Publications by authors named "Marc R Rosen"

49 Publications

Surgery with Post-Operative Endoscopy Improves Recurrence Detection in Sinonasal Malignancies.

Ann Otol Rhinol Laryngol 2021 May 6:34894211011449. Epub 2021 May 6.

Department of Otolaryngology and Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Objective: The mainstay of treatment in sinonasal malignancy (SNM) is surgery, and when combined with chemoradiation therapy, often leads to the best overall prognosis. Nasal endoscopy is essential for post-treatment surveillance along with physical exam and radiologic evaluation. The ability to directly visualize the sinus cavities after surgery may also improve early detection of tumor recurrence and is another reason to potentially advocate for surgery in these patients.

Methods: A retrospective chart review of medical records of patients with pathologically proven SNM was conducted from 2005 to 2019.

Results: The nasal cavity and maxillary sinus were the most common primary tumor sub-sites. The most common pathology was squamous cell carcinoma (42%). The median time to recurrence was 9.8 months. Recurrence was initially detected endoscopically in 34.3% patients, by imaging in 62.7% patients, and by physical exam in 3.0% patients. 67 (29%) total recurrences were detected on follow-up, of which 46 (68.7%) were local. Twenty-three of the local recurrences were identified via nasal endoscopy. Thirteen recurrences were identified via endoscopic surveillance within the surgically patent paranasal sinuses while 13 were identified within the nasal cavity; 5 patients had multiple sites of recurrence.

Conclusion: Local recurrence of SNM is the most common site for recurrent disease and nasal endoscopy identified half of these cases. 50% of these recurrences were within the paranasal sinuses and would not have been easily identified if the sinuses were not open for inspection. Thus, open sinus cavities aid in the detection of tumor recurrence and is another advantage of surgery in the management of SNM.
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http://dx.doi.org/10.1177/00034894211011449DOI Listing
May 2021

Free tissue transfer for central skull base defect reconstruction: Case series and surgical technique.

Oral Oncol 2021 04 13;115:105220. Epub 2021 Feb 13.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, United States. Electronic address:

Objectives: Local reconstruction of central skull base defects may be inadequate for large defects or reoperative cases; free tissue transfer may be necessary. Inset of the flap and management of the pedicle can be challenging. We report our experience and approaches.

Methods: Retrospective review identifying seven patients with central skull base defects who underwent free flap reconstruction from 2016 to 2020.

Results: Four patients with recurrent nasopharyngeal carcinoma, one with recurrent craniopharyngioma, one with clival-cervical chordoma, and one with meningioma of the middle cranial fossa were analyzed. Six defects were closed with an anterolateral thigh free flap and one with a radial forearm free flap. In two patients, the flap was secured in an onlay fashion to the defect via a Caldwell-Luc transmaxillary approach. In one patient, the flap was passed transorally, and the pedicle was delivered into the neck via Penrose drain. In two patients, a parapharyngeal technique and in two others, a retropharyngeal was used for nasopharyngeal inset with endoscopic assistance. There were no flap failures, with an average follow-up time of 20.1 (range 3.2-47.1) months. One patient required flap repositioning on postoperative day three due to midline shift and intracranial contents compression. The transoral inset flap necessitated flap repositioning on postoperative day 13 to improve the nasopharyngeal airway.

Conclusion: Free flap reconstruction of the central skull base is challenging, but transmaxillary, transoral, parapharyngeal, and retropharyngeal approaches can be used with endoscopic assistance to ensure secure inset flap and avoid airway obstruction.
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http://dx.doi.org/10.1016/j.oraloncology.2021.105220DOI Listing
April 2021

Loss of Expression Confers Poor Prognosis to Sinonasal Undifferentiated Carcinoma.

J Neurol Surg B Skull Base 2020 Dec 24;81(6):610-619. Epub 2019 Jul 24.

Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, United States.

 Due to the diverse histopathologic features and variable survival rates seen in sinonasal undifferentiated carcinoma (SNUC), it is likely that this diagnostic entity is comprised of a heterogonous group of morphologically undifferentiated tumors. As advancements in molecular testing have led to a better understanding of tumor biology, it has become increasingly evident that SNUC may actually encompass several tumor subtypes with different clinical behavior. As a result, it is also likely that all SNUC patients cannot be treated in the same fashion. Recent investigations have identified loss of the tumor suppressor (INI1) expression in a subset of undifferentiated sinonasal tumors and extrasinonasal tumors and, studies have suggested that this genetic aberration may be a poor prognostic marker. The objective of this study was to identify differential expression of in SNUC and to analyze and compare the survival outcomes in SNUC patients with and without expression.  All cases of undifferentiated or poorly differentiated neoplasms of the sinonasal tract treated between 2007 and 2018 at a single tertiary care institution were selected. All cases of SNUC were tested for status by immunohistochemistry (IHC). Clinical parameters were analyzed using Student's -test and Fischer's test. Kaplan-Meier methods were used to estimate survival durations, while comparison between both the subgroups was done using the log-rank test. Statistical analysis was performed with the use of SPSS software, Version 25 (IBM, New York, NY, United States).  Fourteen cases of SNUC were identified. Approximately two-thirds (64%;  = 9) of patients were male and the majority (79%;  = 11) were between fifth to seventh decade. Skull base and orbital invasion were seen in 79% (  = 11) and 93% (  = 13) of cases, respectively. Fifty-seven percent of tumors (  = 8) retained expression by IHC (SR-SNUC), while the remaining 43% (  = 6) showed loss of expression and, thus, were considered as -deficient (SD-SNUC). Although clinicopathological features and treatment modalities were similar, SD-SNUC showed poorer (OS:  = 0.07; disease free survival [DFS]:  = 0.02) overall survival (OS) and DFS on Kaplan-Meier curves. Additionally, SD-SNUC showed higher recurrence (75 vs. 17%) and mortality (67 vs. 14%) (hazard rate = 8.562;  = 0.05) rates. Both OS (28.82 ± 31.15 vs. 53.24 ± 37.50) and DFS durations (10.62 ± 10.26 vs. 43.79 ± 40.97) were consistently worse for SD-SNUC. Five-year survival probabilities were lower for SD-SNUC (0.33 vs. 0.85).  SNUC represents a heterogeneous group of undifferentiated sinonasal malignancies. Based on the status of expression, the two subgroups SD-SNUC and SR-SNUC appear to represent distinct clinical entities, with loss of expression conferring an overall worse prognosis.
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http://dx.doi.org/10.1055/s-0039-1693659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755502PMC
December 2020

