OBJECTIVE:Non-English language preference (NELP) poses a barrier to healthcare access and may contribute to delays in seeking care, understanding treatment plans, and communicating health concerns. This study assesses the relationship between NELP and the clinical characteristics and outcomes of patients with pituitary neuroendocrine tumors (PitNETs) at a high-volume tertiary center. METHODS:A retrospective analysis was conducted on 1143 adult patients who underwent PitNET surgery between 2012 and 2019 at a single institution. Clinical and radiological variables were recorded for NELP patients and compared to patients with English language preference (ELP). Multivariable logistic and negative binomial regression analyses were used to assess associations between NELP, tumor characteristics, and postoperative outcomes, adjusting for confounders. RESULTS:Of the 1143 patients, 14.0% had NELP, with Spanish being the predominant language. NELP patients had larger tumor diameters (median [IQR] 2.0 [1.5-2.8] cm vs 1.5 [0.9-2.2] cm, p < 0.001) and higher rates of government insurance (78.2% vs 44.8%, p < 0.001), diagnosis during emergency department presentation (21.3% vs 7.5%, p < 0.001), cavernous sinus invasion (50.6% vs 30.7%, p < 0.001), and tumor apoplexy (8.8% vs 3.9%, p = 0.011), but they were less likely to present with preoperative endocrine disease (23.1% vs 41.6%, p < 0.001), and had shorter times to surgery (median [IQR] 79 [34.0-248.5] days vs 113 [53.0-430.8] days, p = 0.002) compared to ELP patients. NELP patients also had longer length of stay (LOS) (median [IQR] 2.00 [1.00-4.00] days vs 1.00 [1.00-2.00] days, p = 0.005) and higher lumbar drain placement rate (16.3% vs 8.1%, p = 0.002). In multivariable models, NELP was significantly associated with higher incidence rates of cavernous sinus invasion (OR 1.91, 95% CI 1.31-2.78, p < 0.001) and macroadenoma (OR 4.64, 95% CI 1.95-11.06, p < 0.001), prolonged LOS (incidence rate ratio 1.35, 95% CI 1.10-1.67, p = 0.004), and a lower rate of preoperative endocrine dysfunction (OR 0.56, 95% CI 0.35-0.92, p = 0.02), after adjustment for confounders. There were no significant differences in apoplexy at presentation, 30-day readmission rates, or lumbar drain use. CONCLUSIONS:NELP remained an independent risk factor for complex tumor presentation and extended hospital stay after controlling for sociodemographic factors. Understanding how NELP interacts with other health disparities in neurosurgical care can guide strategies to better support this patient population.

Human papillomavirus (HPV)-associated sinonasal squamous cell carcinoma (SNSCC) (HPV+ SNSCC) is a recently recognized entity that accounts for up to one-third of SNSCC. Although at present these cancers are not routinely tested for HPV, the incidence is increasing and HPV+ SNSCC is associated with superior survival outcomes compared with HPV- SNSCC. Here, we present the case of a patient with HPV+ SNSCC treated with endoscopic resection followed by postoperative radiation and review the literature summarizing epidemiology and management of this disease, with emphasis on the importance of HPV testing in SNSCC.

PURPOSE:Neoadjuvant chemotherapy for structure preservation (SP) in nasal and paranasal sinus squamous cell carcinoma (NPNSCC) has been described in single-institution studies but not in randomized studies. EA3163 was a randomized study investigating whether cytoreductive neoadjuvant chemotherapy would improve SP or overall survival (OS). PATIENTS AND METHODS:Patients with T3/T4a and select T4b NPNSCC requiring orbital or base of skull (BOS) resection were randomized to surgery (arm A) versus surgery preceded by docetaxel/cisplatin for three cycles (arm B). The degree of anticipated SP (orbit and BOS) was required preoperatively and after chemotherapy. SP was noted at surgery. Co-primary objectives were the SP rate (orbit/BOS) and OS. Eighty-two patients needed to be accrued for 81% power with a 0.1 one-sided alpha using Fisher's exact test for SP rate and 83% with a 0.1 one-sided alpha using the log-rank test for OS. RESULTS:Among 23 evaluable patients, the overall SP rate was 30%: 15% in arm A (N = 2/13; 95% confidence interval (CI), 1.9%-45.4%) and 50% in arm B (N = 5/10; 95% CI, 18.7%-81.3%; P = 0.17). Among 18 patients with pathologic T3/T4a disease, the overall SP rate was 39%: 18% in arm A (N = 2/11; 95% CI, 2.3%-51.8%) and 71% in arm B (N = 5/7; 95% CI, 29.0%-96.3%; P = 0.049). Orbit and BOS-specific preservation rates were 38% (95% CI, 8.5%-75.5%) versus 83% (95% CI, 35.9%-99.6%) and 33% (95% CI, 9.9%-65.1%) versus 67% (95% CI, 29.9%-92.5%) in arm A versus B, respectively. The most common grade ≥3 toxicities included mucositis, anemia, nausea and lymphopenia (all >10%). No grade 5 events were reported. CONCLUSIONS:These results support neoadjuvant chemotherapy as an effective intervention for SP in T3/T4a NPNSCC and deserve further evaluation.

