Carl H. Snyderman

Background: Sinonasal malignancies (SNMs) are a rare group of diseases with limited high‐level evidence to guide management. Where data are currently lacking, contemporary management principles may be guided by clinical expertise and experience. Methods: Structured qualitative thematic interviews with multidisciplinary international experts in the management of SNMs. A mixed‐methods design involving qualitative and quantitative analysis of the collected data was completed. Results: A total of 40 experts comprising 22 academic institutions across nine countries were included. Surgical factors, including anatomic limitations of resectability and criteria for consideration of orbital exenteration, are discussed. There are mixed opinions on the role of induction systemic therapy and when to employ its use. Nuances in the management of specific histopathologies, including olfactory neuroblastoma, adenoid cystic carcinoma, sinonasal mucosal melanoma, adenocarcinoma, nasopharyngeal carcinoma, sinonasal undifferentiated carcinoma, squamous cell carcinoma, and rhabdomyosarcoma, are explored. Commonalities and discrepancies between experts are summarized. The importance of histopathology‐specific management and multidisciplinary management is highlighted. Conclusions: Management of SNMs is complex, with a wide variety of practice patterns among experts. This work serves as a modern guide for expert management paradigms where little data currently exists.

BACKGROUND AND OBJECTIVES: Tuberculum sella meningiomas (TSM) constitute 5% to 10% of intracranial meningiomas and pose surgical challenges because of their proximity to critical neurovascular structures and the optic chiasm. We aimed to evaluate the long-term efficacy of the endoscopic endonasal approach (EEA) for TSMs at a university skull base center. METHODS: A retrospective study of patients with TSM treated using EEA between 2008 and 2024 with a minimum 6 months of follow-up. Clinical outcomes, including the extent of resection, visual outcomes, complications, and recurrence rates, were evaluated. RESULTS: The 92 patients were predominantly female (82.6%), with a median age of 58.3 (range 27.5-82.1) years. Eighteen patients (19.6%) had multiple meningiomas, and 10 (10.9%) were treated for recurrent TSM. The median maximum diameter of tumor was 2.0 (range 0.4-5.4) cm. Most TSMs were World Health Organization grade I (97.8%). Simpson Grade 1 resection was achieved in 72 cases (78.3%). 57/80 patients (71.3%) with preoperative visual dysfunction reported improvement, and 2 (2.5%) reported decline. Of patients with postoperative testing, the visual acuity improved in 38/52 patients (73.1%) and declined in 1 patient, and visual fields improved in 42/54 patients (77.8%) and declined in 3 patients. Postoperative complications were observed in 19 (20.7%) patients, including 12 (13%) with cerebrospinal fluid leak and 1 Heubner infarct. Seven patients (7.6%) experienced recurrence and the median follow-up was 52 months (IQR 24.0-91.4). On multivariable Cox proportional hazard analysis, only non-Simpson Grade 1 resection (hazard ratio = 22.5, P = .004) was associated with recurrence or regrowth. CONCLUSION: EEA is a safe and effective primary treatment for TSMs, yielding a high Simpson Grade 1 rate, resultantly low long-term recurrence rate, and improved visual outcomes.

Objective: The primary length of stay (PLOS) metric fails to capture added time, costs, and reduced patient quality of life (QOL) associated with readmissions. To address these limitations, we propose a novel metric, the hospitalization utilization metric (HUM), which integrates PLOS and readmission LOS (RLOS). Study Design: Retrospective review of 626 head and neck microvascular free flap (MVFF) cases from August 2019 to May 2024. Setting: University of Pittsburgh Medical Center. Methods: Main outcome measure was HUM, calculated as total length of stay (TLOS) (TLOS = [PLOS + RLOS]/60 days). High HUM, determined by median split, was >0.18. Results: Our 626‐patient cohort averaged 62.7 ± 11.9 years old. The majority of patients were male (68.2%), white (92.0%), with advanced tumors (III/IV: 74.1%), and public insurance (63.1%). The median (interquartile range [IQR]) PLOS was 9 (7‐14), median (IQR) HUM was 0.18 (0.13‐0.28), and the rate of 60‐day re‐presentation/readmission was 34.3%. Multivariable logistic regression identified postoperative complications ( β : .08, P < .001; β : 4.44, P < .001, respectively) and private insurance ( β : −.04, P < .02; −2.71, P < .01) as predictive factors associated with both higher HUM and PLOS (>9 days), respectively. Return to intensive care unit (ICU) ( β : .08, P < .003) and duration of surgery ( β : .005, P < .048) were independently associated with higher HUM, although both effect sizes are relatively small. Kaplan‐Meier survival curves revealed that higher HUM ( P = .030) but not PLOS ( P = .098) was associated with worse survival 1 year postoperatively. Conclusion: HUM provides a comprehensive assessment of healthcare utilization compared to PLOS and re‐presentation alone and may be a practical surrogate for patient QOL and healthcare costs.