Preoperative Screening for Obstructive Sleep Apnea Prior to Endoscopic Skull Base Surgery: A Survey of the North American Skull Base Society.

Allergy Rhinol (Providence) 2020 Jan-Dec;11:2152656720968801. Epub 2020 Nov 12.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: Obstructive sleep apnea (OSA) is a commonly seen comorbidity in patients undergoing endoscopic skull base surgery and its presence may influence perioperative decision-making. Current practice patterns for preoperative screening of OSA are poorly understood.

Objective: The objective of this study was to assess how endoscopic skull base surgeons screen for OSA, and how knowledge of OSA affects perioperative decision-making.

Methods: Seven question survey distributed to members of the North American Skull Base Society.

Results: Eighty-eight responses (10% response rate) were received. 60% of respondents were from academic centers who personally performed >50 cases per year. Most respondents noted that preoperative knowledge of OSA and its severity affected postoperative care and increased their concern for complications. Half of respondents noted that preoperative knowledge of OSA and its severity affects intraoperative skull base reconstruction decision-making. 70% of respondents did not have a preoperative OSA screening protocol. Body mass index and patient history were most frequently used by those who screened. Validated screening questionnaires were rarely used. 76% of respondents agreed or somewhat agreed that a preoperative polysomnogram should ideally be performed for patients with suspected OSA; however, 50% of respondents reported that <20% of their patients with suspected OSA are advised to obtain a preoperative polysomnogram.

Conclusion: This study reveals that most endoscopic skull base surgeons agree that OSA affects postoperative patient care, but only a minority have a preoperative screening protocol in place. Additional study is needed to assess the most appropriate screening methods and protocols for OSA patients undergoing endoscopic skull base surgery.
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http://dx.doi.org/10.1177/2152656720968801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672726PMC
November 2020

Tolerance of Continuous Positive Airway Pressure After Sinonasal Surgery.

Laryngoscope 2021 03 16;131(3):E1013-E1018. Epub 2020 Sep 16.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: For patients with obstructive sleep apnea (OSA) undergoing sinonasal surgery, there is a lack of consensus on the risk and appropriate postoperative use of continuous positive airway pressure (CPAP). The aim of this study was to assess the tolerability of restarting CPAP on postoperative day one.

Study Design: Prospective cohort study.

Methods: A prospective study on patients with OSA on CPAP who required a septoplasty/turbinectomy and/or functional endoscopic sinus surgery (FESS) was performed. Data from the memory card of a patient's CPAP machine and subjective information were obtained on the day of surgery and at scheduled follow-up visits. All subjects were instructed to restart CPAP on the first postoperative night.

Results: A total of 14 patients were analyzed; nine underwent FESS and five had a septoplasty/turbinectomy. There were no postoperative complications encountered. The only significant change in the first postoperative week was a reduction in the percentage of nights used over 4 hours (P < .05). By the third postoperative visit, average 22-item Sino-Nasal Outcome Test, Nasal Obstruction Symptom Evaluation, and CPAP tolerance scores improved from preoperative values. CPAP pressures, residual apnea-hypopnea index, and number of hours and mean percentage of nights used remained stable throughout the study period.

Conclusions: Both quality-of-life and CPAP outcomes improved or remained the same when restarting CPAP immediately postoperatively. Combined with a lack of significant complications, this study suggests that CPAP is well-tolerated when restarted the day after a septoplasty/turbinectomy or FESS.

Level Of Evidence: 4 Laryngoscope, 131:E1013-E1018, 2021.
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http://dx.doi.org/10.1002/lary.28968DOI Listing
March 2021

Quantitative determination of the optimal temporoparietal fascia flap necessary to repair skull-base defects.

Int Forum Allergy Rhinol 2020 11 7;10(11):1249-1254. Epub 2020 Jul 7.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: The ability to reconstruct large cranial base defects has greatly improved with the development of pedicled vascularized flaps. The temporoparietal fascia flap (TPFF) is a viable alternative to the Hadad-Bassagasteguy nasoseptal flap for large ventral skull-base defects. This study aims to characterize the size of the TPFF necessary for optimal ventral skull-base reconstruction.

Methods: Eleven formaldehyde-fixed cadaveric heads were used to harvest TPFF of varying heights on each side (total = 22). TPFF was passed through the pterygomaxillary fissure (PMF) to the ventral skull base to assess its coverage. For a subgroup of 12 sides, the TPFF was trimmed to determine the minimum height necessary for coverage.

