Endoscopic Endonasal Dissection of the Pterygopalatine fossa, Infratemporal fossa, and Post-styloid compartment. Anatomical Relationships and Importance of Eustachian Tube in the Endoscopic Skull Base Surgery

Abstract BACKGROUND COVID-19 poses a risk to the endoscopic skull base surgeon. Significant efforts to improving safety have been employed, including the use of personal protective equipment, preoperative COVID-19 testing, and recently the use of a modified surgical mask barrier. OBJECTIVE To reduce the risks of pathogen transmission during endoscopic skull base surgery. METHODS This study was exempt from Institutional Review Board approval. Our study utilizes a 3-dimensional (3D)-printed mask with an anterior aperture fitted with a surgical glove with ports designed to allow for surgical instrumentation and side ports to accommodate suction ventilation and an endotracheal tube. As an alternative, a modified laparoscopic surgery trocar served as a port for instruments, and, on the contralateral side, rubber tubing was used over the endoscrub endosheath to create an airtight seal. Surgical freedom and aerosolization were tested in both modalities. RESULTS The ventilated mask allowed for excellent surgical maneuverability and freedom. The trocar system was effective for posterior surgical procedures, allowing access to critical paramedian structures, and afforded a superior surgical seal, but was limited in terms of visualization and maneuverability during anterior approaches. Aerosolization was reduced using both the mask and nasal trocar. CONCLUSION The ventilated upper airway endoscopic procedure mask allows for a sealed surgical barrier during endoscopic skull base surgery and may play a critical role in advancing skull base surgery in the COVID-19 era. The nasal trocar may be a useful alternative in instances where 3D printing is not available. Additional studies are needed to validate these preliminary findings.

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Sensitivity and specificity of intrathecal fluorescein and white light excitation for detecting intraoperative cerebrospinal fluid leak in endoscopic skull base surgery: a prospective study

Journal of Neurosurgery ◽

10.3171/2014.12.jns14995 ◽

2016 ◽

Vol 124 (3) ◽

pp. 621-626 ◽

Cited By ~ 22

Author(s):

Shaan M. Raza ◽

Matei A. Banu ◽

Angela Donaldson ◽

Kunal S. Patel ◽

Vijay K. Anand ◽

...

Keyword(s):

Skull Base ◽

Sensitivity And Specificity ◽

Skull Base Surgery ◽

False Negative ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Predictive Values ◽

Endoscopic Skull Base Surgery ◽

Csf Leaks

OBJECT The intraoperative detection of CSF leaks during endonasal endoscopic skull base surgery is critical to preventing postoperative CSF leaks. Intrathecal fluorescein (ITF) has been used at varying doses to aid in the detection of intraoperative CSF leaks. However, the sensitivity and specificity of ITF at certain dosages is unknown. METHODS A prospective database of all endoscopic endonasal procedures was reviewed. All patients received 25 mg ITF diluted in 10 ml CSF and were pretreated with dexamethasone and Benadryl. Immediately after surgery, the operating surgeon prospectively noted if there was an intraoperative CSF leak and fluorescein was identified. The sensitivity, specificity, and positive and negative predictive power of ITF for detecting intraoperative CSF leak were calculated. Factors correlating with postoperative CSF leak were determined. RESULTS Of 419 patients, 35.8% of patients did not show a CSF leak. Fluorescein-tinted CSF (true positive) was noted in 59.7% of patients and 0 false positives were encountered. CSF without fluorescein staining (false negative) was noted in 4.5% of patients. The sensitivity and specificity of ITF were 92.9% and 100%, respectively. The negative and positive predictive values were 88.8% and 100%, respectively. Postoperative CSF leaks only occurred in true positives at a rate of 2.8%. CONCLUSIONS ITF is extremely specific and very sensitive for detecting intraoperative CSF leaks. Although false negatives can occur, these patients do not appear to be at risk for postoperative CSF leak. The use of ITF may help surgeons prevent postoperative CSF leaks by intraoperatively detecting and confirming a watertight repair.

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Endoscopic Endonasal Repair of Internal Carotid Artery Injury during Endoscopic Endonasal Surgery

Journal of Neurological Surgery Reports ◽

10.1055/s-0037-1608635 ◽

2017 ◽

Vol 78 (04) ◽

pp. e125-e128 ◽

Cited By ~ 4

Author(s):

Irit Duek ◽

Gill Sviri ◽

Moran Amit ◽

Ziv Gil

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Skull Base ◽

Internal Carotid ◽

Skull Base Surgery ◽

Endoscopic Management ◽

Carotid Artery Injury ◽

Endoscopic Endonasal ◽

Artery Injury ◽

Endoscopic Skull Base Surgery

Background Injury to the cavernous portion of the internal carotid artery (ICA) during endoscopic skull base surgery is a well-recognized rare complication that can be associated with high rates of morbidity and mortality. Many techniques have been suggested to manage ICA injury with varying degrees of success. Objectives We provide a detailed technical description of an operative technique for endoscopic management of carotid artery injury. Methods A case of ICA injury during endoscopic skull base surgery is presented. The immediate treatment measurements include: (1) early recognition of ICA injury, (2) briefing of the team and preparations, (3) packing, (4) harvesting of temporalis muscle patch, (5) placement of the muscle patch over the defect, and (6) gentle compression for 10 minutes. Results The technique facilitates quick repair and restores normal blood flow through the damaged artery. Exsanguination or the symptoms of stroke that may occur from prolonged occlusion of the ICA are therefore prevented. Conclusion The proposed protocol is useful for the management of a potentially life-threatening ICA injury.

