Publications by authors named "Raj Sindwani"

166 Publications

Postoperative Oral Antibiotics and Sinonasal Outcomes Following Endoscopic Transsphenoidal Surgery for Pituitary Tumors Study: A Multicenter, Prospective, Randomized, Double-Blinded, Placebo-Controlled Study.

Neurosurgery 2021 Oct;89(5):769-776

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

Background: Postoperative prophylactic antibiotics are commonly used in pituitary surgery, but evidence supporting their use is lacking, which has implications for antibiotic stewardship.

Objective: To evaluate whether receipt of postoperative oral antibiotics results in superior sinonasal quality of life (QOL) compared with placebo among patients who undergo endoscopic endonasal transsphenoidal pituitary surgery.

Methods: Patients were randomized to receive either oral placebo or cefdinir (trimethoprim-sulfamethoxazole in patients intolerant to cefdinir) for 7 d after surgery. They were monitored for 12 wk. The primary outcome measure was sinonasal QOL at 2 wk on the Anterior Skull Base Nasal Inventory-12. Supplementary end points included sinonasal QOL reported on the Sinonasal Outcome Test-22 and objective endoscopy scores to assess nasal healing according to the Lund-Kennedy method.

Results: A total of 461 patients were screened, 131 were randomized, and 113 (placebo arm: 55; antibiotic arm: 58) were analyzed. There was no clinically meaningful or statistically significant difference in sinonasal QOL at any measured time point (P ≥ .24) using either instrument. Nasal cavity endoscopy scores were not significantly different at 1 to 2 wk after surgery (P = .25) or at 3 to 4 wk after surgery (P = .08).

Conclusion: Postoperative prophylactic oral antibiotics did not result in superior sinonasal QOL compared with placebo among patients who underwent standard endoscopic transsphenoidal surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyab301DOI Listing
October 2021

Assessment of the Validity of the Sinonasal Outcomes Test-22 in Pituitary Surgery: A Multicenter Prospective Trial.

Laryngoscope 2021 Nov 1;131(11):E2757-E2763. Epub 2021 Jul 1.

Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: Sinonasal Outcomes Test-22 (SNOT-22) is used widely as a patient-reported sinonasal quality-of-life (QOL) instrument for endoscopic endonasal pituitary surgery. However, it has never been validated in this population. This study explores the psychometric validity of SNOT-22 to determine if it is a valid scale in patients undergoing endoscopic pituitary surgery.

Study Design: Multicenter prospective trial.

Methods: Adult patients (n = 113) with pituitary tumors undergoing endoscopic surgery were enrolled in a multicenter study. Patient-reported QOL was assessed using SNOT-22 and the Anterior Skull Base Nasal Inventory-12. Face validity, internal consistency, responsiveness to clinical change, test-retest reliability, and concurrent validity were determined using standard statistical methods.

Results: Internal consistency using Cronbach's alpha at baseline and 2 weeks postoperatively were 0.911 and 0.922, indicating SNOT-22 performed well as a single construct. Mean QOL scores were significantly worse at 2 weeks than baseline (16.4 ± 15.1 vs. 23.1 ± 16.4, P < .001), indicating the scale is responsive to clinical change. However, only 11/22 items demonstrated significant changes in mean scores at 2 weeks. Correlation between scores at 2 and 3 weeks was high, suggesting good test-retest reliability, r(107) = 0.75, P < .001. Factor analysis suggests the five-factor solution proposed for the SNOT-22 in rhinosinusitis patients is not valid in pituitary surgery patients.

Conclusions: The SNOT-22 is a valid QOL instrument in patients undergoing endoscopic pituitary surgery. However, because it includes 22 items, can be applied only as a single construct, 50% of the items do not demonstrate changes after surgery, and is not as sensitive to change as other scales, shorter instruments developed specifically for this patient population may be preferable.