Results: The TPFF height was (mean ± standard deviation [SD]) 14.72 ± 1.02 cm (range, 12.5 to 16.5 cm) and width was 8.43 ± 1.05 cm (range, 6 to 10.5 cm). The distance from the TPFF pedicle through the PMF was 5.8 ± 0.5 cm (range, 5 to 6.5 cm). All TPFF flaps provided complete ipsilateral coverage of clival defects, and all but 1 covered the entire clivus. All TPFF flaps, when rotated anteriorly, provided coverage up to the cribriform plate. The minimum TPFF height necessary for complete coverage of cribriform defects and ventral defects up to the planum sphenoidale was 12 cm. TPFF height for specimens with and without complete ventral skull-base coverage was significantly different (p < 0.0001).

Conclusion: The TPFF is a versatile alternative to the nasoseptal flap and a height of at least 12 cm can provide enough coverage for all ventral skull base defects.
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http://dx.doi.org/10.1002/alr.22609DOI Listing
November 2020

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma.

Int Forum Allergy Rhinol 2020 06 3;10(6):785-790. Epub 2020 May 3.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas.

Methods: A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586).

Results: The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis.

Conclusion: For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).
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http://dx.doi.org/10.1002/alr.22540DOI Listing
June 2020

Qualitative Assessment of the Effect of Continuous Positive Airway Pressure on the Nasal Cavity.

Am J Rhinol Allergy 2020 Jul 26;34(4):487-493. Epub 2020 Feb 26.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: For patients with obstructive sleep apnea (OSA), there is a lack of knowledge regarding the impact of continuous positive airway pressure (CPAP) on the nasal cavity. There is a significant need for evidence-based recommendations regarding the appropriate use of CPAP following endoscopic sinus and skull base surgery.

Objective: The goal of this study is to translate a previously developed cadaveric model for evaluating CPAP pressures in the sinonasal cavity by showing safety in vivo and quantifying the effect of positive pressurized air flow on the nasal cavity of healthy individuals where physiologic effects are at play.

Methods: A previously validated cadaveric model using intracranial sensor catheters has proved to be a reliable technique for measuring sinonasal pressures. These sensors were placed in the nasal cavity of 18 healthy individuals. Pressure within the nose was recorded at increasing levels of CPAP.

Results: Overall, nasal cavity pressure was on average 85% of delivered CPAP. The amount of pressure delivered to the nasal cavity increased as the CPAP increased. The percentage of CPAP delivered was 77% for 5 cmHO and increased to 89% at 20 cmHO. There was a significant difference in mean intranasal pressures between all the levels of CPAP except 5 cmHO and 8 cmHO ( < .001).

Conclusion: On average, only 85% of the pressure delivered by CPAP is transmitted to the nasal cavity. Higher CPAP pressures delivered a greater percentage of pressurized air to the nasal cavity floor. Our results are comparable to the cadaver model, which demonstrated similar pressure delivery even in the absence of anatomic factors such as lung compliance, nasal secretions, and edema. This study demonstrates the safety of using sensors in the human nasal cavity. This technology can also be utilized to evaluate the resiliency of various repair techniques for endoscopic skull base surgery with CPAP administration.
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http://dx.doi.org/10.1177/1945892420908749DOI Listing
July 2020

Management and Surveillance of Frontal Sinus Violation following Craniotomy.

J Neurol Surg B Skull Base 2020 Feb 21;81(1):1-7. Epub 2019 Jan 21.

Department of Otolaryngology and Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.

 In the setting of craniotomy, complications after traversing the frontal sinus can lead to mucocele formation and frontal sinusitis. We review the etiology of frontal sinus violation, timeline to mucocele development, intraoperative management of the violated sinus, and treatment of frontal mucoceles.  Case series in conjunction with a literature review.  A total of 35 patients were included in this meta-analysis. Nine of these patients were treated at a tertiary academic medical center between 2005 and 2014. The remaining patients were identified through a literature review for which 2,763 articles were identified, of which 4 articles met inclusion criteria.  Etiology of frontal violation, timeline to mucocele development, and method of management.  The overall interval from initial frontal sinus violation until mucocele identification was 14.5 years, with a range of 3 months to 36 years. The most common cause of mucocele formation was obstruction of the frontal recess with incomplete removal of the frontal sinus mucosa. The majority of patients were successfully managed with an endoscopic endonasal approach.  Violation of the frontal sinus during craniotomy can result in mucocele formation as an early or late sequela. Image guidance may help avoid unnecessary frontal sinus violation. Mucoceles may develop decades after the initial frontal sinus violation, and long-term follow-up with imaging is recommended. While the endoscopic endonasal approach is usually the preferred method to treat these lesions, it may be necessary to perform obliteration or cranialization in unique situations.
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http://dx.doi.org/10.1055/s-0038-1676826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6997004PMC
February 2020

Management of Orbital Masses: Outcomes of Endoscopic and Combined Approaches With No Orbital Reconstruction.

Allergy Rhinol (Providence) 2020 Jan-Dec;11:2152656719899922. Epub 2020 Jan 14.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Introduction: The endoscopic endonasal approach to management of orbital pathology has expanded. Due to the rarity of these conditions, most reports in the literature consist of small case reports. We report a series from a single institution with a focus on outcomes.

Methods: A retrospective chart review was carried out between 2010 and 2018.

