Publications by authors named "Nyall R London"

73 Publications

Long-Term Exposure to Particulate Matter Air Pollution and Chronic Rhinosinusitis in Non-Allergic Patients.

Am J Respir Crit Care Med 2021 Jun 28. Epub 2021 Jun 28.

Johns Hopkins Medicine, 1501, Otolaryngology Head and Neck Surgery, Baltimore, Maryland, United States;

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http://dx.doi.org/10.1164/rccm.202102-0368LEDOI Listing
June 2021

Endonasal access to lower cranial nerves: From foramina to upper parapharyngeal space.

Head Neck 2021 Jun 24. Epub 2021 Jun 24.

Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.

Lesions arising from the upper parapharyngeal space (UPPS) often involved the jugular foramen region (JFR), occasionally extending into the posterior cranial fossa. This study aims to investigate the surgical anatomy of the JFR and UPPS from the perspective of an expanded endoscopic approach (EEA), tracing the lower cranial nerves from their extracranial foramina to the UPPS. Six cadaveric specimens (12 sides) underwent a transpterygoid EEA to expose the JFR and UPPS. Distances from the medial pterygoid plate (MPP) to the internal carotid artery (ICA), hypoglossal canal (HC), and jugular tubercle (JT) were measured on anonymized Computed tomography angiography images previously obtained from 30 patients with pulsatile tinnitus. Full access to the JFR, and its medial, superior, and anterior aspects, could be adequately achieved via an EEA. Upon exiting the jugular foramen, the glossopharyngeal nerve courses posterior to the ICA, traveling inferiorly into the UPPS between ICA and IJV. The vagus nerve is in close proximity to the hypoglossal nerve traveling posterior to the ICA. The accessory nerve courses lateral to the vagus nerve, running posterior to the IJV. The minimal distances from the MPP to ICA, HC, and JT were 2.52 ± 0.34, 2.86 ± 0.36, and 3.18 ± 0.33 cm, respectively. This anatomical study strongly suggests the feasibility of using an EEA to access to the medial, superior, and anterior aspects of the jugular foramen and the adjacent UPPS.
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http://dx.doi.org/10.1002/hed.26781DOI Listing
June 2021

Aerodynamics Analysis of the Impact of Nasal Surgery on Patients with Obstructive Sleep Apnea and Nasal Obstruction.

ORL J Otorhinolaryngol Relat Spec 2021 May 31:1-8. Epub 2021 May 31.

Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Objective: The purpose of this study was to evaluate the effects of nasal surgery on airflow characteristics in patients with obstructive sleep apnea (OSA) by comparing the alterations of airflow characteristics within the nasal and palatopharyngeal cavities.

Methods: Thirty patients with OSA and nasal obstruction who underwent nasal surgery were enrolled. A pre- and postoperative 3-dimensional model was constructed, and alterations of airflow characteristics were assessed using the method of computational fluid dynamics. The other subjective and objective clinical indices were also assessed.

Results: By comparison with the preoperative value, all postoperative subjective symptoms statistically improved (p < 0.05), while the Apnea-Hypopnea Index (AHI) changed little (p = 0.492); the postoperative airflow velocity and pressure in both nasal and palatopharyngeal cavities, nasal and palatopharyngeal pressure differences, and total upper airway resistance statistically decreased (all p < 0.01). A significant difference was derived for correlation between the alteration of simulation metrics with subjective improvements (p < 0.05), except with the AHI (p > 0.05).

Conclusion: Nasal surgery can decrease the total resistance of the upper airway and increase the nasal airflow volume and subjective sleep quality in patients with OSA and nasal obstruction. The altered airflow characteristics might contribute to the postoperative reduction of pharyngeal collapse in a subset of OSA patients.
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http://dx.doi.org/10.1159/000516243DOI Listing
May 2021

DEK-AFF2 Carcinoma of the Sinonasal Region and Skull Base: Detailed Clinicopathologic Characterization of a Distinctive Entity.

Am J Surg Pathol 2021 May 27. Epub 2021 May 27.

Departments of Pathology Oncology Ophthalmology Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD Institute of Pathology, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital, Erlangen, Germany Department of Laboratory Medicine and Pathobiology, University of Toronto Department of Pathology & Laboratory Medicine, Mount Sinai Hospital Department of Pathology, Sunnybrook Health Sciences Centre Department of Pathology, University Health Network, Toronto, ON Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, KY Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX Department of Pathology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA Department of Head and Neck Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK.

A novel DEK-AFF2 fusion was recently reported in 4 nonkeratinizing squamous cell carcinomas of the sinonasal region and skull base, including 1 with exceptional response to immunotherapy, but it is not yet clear if this rearrangement defines a unique clinicopathologic category or represents a rare event. This study aims to characterize a larger cohort of carcinomas with DEK-AFF2 fusions to assess whether they truly constitute a distinctive entity. Among 27 sinonasal and skull base nonkeratinizing squamous cell carcinoma that were negative for human papillomavirus and Epstein-Barr virus, RNA sequencing identified DEK-AFF2 fusions in 13 cases (48%). Nine were centered in the nasal cavity, 2 in the middle ear/temporal bone, 1 in the nasopharynx, and 1 in the orbit. These tumors displayed recurrent histologic features including (1) complex endophytic and exophytic, frequently papilloma-like growth, (2) transitional epithelium with eosinophilic to amphophilic cytoplasm, (3) absent or minimal keratinization with occasional compact keratin pearls, (4) monotonous nuclei, and (5) prominent tumor-infiltrating neutrophils or stromal lymphocytes. This appearance not only overlaps with high-grade basaloid sinonasal carcinomas but also with benign papillomas and tumors reported as low-grade papillary Schneiderian carcinoma. However, DEK-AFF2 carcinomas showed frequent local recurrence, cervical lymph node metastases, and distant metastasis with 2 deaths from disease, confirming they are aggressive malignancies despite relatively bland histology. Overall, the distinctive molecular, histologic, and clinical features of DEK-AFF2 carcinomas suggest they represent a unique entity in the sinonasal region. This tumor merits increased pathologic recognition to better understand its prognostic and therapeutic implications.
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http://dx.doi.org/10.1097/PAS.0000000000001741DOI Listing
May 2021

Exposure to Particulate Matter Air Pollution and Anosmia.

