Location Of Sinus Research Articles

Carotid sinus massage in clinical practice: the Six-Step-Method.

Carotid sinus massage (CSM) as integral part of cardiovascular autonomic testing is indicated in all patients > 40 years with syncope of unknown origin and suspected reflex mechanism. However, large practice variation exists in performing CSM that inevitably affects the positivity rate of the test and may result in an inaccurate diagnosis in patients with unexplained syncope. Even though CSM was introduced into medical practice more than 100 years ago, the method of performing CSM is still largely operator- and centre-dependent, while in many places, the test has been entirely abandoned. Here, we describe a standardized protocol on how to perform CSM, which basic monitoring equipment is necessary and why CSM is a safe procedure to perform. Our aim is to create a uniform approach to perform CSM. The new proposed algorithm, the Six-Step-Method, includes: (i) check history for exclusion CSM; (ii) turn head slightly contralaterally and posterior (see also explanatory video and poster provided as Supplementary material; (iii) palpation to identify carotid sinus location; (iv) massage for 10 s; (v) monitoring of blood pressure and heart rate to assess of the haemodynamic response type; and (vi) include time intervals between subsequent massages. Carotid sinus massage should be performed on both the left and right and in the supine and upright position. The recommended equipment to perform CSM consists of: (i) a tilt table in order to perform CSM in supine and standing position, (ii) a continuous blood pressure monitor or cardiac monitor, and (iii) at least two persons.

Risk Factors for Recurrence after Surgical Resection of Sinonasal Inverted Papilloma.

Introduction Sinonasal inverted papilloma (SNIP) is a rare benign epithelial tumor of the nasal cavity and paranasal sinuses that accounts for 0.4% and 4.7% respectively, of all tumors of this anatomical region. Objective To analyze the outcomes after surgical resection of SNIP and identify the risk factors for recurrence in a Swiss tertiary center. Methods We conducted a retrospective review of all cases of SNIP treated at the Lausanne university hospital between 2005 and 2018. All data available on the patients and tumors were collected for analysis. We studied the recurrence rate and looked for risk factors. Results We included 57 patients with a mean age of 55.5 years. There were 46 primary cases (80.7%) and 11 recurrences (19.3%). Maxillary sinus was the most frequent location (33.3%). Approximately half of the patients (52.6%) presented with a T3 tumor according to the Krouse classification. The mean recurrence rate after surgery was of 17.5% and it was more frequent among the patients in the recurrence group (45.5%) than among the primary cases (10.9%), reaching statistical significance (odds ratio [OR] = 6.8; 95% confidence interval [95%CI]: 1.5-30.8; p = 0.0165). Most patients were treated endoscopically (94.7%). Frontal sinus location, higher Krouse stage, and combined approach seemed to increase the risk of recurrence, but without statistical significance. Conclusion Difficult surgical access, as in the case of tumors located in the frontal sinus, higher stage of the disease, and previously operated cases carry the higher risk of incomplete resection and recurrence.

Early Recurrence Adenoid Cystic Carcinoma of Paranasal Sinus, A Case Report

Introduction: Adenoid cystic carcinoma (ACC) of the head and neck is a rare salivary gland tumor. It grows and spreads in silence until causing a symptom. Surgery is still the main treatment of choice although complete resection is hard to achieve most of the time. Case Presentation: This report presents an adult female with ACC of the left hard palate and left maxillary sinus, this patient also had slight lymph nodes enlargement. She underwent sub-total maxillectomy followed by locoregional radiotherapy. The tumor spreads out to vertebral bones within one year and keeps on progressing despite bone radiation. It recurred locally and appeared in the neck lymph node 2 months after bone metastasis. Lung metastasis happened 3 months later and soon she passed away. Mortality happened in less than two years after initial treatment. Conclusion: : High tumor grade, advanced T stage, lymph node involvement, perineural invasion, and paranasal sinus location clearly define poor prognostic factors. In this case, adjuvant radiotherapy for poor prognostic factors ACC doesn’t give any benefit in locoregional control or overall survival.

Risk factors and prognostic models of lymph node metastatic hypopharyngeal squamous cell carcinoma.

