Hearing Preservation with the Transcrusal Approach to  the Skull Base Lesion Combined with Other Transcranial Approach: Results of Consecutive Series of 5 Cases

Objective 1) Learn if margins of resection in anterior skull base tumors that are entirely or endoscopic-assisted are comparable with those undergoing traditional craniofacial resection. 2) Understand if there is a difference in patient mortality with traditional CFR compared to endoscopic-assisted surgery. Methods Retrospective review was conducted of patients undergoing surgery at our institution for malignant lesions of the anterior skull base between 2000–2006. 46 patients were identified. 20 underwent endoscopic-assisted or total endoscopic resection. Margins were evaluated by the pathologist. Recurrence rates were calculated based on the presence or absence of recurrence at the last office visit. Follow-up times ranged from 1 month to 5 years. Results Of the 20 patients undergoing endoscopic or endoscopic assisted CFR of anterior skull base lesions, 15/20 patients had negative margins (75%), 4/20 had positive margins (20%), and 1/20 had close margins (5%). In those patients undergoing traditional CFR, 17/26 patients had negative margins (65%), 8/26 had positive margins (30%), and 1/26 (4%) had close margins. Recurrence was noted in 9/26 (35%) of those who underwent traditional CFR and 6/20 (30%) of those with endoscopic assistance. Conclusions There does not appear to be increased risk of positive margins or recurrence in those undergoing endscopic or endoscopic-assisted resection. Endoscopy may aid in identifying margins of tumor in the anterior skull base, leading to a greater likelihood of cure. Endoscopic resections have the potential to avoid morbity and should be considered oncologically sound in the appropriate patient with a skull base lesion.

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The Medially-Invasive Cholesteatoma: An Aggressive Subtype of a Common Pathology

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489420937731 ◽

2020 ◽

Vol 130 (1) ◽

pp. 38-46

Author(s):

Geoffrey Casazza ◽

Matthew L. Carlson ◽

Clough Shelton ◽

Richard K. Gurgel

Keyword(s):

Skull Base ◽

Tertiary Care ◽

Case Series ◽

Hearing Preservation ◽

Csf Leak ◽

Petrous Apex ◽

Otic Capsule ◽

Retrospective Case ◽

Presenting Symptoms ◽

Subtotal Petrosectomy

Objective: Describe the outcomes of treatment for patients with cholesteatomas that are medially invasive to the otic capsule, petrous apex, and/or skull base. Study Design: Retrospective case series Setting: Two tertiary care academic centers. Patients: Patients surgically managed for medially-invasive cholesteatoma at two tertiary care institutions from 2001 to 2017. Interventions: Surgical management of medially-invasive cholesteatomas. Main Outcome Measures: The presenting symptoms, imaging, pre- and post-operative clinical course, and complications were reviewed. Results: Seven patients were identified. All patients had pre-operative radiographic evidence of invasive cholesteatoma with erosion into the otic capsule beyond just a lateral semicircular canal fistula. Five patients had a complex otologic history with multiple surgeries for recurrent cholesteatoma including three with prior canal wall down mastoidectomy surgeries. Average age at the time of surgery was 41.3 years (range 20-83). Two patients underwent a hearing preservation approach to the skull base while all others underwent a surgical approach based on the extent of the lesion. Facial nerve function was maintained at the pre-operative level in all but one patient. No patient developed cholesteatoma recurrence. Conclusions: The medially-invasive cholesteatoma demonstrates an aggressive, endophytic growth pattern, invading into the otic capsule or through the perilabyrinthine air cells to the petrous apex. Surgical resection remains the best treatment option for medially-invasive cholesteatoma. When CSF leak is a concern, a subtotal petrosectomy with closure of the ear is often necessary.

