Rhinologic outcome of endoscopic transnasal-transsphenoidal pituitary surgery: an institutional series, systematic review, and meta-analysis

Purpose We aimed to summarize the available data on the objective rhinologic outcome after endoscopic transnasal-transsphenoidal (ETT) surgery. Methods Retrospective study on a consecutive cohort of treatment-naïve patients undergoing ETT pituitary gland surgery. Additionally, a systematic review and meta-analysis with focus on the rhinologic outcome, including postoperative smell function was performed. Results The institutional series incorporated 168 patients. A concomitant endoscopic septoplasty was performed in 29/168 patients (17.3%). A nasoseptal flap was used for reconstruction of large skull-base defects or high-flow CSF leaks in 4/168 (2.4%) patients. Early postoperative rhinologic complications (< 4 weeks) included epistaxis (3%), acute rhinosinusitis (1.2%) and late postoperative complications (≥ 8 weeks) comprised prolonged crusting (15.6%), symptomatic synechiae (11.9%) and septal perforation (0.6%). Postoperative smell function was not impaired (Fisher’s exact test, p = 1.0). The systematic review included 19 studies on 1533 patients with a median postoperative epistaxis rate of 1.4% (IQR 1.0–2.2), a postoperative acute rhinosinusitis rate of 2.3% (IQR 2.1–3.0), a postoperative synechiae rate of 7.5% (IQR 1.8–19.1) and a postoperative septal perforation rate of 2.2% (IQR 0.5–5.4). Seven studies including a total of 206 patients reported adequate outcome measures for smell function before and after ETT surgery. Only 2/7 studies reported an impairment of smell function postoperatively, especially in patients with nasoseptal flap harvesting. Conclusion Early and late postoperative rhinologic complication rates after ETT surgery for pituitary lesions seem to be low. A thorough evaluation of smell function, in particular in patients at risk for nasoseptal flap harvesting, may be an important factor in optimal postoperative care

Pretherapeutic Assessment and Risk Stratification of Primary Sinonasal Malignancies

Primary sinonasal tumors, are rare malignancies (3-5% of all head and neck cancers) and require a comprehensive oncological workup and interdisciplinary management. Besides a nasal endoscopy and cranial nerve status, a state-of-the art cross-sectional imaging assessment is mandatory. This assessment should incorporate computed tomography (CT), magnetic resonance imaging (MRI) and hybrid wholebody 18F-fluoro-deoxy-D-glucose (FDG) positron emission tomography (PET) imaging. In recent years, FDG-PET/MRI has emerged as a promising modality, since it simultaneously addresses the need for high soft tissue contrast in the paranasal sinuses and skull base, while allowing for whole-body staging, including the skull base and brain. The pretherapeutic assessment should then be complemented by a representative tumor biopsy and exploration of the tumor under general anesthesia. Owing to the rarity of the disease, the specimen should be examined by a dedicated head and neck pathologists at a tertiary referral center. In addition, a biopsy under general anesthesia allows for a thorough exploration of the tumor to assess its epicenter and relationship to adjacent structures, such as the medial orbital wall and skull base. Knowledge of orbital and skull base infiltration is of uttermost importance for sinonasal tumor staging, as it defines the T category and hence serves as a strong predictor of the 5-year diseasespecific survival. As we could show, even state-of-the-art cross-sectional imaging leads to false-positive and false-negative findings regarding orbital and dural infiltration, which underlines the importance of an exploration under general anesthesia. Treatment plans should be discussed with an interdisciplinary tumor board, in order to achieve maximal control of the primary tumor, which is the most common cause of treatment failure. After completion of treatment, a close clinical and radiological follow-up in order to manage treatment-associated complications and to diagnose tumor persistence / recurrence is mandatory

Diagnostic pathway and stage migration of sinonasal malignancies in the era of the COVID-19 pandemic

Objectives The COVID-19 pandemic bears the risk of delayed cancer diagnoses. Methods Study on the diagnostic pathway of sinonasal malignancies during the COVID-19 pandemic. Results Median time from first symptom to treatment initiation was not increased during the pandemic: 137 days (interquartile range [IQR] 104-193) vs 139 days (IQR 103-219) (P = .60). Median time from first appointment at our institution to treatment initiation was even reduced in 2020: 18 days (IQR 11-25) vs 11 days (IQR 7-17) (P = .02). A trend toward advanced tumor stages during the pandemic was seen: 11/30 patients (36.7%) ≥ stage 4 in 2018 to 2019 vs 12/19 patients (63.2%) ≥ stage 4 in 2020 (P = .064). Conclusion Both, time to diagnosis and time to treatment initiation were similar during the pandemic. However, a higher proportion of advanced tumors stages was observed. Despite the pandemic, we provided a swift diagnostic workflow, including a virtual tumor board decision and a prompt treatment initiation. Level of Evidence: 4