Cavernous sinus schwannomas are exceptionally rare tumors. 1,2 Although these tumors commonly originate from the trigeminal nerve, instances involving the oculomotor, abducens, trochlear nerves, and the carotid plexus have also been documented. 2-7 In this operative video, we showcase a 44-year-old man with a medical history of acromegaly and schwannomatosis who presented with retro orbital pain and a growing cystic lesion in the left cavernous sinus. Genetic testing ruled out neurofibromatosis types 1 and 2. An endonasal resection was recommended considering the left side and extradural location of the lesion. 8 The tumor was excised through an endonasal transpterygoid approach using 2 suctions, one of which was equipped with an electrode tip for continuous monitoring of extraocular nerves during the resection process. Imaging postoperatively demonstrated near-total resection. Institutional review board approval was not required; the patient agreed to undergo the procedure and to have his operative video published.

Objectives:Multiple reconstruction techniques exist to repair defects arising from expanded endonasal approach (EEA) surgeries targeting anterior skull base tumors. These repairs aim to minimize post-operative complications such as cerebrospinal fluid (CSF) leak. In 2022, our group described the "Bow tie" trilayer graft, a repair method that incorporates two layers of a collagen matrix graft stitched to a fat graft. The initial data demonstrated a reduction in the rate of CSF leaks following the adoption of this method. This study evaluates the surgical practice of a single surgeon with access to the trilayer technique and the post-operative outcomes. Methods:Retrospective chart review encompassing all EEAs to anterior skull base tumors performed by a single otolaryngologist (JGG) from January 2019 to September 2024 at a tertiary care center. Results:Of 250 cases meeting inclusion criteria, 42 (16.8%) involved bow tie graft reconstruction. Postoperative CSF leaks occurred in 3 subjects (1.2%), with none of these cases involving bow tie grafts. Trilayer grafts were used more frequently in revision cases (p = 0.018) and when intra-operative CSF leaks were encountered (p < 0.0001). There was no difference in average age, sex, BMI, maximum tumor dimension, or the frequency of lumbar drain insertion between the groups with and without trilayer grafts (p > 0.05). Conclusion:The trilayer graft is an efficient and useful tool in the armamentarium of an anterior skull base surgeon. This technique may decrease rates of postoperative CSF leak with limited additional morbidity. Larger multicenter studies are warranted to validate this potential benefit given the relative rarity of this complication. Level of Evidence:4.

BACKGROUND:Recurrent nasopharyngeal carcinoma (NPC) is associated with challenges in treatment due to the complex anatomic location and impact of prior treatment modalities such as radiation therapy. The purpose of this review is to discuss modern treatment strategies for recurrent NPC, potential challenges, and outcomes. METHODS:A narrative review was performed, evaluating management strategies of recurrent NPC, survival measures, and advancements in treatment considerations. RESULTS:Treatment options including radiation, surgery, and chemotherapy are discussed, including data on survival outcomes and treatment-related morbidity. We review additional considerations including advances in endoscopic surgery, operative management of the internal carotid artery (ICA), novel radiation and chemotherapy protocols, and the introduction of immune checkpoint inhibitors. CONCLUSION:This review describes contemporary management strategies for recurrent NPC, highlighting evolving management strategies that may reduce treatment-associated morbidity and improve survival.