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Preauricular Transzygomatic Approach for Infratemporal Fossa and Surrounding Skull Base Lesion: An Institutional Experience

Annals of Otology and Neurotology ◽

10.1055/s-0038-1636945 ◽

2018 ◽

Vol 01 (02) ◽

pp. 094-099

Author(s):

Rajat Jain ◽

Amit Keshri ◽

Ravi Manogaran ◽

Raj Kumar ◽

Pearly Keeranghat

Keyword(s):

Skull Base ◽

Sphenoid Sinus ◽

Malignant Tumors ◽

Postoperative Radiotherapy ◽

Infratemporal Fossa ◽

Benign Tumors ◽

Critical Areas ◽

Institutional Experience ◽

Base Lesion ◽

Better Than

Abstract Background Preauricular transzygomatic surgical approach (PTZA) can be used to approach and resect tumors of infratemporal fossa (ITF) and surrounding skull base lesion. Various modifications in this approach can be used to approach various critical areas such as cavernous sinus, sphenoid sinus. Materials and Methods Clinical charts were reviewed to determine the association among pathological variables, surgical procedures, and outcomes. Results Three out of seven were malignant tumors and required pterional craniotomy and postoperative radiotherapy. 4 out of 7 were benign tumors and required craniofacial osteotomies. Conclusion PTZA is a versatile approach for tumor of ITF with or without intracranial extradural extension and cosmetically better than other approaches. This approach is better suited for lateral ITF tumors that are difficult to access through endoscopic approaches.

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Adherus Dural Sealant in Endoscopic Skull Base Surgery: Safety, Imaging Characteristics, and Sinonasal Quality of Life

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1694048 ◽

2019 ◽

Vol 81 (06) ◽

pp. 659-663

Author(s):

Christian P. Soneru ◽

Charles A. Riley ◽

Shlomo Minkowitz ◽

Abtin Tabaee ◽

Vijay K. Anand ◽

...

Keyword(s):

Quality Of Life ◽

Skull Base ◽

Skull Base Surgery ◽

Consecutive Series ◽

Complication Rates ◽

Tumor Type ◽

Endoscopic Skull Base Surgery ◽

Imaging Characteristics ◽

Snot 22

Abstract Objective This study was aimed to compare the safety profiles, magnetic resonance imaging (MRI) findings, and sinonasal outcome test (SNOT-22) scores of Adherus dural sealant, a novel tissue glue designed for skull base surgery. Design Present study is a prospective case series. Setting The research work took place at a tertiary-care academic medical center. Participants Consecutive series of 26 patients undergoing endoscopic skull base surgery (ESBS) with Adherus was compared with a control group of 24 patients matched for tumor type and size with DuraSeal as a sealant. Main Outcome Measures Postoperative complication rates, imaging characteristics, and postoperative SNOT-22 scores were measured and compared. Results No postoperative cerebrospinal fluid (CSF) leaks, intracranial hemorrhages, or mucoceles were observed in either cohort. Adherus was more likely to be identifiable on immediate postoperative MRI (50 vs. 20.8%, p = 0.032). In patients in whom a nasoseptal flap was utilized, the flap was opposed to the skull base in all cases regardless of sealant selected. Postoperative SNOT-22 total (17.25 [±10.81] vs. 14.85 [±14.22], p = 0.609) and subdomain scores were similar between the two groups. Conclusions Adherus dural sealant appears to be a safe alternative to Duraseal in ESBS with comparable quality of life outcomes and imaging findings. These preliminary results are promising but should be examined in a larger population with long-term follow-up.

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The endoscopic endonasal approach or microscopic transcranial approach for anterior skull base meningiomas—It is all about right indication rather than superiority

Acta Neurochirurgica ◽

10.1007/s00701-019-04080-3 ◽

2019 ◽

Vol 162 (1) ◽

pp. 77-78 ◽

Cited By ~ 1

Author(s):

David Monterroso Cohen ◽

Hamid Borghei-Razavi ◽

Varun R. Kshettry ◽

Pablo F. Recinos

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Transcranial Approach ◽

Skull Base Meningiomas

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Preservation of hearing in patients undergoing excision of acoustic neuromas and other cerebellopontine angle tumors

Journal of Neurosurgery ◽

10.3171/jns.1985.63.2.0168 ◽

1985 ◽

Vol 63 (2) ◽

pp. 168-174 ◽

Cited By ~ 47

Author(s):

Charles H. Tator ◽

Julian M. Nedzelski

Keyword(s):

