Role of transnasal endoscopic surgery for the management of orbital diseases

BACKGROUND. Indications for endoscopic sinus surgery have been widely expanding since its introduction, to such an extent that it is now accepted as the ideal method for the treatment of some orbital conditions. Endoscopic approach to orbits provides excellent visualization with minimal cosmetic and functional morbidity. MATERIAL AND METHODS. This descriptive study has been conducted in the Department of Otolaryngology - Head and Neck Surgery, KMC, Manipal, during July 2010 and July 2014. We evaluated the role of endoscopic sinus surgery (ESS) as a surgical mode of treatment in different types of orbital diseases. RESULTS. 24 patients underwent ESS approach for various ophthalmologic conditions. CONCLUSION. Results from our studies showed that the endoscopic sinus surgery approach is effective and has better results than an open approach in the management of certain types of orbital pathology.

Supratotal Resection of Glioblastoma Allows Better Survival Outcomes Than Gross Total Resection

Objective: Supra-total resection (SupTR) of glioblastoma allows superior long-term disease control and increases overall survival. On the other hand, aggressive conventional approaches, including gross total resections (GTR), are limited by the impairment risk of adjacent eloquent areas, which may cause severe postoperative functional morbidity. This study aimed to analyze institutional cases with respect to the potential survival benefits of additional resection, including lobectomy, as a paradigm for SupTR in patients of glioblastoma.Methods: Between 2014 and 2018, 15 patients with glioblastoma underwent GTR and additional lobectomy at our institution. The postoperative Karnofsky performance score (KPS), progression-free survival (PFS), and overall survival (OS) were analyzed for the patients.Results: Patients with SupTR showed significantly prolonged PFS and OS. The median PFS and OS values for the entire study group were 33.5 months (95% confidence intervals [CI]: 18.5–57.3 months) and 49.1 months (95% CI: 24.7–86.6 months), respectively. Multivariate analysis revealed that O6-DNA-methylguanine methyltransferase (MGMT) promoter methylation status was the only predictor for both superior PFS (p = 0.03, OR 5.7, 95% CI 1.0–49.8) and OS (p = 0.04, OR 6.5, 95% CI 1.1–40.2). There was no significant difference between the pre- and post-operative KPS scores. Conclusions: Our results strongly suggest that SupTR with lobectomy allows superior PFS and OS without negatively affecting the patient performance.

Supratotal Resection of Glioblastoma Allows Better Survival Outcomes than Gross Total Resection

Objective: Supra-total resection (SupTR) of glioblastoma allows superior long-term disease control and increases overall survival. On the other hand, aggressive conventional approaches, including gross total resections (GTR), are limited by the impairment risk of adjacent eloquent areas, which may cause severe postoperative functional morbidity. This study aimed to analyze institutional cases with respect to the potential survival benefits of additional resection, including lobectomy, as a paradigm for SupTR in patients of glioblastoma.Methods: Between 2014 and 2018, 15 patients with glioblastoma underwent GTR and additional lobectomy at our institution. The postoperative Karnofsky performance score (KPS), progression-free survival (PFS), and overall survival (OS) were analyzed for the patients.Results: Patients with SupTR showed significantly prolonged PFS and OS. The median PFS and OS values for the entire study group were 33.5 months (95% confidence intervals [CI]: 18.5–57.3 months) and 49.1 months (95% CI: 24.7–86.6 months), respectively. Multivariate analysis revealed that O6-DNA-methylguanine methyltransferase (MGMT) promoter methylation status was the only predictor for both superior PFS (p = 0.03, OR 5.7, 95% CI 1.0–49.8) and OS (p = 0.04, OR 6.5, 95% CI 1.1–40.2). There was no significant difference between the pre- and post-operative KPS scores. Conclusions: Our results strongly suggest that SupTR with lobectomy allows superior PFS and OS without negatively affecting the patient performance.

Cancer-Related Fatigue

Cancer-related fatigue (CRF) is abundantly represented in most cancer populations and is highly distressing, causing significant psychological and functional morbidity. It does not receive enough attention from cancer clinicians as a certain amount of fatigue is expected from cancer and treatments. However, CRF is a distinct entity and category of fatigue that does not respond to usual restorative measures. This chapter reviews its definition, prevalence, pathophysiology, and assessment including unique contributory causes and distinguishing CRF from other symptoms such as depression and pain. Measurement tools are discussed. Strategies for the management of CRF including pharmacologic and nonpharmacologic interventions are reviewed and tips are provided. Evidence is presented for the use of psychostimulants and other drug therapy as well as exercise, psychotherapies, and mind-body interventions (e.g., yoga, acupuncture). CRF is a distinct entity with significant consequences for patients. Its assessment should be thorough and treatment directed toward underlying causes.

A retrospective study to analyze local flaps for coverage of facial defects

Background: Face is the center of attention during communication and the expression of emotion. Facial defects resulting from trauma and the excision of skin malignancies are relatively common. How this defect is treated is determined by a variety of factors including the location, size and the underlying cause of the defect, the projected functional morbidity, the medical history of the patient, and feasibility of surgery. Aim was to study various local flaps using for coverage of defect, outcomes and complications.Methods: This was a retrospective cohort study. Our study shows result of 92 patients during January 2016 to December 2019 who had facial defects were taken up for the study. Reconstructive options were selected depending on defect size, location. Follow-up of patients ranged from 6 months to 1 year.Results: The most common malignant tumors of the face are basal cell carcinoma, squamous cell carcinoma and melanoma. Local flap is always preferable than skin grafts as it produces a superior match in color and texture with the additional advantage of producing a vascularized soft tissue cover for skeleton and resistant to contractures.Conclusions: In our study, variety of local flaps were used to cover the facial defects of the 92 patients with minimal post-operative complications.

