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Biomedical subjects

I P Janecka

Publications and source records attributed to I P Janecka.

At least 19 recordsLinked to original sources
PubMed2000

New reconstructive technologies in skull base surgery: role of titanium mesh and porous polyethylene.

OBJECTIVE: To report on 8 years of experience with 156 titanium mesh and porous polyethylene implants used for craniofacial reconstruction after skull base surgery in 100 patients. DESIGN: Cohort study with a mean follow-up of 5 years. SETTING: Population based. PATIENTS: A consecutive sample of 100 patients treated for skull base tumors or craniofacial trauma who underwent reconstruction with 156 3-dimensional titanium mesh and/or porous polyethylene implants. A retrospective review of the Skull Base Program database, along with photographic and imaging documentation, was undertaken. MAIN OUTCOME MEASURES: Rate of complications as well as the degree of functional and esthetic reconstruction. INTERVENTION: The reconstructive technique focused primarily on the substitution of removed craniofacial skeleton for oncologic reasons or soft tissue defects. RESULTS: After completion of follow-up (mean, 5 years), all 100 patients remained healed except for 7 patients (7%) with 8 implants (5%). Overall, excellent craniofacial symmetry and stability were achieved with both types of implants. CONCLUSIONS: Immediate craniofacial skeletal reconstruction and soft tissue augmentation is feasible with 3-dimensional titanium mesh and porous polyethylene implants. The reviewed 8-year evolution in the use of these technologies (156 implants in 100 patients) highlights the excellent tolerance of these implants (5% implant complication rate) in 100 patients (7% complication rate). The few encountered complications were judged to be primarily related to the quality of the overlying soft tissue and not to the implants themselves. The advantages of using these implants for immediate 3-dimensional skeletal and soft tissue substitution, including availability, easy contouring, stability, primary healing, and tolerance of adjuvant therapy, translate to an improved function and esthetic appearance, with a better quality of life for patients.

Adolescent↗
PubMed1999

The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract.

BACKGROUND: Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated. METHODS: A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome. RESULTS: Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months. CONCLUSIONS: ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens.

Adult↗
PubMed1999

Squamous cell carcinoma of the sinonasal tract invading the orbit.

OBJECTIVE/HYPOTHESIS: The treatment of squamous cell carcinoma (SCC) of the sinonasal tract has evolved from routine exenteration of the orbital contents to sparing of the orbit when the SCC does not transgress the periorbita. Nonetheless, the influence of this change in treatment over the rate of local recurrence or survival has not been clearly elucidated. The objective was to ascertain whether orbital sparing surgery for the treatment of SCC of the paranasal sinuses influences the rate of local recurrence or survival. STUDY DESIGN: This is a retrospective study of patients presenting with SCC arising in the sinonasal tract, treated primarily at the University of Pittsburgh Medical Center from 1977 to 1990, including meta-analysis of the English literature regarding SCC of the sinonasal tract. METHODS: Review of medical records regarding demographics, histology, extension of tumor, pathologic results, type of surgery, adjunctive therapy, and outcome. Articles for meta-analysis were identified by Medline search and cross-referencing. RESULTS: Fifty-eight patients with orbital invasion, including bone and/or soft tissue invasion, were included in the study. Patients presenting with invasion of the bony orbit without soft tissue invasion were treated with maxillectomy and/or ethmoidectomy, sparing the orbital contents. Patients presenting with invasion of the orbital bones and soft tissues were treated with ethmoidectomy or maxillectomy, including orbital exenteration. At 3 years' follow-up, 52% of the patients whose orbit was exenterated were alive and without evidence of disease, compared with 59% of the patients whose orbit was spared. This difference was not statistically significant. Similarly, the rate of local recurrence was not statistically significant (P > .05). A meta-analysis of the literature revealed similar results. CONCLUSIONS: Our data suggest that sparing of the soft tissues of the orbit when the periorbita has not been transgressed by SCC does not downgrade the rate of cure or local control.

Carcinoma, Squamous Cell↗
PubMed1999

Atraumatic pneumocephalus: a case report and review of the literature.

Pneumocephalus or air within the cranial vault is usually associated with disruption of the skull caused by head trauma, neoplasms, or after craniofacial surgical interventions. We report a child who presented with headache and the pathognomonic "succussion splash" and was found to have atraumatic pneumocephalus from forceful valsalva maneuvers. Pneumocephalus forms, caused by either a ball-valve mechanism that allows air to enter but not exit the cranial vault, or cerebrospinal fluid (CSF) leaks, which create a negative pressure with subsequent air entry. We review the literature for traumatic and atraumatic causes of pneumocephalus, its complications, and therapy.

Child↗
PubMed1998

Computer-assisted three-dimensional reconstruction of head and neck tumors.