Results: Twenty-four patients were identified (average age 58 years, 15 males, 9 females). Average follow-up was 14.9 months. Most common etiologies included cavernous hemangioma (7), metastases (6), idiopathic orbital inflammatory syndrome (6), orbital hematoma/clot (2), and schwannoma (1). Most common presenting symptoms were decreased visual acuity (8), proptosis (8), diplopia (7), and incidental findings (2). All patients underwent endoscopic medial wall orbital decompressions. Sixteen involved a combined open approach by an ophthalmologist. Pathology was either biopsied (15), resected (6), or could not be identified (3). No intraoperative complications were noted. No patients underwent orbital reconstruction of the medial wall. Six patients developed postoperative sinusitis successfully managed with antibiotics. One patient developed epistaxis managed conservatively. In 5 patients, Sino-Nasal Outcome Test-22 scores increased immediately postop and then decreased, whereas scores only decreased in 6 patients. Six patients noted reduced proptosis. There were no new cases of diplopia or worsening visual acuity.

Conclusions: A combined endoscopic endonasal and external approach can be useful for managing orbital lesions. Patients tolerated the procedure well with improvement in ocular symptoms and minimal sinonasal complications. Reconstruction of the medial wall may not be warranted to prevent postoperative diplopia.
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http://dx.doi.org/10.1177/2152656719899922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6961138PMC
January 2020

Rate of rhinosinusitis and sinus surgery following a minimally destructive approach to endoscopic transsphenoidal hypophysectomy.

Int Forum Allergy Rhinol 2020 03 25;10(3):405-411. Epub 2019 Nov 25.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: There remains considerable variation in the extent of sinonasal preservation during the approach for endoscopic transsphenoidal hypophysectomy (TSH). We advocate for a minimally destructive approach utilizing turbinate lateralization, small posterior septectomy, no ethmoidectomy, and preservation of nasoseptal flap (NSF) pedicles bilaterally. Due to these factors, this approach may affect the rates of postoperative rhinosinusitis. The objective of this study is to define the rates of postoperative rhinosinusitis in patients undergoing this approach.

Methods: Single institution, retrospective chart review of patients undergoing TSH from 2005 to 2018.

Results: A total of 415 patients were identified and 14% developed an episode of postoperative rhinosinusitis within 3 months. These patients were significantly more likely to have had a history of recurrent acute or chronic rhinosinusitis. Most cases were sphenoethmoidal sinusitis managed with 1 to 2 courses of antibiotics. Of patients with postoperative rhinosinusitis, most did not undergo NSF. Average follow-up was 38 months. Six patients (1.4%) underwent post-TSH functional endoscopic sinus surgery (FESS). Average time from TSH to FESS was 26.3 months. Two of these patients had a history of prior chronic rhinosinusitis without polyposis. Two patients underwent revision TSH for recurrent tumor as the primary indication for surgery at time of FESS. Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores generally increased immediately postoperatively, but frequently decreased below preoperative level by the time of last follow-up, regardless of whether patients developed rhinosinusitis.

Conclusion: Sinonasal preservation during TSH is associated with a low rate of postoperative rhinosinusitis requiring FESS and excellent long-term patient reported outcomes. We continue to advocate for sinonasal preservation during pituitary surgery.
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http://dx.doi.org/10.1002/alr.22482DOI Listing
March 2020

Management of Nonfunctioning Recurrent Pituitary Adenomas.

Neurosurg Clin N Am 2019 Oct 7;30(4):473-482. Epub 2019 Aug 7.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Pituitary adenomas are typically slow-growing benign tumors. However, 50% to 60% of tumors progress following subtotal resection and up to 30% recur after apparent complete resection. Options for treatment of recurrent pituitary adenomas include repeat surgical resection, radiation therapy, and systemic therapies. There is no consensus approach for the management of recurrent pituitary adenomas. This article reviews the natural history of recurrent adenomas and emerging biomarkers predictive of clinical behavior as well as the outcomes associated with the various treatment modalities for these challenging tumors, with an emphasis on the surgical treatment.
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http://dx.doi.org/10.1016/j.nec.2019.05.006DOI Listing
October 2019

Adenosine-induced transient hypotension for carotid artery injury during endoscopic skull-base surgery: case report and review of the literature.

Int Forum Allergy Rhinol 2019 09 10;9(9):1023-1029. Epub 2019 Jul 10.

Department of Neurosurgery and Neurological Sciences, Thomas Jefferson University Hospitals, Philadelphia, PA.

Background: As the management of ventral skull-base pathology has transitioned from open to endonasal treatment, there has been an increased focus on the prevention and endoscopic endonasal management of internal carotid artery (ICA) and major vascular injury. The use of adenosine to induce transient hypotension or flow arrest has been previously described during intracranial aneurysm surgery; however, there have been no reports of the technique being used during endonasal skull-base surgery to achieve hemostasis following major vascular injury.

Methods: Case report (n = 1) and literature review.

Results: A 25-year-old female underwent attempted endoscopic endonasal resection of an advanced right-sided chondrosarcoma. During resection of the tumor, brisk arterial bleeding was encountered consistent with focal injury to the right cavernous ICA. Stable vascular hemostasis could not be achieved with tamponade. An intravenous bolus dose of adenosine was administered to induce a transient decrease in systemic blood pressure and facilitate placement of the muscle patch over the direct site of vascular injury. The patient subsequently underwent endovascular deconstruction of the right ICA.

Conclusion: This is the first reported use of adenosine to induce transient hypotension for a major vascular injury sustained during endonasal skull-base surgery. Based on well-established safety data from neurosurgical application, adenosine has the potential to be used as a safe and effective adjunctive technique in similar endonasal circumstances and may represent an additional tool in the armamentarium of the skull-base surgeon. Surgeons should consider having adenosine available when a risk of ICA injury is anticipated.
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http://dx.doi.org/10.1002/alr.22381DOI Listing
September 2019

Evaluation of cranial base repair techniques utilizing a novel cadaveric CPAP model.