Tuberculous retropharyngeal abscess presenting as severe dyspnea

<p>Tuberculous retropharyngeal abscess is an exceptional condition, with high potential of functional morbidity and mortality if not treated appropriately. The authors report a new case of airway obstructive retropharyngeal abscess revealing cervical Pott disease. A 59 years old man presented at Ear, neck and throat (ENT) department with severe acute dyspnea. The history revealed progressive chronic dysphagia associated with asthenia and important weight loss. Physical examination found a state 3 dyspnoeic patient, presenting hyper flexed neck with limited movements. Nasofibroscopy showed a huge retropharyngeal bulge. Computed tomography (CT) scan showed a large retropharyngeal abscess located in front of vertebral spondylodiscitis with anterior dislocation of C4-C5-C6 vertebrae. Trans-oral incision with drainage of the retropharyngeal abscess was performed under general anaesthesia. Bacteriologic assessment of the pus confirmed tuberculosis infection. Anti-tuberculous medication was delivered, associated with spinal stabilization by a rigid cervical collar. Tuberculous retropharyngeal abscess is a very rare condition. Early diagnosis and treatment are necessary to prevent neurological and life-threatening complications. Collaboration between ENTs, anaesthetists, neurosurgeons and infectious disease specialists remains incontournable.</p>

Dual spinal accessory nerve: caution during neck dissection

Preserving the spinal accessory nerve (SAN) is an important step in the modern-day neck dissection to avoid postoperative functional morbidity in patients. This goal can become technically difficult, especially, when rare anatomical variations are encountered. We present a case of dual SAN in a patient undergoing selective neck dissection for oral squamous cell carcinoma. Both SANs were preserved and patient had no shoulder dysfunction postoperatively. We take this opportunity to emphasise that meticulous dissection is the only proven way to preserve the nerve. And that surgeons should be aware of this anatomical variation. SAN should be subjected to minimal traction during neck dissection to avoid tension neuropraxia and long-term shoulder dysfunction.

Novel Use of Stimulating Fence-Post Technique for Functional Mapping of Subcortical White Matter During Tumor Resection: A Technical Case Series

Background Maximal safe resection remains a key principle in infiltrating glioma management. Stimulation mapping is a key adjunct for minimizing functional morbidity while “fence-post” procedures use catheters or dye to mark the tumor border at the start of the procedure prior to brain shift. Objective To report a novel technique using stereotactically placed electrodes to guide tumor resection near critical descending subcortical fibers. Methods Navigated electrodes were placed prior to tumor resection along the deep margin bordering presumed eloquent tracts. Stimulation was administered through these depth electrodes for subcortical motor and language mapping. Results Twelve patients were included in this preliminary technical report. Seven patients (7/12, 58%) were in asleep cases, while the other 5 cases (5/12, 42%) were performed awake. Mapping of motor fibers was performed in 8 cases, and language mapping was done in 1 case. In 3 cases, both motor and language mapping were performed using the same depth electrode spanning corticospinal tract and the arcuate fasciculus. Conclusion Stereotactic depth electrode placement coupled with stimulation mapping of white matter tracts can be used concomitantly to demarcate the border between deep tumor margins and eloquent brain, thus helping to maximize extent of resection while minimizing functional morbidity.

The Effect of Forearm Tattoos on Flap Choice in Transmasculine Phalloplasty Patients

Purpose. The radial forearm free flap (RFFF) is considered the gold standard for gender affirming phalloplasty. Ideally, a nondominant forearm flap is used to minimize the risk of functional morbidity. However, many transmasculine individuals have tattooed forearms, which can affect decision making. The purpose of this study was to understand the prevalence of forearm tattoos among transmasculine patients seeking phalloplasty and how and whether tattoos affected decision making about flap source. Methods. Participants were 50, consecutive, adult, transmasculine patients seeking phalloplasty. The presence and location of tattoos were assessed using consult notes in the electronic medical record. A one-tailed test of proportions was used to test whether forearm tattoos increased the likelihood of alternative flap choice. Results. More than half of patients (56%) had tattoos on either one or both forearms ( n = 28), 75% on their nondominant arm ( n = 21). Among the patients with forearm tattoos, the presence of tattoos affected the flap site decision for 46% of patients ( n = 13). For the patients that chose an alternative flap site, 46% chose a dominant forearm RFFF ( n = 6) and 54% an anterolateral thigh flap ( n = 7). The percentage of patients whose records indicated that they were planning on using an alternative flap due to a tattoo on their nondominant forearm was significantly higher than the percentage of patients without such tattoos, indicating the desire for an alternate flap ( P < 0.01). Conclusion. Many transmasculine patients seeking phalloplasty have tattoos on either one or both of their forearms. Because of this, a substantial fraction of patients may choose flap donor sites that are less ideal. Providers from all disciplines may wish to educate young transmasculine patients about how tattoo placement may affect surgical options earlier during transition.