Reduction of otorhinolaryngological consultations due to the COVID-19 lockdown and its impact on disease progression

OBJECTIVES To compare consultations at the Otorhinolaryngological Department at a tertiary referral centre between the COVID-19 lockdown in 2020 and the same period in 2019, as well as to study the impact of deferring visits on disease progression. METHODS The emergency consultations during these time periods were analysed retrospectively. The effect of postponing appointments on disease progression was examined for 122 patients with chronic rhinosinusitis, for 50 patients with a benign tumour and for 22 patients with the diagnosis of a malignant tumour. To compare disease progression, patients with the diagnosis of a malignant tumour were matched to patients seen over the same period in 2019. RESULTS During the lockdown, a reduction of 44.1% in emergency consultations compared with 2019 was observed. The largest significant decrease of consultation numbers was seen for otitis media and for Eustachian tube dysfunction. Fewer patients with tonsillitis sought emergency assistance; however, no difference in frequency of abscesses was observed. Disease progression was seen in 44.4% of patients with chronic rhinosinusitis. In 2020, 18.8% of patients with the diagnosis of a malignant tumour showed disease progression, yet no difference from the previous year was observed. CONCLUSION Fewer emergency consultations took place during the COVID-19 lockdown; among others, there were fewer visits due to otitis media and tonsillitis. However, no change in the incidence of complications was noted. Almost 50% of patients with chronic rhinosinusitis showed disease progression, leading to prolonged suffering due to the rescheduling of appointments. The treatment of patients with the diagnosis of a malignant tumour was not affected by the postponement of consultations

The Monocle Sign in FDG-PET: A Sign of Contralateral Facial Nerve Palsy

We report three cases of unilateral F-FDG uptake in the orbicularis oculi muscle in subjects with contralateral peripheral facial nerve palsy. We argue that this asymmetric uptake pattern in fact reflects lack of metabolism on the side affected by facial nerve palsy, owing to denervation. Since the unilateral periorbital uptake resembles a monocle, we chose to call this finding the monocle sign. The monocle sign should not be confused with inflammation or tumor, but should prompt a neurological assessment for facial nerve palsy and a potential underlying disease

The Role of Regional Disease and Patterns of Treatment Failure in Primary Sinonasal Malignancies

BACKGROUND The question how to treat the clinically negative neck in sinonasal malignancies is controversial. OBJECTIVES To investigate patterns of treatment failure and to assess outcome measures in patients with primary sinonasal malignancies. METHODS Retrospective cohort study of patients treated for primary malignant sinonasal malignancies. RESULTS Lymph node (LN) metastases at initial presentation were present in 8 of 152 patients (5.3%). Ipsi- and contralateral LN levels 1 and 2 were identified as nodal basins at risk. We found a 5-year overall survival (OS) of 75.2% and disease free survival of 61.1%. Among patients with cN0 neck, nodal recurrence free survival was not different between patients with and without elective neck treatment (P  =  .23). On logistic regression analysis, we found initial T classification as an independent factor for achievement of complete remission (CR) and OS. CONCLUSIONS LN metastases at initial presentation are rare and initial T classification was identified as the most important prognostic factor for OS and CR, emphasizing the need for a thorough initial staging of the primary tumor

Need for long‐term follow‐up in sinonasal inverted papilloma: A Single‐institution experience

Background: Most studies on sinonasal inverted papillomas (SNIPs) regarding risk factors for recurrence, recurrence rates (RRs) and malignant transformation are biased by a significant proportion of revision cases. Methods: Retrospective study on patients with consecutive, treatment-naïve SNIPs at a tertiary referral center between 1999 and 2019. Results: Overall, RR was 9.8% (10 of 102 patients), with 2 of 10 recurrences (20%) occurring after more than 5 years. Histopathological workup revealed synchronous malignancy in 2 of 102 patients (2%). Subgroup analysis revealed a significantly higher RR for SNIPs involving the frontal sinus (26.3% vs 6.0%, P = .02). No SNIPs primarily originating from the frontal sinus were observed. Conclusion: Overall, RR of treatment-naïve SNIPs is comparably low; however, long-term follow-up is mandatory due to late recurrences. Secondary involvement of the frontal sinus was identified as risk factor for recurrence. No SNIPs primarily originating from frontal sinus were observed