Level Of Evidence: 2 Laryngoscope, 131:E2757-E2763, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.29711DOI Listing
November 2021

Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide.

Laryngoscope 2021 10 7;131(10):2224-2230. Epub 2021 Jun 7.

Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.

Objectives: Cerebrospinal fluid (CSF) leaks and meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be challenging. The traditional transpterygoid approach through the pterygopalatine fossa (PPF) is time consuming and places important structures at risk, which can lead to significant morbidity. We report a multi-institutional experience using a simplified, endoscopic modified transpterygoid approach (MTPA), which spares the PPF contents in the management of lateral sphenoid sinus meningoencephaloceles and CSF leaks.

Study Design: Multi-Institutional, Retrospective Case Series.

Methods: Patients with lateral sphenoid recess CSF leaks and meningoencephaloceles between 2014 and 2020 who underwent the MTPA at two academic medical centers were identified. Repair techniques and outcomes were evaluated.

Results: Thirty-three patients underwent the MTPA for management. Skull base reconstruction was performed using a free mucosal graft (24/33, 72.7%), nasoseptal flap (4/33, 12.1%), bone grafts (3/33, 9.1%), and abdominal fat grafts (2/33, 6.1%). Lumbar drains and perioperative intracranial pressure measurements were routinely employed. Postoperative complications were uncommon and included three patients (9.7%) with temporary V2 anesthesia, one patient (3.2%) with prolonged V2 anesthesia, and one patient (3.2%) with subjective dry eye, all of which resolved at 9 months postoperatively. There were no recurrent CSF leaks resulting in a 100% success rate. Average follow-up was 13 months.

Conclusion: The MTPA reduces morbidity and greatly simplifies access to the lateral sphenoid sinus for the management of CSF leaks and meningoencephaloceles, without compromising exposure. This technique avoids the need for extensive PPF dissection and should be considered for the management of benign lesions involving the lateral sphenoid sinus.

Level Of Evidence: 4 Laryngoscope, 131:2224-2230, 2021.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lary.29672DOI Listing
October 2021

Simplifying Access to the Lateral Sphenoid Recess: A Modification of the Transpterygoid Approach.

Am J Rhinol Allergy 2021 Mar 24:19458924211003813. Epub 2021 Mar 24.

Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be difficult to access. Historically, the endoscopic transpterygoid approach was advocated, which carries additional morbidity given the dissection of the pterygopalatine fossa (PPF) contents to provide a direct line approach to the defect. Given our increased facility with angled endoscopes and instrumentation, we now approach this region in a less invasive manner.

Methods: We describe the endoscopic modified transpterygoid approach (MTPA), a quicker approach to the lateral sphenoid recess which preserves the PPF contents through a single nostril corridor.

Results: In the MTPA, the face of the sphenoid and anterior junction of the pterygoid plates are removed, allowing for mobilization of the PPF contents with the periosteum intact. Angled instrumentation is then used to resect the meningoencephalocele and repair the skull base defect in the lateral recess. If increased exposure is needed, this can be gained by sacrificing the sphenopalatine artery and even the vidian nerve, although this is rarely required.

Conclusions: The MTPA obviates the need for PPF dissection and simplifies access to the lateral sphenoid recess while minimizing postoperative morbidity. This approach should be considered for accessing meningoencephaloceles and other benign lesions in this challenging location.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/19458924211003813DOI Listing
March 2021

International consensus statement on allergy and rhinology: rhinosinusitis 2021.

Int Forum Allergy Rhinol 2021 03;11(3):213-739

Rutgers New Jersey Medical School, Newark, NJ.

I.

Executive Summary: BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

Methods: ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

Results: ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

Conclusion: This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/alr.22741DOI Listing
March 2021

International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea.

Int Forum Allergy Rhinol 2021 04 25;11(4):794-803. Epub 2020 Oct 25.

Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, AL.

