Abiri, Arash

ABSTRACT Objective There is limited consensus on endoscopic skull base surgery (ESBS) reconstruction principles. This study aims to generate comprehensive themes regarding ESBS reconstruction by pooling the experiences of ESBS experts, with comparison to a literature review of current published evidence. Methods Structured qualitative interviews of ESBS experts regarding postoperative management and reconstruction of various defect locations were conducted. Results A total of 68 experts comprising 40 academic teams across 13 countries with an average of 18 years of ESBS experience were included. We propose 10 stepwise algorithms for common skull base reconstruction scenarios based on these expert interviews. When available, the nasoseptal flap is used for all high_flow cerebrospinal leak defects. Multilayered reconstruction is favored at all anatomical subsites with increasing number of layers for increasing defect size and complexity. Heterogeneity exists in terms of inlay technique and materials, free grafting versus various pedicled flap options for low‐flow defects or in the absence of a nasal septum, nasal packing, tissue sealant, lumbar drain use, and postoperative management. Commonalities and discrepancies between experts were summarized. Conclusion Skull base reconstruction and post‐ESBS management is highly complex with a wide variety of practice patterns and expert strategies. Further research of higher quality evidence is warranted to identify optimal management patterns, though the current work aims to inform surgeons on these controversial areas by drawing from numerous experiences.

ABSTRACTBackgroundOlfactory neuroblastoma (ONB) is a rare sinonasal malignancy primarily treated with surgery. For tumors arising from the olfactory area, traditional treatment involves transcribriform resection of the anterior cranial fossa. Surgery can be performed with unilateral or bilateral resection depending on extent of involvement; however, there are currently no studies comparing outcomes between the two.MethodsProspective and retrospective data on primary ONB patients were collected from a multicenter registry involving eight academic sites. Propensity score matching (PSM) was used to create patient cohorts with similar baseline characteristics. Cox proportional hazards and Kaplan Meier analyses assessed overall survival (OS). Logistic regression assessed associations between extent of resection (unilateral versus bilateral) and tumor recurrence or postoperative cerebrospinal fluid (CSF) leak.ResultsA total of 187 ONB patients (47.6% female) with an average age of 53.6 ± 15.1 years were analyzed. Most tumors were unilateral (81.3%) and predominantly Kadish C (58.3%) or Hyams II (55.8%). Overall, 56.7% of patients underwent bilateral resection. Fifty‐four patients experienced tumor recurrence and nine had postoperative CSF leaks. Following PSM (n = 45/group), extent of resection was not associated with mortality (hazard ratio [HR] 1.73; p = 0.407) or OS (p = 0.400). There was no association between extent of resection and recurrence (odds ratio [OR] 0.90; p = 0.814) or postoperative CSF leak (OR 1.54; p = 0.647).ConclusionsFor ONB tumors where unilateral resection may be feasible and oncologically sound, the decision for unilateral versus bilateral resection showed no significant effect on survival, recurrence, or postoperative CSF leak. Oncologic outcomes may be comparable when resection is tailored to individual patient and tumor characteristics.

Background Sinonasal mucosal melanoma has poor survival despite multimodality treatment. While the impact of immunotherapy (IT) on metastatic cutaneous melanoma is well-defined, there are relatively little data on sinonasal mucosal melanoma. Objective We sought to define immunotherapy outcomes in patients with sinonasal mucosal melanoma. Methods A retrospective cohort study evaluated patients treated with IT during their overall treatment strategy for SNMM. Patient demographics, treatment, and survival outcomes were recorded. Results 52 patients had IT treatment for SNMM from 2000 to 2022, with an average age of 69.1 ± 11.9 years. The most common treatment was surgery with radiation and IT ( n = 26, 50%). Most regimens consisted of a combination of Nivolumab and Ipilimumab ( n = 17, 32.7%) or pembrolizumab ( n = 14, 26.9%). 44.2% of patients experienced reported complications. Overall survival at 1-, 2-, and 5 years was 86.9%, 74.1%, and 39.1%, respectively. Conclusion Approximately half of patients will have a local response following immunotherapy, but it is rare to have improvement at metastatic locations. Further research within our group will assess optimal timing and markers that are predictive of response.

AbstractObjectiveTo evaluate recurrence patterns and survival after recurrence among patients with sinonasal mucosal melanoma (SNMM).MethodsThis was a multi‐institutional retrospective review from seven U.S. institutions of patients with SNMM from 1991 to 2022. Recurrence was categorized as local, regional, distant, or multifocal. Kaplan‐Meier tests were used to evaluate disease‐free survival (DFS), overall survival (OS), and post‐recurrence survival (PRS) reported with standard errors (SE) and log‐rank testing used for comparison. Cox‐regression was further used, with hazard ratios (HR) and 95% confidence intervals (CI) reported.ResultsAmong 196 patients with SNMM, there were 146 patients with recurrence (74.5%). Among all patients, 60‐month DFS (SE) was 15.5% (2.9%), 60‐month OS (SE) was 44.7% (3.7%), mean age ± standard deviation at diagnosis was 69.7 ± 12.5 years, and 54.6% were female. In 26 patients who underwent primary treatment of the neck, 60‐month DFS did not differ from no treatment (p > 0.05). Isolated distant recurrence was most common (42.8%), followed by local (28.3%), multifocal (20.7%), and regional recurrence (8.3%). Among patients with regional recurrence in the neck, there was no 60‐month PRS benefit for patients undergoing salvage neck dissection or radiation (p > 0.05). Among patients with distant recurrence, only immunotherapy was associated with improved 12‐month PRS (HR = 0.32, 95% CI = 0.11–0.92, p = 0.034), and no treatment group was associated with improved 24‐ or 60‐month PRS (p > 0.05).ConclusionSNMM is associated with a high recurrence rate and poor survival. Primary treatment of the neck was not associated with reduced recurrence, and immunotherapy for treatment of distant recurrence was associated with increased 12‐month PRS.

AbstractBackgroundPostoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence‐based guidance.MethodsThe PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated.ResultsA total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction.ConclusionThe evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high‐quality studies are needed in order to devise optimal postoperative ESBS protocols.