Expanded Endonasal Approach for Resection of Extradural Infratemporal Fossa Trigeminal Schwannoma: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E396-E397
Author(s):  
Karam Asmaro ◽  
Jack Rock ◽  
John Craig
Keyword(s):  
Maxillary Sinus ◽  
Skull Base ◽  
Infratemporal Fossa ◽  
Posterior Wall ◽  
Sinus Surgery ◽  
Csf Leak ◽  
Foramen Ovale ◽  
Nasoseptal Flap ◽  
Carotid Canal ◽  
Expanded Endonasal Approach

Abstract The infratemporal fossa (ITF) is bounded superiorly by the skull base, specifically the greater wing of the sphenoid, which contains foramen ovale. It is bordered posteriorly by the temporal bone, including the petrous portion of the carotid canal, anteriorly by the posterior wall of the maxillary sinus, laterally by the mandible, and medially by the pterygoid body and lateral pterygoid plate.1-3 In this video, we report a case of a rare, exclusively extradural, schwannoma originating from the third division of the trigeminal nerve with a widened foramen ovale at the skull base. The tumor filled the ITF and extended laterally just through the sigmoid notch of the mandible. The patient complained of left cheek and lower jaw numbness and intermittent left jaw spasms. The tumor was deemed appropriate for endoscopic resection. To access the ITF, left-sided endoscopic sinus surgery, a modified endoscopic Denker's approach,4 and posterior nasal septectomy were first performed. A nasoseptal flap was also harvested in case an intraoperative cerebrospinal fluid (CSF) leak required repair. Dissection was carried out through the posterior wall of the maxillary sinus and pterygopalatine fossa to reach the ITF. Tumor resection was achieved through a 2-surgeon, 4-handed approach in which appropriate traction and countertraction were carefully applied to tease the tumor away from the skull base and dehiscent carotid canal. No CSF leak or carotid injury occurred, and the posterior maxillary sinus wall defect was repaired with the nasoseptal flap. The patient did well postoperatively. The patient consented to the procedure in a standard fashion.

In Vivo Laser Tissue Welding in the Rabbit Maxillary Sinus

2008 ◽  
Vol 22 (6) ◽  
pp. 625-628 ◽  
Author(s):  
Benjamin S. Bleier ◽  
James N. Palmer ◽  
Michael A. Gratton ◽  
Noam A. Cohen
Keyword(s):  
Intracranial Pressure ◽  
Maxillary Sinus ◽  
Skull Base ◽  
Thermal Injury ◽  
Surrounding Tissue ◽  
Csf Leak ◽  
Tissue Welding ◽  
Laser Tissue Welding ◽  
And Control

Background One of the challenges in the current expansion of endoscopic sinonasal surgery is the ability to adequately reconstruct the skull base. Laser tissue welding (LTW) uses laser energy coupled to a biological solder to produce tissue bonds with burst thresholds exceeding human intracranial pressure. This technology could be used to reduce the rate of postoperative cerebrospinal fluid (CSF) leak. We performed this study to determine whether LTW can create durable tissue bonds in sinonasal mucosa that support normal wound healing and produce minimal collateral thermal injury. Methods Bilateral maxillary sinus mucosal incisions were made in 20 New Zealand white rabbits and one side was repaired using LTW. Burst pressure thresholds were measured on postoperative days 0, 5, and 15 and were compared with control using a two- way ANOVA and a post hoc Tukey test. Welds were examined histologically for thermal injury, inflammation, and fibroplasia and graded on a 4-point scale by three blinded observers. Results The burst pressures of the LTW group were significantly higher than control on postoperative day 0 (120.85 mm Hg, N = 4, SD = 47.84 versus 7.85 mm Hg, N = 4, SD = 0.78), and day 5 (132.56 mm Hg, N = 8, SD = 24.02 versus 41.7 mm Hg, N = 8, SD = 7.2; p < 0.05). By postoperative day 15 there was no significant difference between LTW (169.64 mm Hg, N = 8, SD = 18.49) and control (160.84 mm Hg, N = 8, SD = 14.16) burst thresholds. There was no evidence of thermal injury to the surrounding tissue in any group as well as no difference between experimental group and control with respect to inflammation or fibroplasia. Conclusion This is the first in vivo study showing that LTW is capable of producing tissue bonds exceeding human intracranial pressure with negligible thermal injury in sinonasal tissue. Welding can be performed endoscopically using a fiberoptic cable and may be useful in CSF leak and skull base repair.