ObjectiveTo determine the relationship between pretreatment neutrophil-to-lymphocyte ratio (NLR) and 6-month progression-free survival (PFS)/2-year overall survival (OS) among patients with recurrent or metastatic (R/M) oral cavity cancer on pembrolizumab. Study DesignThis study was a retrospective, observational study performed at a tertiary care academic center. SettingParticipants included patients with oral cavity squamous cell carcinoma (OCSCC) who began pembrolizumab treatment at the University of California, San Francisco between May 2016 and May 2022. MethodsThe primary outcome was a 6-month PFS. The secondary outcome was a 2-year OS. NLR was treated as a continuous variable. Disease progression was determined using radiographic criteria, adopted from the Response Evaluation Criteria in Solid Tumors. ResultsFifty-two patients with OCSCC were included. Immune checkpoint inhibitor (ICI) indication was recurrence/metastasis for all patients. The median pretreatment NLR was 5.7 (interquartile range: 3.6-7.6). Twenty-seven (55%) patients received pembrolizumab alone. Of those receiving treatment for R/M prior to ICI, 9 (18%) received salvage surgery and adjuvant therapy, 2 (4%) received chemotherapy alone, 1 (2%) received chemoradiation, and 10 (20%) received salvage surgery. Nineteen (36.5%) patients had distant metastases at the start of ICI. Six-month PFS was 46%. Two-year OS was 44%. NLR was independently associated with 6-month PFS [hazard ratio, HR: 1.05 (95% confidence interval, CI: 1.01-1.11), P = .028] and 2-year OS [HR: 1.12 (95% CI: 1.05-1.20), P < .001]. ConclusionHigher pretreatment NLR was associated with poorer 6-month PFS and 2-year OS in OCSCC patients treated with pembrolizumab.

PURPOSE:Pituitary neuroendocrine tumors (PitNETs), also known as pituitary adenomas, are typically hypoenhancing and rarely display hyperenhancement on post-contrast T1-weighted MRI. The frequency and significance of this hyperenhancement has not been studied. METHODS:We conducted a retrospective review on PitNET transsphenoidal surgeries performed at a high-volume pituitary center from 2012 to 2019. Tumor hyperenhancement was defined by neuroradiologist impression of preoperative brain MRIs with contrast. Preoperative covariates included patient age, sex, number of prior pituitary surgeries, endocrine symptoms, tumor size, cavernous sinus invasion, and tumor functional vs nonfunctional status. Postoperative variables included tumor Ki-67 rating, extent of resection, incidence of postoperative transient and permanent diabetes insipidus (DI), and need for adjuvant radiation therapy. Correlation with hyperenhancement was assessed with Pearson's chi-squared, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. Dichotomous and numeric variables with p < 0.1 were included in a multiple regression analysis to assess confounding. RESULTS:836 patients were identified with PitNETs who underwent transsphenoidal resection. Among these, 14 tumors (1.67 %) demonstrated contrast hyperenhancement on preoperative MRI. Hyperenhancing tumors were more commonly microadenomas (43 % vs 19 %, p = 0.034). On multiple regression analysis, hyperenhancing tumors were more commonly associated with postoperative transient DI (odds ratio 2.80, 95 % confidence interval 1.09-6.36, p = 0.019). On univariate and multiple regression, all other tumor characteristics and outcomes were unaltered by hyperenhancement. CONCLUSION:Hyperenhancing PitNETs are a rare finding on preoperative post-contrast T1-weighted MRI imaging (1.67 % prevalence) and carry 2.8 × higher odds of postoperative transient diabetes insipidus after surgical resection (OR 2.80, 95 % CI 1.09-6.36, p = 0.019). Surgical teams may consider additional approaches to preserving the pituitary stalk and postoperative monitoring for dysnatremia to minimize postoperative risk of diabetes insipidus.

