Endoscopic graduated multiangle, multicorridor resection of juvenile nasopharyngeal angiofibroma: an individualized, tailored, multicorridor skull base approach

OBJECT Juvenile nasopharyngeal angiofibromas (JNAs) are formidable tumors because of their hypervascularity and difficult location in the skull base. Traditional transfacial procedures do not always afford optimal visualization and illumination, resulting in significant morbidity and poor cosmesis. The advent of endoscopic procedures has allowed for resection of JNAs with greater surgical freedom and decreased incidence of facial deformity and scarring. METHODS This report describes a graduated multiangle, multicorridor, endoscopic approach to JNAs that is illustrated in 4 patients, each with a different tumor location and extent. Four different surgical corridors in varying combinations were used to resect JNAs, based on tumor size and location, including an ipsilateral endonasal approach (uninostril); a contralateral, transseptal approach (binostril); a sublabial, transmaxillary Caldwell-Luc approach; and an orbitozygomatic, extradural, transcavernous, infratemporal fossa approach (transcranial). One patient underwent resection via an ipsilateral endonasal uninostril approach (Corridor 1) only. One patient underwent a binostril approach that included an additional contralateral transseptal approach (Corridors 1 and 2). One patient underwent a binostril approach with an additional sublabial Caldwell-Luc approach for lateral extension in the infratemporal fossa (Corridors 1–3). One patient underwent a combined transcranial and endoscopic endonasal/sublabial Caldwell-Luc approach (Corridors 1–4) for an extensive JNA involving both the lateral infratemporal fossa and cavernous sinus. RESULTS A graduated multiangle, multicorridor approach was used in a stepwise fashion to allow for maximal surgical exposure and maneuverability for resection of JNAs. Gross-total resection was achieved in all 4 patients. One patient had a postoperative CSF leak that was successfully repaired endoscopically. One patient had a delayed local recurrence that was successfully resected endoscopically. There were no vascular complications. CONCLUSIONS An individualized, multiangle, multicorridor approach allows for safe and effective surgical customization of access for resection of JNAs depending on the size and exact location of the tumor. Combining the endoscopic endonasal approach with a transcranial approach via an orbitozygomatic, extradural, transcavernous approach may be considered in giant extensive JNAs that have intracranial extension and intimate involvement of the cavernous sinus.

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

Neurosurgical FOCUS ◽

10.3171/foc.2005.19.1.7 ◽

2005 ◽

Vol 19 (1) ◽

pp. 1-10 ◽

Cited By ~ 269

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.

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Anterior Skull Base Meningioma: Surgical approach and complication avoidance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1733-9320 ◽

2022 ◽

Author(s):

Bhawan Nangarwal ◽

Jaskaran Singh Gosal ◽

Kuntal Kanti Das ◽

Deepak Khatri ◽

Kamlesh Singh Bhaisora ◽

...

Keyword(s):

Skull Base ◽

Tumor Resection ◽

Vascular Complications ◽

Good Alternative ◽

Anterior Skull Base ◽

Csf Leak ◽

Medical Complication ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Skull Base Meningioma

Background: Endoscopic endonasal approach (EEA) and keyhole transcranial approaches are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective: We compare tumor resection rates and complication profiles of EEA and supraorbital key hole approach (SOKHA) against conventional transcranial approaches (TCA). Methods: Fifty-four patients with ASBM [olfactory groove (OGM), n=19 and planum sphenoidale/tuberculum sellae (PS/TSM), n=35) operated at a single centre over 7 years were retrospectively analyzed. Results: The overall rate of GTR was higher in OGM (15/19, 78.9%) than PS-TSM group (23/35, 65.7%, p=0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death (n=1) following medical complication (TCA) and CSF leak requiring re-exploration (n=2, one each in TCA and EEA) accounted for the major complications in OGM. For the PS/TSM group, the GTR rates were 73.3% (n=11/15), 53.8% (n=7/13) and 71.4% (n=5/7) with TCA, EEA and SOKHA respectively. Seven patients (20%) of PS-TSM developed major postoperative complications including 4 deaths (one each in TCA, SOKHA and 2 in EEA group) and 3 visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PS-TSM especially if the tumor has encased intracranial arteries. Conclusions: No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma related problems. SOKHA may be a good alternative to TCA in selected PS-TSMs while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PS-TSM.