JAMA Netw Open 2021 May 3;4(5):e2111606. Epub 2021 May 3.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Anosmia, the loss of the sense of smell, has profound implications for patient safety, well-being, and quality of life, and it is a predictor of patient frailty and mortality. Exposure to air pollution may be an olfactory insult that contributes to the development of anosmia.

Objective: To investigate the association between long-term exposure to particulate matter (PM) with an aerodynamic diameter of no more than 2.5 μm (PM2.5) with anosmia.

Design, Setting, And Participants: This case-control study examined individuals who presented from January 1, 2013, through December 31, 2016, at an academic medical center in Baltimore, Maryland. Case participants were diagnosed with anosmia by board-certified otolaryngologists. Control participants were selected using the nearest neighbor matching strategy for age, sex, race/ethnicity, and date of diagnosis. Data analysis was conducted from September 2020 to March 2021.

Exposures: Ambient PM2.5 levels.

Main Outcomes And Measures: Novel method to quantify ambient PM2.5 exposure levels in patients diagnosed with anosmia compared with matched control participants.

Results: A total of 2690 patients were identified with a mean (SD) age of 55.3 (16.6) years. The case group included 538 patients with anosmia (20%), and the control group included 2152 matched control participants (80%). Most of the individuals in the case and control groups were women, White patients, had overweight (BMI 25 to <30), and did not smoke (women: 339 [63.0%] and 1355 [63.0%]; White patients: 318 [59.1%] and 1343 [62.4%]; had overweight: 179 [33.3%] and 653 [30.3%]; and did not smoke: 328 [61.0%] and 1248 [58.0%]). Mean (SD) exposure to PM2.5 was significantly higher in patients with anosmia compared with healthy control participants at 12-, 24-, 36-, 60-month time points: 10.2 (1.6) μg/m3 vs 9.9 (1.9) μg/m3; 10.5 (1.7) μg/m3 vs 10.2 (1.9) μg/m3; 10.8 (1.8) μg/m3 vs 10.4 (2.0) μg/m3; and 11.0 (1.8) μg/m3 vs 10.7 (2.1) μg/m3, respectively. There was an association between elevated PM2.5 exposure level and odds of anosmia in multivariate analyses that adjusted for age, sex, race/ethnicity, body mass index, alcohol or tobacco use, and medical comorbidities (12 mo: odds ratio [OR], 1.73; 95% CI, 1.28-2.33; 24 mo: OR, 1.72; 95% CI, 1.30-2.29; 36 mo: OR, 1.69; 95% CI, 1.30-2.19; and 60 mo: OR, 1.59; 95% CI, 1.22-2.08). The association between long-term exposure to PM2.5 and the odds of developing anosmia was nonlinear, as indicated by spline analysis. For example, for 12 months of exposure to PM2.5, the odds of developing anosmia at 6.0 µg/m3 was OR 0.79 (95% CI, 0.64-0.97); at 10.0 µg/m3, OR 1.42 (95% CI, 1.10-1.82); at 15.0 µg/m3, OR 2.03 (95% CI, 1.15-3.58).

Conclusions And Relevance: In this study, long-term airborne exposure to PM2.5 was associated with anosmia. Ambient PM2.5 represents a potentially ubiquitous and modifiable risk factor for the loss of sense of smell.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.11606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8160589PMC
May 2021

Management of Multiple Head and Neck Paragangliomas With Assistance of a 3-D Model.

Ear Nose Throat J 2021 Apr 8:1455613211009441. Epub 2021 Apr 8.

Department of Otolaryngology-Head and Neck Surgery, 1500Johns Hopkins School of Medicine, Baltimore, MD, USA.

Introduction: Extirpation of multiple head and neck paragangliomas carries challenge due to close anatomic relationships with critical neurovascular bundles.

Objectives: This study aims to assess whether the application of 3-D models can assist with surgical planning and treatment of these paragangliomas, decrease surgically related morbidity and mortality.

Methods: Fourteen patients undergoing surgical resection of multiple head and neck paragangliomas were enrolled in this study. A preoperative 3-D model was created based on radiologic data, and relevant critical anatomic relationships were preoperatively assessed and intraoperatively validated.

Results: All 14 patients presented with multiple head and neck paragangliomas, including bilateral carotid body tumors (CBT, n = 9), concurrent CBT with glomus jugulare tumors (GJT, n = 4), and multiple vagal paragangliomas (n = 1). Ten patients underwent genomic analysis and all harbored succinate dehydrogenase complex subunit D (SDHD) mutations. Under guidance of the 3-D model, the internal carotid artery (ICA) was circumferentially encased by tumor on 5 of the operated sides, in 4 (80%) of which the tumor was successfully dissected out from the ICA, whereas ICA reconstruction was required on one side (20%). Following removal of CBT, anterior rerouting of the facial nerve was avoided in 3 (75%) of 4 patients during the extirpation of GJT with assistance of a 3-D model. Two patients developed permanent postoperative vocal cord paralysis. There was no vessel rupture or mortality in this study cohort.

Conclusion: The 3-D model is beneficial for establishment of a preoperative strategy, as well as planning and guiding the intraoperative procedure for resection of multiple head and neck paragangliomas.
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http://dx.doi.org/10.1177/01455613211009441DOI Listing
April 2021

Endoscopic Endonasal Odontoidectomy with Nasopharyngeal Flap Reconstruction.

J Neurol Surg B Skull Base 2021 Feb 23;82(Suppl 1):S12-S13. Epub 2020 Nov 23.

Department of Neurosurgery, The Ohio State University, Columbus, Ohio, United States.

