Risk factors for cerebrospinal fluid leak in pediatric patients undergoing endoscopic endonasal skull base surgery

Publication date: February 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 93
Author(s): Amanda L. Stapleton, Elizabeth C. Tyler-Kabara, Paul A. Gardner, Carl H. Snyderman, Eric W. Wang
ObjectivesTo determine the risk factors associated with cerebrospinal fluid (CSF) leak following endoscopic endonasal surgery (EES) for pediatric skull base lesions.MethodsRetrospective chart review of pediatric patients (ages 1 month to 18 years) treated for skull base lesions with EES from 1999 to 2014. Five pathologies were reviewed: craniopharyngioma, clival chordoma, pituitary adenoma, pituitary carcinoma, and Rathke's cleft cyst. Fisher's exact tests were used to evaluate the different factors to determine which had a statistically higher risk of leading to a post-operative CSF leak.Results55 pediatric patients were identified who underwent 70 EES's for tumor resection. Of the 70 surgeries, 47 surgeries had intraoperative CSF leaks that were repaired at the time of surgery. 11 of 47 (23%) surgeries had post-operative CSF leaks that required secondary operative repair. Clival chordomas had the highest CSF leak rate at 36%. There was no statistical difference in leak rate based on the type of reconstruction, although 28% of cases that used a vascularized flap had a post-operative leak, whereas only 9% of those cases not using a vascularized flap had a leak. Post-operative hydrocephalus and perioperative use of a lumbar drain were not significant risk factors.ConclusionsPediatric patients with an intra-operative CSF leak during EES of the skull base have a high rate of post-operative CSF leaks. Clival chordomas appear to be a particularly high-risk group. The use of vascularized flaps and perioperative lumbar drains did not statistically decrease the rate of post-operative CSF leak.



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Cardiac Lymphatics – A New Avenue for Therapeutics?

Publication date: Available online 10 January 2017
Source:Trends in Endocrinology & Metabolism
Author(s): Taina Vuorio, Annakaisa Tirronen, Seppo Ylä-Herttuala
Recent progress in lymphatic vessel biology and in novel imaging techniques has established the importance of the lymphatic vasculature as part of the cardiovascular system. The lymphatic vessel network regulates many physiological processes important for heart function such as fluid balance, transport of extravasated proteins, and trafficking of immune cells. Therefore, lymphangiogenic therapy could be beneficial in the treatment of cardiovascular diseases, for example by improving reverse cholesterol transport (RCT) from atherosclerotic lesions or by resolving edema and fibrosis after myocardial infarction. In this review we first describe recent findings on the development and function of cardiac lymphatic vessels, and subsequently focus on the prospects of pro- and anti-lymphangiogenic therapies in cardiovascular diseases.



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Hydroxy-Carboxylic Acid Receptor Actions in Metabolism

Publication date: Available online 10 January 2017
Source:Trends in Endocrinology & Metabolism
Author(s): Stefan Offermanns
Lactic acid, the ketone body 3-hydroxy-butyric acid, also known as β-hydroxybutyrate, and the β-oxidation intermediate 3-hydroxy-octanoic acid are hydroxy-carboxylic acids (HCAs) that serve as intermediates of energy metabolism. However, they also regulate cellular functions, in part by directly activating the G protein-coupled receptors HCA1/GPR81, HCA2/GPR109A, and HCA3/GPR109B. During the past decade, it has become clear that HCA receptors help to maintain homeostasis under changing metabolic and dietary conditions, by controlling metabolic, immune, and other body functions. Work based on genetic mouse models and synthetic ligands of HCA receptors has, in addition, shown that members of this receptor family can serve as targets for the prevention and therapy of diseases such as metabolic and inflammatory disorders.



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Skin Necrosis After Implantation With the BAHA Attract: A Case Report and Review of the Literature.

Objective: The bone-anchored hearing aid (BAHA) Attract is a transcutaneous bone conduction hearing aid that uses magnetic coupling to enable sound conduction. We report the first case of skin necrosis associated with the BAHA Attract and perform a literature review of soft tissue complications related to the device. Patient: A single patient who was found to develop skin necrosis 2 weeks after being fitted for the BAHA Attract speech processor. Intervention: After the patient developed skin necrosis from the device, she was advised to immediately discontinue use of the Attract to allow complete wound healing, upon which the Attract was successfully converted to a percutaneous BAHA. Main Outcome and Results: We monitored for the development of skin complications from the BAHA Attract. The patient's immediate postoperative course was unremarkable and she was fitted with a speech processor of M5 magnet strength at 1 month postoperatively. After 1 week of use, she reported discomfort and was advised to downgrade to an M4 magnet; however, she continued to use the M5 and the following week was found to have developed skin necrosis around the device. Conclusion: Despite the infrequency of skin necrosis related to the BAHA Attract, it must be considered in counseling and managing candidates for the device. Copyright (C) 2017 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Adverse Events Following Vestibular Schwannoma Surgery: A Comparison of Surgical Approach.