OBJECTIVE: Because head and neck tumors reside in a complex area, having a three-dimensional (3-D) model of the patient's unique anatomical features may assist in the delineation of pathology. The authors describe a new computer technique of 3-D anatomical reconstruction from two-dimensional computed tomography (CT) and magnetic resonance (MR) data and discuss how it represents a step forward in the continuing evolution of 3-D imaging. STUDY DESIGN: The authors selected three patients with solitary head and neck tumors and reconstructed their anatomy in a 3-D format for study. The tumors represented locations in the nose and central skull base (patient 1), temporal bone (patient 2), and neck (patient 3). MATERIALS AND METHODS: MR and CT images from the individual patients were electronically transferred to workstations in the Surgical Planning Laboratory of the authors' institution. Registration (or fusion) was carried out between the MR and CT images. The desired anatomic components underwent segmentation (identification and isolation). Assembly of the segmented images was performed and the resulting structures were integrated to produce a 3-D model. RESULTS: 3-D models of the following were constructed and displayed in an interactive format on high-capacity computer workstations: 1) a skull base sarcoma with extension into the nasopharynx and nose; 2) an acoustic neuroma with internal auditory canal involvement; and 3) a metastatic recurrence of a tongue base squamous cell carcinoma in the posterior triangle of the right side of the neck with extension to the skull base. CONCLUSION: The authors' Surgical Planning Laboratory has developed a 3-D reconstruction technique that has several new features. The models provided a very good 3-D interactive representation of the tumors and patient anatomy. The need now exists to develop this method of 3-D reconstruction of head and neck tumors for potential applications in treatment, research, and medical education.

Adult↗
PubMed1997

Delayed resection in the management of non-orbital rhabdomyosarcoma of the head and neck in childhood.

This retrospective study was undertaken to evaluate the effect of delayed resection on outcome of head and neck rms in a single institution which has experience in cranial base surgery. Since 1988, patients with primary non-orbital rms of the head and neck following treatment at the Children's Hospital of Pittsburgh, were evaluated by the Department of Otolaryngology, Eye and Ear Hospital at the University of Pittsburgh Medical Center either at the time of presentation or when response to chemotherapy and/or radiation therapy was thought to have been optimized for the possibility of definitive surgery. Medical records of patients who did or did not have delayed surgery were reviewed and compared with respect to demographics, tumor stage, response to therapy, survival, and cosmetic results. Of 16 children diagnosed with non-orbital head and neck rms from 1988-1994 and treated with chemotherapy according to IRS II-IV, 3 had group I or II disease following extensive surgery at diagnosis. Thirteen had group III or IV disease. Of these, 6 patients had delayed resection and 7 did not. Delayed resection was undertaken 3-12 months (median, 4 months) from diagnosis in 4 children who had a partial response (PR) and 2 children who had stable disease (SD) with chemotherapy and/or radiation. Delayed resection converted all children to complete responses (CR), including one child with clinical SD and one with PR who were found to have no viable tumor at surgery. The overall percentages of CRs for patients with group III or IV disease (documented any time post-diagnosis) were at least as good for patients who had undergone delayed surgery as for those who had not (100% vs. 71%, p = .465). Median survivals for patients with advanced disease were 3 1/2 years and 2 years, respectively (p = .2801). Cosmetic and functional problems attributable to surgery were not severe but included facial asymmetry (n = 4), trismus (n = 1), cranial nerve deficits (n = 1), and abnormal dentition (n = 1). In locally extensive head and neck rms, cranial base surgery should be considered after initial cytoreductive therapy, since it may contribute to achievement of CR and to survival with acceptable morbidity.

Child↗
PubMed1997

Nasopharyngeal angiofibromas: selecting a surgical approach.

BACKGROUND: A review of 16 juvenile nasopharyngeal angiofibromas, managed at the University of Pittsburgh, is presented. METHODS: A retrospective chart review was done. Surgical approaches and factors affecting recurrence are analyzed. RESULTS: Endoscopic transnasal, transpalatal, medial maxillectomy, facial translocation, and infratemporal fossa approaches, with or without craniotomy, were employed. The 37.5% recurrence rate reflects the advanced stage of the tumors. A major risk factor for recurrence was tumor involvement of the cranial base. CONCLUSIONS: The surgical approach should be selected according to tumor location and effectiveness of embolization. In young patients, the approach should minimize the potential for facial growth retardation. Tumors confined to the nasopharynx, nasal cavity, and paranasal sinuses may be removed endoscopically. Medial maxillectomy is recommended for tumors that extend to the medial intratemporal fossa or medial cavernous sinus. Significant involvement of the infratemporal fossa, cavernous sinus, or middle cranial fossa requires infratemporal fossa or transfacial approaches.