Int Forum Allergy Rhinol 2019 07 12;9(7):795-803. Epub 2019 Feb 12.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Although recent guidelines for obstructive sleep apnea recommend early postoperative use of continuous positive airway pressure (CPAP) after endonasal skull base surgery, the time of initiation of CPAP is unclear. In this study we used a novel, previously validated cadaveric model to analyze the pressures delivered to the cranial base and evaluate the effectiveness of various repair techniques to withstand positive pressure.

Methods: Skull base defects were surgically created in 3 fresh human cadaver heads and repaired using 3 commonly used repair techniques: (1) Surgicel™ onlay; (2) dural substitute underlay with dural sealant onlay; and (3) dural substitute underlay with nasoseptal flap onlay with dural sealant. Pressure microsensors were placed in the sphenoid sinus and sella, both proximal and distal to the repair, respectively. The effectiveness of each repair technique against various CPAP pressure settings (5-20 cm H O) was analyzed.

Results: Approximately 79%-95% of positive pressure administered reached the sphenoid sinus. Sellar pressure levels varied significantly across the 3 repair techniques and were lowest after the third technique. "Breach" points (CPAP settings at which sellar repair was violated) were lowest for the first group. All 3 specimens showed a breach after the first repair technique. For the second repair technique, only a single breach was created in 1 specimen at 20 cm H O. No breaches were created in the third group.

Conclusion: Different skull base repair techniques have varying ability to withstand CPAP. Both second and third repair techniques performed in a nearly similar fashion with regard to their ability to withstand positive pressure ventilation.
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http://dx.doi.org/10.1002/alr.22313DOI Listing
July 2019

The Role of Free Tissue Transfer in the Management of Chronic Frontal Sinus Osteomyelitis.

Laryngoscope 2019 07 14;129(7):1497-1504. Epub 2018 Dec 14.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Objectives/hypothesis: Chronic frontal sinus infection is managed with a combination of medical and surgical interventions. Frontal bone osteomyelitis due to recurrent infection following trauma or prior open surgery may require more significant debridement. Free tissue transfer may allow for extensive debridement with replacement of tissue, and definitive eradication of osteomyelitis.

Study Design: Retrospective chart review.

Methods: Patients undergoing free flap obliteration of the frontal sinus for frontal bone osteomyelitis at a single institution were included in the study. Clinical, radiologic, and surgical data were collected. Surgeries before and after free flap obliteration were compared by Wilcoxon signed rank test.

Results: Fifteen patients were identified; however, one patient had less than 6 months of follow-up and was excluded from analysis. Of the remaining 14 patients, mean follow-up duration was 26 months (range, 6-120 months). Mean number of surgeries prior to free flap was 3.7 (range, 1-8 surgeries). Free flap obliteration resolved chronic frontal sinusitis in all patients. Two patients experienced postoperative infection, and the overall complication rate was 29%. Eight patients underwent cranioplasty (six immediate, two delayed) without complication. All patients received planned courses of postoperative antibiotics. A statistically significant decrease in the number of surgeries after free flap obliteration was observed P ≤ .01).

Conclusions: Extensive debridement followed by free tissue transfer and antibiotics offers a definitive treatment for complicated, recurrent frontal osteomyelitis. Simultaneous cranioplasty provides immediate protective and aesthetic benefit without complication. Consideration should be given for free tissue transfer and cranioplasty earlier in the algorithm for treatment of refractory frontal sinus osteomyelitis.

Level Of Evidence: 4 Laryngoscope, 129:1497-1504, 2019.
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http://dx.doi.org/10.1002/lary.27669DOI Listing
July 2019

A cadaveric model for measuring sinonasal continuous positive airway pressure-a proof-of-concept study.

Int Forum Allergy Rhinol 2019 02 15;9(2):197-203. Epub 2018 Nov 15.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Obstructive sleep apnea is a common respiratory disorder that can have negative effects on health and quality of life. Positive pressure therapy (CPAP) is the primary treatment. There is a lack of consensus on the risk of postoperative CPAP after endoscopic sinus or skull base surgery. We present a proof-of-concept cadaver model for measuring sinonasal pressure delivered by CPAP.

Methods: Three fresh cadaver heads were prepared by removing the calvaria and brain. Sphenoidotomies were made and sellar bone was removed. Pressure sensors were placed in the midnasal cavity, sphenoid sinus, and sella. CPAP was applied and the delivered pressure was recorded at increasing levels of positive pressure. Paired t tests and intraclass correlation coefficients were used to analyze results.

Results: Increases in positive pressure led to increased pressure recordings for all locations. Nasal cavity pressure was, on average, 81% of delivered CPAP. Pressure was highest in the sphenoid sinus. The effect of middle turbinate medialization on intrasphenoid pressure was not statistically significant in 2 heads. Intrasellar pressure was 80% of delivered CPAP with lateralized turbinates and 84% with medialized turbinates. Pressure recordings demonstrated excellent reliability for all locations. All heads developed non-sellar-based cranial base leaks at higher pressures. Cribriform region leaks were successfully sealed with DuraSeal®.

Conclusion: Our proof-of-concept cadaver model represents a novel approach to measure pressures delivered to the nasal cavity and anterior skull base by CPAP. With further study, it may have broader clinical application to guide the safe postoperative use of CPAP in this population.
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http://dx.doi.org/10.1002/alr.22235DOI Listing
February 2019

A case of concurrent silent sinus syndrome, thyroid eye disease, idiopathic orbital inflammatory syndrome, and dacryoadenitis.