Tumor Size ◽

Cerebellopontine Angle ◽

Internal Auditory Canal ◽

Hearing Preservation ◽

Cochlear Nerve ◽

Consecutive Series ◽

Speech Discrimination ◽

Content Type ◽

Acoustic Neuromas ◽

Fine Print

✓ Microsurgical techniques have made it possible to identify and preserve the cochlear nerve from its origin at the brain stem and along its course through the internal auditory canal in patients undergoing removal of small or medium-sized acoustic neuromas or other cerebellopontine angle (CPA) tumors. In a consecutive series of 100 patients with such tumors operated on between 1975 and 1981, an attempt was made to preserve the cochlear nerve in 23. The decision to attempt to preserve hearing was based on tumor size and the degree of associated hearing loss. In cases of unilateral acoustic neuroma, the criteria for attempted preservation of hearing were tumor size (2.5 cm or less), speech reception threshold (50 dB or less), and speech discrimination score (60% or greater). In patients with bilateral acoustic neuromas or tumors of other types, the size and hearing criteria were significantly broadened. All patients were operated on through a suboccipital approach. Hearing was preserved postoperatively in six (31.6%) of the 19 patients with unilateral acoustic neuromas, although the cochlear nerve was preserved in 16. Of the six patients with postoperative hearing, three retained excellent hearing, and the other three had only sound awareness and poor discrimination. Hearing was preserved in three cases with other CPA tumors, including an epidermoid cyst and small petrous meningiomas in the internal auditory canal. Of the two cases with bilateral tumors, hearing was preserved in one. Of the 23 patients in whom hearing preservation was attempted, nine (39.1%) had some postoperative hearing, which in six was equal to or better than the preoperative level. Thus, it is worthwhile to attempt hearing preservation in selected patients with CPA tumors.

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Hearing Preservation With the Transcrusal Approach to the Petroclival Region

Otology & Neurotology ◽

10.1097/00129492-200407000-00029 ◽

2004 ◽

Vol 25 (4) ◽

pp. 594-598 ◽

Cited By ~ 21

Author(s):

David M. Kaylie ◽

Michael A. Horgan ◽

Johnny B. Delashaw ◽

Sean O. McMenomey

Keyword(s):

Hearing Preservation ◽

Petroclival Region ◽

Transcrusal Approach

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Synchronous metastatic skull base chordoma to the breast: case report and literature review

Current Oncology ◽

10.3747/co.23.2896 ◽

2016 ◽

Vol 23 (2) ◽

pp. 154 ◽

Cited By ~ 2

Author(s):

S.I. Shakir ◽

M. Pelmus ◽

A. Florea ◽

J.F. Boileau ◽

M.C. Guiot ◽

...

Keyword(s):

Skull Base ◽

Adjuvant Radiotherapy ◽

Breast Lesion ◽

Left Breast ◽

Foramen Magnum ◽

Safe Management ◽

Central Nervous System Tumour ◽

Base Lesion ◽

Work Up ◽

Skull Base Chordoma

Clinical Scenario During routine staging work-up for a left breast mass, a 68-year-old woman complained of dysphagia and dysphonia. During further investigations, a left-sided lesion at the foramen magnum was observed on brain imaging. Both lesions were biopsied and showed a classical chordoma.Management The skull-base lesion and the breast lesion were surgically resected, and adjuvant radiotherapy was given.Summary Chordoma is a rare primary central nervous system tumour that seldom metastasizes. The lung is the most common site of metastasis. Synchronous breast metastasis from a skull-base chordoma is very rare, and a safe management option includes a maximum resection followed by adjuvant radiotherapy.

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Site-Specific Considerations in the Surgical Management of Skull Base Chondrosarcomas

Operative Neurosurgery ◽

10.1093/ons/opx171 ◽

2017 ◽

Vol 14 (6) ◽

pp. 611-619 ◽

Cited By ~ 5

Author(s):

Shaan M Raza ◽

Paul W Gidley ◽

Michael E Kupferman ◽

Ehab Y Hanna ◽

Shirley Y Su ◽

...