BACKGROUND AND OBJECTIVES:Functional gonadotroph adenomas (FGAs) are rare pituitary neuroendocrine tumors derived from the steroidogenic factor 1 (SF-1) lineage that present clinically with elevated serum levels of follicle-stimulating hormone (FSH) and/or luteinizing hormone (LH). While previous research has predominantly featured female patients, this study specifically aims to better understand the clinical characteristics and postoperative outcomes of FGAs in male patients. METHODS:A retrospective review of medical records from a single institution, encompassing 1306 pituitary adenomas, identified 12 male patients who underwent transsphenoidal resection for FGAs. RESULTS:Mean (SD) age was 66.5 (9.4) years. Mean (SD) size was 28.8 (21.6) mm. Preoperatively, all patients exhibited elevated FSH (mean [SD] = 21.9 (7.0) mIU/mL, range = 13.7-34.9 mIU/mL, normal = 1.5-12.4 mIU/mL). Mean (SD) preoperative LH was 6.5 (5.9) mIU/mL (range = 1.3-20.9 mIU/mL, normal = 1.8-8.6 mIU/mL), and it was elevated in 2 patients. 3 patients possessed preoperative testosterone dysfunction (2 with low total and free testosterone, 1 with low total testosterone). All patients were symptomatic preoperatively, with fatigue, headache, and visual problems being the most common. Gross total resection was achieved in 9 patients (75.0%). Postoperatively, mean (SD) FSH was 18.5 (17.8) mIU/mL (range = 0.7-53.6 mIU/mL), and remained elevated in 5 patients. LH remained elevated in 2 out of the 2 patients with elevated preoperative LH. 6 patients (50.0%) were prescribed testosterone gel postoperatively. 41.7% of patients did not report symptoms postoperatively. CONCLUSION:All patients presented with elevated FSH levels, and a minority also had elevated LH or low testosterone. Surgery led to a reduction in symptomatic complaints in many cases, and the majority achieved gross total resection. Given that most patients continue to exhibit hormonal abnormalities postoperatively, close follow-up and thorough investigation of gonadal dysfunction is essential, as many patients may require ongoing medical management.

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.

Objectives:To analyze management strategies and outcomes for patients with esthesioneuroblastoma (ENB) undergoing surgical resection at a single institution. Methods:Retrospective review from 1971 to 2022 from a single, high-volume tertiary academic center of all patients with ENB. Results:A total of 60 patients received their primary treatment for ENB at our institution. The average age at diagnosis was 52 years (range 13-91), and most were male (66.7%) with Kadish C (61.7%) stage at presentation. Most patients were treated with an open approach (68.3%) compared with a purely endoscopic approach (31.7%). Median follow-up was 96.9 months (mean 118.8 months, interquartile range 28.4-183.8 months). There was one patient with local recurrence in the endoscopic cohort (5.3%) compared with 22.0% (9 patients) among those who underwent an open resection ( p  = 0.21). The 5-year survival was 87.2% (95% CI, 71.9-100.0%) in the endoscopic cohort compared with 80.2% (95% CI, 68.8-93.5%) in the open group ( p  = 0.60). The rate of death or recurrence within 5 years of treatment was comparable between open and endoscopic (32.5% vs. 15.0%, p  = 0.26). Among Kadish C patients treated in the endoscopic era (after 2006), 5-year survival was 76.2% (95% CI, 52.1-100.0%) in the endoscopic cohort and 64.8% (95% CI, 39.3-100.0%) in the open group ( p  = 0.70). Conclusion:The surgical approach for ENB resection is dictated by tumor extension. Endoscopic resection offers a less invasive approach with comparable postoperative outcomes in appropriately selected patients.

BACKGROUND:Atlanto-occipital (AO) juxta-articular cysts are positioned within the hypoglossal canal, which houses the hypoglossal nerve. These cysts, whether intraneural or extraneural, can exert localized pressure on the nerve, causing isolated ipsilateral hypoglossal nerve palsy (HNP), an unusual clinical finding. The authors contribute to the scarce literature on this atypical and challenging pathology, reviewing the diagnostic complexities, preoperative indicators, key imaging features, and management strategies. OBSERVATIONS:A 55-year-old male presented with tongue deviation, difficulty moving his tongue, and slurring of speech. Physical examination revealed isolated right HNP. MRI showed a lobulated T2 hyperintense lesion with thin rim enhancement at the right hypoglossal canal, extending to the AO joint, suggesting a juxta-articular cyst. CT-guided cyst aspiration decompressed the lesion but yielded no fluid. The patient's symptoms temporarily improved but then were unchanged over 10 months. LESSONS:AO juxta-articular cysts, although rare, should be considered in the differential diagnosis of isolated HNP. High-resolution imaging is crucial for accurate diagnosis. While surgical options exist, conservative management could be appropriate depending on the clinical scenario. CT-guided cyst aspiration can provide temporary relief, but long-term improvement is uncertain. This case emphasizes the link between spinal pathology and cranial nerve dysfunction, underscoring the need for individualized treatment approaches. https://thejns.org/doi/10.3171/CASE24776.