Orbit 2017 Dec 16;36(6):462-464. Epub 2017 Aug 16.

c Oculoplastic and Orbital Surgery Service , Wills Eye Hospital , Philadelphia , Pennsylvania , USA.

This is a retrospective case description of a single female patient found to have concomitant bilateral silent sinus syndrome, bilateral thyroid eye disease, unilateral dacryoadenitis, and idiopathic orbital inflammation that presented as progressive unilateral right-sided proptosis. The spectrum of inflammatory orbital diseases can make discerning between different entities challenging, but more unique in this case was the simultaneous presentation with bilateral silent sinus syndrome, a rare entity in its own right. Identifying each of these concurrent disease processes is important to establishing a multidisciplinary treatment approach to address all the patient's orbital and peri-orbital pathology. We hope to highlight the clinical and radiographic findings unique to each of these entities and share our approach to treatment in this complex case.
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http://dx.doi.org/10.1080/01676830.2017.1337194DOI Listing
December 2017

Paranasal sinus lymphoma: Retrospective review with focus on clinical features, histopathology, prognosis, and relationship to systemic lymphoma.

Head Neck 2017 06 24;39(6):1065-1070. Epub 2017 Mar 24.

Department of Oculoplastic and Orbital Surgery, Wills Eye Hospital, Philadelphia, Pennsylvania.

Background: Paranasal sinus lymphoma is a rare clinical entity.

Methods: We conducted a retrospective case series of 68 patients with biopsy-confirmed paranasal sinus lymphoma with attention on systemic disease association.

Results: Of 63 patients with paranasal sinus lymphoma, 35 (56%) had systemic involvement. Four patient groups were identified: (1) primary paranasal sinus lymphoma (44%); (2) systemic disease occurring concurrently with paranasal sinus lymphoma (25%); (3) paranasal sinus lymphoma with relapse of preexisting systemic lymphoma (22%); and (4) progression to systemic disease after primary paranasal sinus lymphoma (8%). Most of the patients with systemic disease were diagnosed at 50 + years and had positive smoking histories. There was a trend toward disease activity in the neighboring ocular location. For patients with preexisting systemic lymphoma, the mean time to paranasal sinus lymphoma was 65 months. When systemic lymphoma developed after localized paranasal sinus lymphoma, mean time to progression was 23 months. Diffuse large B cell lymphoma was the most common paranasal sinus lymphoma.

Conclusion: There is a risk of systemic involvement during the disease course of paranasal sinus lymphoma. Biopsy is the preferred first management step and should precede debulking or mass resection in nonemergent cases. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1065-1070, 2017.
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http://dx.doi.org/10.1002/hed.24686DOI Listing
June 2017

Update on nonmalignant lesions of the inferior turbinate.

Curr Opin Otolaryngol Head Neck Surg 2017 Feb;25(1):69-72

Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Purpose Of Review: The inferior turbinates are routinely examined by otolaryngologists on anterior rhinoscopy and nasal endoscopy. Most lesions of the inferior turbinate are benign but can often be confused with malignancy. This review highlights the broad differential of nonmalignant lesions of the inferior turbinates and their management.

Recent Findings: A variety of infectious, inflammatory, neoplastic, and vascular lesions may affect the inferior turbinates. The most common nonmalignant lesions of the sinonasal region are nasal polyps, inverted papillomas, hemangiomas, and angiofibromas. Early lesions are often asymptomatic and discovered incidentally on routine examination. As these lesions grow they present with nonspecific signs that can be seen in benign, malignant, and infectious etiologies. The most common signs and symptoms are nasal obstruction, rhinorrhea, epistaxis, sinusitis, and hyposmia. Most nonmalignant lesions have characteristic appearances but definitive diagnosis is achieved with biopsy or culture. If the lesions are small the biopsy itself is often curative.

Summary: Lesions of the inferior turbinates are rarely isolated to these structures alone. Careful examination can noninvasively assist in early diagnosis of extensive lesions. Once malignancy and processes such as invasive fungal sinusitis or inverted papillomas have been ruled out, treatment of these lesions is ordinarily noncomplicated and definitive.
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http://dx.doi.org/10.1097/MOO.0000000000000325DOI Listing
February 2017

Head and Neck Manifestations of Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review.

Otolaryngol Head Neck Surg 2016 11 28;155(5):771-778. Epub 2016 Jun 28.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: To conduct the first and only systematic review of the existing literature on head and neck manifestations of eosinophilic granulomatosis with polyangiitis to guide clinical decision making for the otolaryngologist.

Data Sources: PubMed, Cochrane Library, Scopus, and LILACS.

Review Methods: A systematic review of the aforementioned sources was conducted per the PRISMA guidelines.

Results: From an initial 574 studies, 28 trials and reports were included, accounting for a total of 1175 patients with eosinophilic granulomatosis with polyangiitis. Among clinical and cohort studies, 48.0% to 96.0% of all included patients presented with head and neck manifestations. In a distinct group of patients detailed in case reports describing patients presenting with head and neck manifestations, patients on average fulfilled 4.6 diagnostic criteria per the American College of Rheumatology. Furthermore, 95.8% of reported cases were responsive to steroids, and 60% required additional therapy.

