Publications by authors named "Mindy R Rabinowitz"

28 Publications

  • Page 1 of 1

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

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

Orbital Schwannoma.

J Neurol Surg B Skull Base 2020 Aug 24;81(4):376-380. Epub 2020 Aug 24.

Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, United States.

Orbital schwannomas are rare neoplasms of the orbit. The presenting symptoms are often nonspecific. Classic imaging characteristics seen on magnetic resonance imaging (MRI) and orbital ultrasound can be useful to help aid in the diagnosis of orbital schwannoma. When diagnosed, the goal of treatment is complete surgical excision. The location of the tumor within the orbit dictates which surgical approach would provide the best exposure. When complete excision is achieved, recurrence rates are very low. This article addresses the etiology, patient population, presentation, natural history, and differential diagnosis of orbital schwannomas. Imaging characteristics and histopathologic subtypes are reviewed. Treatment goals, approaches, and specialties involved in the management of these patients is discussed. Finally, a representative case is presented.
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http://dx.doi.org/10.1055/s-0040-1713935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561453PMC
August 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 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

Combined Endoscopic and External Resection of an Inverted Papilloma of the Lacrimal Sac: A Case Report and Review of the Literature.

Allergy Rhinol (Providence) 2019 Jan-Dec;10:2152656719876254. Epub 2019 Sep 16.

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

Background: Inverted papillomas (IPs) are benign, locally aggressive neoplasms with a high recurrence rate that most commonly arise from the lateral nasal wall. Rarely, IP can originate from the lacrimal sac and/or nasolacrimal duct (NLD) system. A 58-year-old man presented with chronic epiphora and an enlarging mass inferior to his left medial canthal tendon (MCT) for 2 years.

Objective: The patients' clinical presentation and surgical management are described. A literature review on IP of the lacrimal sac and NLD system was conducted.

Methods: Case report.

Results: We present a case of an IP that arose primarily from the lacrimal sac and grew below the MCT rather than extending above it. This is one of few published case reports detailing the use of a combined endoscopic and external approach for the resection of an IP of the lacrimal sac.

Conclusion: Combined endoscopic and external resection is a viable approach for complete removal of extensive IP of the lacrimal sac and NLD system. IP arising from the lacrimal sac may grow below the MCT or extend above it as previously reported.
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http://dx.doi.org/10.1177/2152656719876254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6747856PMC
September 2019

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

Endoscopic Management of Lacrimal System Dysgenesis and Dacryocystoceles in Fraser Syndrome: A Case Report and Literature Review.

Allergy Rhinol (Providence) 2018 Jan-Dec;9:2152656718804905. Epub 2018 Oct 22.

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

Background: Fraser syndrome is an autosomal recessive disorder characterized primarily by syndactyly, cryptophthalmos, urinary tract anomalies, ambiguous genitalia, and laryngeal anomalies. A 28-year-old man with Fraser syndrome presented with cryptophthalmos, microphthalmia, lacrimal system dysgenesis, and chronic sinusitis.

Objective: The patients' clinical condition and surgical treatment are described. A literature review was conducted, and articles relevant to the case are presented.

Methods: Case report.

Results: To our knowledge, this is the first published case report of endonasal management of dacryocystoceles in a Fraser syndrome patient. The patient was treated via endoscopic endonasal marsupialization and drainage.

Conclusion: Fraser syndrome patients may initially present to many different specialties as the spectrum of clinical manifestations is broad. Physicians treating these patients should take a collaborative approach to surgical and medical management.
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http://dx.doi.org/10.1177/2152656718804905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198391PMC
October 2018

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

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

Blood-Sparing Techniques in Head and Neck Surgery.

Otolaryngol Clin North Am 2016 Jun;49(3):549-62

Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA.

Given the risks and potential complications of allogenic blood transfusion (ABT), as well as the expanding population of patients for whom ABT may not be an option, it is important for the treating physician, anesthesiologist, and surgeon to be well-versed in various alternatives. A good grasp of the concepts discussed in this article will help to customize a treatment plan that is specific to each patient's underlying disease and personal preferences without compromising appropriate medical care.
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http://dx.doi.org/10.1016/j.otc.2016.02.008DOI Listing
June 2016

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

Contrast-enhanced ultrasound-guided Sentinel lymph node biopsy of the ocular conjunctiva.