This study aimed to describe how olfactory neuroblastoma (ONB) recurrences are managed and whether these salvage strategies lead to freedom from disease at the location of recurrence. Retrospective cross-sectional analysis. Single academic hospital in the United States. Patients with recurrent ONB undergoing salvage treatment from April 2006 to February 2021. Persistence or freedom from recurrent disease. A total of 27 cases were identified. Among these cases, 59 recurrences were observed. The mean time to recurrence was 72 months. The mean duration from time of recurrence management to most recent follow-up was 59 months. A total of 19 cases underwent surgery for local sinonasal or local intracranial disease, 20 cases underwent surgery for regional disease, 2 underwent surgery for distant extracranial disease, and no patients underwent surgery for distant intracranial disease. About 22 recurrences were treated with radiation, 8 recurrences were treated with chemotherapy or immunotherapy, and 9 recurrences were treated with radioligand therapy. About 5 patients (20%) had 1-year disease-free survival following salvage treatment and 4 patients (16%) had 5-year disease-free survival following salvage treatment. Surgery, radiation, and radioligand therapy were the most common salvage treatments used for recurrent OBN. Local sinonasal, local intracranial, and regional recurrences were primarily managed surgically, whereas distal intracranial and distant disease were most often treated with radiation or radioligand therapy. This report is the first to characterize treatment strategies and outcomes used for specific locations of recurrences.

Background: Olfactory neuroblastoma (ONB) exhibits variable recurrence patterns, with significant late recurrences occurring years after treatment. We investigated cutoff periods to define late recurrence and identified predictors that distinguish patients at risk of late recurrence from those considered cured. Methods: From a multi‐institutional cohort of 219 ONB patients treated at nine centers, we analyzed 77 patients with documented recurrence. Using a 48‐month cutoff to define early (< 48 months) versus late (≥ 48 months) recurrence, we evaluated 35 clinical, anatomic, and treatment variables using Firth penalized logistic regression across three comparisons: (1) late versus early recurrence timing, (2) late recurrence versus no recurrence, and (3) early recurrence versus no recurrence. Results: Thirty‐four of the 77 (44.2%) recurrences were classified as late. Among the 77 patients who recurred, smaller tumor volume (OR 0.243, p = 0.035) and lower novel Dulguerov staging (OR 0.802, p = 0.038) were associated with late, rather than early recurrence. When patients with late recurrence were compared to those who remained disease‐free, radiographic skull base bone involvement was the strongest independent predictor (OR 2.90, 95% CI 1.14–8.64, p = 0.025), and this effect strengthened after adjusting for tumor volume (OR 3.80, p = 0.029). Pathologic dural invasion (OR 3.29, p = 0.013), Kadish stage (OR 2.02, p = 0.026), and T‐stage (OR 1.32, p = 0.040) were also significant. Conclusions: A 48‐month cutoff effectively stratifies ONB recurrence risk. Skull base bone involvement independently predicts recurrence when compared to nonrecurrent cases and uniquely persists as a risk factor for late recurrence. These findings establish skull base bone involvement as a novel biomarker for risk‐stratified surveillance protocols.

Background: Survival for patients with sinonasal cancers has improved over the past decades, but there are no dedicated survivorship guidelines for this cohort. Objective: To understand experts’ priorities and perspectives on key survivorship tenets (surveillance, second tumor screening, toxicity, and symptom management). Method: A modified Delphi method was used for developing consensus. A preliminary list of statements was generated from literature review and rated for importance by otolaryngology experts from 15 high‐volume North American centers. Statements were rated on a Likert scale and results were discussed. Two Delphi rounds were performed to determine consensus. Results: Consensus was reached for 30 statements. These include the role of endoscopy, imaging, frequency of surveillance stratified by histology and grade, and time following treatment completion. The group reached consensus on the importance of long‐term follow‐up for symptom and toxicity management, survivorship program enrollment, and recognizing quality of life related issues, including pituitary hormone abnormalities, neurocognition, mental health disorders, sinonasal dysfunction, vision, hearing, dental health, speech and swallowing, and neck morbidity. Conclusion: The group reached consensus on key aspects of surveillance, toxicity and symptom management, and the importance of long‐term follow‐up and enrollment in survivorship programs. Several areas require further research, including the role of second primary tumor screening.