OBJECTIVE There is persistent debate in the literature surrounding the true predictors of biochemical remission after resection of somatotroph adenoma. A multimodal analysis of a large number of patients is needed to better understand which patients may be at higher or lower risk for remission failure after surgery. METHODS A retrospective review was performed on patients undergoing somatotroph adenoma resection. Biochemical remission was defined as age- and sex-adjusted normalization of serum insulin growth factor-1 (IGF-1) levels at least 6 months after surgery. Patient case characteristics and clinicopathologic variables were tested for statistical associations with remission and were included in a random forest machine learning model to assess for their importance in determining remission status. Preoperative variables found to be significant remission predictors on statistical testing and important in the random forest model were subsequently assessed via receiver operating characteristic (ROC) analysis to determine numeric thresholds that optimally predicted preoperative likelihood of remission success or failure. RESULTS Eighty patients were identified with somatotroph adenoma who underwent transsphenoidal resection, with 60 patients (75%) achieving biochemical remission. Statistical testing found that patients with failed remission were more likely to have larger tumors (1.9 vs 1.6 cm by the largest axis, p = 0.014; and 3.61 vs 2.66 cm3 by 3D volume, p = 0.013) that invaded the cavernous sinus more frequently (70% vs 22% of patients, p < 0.001) and have higher preoperative IGF-1 level (860 vs 660 ng/ml, p = 0.044). An optimized random forest machine learning model with 10,000 iterations found that tumor size, preoperative growth hormone and IGF-1 levels, and cavernous sinus invasion were important preoperative predictors of remission status. ROC analysis revealed that 96% of patients with preoperative 3D tumor volume less than 1.51 cm3 (area under the curve [AUC] 0.691, p = 0.003) and 100% with nonadjusted preoperative IGF-1 level less than 718.5 ng/ml (AUC 0.736, p = 0.002) achieved remission. CONCLUSIONS Important preoperative predictors of postoperative remission for somatotroph adenoma resection include serum IGF-1 level, cavernous sinus invasion, and tumor size. Ninety-five percent of patients who achieved postoperative remission had preoperative 3D tumor volume less than 1.51 cm3.

Introduction: Neuroanatomical volumetric models acquired with surface scanning have emerged as a powerful tool in surgical neuroanatomy education, enabling detailed and immersive representations of complex structures. This technical note presents the use of previously documented photogrammetry concepts in combination with Instant NeRF (Neural Radiance Fields) for acquiring hyperrealistic neuroanatomical models.

OBJECTIVES:To describe the clinicopathologic presentation of buccal squamous cell carcinoma and identify risks factors for recurrence and overall survival. METHODS:This is a retrospective case-control study of patients with oral cavity squamous cell carcinoma (OCSCC) treated at a single tertiary care center between 2010 and 2022. All patients with buccal subsite OCSCC treated during this time frame were included and paired with a randomly selected age and gender matched patient with non-buccal OCSCC. Relevant data was collected via chart review. RESULTS:Seventy-seven patients with buccal SCC were matched with 77 non-buccal OCSCC controls. The median follow-up time was 27 months (IQR 14-61). Median age was 67 years (IQR 57-75) and 53% of the cohort was female. Twenty (26%) buccal SCC patients experienced a recurrence versus 19 (25%) in the controls. Age ≥65-years-old increased odds of all-cause mortality in the buccal SCC group, but not in the control group. Perineural invasion and positive margins increased odds of recurrence in the buccal group only. Overall survival and progression-free survival did not differ between the groups, despite a greater number of T2 buccal tumors and T1 non-buccal tumors. CONCLUSIONS:Buccal SCC presents at a higher T stage than other oral cavity SCC subsite and may exhibit variance in the pathologic risk factors that predict poor outcomes versus non-buccal OCSCC. Despite these relatively minor differences, however, oncologic outcomes between these groups were similar.

To date, there are no validated intraoperative tools to predict postoperative visual function following endoscopic endonasal surgery (EES). Assessment of post-surgical vision during surgery can help in postoperative planning and disposition and inform surgical decisions in real-time. The objective of this study was to evaluate the capability of intraoperative endoscopic indocyanine green (ICG) angiography to measure optic chiasm perfusion and determine its relationship with postoperative visual function. A retrospective review was performed on patients undergoing EES for sellar and suprasellar lesions. ICG was injected prior to surgical closure at a time when the optic chiasm and anterior circulation were visible. Luminescence of the superior hypophyseal artery (SHA) branches enveloping the optic chiasm was registered 10 seconds after ICG penetration into the anterior cerebral arteries (ACAs). Pre and post-operative visual acuity and field exams were used to assess visual function. Patients with and without new deficits were compared to examine statistical association with intraoperative ICG findings. Twenty patients were included (mean age 49 years, 55