Laryngoscope 2014 Nov 13;124(11):2531-6. Epub 2014 Jun 13.

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

Objectives/hypothesis: Sentinel lymph node biopsy (SLNB) has been utilized for cutaneous melanoma and other malignancies arising from the eye and ocular adnexa. Currently, SLNB requires blue dyes and/or radiopharmaceuticals; both of which have significant shortcomings. This study sought to evaluate the feasibility of SLNB with the use of real-time, contrast-enhanced ultrasound (CEUS) as an alternative technique for tumors arising in the conjunctiva.

Study Design: Prospective feasibility study in a porcine model.

Methods: Twelve experiments were performed on six non-tumor-bearing Yorkshire swine. An ultrasound contrast agent, Sonazoid (GE Healthcare, Oslo, Norway), (99m) technetium ((99m) Tc), and methylene blue (MB) (Covidien, Mansfield, MA) were injected in the ocular conjunctiva. Sentinel lymph nodes (SLNs) were localized with CEUS and findings were compared to that of MB and (99m) Tc. Fisher exact test was used.

Results: Contrast-enhanced SLNs were identified within an average of 6.2 minutes from time of injection of Sonazoid. A total of 17 SLNs were identified by at least one of the three techniques. Correlation between Sonazoid and (99m) Tc was 94.1% (16/17 SLNs). Correlation between (99m) Tc and MB was 88.2% (15/17). One SLN that was positive for (99m) Tc but negative for Sonazoid and was considered to be a false positive (1/17); findings were similar for MB (1/17). Differences between the three techniques were not significant (P = .886).

Conclusions: CEUS-guided injection of conjunctiva for SLNB is technically feasible and correlates well with standard detection techniques. This technique shows promise for rapid, real-time, intraoperative imaging for SLNB, using a widely available imaging modality and avoiding the need for radiopharmaceuticals.

Level Of Evidence: NA
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http://dx.doi.org/10.1002/lary.24789DOI Listing
November 2014

Learning Progression in the Use of Sialendoscopy for Sialolithiasis: Effect on Gland Preservation.

Otolaryngol Head Neck Surg 2014 08 8;151(2):240-5. Epub 2014 May 8.

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

Objective: Evaluate how learning progression affects outcomes for the use of sialendoscopy for sialolithiasis.

Study Design: Case series with chart review.

Setting: Academic tertiary care center.

Subjects And Methods: A retrospective chart review was conducted on 81 patients presenting with sialolithiasis between 2008 and 2012 who underwent surgical intervention on 85 salivary glands. Outcomes compared between the first 43 and subsequent 42 consecutive glands included successful removal, surgical method, and need for further intervention.

Results: For the first 43 patients (group A), mean age was 47.3 years (range, 15-77), and 44.2% were male. For the second 38 patients (group B), mean age was 49.9 (range, 23-76), and 50% were male. Mean stone size was similar in both groups; 8.3 versus 7.6 mm, respectively. In cases of stone visualization and removal, complete removal without gland excision was accomplished in 78.4% of cases in group A versus 94.3% in group B (P = .04). Endoscopic removal occurred in 24.3% of patients in group A, versus 45.8% in group B. A combined approach was used in 54.1% of patients in group A versus 48.6% in group B. In group A, 18.9% underwent gland removal as part of initial intervention versus 0% in group B (P = .007). Overall gland preservation was 81.4% in group A versus 97.6% in group B (P = .015).

Conclusion: This study documents the effect of learning curve on sialendoscopy for the management of sialolithiasis. With experience, the success of sialendoscopy increases with a significant decrease in the number of gland excisions.
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http://dx.doi.org/10.1177/0194599814533658DOI Listing
August 2014

Endoscopic ultrasonic dacryocystorhinostomy for recurrent dacryocystitis following rhinoplasty.

Aesthet Surg J 2014 May 21;34(4):520-5. Epub 2014 Mar 21.

Dr Mostovych and Dr Rabinowitz are Residents and Dr Pribitkin is a Professor in the Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Unlabelled: The lacrimal sac is the structure most vulnerable to injury when performing rhinoplastic osteotomies. When performed in a low lateral position or along the frontal process of the frontal-maxillary suture, osteotomies can potentially tear the medial canthal tendon and injure the underlying lacrimal sac, possibly resulting in dacryocystitis. In this case report, the authors discuss a case of dacryocystitis following primary rhinoplasty; this injury was repaired with endoscopic dacryocystorhinostomy (DCR) using a Sonopet ultrasonic bone aspirator (Stryker, Kalamazoo, Michigan) at a single institution. This method achieved nasolacrimal duct patency, and the patient continued to be symptom-free at an 18-month follow-up. This is the first reported case of recurrent dacryocystitis following rhinoplasty as treated by endoscopic DCR.