To explore the risk factors for lymph node metastasis (LNM) and establish nomograms for predicting survival outcomes and assessing individual risk in patients with LNM and hypopharyngeal squamous carcinoma (HSCC). Clinical data of patients with HSCC were retrospectively reviewed. The study's primary endpoints were overall survival (OS) and disease-specific survival (DSS). Nomograms were established based on Cox regression analyses. The accuracy and calibration ability of the nomograms were evaluated using the C-index, area under the curve, calibration curves, and decision curve analysis. Overall, 2888 patients were enrolled, and the LNM rate was 74.2%. Age ≤ 60 years, male sex, unmarried status, pyriform sinus location, grade III-IV, tumor larger than 4 cm, and advanced T stage increased the risk of LNM. In addition, LNM was a negative prognostic factor for OS and DSS. Ten variables were identified and incorporated into nomograms to estimate OS and DSS. Our nomograms outperformed the traditional staging system in training and validation cohorts. Patients were stratified into risk subgroups based on the OS- and DSS-nomogram scores. Patients in the high-risk subgroup had a higher risk of death and disease-specific mortality than those in the low- and intermediate-risk subgroups. LNM worsens the prognosis of HSCC. This study identified the independent prognostic factors for HSCC with LNM and developed satisfactory OS- and DSS-monogram to provide individual prediction and risk classification for patients with this diagnosis.

Catheter ablation of coronary sinus accessory pathways in the young

Accessory atrioventricular pathways (APs) are the most common tachycardia substrate for supraventricular tachycardia (SVT) in the young. Endocardial catheter ablation of AP may be unsuccessful in up to 5% of patients because of a coronary sinus location. The purpose of this study was to obtain data on ablation of accessory pathways within the coronary venous system (CVS) in the young. Analysis of feasibility, outcome, and safety in patients ≤18 years with coronary sinus accessory pathways (CS-APs) and catheter ablation via CVS in a tertiary pediatric electrophysiological referral center (May 2003 to December 2021) was performed. The control group adjusted for age, weight, and pathway location was established from patients of the prospective European Multicenter Pediatric Ablation Registry who all had undergone endocardial AP ablation. Twenty-four individuals underwent mapping and intended AP ablation within the CVS (age 2.7-17.3 years; body weight 15.0-72.0 kg). Because of proximity to the coronary artery, ablation was withheld in 2 of the patients. Overall procedural success was achieved in 20 of 22 study patients (90.9%) and in 46 of 48 controls (95.8%). Coronary artery injury after radiofrequency ablation was noted in 2 of 22 study patients (9%) and in 1 of 48 controls (2%). In CVS patients, repeat SVT occurred in 5 of 22 patients (23%) during median follow-up of 8.5 years, and 4 of the 5 underwent reablation, resulting in 94.4% overall success. Controls were free from SVT during follow-up of 12 months as defined by the registry protocol. Success of CS-AP ablation in the young was comparable to that of endocardial AP ablation. Substantial risk of coronary artery injury should be considered when CS-AP ablation is performed in the young.

In Reply: Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Systematic Review and Meta-Analysis and International Stereotactic Radiosurgery Society Practice Guidelines.