scholarly journals Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

2019 ◽  
Vol 81 (06) ◽  
pp. 645-650
Author(s):  
Roshni V. Khatiwala ◽  
Karthik S. Shastri ◽  
Maria Peris-Celda ◽  
Tyler Kenning ◽  
Carlos D. Pinheiro-Neto
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Fascia Lata ◽  
High Flow ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Csf Diversion ◽  
Csf Leaks

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

2012 ◽  
Vol 32 (6) ◽  
pp. E7 ◽  
Author(s):  
James K. Liu ◽  
Richard F. Schmidt ◽  
Osamah J. Choudhry ◽  
Pratik A. Shukla ◽  
Jean Anderson Eloy
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Cranial Base ◽  
High Flow ◽  
Csf Leak ◽  
Reconstruction Technique ◽  
Dural Defect ◽  
Nasoseptal Flap ◽  
Endoscopic Skull Base Surgery ◽  
Csf Leakage

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

scholarly journals Management of an Unusual Intranasal Foreign Body Abutting the Cribriform Plate: A Case Report and Review of Literature

2019 ◽  
Vol 12 ◽  
pp. 117955061985860
Author(s):  
Mingyang L Gray ◽  
Catharine Kappauf ◽  
Satish Govindaraj
Keyword(s):  
Foreign Body ◽  
Skull Base ◽  
Foreign Bodies ◽  
Cribriform Plate ◽  
Sinus Surgery ◽  
Csf Leak ◽  
Intracranial Involvement ◽  
History Of ◽  
Initial Imaging ◽  
The Right

A 35-year-old man with history of schizophrenia presented 3 weeks after placing a screw in his right nostril. Initial imaging showed a screw in the right ethmoid sinus with the tip penetrating the right cribriform plate. On exam, the patient was hemodynamically stable with purulent drainage in the right nasal cavity but no visible foreign body. While most nasal foreign bodies occur in children and are generally removed at the bedside, intranasal foreign bodies in adults tend to require further assessment. The foreign body in this case was concerning for skull base involvement and the patient was brought to the operating room (OR) with neurosurgery for endoscopic sinus surgery (ESS) and removal of foreign body. The screw was removed and the patient recovered with no signs of cerebrospinal fluid (CSF) leak postoperatively. Any concern for skull base or intracranial involvement should call for a full evaluation of the mechanism of injury and intervention in a controlled environment.

scholarly journals Validation of the Maxillary Sinus Roof as a Landmark for Navigating the Pediatric Skull Base

2019 ◽  
Vol 129 (1) ◽  
pp. 12-17
Author(s):  
Sean S. Evans ◽  
Catherine Banks ◽  
Joshua Richman ◽  
Audie Woolley ◽  
Do Yeon Cho ◽  
...  
Keyword(s):  
Maxillary Sinus ◽  
Skull Base ◽  
Retrospective Analysis ◽  
Pediatric Population ◽  
Statistical Significance ◽  
Tertiary Care ◽  
Growth Patterns ◽  
Sinus Surgery ◽  
Nasal Floor ◽  
Anatomic Relationship

Objective: To define a new anatomic relationship in pediatric sinus surgery, assessing the maxillary roof as a constant safe landmark to avoid skull base injury in the pediatric population. Study Design: Retrospective analysis. Setting: Tertiary care children hospital. Subjects and Methods: A retrospective analysis was performed of all computed tomography scans of the sinuses and facial bones at the emergency department of a tertiary children’s hospital over the course of a year. Radiographic measurements included the lowest cribriform plate and planum sphenoidale (PS) heights, or posterior skull base when not yet pneumatized, as well as the highest maxillary roof height. The nasal floor was used for reference. Statistics were performed via Shapiro-Wilks test with a P-value of .05 indicating statistical significance. Results: Three hundred and seven unique scans were reviewed (38.9% female; n = 122; P = .58). Age stratification was based on previously described sinus growth patterns. In all patients, the maximum maxillary height was inferior to the lowest measured cribriform lamella and PS ( P < .001; CI, 98.5%-99%). Inter- and intrarater reliability and accuracy were verified through blinded review and re-review (ρ = .99 and .98 respectively, P ≤ .001). The validity of sole coronal measurements due to incomplete sagittal reformatting was also confirmed (ρ = 1.00, P ≤ .001). Conclusion: Despite variation in sinus growth and development in children, the current study demonstrated the validity of the maxillary sinus roof as a constant safe landmark in the pediatric population, offering a novel anatomic relationship for teaching safety in performing pediatric sinus surgery. Level of Evidence: 4