Background: The association between spontaneous cerebrospinal fluid (CSF) leak/rhinorrhea and idiopathic intracranial hypertension (IIH) has been increasingly recognized over the last years. However, considerable variability of opinion regarding the assessment, investigations, and management of patients with spontaneous CSF rhinorrhea remains.

Methods: A consensus group was formed from experts from Europe, Asia, Australia, South and North America. Following literature review and open discussions with members of the panel, a set of 61 statements was produced. A modified Delphi method was used to refine expert opinion with 3 rounds of questionnaires and a consensus group meeting in Santo-Rhino meeting in September 2019.

Results: Fifty statements (82% of total) on spontaneous CSF leak and IIH reached consensus. In 38 of 50 statements, the median response was 7 (strongly agree) and in the 12 remaining statements the median response was 6 (agree). Eleven statements were excluded because they did not reach consensus and one new statement was added during SantoRhino meeting. The final statements refer to patient history and clinical examination ("History taking should include presence of headache, tinnitus and visual defects"), investigations (role of Thin Slice Computed Tomography and CISS/FLAIR sequences in Magnetic Resonance Imaging), principles of management (watchful waiting or measures to reduce ICP are supplementary but cannot subsitute surgical closure), surgical technique, intraoperative, early postoperative and long term management.

Conclusion: We present fifty consensus statements on the diagnosis, investigation, and management of spontaneous CSF rhinorrhea based on the currently available evidence and expert opinion. Although by no means comprehensive and final, we believe they can contribute to the standardization of clinical practice. Early diagnosis, prompt surgical closure of the defect, assesment for and treatment of potentially co-existing idiopathic intracranial hypertension in a comprehensive multidisciplinary approach are essential in order to successfully manage spontaneous CSF rhinorrhea, reduce associated morbidity and prevent recurrence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/alr.22704DOI Listing
April 2021

Staying Safe, Caring for Each Other, and Moving the Needle-Together.

Authors:
Raj Sindwani

Am J Rhinol Allergy 2020 Jul;34(4):449-450

Editor-in-Chief, American Journal of Rhinology and Allergy Cleveland Clinic, Cleveland, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1945892420928162DOI Listing
July 2020

Endoscopic Orbital Decompression: Technical Pearls and Pitfalls of an Evolving Technique.

Am J Rhinol Allergy 2021 Jul 13;35(4):548-550. Epub 2020 Oct 13.

Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.

Background: First described in the early 1990s, endoscopic orbital decompression has become increasingly popular and has been shown to be a safe and effective approach for surgical decompression of the medial and inferior orbit.

Methods: We present our preferred technique for performing an endoscopic orbital decompression, highlighting key pearls and pitfalls.

Results: An endoscopic wide maxillary antrostomy and sphenoethmoidectomy is performed in standard fashion. We prefer to resect the middle turbinate for optimal exposure and access. The medial orbital wall is skeletonized and the lamina papyracea is carefully elevated, preserving the underlying periorbita. The orbital floor medial to the infraorbital nerve is resected. Once the periorbita is fully exposed, parallel axial incisions along the medial orbit and orbital floor are made from posterior to anterior using a sickle knife, taking care not to bury the tip to avoid injuring underlying orbital contents. The remaining fibrous bands are incised and prolapse of orbital fat is observed. Post extubation bag mask ventilation is limited to avoid subcutaneous emphysema.

Conclusion: Compared to open techniques, endoscopic orbital decompression provides superior visualization of critical anatomical landmarks, assures healthy sinus functioning post procedure, offers a lower complication rate, and avoids external incisions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1945892420965479DOI Listing
July 2021

Prevalence and Clinical Significance of Radiographic Sinus Disease on Preoperative Computed Tomography Imaging in the Endoscopic Skull Base Surgery Population.

Am J Rhinol Allergy 2021 Mar 11;35(2):239-244. Epub 2020 Aug 11.

Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.