Adolescent↗
PubMed1997

Neural cell adhesion molecule in adenoid cystic carcinoma invading the skull base.

Neural cell adhesion molecules (N-CAMs) are expressed in neuromuscular tissues, neuroblastoma, and small cell lung carcinoma. Adenoid cystic carcinoma may invade the skull by either direct extension or neural involvement, particularly along the second and third divisions of the trigeminal nerve (V2 and V3). Eighteen patients with adenoid cystic carcinoma that invaded the skull base were studied. The tumors were graded into predominantly solid (3), cribriform (11), or tubular-trabecular (4) patterns, and neural involvement was evaluated histologically. Paraffin sections were examined by use of monoclonal antibodies for N-CAM and Ki-67, a proliferation marker, with the avidin-biotin-peroxidase method. Fifteen (83%) tumors showed perineural involvement; in the remaining three cases no nerves were present for histologic examination. Fourteen (93%) of 15 tumors with perineural involvement were reactive with N-CAM. Proliferation, measured by the presence of nuclear Ki-67, was markedly increased in tumors with predominantly solid patterns. We demonstrated that N-CAM is expressed in adenoid cystic carcinoma. The role of N-CAM as a neurodeterminant that facilitates the spread of adenoid cystic carcinoma along nerves, however, remains unanswered and warrants further study.

Antibodies, Monoclonal↗
PubMed1996

Chondrosarcoma of the nasal septum: skull base imaging and clinicopathologic correlation.

Chondrosarcoma arising in the head and neck and craniofacial region is an uncommon lesion. The nasal septum is a particularly rare site of origin, with approximately 30 cases previously reported in the English literature. We present six new cases of chondrosarcoma arising in the nasal septum. Each of these tumors required cranial base surgical approaches for removal. Current imaging techniques allow a very accurate diagnosis to be made before biopsy. The characteristic ring-forming calcifications seen on computed tomography scans can be correlated with the histologic pattern of calcification. Magnetic resonance imaging techniques allow precise definition of tumor extent, which is particularly important because the disease is best treated with primary surgery. Advances in imaging and surgical techniques allow a much more complete tumor removal. It is hoped that this will increase the likelihood of cure in these patients. Surgical management and indications for adjuvant therapy are discussed.

Adult↗
PubMed1996

Optic nerve elongation: does it exist?

The length of the optic nerves is a reflection of normal postnatal cranio-orbital development. Unilateral elongation of an optic nerve has been observed in two patients with orbital and skull base neoplasms. In the first case as compared to the patient's opposite, normal optic nerve, an elongated length of the involved optic nerve of 45 mm was present. The involved optic nerve in the second patient was 10 mm longer than the normal opposite optic nerve. The visual and extraocular function was preserved in the second patient. The first patient had only light perception in the affected eye. In this paper, the embryology, anatomy, and physiology of the optic nerve and its mechanisms of stretch and repair are discussed.

Journal Article↗
PubMed1996

Applications of image-guided navigation in the middle cranial fossa: an anatomic study.

Determining the location of pertinent anatomic structures (ie, the internal auditory canal [IAC]) in middle cranial fossa surgery is commonly based on indirect inferences from bony landmarks. Several methods have been proposed for identification of the IAC, each using bony landmarks coupled with geometric formulation. Identification of the IAC based on bony architecture and geometry may be severely limited when a mass lesion is present. Image-guided surgery has the advantage of rapid localization and may be helpful in navigating a complex surgical field which has been distorted by tumor. This study evaluates the feasibility and accuracy of the ISG viewing wand in determining pertinent anatomic landmarks in the middle fossa of the human cadaver. High-resolution (1 mm) computed tomography was performed on a preserved human cadaver head in which fixed fiducial markers had been placed. Subsequently, the cadaver head was registered in a simulated operative field, and middle fossa craniotomy was performed. The foramen spinosum, foramen ovale, greater superficial petrosal nerve, internal carotid artery, arcuate eminence, and IAC were identified visually, and three independent localizations of each structure were performed with the viewing wand. Accurate localizations were consistently performed within 1 mm for each anatomic landmark. Image-guided navigation is both feasible and accurate in determining intraoperative landmarks in the middle fossa. Image-guidance may enhance surgical accuracy and efficiency. Further clinical studies evaluating image-guided techniques in the middle fossa are warranted.

Journal Article↗
PubMed1996

Abnormalities of the cranial base in synostotic frontal plagiocephaly.