To the Editor: We appreciate the insights regarding our systematic review and meta-analysis and practice guidelines from the International Stereotactic Radiosurgery Society (ISRS) on stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (dAVFs) in a recent Letter to the Editor by Raper et al.1,2 As noted, our analysis found that SRS was estimated to result in complete obliteration (CO) rates of approximately 70% with very favorable symptom improvement and symptom cure rates of roughly 97% and 79%, respectively. CO rates after SRS compare quite favorably with those with Onyx embolization only per the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) of approximately 55%.3 Of note, multimodality therapy with prior embolization was also noted to be associated with improved symptom cure rates in our analysis, suggesting a potential benefit in the therapeutic ratio for patients with poor prognostic factors for achievement of CO after either SRS or embolization alone. Treatment-related morbidity was also found to be quite limited with incidences of either permanent neurological deficits or hemorrhage after SRS both estimated to be roughly 1%. In our guidelines analysis, we were unable to report on favorable outcomes (as was performed in CONDOR and defined as achievement of CO without hemorrhage) because of lack of patient-level data. As noted, the risk of permanent neurological deficits after SRS compares favorably with embolization with estimates ranging from 4% to 16.1%.3,4 Previous analyses have noted similar rates of hemorrhage after embolization of 1.6%, quite similar to those observed in our analysis after SRS.3 We also noted in our analysis that previous hemorrhage was associated with a higher risk of hemorrhage after SRS similar to findings from CONDOR noting patients with prior hemorrhage had lower rates of favorable outcomes. The favorable risk profile and outcomes of SRS highlighted by our meta-analysis suggest it is an excellent therapeutic option for management of appropriately selected patients with dAVFs. Of note, limitations regarding both our analysis and CONDOR are inclusion of data from experienced and high volume sites that may not be reflective of sites with less experience in management of dAVFs. In the absence of prospective randomized data in part secondary to the rarity of dAVFs, prospective registries are key to further characterize both efficacy and toxicity of SRS for treatment of dAVFs. The prospectively maintained NeuroPoint Alliance SRS registry allows an avenue for analysis of patient-level data and further characterization of the impact of patient, lesion, and treatment characteristics on clinical outcomes after SRS for dAVFs.5 In addition, the International Radiosurgery Research Foundation (IRRF) has a long-standing history of conducting and publishing multi-institutional outcomes on SRS for a variety of indications. On the topic of SRS for dAVFs, the IRRF has published CO rates without hemorrhage ranging from 37% to 80% for 120 patients dependent on the presence of corticovenous reflux (CVR), prior hemorrhage, and noncavernous sinus (NCS) location.6 These findings are similar to our analysis where prior hemorrhage was associated with higher risk of hemorrhage after SRS and NCS dAVF associated with poorer CO and symptom control rates. Another analysis by the IRRF of 131 patients noted inferior CO rates in patients with NCS dAVFs as compared with cavernous sinus (CS) dAVFs with an association with CO and symptom improvement among NCS dAVFs but not among CS dAVFs.7 These findings in combination with those of our analysis suggest a need for improved CO rates, potentially through multimodality approaches for NCS dAVFs. The latency period for dAVFs, similar to arteriovenous malformations treated with SRS, has been characterized through work by the IRRF with similar rates of hemorrhage noted before and after SRS before CO being achieved.8 As noted by Raper et al, counseling on the risk of hemorrhage after SRS during the latency period is key as is patient selection given the association of prior hemorrhage and risk of hemorrhage during the latency period after SRS. Through these successful multi-institutional initiatives through the IRRF, robust clinical evidence has demonstrated the efficacy and safety of SRS for dAVFs. Further studies examining the potential role of multimodality approaches for patients at risk of unfavorable outcomes (particularly those with prior hemorrhages or NCS dAVFs) are warranted.

Application of Surface Landmarks Combined with Image-Guided Sinus Location in the Retrosigmoid Approach and Their Clinic-Image Relationship Analysis.

Objectives During craniotomy for cerebellopontine angle (CPA) lesions, the exact exposure of the margin of the venous sinuses complex remains an essential but risky part of the procedure. Here, we revealed the exact position of the asterion and sinus complex by combining preoperative image information and intraoperative cranial landmarks, and analyzed their clinic-image relationship. Methods Ninety-four patients who underwent removal of vestibular schwannoma (VS) through retrosigmoid craniotomies were enrolled in the series. To determine the exact location of the sigmoid sinus and the transverse sinus and sigmoid sinus junction (TSSJ), we used preoperative images, such as computed tomography (CT) and/or magnetic resonance imaging (MRI) combined with intraoperative anatomical landmarks. The distance between the asterion and the sigmoid sinus was measured using MRI T1 sequences with gadolinium and/or the CT bone window. Results In 94 cases of retrosigmoid craniotomies, the asterion lay an average of 12.71 mm on the posterior to the body surface projection to the TSSJ. Intraoperative cranial surface landmarks were used in combination with preoperative image information to identify the distance from the asterion to the sigmoid sinus at the transverse sinus level, allowing for an appropriate initial burr hole (the margin of the TSSJ). Conclusion By combining intraoperative anatomical landmarks and preoperative image information, the margin of the TSSJ, in particular, the inferior margin of the transverse sinus, can be well and thoroughly identified in the retrosigmoid approach.

Maxillary Sinus Mucopyocele: About an Endoscopic Management

Introduction: Mucocele is a benign but expansive cystic formation, lined by a respiratory epithelium. When its content is infected, it is called a mucopyocele. It usually develops in the frontal-ethmoid complex. The maxillary sinus location is exceptional.
 Case report: a 43 year old man, presented with chronic unilateral nasal obstruction, purulent rhinorrhea and anosmia. Rhinoscopy showed a bulge in the middle meatus. The computed tomography (CT) showed complete filling of the left maxillary with low-density mass. Magnetic resonance imaging (MRI) confirmed the diagnosis of mucpyeocele of the left maxillary sinus. Patient underwent endoscopic endonasal marsupialization with complete recovery.
 Conclusion: Mucopyocele of the maxillary sinus is a benign rare lesion, however destructive. A radiological assessment is essential to guide the choice of surgical treatment. The endonasal route remains the reference treatment for this pathology.