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The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave

Journal of Neurosurgery ◽

10.3171/2009.10.jns09157 ◽

2010 ◽

Vol 113 (5) ◽

pp. 967-974 ◽

Cited By ~ 87

Author(s):

Christoph P. Hofstetter ◽

Ameet Singh ◽

Vijay K. Anand ◽

Ashutosh Kacker ◽

Theodore H. Schwartz

Keyword(s):

Skull Base ◽

Sphenoid Sinus ◽

Infratemporal Fossa ◽

Pterygopalatine Fossa ◽

Csf Leak ◽

Petrous Apex ◽

Subtotal Resection ◽

Endoscopic Endonasal ◽

Lateral Skull Base ◽

Neural Origin

Object In this paper the authors' goal was to present their clinical experience with lesions of the pterygopalatine fossa, infratemporal fossa, lateral sphenoid sinus, cavernous sinus, petrous apex, and Meckel cave using simple and extended endoscopic transpterygoid approaches to the lateral skull base. Methods Simple and expanded endoscopic transpterygoid approaches were performed in a series of 13 patients with varying pathology that included lateral sphenoid sinus encephaloceles, benign and malignant sinonasal tumors, and lesions of neural origin. Results A gross-total resection was achieved in 5 of 9 patients, while a subtotal resection for tissue diagnosis and cytoreduction prior to further adjuvant treatment was performed in the remaining patients. Sphenoid sinus encephaloceles were successfully repaired via a transpterygoid approach in all 4 patients. The skull base defect was reconstructed using a multilayered closure. One patient developed a postoperative CSF leak, which was successfully treated conservatively. The mean follow-up time was 16 months. Five patients complained of recurrent sinusitis. One patient experienced xerophthalmia and palate numbness. Three patients had died by the time of this report. Two patients died of unrelated causes. The third patient died of progression of an aggressive pterygopalatine osteosarcoma despite undergoing cytoreductive surgery and adjuvant chemotherapy. Conclusions An endoscopic transpterygoid approach is a minimally invasive endoscopic approach for lesions located or extending to the pterygopalatine fossa, infratemporal fossa, petrous apex, Meckel cave, and other regions of the paramedian skull base.

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Significance of the simultaneous combined transcranial and endoscopic endonasal approach for prevention of postoperative CSF leak after surgery for lateral skull base meningioma

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2020.09.028 ◽

2020 ◽

Vol 81 ◽

pp. 21-26

Author(s):

Masahide Matsuda ◽

Hiroyoshi Akutsu ◽

Shuho Tanaka ◽

Eiichi Ishikawa

Keyword(s):

Skull Base ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Skull Base Meningioma ◽

Lateral Skull Base

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Chondro-osseous respiratory epithelial adenomatoid hamartoma of the nasal cavity (COREAH): A case report

Journal of Otolaryngology-ENT Research ◽

10.15406/joentr.2019.11.00429 ◽

2019 ◽

Vol 11 (3) ◽

pp. 175-179

Author(s):

Nikolopoulos Elias MD

Keyword(s):

Nasal Cavity ◽

Skull Base ◽

Anterior Skull Base ◽

Adult Patients ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Clinical Records

Objective: Determine the efficacy of the anterior skull base reconstruction in adult patients with intranasal meningoceles and meningoencephaloceles treated by endoscopic endonasal approach. Study design: Retrospective observational study of adult patients admitted to a tertiary hospital. Materials and methods: Intranasal meningocele was defined as a protrusion of meninges through a defect in the skull base forming a cyst filled with cerebrospinal fluid in the nasal cavity or paranasal sinuses. If the cyst had brain tissue it was called meningoencephalocele. The electronic clinical records of patients admitted with suspected of intranasal MC or MEC between January 2010 and December 2018 were reviewed. All patients treated by endoscopic endonasal approach were included. We excluded those cases with anterior skull base previous surgeries (iatrogenic or following tumoral resections), reconstruction with external surgical approaches and those who were less than 18 years old. Results: Intranasal MC was the most frequent lesion (6/5) and there was one patient with MEC (1/6). 5 cases were idiopathic and one patient had history of transnasal surgery. A total of 83,3% of the cases were primary surgeries and one patient had 3 prior MC surgeries. Only in four of them (66,6%) the lesion location was detected by at least one of the studies (CT, MRI and/or endoscopy). We performed a multilayer closure technique in all patients. During the immediate postoperative period, one patient had acute meningitis. One patient had a CSF leak recurrence 4 months after surgery. The success rate of the reconstructions performed by endonasal approach was 83.33% (5/6). The average follow-up of the patients was 15 months. Conclusion: The effectiveness of the anterior skull base reconstruction in adult patients with meningoceles and meningoencephaloceles performed by endoscopic endonasal approach in our series was 83.33% (5/6). This procedure is currently the gold standard due to its high efficacy and low morbidity. According to current studies, it is recommended to perform the reconstruction with a multilayer technique.