 This study aimed to demonstrate the nuances in preoperative management, surgical technique, and reconstruction for an endoscopic endonasal odontoidectomy.  Assembly of an operative video demonstrating technique for endoscopic endonasal odontoidectomy.  this study is a comprehensive skull base team at a tertiary care center.  The patient is a 53-year-old male, with basilar invagination and myelopathy, who underwent cervical fusion, 6 years back, without ventral decompression at an outside hospital. He presented to our clinic with persistent myelopathy and generalized weakness, thus an endoscopic endonasal odontoidectomy for brainstem decompression was recommended.  Preoperative computed tomography (CT) angiography and intraoperative CT navigation demonstrated normal carotid artery anatomic localization. An inverted -shaped mucosal flap was reflected inferiorly and preserved. The C1 arch was identified and resected with a high speed drill. The resultant diseased soft tissue arising from retropulsion of the odontoid process was then removed and the odontoid process identified. This bone was removed centrally until a thin cap remained. After removal of the cap, the underlying ligamentous tissue was removed until dural pulsations were appreciated and brainstem decompression achieved. Hemostasis was attained and the mucosal flap mobilized into position.  Postoperative CT imaging demonstrated resolution of basilar invagination and brainstem decompression ( Fig. 1 ). The patient improved both in arm dexterity and ambulation after surgery and the reconstruction demonstrated appropriate healing on nasal endoscopy 2 months postoperatively.  This operative video demonstrates nuances in endoscopic endonasal odontoidectomy. This case also demonstrates that ventral decompression after long-term cervical fusion can improve myelopathy and that fusion in the setting of bony ventral compression, rather than rheumatoid panus, may not reduce over time with fusion only. The link to the video can be found at: https://youtu.be/370FFuBA89Y .
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http://dx.doi.org/10.1055/s-0040-1714408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935724PMC
February 2021

Organoid and Spheroid Tumor Models: Techniques and Applications.

Cancers (Basel) 2021 Feb 19;13(4). Epub 2021 Feb 19.

Sinonasal and Skull Base Tumor Program, Head and Neck Surgery Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD 20892, USA.

Techniques to develop three-dimensional cell culture models are rapidly expanding to bridge the gap between conventional cell culture and animal models. Organoid and spheroid cultures have distinct and overlapping purposes and differ in cellular sources and protocol for establishment. Spheroids are of lower complexity structurally but are simple and popular models for drug screening. Organoids histologically and genetically resemble the original tumor from which they were derived. Ease of generation, ability for long-term culture and cryopreservation make organoids suitable for a wide range of applications. Organoids-on-chip models combine organoid methods with powerful designing and fabrication of micro-chip technology. Organoid-chip models can emulate the dynamic microenvironment of tumor pathophysiology as well as tissue-tissue interactions. In this review, we outline different tumor spheroid and organoid models and techniques to establish them. We also discuss the recent advances and applications of tumor organoids with an emphasis on tumor modeling, drug screening, personalized medicine and immunotherapy.
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http://dx.doi.org/10.3390/cancers13040874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922036PMC
February 2021

Resection of Carotid Body Tumors in Patients of Advanced Age: Experience From a Single Center.

Ear Nose Throat J 2021 Jan 25:145561320981442. Epub 2021 Jan 25.

Department of Otolaryngology-Head and Neck Surgery, 1500Johns Hopkins School of Medicine, Baltimore, MD, USA.

Introduction: Resection of carotid body tumor (CBT) in patients of advanced ages has not been appreciated.

Objectives: This study aims to assess the clinical characteristics and perioperative comorbidities for CBT resection in patients of advanced age and to validate the application of an "isolated island" technique for extirpation of CBT.

Methods: Eight patients of advanced age (≥60 years) who underwent CBT resection were enrolled as the study group (SG). Another 29 patients of younger age (<45 years old) underwent CBT extirpation were assigned as the control group (CG). The perioperative issues were compared between these 2 groups.

Results: The "isolated island" technique was successfully applied for resection of CBT in all 37 patients. The prevalence of Shamblin classification I, II, and III tumors in the SG was 12.5%, 62.5%, and 25%; whereas in the CG was 10.3%, 55.2%, and 34.5%, respectively. Bilateral CBT was observed in 7 patients of the CG and none in the SG. Vascular reconstruction was required for 1 (12.5%) patient in the SG, while it was required for 8 (27.6%) patients in the CG. Postoperative vocal cord palsy occurred in 37.5% of patients in SG, whereas the vocal cord palsy (34.5%) and dysphagia (6.9%) were commonly encountered in CG. In addition to postoperative length of stay ( = .004), no significant difference for operative time, intraoperative blood loss, or mortality were observed between these 2 groups ( > .05).

Conclusion: Extirpation of CBT in patients of advanced age is rationale in appropriately selected patients. The "isolated island" technique is safe for CBT resection with seemingly low complication rates.
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http://dx.doi.org/10.1177/0145561320981442DOI Listing
January 2021

Deletion of Reduces Eosinophilic Inflammation and Interleukin-5 Expression in a Murine Model of Rhinitis.

Ear Nose Throat J 2021 Jan 4:145561320986055. Epub 2021 Jan 4.

Department of Otolaryngology-Head and Neck Surgery, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: ARF nucleotide-binding site opener (ARNO) is a guanine nucleotide-exchange factor for ADP-ribosylation factor proteins. ARF nucleotide-binding site opener also binds MyD88, and small-molecule inhibition of ARNO reduces inflammation in animal models of inflammatory arthritis and acute inflammation. However, whether genetic deletion of in mice reduces pathologic inflammation has not yet been reported. Furthermore, its role in the nasal cavity has yet to be investigated.

Objective: To generate knockout mice and to determine whether genetic loss of reduces eosinophilic inflammation in the ovalbumin (OVA) murine model of rhinitis.

Methods: knockout mice were generated and wild type and knockout littermates were subjected to the OVA-induced mouse model of rhinosinutitis. Eosinophilic inflammation was assessed through immunofluorescent quantification of EMBP eosinophils in the septal mucosa and cytokine expression was assessed by quantitative polymerase chain reaction.

Results: knockout mice are viable and fertile without any noted deficits. wild type and knockout mice subjected to the OVA-induced model of rhinitis demonstrated an average of 314.5 and 153.8 EMBP cells per mm septal tissue, respectively ( < .05). Goblet cells per mm of basal lamina were assessed via Alcian blue and there was no statistically significant difference between wild type and knockout mice. Ovalbumin-induced expression of interleukin-5 (IL-5) was significantly reduced in knockout mice ( < .05). There was no statistically significant reduction in IL-4, IL-13, or eotaxin-1 expression.

