolled. Patients completed demographic and psychometric questionnaires assessing attitudes toward pain, baseline anxiety, and depression before surgery. Postoperatively, patients documented peak pain levels (0-100 visual analog scale) and daily prescription and nonprescription medication requirements over a 2-week period.

Results: Of the 42 patients enrolled, 15 underwent ESS, 14 septoplasty, and 13 ESS with septoplasty. Five patients (11.9%) reported a history of chronic pain before surgery. Patients were given a median of 30 opioid pain pills after surgery: acetaminophen with codeine 325/30 mg (10 patients) or oxycodone with acetaminophen 5/325 mg (32 patients). Patients had a median of 27 pills left over at the end of the study period. Median peak pain levels for all procedures were 22 (range, 0-94) on day 0, 26.5 (range, 0-86) on day 1, 8.5 (range, 0-85) on day 3, and 3 (range, 0-52) on day 7. Median opioid requirements measured in morphine milligram equivalents (MME) over those same days were 6.0, 4.1, 0, and 0, respectively.

Conclusion: Postoperative pain after elective rhinologic surgery appears to peak over the first 3 days and decreases rapidly afterward. Most patients require a few doses of opioid analgesics. Opioid requirements and pain levels did not vary based on surgeon, type and extent of surgery, and demographic factors. Judicious prescribing of opioid medication after rhinologic surgery represents a practical opportunity for rhinologists and otolaryngologists to reduce opioid overprescription and abuse.
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http://dx.doi.org/10.1002/alr.22260DOI Listing
April 2019

Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas.

J Neurosurg 2018 Nov 1:1-9. Epub 2018 Nov 1.

Departments of1Neurological Surgery.

OBJECTIVEGross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.METHODSA retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.RESULTSA total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.CONCLUSIONSWhile the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.
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http://dx.doi.org/10.3171/2018.6.JNS18901DOI Listing
November 2018

Endonasal endoscopic transsphenoidal resection of intrinsic third ventricular craniopharyngioma: surgical results.

J Neurosurg 2018 Nov 1:1-11. Epub 2018 Nov 1.

1Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.

OBJECTIVEIntrinsic third ventricular craniopharyngiomas (IVCs) have been reported by some authors to "pose the greatest surgical challenge" of all craniopharyngiomas (CPAs). A variety of open microsurgical approaches have historically been used for resection of these tumors. Despite increased utilization of the endoscopic endonasal approach (EEA) for resection of CPAs in recent years, many authors continue to recommend against use of the EEA for resection of IVCs. In this paper, the authors present the largest series to date utilizing the EEA to remove IVCs.METHODSThe authors reviewed a prospectively acquired database of the EEA for resection of IVCs over 14 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital. Preoperative MR images were examined independently by two neurosurgeons and a neuroradiologist to identify IVCs. Pre- and postoperative endocrinological, ophthalmological, radiographic, and other morbidities were determined from retrospective chart review and volumetric radiographic analysis.RESULTSBetween January 2006 and August 2017, 10 patients (4 men, 6 women) ranging in age from 26 to 67 years old, underwent resection of an IVC utilizing the EEA. Preoperative endocrinopathy was present in 70% and visual deterioration in 60%. Gross-total resection (GTR) was achieved in 9 (90%) of 10 patients, with achievement of near-total (98%) resection in the remaining patient. Pathology was papillary in 30%. Closure incorporated a "gasket-seal" technique with nasoseptal flap coverage and either lumbar drainage (9 patients) or a ventricular drain (1 patient). Postoperatively, complete anterior and posterior pituitary insufficiency was present in 90% and 70% of patients, respectively. In 4 patients with normal vision prior to surgery, 3 had stable vision following tumor resection. One patient noted a new, incongruous, left inferior homonymous quadrantanopsia postoperatively. In the 6 patients who presented with compromised vision, 2 reported stable vision following surgery. Each of the remaining 4 patients noted significant improvement in vision after tumor resection, with complete restoration of normal vision in 1 patient. Aside from the single case (10%) of visual deterioration referenced above, there were no instances of postoperative neurological decline. Postoperative CSF leakage occurred in 1 morbidly obese patient who required reoperation for revision of closure. After a mean follow-up of 46.8 months (range 4-131 months), tumor recurrence was observed in 2 patients (20%), one of whom was treated with radiation and the other with chemotherapy. Both of these patients had previously undergone GTR of the IVC.CONCLUSIONSThe 10 patients described in this report represent the largest number of patients with IVC treated using EEA for resection to date. EEA for resection of IVC is a safe and efficacious operative strategy that should be considered a surgical option in the treatment of this challenging subset of tumors.
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http://dx.doi.org/10.3171/2018.5.JNS18198DOI Listing
November 2018

Role of Complementary and Alternative Medicine in Otolaryngologic Perioperative Care.

Ochsner J 2018 ;18(3):253-259

Department of Otolaryngology, Weill Cornell Medical College, New York, NY.

Background: During the perioperative period for otolaryngologic surgical cases, complications and delays can occur as the result of anxiety, pain, nausea, and vomiting. Conventional methods used to treat these symptoms include medications that can be expensive and invasive or that can cause adverse effects. Because of the concerns about opioid use in the United States, providers might want to consider using complementary and alternative medicine (CAM) as adjunctive or primary treatment plans.

Methods: To assess the current knowledge about the clinical effectiveness of CAM for patients undergoing otolaryngologic procedures, we searched the literature using MEDLINE, PubMed, and Google Scholar. We excluded studies published prior to 1990 and articles about surgeries that were unrelated to otolaryngology.

Results: An analysis of the selected studies revealed that CAM therapies-acupuncture, aromatherapy, hypnosis, and music therapy-have been shown to be effective at reducing preoperative anxiety, postoperative pain, and postoperative nausea and vomiting. No adverse side effects were associated with CAM use in these studies.

Conclusion: The use of CAM in patients undergoing otolaryngologic surgeries may relieve common perioperative symptoms. While further study is warranted, otolaryngology providers might consider implementing CAM with patients electing surgery.
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http://dx.doi.org/10.31486/toj.18.0014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162121PMC
January 2018
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