Introduction: Endoscopic skull base surgery (ESBS) provides a safe, minimally invasive approach to treat benign and malignant skull base lesions. The significance of concomitant sinonasal pathology on imaging in patients undergoing ESBS and its effect on perioperative management is not well described. We sought to identify the prevalence and clinical significance of incidentally found radiographic sinus disease on preoperative imaging in patients undergoing ESBS and provide a protocol for management of these patients.

Design: A retrospective chart review was performed of consecutive patients who underwent ESBS from January 1, 2016 to June 30, 2018. Preoperative computed tomography (CT) scans were reviewed and scored using the Lund-Mackay (LM) staging system. Preoperative nasal endoscopy findings were analyzed. Any preoperative treatment based on these findings and changes in intraoperative management were examined.

Results: A total of 156 patients (81 women, 74 men) who underwent ESBS were reviewed. The average LM score was 2 ± 2.7 (range: 0-12). A total of 94 patients (60.3%) had evidence of radiographic sinus disease (LM score > 0) and 23 patients (14.7%) had presence of sphenoid sinus disease. Seven patients (4.5%) were treated preoperatively based on CT and/or nasal endoscopy findings. All patients who received preoperative treatment had evidence of sinus disease on imaging with an average score of 4.7 and were evaluated and treated within 1-2 weeks prior to ESBS. One patient had ESBS postponed until endoscopic sinus surgery was performed for extensive chronic rhinosinusitis (CRS) findings on imaging.

Conclusion: A review of preoperative imaging in patients undergoing ESBS can help identify concurrent sinonasal disease, which has the potential to alter preoperative as well as intraoperative management in these patients. We report a diligent but conservative approach for the treatment of concomitant CRS in the ESBS population with decision for preoperative treatment guided by various factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1945892420949130DOI Listing
March 2021

Using the Middle Turbinate to Protect the Skull Base in Endoscopic Transsphenoidal Surgery: A Cadaver Study.

Am J Rhinol Allergy 2021 Jan 19;35(1):59-63. Epub 2020 Jun 19.

Section of Rhinology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.

Objectives: Inadvertent intracranial injury from nasogastric tube (NGT) placement is a described and potentially fatal complication following endoscopic transsphenoidal hypophysectomy (TSH). This cadaver study assessed the role of middle turbinate (MT) preservation and medialization in preventing accidental skull base injury from NGT insertion after TSH. Standard approach for TSH was performed on 3 human cadavers. MTs were placed into neutral position (MTN), then medialized via suture pexy to the septum (MTP), and subsequently resected (MTR). After each stage, 3 blinded individuals passed a 10 F Dobhoff and a 16 F NGT on each side of each cadaver (5 passes per side). Using endoscopic visualization, each pass was scored by a blinded reviewer based on the first contact point of the tube (0 = nasopharynx, 1 = inferior sphenoid face, 2 = sphenoid sinus), with higher scores suggestive of increased risk of intracranial injury. There were 270 Dobhoff and 270 NGT passes scored. Data was divided into 3 groups based on presence and position of the MT. Significant differences were demonstrated between all three groups [one-way ANOVA: Dobhoff F(2,267) = 6.981, p = 0.001], [NGT F(2,267) = 17.582, p < 0.001]. There were significant differences between means for MTN versus MTP groups [Dobhoff (0.43 vs 0.22, p = 0.007), NGT (0.73 vs 0.28, p < 0.001)] and MTP versus MTR groups [Dobhoff (0.22 vs 0.55, p < 0.001), NGT (0.28 vs 0.81, p < 0.001)], indicating that the presence and position of the MT can significantly affect the accessibility of the sphenoid sinus interior after TSH. There was a trend toward lower means in the MTN group compared to the MTR group. MT preservation and deliberate medialization against the septum may reduce risk of inadvertent intracranial NGT injury in postop TSH patients. This simple maneuver should be considered in all routine TSH procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1945892420933173DOI Listing
January 2021
-->