Person:

Gray, Stacey

Objective: Determining the indications for osteoplastic frontal sinus obliteration (OFSO) for the treatment of inflammatory frontal sinus disease. Study Design: Retrospective case series from a single tertiary care facility. Methods: Thirty-four patients who underwent OFSO for chronic frontal sinusitis (n = 23) and frontal sinus mucocele (n = 11) comprised our study group. Data reviewed included demographics, history of prior frontal sinus operation(s), imaging, diagnosis, and operative complications. Results: The age range was 19 to 76 years. Seventy percent of patients with chronic frontal sinusitis underwent OFSO as a salvage surgery after previous frontal sinus surgery failures, while 30% underwent OFSO as a primary surgery. For those in whom OFSO was a salvage procedure, the failed surgeries were endoscopic approaches to the frontal sinus (69%), Lynch procedure (12%), and OFSO outside this study period (19%). For patients with frontal sinus mucocele, 72% had OFSO as a first-line surgery. Within the total study population, 15% of patients presented for OFSO with history of prior obliteration, with a range of 3 to 30 years between representations. Conclusions: Osteoplastic frontal sinus obliteration remains a key surgical treatment for chronic inflammatory frontal sinus disease both as a salvage procedure and first-line surgical therapy.

Background: Schwannomas of the vidian canal are an extremely rare type of intracranial tumor that can have variable clinical presentations including headache, facial pain, facial muscle paralysis, decreased lacrimation, or nasal dryness. We present an atypical case of an incidentally identified asymptomatic vidian canal schwannoma. Case Description A 49-year-old woman with a history of multiple sclerosis presented for routine surveillance magnetic resonance imaging that detected an ovoid mass originating in the vidian canal. Given the unusual location of the lesion, an endoscopic endonasal biopsy was performed and confirmed the diagnosis of a vidian canal schwannoma, for which the patient chose to receive fractionated radiation therapy. Conclusion: When a vidian canal tumor is identified, endoscopic endonasal biopsy can be used to confirm the diagnosis before pursuing either surgical or radiotherapy treatment. In particular, fractionated radiation therapy offers a radiobiologically safe means of delivering radiation when there is concern for late radiation-related side effects following treatment completion.

Internal carotid artery injury is a rare and devastating complication of endoscopic sinus and skull base surgery that has an associated mortality rate of 15%. This case describes a patient who developed massive epistaxis following routine sinus surgery and was eventually diagnosed with a pseudoaneurysm of the cavernous internal carotid artery. Endovascular coiling and Onyx (Covidien, Irvine, California, United States) liquid embolization were ultimately used to completely occlude the internal carotid artery with resolution of bleeding; however, the patient had an unexpected late complication of coil extrusion through the pseudoaneurysm sac into the sphenoid sinus and nasal cavity. The endoscopic skull base team safely excised the coils endoscopically without recurrent bleeding. We describe the multidisciplinary operative management of this case of endovascular coil extrusion to increase awareness of this potentially life-threatening complication.

Objectives: To describe the presentation, work-up, and management of patients with metastatic renal cell carcinoma (RCC) to the sinonasal cavity and skull base, and to describe our current treatment algorithm of endoscopic surgical resection followed by radiation therapy. Design: Retrospective review of two recent cases from our institution over a 1-year period, with a relevant review of the literature. Setting: A large regional tertiary care facility. Participants: Consecutive cases of RCC with metastases to the sinonasal cavity presenting to our institution. Main Outcome Measures: Preoperative and postoperative sinonasal outcome test (SNOT)-22 scores, duration of hospital stay, complications, and local disease control Results: Patients in this series underwent preoperative embolization followed by endoscopic resection without complication. Postoperatively they were treated with radiation therapy. They experienced improvement in their SNOT-22 scores and are currently free of local disease. Conclusion: Metastatic RCC to the sinonasal cavity can be safely treated with preoperative embolization followed by endoscopic surgical resection and radiation therapy, which can result in improvement in sinonasal quality of life and is a potential adjunct for local control of disease.

Background: Sphenoid sinus fungal balls (SSFB) are rare entities that can result in serious orbital and intracranial complications. There are few published reports of complications that result from SSFB. Objective: To review the incidence of skull base erosion and orbital or intracranial complications in patients who present with SSFB. Methods: A retrospective review was performed of all the patients with SSFB who were treated at the Massachusetts Eye and Ear Infirmary from 2006 to 2014. Presenting clinical data, radiology, operative reports, pathology, and postoperative course were reviewed. Results: Forty-three patients with SSFB were identified. Demographic data were compared between patients with (39.5%) and those without (61.5%) skull base erosion. Two patients underwent emergent surgery for acute complications of SSFB (one patient with blindness, one patient who had a seizure). Both patients with acute complications had evidence of skull base erosion, whereas no patients with an intact skull base developed an orbital or intracranial complication (p = 0.15). All the patients were surgically managed via an endoscopic approach. Conclusion: SSFBs are rare but may cause significant skull base erosion and potentially severe orbital and intracranial complications if not treated appropriately. Endoscopic sphenoidotomy is effective in treating SSFB and should be performed emergently in patients who presented with associated complications.

Objectives To characterize the temporal distribution and resolution rate of postoperative complications from endoscopic skull base surgery.

Design Retrospective review of patients undergoing endoscopic resection of paranasal sinus or skull base neoplasm from 2007 to 2013.

Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center.

Participants Fifty-eight consecutive patients.

Main Outcome Measures Postoperative complications were categorized as cerebrospinal fluid (CSF) leak, pituitary, orbital, intracranial, or sinonasal. Complications were temporally categorized as “perioperative” (within 1 week), “early” (after 1 week and within 6 months), or “delayed” (after 6 months).

Results The most common perioperative complications were diabetes insipidus (19.0%), CSF leak (5.2%), and meningitis (5.2%), with resolution rates of 75%, 100%, and 100%, respectively. Overall, CSF leak occurred in 13.8% of patients and resolved in all cases. A total of 53.8% of all complications were evident within 1 week of surgery. Chronic rhinosinusitis was the most common delayed complication (3.4%). Hypopituitarism and delayed complications were less likely to resolve (p = 0.014 and p = 0.080, respectively).

Conclusions Monitoring of complications after endoscopic skull base surgery should focus on neurologic complications and CSF leak in the early postoperative period and development of chronic rhinosinusitis in the long term. Late-onset complications and hypopituitarism are less likely to resolve.