Orbital Apex Tumor Resection via Extended Endoscopic Endonasal Approach

Abstract BACKGROUND: Surgical exposure of the jugular foramen (JF) is challenging given its complex regional anatomy and proximity to critical neurovascular structures. OBJECTIVE: To describe the anatomical basis, surgical technique, and outcomes of a group of patients who underwent the endoscopic endonasal approach to the JF. METHODS: Five silicon-injected anatomical specimens were prepared for dissection. Additionally, a chart review was conducted through our patient database, searching for endonasal exposure of the JF. Demographic data, clinical presentation, pathological findings, extent of resection in the JF, and occurrence of complications were analyzed. RESULTS: The endonasal exposure of the JF requires 3 sequential steps: a transpterygoid, a “far-medial,” and an “extreme-medial” approach. Mobilization or transection of the cartilaginous portion of the eustachian tube (ET) is necessary. In the clinical series, cranial neuropathies were the presenting symptoms in 16 patients (89%). Eighteen tumors (10 chondrosarcomas, 7 chordomas, 1 adenocarcinoma) extended secondarily into the JF. Total tumor resection was achieved in 10 patients (56%), near total (≥90%) in 6 (33%), and subtotal (<90%) in 2 (11%). ET dysfunction (75% of cases), transient palatal numbness (17%), cerebrospinal fluid leakage (17%), and lower cranial nerve palsy (17%) were the most common postoperative complications. There were no carotid artery or jugular vein injuries. CONCLUSION: The endoscopic endonasal approach to the JF requires mobilization or transection of the cartilaginous portion of the ET. This maneuver provides a safe infrapetrosal surgical route to the JF. It may be considered a valid option, in well-selected cases, for resection of malignant and recurrent cranial base tumors.

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Placement of cesium-131 permanent brachytherapy seeds using the endoscopic endonasal approach for recurrent anaplastic skull base meningioma: case report and technical note

Journal of Neurosurgery ◽

10.3171/2018.11.jns181943 ◽

2020 ◽

Vol 132 (3) ◽

pp. 921-926 ◽

Cited By ~ 2

Author(s):

Asif Raza Shafiq ◽

A. Gabriella Wernicke ◽

Charles Alex Riley ◽

Peter F. Morgenstern ◽

Lucy Nedialkova ◽

...

Keyword(s):

Skull Base ◽

Local Control ◽

Tumor Resection ◽

External Beam Radiation ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Beam Radiation ◽

Invasive Approach ◽

Skull Base Meningioma

There are few therapeutic options available for the treatment of recurrent meningiomas that have failed treatment with surgery and external-beam radiation therapy (EBRT). As additional EBRT is clinically risky, brachytherapy offers an important alternative for optimizing local control. In skull base meningiomas, the endoscopic endonasal approach (EEA) has demonstrated an excellent extent of resection. However, in the case of recurrent, atypical, or residual meningiomas, the EEA alone may not be adequate to address microscopic, residual, highly proliferative disease. In this situation, local radioactive seed brachytherapy has been shown to improve control, but few reports of this technique exist. A 48-year-old right-handed man presented on multiple occasions with recurrence of an anaplastic skull base meningioma, after multiple prior gross-total resections and multiple rounds of radiotherapy had failed. The authors performed a maximally safe neurosurgical tumor resection via EEA supplemented by the intraoperative implantation of 131Cs low-dose permanent brachytherapy seeds. They describe a technique for permanent implantation of brachytherapy seeds and provide operative video of this technique. The authors submit that utilizing this technique in combination with EEA tumor resection renders a minimally invasive approach to improving local control in a patient with a recurrent anaplastic or atypical meningioma of the skull base.

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Expanding indications for the extended endoscopic endonasal approach to hypothalamic gliomas: preliminary report

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14317 ◽

2014 ◽

Vol 37 (4) ◽

pp. E11 ◽

Cited By ~ 11

Author(s):

Matteo Zoli ◽

Diego Mazzatenta ◽

Adelaide Valluzzi ◽

Gianluca Marucci ◽

Nicola Acciarri ◽

...

Keyword(s):

