OBJECTIVE-No study has evaluated the effect of the multidisciplinary head and neck tumor board on treatment planning. The objective of this study is to determine the efficacy of the multidisciplinary tumor board in altering diagnosis, stage, and treatment plan in patients with head and neck tumors.STUDY DESIGN-Case series with planned data collection. SETTING-Comprehensive cancer center and tertiary academic hospital.SUBJECTS AND METHODS-A prospective study of the discussions concerning 120 consecutive patients presented at a multidisciplinary head and neck tumor board was performed. As each patient was presented, record was made of the "pre-conference" diagnosis, stage, and treatment plan. After case discussion, the "post-conference" diagnosis, stage, and treatment plan were recorded. Results are compared between malignant and benign tumor cohorts. RESULTS-The study population was comprised of 120 patients with new presentations of head and neck tumors -84 malignancies and 36 benign tumors. Approximately 27% of patients had some change in tumor diagnosis, stage, or treatment plan. Change in treatment was significantly more common in cases of malignancy, occurring in 24% of patients versus 6% of benign tumors (p = 0.0199). Changes in treatment were also noted to be largely escalations in management (p = 0.0084), adding multi-modality care.CONCLUSION-A multidisciplinary tumor board affects diagnostic and treatment decisions in a significant number of patients with newly diagnosed head and neck tumors. The multidisciplinary approach to patient care may be particularly effective in managing malignant tumors, in which treatment plans are most frequently altered.

Several potential anatomic limits must be considered in pediatric skull base surgery, and these vary according to age. Piriform aperture is likely a limit only in the youngest patients (under 2 years). Sphenoid pneumatization to the planum and sella start at 3 years and complete by age 10 years. Clival intercarotid distances do not change significantly and are not prohibitively narrow in any age group.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. E xternal approaches to the orbit are well established, including the lateral, medial, and inferior orbitotomy. Orbitozygomatic craniotomy can be used for tumors that extend both intracranially and into the orbit and is used for exposure of the optic nerve and canal. 1 Since the 1980s, endoscopic measures have been used to enhance visualization in standard external approaches. 2 Endoscopic endonasal orbital and optic nerve decompressions have become accepted treatments for thyroid eye disease and traumatic optic neuropathy that is unresponsive to steroids. A few case reports of endoscopic decompression, biopsy, and resection of tumors that involve the orbit also have been reported. [3][4][5] The expanded endonasal approach (EEA) has been extended to resection of all types of skull base tumors, including posterior, middle, and anterior fossa masses. In this report, we describe the anatomic principles, indications, technical nuances, and limitations of the medial-inferior intraconal EEA to intraorbital tumor surgery, illustrated through a case series of six patients. This approach is ideally suited to benign soft-tissue masses (hemangioma/lymphangioma) in the medial-inferior quadrant of the orbit that do not extend superolaterally. The use of this technique would avoid the technical difficulties in approaching such masses and limit the dissection to the areas bordering the endonasal corridor.

Objectives: The introduction of the pedicled nasoseptal flap (NSF) has decreased postoperative cerebrospinal fluid (CSF) leak rates from >20% to <5% during expanded endoscopic skull base surgery. The NSF must be raised at the beginning of the operation to protect the posterior pedicle during the expanded sphenoidotomy. However, in most pituitary tumor cases, an intraoperative CSF leak is not expected but at times encountered. In these cases, a ''rescue'' flap approach can be used, which consists of partially harvesting the most superior and posterior aspect of the flap to protect its pedicle and provide access to the sphenoid face during the approach. The rescue flap can be fully harvested at the end of the case if the resultant defect is larger than expected, or if an unexpected CSF leak develops. This technique minimized septum donor site morbidity for those patients without intraoperative CSF leaks.Results: The rescue flap technique allows for binaural and bimanual access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. If an intraoperative CSF leak is encountered, the rescue flap is then converted into a normal nasoseptal flap for skull base reconstruction. If no leak is obtained, then the patient does not suffer additional donor site morbidity from the full flap harvest.Conclusions: This new technique allows for sellar tumor removal prior to the nasoseptal harvest, thereby eliminating donor site morbidity for those pituitary tumor patients who do not have an intraoperative CSF leak.

Introduction The nasoseptal flap provides hearty, vascularized tissue for reconstruction of Expanded Endonasal Approaches (EEA); however, it produces donor site morbidity due to exposed cartilage. Mucosalization of the septum requires 12 weeks, multiple debridements, and frequent saline rinses. This study addresses the reduction of nasal morbidity by grafting middle turbinate mucosa onto the exposed septum. Methods 15 patients undergoing EEA of the ventral skull base were prospectively enrolled. In seven cases, the sacrificed middle turbinate mucosa was harvested and placed as a free mucosal graft on the septal cartilage. In eight controls middle turbinate grafting was not performed due to tumor involvement. Septal mucosalization and crusting of all patients was quantified at follow-up appointments. An additional 46 patients were retrospectively identified who received middle turbinate grating on their exposed septal cartilage and mucosalization rates determined from clinical records. Results Three weeks after initial operation, the mucosalization rate was 70% versus 5% in the graft and non-graft groups, respectively. At post-operative week six, the mucosalization and crusting were 97% and 5% for the graft group versus 60% and 85% for the non-graft group. Mucosalization rates in the retrospective graft series agreed with the prospective series. Conclusions Despite donor site morbidity, the nasoseptal flap is becoming the standard of care for skull base reconstruction due to its reliability in reestablishing a barrier between the subarachnoid space and the sinonasal tract. It is possible to dramatically increase the rate of septal mucosalization and decrease crusting by using a middle turbinate free mucosal graft. Level of Evidence 1b

Expansion of the limits of endoscopic skull base surgery must be accompanied by the development of new reconstructive options. This report illustrates the ability to take down and reuse the nasoseptal flap in staged and revision cases with a high success rate and minimal additional nasal morbidity.

Three-dimensional endoscopy may improve depth perception and performance for novices. The 3D endoscope is a safe and feasible tool for endoscopic sinus and skull base surgery; it is promising for improving microneurosurgical dissection precision transnasally.

EEAs to ITF tumors are technically feasible with low risk of complications for well-selected patients. The proposed classification system is useful for anticipating potential sequelae for each approach.