Conclusions: These data demonstrate that deletion of reduces eosinophilic inflammation and IL-5 expression in an OVA-induced model of rhinitis.
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http://dx.doi.org/10.1177/0145561320986055DOI Listing
January 2021

Simulation of Pediatric Anterior Skull Base Anatomy Using a 3D Printed Model.

World Neurosurg 2021 03 5;147:e405-e410. Epub 2021 Jan 5.

Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA; Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA. Electronic address:

Objective: The pediatric skull base may present anatomic challenges to the skull base surgeon, including limited sphenoid pneumatization and a narrow nasal corridor. The rare nature of pediatric skull base pathology makes it difficult to gain experience with these anatomic challenges. The objective of this study was to create a 3-dimensionally (3D) printed model of the pediatric skull base and assess its potential as a training tool.

Methods: Twenty-eight participants at various stages of training and practice were included in our study. They completed a pre- and postdissection questionnaire assessing challenges with endoscopic endonasal skeletonization of the carotid arteries and sella face using the 3D printed model.

Results: The majority of participants had completed a skull base surgery fellowship (60.7%), were <5 years into practice (60.7%), and had <10 cases of pediatric skull base experience (82.1%). Anticipated challenges included limitation of maneuverability of instruments (71.4%), narrow nasal corridor and nonpneumatized bone (57.1%). On a scale of 0-10, 10 being very difficult, the average participant expected level of difficulty with visualization was 6.89 and expected level of difficulty with instrumentation was 7.3. On postdissection assessment, there was a nonstatistically significant change to 6.93 and 7.5, respectively. Participants endorsed on a scale of 0-10, 10 being very realistic, an overall model realism of 7.0 and haptic realism of 7.1.

Conclusions: A 3D printed model of the pediatric skull base may provide a realistic model to help participants gain experience with anatomic limitations characteristic of the pediatric anterior skull base.
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http://dx.doi.org/10.1016/j.wneu.2020.12.077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946774PMC
March 2021

Intercarotid artery distance in the pediatric population: Implications for endoscopic transsphenoidal approaches to the skull base.

Int J Pediatr Otorhinolaryngol 2021 Jan 25;140:110520. Epub 2020 Nov 25.

Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA. Electronic address:

Objective: Comprehensive quantitative evaluation of the intercarotid artery distance (ICD) in the pediatric population has not been sufficiently explored. This study aims to measure the minimal ICDs at multiple levels of the skull base to assess changes in the ICD during development.

Methods: Measurement of the ICDs between the paired paraclival, parasellar, and paraclinoid segments of the internal carotid artery (ICA) was performed on coronal MRI from 540 patients ranging from 0 to 17 years old (n = 30 for each age). Comparison of these indices in the very young (0-5 years, Group 1) and young (6-17 years, Group 2) patients, and assessment of the degree of sphenoid sinus pneumatization was employed.

Results: The narrowest ICD was located at the paraclinoid ICAs in the vast majority of cases (89.44%). When comparing the ICDs in very young age patients with the ICDs of 17 years old subjects, a statistically significant difference was found at the paraclival (ages 0-5), parasellar (ages 0-2), and paraclinoid (ages 0-4) ICDs (p < 0.05). Comparison of the ICDs between the intergroups (Group 1 and 2) also demonstrated a statistically significant difference (p < 0.0001). Pneumatization of the sphenoid sinus was initially noted to start at 3 years of age, and there were no patients with a non-pneumatized sphenoid sinus identified after 7 years of age in our cohort.

Conclusion: Measurement of ICDs at multiple levels provides a valuable reference for EEA procedures in the pediatric population. While the ICD may be largely stable in the pediatric population after 5 years of age, additional anatomic factors may restrict transsphenoidal access in very young patients (0-5 years).
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http://dx.doi.org/10.1016/j.ijporl.2020.110520DOI Listing
January 2021

Role of resection of torus tubarius to maximize the endonasal exposure of the inferior petrous apex and petroclival area.

Head Neck 2021 02 10;43(2):725-732. Epub 2020 Nov 10.

Department of Otolaryngology - Head & Neck Surgery, The James Cancer Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.

Endoscopic access to the petrous apex and petroclival region often requires sacrificing the Eustachian tube (ET). This study aimed to compare the maximum exposure of the petrous apex and petroclival region via an endonasal corridor when sparing or resecting the ET and its torus. Six cadaveric specimens (12 sides) were dissected through an endonasal transpterygoid approach. Endonasal exposure of the petroclival region was completed using techniques that included the preservation of the ET (group 1), resection of the torus tubarius (group 2), and resection of the ET (group 3) were sequentially performed on each side. The working distances from the anterior genu of the petrous internal carotid artery (ICA) to the inferior boundaries of each corridor were measured and compared. In group 1, the medial petrous apex and petroclival sulcus could be exposed with a working distance of 4.08 ± 0.67 mm. In group 2, the fossa of Rosenmüller, inferior petrous apex, and hypoglossal canal could be exposed, with a significantly increased working distance of 18.33 ± 0.89 mm (P = .001). In group 3, the exposure and ICA control was superior and offered a working distance of 20.67 ± 0.78 mm. No statistically significant difference derived from comparing groups 2 and 3 (P = .875). Resection of the torus tubarius can increase exposure of the petrous apex and petroclival region. It provides an alternative to resecting the ET, which might be beneficial for maintenance of middle ear function. ET resection, however, seems superior when ICA control is required.
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http://dx.doi.org/10.1002/hed.26538DOI Listing
February 2021

Video Demonstration of a Tunneled Temporoparietal Fascia Flap: How I Do It.

Laryngoscope 2021 04 23;131(4):E1088-E1093. Epub 2020 Sep 23.

Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Medical Center, Columbus, Ohio, USA.

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http://dx.doi.org/10.1002/lary.29069DOI Listing
April 2021

Endoscopic transoral approach for resection of retrostyloid parapharyngeal space tumors: Retrospective analysis of 16 patients.

Head Neck 2020 12 25;42(12):3531-3537. Epub 2020 Aug 25.

Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.

Background: The purpose of this study was to assess the feasibility of the endoscopic transoral approach for resection of retrostyloid benign tumors.

Methods: We retrospectively reviewed 16 patients with retrostyloid parapharyngeal space (PPS) tumors resected via an endoscopic transoral approach. After separation and control of the internal carotid artery (ICA), tumors in the retrostyloid PPS were then removed under the guidance of angled endoscope (45°).