Objective: Compare complications of vestibular schwannoma (VS) resection by surgical approach. Study Design: Retrospective cohort. Setting: The 2008 to 2013 American College of Surgeons-National Surgical Quality Improvement Program. Patients: Adult patients with VS resection by an otolaryngologist. Interventions: VS resection via transtemporal (TT), retrosigmoid (RS), or middle cranial fossa (MCF) approaches. Main Outcome Measures: Hearing preservation approaches were compared with hearing sacrificing approaches. Demographics and intraoperative factors were analyzed to identify predictors of medical and surgical complications, return to the operating room, and death. The effect of trainee presence was evaluated with respect to complications, operative length, and hospital length of stay. Results: One hundred eleven VS resections were identified. Patients were predominantly women (57%) and older than 50 years (69%). The TT approach accounted for 50% of the cases, while RS (36%) and MCF (14%) were less common. The risk of any postoperative complication was 17%. There were no patient deaths. There was no difference in the overall complication rate among surgical approaches, nor in the overall, surgical, or medical complication rates between hearing preservation and hearing sacrificing approaches. Trainee presence did not change operation length, hospital length of stay, or complication rates. Conclusions: Complication rates of VS resection are no different when comparing TT, RS, or MCF approaches. Trainee involvement did not significantly affect complications. This study is limited by the inability to evaluate procedure-specific variables (e.g., facial nerve weakness and hearing preservation rates), but offers a unique survey of global 30-day complication rates reported to a large, multi-institutional, publically available database. Copyright (C) 2017 by Otology & Neurotology, Inc. Image copyright (C) 2010 Wolters Kluwer Health/Anatomical Chart Company

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Isosorbide-Induced Decompression Effect on the Scala Media: Participation of Plasma Osmolality and Plasma Arginine Vasopressin.

Objective: The correlation between the isosorbide-induced decompression effect on the endolymphatic space and plasma osmolality (p-OSM) or plasma arginine vasopressin (p-AVP) was investigated on comparing two different dosages of isosorbide (2.8 and 1.4 g/kg) to elucidate why the decompression effect is delayed with a large dose of isosorbide. Materials and Methods: Two experiments were performed using 80 guinea pigs. Experiment 1 was designed to morphologically investigate the sequential influence of the oral intake of 1.4- and 2.8-g/kg doses of isosorbide on the endolymphatic volume. The animals used were 50 guinea pigs (control: 10, experimental: 40). All animals underwent surgical obliteration of the endolymphatic sac of the left ear. One month after the surgery, control animals were sacrificed 3 hours after the intake of distilled water, and experimental animals were sacrificed 3 and 6 hours after the isosorbide intake. All of the left temporal bone served for the quantitative assessment of changes in the endolymphatic space, and the cross-sectional area of the scala media was measured from the mid-modiolar sections of the cochlea. Experiment 2 was designed to investigate changes in p-OSM and p-AVP levels 3 hours after the oral intake of isosorbide. Animals used were 15 guinea pigs (control: 5, experimental: 10). The control group received the oral administration of distilled water (4 ml/kg), and the experimental animals were subdivided into two groups consisting of 10 animals each by the dosage of isosorbide (1.4 or 2.8 g/kg). All animals were sacrificed for the measurement of p-OSM and p-AVP concentrations 3 hours after the intake of water or 70% isosorbide solution. Results: Morphologically, an isosorbide-induced decompression effect was noted in animals with both 1.4- and 2.8-g/kg doses of isosorbide. According to the regression analysis, however, the volumetric decrease of the endolymphatic space was more evident in cases with the small dose (1.4 g/kg) 3 hours after the intake (analysis of covariance [ANCOVA], p

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Assessment of Cochlea Endolymphatic Hydrops Using 3-D FLAIR and 3-D Real IR Sequence in Guinea Pigs via 3T MRI After Intratympanic Gadolinium: A Histopathological Comparison.

Objective: We assessed whether the three-dimensional fluid-attenuated inversion-recovery (3-D FLAIR) and three-dimensional inversion-recovery with real reconstruction (3-D real IR) sequences can be used to detect cochlea endolymphatic hydrops (EHs) in guinea pigs using 3 Tesla magnetic resonance imaging (3T MRI). The results of 3-D real IR imaging were compared with histopathological outcomes. Materials and Methods: Fourteen healthy men and women albino guinea pigs were used in this study. Their right ears received procedures that promoted EHs, and their left ears were used as untreated controls. High-resolution 3T MRI, combined with the intratympanic injection of gadolinium (Gd) in both ears, was performed 8 to 12 weeks after surgery. Both sides of the cochlea midmodiolar sections were observed under a light microscope and saved as the histopathological images. The signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) between the T2-weighted 3-D FLAIR and T2-weighted 3-D real IR sequences were compared. The appearance of EHs in the basal, second, third, and apical turns of the cochlea was further evaluated using 3-D FLAIR, 3-D real IR, and the histopathological images. Moreover, the maximum scala media area ratios (SMRs) on the histopathological sections were compared with the grading of the EHs on the 3-D real IR sequence with regard to each turn of the cochlea. Results: Significant differences were found between the 3-D FLAIR and 3-D-real IR sequences with regard to the SNRs and CNRs (p

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