Language of Lullabies: The Russification and De-Russification of the Baltic States

This article argues that the laws for promotion of the national languages are a legitimate means for the Baltic states to establish their cultural independence from Russia and the former Soviet Union

Craniopharyngioma surgery for rhinologists

PURPOSE OF REVIEW: Craniopharyngiomas are rare tumors that that present with loss of pituitary function in most cases. They present in a bimodal age distribution and the most common treatment paradigms include gross total resection or subtotal resection followed by radiation. Endoscopic transnasal access to intradural tumors has become increasingly common due to improvements in equipment, increased familiarity with the surgical corridor and anatomy, and reconstruction techniques. As such, rhinologists play an increasingly important role in the management of craniopharyngiomas. RECENT FINDINGS: Recent years have highlighted our growing experience with pediatric endonasal skull base surgery. Prior concerns including sphenoid pneumatization, midfacial growth restrictions, and intercarotid space limitations have been studied more extensively. It has been found that there are no increased complications with lack of sphenoid pneumatization, no changes to midfacial growth with endonasal techniques, and the inter-carotid distance is stable after around age 5. Advances in surgical and skull base reconstruction techniques and intraoperative monitoring have reduced the risks of complications from surgery. SUMMARY: Rhinologists play an important role in craniopharyngioma surgery. The approach to and reconstruction after tumor removal are vital portions of the procedure that allow for resection and prevent postsurgical complications

Carcinosarcoma of the nasal cavity and paranasal sinuses: Review of the national cancer database

Abstract Background Carcinosarcomas are rare, aggressive malignancies that can arise in the nasal cavity and paranasal sinuses. There are limited outcome data available. Accordingly, we sought to use the National Cancer Database (NCDB) to characterize patient demographics and outcomes. Method A retrospective analysis of the NCDB from 2004 to 2016 for patients with sinonasal carcinosarcoma was conducted. Results Thirty patients were included. The patients were predominantly male (n = 20), white (n = 23), and privately insured (n = 15), with an average age of 62.4 years. The nasal cavity was the most common subsite (n = 14), followed by the maxillary sinus (n = 8). Most patient were treated with surgery followed by radiation (n = 23), with the remaining undergoing surgery alone (n = 4), radiation alone (n = 2), or no treatment (n = 1). One‐third (n = 10) received adjuvant chemotherapy. The 1‐ and 5‐year overall survival (OS) in the cohort were 79.2% and 43.3%, respectively. Univariate log‐rank testing showed OS varied based on intervention (P < 0.029), sex (P < 0.042), and age (P < 0.025), while on multivariate analysis none of these factors independently predicted OS. Conclusions We describe the demographics and presenting features of a national cohort of sinonasal carcinosarcoma patients. Future research is needed to identify predictors of overall survival, and to assess the optimal roles for radiation and systemic chemotherapy

Sinonasal Inverted Papilloma and Squamous Cell Carcinoma: Contemporary Management and Patient Outcomes

Inverted papillomas (IP) are the most common sinonasal tumor with a tendency for recurrence, potential attachment to the orbit and skull base, and risk of malignant degeneration into squamous cell carcinoma (SCC). While the overall rate of recurrence has decreased with the widespread adoption of high-definition endoscopic optics and advanced surgical tools, there remain challenges in managing tumors that are multiply recurrent or involve vital neurovascular structures. Here, we review the state-of-the-art diagnostic tools for IP and IP-degenerated SCC, contemporary surgical management, and propose a surveillance protocol

Using Ipratropium Bromide Nasal Spray Response as a Screening Tool in the Diagnostic Workup of Cerebrospinal Fluid Rhinorrhea