Level Of Evidence: 5.
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http://dx.doi.org/10.1177/1090820X14526615DOI Listing
May 2014

Recurrent epistaxis and nasal congestion.

JAMA Otolaryngol Head Neck Surg 2014 Jan;140(1):73-4

Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1001/jamaoto.2013.4532DOI Listing
January 2014

A homozygous SLITRK6 nonsense mutation is associated with progressive auditory neuropathy in humans.

Laryngoscope 2014 Mar 17;124(3):E95-103. Epub 2013 Dec 17.

Auditory Physiology and Psychoacoustics Research Laboratory, duPont Hospital for Children, Wilmington, Delaware, U.S.A.

Objectives/hypothesis: SLITRK family proteins control neurite outgrowth and regulate synaptic development. In mice, Slitrk6 plays a role in the survival and innervation of sensory neurons in the inner ear, vestibular apparatus, and retina, and also influences axial eye length. We provide the first detailed description of the auditory phenotype in humans with recessive SLITRK6 deficiency.

Study Design: Prospective observational case study.

Methods: Nine closely related Amish subjects from an endogamous Amish community of Pennsylvania underwent audiologic and vestibular testing. Single nucleotide polymorphism microarrays were used to map the chromosome locus, and Sanger sequencing or high-resolution melt analysis were used to confirm the allelic variant.

Results: All nine subjects were homozygous for a novel nonsense variant of SLITRK6 (c.1240C>T, p.Gln414Ter). Adult patients had high myopia. The 4 oldest SLITRK6 c.1240C>T homozygotes had absent ipsilateral middle ear muscle reflexes (MEMRs). Distortion product otoacoustic emissions (DPOAEs) were absent in all ears tested and the cochlear microphonic (CM) was increased in amplitude and duration in young patients and absent in the two oldest subjects. Auditory brainstem responses (ABRs) were dys-synchronised bilaterally with no reproducible waves I, III, or V at high intensities. Hearing loss and speech reception thresholds deteriorated symmetrically with age, which resulted in severe-to-profound hearing impairment by early adulthood. Vestibular evoked myogenic potentials were normal in three ears and absent in one.

Conclusion: Homozygous SLITRK6 c.1240C>T (p.Gln414Ter) nonsense mutations are associated with high myopia, cochlear dysfunction attributed to outer hair cell disease, and progressive auditory neuropathy.
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http://dx.doi.org/10.1002/lary.24361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925201PMC
March 2014

Castleman disease in the pediatric neck: a literature review.

Otolaryngol Head Neck Surg 2013 Jun 4;148(6):1028-36. Epub 2013 Mar 4.

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

Objective: To investigate the common features of cervical pediatric Castleman disease.

Data Sources: Literature review of pediatric patients with cervical Castleman disease.

Review Methods: Online medical journal databases were searched for patients aged 18 years or younger. Eighteen published studies were found, comprising 29 patients.

Conclusions: An asymptomatic or slowly enlarging neck mass was the most common presentation. No sex differences were noted. Magnetic resonance imaging demonstrates a homogeneous, isointense to slightly hyperintense T1-weighted signal and high signal intensity on T2-weighted imaging. Lymphoma was the most common differential diagnosis. All patients were treated with complete surgical excision and diagnosed as hyaline-vascular type on histology, except for 1 patient for whom histologic type was not reported. No reports of multicentric disease, plasma cell, or mixed histology were found. No recurrences were reported.

Implications For Practice: In this article, we provide the largest known literature review of pediatric patients with cervical Castleman disease. Although Castleman disease is rare, it should be considered on the differential for a pediatric neck mass, particularly when presenting with an asymptomatic posterior neck mass and equivocal workup. Fortunately, our study suggests that if diagnosed as Castleman disease, the most likely diagnosis is hyaline-vascular type, for which the long-term prognosis is good. Surgical excision is both diagnostic and therapeutic.
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http://dx.doi.org/10.1177/0194599813479931DOI Listing
June 2013