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Endoscopic endonasal resection of a large tuberculum sella meningioma

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.19981 ◽

2020 ◽

Vol 2 (2) ◽

pp. V3

Author(s):

Ahmed Mohyeldin ◽

Jayakar V. Nayak ◽

Juan C. Fernandez-Miranda

Keyword(s):

Skull Base ◽

Wide Spectrum ◽

Direct Access ◽

Csf Leak ◽

Anterior Communicating Artery ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Tuberculum Sella ◽

Ventral Skull Base

Over the past three decades, endoscopic endonasal surgery has unlocked new corridors to treat a wide spectrum of ventral skull base lesions. Tuberculum sella meningiomas represent one of the most ideal pathologies for ventral skull base access. Traditionally, these lesions were approached primarily through various subfrontal and frontal-lateral transcranial approaches that have unfortunately been shown to be associated with worsening visual decline postoperatively. The endoscopic endonasal approach is now being attempted by more surgeons and leverages an infrachiasmatic trajectory that provides direct access to the tuberculum sella where most of the vascular supply for these lesions can be taken early, facilitating more efficient surgical resection and mitigating the risk of optic nerve injury. Here we review a challenging case of a large (∼3 cm) tuberculum sella meningioma, encasing critical vessels off the circle of Willis and resected via an endoscopic endonasal approach. We discuss the technical nuances and relevant surgical anatomy of this approach and highlight important considerations in the safe and successful removal of these meningiomas. We show that certain tumors that appear to encase the supraclinoidal carotid artery can be fully resected via an endonasal approach with precise surgical technique and adequate exposure. Furthermore, this case illustrates the risk of injuring a key perforating vessel from the anterior communicating artery complex, called the subcallosal artery. Injury to this vessel is highly associated with tumors like the one presented here that extend into the suprachiasmatic space between the optic chiasm and the anterior communicating complex. Meticulous surgical dissection is required to preserve this perforating vessel as well as branches from the superior hypophyseal artery. Finally, we review our current closure techniques for these challenging approaches and discuss the use of a lumbar drain for 3 days to lower CSF leak rates.The video can be found here: https://youtu.be/mafyXi5B0MA.

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Endoscopic endonasal repair of anterior skull base non-traumatic cerebrospinal fluid leaks, meningoceles, and encephaloceles

Journal of Neurosurgery ◽

10.3171/2009.10.jns08986 ◽

2010 ◽

Vol 113 (5) ◽

pp. 961-966 ◽

Cited By ~ 68

Author(s):

Gurston G. Nyquist ◽

Vijay K. Anand ◽

Saral Mehra ◽

Ashutosh Kacker ◽

Theodore H. Schwartz

Keyword(s):

Skull Base ◽

Frontal Sinus ◽

Anterior Skull Base ◽

Cribriform Plate ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Closure Rate ◽

Endoscopic Endonasal ◽

Csf Leaks

Object The endoscopic endonasal approach has become the preferred technique for CSF leak and encephalocele repair of the anterior skull base. The purpose of this study is to identify patient characteristics; review adjunctive perioperative treatments, reconstruction techniques, and outcomes; and identify risk factors for failure in patients undergoing endoscopic endonasal repair of anterior skull base CSF leaks and encephaloceles. Methods This is a prospective observational study of patients undergoing endoscopic endonasal repair of a CSF leak between October 2004 and May 2009. Twenty-eight consecutive patients underwent 32 procedures. Twenty-two of the patients were women, which represents a statistically significant trend toward the female sex (p < 0.05). The average body mass index (33.9) was significant for obesity. The origin of the skull base defect included the cribriform plate (in 9 cases), fovea ethmoidalis (in 7), combined fovea ethmoidalis/cribriform plate (in 2), lateral sphenoid sinus (in 6), sella (in 4), clivus (in 3), and frontal sinus (in 1). Results The overall endonasal closure rate was 93.8% (30 of 32 procedures). One failure occurred due to overaggressive postoperative debridement, while the other recurred along the posterior wall of the frontal sinus, and endoscopic repair would have occluded the recess. Conclusions The endoscopic endonasal approach for the treatment of CSF leaks and encephaloceles of the anterior skull base is the preferred method of repair in the vast majority of cases. The authors' 93.8% closure rate in a variety of anatomical locations compares favorably with the transcranial approach and echoes the results of other endoscopic series.

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