Keyword(s):

Skull Base ◽

Primary Outcome ◽

Extent Of Resection ◽

Subtotal Resection ◽

Related Factors ◽

Endoscopic Endonasal ◽

Factors Affecting ◽

Cavernous Sinus Invasion ◽

Soft Tissue Involvement ◽

Transcranial Approach

Abstract BACKGROUND Numerous approaches have been reported in the management of skull base chondrosarcomas. Data are lacking for surgical outcomes by the tumor site of origin. OBJECTIVE To provide insight into outcomes by site of origin and factors affecting resection in order to aid in surgical approach selection. METHODS A retrospective review was conducted of 49 patients with chondrosarcoma treated at our institution. Charts were reviewed for tumor- and treatment-related factors. Extent of resection was the primary outcome, while neurological function and surgical complications were secondary outcomes. Statistical analyses were performed assessing variables for their impact on the primary outcome. RESULTS The gross total resection rate for the overall cohort was 67.3%, and 97.8% of patients were either neurologically stable or improved postoperatively. A petroclival site of origin had lower rates of resection vs all other sites (P < .05). Histology and previous surgery did not predict outcome (P > .05), while previous radiotherapy and cavernous sinus invasion correlated with a subtotal resection (P < .05). In the petroclival cohort, clival, jugular tubercle, and soft tissue involvement correlated with a subtotal resection (P < .05). An endoscopic endonasal transpterygoid approach alone or combined with a transcranial approach yielded the highest resection rates for petroclival tumors (P < .05). CONCLUSION Chondrosarcomas pose unique challenges based on the site of origin and pattern of extension. While current surgical strategies appear to yield adequate results at a majority of skull base sites, petroclival tumors represent a particular cohort in which improvement is needed. Based on our analysis, strategies incorporating both endoscopic and transcranial skull base approaches are likely necessary to achieve optimal outcomes.

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The quiet revolution: retractorless surgery for complex vascular and skull base lesions

Journal of Neurosurgery ◽

10.3171/2011.8.jns101896 ◽

2012 ◽

Vol 116 (2) ◽

pp. 291-300 ◽

Cited By ~ 49

Author(s):

Robert F. Spetzler ◽

Nader Sanai

Keyword(s):

Skull Base ◽

Surgical Techniques ◽

Patient Positioning ◽

Major Change ◽

Surgical Instruments ◽

Vascular Lesions ◽

Consecutive Series ◽

Cavernous Malformations ◽

Quiet Revolution ◽

Skull Base Lesions

Object Smaller operative exposures, endoscopic approaches, and minimally invasive neurosurgery have emerged as a dominant trend in the modern era. In keeping with this evolution, the authors have recently eliminated the use of fixed retractors, instead employing dynamic retraction, with the use of handheld instruments. In the present study, the authors report the results of applying this strategy to challenging vascular and skull base lesions. Methods This 6-month study prospectively analyzed the use of retractorless surgery in a consecutive series of 223 patients with intracranial vascular or skull base lesions undergoing craniotomy. A single surgeon performed all operations. Results The microsurgical approaches (in descending order of frequency) included an orbitozygomatic craniotomy (77 patients [35%]), frontal (36 patients [16%]), retrosigmoid (27 patients [12%]), interhemispheric (16 patients [7%]), and lateral supracerebellar (15 patients [7%]). The most common lesions were aneurysms (83 lesions overall [37%]), 18 of which required a bypass. Of 159 vascular lesions, there were also 46 cavernous malformations (29%). Meningiomas were the most common skull base tumors (37 cases [58%]). Of the 223 patients, 7 cases of various vascular and skull base lesions required fixed retraction. Therefore, 97% of the cases were successfully treated without a self-retaining retractor system. Conclusions Fixed retraction can be supplanted by dynamic retraction with surgical instruments, limiting the risk of retractor-induced tissue edema and injury. This quiet revolution has precipitated a major change in surgical techniques. Extensive dissection of arachnoidal planes, careful placement of the handheld suction device, patient positioning that enhances gravity retraction, the refinement of microsurgical instrumentation, and appropriate selection of the operative corridor all serve to obviate the need for fixed retraction in most intracranial procedures. Retractorless neurosurgery is an achievable goal, even when complex lesions of the vasculature and skull base are being treated.

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