Results: All 16 patients with retrostyloid PPS tumors were successfully removed via an endoscopic transoral approach. There were 15 schwannomas and 1 paraganglioma. Two tumors were removed en bloc, and the other 14 tumors were removed by piecemeal. In five patients, the tumor extended into the jugular foramen, and was completely removed via the transoral corridor, without cerebrospinal fluid leak. No ICA injury was encountered in any of the 16 patients.

Conclusion: The endoscopic transoral approach is suitable for the resection of retrostyloid PPS tumors and is associated with low morbidity.
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http://dx.doi.org/10.1002/hed.26415DOI Listing
December 2020

Expanded exposure and detailed anatomic analysis of the superior orbital fissure: Implications for endonasal and transorbital approaches.

Head Neck 2020 10 1;42(10):3089-3097. Epub 2020 Aug 1.

Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.

This study aimed to ascertain the maximal exposure of the superior orbital fissure (SOF) afforded by combining endonasal and transorbital endoscopic approaches. Six cadaveric specimens (12 sides) were dissected using endonasal and transorbital endoscopic approaches to access the SOF. The order of the approaches was alternated in each specimen (eg, starting with an endonasal approach in one side followed by a transorbital exposure and reversing the order on the contralateral side). Maximal exposure of the SOF and its contents for individual and combined approaches were explored. The endonasal corridor provided adequate access to the inferomedial 1/3 of the SOF and including the proximal segments of cranial nerves (CN) III, V and VI. A transorbital approach was superior accessing the superolateral 2/3's of the SOF, including the superior ophthalmic vein, lacrimal nerve, and distal segment of the CN VI at the lateral aspect; the nasociliary nerve and divisions of CN III centrally; and the frontal nerve and CN IV at the dorsal aspect of levator palpebrae superioris. This study suggests that a combined endonasal and transorbital exposure of the SOF may be advantageous to address lesions in this challenging region.
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http://dx.doi.org/10.1002/hed.26399DOI Listing
October 2020

The 5-factor modified frailty index predicts health burden following surgery for pituitary adenomas.

Pituitary 2020 Dec;23(6):630-640

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21231, USA.

Purpose: Frailty is known to influence cost-related surgical outcomes in neurosurgery, but quantifying frailty is often challenging. Therefore, we investigated the predictive value of the 5-factor modified frailty index (mFI-5) on total hospital charges, LOS, and 90-day readmission for patients undergoing pituitary surgery.

Methods: The medical records of all patients undergoing endoscopic endonasal resection of pituitary adenomas at an academic medical center between January 2017 and December 2018 were retrospectively reviewed. Bivariate statistical analyses were conducted using Fisher's exact test, chi-square test, and independent samples t-test. Linear and logistic regression models were used for multivariate analysis.

Results: Our cohort (n = 234) had a mean age of 53.8 years (standard deviation 14.6 years). Sex distributions were equal, and most patients were Caucasian (59%). On multivariate linear regression, with each one-point increase in mFI-5, total LOS increased by 0.64 days in the overall cohort (p < 0.001), 1.08 days in the Cushing disease cohort (p = 0.045), and 0.59 days in non-functioning tumors cohort (p = 0.004). Total charges increased by $3954 in the whole cohort (p < 0.001), $10,652 in the Cushing disease cohort (p = 0.033), and $2902 in the non-functioning tumors cohort (p = 0.007) with each one-point increase in mFI-5. Greater mFI-5 scores were associated with greater odds of 90-day readmission in both overall and Cushing disease cohorts, but these associations did not reach statistical significance.

Conclusion: A patient's mFI-5 score is significantly associated with increased length of stay and hospital charges for patients undergoing pituitary surgery. The mFI-5 may hold peri-operative value in patient counseling for pituitary adenoma surgery.
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http://dx.doi.org/10.1007/s11102-020-01069-5DOI Listing
December 2020

Sinonasal undifferentiated carcinoma: Institutional trend toward induction chemotherapy followed by definitive chemoradiation.

Head Neck 2020 11 18;42(11):3197-3205. Epub 2020 Jul 18.

Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA.

Background: Recent reports have investigated the nascent role of induction chemotherapy for sinonasal undifferentiated carcinoma (SNUC). The goal of this study was to ascertain trends in treatment pattern changes for SNUC at a single institution and design a treatment algorithm utilized at our institution.

Methods: Retrospective chart analysis of 21 cases of SNUC from 2010 to 2018.

Results: Of 21 patients in this cohort, 18 (85.7%) presented with T4 disease, 7 (33.3%) presented with nodal disease, and 3 (14.3%) presented with distant metastasis. Since 2016, patients have been managed by induction chemotherapy followed by concurrent chemoradiation. To this point, patients treated with TPF induction chemotherapy followed by concurrent chemoradiation show no evidence of disease; however, the average follow up time is 16.8 months.

Conclusions: The multimodality treatment for SNUC continues to evolve, as highlighted by this study, toward increased use of induction chemotherapy followed by chemoradiotherapy.
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http://dx.doi.org/10.1002/hed.26357DOI Listing
November 2020

Disruption of Sinonasal Epithelial Nrf2 Enhances Susceptibility to Rhinosinusitis in a Mouse Model.

Laryngoscope 2021 04 6;131(4):713-719. Epub 2020 Jul 6.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, U.S.A.

Objectives/hypothesis: Oxidative stress has been postulated to play an important role in chronic rhinosinusitis. Nrf2 is a transcription factor that is involved in the regulation of multiple antioxidant genes, and its function has been previously shown to be important in sinonasal inflammation. Although the sinonasal implications of whole body Nrf2 has been reported, the function of sinonasal epithelial expression of Nrf2 has not been studied. The primary aim of this study was to generate a mouse model that is genetically deficient in epithelial-specific Nrf2 and to understand its role in regulating sinonasal inflammation.

Study Design: Basic science.

Methods: An epithelial-specific Nrf2 knockout mouse was generated by crossing Krt5-cre(K5) with Nrf2 . A papain-induced model of rhinosinusitis was performed in the resulting K5 Nrf2 mouse. Immunohistochemistry was performed to quantify goblet cell hyperplasia. Mucosal cellular infiltrates were quantified using flow cytometry, and tissue cytokines were measured using an enzyme-linked immunosorbent assay. Lastly, the cellular source of type 2 cytokines was determined using intracellular cytokine staining.