Frontal sinus foreign body. A systematic review

Introduction and objective: Accidents with foreign bodies of all types have been described in most parts of the body. The presence of foreign bodies (FB) are common complaints in urgent and otorhinolaryngology consultations. The most common places are the natural head and neck cavities. The objective of this study is to know the situation of the foreign body in front sinus. Method: We conducted a search in PubMed, Cochrane, Scopus and WoS, selecting those articles in which the existence of foreign bodies in the frontal sinus was mentioned. Results: Of the 72 articles identified by means of information sources, 34 were excluded because they are not clinical cases, determining a selection of 38 clinical cases. Of these, 35 excluded for not complying with inclusion criteria. 3 Full-text articles assessed for eligibility. Of this, 2 Records excluded for not being related to the topic under study, only one case remaining. Discussion: Of the articles found there are few studies about foreign bodies located in frontal sinus. One of the first published cases dates from 1967, in Bristol, England. Conclusions: Accidents with foreign bodies are common in ENT clinical practice, however, in sinus location are very rare. The maxillary sinus is the most common site. Although the frontal sinus is more prominent on the face. Foreign bodies are rare. Most of them result from trauma by accident, gunshot or surgery or dental treatment. Accidents with foreign bodies are common in ENT clinical practice, however, in sinus location are very rare.

Pneumosinus Dilatans: A Novel Algorithm for its Classification and Management.

Pneumosinus dilatans (PD) is a rare condition in which one or more paranasal sinuses are pathologically hyperaerated. Patients commonly present with an aesthetic complaint, however it has been associated with several serious conditions. The etiology is largely theoretical and the management remains unstandardized, potentially leading to missed diagnoses. This article aims to establish a presumptive classification scheme and management algorithm based on a comprehensive review of the literature. A systematic review of all available publications on the search term "Pneumosinus dilatans" was conducted in PubMed. Associated conditions were identified and clustered based on the number and anatomic location of the sinuses involved. The resultant data was used to formulate an evidence-based algorithm for the evaluation and management of PD patients. A total of 145 patients from 103 articles were included. The majority of patients were male (57.2%) with an average age of 32.6 years-old at onset. The frontal sinus was most commonly involved (62.8%) and one pathologic sinus was most common (84.6%). 51% of patients presented with an associated condition; with it least common in frontal sinus PD (29.7% cases) and most common in ethmoid sinus PD (81.5%). To date, no articles to date have proposed a management algorithm for PD based on the number or location of sinus involved. A standardized evidence-based management algorithm and classification scheme for patients with PD will not only lead to the highest-quality treatment, but will also be instrumental in elucidating an etiology for this rare, and potentially serious, condition.

Proof-of-Concept Comparative Dosimetric Analysis of Coplaner Horizontal-Port Carbon-Ion Radiotherapy in the Head and Neck