Conclusion: Otolaryngologists are in a unique position for the early diagnosis and prevention of late complications of eosinophilic granulomatosis with polyangiitis. The American College of Rheumatology criteria should be relied on in the diagnostic workup. Close surveillance of these patients in a multidisciplinary fashion and with baseline complete blood counts, chest radiographs, and autoimmune laboratory tests is often necessary. Such patients with head and neck manifestations of the disease are nearly always responsive to steroids and often require additional immunosuppressive therapy or surgical intervention in cases of cranial neuropathies, temporal bone involvement, and refractory symptoms.
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http://dx.doi.org/10.1177/0194599816657044DOI Listing
November 2016

Sinonasal malignancy: What to do with an unexpected pathology result?

Am J Otolaryngol 2016 Sep-Oct;37(5):473-6. Epub 2016 May 4.

Thomas Jefferson University Hospital, Department of Otolaryngology-Head and Neck Surgery, Philadelphia, PA.

Background: Endoscopic sinus surgery has become the mainstay in surgical treatment of sinusitis and nasal polyps. While rare, diagnostic discrepancies or pathological contamination during routine specimen analysis has been described. Thus, an accurate diagnosis and indication for surgery are mandatory before proceeding with surgical intervention.

Methods: We present the case of a 40-year-old female patient who underwent endoscopic sinus surgery (ESS) for chronic sinusitis without nasal polyposis and fragments of squamous cell carcinoma (SCC) were found in the pathology specimen.

Results: We propose an algorithm to help guide physicians presented with a tissue diagnosis that does not match the clinical scenario. Moreover, we discuss strategies to help prevent medical errors and the importance of DNA genetic analysis in this situation.

Conclusion: When an unexpected diagnosis occurs, the pathology slides should be reviewed for a second opinion. If the unexpected diagnosis is confirmed, the tissue should undergo STR genetic analysis to ensure against tissue contamination.
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http://dx.doi.org/10.1016/j.amjoto.2016.04.003DOI Listing
March 2017

Bordetella petrii recovered from chronic pansinusitis in an adult with cystic fibrosis.

IDCases 2015 26;2(4):97-8. Epub 2015 Sep 26.

Department of Pathology, Anatomy and Cell Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Pavilion Building, Suite 207, Philadelphia, PA 19107, USA.

To date Bordetella petrii has infrequently been identified within the clinical setting likely due to the asaccharolytic nature of this organism. We present a case of B. petrii recovered on two separate events in a patient with adult cystic fibrosis experiencing chronic pansinusitis.
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http://dx.doi.org/10.1016/j.idcr.2015.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4712203PMC
January 2016

Principles of Pituitary Surgery.

Otolaryngol Clin North Am 2016 Feb;49(1):95-106

Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, PA 19107, USA.

Since the description of a transnasal approach for treatment of pituitary tumors, transsphenoidal surgery has undergone continuous development. Hirsch developed a lateral endonasal approach before simplifying it to a transseptal approach. Cushing approached pituitary tumors using a transsphenoidal approach but transitioned to the transcranial route. Transsphenoidal surgery was not "rediscovered" until Hardy introduced the surgical microscope. An endoscopic transsphenoidal approach for pituitary tumors has been reported and further advanced. We describe the principles of pituitary surgery including the key elements of surgical decision making and discuss the technical nuances distinguishing the endoscopic from the microscopic approach.
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http://dx.doi.org/10.1016/j.otc.2015.09.005DOI Listing
February 2016

Surgical management of rhinosinusitis in endoscopic-endonasal skull-base surgery.

Int Forum Allergy Rhinol 2015 Apr 12;5(4):339-43. Epub 2015 Feb 12.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA.

Background: Endoscopic-endonasal skull base surgery (ESBS) provides an important approach to select pathologies. There remains a paucity of data, however, regarding morbidity in patients undergoing ESBS with comorbid acute rhinosinusitis (ARS), a fungal ball (FB), or chronic rhinosinusitis (CRS).

Methods: A retrospective database review between January 2008 and January 2013 identified 35 patients with concurrent skull-base pathology and refractory ARS, FB, CRS, and CRS with nasal polyposis (CRSP) who underwent endoscopic sinus surgery (ESS) and ESBS.

Results: Two of 35 (5.7%) had an FB, 3 of 35 (8.6%) had ARS, 19 of 35 (54.2%) had CRSP, and 11 of 35 (31.4%) had CRS. Five of 35 (14.3%) were staged procedures whereas 30 of 35 (85.7%) underwent concurrent ESS and ESBS. Four patients (80%) who were staged carried diagnoses of an FB and ARS. Two patients in the concurrent group required revision ESS for recurrent polyposis. There were no cases of intraorbital or intracranial infectious complications.

Conclusion: Management of the paranasal sinuses is paramount to maintain healthy sinonasal function in patients undergoing ESBS. In our experience, most cases of CRS and CRSP can be surgically managed at the time of ESBS without increased risk of intracranial infection. Patients with ARS at the time of surgery or an FB should be staged to avoid postoperative ESBS morbidity.
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http://dx.doi.org/10.1002/alr.21476DOI Listing
April 2015

Perforation of a nasoseptal flap does not increase the rate of postoperative cerebrospinal fluid leak.

Int Forum Allergy Rhinol 2015 Apr 26;5(4):353-5. Epub 2015 Jan 26.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, PA.

Background: The nasoseptal flap (NSF) has been shown to be a valuable addition to the reconstructive armamentarium of the endoscopic skull-base surgeon. We aimed to evaluate the rate of postoperative cerebrospinal fluid (CSF) leak after use of a NSF that had a small tear during harvest.

Methods: After Institutional Review Board (IRB) approval, we analyzed our database of patients undergoing skull-base resection. We included all patients who had a NSF reconstruction, septoplasty, and/or spur on preoperative computed tomography (CT) imaging. We then evaluated video of each procedure to determine if a tear occurred in the NSF during harvest. Patient records were reviewed to determine if a postoperative CSF leak occurred.