Skeletal abnormalities of the cranial base in various craniosynostoses are well known. Cranial base angulation has been documented in synostotic frontal plagiocephaly--"unilateral coronal synostoses." We analyzed four infants with synostotic frontal plagiocephaly, focusing on computed tomographic images through the cranial base. The scans were performed on a GE advantage spiral with 1.5-mm images. The anatomical structures examined were length of the foramina ovale, length of the eustachian tubes, and sphenotemporal angles. Ratios for these measures were calculated comparing the normal and synostotic sides. The foramen ovale was 21% longer on the synostotic side; the eustachian canal was 11% shorter on the synostotic side. The average sphenotemporal angle on the synotic side was 121 degrees compared with 149 degrees on the nonsynostotic side. Deformities of the cranial base (i.e., elongation of structures anterior to the synostosis and shortening of the structures posterior to the synostosis) can be documented before surgical correction of synostotic frontal plagiocephaly. Follow-up computed tomographic studies will permit study of the effect of fronto-orbital advancement and modeling on these basilar abnormalities.

Cephalometry↗
PubMed1996

Management and long-term outcome of adenoid cystic carcinoma with intracranial extension: a neurosurgical perspective.

Adenoid cystic carcinoma is a tumor of minor and major salivary glands that often invades the cranial base and intracranial cavity via local and perineural spread. In the past, the role of neurosurgeons in managing these tumors has been limited. The growth of interdisciplinary cranial base surgical approaches has now increased the involvement of neurosurgeons in the management of these tumors. We present a series of 16 patients with adenoid cystic carcinomas with cranial base and intracranial extension, the largest series reported in the neurosurgical literature. We have focused our approach on a neurosurgical perspective and made recommendations for the treatment of these tumors in relation to the following specific aspects of this disease. 1) The management of the carotid artery: In our experience, when the carotid artery is involved by tumor, a preliminary cerebral revascularization procedure with a cervical carotid to middle cerebral artery vein bypass graft should be performed before tumor resection. 2) The management of the cavernous sinus and orbit: Cavernous sinus tumor should be removed as fully as possible, but every effort should be made to preserve the IIIrd and IVth cranial nerves to achieve optimal functional and cosmetic results. The orbit should be exenterated when there is intraconal involvement; otherwise, intraorbital tumor can be removed with orbital preservation. 3) The use of palliative surgery: We have found that the use of palliative surgery can be considered even in patients whose extent of local disease precludes a surgical cure. The slow progression of the disease allows for long-term survival of many patients with advanced local disease and even of those with metastatic disease. 4) The long-term survival of these patients: In our series, six patients had no evidence of local disease and a mean survival of 72 months, one living patient had evidence of local disease and has survived 56 months, eight patients died of disease, with a mean survival of 137 months, and one patient died of complications after surviving for 63 months.

Adult↗
PubMed1996

Correction of ocular dystopia.

The purpose of this study was to examine results with elective surgical correction of enophthalmos. The study was a retrospective assessment in a university-based referral practice. A consecutive sample of 10 patients who developed ocular dystopia following orbital trauma was examined. The main outcome measures were a subjective evaluation by patients and objective measurements of patients' eye position. The intervention was three-dimensional orbital reconstruction with titanium plates. It is concluded that satisfactory correction of enophthalmos and ocular dystopia can be achieved with elective surgery using titanium plates. In addition, intraoperative measurements of eye position in three planes increases the precision of surgery.

Adult↗
PubMed1995

Frameless stereotactic guidance. An intraoperative adjunct in the transoral approach for ventral cervicomedullary junction decompression.

METHODS: The application of a video-interactive frameless stereotactic guidance system for the treatment of ventral cervicomedullary junction compression is described in a patient with basilar invagination, odontoid dysgenesis, and a Chiari malformation who had irreducible impingement on the ventral brainstem by a partially fused mass of bone made up of the malformed odontoid peg, the inferior clivus, and dorsally protruding osteophytes at the odontoid-clival junction. RESULTS: This technology permitted instantaneous feedback of the surgeon's orientation in all planes, facilitating extensive removal of the dens and clival tip to achieve adequate ventral brainstem decompression. In view of the distortion of the craniovertebral anatomy produced by the patient's anomalies, the ability to visualize three dimensionally the location of the vertebral arteries also added an element of safety to the lateral bone removal. Similarly, the ability to localize the rostral limit of the clivus that needed to be resected and the caudal extent of C2 that needed to be removed to achieve an adequate decompression helped ensure that the extent of bone removal was appropriately tailored to the patient's anatomy. CONCLUSION: The authors believe this technique represents a significant advance over standard radiographic intraoperative localization techniques during transoral approaches to the ventral cervicomedullary junction for patients in whom the odontoid is fixed in position in relation to the clivus. This is based on the speed with which localization can be obtained, the accuracy of the information provided, the ability to obtain localization in multiple planes simultaneously, and the lack of radiation exposure during the procedure.

Brain Stem↗