Posterior Maxillary Sinus Wall: A Landmark for Identifying the Sphenoid Sinus Ostium

2018 ◽  
Vol 128 (3) ◽  
pp. 215-219 ◽  
Author(s):  
Raj D. Dedhia ◽  
Tsung-yen Hsieh ◽  
Yecenia Rubalcava ◽  
Paul Lee ◽  
Peter Shen ◽  
...  
Keyword(s):  
Maxillary Sinus ◽  
Endoscopic Sinus Surgery ◽  
Sphenoid Sinus ◽  
Average Distance ◽  
Posterior Wall ◽  
Sinus Surgery ◽  
Endoscopic Endonasal ◽  
Sinus Wall ◽  
Significant Difference ◽  
Sinus Ostium

Importance: Safe entry into sphenoid sinus is critical in endoscopic sinus and skull base surgery. A number of surgical landmarks have been used to identify the sphenoid sinus ostium during endoscopic endonasal surgery with variable reliability and intraoperative feasibility. Objective: To determine if the posterior wall of the maxillary sinus is a reliable landmark to determine the depth of the sphenoid sinus ostium during anterior to posterior dissection. Design, Setting, and Participants: Prospective study of adult patients undergoing endoscopic sinus surgery between August 2016 and September 2017. Measurements were made intraoperatively between the depth of the posterior maxillary sinus wall and sphenoid sinus ostium. Main Outcomes and Measures: The primary measurement is the distance between the depth of the posterior maxillary sinus wall and sphenoid sinus ostium. Additional data points included age, gender, surgical indication, and primary versus revision endoscopic sinus surgery. Results: Forty-five patients (38% male, 62% female) with an average age of 56 were enrolled, resulting in 88 operated sides. The average distance between the depth of the posterior wall of the maxillary sinus and the sphenoid ostium was 1.5 mm ± 1.4 mm. The most common position of the sphenoid sinus ostium was posterior to the level of the posterior maxillary sinus wall (54%), followed by same level (23%) and anterior (23%). There was no significant difference between different disease states ( P = .75) and between primary and revision cases ( P = .13). Conclusions and Relevance: The posterior wall of the maxillary sinus serves as an adjunctive intraoperative landmark to determine the depth of the sphenoid sinus ostium. While the posterior wall of the maxillary sinus approximates the depth of the sphenoid sinus ostium, the relative position is variable and can be anterior or posterior.

Nasoseptal Flap Reconstruction of High Flow Intraoperative Cerebral Spinal Fluid Leaks during Endoscopic Skull Base Surgery

2009 ◽  
Vol 23 (5) ◽  
pp. 518-521 ◽  
Author(s):  
Adam M. Zanation ◽  
Ricardo L. Carrau ◽  
Carl H. Snyderman ◽  
Anand V. Germanwala ◽  
Paul A. Gardner ◽  
...  
Keyword(s):  
Risk Factors ◽  
Radiation Therapy ◽  
Skull Base ◽  
Cerebral Spinal Fluid ◽  
High Flow ◽  
Spinal Fluid ◽  
Csf Leak ◽  
Flap Reconstruction ◽  
Nasoseptal Flap ◽  
Reconstructive Technique

Background Over the past 10 years, significant anatomic, technical, and instrumentation advances have facilitated the exposure and resection of intradural lesions via a fully endoscopic expanded endonasal approach (EEA). The vascularized nasoseptal flap (based on the posterior nasoseptal artery) has become our primary endoscopic reconstructive technique. The goals of this study are to prospectively evaluate the nasoseptal flap and high-risk cerebral spinal fluid (CSF) leak variables. Methods Prospective evaluation was performed of EEA patients with intraoperative high-flow leaks (either a cistern or ventricle open to nasal cavity during tumor dissection) who underwent nasoseptal flap reconstruction. Results Seventy consecutive nasoseptal flaps for high-flow intraoperative leaks were evaluated prospectively by the primary author. Twelve risk factors were then graded at the time of the operations and correlated to CSF leak outcomes. The overall postoperative CSF leak rate was 5.7% (4/70). All four postoperative leaks were successfully managed with endoscopic repair and CSF diversion. A multivariate analysis of all 12 risk factors is detailed. Pediatric patients, large dural defects, and radiation therapy were noted to be factors in reconstructive failure. One flap death occurred in a patient with prior surgery and proton therapy, this leak was managed with a temporoparietal flap and endonasal repair. Conclusion The nasoseptal flap is an excellent anterior skull base reconstructive technique. Patients with high-flow intraoperative CSF leaks had a 94% successful reconstruction rate. Patients with skull base proton radiation therapy are at higher risk for flap failure and preparation for nonradiated tissue reconstruction should be discussed with the patient.