Diagnostic accuracy of computed tomography and magnetic resonance imaging compared to surgical exploration for anterior skull base and medial orbital wall infiltration in advanced sinonasal tumors

BACKGROUND Knowledge of medial orbital wall (MOW) and anterior skull base (ASB) infiltration is of uttermost importance for staging and therapy planning of advanced sinonasal tumors. METHODS We assessed the diagnostic performance of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) for MOW and ASB infiltration compared to intraoperative exploration. RESULTS Both CT and MRI yielded higher diagnostic accuracy for MOW infiltration (Reader 1: 83.6% CT; 89.0% MRI, Reader 2: 91.8% CT, 93.2% MRI) than for ASB infiltration (Reader 1: 82.2% CT, 82.2% MRI, Reader 2: 67.7% CT, 67.7% MRI). Both modalities were equal to the gold standard, except for ASB assessment by Reader 2 with MRI. A postoperative change of T classification is common (Reader 1: 28.8%, Reader 2: 31.5%). CONCLUSIONS CT and MRI are accurate methods for the assessment of MOW infiltration. ASB assessment is challenging and false-positive and false-negative findings are common with both methods, emphasizing the need for intraoperative exploration

Does Length Matter? A Comparison of Rapid Rhino™ Nasal Packings for the Treatment of Epistaxis

Background Epistaxis is the most common otorhinolaryngologic emergency around the world. A broad variety of treatment options is available; ranging from conservative measures such as cauterization and nasal packings to surgery. For posterior epistaxis, nasal packings are usually the preferred initial treatment method. There are 2 different models of the widely used Rapid Rhino™ packing available at our department; the 7.5 cm, single-lumen, and the 9 cm, double-lumen variant with 2 separately inflatable balloons. Identifying whether one packing is superior to the other will help with the choice of the best possible treatment. Objective The goal of this study was to determine whether the new, double-lumen model had advantages compared to its shorter counterpart. Methods All patients treated with Rapid Rhino™ packings for spontaneous epistaxis between December 2005 and October 2017 were analyzed for various parameters such as recurrence rates, hospitalization rate, and duration of in-patient stay. The groups were divided by model and whether patients were treated before or after the introduction of the double-lumen version (December 2010). Results A total of 865 cases of patients treated with Rapid Rhino™ packs were analyzed. Before December 2010, 210 of 372 cases (56%) were hospitalized, whereas afterwards it was only 48% (235/493; P = .01). The duration of the in-patient stay decreased from 3.7 to 3.1 days (P < .01). There was no difference in recurrence rates. Conclusion The introduction of the double-lumen, 9 cm Rapid Rhino™ packing has led to a decrease of in-patient time and to less hospitalizations. Therefore, it should be preferred to the shorter, single-lumen model in the treatment of posterior epistaxis

Surgery as Single-Modality Treatment for Early-Stage Olfactory Neuroblastoma: An Institutional Experience, Systematic Review and Meta-analysis

Background For olfactory neuroblastoma (ONB), the combination of surgical tumor resection and radiation therapy (RT) has been considered the “gold standard” in treatment protocols intended to cure. Objective To summarize evidence on the treatment of ONB using surgery alone. Methods A retrospective institutional case series, a systematic review of the literature, and an individual patient data (IPD) meta-analysis on only surgically treated ONB patients. Results At our institution, a total of 10 patients were treated through surgery alone and remained alive and free of disease at last follow-up. The IPD meta-analysis on 128 patients revealed a disease-free survival (DFS) and overall survival (OS) of 67.7% and 75.4% at 5 years and 57.1% and 71.9% at 10 years, respectively. Univariate analysis showed that Kadish stage C/D and Hyams grading III//IV significantly affected OS (P = 0.000 and P = 0.000) and DFS (P = 0.000 and P = 0.002). For low-risk patients, the DFS was 80.6% at 5 years and 67.8% at 10 years, respectively. Conclusions Surgery alone is an equivalent alternative to combined treatment in carefully selected low-risk ONB patients with better outcome measures than previously reported. </jats:sec