Carbon-ion radiotherapy (CIRT) may offer improved treatment of radioresistant disease in complex anatomy, such as in head and neck (H&N) cancer. Nonetheless, center cost remains prohibitive. A compact center implementing only horizontal ports has been theorized; coplaner irradiation may improve target coverage. As proof of concept, horizontal+coplaner (H+C) treatment was dosimetrically compared in variously located, complex H&N cases, to evaluate feasibility of this approach. 3 previously-treated patients with adenoid cystic carcinoma (ACC) (L. maxillary sinus, R. parotid, upper R. sinus), 1 with R. nasal angiosarcoma, and 1 with R. parotid adenocarcinoma, were selected. A H+C plan was developed on identical CIRT software per standard. Prescription dose was maintained (64-70.4 Gy (RBE)). Bed roll of +/-30 degrees and off-medial transcranial irradiation were employed to improve targeting and organ at risk (OAR) protection. OAR limits included a Dmax 40 Gy (RBE) with V40 20% for optic nerves and chiasm and Dmax 30 Gy (RBE) for brain stem. Individual dose-volume histograms (DVH) were qualitatively compared. PTV and GTV coverage varied <1% in all cases, with comparable DVHs. Stem dose was below Dmax 30 Gy (RBE) in all patients, with reduced H+C dose noted in the upper R. sinus and L maxillary sinus ACC patients (Dmax 6.8 vs 14.7 Gy (RBE) and 1.3 vs 17.8 Gy (RBE), respectively). H+C unilateral optic nerve dose was above the Dmax limit of 40 Gy (RBE) in the upper R sinus and L maxillary sinus ACC cases as well (40.4 vs 37.0 Gy (RBE) and 45.7 vs 46.2 Gy (RBE), respectively). In the latter case, left H+C optic nerve V40 dose exceeded the 20% limit, at 21.6% vs 3.6% standard. In the former, the upper sinus location increased bilateral eye irradiation: V10 rose from 57% and 0% to 100% each, with Dmax increased to 51.7 from 47 Gy (RBE) in the right, and 30.9 from 8 Gy (RBE) in the left. The sarcoma case experienced increased H+C chiasm Dmax to 28.7 from 1.8 Gy (RBE), below the 40 Gy (RBE) limit. H+C irradiation raised all V5, V10, and V20 brain dosages, with averages of 16.2 vs 2.2%, 10.9 vs 1.5%, and 2.8 vs 0.8%, respectively. Maximums of 25%, 20%, and 7% were noted in the right parotid ACC. Adequate CIRT dose delivery with protection of key OARs in complex H&N cancer appears feasible using only a horizontal port with coplaner approach. Dose increase could be seen in optic nerves and eyes when near or obstructing tumor from the port, highlighting disease location and anatomical limitations of treating solely within the horizontal plane. Increased brain dosage was noted in all cases. The impact of low-dose high-LET CIRT on neural tissue requires further exploration prior to deployment of a coplaner approach. Potentials such as sitting-up immobilization for anteroposterior delivery may mitigate the limitations seen here. A larger cohort analysis is in progress.

Magnetic resonance venography for 3-dimensional live guidance during venous sinus stenting

PurposeThe purpose of this study was to report the technique for intraprocedural guidance of endovascular Venous Sinus Stenting procedures using 3-Dimensional (3D) Magnetic Resonance Venography (MRV) as an overlay on live biplanar fluoroscopy.Materials and methodsVenous sinus stenting procedures performed between April and December, 2017 with 3D MRV fusion for live guidance were reviewed in this study. A thin-slice, contrast-enhanced MR Venogram was used to create 2 3D models – vessels and skull – for procedural guidance via augmented fluoroscopy (Vessel ASSIST, GE Healthcare, Chicago, IL). The skull model was used in the registration of the 3D overlay on both the frontal and lateral planes, which required 1–2 min of procedural time. The vessel model was used to mark landmarks such as the cortical vein ostia and stenosis on the 3D overlay fused with biplanar fluoroscopy.The retrospective imaging review was conducted by 3 neurointerventionalists and relied on a consensus confidence ranking on a 3-point Likert scale from 1- low confidence to 3- high confidence. The neurointerventionalists first reviewed the conventional 2-dimensional pre-stent deployment fluoroscopy images and then reviewed the corresponding images with the 3D MRV overlay. They ranked their confidence in their understanding of cortical venous anatomy for each group. Statistical analysis was performed using a Paired T Test at a 99% confidence interval.ResultsTen cases were included in the retrospective image review. Operator confidence regarding the location of cortical veins was significantly increased using 3D MRV fusion during venous sinus stenting procedures (1.9 vs 2.9, p = .001).Conclusion3-Dimensional MRV fusion is feasible and helpful in understanding the venous sinus anatomy and location of important cortical veins during venous sinus stenting procedures.

A Proposed Grading Scale for Predicting Outcomes After Stereotactic Radiosurgery for Dural Arteriovenous Fistulas

There are presently no grading scales that specifically address the outcomes of cranial dural arteriovenous fistula (dAVF) after stereotactic radiosurgery (SRS). To design a practical grading system that would predict outcomes after SRS for cranial dAVFs. From the International Radiosurgery Research Foundation (University of Pittsburgh [41 patients], University of Pennsylvania [6 patients], University of Sherbrooke [2 patients], University of Manitoba [1 patient], West Virginia University [2 patients], University of Puerto Rico [1 patient], Beaumont Health System 1 [patient], Na Homolce Hospital [13 patients], the University of Virginia [48 patients], and Yale University [6 patients]) centers, 120 patients with dAVF treated with SRS were included in the study. The factors predicting favorable outcome (obliteration without post-SRS hemorrhage) after SRS were assessed using logistic regression analysis. These factors were pooled with the factors that were found to be predictive of obliteration from 7 studies with 736 patients after a systematic review of literature. These were entered into stepwise multiple regression and the best-fit model was identified. Based on the predictive model, 3 factors emerged to develop an SRS scoring system: cortical venous reflux (CVR), prior intracerebral hemorrhage (ICH), and noncavernous sinus location. Class I (score of 0-1 points) predicted the best favorable outcome of 80%. Class II patients (2 points score) had an intermediate favorable outcome of 57%, and class III (score 3 points) had the least favorable outcome at 37%. The ROC analysis showed better predictability to prevailing grading systems (AUC=0.69; P=.04). Kaplan-Meier analysis showed statistically significant difference between the 3 subclasses of the proposed grading system for post-SRS dAVF obliteration (P=.001). The proposed dAVF grading system incorporates angiographic, anatomic, and clinical parameters and improves the prediction of the outcomes following SRS for dAVF as compared to the existing scoring systems.

Prevalence and morphological variations of maxillary sinus septa in different age groups: a CBCT analysis.

ABSTRACTBACKGROUND: There are limited data from Saudi Arabia on the prevalence and characteristics of maxillary sinus septa.OBJECTIVE: Determine the prevalence and morphological characteristics of septa in the maxillary sinus and their relationship to gender and age using cone beam computed tomography (CBCT).DESIGN: Cross-sectionalSETTING: CBCT images acquired from the maxillofacial radiology department in a dental school.PATIENT AND METHODS: CBCT scans of 1010 maxillary sinuses from 505 patients were analyzed to determine the prevalence, location, type, and orientation of maxillary sinus septa. Descriptive statistics, chi-square tests and t tests were used to analyze the data.MAIN OUTCOME MEASURES: The prevalence, location, type, and orientation of maxillary sinus septa.SAMPLE SIZE: 1010 sinuses from 505 patients.RESULT: Approximately 46% of the studied patients had maxillary septa, which were present in 370 (37%) sinuses. About 64% of the septa were present on the right side and 85.7% of all septa were mediolater-ally oriented. The mean height of the septa was 6.06 mm (0.84) in the right sinuses and 5.70 mm (0.93) in the left sinuses. Multiple septa were found in 101 patients (20%). Among males, 58.5% had septa compared to 34% of females (P<.001.) A significant positive association was found between age and the presence and number of septa, P<.001.CONCLUSIONS: Maxillary sinus septa were highly prevalent with various heights and directions among the studied sample. Careful assessment of different anatomic variation must be conducted prior to any maxillary sinus augmentation, particularly in older patients.LIMITATIONS: Cross-sectional evaluation of CBCT images from one dental school patient population; thus, the findings cannot be generalized to other populations.CONFLICT OF INTEREST: None.

Long-term outcomes after endoscopic endonasal surgery for nonfunctioning pituitary macroadenomas.

Nonfunctioning pituitary adenomas are benign, slow-growing tumors. After gross-total resection (GTR) or subtotal resection (STR), tumors can recur or progress and may ultimately require additional intervention. A greater understanding of long-term recurrence and progression rates following complete or partial resection and the need for further intervention will help clinicians provide meaningful counsel for their patients and assist data-driven decision-making. The authors retrospectively analyzed their institutional database for patients undergoing endoscopic endonasal surgery (EES) for nonfunctioning pituitary macroadenomas (2003-2014). Only patients with follow-up of at least 5 years after surgery were included. Tumor volumes were measured on pre- and postoperative MRI. Tumor recurrence was defined as the presence of a 0.1-cm3 tumor volume after GTR, and tumor progression was defined as a 25.0% increase in residual tumor after STR. A total of 190 patients were included, with a mean age of 63.8 ± 13.2 years; 79 (41.6%) were female. The mean follow-up was 75.0 ± 18.0 months. GTR was achieved in 127 (66.8%) patients. In multivariate analysis, age (p = 0.04), preoperative tumor volume (p = 0.03), Knosp score (p < 0.001), and Ki-67 (p = 0.03) were significant predictors of STR. In patients with GTR, the probability of recurrence at 5 and 10 years was 3.9% and 4.7%, and the probability of requiring treatment for recurrence was 0.79% and 1.6%, respectively. In 63 patients who underwent STR, 6 (9.5%) received early postoperative radiation and did not experience progression, while the remaining 57 (90.5%) were observed. Of these, the probability of disease progression at 5 and 10 years was 21% and 24.5%, respectively, and the probability of requiring additional treatment for progression was 17.5% and 21%. Predictors of recurrence or progression in the entire group were Knosp score (p < 0.001) and elevated Ki-67 (p = 0.03). Significant predictors of progression after STR in those who did not receive early radiotherapy were cavernous sinus location (p < 0.05) and tumor size > 1.0 cm3 (p = 0.005). Following GTR for nonfunctioning pituitary adenomas, the 10-year chance of recurrence is low and the need for treatment even lower. After STR, although upfront radiation therapy may prevent progression, even without radiotherapy, the need for intervention at 10 years is only approximately 20% and a period of observation may be warranted to prevent unnecessary prophylactic radiation therapy. Tumor volume > 1 cm3, Knosp score ≥ 3, and Ki-67 ≥ 3% may be useful metrics to prompt closer follow-up or justify early prophylactic radiation therapy.

Sinus of Valsalva Thrombosis Detected on Computed Tomography after Transcatheter Aortic Valve Replacement.

Background and ObjectivesLeaflet thrombosis after transcatheter aortic valve replacement (TAVR) has been reported recently, whereas thrombus formation in sinus of Valsalva has yet to be fully evaluated. This study describes clinical and cardiac computed tomography (CT) findings of patients with sinus of Valsalva thrombosis.MethodsBetween March 2011 and Aug 2019, 192 patients underwent cardiac CT after TAVR. After a retrospective review of CT images, 9 patients (82 years, male:female=2:7) who had sinus of Valsalva thrombosis identified by cardiac CT were selected for this study. Patient demographics, interval between TAVR and cardiac CT scan, location and CT attenuation of sinus of Valsalva thrombosis, and presence of concurrent leaflet thrombosis were evaluated.ResultsThe median interval between TAVR and cardiac CT was 11 days. Sinus of Valsalva thrombosis was frequently detected in the non-coronary sinus (89%, 8/9), and predominantly located in the bottom of the sinus extending upward towards the sinotubular junction. Three patients had concomitant leaflet thrombosis, and 3 patients had subclinical embolic stroke noted on brain magnetic resonance imaging. All patients had been prescribed aspirin and clopidogrel after TAVR for at least 6 months without anticoagulants.ConclusionsCardiac CT after TAVR can detect sinus of Valsalva thrombosis, and attention should be paid to this potential source of subsequent systemic embolization.

Odontogenic Cutaneous Sinus Tracts: A Clinician's Dilemma.

Background:Odontogenic cutaneous sinus tract (OCST) is one of the rare manifestations of chronic dental infections. Although well reported in literature, it is often misdiagnosed or under diagnosed. Apart from isolated case reports especially in dental literature there is a paucity of comprehensive case series on OCST.Aims and Objectives:We undertook this study to observe the prevalence, clinico epidemiological features and management issues in these patients from a dermatological perspective.Methods:A retrospective study was undertaken analyzing the clinical records of patients registered at our outpatient department (OPD) from 2011 to 2018. Cases with a clinical and radiological diagnosis of odontogenic cutaneous sinus were included in the study. We studied the following variables: frequency, gender, age, localization, morphology, mean time of evolution and treatment response.Results:21 patients with OCST were identified from our records. Females outnumbered males; patients in the age group between 31-40 years were more commonly affected. Three morphological presentations were noted in the form of flesh-colored dry nodules with sinus, adherent plaques with mucopurulent discharge and ulcer. Posterior set of teeth were commonly affected and mandible was the commonest site for location of sinus. The time taken for appropriate diagnosis in these cases ranged from 7-16 months. Almost all the patients responded to endodontal or root canal treatment and there were no recurrences.Conclusion:A CST of dental origin is often a diagnostic challenge, especially in cases with minimal or no dental symptoms. A thorough skin and dental examination is required for sinuses on the head and neck area with a high index of suspicion for OCST. Most cases respond to conservative, root canal therapy. An early diagnosis can save the patient from unnecessary and ineffective therapies and sometimes surgeries.

INDIVIDUAL PLANNING OF SUPRAORBITAL KEYHOLE APPROACHES FOR PATIENTS WITH INTRA- AND EXTRACRANIAL TUMORS

The study objectiveis to generalize the basic principles of the individual preoperative planning in surgery of extra- and intraaxial brain tumors of the frontal lobe and anterior cranial fossa via eyebrow supraorbital keyhole approach.Materials and methods.In 2014–2018, we treated 40 patients with different tumors (meningiomas, gliomas, metastasis) through an eyebrow supraorbital keyhole craniotomy (in F.I. Inozemtsev City Clinical Hospital, Moscow Healthcare Department). Computed tomographyand magnetic resonance imaging with enhancement were performed to evaluate location and size of the tumor, relation to the approach-related anatomical structures (size and location of frontal sinus, pneumatization of the anterior clinoid process, depth of olfactory groove) and individual facial anatomy.Results.Gross total removal of the intraaxial tumors was achieved in 69 %, near-total removal in 31 %. The cranial base meningiomas were removed by Simpson II in 23 (96 %) patients, Simpson III in 1 (2.5 %) patient. A breach of frontal sinus was performed in 2 (5 %)patients. There were no cerebrospinal fluid leakage, infection, hemorrhage, morbidity and mortality.Conclusion.Keyhole surgery for patients with large intracranial tumors requires a thorough preoperative assessment of individual anatomical features, which is necessary to plan an optimal route, reduce the risk of injuries to other structures (not related to the surgical target), as well as the frequency of complications. These principles ensure high efficacy and safety of surgical treatment.

A Propensity Score–Matched Cohort Analysis of Outcomes After Stereotactic Radiosurgery in Older versus Younger Patients with Dural Arteriovenous Fistula: An International Multicenter Study

This study aims to evaluate the outcomes of Gamma Knife stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (dAVFs) in older patients (≥65 years) compared with younger patients (age <65 years). Two groups with a total of 96 patients were selected from a database of 133 patients with dAVF from 9 international medical centers with a minimum 6 months follow-up. A 1:2 propensity matching was performed by nearest-neighbor matching criteria based on sex, Borden grade, maximum radiation dose given, and location. The older cohort consisted of 32 patients and the younger cohort consisted of 64 patients. The mean overall follow-up in the combined cohort was 42.4 months (range, 6-210 months). In the older cohort, a transverse sinus location was found to significantly predict dAVF obliteration (P=0.01). The post-SRS actuarial 3-year and 5-year obliteration rates were 47.7% and 78%, respectively. There were no cases of post-SRS hemorrhage. In the younger cohort, the cavernous sinus location was found to significantly predict obliteration (P= 0.005). The 3-year and 5-year actuarial obliteration rates were 56% and 70%, respectively. Five patients (7.8%) hemorrhaged after SRS. Margin dose ≥25 Gy was predictive of unfavorable outcome. The obliteration rate (P= 0.3), post-SRS hemorrhage rate (P= 0.16), and persistent symptoms after SRS (P= 0.83) were not statistically different between the 2 groups. SRS achieves obliteration in most older patients with dAVF, with an acceptable rate of complication. There was no increased risk of postradiosurgery complications in the older cohort compared with the younger patients.

Optic nerve changes in chronic sinusitis patients: Correlation with disease severity and relevant sinus location.

PurposeThis study was to evaluate whether optic nerve damage occurs in eyes with adjacent chronic sinusitis.MethodsData were collected from eighty-eight eyes of 46 chronic sinusitis patients and 93 eyes of 57 normal controls. Visual sensitivity using standard automated perimetry (SAP) and inner retinal thickness using optical coherence tomography (OCT) were measured. The Lund-Mackay system was used to quantify radiographic findings on the ostiomeatal unit CT scan with a numerical score representing the severity of sinusitis.ResultsThere was a significant positive correlation between the pattern standard deviation (dB) and Lund-Mackay score (P = 0.031). Nasal retinal nerve fiber layer (RNFL) thickness, average, minimum, superotemporal, superior, superonasal, and inferonasal ganglion cell-inner plexiform layer (GCIPL) thickness were negatively correlated significantly with Lund-Mackay score (all, P < 0.05). Eyes with grade 2 opacification of the posterior ethmoid sinus showed a significantly lower mean deviation (dB) and higher pattern standard deviation (dB) than those with clear respective sinuses (P = 0.007 and <0.001, respectively). Eyes with grades 1,2 and 3 opacification of the sphenoid sinus had a significantly less average RNFL thickness (P = 0.004, <0.001, and <0.001, respectively) and a significantly less average GCIPL thickness (P = 0.004, 0.003, and 0.003, respectively) than those with a clear sphenoid sinus.ConclusionsStructural and functional optic nerve changes were correlated with the severity of chronic sinusitis. Inflammation of the posterior ethmoid and sphenoid sinuses was associated with optic nerve changes to a greater extent than that of the other paranasal sinuses.