Results: We evaluated video of 21 patients who underwent a skull-base resection, were reconstructed with a NSF, and had either a septoplasty or evidence of a septal spur on CT imaging. Of these 21 cases, 11 small tears occurred during harvest of the NSF flap and none of the patients with a torn NSF had a postoperative CSF leak.

Conclusion: Our series shows a 0% postoperative CSF leak rate in patients undergoing skull-base reconstruction with a NSF that was torn during harvest. Small tears in the NSF do not seem to affect postoperative CSF leak rates.
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http://dx.doi.org/10.1002/alr.21480DOI Listing
April 2015

Comprehensive management of the paranasal sinuses in patients undergoing endoscopic endonasal skull base surgery.

World Neurosurg 2014 Dec;82(6 Suppl):S54-8

Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: The endonasal route often provides the most direct and safe approach to skull base pathology. In this article we review the literature with regard to management of the paranasal sinuses in the setting of skull base surgery.

Methods: We describe our institutional experience and review the literature of concurrent management of the sinusitis in patients undergoing endoscopic skull base surgery.

Results: Patients should be optimized preoperatively to ensure the endonasal route is a safe corridor to enter the intracranial cavity. Often the paranasal sinuses can be surgically addressed at the same time as endoscopic skull base surgery. We describe the technical details of management of the paranasal sinuses when addressing skull base pathology.

Conclusions: Careful management of the paranasal sinuses throughout the peri-operative course is paramount to optimizing sinonasal function and safety.
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http://dx.doi.org/10.1016/j.wneu.2014.07.027DOI Listing
December 2014

Surgical pathway seeding of clivo-cervical chordomas.

J Neurol Surg Rep 2014 Dec 12;75(2):e246-50. Epub 2014 Nov 12.

Division of Neuro-Oncologic Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States.

Unlabelled: Objective Clival chordomas are slow-growing aggressive tumors that originate from the extra-axial remnants of the notochord. Current management of these tumors use surgical resection combined with radiation therapy. Given the location and invasive nature of these tumors, complete resection is difficult. A variety of both open and endoscopic therapeutic approaches have evolved and combined with the improvements in proton therapy, long-term control of these tumors appears to be improving. However, in recent literature the relatively rare complication of surgical seeding or surgical pathway recurrence has been reported. We report a case of surgical seeding following primary resection and review the world literature regarding surgical pathway recurrence. Study Design Retrospective chart review and review of current literature. Methods We report a case of a patient with a large chordoma that required treatment with a staged endoscopic endonasal and external transcervical approach. The patient subsequently developed recurrent disease along the cervical skin incision due to surgical seeding. Literature review and case reports were identified by a comprehensive search of Medline for the years 1950 to 2012. Results The overall surgical pathway recurrence rate for clival chordoma resection based on analysis of the open nonendoscopic published case studies was 14 of 497 (2.8%). Conclusion Tumor seeding can occur anywhere along the operative route and is often outside the field of radiotherapy. Increased awareness of this rare occurrence is necessary. The use of novel techniques to minimize exposure to tumor including primary endoscopic resection and so-called clean oncologic technique may help limit tumor seeding.

Level Of Evidence: 4.
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http://dx.doi.org/10.1055/s-0034-1387184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242824PMC
December 2014

Septal transposition: a novel technique for preservation of the nasal septum during endoscopic endonasal resection of olfactory groove meningiomas.

Neurosurg Focus 2014 ;37(4):E6

Departments of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.

Endonasal resection of olfactory groove meningiomas allows for several advantages over transcranial routes, including a direct approach to the bilateral anterior cranial base and dura mater, early tumor devascularization, and avoidance of brain retraction. Although considered minimally invasive, the endoscopic approach to the cribriform plate typically requires resection of the superior nasal septum, resulting in a large superior septal perforation. The septal transposition technique improves preservation of sinonasal anatomy through the elimination of a septal perforation while allowing for wide exposure to the midline anterior cranial base and harvest of a nasal septal flap. Herein, the authors describe a 39-year-old female who presented with a progressively enlarging olfactory groove meningioma. An endoscopic endonasal resection with a septal transposition technique was performed. On follow-up, the nasal cavity had completely normal anatomy with preservation of the turbinates and nasal septum. The authors conclude that septal transposition is a useful technique that allows wide exposure of the anterior cranial base with maximal preservation of normal nasal anatomy and avoidance of a large septal perforation.
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http://dx.doi.org/10.3171/2014.7.FOCUS14308DOI Listing
June 2015

Orbital Involvement by NUT Midline Carcinoma.

Ophthalmic Plast Reconstr Surg 2015 Nov-Dec;31(6):e147-50

*Department of Otolaryngology/Head Neck Surgery, Thomas Jefferson University Hospital, Philadelphia; †Department of Ophthalmology, Geisinger Health System, Danville; ‡The Commonwealth Medical College, Scranton; §Department of Pathology; ‖Department of Neurosurgery, Thomas Jefferson University Hospital; and ¶Skull Base Division, Neuro-Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, U.S.A.

A 32-year-old female presented with a sino-orbital lesion that proved to be a NUT midline carcinoma. This is only the third case of orbital involvement by this aggressive lesion. The clinical, radiographic, and histopathologic features of NUT midline carcinoma are discussed, as well as its management options.
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http://dx.doi.org/10.1097/IOP.0000000000000179DOI Listing
June 2016