Results: Papain-sensitized mice lacking epithelial-specific Nrf2 demonstrate increased goblet cell hyperplasia, significant tissue eosinophilia, and statistically significant increase in mucosal IL-13 when compared to Nrf2 wild-type mice. Lastly, mucosal T cells were identified as the cellular source of IL-13.

Conclusions: We demonstrate enhanced severity of eosinophilic sinonasal inflammation from disruption of the epithelial-specific Nrf2 pathway. The responsiveness of Nrf2-directed antioxidant pathways may act as a major determinant of susceptibility to eosinophilic inflammation and may have potential as a therapeutic target for chronic rhinosinusitis.

Level Of Evidence: NA Laryngoscope, 131:713-719, 2021.
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http://dx.doi.org/10.1002/lary.28884DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785671PMC
April 2021

Immunotherapy in sinonasal melanoma: treatment patterns and outcomes compared to cutaneous melanoma.

Int Forum Allergy Rhinol 2020 09 5;10(9):1087-1095. Epub 2020 Jul 5.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, La Jolla, CA.

Background: Although treatment with checkpoint blockade is now accepted as standard of care for cutaneous melanoma, few studies have investigated its role in sinonasal melanoma (SNM). We aimed to evaluate whether immunotherapy was associated with improved survival in SNM and to compare the effect of immunotherapy in metastatic sinonasal and cutaneous melanoma.

Methods: This was a cohort study of patients included in the United States National Cancer Database who had been diagnosed with sinonasal or cutaneous melanoma between 2012 and 2015 and had complete information regarding immunotherapy status. The primary outcome was overall survival. The influence of immunotherapy on overall survival was compared by Kaplan-Meier and Cox proportional hazards models. Propensity score matched analyses between SNM patients who received immunotherapy and those who did not were based on clinicopathological covariates associated with survival in univariate Cox models.

Results: The analytic cohort consisted of 704 patients with SNM, 94 of whom were treated with immunotherapy and 152,896 patients with cutaneous melanoma, 8055 of whom were treated with immunotherapy. Immunotherapy was not associated with survival in the propensity-score matched cohort (n = 195; hazard ratio [HR] = 1.0; 95% confidence interval [CI], 0.7 to 1.5; p = 0.88) or in adjusted Cox proportional hazards model (n = 549; HR = 1.0; 95% CI, 0.74 to 1.4; p = 0.88). Regimens including immunotherapy were associated with improved overall survival in metastatic cutaneous melanoma (HR = 0.57; 95% CI, 0.49 to 0.66; p < 0.0001), but not metastatic SNM (HR = 1.1; 95% CI, 0.67 to 1.7; p = 0.75).

Conclusion: Compared to current standard of care therapy, inclusion of immunotherapy as first-line therapy was not associated with improved survival in SNM.
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http://dx.doi.org/10.1002/alr.22628DOI Listing
September 2020

Endoscopic Endonasal Approaches to the Medial Intraconal Space: Comparison of Transethmoidal and Prelacrimal Corridors.

Am J Rhinol Allergy 2020 Nov 17;34(6):792-799. Epub 2020 Jun 17.

Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.

Background: Endoscopic transethmoidal and prelacrimal approaches can access the medial intraconal space (MIS).

Objective: This study aimed to compare advantages and drawbacks of these two approaches, and to explore their appropriate indications for management of lesions at various locations within the MIS.

Methods: Six injected cadaveric specimens were dissected using an endonasal approach performing a transethmoidal approach on one side and a prelacrimal approach on the contralateral side. The MIS was divided into three : was defined as the area above the superior border of the medial rectus muscle (MRM), as the area between the MRM and the optic nerve, and as the area below the inferior border of MRM. The exposure provided by these two approaches to various Zones within the MIS was assessed and compared.

Results: The average height of to was 10.35 ± 0.45 mm, 11.07 ± 0.59 mm, and 6.53 ± 0.59 mm, respectively. Both approaches provided adequate exposure of and ; however, the prelacrimal approach provided direct exposure of the posterosuperior aspect of without retraction of MRM. Retraction of MRM was unavoidable using a transethmoidal approach to enhance further exposure. Access to was adequately achieved through the corridor between superior oblique muscle and MRM via a transethmoidal corridor.

Conclusion: Conceptualizing the MIS into the three aforementioned Zones seems beneficial to select the optimal approach for lesions restricted to each specific Zone. Both the transethmoidal and prelacrimal approaches provide adequate exposure for select lesions in the MIS.
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http://dx.doi.org/10.1177/1945892420930938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797577PMC
November 2020

Transpalatal Approaches to the Skull Base and Reconstruction: Indications, Technique, and Associated Morbidity.

Semin Plast Surg 2020 May 6;34(2):99-105. Epub 2020 May 6.

Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio.

Multiple anterior surgical approaches are available to obtain access to the nasopharynx, clivus, and craniocervical junction. These include the direct and transoral robotic surgery transpalatal, maxillary swing, and endoscopic endonasal approaches. In this article, we describe the indications for these techniques, surgical steps, and associated morbidities. This article is a PubMed literature review. A review of the literature was conducted to assess the techniques, surgical steps, and associated morbidities with transpalatal approaches to the skull base and nasopharynx. The transpalatal approach has been traditionally utilized to obtain surgical access to the nasopharynx, clivus, and craniocervical junction. Morbidity includes velopalatine insufficiency due to shortening of the soft palate from scar contraction or neuromuscular damage, thus leading to hypernasal speech and dysphagia. Middle ear effusion and oronasal or oronasopharyngeal palatal fistula are additional potential morbidities. The choice of surgical approach depends on a variety of factors including the disease location and extent, surgeon experience, and available resources.
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http://dx.doi.org/10.1055/s-0040-1709432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202914PMC
May 2020

Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm.

Int Forum Allergy Rhinol 2020 06 3;10(6):779-784. Epub 2020 May 3.

Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH.

Background: Delayed postoperative cerebrospinal fluid (CSF) leaks are uncommon and largely unstudied complications. In this study we aim to identify their etiology and understand the efficacy of various reconstruction strategies.

