Capillary Blood Gas Measurement as a Novel Means of Assessing Flap Perfusion in Free Tissue Transfer

CAPILLARY BLOOD GAS MEASUREMENT AS A NOVEL MEANS OF ASSESSING FLAP PERFUSION IN FREE TISSUE TRANSFER. Aaron K. Remenschneider and Douglas A. Ross (Sponsored by Dr. Clarence Sasaki). Section of Otolaryngology, Department of Surgery, Yale University, School of Medicine, New Haven, CT. To demonstrate that in comparison to implantable O2 microelectrodes, Capillary Blood Gas measurements represent a reliable, accessible and easy method of identifying failing free flaps, and furthermore, to assess post-operative free-flap monitoring techniques nation-wide, determining the openness of surgeons to new surveillance modalities. Groin fasciocutaneous flaps were elevated in 10 rats and following arterial or venous occlusion, oxygen microelectrode measurements (pO2 and flow) and Capillary Blood Gas measurements (pO2, pCO2, pH, HCO3) were obtained at 0, 10 and 20 minutes. A nine question, Internet based survey on post-operative flap surveillance techniques was sent to the personal email addresses of 238 microvascular surgeons from around the country. Response data were collected and analyzed utilizing an online resource. Measurements with capillary blood gas paralleled measurements with O2 microelectrodes. Average capillary blood gas pO2 fell from 42.72 mm Hg at 10 minutes and then to 28.67 mm Hg at 20 minutes. Average pH fell from 7.38 to 7.33 at 10 minutes and to 7.30 at 20 minutes. Results were statistically significant with both the paired Students t test and the Wilcoxon signed rank test. 75% of survey respondents indicated that clinical assessment was more important than available adjunctive tests in the decision to re-explore the vascular pedicle in a threatened free flap and 56% listed pinprick with flap bleeding as an important marker of flap health in their practice. 90% of respondents indicated they are open to new quantitative monitoring techniques. While providing users the ability to simultaneously monitor accepted modalities of flap surveillance, pH and pO2, the capillary blood gas is a reliable and reproducible marker of flap tissue health. Given that no single monitoring modality enjoys a clear preference among microvascular surgeons and that more than half of these surgeons already utilize pinprick assessment of the flap, this study demonstrates that the capillary blood gas may be well positioned for further study in humans

Metastatic Renal Cell Carcinoma to the Sinonasal Cavity: A Case Series

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

Delayed Endovascular Coil Extrusion following Internal Carotid Artery Embolization

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

Skull base erosion and associated complications in sphenoid sinus fungal balls

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

International Survey of Operative Practices for Otologists and Neurotologists During the COVID-19 Crisis

OBJECTIVE: To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally. STUDY DESIGN: Cross-sectional survey. METHODS: A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition. RESULTS: Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria. Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p \u3c 0.001). 71.5% of providers did not perform an elective otologic or neurotologic operative procedure during the initial crisis period. 49.8% reported modifying their surgical technique due to the COVID-19 pandemic. Use of powered air-purifying respirators and filtering facepiece 2 or 3 (FFP2/FFP3) respirators were in minimal supply for 66.9% and 62.3% of respondents, respectively. CONCLUSION: The COVID-19 pandemic impacted the otology and neurotology community globally, resulting in significant changes in operative volume and case selection. Modification of surgical technique and shortages of personal protective equipment were frequently reported

Plasmacytoma of the Clivus Presenting as Bilateral Sixth Nerve Palsy

Background and Importance Plasmacytomas are monoclonal proliferations of plasma cells that may arise within soft tissue or bone. The skull base is a rare site for plasmacytomas to occur, and few cases have been reported in the literature. When present in the skull base, plasmacytomas may result in cranial neuropathies and often progress to multiple myeloma more rapidly than other intracranial or skeletal plasmacytomas. Clinical Presentation A 69-year-old man presented with a primary complaint of diplopia and an examination consistent with bilateral abducens nerve palsy. No other deficits were noted. Magnetic resonance imaging of the skull base demonstrated a large T1 isointense moderately enhancing lesion centered within the clivus. Endoscopic biopsy of the mass revealed sheets and aggregates of mature monoclonal plasma cells. The patient's initial systemic work-up revealed that this was a solitary lesion, and he was treated with radiation therapy to the skull base with a durable local effect at 18-month follow-up. Unfortunately he progressed to multiple myeloma with peripheral osteolytic lesions but has been stabilized on chemotherapeutics. Conclusion: The clivus is an unusual site for intracranial plasmacytomas, and enhancing lesions must be differentiated from chordoma. Characteristic findings on histopathology include an immunoglobulin light-chain restricted clonal proliferation of plasma cells. Treatment is most commonly radiotherapy with surgery reserved for biopsy and palliation. Clinicians should be aware of the increased risk of progression to multiple myeloma in skull base plasmacytomas

Blunting of the Anterior Tympanomeatal Angle Following Tympanoplasty

Outcomes following tympanoplasty procedures are variable and depend on the duration, etiology, and location of the perforation as well as the approach for tympanic membrane (TM) grafting (1). Complications following tympanoplasty, including infection, canal stenosis, and lateralization of the graft are known to impact postoperative hearing outcomes (1). “Blunting” is an additional postoperative complication that may compromise the viability and sound conduction properties of the reconstructed TM (1). Blunting occurs when there is loss of the normally acute (45–50 degrees) anterior tympanomeatal angle (ATMA) at the junction between the TM and external auditory canal (EAC) (2)

Ossicular joint histopathology in cases of age‐related hearing loss

Abstract Objectives Age‐related hearing loss (presbycusis) is a prevalent condition traditionally attributed to inner ear dysfunction. Little is known about age‐related changes in the ossicular joints or their contribution to presbycusis. Herein, we performed an otopathologic evaluation of the ossicular joints in cases of presbycusis without a clear sensorineural explanation. Methods Histopathologic analysis of the incudomallear (IM) and incudostapedial (IS) joints was performed in specimens from the National Temporal Bone Registry with audiometrically confirmed presbycusis but without histologically observed sensorineural, strial, or mixed features; deemed cases of “indeterminate” presbycusis. Specimens identified as “indeterminate” presbycusis (IP, n = 18) were compared to specimens with histologically confirmed sensorineural presbycusis (n = 16) and strial presbycusis (n = 11). Presbycutic specimens were also compared to age‐matched controls (n = 9) and young controls (n = 14). Results The synovial space at the center of the IM joint was wider in the IP group (194 ± 36.8 μm) compared to age‐matched controls (138 ± 36.5 μm), young controls (149 ± 32.2 μm), and ears with sensorineural presbycusis (148 ± 52.7 μm) (p < .05). The synovial space within the IS joint was wider in the IP group (105 ± 33.0 μm) when compared to age‐matched controls (57.9 ± 13.1 μm) and ears with sensorineural presbycusis (62.3 ± 31.2 μm) (p < .05). Conclusion IP ears have wider IM and IS joints when compared to ears with sensorineural presbycusis and age‐matched controls. Findings point to a potential middle ear source of high frequency conductive hearing loss in a subset of presbycutic ears. Level of Evidence Retrospective study