OBJECTIVES: Unilateral clear thin rhinorrhea (UCTR) can be concerning for a nasal cerebrospinal fluid (CSF) leak. Beta-2 transferrin electrophoresis has been the gold standard for initial non-invasive confirmatory testing for CSF rhinorrhea, but there can be issues with fluid collection and testing errors. Ipratropium bromide nasal spray (IBNS) is highly effective at reducing rhinitis-related rhinorrhea, and should presumably not resolve CSF rhinorrhea. This study assessed whether different clinical features and IBNS response helped predict presence or absence of CSF rhinorrhea. METHODS: A prospective cohort study was conducted where all patients with UCTR had nasal fluid tested for beta-2 transferrin, and were prescribed 0.06% IBNS. Patients were diagnosed with CSF rhinorrhea or other rhinologic conditions. Clinical variables like IBNS response (rhinorrhea reduction), positional worsening, salty taste, postoperative state, female gender, and body-mass index were assessed for their ability to predict CSF rhinorrhea. Sensitivity, specificity, and predictive values and odds ratios were calculated for all clinical variables. RESULTS: Twenty patients had CSF rhinorrhea, and 53 had non-CSF etiologies. Amongst clinical variables assessed for predicting CSF absence or presence, significant associations were shown for IBNS response (OR = 844.66, p = 0.001), positional rhinorrhea worsening (OR = 8.22, p = 0.049), and body-mass index ≥30 (OR = 2.92, p = 0.048). IBNS response demonstrated 96% sensitivity and 100% specificity, and 100% positive and 91% negative predictive values for predicting CSF rhinorrhea. CONCLUSIONS: In patients with UCTR, 0.06% IBNS response is an excellent screening tool for excluding CSF rhinorrhea, and should be considered in the diagnostic workup of CSF rhinorrhea. LEVEL OF EVIDENCE: 2 Laryngoscope, 2023

The Impact of Preoperative Frailty on Endoscopic Cerebrospinal Fluid Leak Repair Outcomes in the Anterior Skull Base

Background: Measurements of surgical frailty estimate a patient\u27s ability to withstand the physiologic stress of a procedure. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair. Methods: Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indexes, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission. Results: A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average BMI was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). The average duration of leak was 9.31 ± 22.14 months. 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and definitively diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes (myocardial infarction, cerebrovascular accident, pneumonia, pulmonary embolism/deep vein thrombosis, and meningitis), surgical outcomes (bleeding requiring transfusion, postoperative CSF leak), or readmission (all p \u3e 0.05). Discussion: Endoscopic CSF leak repair in a frail population, including lumbar drain placement and postoperative bedrest, did not have an increased rate of complications. Previous data suggests there are increased complications in open craniotomy procedures in patients with significant comorbidities. Our preliminary data suggests that the endoscopic approach to CSF leak repair may be better tolerated in the frail population

Rapidly Injecting 10 MG of Intrathecal Fluorescein Caused No Neurologic Complications

Background: Intrathecal fluorescein (ITF) is often effective in localizing nasal cerebrospinal fluid (CSF) leaks along the skull base under nasal endoscopy. Previous reports of seizures and paralysis have led to administration practices aimed at minimizing the risk of these potentially catastrophic neurologic complications. Since these early reports, surgeons have often reported injecting ITF slowly over a variable number of minutes, and that it should be diluted either in saline or patients\u27 CSF. However, no study has assessed whether ITF administration duration or dilution alters the risks of these neurologic complications. Methods: From September 2015 through August 2022, all patients undergoing ITF injection through lumbar drains for localization of possible or confirmed nasal CSF leaks were included. All patients had ITF administered by mixing 0.1 mL of 10% fluorescein (10 mg) with 3 to 5 mL of CSF, with no additional fluorescein dilution. The solutions were then injected through lumbar drains rapidly over 1 to 2 seconds. Patient demographics, CSF leak etiologies, and histories of seizures or cerebrovascular accidents were recorded. Results: Sixty-one patients were included, mean age was 56.3 ± 15.6 years, and 82% were female. Fifty patients had CSF leaks repaired successfully, and 11 patients had negative explorations. CSF leaks were due to the following etiologies: idiopathic intracranial hypertension (76%), skull base tumors (10%), accidental trauma (8%), and surgical trauma (6%). Four patients had histories of seizure disorders, and five patients had remote histories of prior cerebrovascular accidents. There were no intraoperative or postoperative episodes of seizure, paralysis, or other neurologic complications. Conclusion: Injecting 10 mg of ITF through lumbar drains rapidly and without true dilution resulted in no seizures, paralysis, or other neurologic complications in patients undergoing endoscopic exploration with or without nasal CSF leak repair