Methods: A retrospective chart analysis of 1017 endonasal skull base surgeries performed by a single neurosurgeon was completed identifying delayed CSF leaks (occurring >1 week after surgery).

Results: Seventeen cases of early (1-2 weeks after surgery) or delayed (>2 weeks after surgery) postoperative CSF leak were identified. The most common reconstruction during the initial surgery consisted of an inlay or gasket seal collagen matrix (82.4% of patients) with an onlay pedicled flap (76.5% of patients). Presenting symptoms of delayed CSF leak included rhinorrhea (82.4%), headache (41.2%), and meningitis (23.5%). The most common causes included flap dehiscence (17.6%); provoking events such as emesis, sneezing, or fall (17.6%); flap necrosis (11.8%); flap displacement (11.8%); and inadequate apposition of the flap, that is, folded flap (11.8%). Reconstructive techniques of the delayed CSF leak included fortification of the initial reconstruction with free fat grafts (29.4% of patients), combined collagen matrix with a fat graft (23.5% of patients), repositioning of the previous flap (11.8% of patients), and repair with a new flap (11.8% of patients). CSF diversion (spinal/ventricular drain or shunt) was used in 17.6% of patients.

Conclusion: This study identifies the most common etiologic factors leading to a delayed CSF leak and its initial symptoms. Furthermore, it serves as the foundation for a reconstructive algorithm based on reinforcement of the initial repair with free abdominal fat graft with or without collagen matrix.
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http://dx.doi.org/10.1002/alr.22544DOI Listing
June 2020

The Anterolateral Triangle: Implications for a Transnasal Prelacrimal Approach to the Floor of the Middle Cranial Fossa.

Am J Rhinol Allergy 2020 Sep 29;34(5):671-678. Epub 2020 Apr 29.

Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio.

Background: The anterolateral triangle enclosed by the foramen rotundum and foramen ovale constitutes part of the floor of the middle cranial fossa (MCF).

Objective: To assess the feasibility of a transnasal prelacrimal approach for accessing the floor of MCF via an anterolateral triangle corridor and to determine the extent of maximal exposure while safeguarding neurovascular structures.

Methods: A transnasal prelacrimal approach was performed in 5 cadaveric specimens (10 sides). Following the identification of foramen rotundum and foramen ovale, the bony ridge between 2 was drilled to expose the MCF. The temporal lobe dura was then elevated laterally, and the distances from foramen ovale to the respective borders of the area of the MCF window were measured using a surgical navigation device.

Results: The MCF was exposed with a 0° scope in all specimens also exposing significant landmarks including the middle meningeal artery, greater superficial petrosal nerve, superior petrous sinus, and arcuate eminence. Average distances from foramen ovale to the anterior, posterior, and lateral exposed borders were 22.86 ± 1.87 mm, 27.24 ± 0.94 mm, and 24.23 ± 1.61 mm, respectively. The average area of exposed MCF window was 554.12 ± 60.22 mm. Preservation of vidian nerve, greater palatine nerve, lateral nasal wall, and nasolacrimal duct was possible in all 10 sides.

Conclusion: It is feasible to access the floor of MCF via an endoscopic transnasal prelacrimal approach with seemingly low risk.
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http://dx.doi.org/10.1177/1945892420922757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705195PMC
September 2020

The expanded endonasal approach in pediatric skull base surgery: A review.

Laryngoscope Investig Otolaryngol 2020 Apr 4;5(2):313-325. Epub 2020 Mar 4.

Otolaryngology-Head and Neck Surgery The Ohio State University Columbus Ohio USA.

Objective: Surgery of the pediatric skull base has multiple unique challenges and has seen recent rapid advances. The objective of this review is to assess key issues in pediatric skull base surgery (SBS), including anatomic limitations, surgical approaches, reconstruction techniques, postoperative care, complications, and outcomes.

Data Sources: PubMed literature review.

Review Methods: A review of the literature was conducted to assess the challenges, recent advances, and reported outcomes in pediatric SBS.

Results: The pediatric skull base presents multiple anatomic challenges, including variable patterns of pneumatization, narrow piriform aperture width, and narrow intercarotid distance at the level of the cavernous sinus but not the superior clivus. These issues may be particularly challenging in patients less than 2 years of age. Endoscopic endonasal approaches in the sagittal and coronal plane have been applied to the pediatric skull base while open approaches may still be necessary in the setting of extensive intracranial or orbital disease, as well as disease lateral to critical neurovascular structures. While the nasoseptal flap was initially called into question for pediatric cases, it has been shown through multiple reports to be a feasible and robust reconstructive option. Complications and outcomes often depend upon the pathology. In children, response to noxious stimuli, ability to avoid Valsalva, and adherence to nasal precautions is variable. The use of lumbar drains is more common in pediatric than adult patients.

Conclusion: While the pediatric skull base presents unique challenges, outcomes data support that endoscopic endonasal approaches are a pertinent surgical technique in appropriately selected patients.

Level Of Evidence: 3a.
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http://dx.doi.org/10.1002/lio2.369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178460PMC
April 2020

Characterization and implications of the lingual process of the sphenoid bone: a cadaveric and radiographic study.

Int Forum Allergy Rhinol 2020 12 24;10(12):1316-1321. Epub 2020 Jun 24.

Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, OH.

Background: The surgical significance of the lingual process of the sphenoid bone (LPSB) has not been sufficiently addressed. The purpose of this study was to describe the anatomical details of the LPSB in relation to the quadrangular space. Moreover, the incidence of the LPSB and its correlation with the pneumatization of the sphenoid sinus and the development of the lateral recess of the sphenoid sinus (LRSS) were also evaluated.

Methods: A dissection and exposure of the LPSB and the quadrangular space was performed on 10 cadaveric specimens (20 sides). The incidence, length, and height of the LPSB were also assessed on computed tomography (CT) images (60 patients, 120 sides). The association between the presence of the LPSB with the pneumatization type of the sphenoid sinus and the presence of a LRSS was evaluated.

