Citations

ObjectivesBiphenotypic sinonasal sarcoma (BSS) is a new, rare tumor characterized by concomitant neural and myogenic differentiation. The aim of this study is to describe the imaging characteristics and clinical outcomes of this neoplasm.MethodsA retrospective review of BSS patients surgically treated within a tertiary academic health care system was performed. Imaging characteristics and clinical outcomes were reviewed.ResultsFive patients underwent surgical resection of BSS tumors. Negative surgical margins were achieved in four (80%) patients. There were no deaths but two (40%) patients developed local recurrences during the postoperative follow‐up period (median follow‐up 31.4 months). Review of imaging characteristics revealed a median tumor size of 3.8 cm in greatest dimension. All tumors were unilateral and centered within the nasoethmoidal region. In all cases, the tumors extended to the nasal septum, lamina papyracea, and anterior skull base with variable degrees of erosion through these structures. On CT, involved bony structures demonstrated mixed lytic and sclerotic pattern, with definitive hyperostotic bone identified in four (80%) cases. On MRI, tumors were isointense‐to‐mixed iso/hypointense on both T1‐ and T2‐weighted sequences with one tumor demonstrating mixed T2 hyperintensity. All cases demonstrated gadolinium contrast enhancement.ConclusionsBSS is a locally aggressive tumor with a low risk of regional or distant metastases but has a significant rate of recurrence even with adequate resection. Despite its rarity, BSS should be considered in the differential diagnosis when imaging demonstrates a unilateral nasoethmoidal mass that is predominantly isointense to cerebral gray matter on T2‐weighted MRI and is hyperostotic on CT.Level of Evidence4

ObjectivesStructured histopathology reporting has been recently described for detailing immunopathological characteristics of chronic rhinosinusitis (CRS), and can be utilized for subtyping CRS and personalizing management. This study scrutinized elements of structured histopathology to identify characteristics that prognosticate outcomes following endoscopic sinus surgery (ESS) for CRS patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP).MethodsOutcomes following ESS were measured using the patient‐reported 22‐item sinonasal outcome test (SNOT‐22). Changes in total SNOT‐22 scores at 6 and 12 months postoperatively were analyzed. Thirteen parameters reported in structured histopathology of sinus surgical tissue were studied for association with outcomes postsurgery. The overall cohort of all CRS patients was studied, along with subgroup analyses of CRSwNP and CRSsNP patients.ResultsIn the entire CRS cohort (n = 171), eosinophil count >10 per high power field (HPF) was associated with greater improvement in SNOT‐22 scores at 6 months post‐ESS (P = .039). At 12 months follow‐up, no histopathological characteristic was associated with change in total SNOT‐22 score. In the CRSwNP (n = 66) subgroup, the presence of fibrosis (P = .006) and eosinophil count ≤10 per HPF (P = .025) were associated with less favorable changes in SNOT‐22 scores at 12 months follow‐up. Fibrosis remained statistically significant in multivariable analysis (P = .007).ConclusionsAt 6 months post‐ESS, tissue eosinophilia is associated with significantly higher improvement in SNOT‐22 scores, but this difference is diluted by 12 months. Fibrosis was associated with less favorable outcomes in SNOT‐22 scores for CRSwNP patients at 12 months and may be a prognosticator for poorer long‐term outcomes.Level of Evidence4

Abstract Background We previously tested an intervention featuring educational outreach with modified academic detailing (AD) to increase anticoagulation (AC) use in patients with atrial fibrillation (AF). Currently, we compare providers receiving and not receiving AD in terms of inclusion of our AD educational topics and shared decision-making elements in documentation. Methods Physicians reviewed themes discussed with providers during AD and evaluated charts for evidence of shared decision-making. We then compared frequency of documentation of individual items for providers receiving AD compared with non-AD providers. To understand baseline documentation practices of AD providers, we also randomly selected encounters of AD providers before their AD participation. Results There were 113 eligible encounters in the four months after AD - 36 from AD providers and 77 from non-AD providers. We also identified 35 encounters from AD providers before participating in the intervention. Providers infrequently documented many reviewed items (% documenting): AC mentioned (44%), multiple options for AC (5%), CHA2DS2-VASc score (11%), bleeding risk factors (2%). Compared with non-AD providers, AD providers had statistically significant higher percentages for the following items: mention of AC (64% versus 35%), stroke risk (11% versus 0%), AC benefits (8% versus 0%), patient involvement (70% versus 0%). There was no improvement, however, for AD providers compared with baseline documentation percentages. Conclusions Providers infrequently documented important items in AC management and shared decision-making. AD participation did not improve documentation. Improving adoption of AD educational items may require more prolonged interaction with providers. Improving shared decision-making may require an intervention more focused on it and its documentation. Trial Registration The trial was registered as NCT03583008 on Clinicaltrials.gov on July 11, 2018.

Background Endoscopic skull‐base surgery (ESBS) is employed in the management of diverse skull‐base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull‐base surgery have produced the International Consensus Statement on Endoscopic Skull‐Base Surgery (ICAR:ESBS). Methods Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence‐based review or evidence‐based review with recommendations format. Subsequently, each topic was written and then reviewed by skull‐base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. Results The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull‐base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. Conclusion A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence‐based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull‐base community to embrace these opportunities and collaboratively address these shortcomings.