Quality Of Life ◽

Tumor Resection ◽

Small Sample ◽

Anterior Communicating Artery ◽

Moderate Increase ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

Object In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach. Methods Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. Preoperative and postoperative neuroimaging as well as endocrinological, neurological, and visual symptoms were analyzed to assess the surgical outcome. Signs and symptoms of hypothalamic dysfunction including body mass index (BMI), memory, sleep-wake rhythm, and polyphagia were prospectively collected pre- and postoperatively to assess hypothalamic function. Quality of life was evaluated using the Katz scale. Results In the initial phase the endoscopic endonasal approach was adopted in 3 cases with a palliative intent, to obtain a biopsy sample or for debulking of the mass followed by radio- or chemotherapy. In 2 later cases it was successfully adopted to achieve gross-total tumor resection. Complications consisted of 2 postoperative CSF leaks, which required an endoscopic endonasal reintervention. Visual deficit improved in 3 cases and normalized in the other 2. Four patients developed diabetes insipidus, and 3 an anterior panhypopituitarism. All patients had a moderate increase in BMI. No patients presented with any other signs of hypothalamic damage, and their quality of life at follow-up is normal. Conclusions Despite the limitations of a short follow-up and small sample, the authors’ early experience with the endoscopic endonasal approach has revealed it to be a direct, straightforward, and safe approach to third ventricle astrocytomas. It allowed the authors to perform tumor resection with the same microsurgical technique: dissecting the tumor with 2 hands, performing a central debulking, and controlling the bleeding with bipolar coagulation. The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.

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Endoscopic Endonasal Approach for Orbital and Orbital Apex Lesions: A Series of 77 Patients

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0035-1546533 ◽

2015 ◽

Vol 76 (S 01) ◽

Author(s):

Nathan Zwagerman ◽

Susan Stefko ◽

Eric Wang ◽

Juan Fernandez-Miranda ◽

Carl Snyderman ◽

...

Keyword(s):

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Orbital Apex ◽

Endoscopic Endonasal

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An Update on the Endoscopic Endonasal Approach to Orbital and Orbital Apex Lesions: A Series of 97 Patients

10.1055/s-0040-1702333 ◽

2020 ◽

Author(s):

Joel Franco ◽

Nathan Zwagerman ◽

Carl Snyderman ◽

Paul Gardner ◽

Tonya Stefko ◽

...

Keyword(s):

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Orbital Apex ◽

Endoscopic Endonasal

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How I do it: endoscopic endonasal approach to the orbital apex

Acta Neurochirurgica ◽

10.1007/s00701-021-04900-5 ◽

2021 ◽

Author(s):

Felipe Constanzo ◽

Jaime Pinto ◽

Thomas Schmidt

Keyword(s):

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Orbital Apex ◽

Endoscopic Endonasal

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Pseudocapsule-Based Resection for Pituitary Adenomas via the Endoscopic Endonasal Approach

Frontiers in Oncology ◽

10.3389/fonc.2021.812468 ◽

2022 ◽

Vol 11 ◽

Author(s):

Yuefei Zhou ◽

Jialiang Wei ◽

Feng Feng ◽

Jianguo Wang ◽

Pengfei Jia ◽

...

Keyword(s):

Pituitary Adenomas ◽

Tumor Resection ◽

Csf Leak ◽

Safe Procedure ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Csf Leakage ◽

Extracapsular Resection

IntroductionThe endoscopic endonasal approach (EEA) is a safe and effective treatment for pituitary adenomas (PAs). Since extracapsular resection (ER) of PAs improves tumor resection and endocrine remission rates, the interface between the pseudocapsule and gland draws increasing attention. However, it is difficult to precisely dissect the tumor along the exact boundary, and complete removal of the tumor increases the risks of normal tissue damage and cerebrospinal fluid (CSF) leakage. In this study, we investigated the extracapsular resection as well as the pseudocapsule histology to evaluate the effectiveness and safety of pseudocapsule-related surgical interventions.MethodsFrom December 2017 to December 2019, 189 patients of PAs via EEA in our single center were analyzed retrospectively. The images, operative details, and clinical follow-up of patients were collected. Sixty-four patients underwent pseudocapsule-based ER, and 125 patients also underwent traditional intracapsular resection (IR) with or without intensive excision for FPAs. The clinical characteristics, tumor resection, endocrinological outcomes, and postoperative morbidities of the two groups were compared. Informed consent for publication of our article was obtained from each patient. Histological examination of pseudocapsule was performed using hematoxylin and eosin and reticulin staining.ResultsThe gross total recession was 62 (96.9%) in the ER group and 107 (85.6%) cases in the IR group, whereas the endocrine remission rate was 29/31 (93.5%) and 40/53 (75.5%) cases, respectively. Anterior pituitary functions were not aggravated postoperatively in any patient, but transient diabetes insipidus (DI) occurred more in the IR group (64.0%) than in ER (48.4%). Pseudocapsule specimens were obtained in 93 patients, and clusters of small cell aggregation were detected in 11 pseudocapsule specimens (11.8%) whereas other patients showed no remarkable developed pseudocapsule. Intraoperative CSF leak occurred more in the ER group (28.1%) than in the IR group (13.6%), but no difference was seen between two groups postoperatively. No case of intracranial hematoma or pituitary crisis occurred in both groups. After a mean follow-up of 22.8 months, tumor recurrence was observed in 4 (2.1%) cases.ConclusionPseudocapsule-based extracapsular resection of PAs via EEA is an effective and safe procedure to achieve complete resection with high and sustained endocrine remission and without deteriorating pituitary function.

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