Results: In a cadaveric model, the LPSB, in association with the petrolingual ligament extending from the LPSB to the petrous apex, was identified on 7 sides (35%). The LPSB was continuous with the mandibular strut. The overall incidence of a LPSB was 48.33% on CT images, and the average length and height of the LPSB was (mean ± standard deviation) 5.30 ± 1.44 mm and 6.51 ± 1.32 mm, respectively. A significant correlation was identified between presence of the LPSB with the pneumatization type of the sphenoid sinus (p = 0.004) but no correlation was identified with the presence of the LRSS (p = 0.071).

Conclusion: The LPSB and the petrolingual ligament are useful landmarks for procedures in the quadrangular space and Meckel's cave. However, the LPSB is not consistently present.
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http://dx.doi.org/10.1002/alr.22594DOI Listing
December 2020

Focused endoscopic endonasal craniocervical junction approach for resection of retro-odontoid lesions: surgical techniques and nuances.

Acta Neurochir (Wien) 2020 06 8;162(6):1275-1280. Epub 2020 Apr 8.

Department of Neurological Surgery, The Ohio State University Medical Center, N-1049 Doan Hall, 410 West 10th, Avenue, Columbus, OH, 43210, USA.

Background: Lesions posterior to the odontoid process pose a surgical challenge. Posterolateral approaches to this region are considerably risky for the spinal cord. Transoral approaches are limited in terms of exposure and can also carry morbidity.

Methods: We describe a focused endoscopic endonasal approach (EEA) for removing an osteochondroma located dorsal to the odontoid process. The surgical pearls and pitfalls using stepwise image-guided EEA cadaveric dissections are highlighted defining the importance of various craniocervical junction (CCJ) lines on imaging.

Conclusion: EEA to CCJ can be offered, with lower morbidity than other approaches, even for lesions that extend posterior and caudal to the odontoid process. Radiologic predictors of exposure and intraoperative techniques to enhance endoscopic visualization are discussed.
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http://dx.doi.org/10.1007/s00701-020-04319-4DOI Listing
June 2020

Nasal Bone Fractures: Analysis of 1193 Cases with an Emphasis on Coincident Adjacent Fractures.

Facial Plast Surg Aesthet Med 2020 Jul/Aug;22(4):249-254. Epub 2020 Apr 6.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

The nasal bone is one of the most commonly fractured bones of the midface. However, the frequency of coincident fractures of adjacent bones such as the frontal process of the maxillary bone, nasal septum, and medial or inferior orbital walls has not been fully evaluated. The purpose of this study was to investigate the incidence of fractures of adjacent structures in the setting of a nasal bone fracture. Second, we propose a new classification system of nasal bone fractures with involvement of adjacent bony structures. One thousand, one hundred ninety-three patients with midfacial fractures were retrospectively reviewed. The characteristics of fractures of the nasal bone and the incidence of coincident fractures of the frontal process of maxilla, bony nasal septum, medial, or inferior orbital walls were analyzed. All patients included in the study presented with nasal trauma. The coincident fractures of adjacent midfacial structures were assessed, and a new classification of midfacial fractures based on computed tomography (CT) scan images was proposed. Among the 1193 cases, bilateral fractures of the nasal bone were most common (69.24%), and coexistent fracture of the frontal process of the maxilla and bony nasal septum was 66.89% and 42.25%, respectively. Coincident fracture of the orbital walls was observed in 16.51% of cases. The major etiology of fracture for the younger and elderly groups was falls, compared with assault as the most common etiology in the adult group. A classification scheme was generated in which fractures of the nasal bone were divided into five types depending on coexisting fractures of adjacent structures. External force applied to the nasal bone can also lead to coexistent fracture of adjacent bony structures including the frontal process of the maxilla, nasal septum, and orbital walls. The proposed classification of nasal fracture based on CT imaging helps to incorporate coincident disruption of adjacent structures.
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http://dx.doi.org/10.1089/fpsam.2020.0026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476382PMC
November 2020

Surgical nuances of the expanded endoscopic anterior skull base craniectomy for hyperostotic meningioma resection.

Acta Neurochir (Wien) 2020 06 15;162(6):1269-1274. Epub 2020 Mar 15.

Department of Neurological Surgery, The Ohio State University Medical Center, N-1049 Doan Hall, 410 West 10th, Avenue, Columbus, OH, 43210, USA.

Background: The rostral expanded endoscopic approach (EEA) to anterior cranial fossa (ACF) has several advantages over transcranial/craniofacial surgery, providing early access to the vascular supply of tumors and reducing morbidities of craniotomy especially that of brain retraction. This article presents endoscopic landmarks and nuances for a wide ACF corridor, with stepwise image-guided dissections highlighting surgical tricks and techniques to enhance surgical safety.

Methods: We describe an expanded endoscopic endonasal anterior skull base craniectomy for a recurrent large olfactory groove hyperostotic meningioma, with correlated cadaveric dissections.

Conclusion: The widening of rostral EEA can provide a safe and feasible route to access ACF. This article highlights the specific landmarks in endoscopic anatomy with reference to the angle of visualization and bayonetted instruments.
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http://dx.doi.org/10.1007/s00701-020-04277-xDOI Listing
June 2020

Endonasal endoscopic transpterygoid approach to the upper parapharyngeal space.

Head Neck 2020 09 4;42(9):2734-2740. Epub 2020 Mar 4.

Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio, USA.

Background: Lesions of the upper parapharyngeal space (UPPS) present a surgical challenge. The objective of this study was to ascertain the feasibility of a novel technique of modified transpterygoid approach to the UPPS.

Methods: Six fresh cadaveric specimens (12 sides) were dissected, developing a technique that includes en bloc mobilization of the lateral pterygoid plate and muscle to access the UPPS.

Results: Following an endoscopic Denker's approach and the removal of posterolateral wall of the antrum, the lateral pterygoid plate was detached from the pterygoid process. Subsequently, the lateral pterygoid plate and muscle were displaced laterally as a unit, allowing the identification of the posterior trunk of V and the fat in prestyloid compartment. Dissecting off the styloid aponeurosis affords entering the poststyloid UPPS exposing the internal carotid artery, internal jugular vein, and cranial nerves IX to XII.

Conclusion: This novel modification of the endonasal transpterygoid approach offers a viable alternative for access to the UPPS.
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http://dx.doi.org/10.1002/hed.26127DOI Listing
September 2020
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