scholarly journals Expanded Endoscopic Endonasal Approach to Anterior and Ventral Skull Base: An Evolving Paradigm

2013 ◽  
Vol 2013 ◽  
pp. 1-11 ◽  
Author(s):  
Balwant Singh Gendeh
Keyword(s):  
Skull Base ◽  
Cranial Base ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Perioperative Morbidity ◽  
Number Of Patients ◽  
Cranial Base Surgery ◽  
Long Term Impact ◽  
Ventral Skull Base

The transition from external approaches to an endonasal corridor has seen a significant decline in patient morbidity and inpatient care. Our Rhinology and Cranial Base Surgery Group has been able to focus on the management of certain pathologies, endoscopic access to various areas in the skull base, reconstruction of the defect, ensuring that clear anatomical landmarks can be identified during the surgery, and improving the quality of life/function after treatment. The focus on surgical treatment is always to control disease and cure patients by not only reducing recovery time and perioperative morbidity, but also decreasing the long-term impact of having a tumour removed. With a dedicated combined operating theater setting with updated instrumentation, the Neuro-ENT team is able to continue to expand and develop endoscopic care for a greater number of patients and wider range of pathologies. The collaborative Neuro-ENT to work closely via the nose using the two-hole and four-hand technique when performing the operation simultaneously is of added advantage in the diverse and expanding field of cranial base surgery. Our skull base team is joined by expert radiation and medical oncologists who provide essential adjunctive care in the multidisciplinary management of these patients.

Pericranial Flap for Endoscopic Anterior Skull-Base Reconstruction

Neurosurgery ◽  
2010 ◽  
Vol 66 (3) ◽  
pp. 506-512 ◽  
Author(s):  
Mihir R. Patel ◽  
Rupali N. Shah ◽  
Carl H. Snyderman ◽  
Ricardo L. Carrau ◽  
Anand V. Germanwala ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Preoperative Planning ◽  
Cranial Base ◽  
Anterior Skull Base ◽  
Dural Defect ◽  
Skull Base Reconstruction ◽  
Pericranial Flap ◽  
Endonasal Reconstruction ◽  
Ventral Skull Base

Abstract BACKGROUND One of the major challenges of cranial base surgery is reconstruction of the dural defect and prevention of postoperative cerebrospinal fluid (CSF) fistula. The introduction of endoscopic techniques and an endonasal approach to the ventral skull base has created new challenges for reconstruction. OBJECTIVE We have developed an endoscopic pericranial flap (PCF) for skull base reconstruction and hereby present the initial cohort of patients who had endonasal reconstruction with a PCF after endoscopic skull base resection. We also demonstrate a method to radiographically incorporate anticipated skull base defects for preoperative planning of PCF length. METHODS Dural defects after endonasal skull base resection of invasive tumors were reconstructed with an onlay PCF (n = 10). We performed radiological studies to assist preoperative planning for where to make incisions while harvesting a PCF for anterior skull base, sellar, and clival defects. RESULTS Each of the 10 patients had excellent healing of their skull base and had no evidence of any postoperative cerebrospinal fluid leaks. Eight patients had radiation therapy without flap complications. Radiographic studies demonstrate that the adequate PCF length, covering defects of the anterior skull base, sellar, and clival defects are 11.31 to 12.44 cm, 14.31 to 15.57 cm, and 18.5 to 20.42 cm, respectively. CONCLUSION The PCF provides an option for endonasal reconstruction of cranial base defects and can be harvested endoscopically. Pre-operative radiographic evaluation may guide surgical planning. There is minimal donor site morbidity, and the flap provides enough surface area to cover the entire ventral skull base.

scholarly journals Sellar trough technique for endoscopic endonasal transclival repair

2020 ◽  
Vol 11 ◽  
pp. 99
Author(s):  
Andrew K. Wong ