Patients Undergoing Skull Base Surgery Research Articles

Venous thromboembolism chemical prophylaxis after skull base surgery

PurposeThere is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis.MethodsReview of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009–2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons.ResultsOne thousand five hundred fifty-one patients were included with a median age of 52 years (range 16–89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM.ConclusionPostoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

Frailty as a Predictor of Postoperative Complications Following Skull Base Surgery.

Frailty has emerged as a powerful risk stratification tool across surgical specialties; however, an analysis of the impact of frailty on outcomes following skull base surgery has not been published. The aim of this study was to assess the validity of the 5-factor modified frailty index (mFI-5) as a predictor of perioperative morbidity and mortality in patients undergoing skull base surgery. A mFI-5 score was calculated for patients undergoing skull base surgeries using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2018. Multivariate logistic regression analysis was used to evaluate the association of increasing frailty with complications in the 30-day postoperative period, with a subanalysis by operative location. A total of 17,912 patients who underwent skull base procedures were identified, with 45.5% of patients having a frailty score of one or greater; 44.9% were male and the mean age was 52.0 (±16.1 SD) years. Multivariable regression analysis revealed frailty to be an independent predictor of overall complications (odds ratio [OR]: 1.325, P < .001), life-threatening complications (OR: 1.428, P < .001), and mortality (OR: 1.453, P < .001). Higher frailty also correlated with increased length of stay. When procedures were stratified by operative location, frailty correlated significantly with overall complications for middle, posterior, and multiple-fossae operations but not the anterior fossa. Frailty demonstrates a significant and stepwise association with life-threatening postoperative morbidity, mortality, and length of stay following skull base surgeries. mFI-5 is an objective and easily calculable measure of preoperative risk, which may facilitate perioperative planning and counseling regarding outcomes prior to surgery. 3 Laryngoscope, 131:1977-1984, 2021.

Short-Term Morbidity and Predictors of Adverse Events Following Esthesioneuroblastoma Surgery.

The short-term adverse events and predictors of morbidity in surgical resection of esthesioneuroblastoma (ENB) are largely unknown, and investigating these variables can help direct planning for at-risk patients. The 2005-2017 National Surgical Quality Improvement Program database was queried to identify patients with a diagnosis of ENB undergoing skull base surgery for tumor resection. Information regarding demographics, patient morbidity score, pre-operative and intra-operative data, and post-operative outcomes were extracted. Cox proportional hazard analysis was utilized to assess complication and readmission/reoperation rates. A total of 95 patients undergoing skull base surgery for resection of ENB were included. Mean age, BMI, operation time, and post-operative length of stay (LOS) of the cohort were 53.6 ± 16.2 years, 29.1 ± 6.5, 392.0 ± 204.6 minutes, and 5.8 ± 4.6 days, respectively. In total, 31 patients (32.6%) experienced at least one 30-day adverse event, which included blood transfusion intra-operatively or within 72 hours from the operation (22.1%), readmission (10.7%), intubation >48 hours (7.4%), reintubation (4.2%), organ or space infection (4.2%), reoperation (4.0%), superficial or deep surgical site infection (2.1%), sepsis (2.1%), pulmonary embolism (1.1%), and myocardial infarction (1.1%). Patients who experienced at least one adverse event had significantly higher operation time (486.8 ± 230.4 vs. 347.5 ± 176.2 minutes, p = 0.002), LOS (9.2 ± 5.6 days vs. 4.2 ± 3.0, p < 0.001), and lower hematocrit (37.3 ± 5.9 vs. 41.2 ± 3.8, p < 0.001) and albumin levels (3.8 ± 0.6 vs. 4.2 ± 0.3, p = 0.009). Patients with a higher American Society of Anesthesiologists (ASA) score (HR = 2.39; p = 0.047) or longer operation time (HR = 1.004; p = 0.001) had a significantly higher risk for experiencing adverse events. Obesity was not associated with different intra- or post-operative outcomes, but older patients had shorter operations (p = 0.002) and LOS (p = 0.0014). Longer operation time and lower pre-operative hematocrit and albumin levels may all increase complication rates in ENB resection. Patients with high ASA score or more advanced age may have different short-term outcomes.

Safety and Efficacy of TachoSil (Absorbable Fibrin Sealant Patch) Compared With Current Practice for the Prevention of Cerebrospinal Fluid Leaks in Patients Undergoing Skull Base Surgery: A Randomized Controlled Trial.

Cerebrospinal fluid (CSF) leakage associated with incomplete sealing of the dura mater is a major complication of intradural procedures. To compare the efficacy and safety of adjunctive TachoSil (Takeda Pharma A/S, Roskilde, Denmark) with current practice for the prevention of postoperative CSF leaks in patients undergoing elective skull base surgery involving dura mater closure. Patients were intraoperatively randomized to TachoSil or current practice immediately before primary dura closure by suturing ± duraplasty. Choice of adjunctive treatment in the current practice group was at the surgeon's discretion. Primary efficacy endpoint was occurrence of clinically evident verified postoperative CSF leak or clinically evident pseudomeningocele within 7 weeks after surgery or treatment failure (third application of trial treatment or use of other treatment). A total of 726 patients were randomized to TachoSil (n = 361) or current practice (n = 365). More current practice patients had sutures plus duraplasty for primary dura closure compared with TachoSil (49.6% vs 35.7%) and fewer had sutures only (45.5% vs 63.2%). The primary endpoint of estimated leak rate favored TachoSil with events in 25 (6.9%) patients vs 30 (8.2%) current practice patients; however, this was not statistically significant (odds ratio: 0.82; 95% confidence interval: 0.47, 1.43; P = .485). Both treatments were well tolerated with similar frequency of adverse events. Very low rates of postoperative CSF leaks can be achieved in patients undergoing skull base surgery of various indications. Although the study did not meet its primary endpoint, TachoSil appears to be safe and effective for the prevention of CSF leaks and associated complications.

Incidence of Posttraumatic Stress Disorder (PTSD) Symptoms in Skull Base Surgery

Objective: To assess the incidence of posttraumatic stress disorder (PTSD) symptoms in patients undergoing elective skull base surgery in comparison to other elective brain surgery. Methods: A prospective cohort study of patients undergoing elective brain surgery was examined. The incidence of development of PTSD symptoms was evaluated in comparison between general cranial cases and skull base cases using a structured clinical interview (SCID) and a battery of standardized questionnaires before surgery as well as 1 week and 3 months postoperatively. In addition, the short form SF36 and EuroQOL-3D were completed preoperatively and at 3 months postoperatively. Results: A prospective cohort study of 36 patients undergoing elective brain surgery was examined. Nine patients (25%) had skull base surgery. Before surgery the PTSD symptoms were reported in two (22%) and two cases (7%) in the skull base and general cranial cases, respectively. At 3 months follow-up PTSD symptoms were observed in two (22%) and three patients (11%) in the skull base and general cranial cases, respectively. Conclusions: Our results reveal that PTSD symptoms have initially a higher incidence in patients undergoing skull base surgery. Further research is needed to determine the relevant incident triggering the PTSD symptoms. Psychological support is needed for patients suffering from PTSD symptoms as we could observe stabilization in the symptoms also at 3 months follow-up.

The Clinical Importance of Quality-of-Life Scores in Patients with Skull Base Tumors: A Meta-Analysis and Review of the Literature

Health-related quality of life (QOL) outcomes are frequently used by clinicians, patients, and researchers for assessing the effectiveness of an intervention. Small differences in QOL may be statistically significant but their clinical relevance remains undefined. The smallest changes in QOL scores of the anterior skull base surgery questionnaire (ASBS-Q) which could be considered clinically significant have not been delineated. Here we present a meta analysis and review of the literature of 273 patients undergoing skull base tumor resection. The minimal clinically important difference (MCID), defined as "the smallest change in QOL which patients perceive as beneficial", was calculated using several statistical approaches. The MCID of the ASBS-Q was 0.4 (8%, score range 1-5). Various other instruments for QOL estimations revealed a larger range of MCID score (between 6.2%-17.5%) for the different QOL domains. The statistical analyses reveal that histology (benign vs malignant), time elapsed from surgery (< or ≥6months), and surgical approach (open vs endoscopic) have significant clinical impact on different QOL domains. This paper brings level 1b evidence which demonstrates the importance of MCID as an adjunct for estimation of QOL in patients undergoing skull base surgery.

Quality of Life after Skull Base Surgery: The Patient's Predicament

Quality of Life after Skull Base Surgery: The Patient's Predicament

Postoperative Acute Sialadenitis after Skull Base Surgery

During retrosigmoid and far-lateral skull base surgical approaches, the head may be positioned at the extreme limits of rotation and flexion. In rare instances, patients may develop acute sialadenitis after surgery as a result of this positioning technique. Over a 4-year period, five patients developed postoperative sialadenitis after undergoing either a retrosigmoid craniotomy in the supine position (n = 4) or a far-lateral craniotomy in the park-bench position. Based on all the retrosigmoid and far-lateral approaches performed by the senior author (RFS), the incidence of sialadenitis was 0.84%. In all five patients, the acute sialadenitis was not clinically apparent at the conclusion of the operation. However, the diagnosis was evident within 4 hours of surgery. In each case, the neck swelling in the vicinity of the submandibular gland was contralateral to the craniotomy site. All patients were treated with intravenous hydration and antibiotic therapy. One patient was extubated immediately after surgery with no obvious evidence of sialadenitis. However, she required emergent reintubation due to airway compromise. The mechanism of acute sialadenitis in these patients was obstruction of the salivary duct caused by surgical positioning. This previously unreported observation in patients undergoing skull base surgery deserves consideration during perioperative and postoperative management.

Intraoperative facial motor evoked potential monitoring with transcranial electrical stimulation during skull base surgery

Objective: To address the limitations of standard electromyography (EMG) facial nerve monitoring techniques by exploring the novel application of multi-pulse transcranial electrical stimulation (mpTES) to myogenic facial motor evoked potential (MEP) monitoring. Methods: In 76 patients undergoing skull base surgery, mpTES was delivered through electrodes 1 cm anterior to C1 and C2 (M1–M2), C3 and C4 (M3–M4) or C3 or C4 and Cz (M3/M4–Mz), with the anode contralateral to the operative side. Facial MEPs were monitored from the orbicularis oris muscle on the operative side. Distal facial nerve excitation was excluded by the absence of single pulse responses and by onset latency consistent with a central origin. Results: M3/M4–Mz mpTES ( n=50) reliably produced facial MEPs while M1–M2 ( n=18) or M3–M4 ( n=8) stimulation produced 6 technical failures. Facial MEPs could be successfully monitored in 21 of 22 patients whose proximal facial nerves were inaccessible to direct stimulation. Using 50, 35 and 0% of baseline amplitude criteria, significant facial deficits were predicted with a sensitivity/specificity of 1.00/0.88, 0.91/0.97 and 0.64/1.00, respectively. Conclusions: Facial MEPs can provide an ongoing surgeon-independent assessment of facial nerve function and predict facial nerve outcome with sufficiently useful accuracy. Significance: This method substantially improves facial nerve monitoring during skull base surgery.

Nasal reconstruction in surgery of the anterior skull base

Objectives We sought to evaluate the effectiveness of a number of surgical maneuvers in nasal reconstruction of a diverse population of patients undergoing skull base surgery. Study design We conducted a retrospective review of a cohort of patients undergoing nasal reconstruction during surgery of the anterior skull base and craniovertebral junction. Methods All patients undergoing skull base surgery and nasal reconstruction by the senior author (Y.D.) with a minimum follow-up of 12 months from 1997 to 2001 were evaluated. Preoperative and postoperative photographs and clinical evaluation were examined in detail with particular attention focused on the nasal complex. Results A total of 47 patients were evaluated for this study, including those who had undergone anterior craniofacial resections (n = 14), Le Fort osteotomies (n = 5), subcranial approaches (n = 10), maxillotomies (n = 8), and midfacial disassemblies (n = 10). Primary calvarial bone graft reconstruction of the anterior craniofacial group was facilitated with the use of positioning plates and resuspension of the upper lateral cartilages when available. In contradistinction to secondary bone grafting, dorsal grafts in this group extended to the native nasal bone length. A small overlay bone graft was thought to be necessary when the nasal root was osteotomized in conjunction with the orbital and/or maxillary segments to maintain dorsal height in the long term. Le Fort osteotomy patients require refixation of the septum to the anterior nasal spine region for stability. Conclusions Use of the techniques outlined in this article appears to be associated with gratifying long-term nasal form in reconstruction of the anterior skull base.

Digital camera documentation system for facial nerve outcome assessment.

To describe the use of a digital camera to document facial nerve function after skull base surgery. Patients undergoing skull base surgery at a tertiary care otologic and neurotologic clinic were used in the study. None. A digital camera system provided still images and a video strip lasting less than a minute to document facial nerve motion. An inexpensive digital camera system can be used to capture still and moving images of facial nerve function on a floppy disk. The images can then be transferred to compact disks for storage of many patient files. Such a system allows documentation for research, exchange of data between offices, and patient education, and it can be used for medical-legal purposes among other uses.

Laryngeal framework surgery for the treatment of aspiration

Laryngeal framework surgery for the treatment of aspiration secondary to deficits of the glottic sphincter is a reliable and versatile technique. Improvement in the degree of aspiration, dict, and voice after laryngeal framework surgery have been seen in many patients. Rehabilitation of patients undergoing skull base surgery is also facilitated in respect to avoidance of trachcotomy, early swallowing, and a decrease in number of hospital days. Restoration of subglottic pressure is essential to achieve effective swallowing, and this is accomplished to varying degrees using medialization thyroplasty and arytenoid adduction. Laryngeal framework surgery is associated with low morbidity, and should remain an effective treatment option in those suffering from aspiration secondary to glottic insufficiency.

Computer-assisted intraoperative navigation during skull base surgery

Purpose: In patients with diseases of the cranial base, anatomical landmarks are often obliterated by tumor inflammatory diseases or previous surgery. The surgeon may fail to recognize important anatomical structures or tumor margins, increasing the morbidity of the surgery and downgrading the oncological outcome. Materials and Methods: The ISG Viewing Wand is an intraoperative navigational device that uses a position-sensing articulated arm linked to a computer that allows the surgeon to correlate the anatomy of the patient with the computerized display of the reformatted images of preoperative computerized tomography or magnetic resonance. We used the ISG system in 20 patients undergoing skull base surgery for the treatment of tumor inflammatory diseases and trauma. Results: The use of the ISG wand translated into a decreased need for the resection of vital structures and provided reliable mapping of the boundaries of the paranasal sinuses and tumor margins. Conclusion: Intraoperative navigation is a promising technology that complements the surgeon's interpretation of the surgical field. Further refinements of this technology will ease the incorporation of these intraoperative navigation systems into other surgical procedures.

Intraoperative electrophysiologic monitoring of cranial motor nerves in skull base surgery

BACKGROUND Intraoperative cranial nerve monitoring has been applied for the preservation of nerve function during skull base surgery. However, its usefulness is controversial because clinical results reported are limited METHODS We evaluated the usefulness of intraoperative electro-physiologicmonitoring of the third to seventh cranial motor nerves in 15 patients undergoing skull base surgery intracranial bipolar electrical stimulation of each nerve was performed and compound muscle action potentials (CMAP) were recorded from the innervated muscles RESULTS CMAP's were successfully recorded form 23 of the innervated muscles. The loss of the CMAP response during the manipulation of lesions or high stimulos intensity at the end of manipulations seem to be related to the postoperative beats of nerve function CONCLUSIONS The results suggest that intraoperative electrophysiologic monitoring of cranial motor nerves is useful for prediction of postoperative nerve function

Accurate frameless registration of MR and CT images of the head: applications in planning surgery and radiation therapy.

To evaluate the feasibility and efficacy of a three-dimensional image registration technique for planning skull base surgery, performing frameless image registration for stereotaxic neurosurgery, and staging nasopharyngeal carcinoma. Computed tomographic (CT) and magnetic resonance (MR) images from 35 patients were registered by identifying 12-16 homologous landmarks with each modality. Images were displayed as overlaid sections or rendered three-dimensional scenes. The clarity of the combined images from 15 patients undergoing skull base surgery was compared with that of the conventional displays. Images were combined for three applications, with an accuracy of 1-2 mm. For the 15 patients undergoing skull base surgery, the combined images were significantly better at depicting the relationship between bone and lesion than conventional display (P < .01). MR and CT images of the head can be accurately registered without using external markers or substantially altering image acquisition protocols. The resulting images can show the radiologic information more clearly than conventional viewing.