Skull base chordomas are rare and locally aggressive tumors with the potential for metastasis. This study aimed to identify clinical, histopathological, and molecular risk factors for the development of metastasis in patients with chordomas across the axial skeleton. Retrospective, single-center cohort study with multivariable logistic regression to identify independent risk factors for metastasis. Single tertiary care center; patients treated between January 2001 and June 2020. A total of 194 patients with chordomas treated during the study period. Development of metastasis during follow-up; time to metastasis and frequency of distant spread. Candidate predictors included age, gender, tumor location, Ki-67 proliferation index, and chromosomal aberrations. Among 194 patients, 20 (10.3%) developed metastasis during a mean overall follow-up of 65.4 months; mean follow-up among the metastatic subgroup was 93.9 months. On multivariate analysis, higher Ki-67 index (OR, 1.07; 95% CI, 1.01–1.14; p = 0.02) and tumor location at the craniocervical junction (OR, 4.91; 95% CI, 1.44–15.77; p = 0.01) were associated with increased odds of metastasis. Male gender was associated with lower odds of metastasis (OR, 0.31; 95% CI, 0.10–0.84; p = 0.03), indicating female gender as the higher-risk category. Higher Ki-67 index, craniocervical junction location, and female gender are key risk factors for metastasis in chordoma patients. Early identification of high-risk patients may support more aggressive surveillance and tailored therapeutic strategies across chordoma types.

Background: Sinonasal malignancies (SNM) are rare cancers associated with poor prognosis and impaired quality of life (QOL). The 22-question Sino-Nasal Outcome Test (SNOT-22) has been used to assess QOL in patients with SNM. Objective: To determine the minimal clinically important difference (MCID) for the SNOT-22 in patients with SNM. Methods: About 264 patients with SNM were drawn from a prospective, longitudinal, multi-institutional study. SNOT-22 scores were collected at pre-treatment baseline and follow-up through 5 years post-treatment. Cronbach’s alpha was used to assess the internal consistency of the SNOT-22. Distribution-based approaches were used to estimate the MCID. Multivariable regression identified factors associated with SNOT-22 improvement exceeding the determined MCID. Results: Cronbach’s alpha was >.85. The estimated MCIDs were: 1.44 (Cohen’s effect size), 1.32 (standard error of the mean), 10.45 (1/2 of baseline standard deviation), and 3.67 (minimum detectable change). The mean MCID across methods was 4.22. Multivariable regression demonstrated higher odds of clinically meaningful improvement from baseline in patients with early-stage disease (odds ratio (OR) 3.510, P = .035), no neck irradiation (OR 11.050, P = .014), and neoadjuvant therapy (OR 16.667, P = .047). Conclusions: The SNOT-22 MCID was estimated as 4.22 in a large multi-center cohort of patients with SNM, suggesting that relatively small QOL changes are clinically relevant. When applying the MCID to the current cohort, advanced stage, treatment of neck disease, and not requiring neoadjuvant therapy were predictive of worse QOL.

Objective: To evaluate procedure‐related complications after ACSS and identify key influential factors that increase or decrease the risk of perioperative complications. Methods: This single institution retrospective cohort study included 3401 patients who underwent ACSS by spine‐surgeons at a single institution from January 2015 to August 2023. Our main outcome of interest was perioperative complications after ACSS, divided into objective and subjective outcomes. Covariates included patient, procedure, surgeon, and institutional factors. Univariable and multivariable logistic regression were used to identify factors associated with complications. Results: Our cohort included 3401 patients averaging 55 ± 12 years and 50% ( n = 1689) were male. The objective complication rate was 4.44% ( n = 151) and subjective complications were 6.70% ( n = 228). Otolaryngologists were involved in 17% ( n = 591) of cases. On multivariable logistic regression, high volume (≥ 15 annual cases) surgeons (OR: 0.58, 95% Cl: 0.35–0.95, p = 0.030), and otolaryngologist involvement in revision surgeries (OR: 0.31, 95% Cl: 0.12–0.77, p = 0.011) were independent predictors of decreased odds of objective complications. Advanced age (OR: 1.04, 95% Cl: 1.02–1.05, p < 0.001) and surgeries involving multiple (≥ 3) spinal levels (OR: 1.70, 95% Cl: 1.23–2.34, p = 0.001) independently predicted an increased odd of subjective complications. Otolaryngologist involvement in upper (C1–4) cervical spinal cases (OR: 0.28, 95% Cl: 0.08–0.96, p = 0.042) independently decreased odds of subjective complications. Conclusion: Adopting a multidisciplinary approach with otolaryngologists as co‐surgeons in complex procedures and increasing surgeons' case volume may improve surgical outcomes, decrease complication rates, and improve quality of care. Level of Evidence: 4