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Eustachian Tube as a Landmark to the Internal Carotid Artery in Endoscopic Skull Base Surgery

Otolaryngology ◽

10.1177/0194599815616799 ◽

2015 ◽

Vol 154 (2) ◽

pp. 377-382 ◽

Cited By ~ 6

Author(s):

Juan Liu ◽

Xicai Sun ◽

Quan Liu ◽

Dehui Wang ◽

Huan Wang ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Skull Base ◽

Eustachian Tube ◽

Internal Carotid ◽

Skull Base Surgery ◽

Endoscopic Skull Base Surgery

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Collateral thermal injury during endoscopic skull base surgery from endonasal CO2 laser and coblation

The Journal of Laryngology & Otology ◽

10.1017/s0022215113000510 ◽

2013 ◽

Vol 127 (S2) ◽

pp. S29-S32 ◽

Cited By ~ 1

Author(s):

D Chin ◽

K Snidvongs ◽

R Sacks ◽

R J Harvey

Keyword(s):

Skull Base ◽

Thermal Injury ◽

Skull Base Surgery ◽

Injury Patterns ◽

Endoscopic Endonasal ◽

Endoscopic Skull Base Surgery ◽

Tissue Removal ◽

Depth Control ◽

Fresh Frozen ◽

Two Sides

AbstractIntroduction:Effective tissue removal techniques are essential in endoscopic skull base surgery. Improvements in technology permit more accurate application of CO2 laser and coblation during endonasal procedures. This study assessed the thermal injury patterns associated with fibre CO2 laser and coblation.Methods:Fresh frozen cadaveric heads were used. Mucosal removal was performed at the ethmoid roof. Structured lesions were created using either CO2 laser or coblation. The corresponding thermal injury patterns on dural tissue were assessed and compared between the two groups.Results:Five cadaveric heads were obtained; five sides received CO2 laser lesions and five coblation lesions. Forty per cent (n = two sides) of the CO2 specimens had macroscopic foci of grey-black discolouration on the dural aspect. No macroscopic dural changes were seen in the coblation specimens.Conclusion:Dural injury was seen following CO2 laser use despite attempts to avoid it. Both CO2 laser and coblation have their advantages; however, the lower thermal working power of coblation and superior depth control may make it more suitable for endoscopic endonasal periorbital and peridural surgery.

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Straws Don't Suck: Are Straws Dangerous after Endoscopic Skull Base Surgery?

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1714095 ◽

2020 ◽

Author(s):

Erin K. Reilly ◽

Judd H. Fastenberg ◽

Mindy R. Rabinowitz ◽

Colin T. Huntley ◽

Maurits S. Boon ◽

...

Keyword(s):

Nasal Cavity ◽

Skull Base ◽

Negative Pressure ◽

Skull Base Surgery ◽

Pressure Measurements ◽

Average Pressure ◽

Endoscopic Endonasal ◽

Endoscopic Skull Base Surgery ◽

Significant Difference ◽

Pressure Dynamics

Abstract Objective Patients undergoing endoscopic endonasal surgery have historically been restricted from using straws postoperatively, due to the concern that this activity generates negative pressure. The objective of this study is to evaluate the pressure dynamics in the sinonasal cavity associated with the use of a straw. Methods Intracranial pressure catheters were placed in the nasal cavity of 20 healthy individuals. Pressure measurements were then recorded while participants drank liquids of different viscosities from a cup and from a straw. Measurements were recorded with and without subjects occluding their nose to simulate postoperative nasal obstruction. Results The average pressure in the nasal cavity while drinking water from a cup was −0.86 cmH2O, from a straw was −1.09 cmH2O, and while occluding the nose and using a straw was −0.81 cmH2O. The average pressure in the nasal cavity while drinking a milkshake from a cup was −0.98 cmH2O, from a straw was −1.88 cmH2O, and while occluding the nose and using a straw was −1.37 cmH2O. There was no statistically significant difference in pressure measurements when comparing either task or consistency (p > 0.05). Conclusion Straw use is not associated with the generation of significant negative pressure in the nasal cavity. The pressure generated when drinking from a straw is not significantly different from that of drinking from a cup. This data suggest that straw use may be safe for patients following endoscopic skull base surgery, but further investigation is warranted.

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