scholarly journals Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa

2005 ◽  
Vol 19 (1) ◽  
pp. 1-10 ◽  
Author(s):  
Amin B. Kassam ◽  
Paul Gardner ◽  
Carl Snyderman ◽  
Arlan Mintz ◽  
Ricardo Carrau
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Surgical Anatomy ◽  
Illustrative Case ◽  
Endonasal Approach ◽  
Transnasal Approach ◽  
Endoscopic Endonasal ◽  
Expanded Endonasal Approach ◽  
Neurovascular Structures

Object The middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module. Methods The anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region. Conclusions The expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.

scholarly journals Assessment of Mucocele Formation after Endoscopic Nasoseptal Flap Reconstruction of Skull Base Defects

2013 ◽  
Vol 4 (1) ◽  
pp. ar.2013.4.0050 ◽  
Author(s):  
Qasim Husain ◽  
Saurin Sanghvi ◽  
Olga Kovalerchik ◽  
Pratik A. Shukla ◽  
Osamah J. Choudhry ◽  
...  
Keyword(s):  
Skull Base ◽  
Demographic Data ◽  
Cranial Base ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Inherent Risk ◽  
Defect Site ◽  
Skull Base Defects ◽  
Csf Leaks

Advances in endoscopic skull base (SB) surgery have led to the resection of increasingly larger cranial base lesions, resulting in large SB defects. These defects have initially led to increased postoperative cerebrospinal fluid (CSF) leaks. The development of the vascularized pedicled nasoseptal flap (PNSF) has successfully reduced postoperative CSF leaks. Mucocele formation, however, has been reported as a complication of this technique. In this study, we analyze the incidence of mucocele formation after repair of SB defects using a PNSF. A retrospective review was performed from December 2008 to December 2011 to identify patients who underwent PNSF reconstruction for large ventral SB defects. Demographic data, defect site, incidence of postoperative CSF leaks, and rate of mucocele formation were collected. Seventy patients undergoing PNSF repair of SB defects were identified. No postoperative mucocele formation was noted at an average radiological follow-up of 11.7 months (range, 3–36.9 months) and clinical follow-up of 13.8 months (range, 3–38.9 months), making the overall mucocele rate 0%. The postoperative CSF leak rate was 2.9%. Proper closure of SB defects is crucial to prevent CSF leaks. The PNSF is an efficient technique for these repairs. Although this flap may carry an inherent risk of mucocele formation when placed over mucosalized bone during repair, we found that meticulous and strategic removal of mucosa from the site of flap placement resulted in a 0% incidence of postoperative mucocele formation in our cohort.

Mini-invasive surgery of infratemporal fossa schwannomas

2015 ◽  
Vol 129 (2) ◽  
pp. 187-193 ◽  
Author(s):  
H Haidar ◽  
A Deveze ◽  
J P Lavieille
Keyword(s):  
Maxillary Sinus ◽  
Infratemporal Fossa ◽  
Posterior Wall ◽  
Endoscopic Approach ◽  
Surgical Approaches ◽  
Anatomical Location ◽  
Subtemporal Approach ◽  
Non Invasive ◽  
Transnasal Endoscopic Approach ◽  
Nerve Dysfunction

AbstractBackground:Infratemporal fossa schwannomas are benign, encapsulated tumours of the trigeminal nerve limited to the infratemporal fossa. Because of the complications and significant morbidity associated with traditional surgical approaches to the infratemporal fossa, which include facial nerve dysfunction, hearing loss, dental malocclusion and cosmetic problems, less invasive alternatives have been sought.Methods:This paper reports two cases of infratemporal fossa schwannomas treated in 2012 using mini-invasive approaches. The literature regarding different infratemporal fossa approaches was reviewed.Results:The first schwannoma was 30 mm in size and was removed completely by a preauricular subtemporal approach. The second one was 25 mm in size and was removed completely using a purely transnasal endoscopic approach. In both cases, there were no intra-operative or post-operative complications.Conclusion:These two approaches allow non-invasive and wide exposure of the infratemporal fossa as compared to classical approaches. Surgical approach should be selected according to the tumour's anatomical location with respect to the maxillary sinus posterior wall. The preauricular subtemporal approach is recommended for tumours localised posterolaterally with respect to the maxillary sinus posterior wall. Medial and anterior tumours near the maxillary sinus posterior wall can be best removed using a transnasal endoscopic approach.

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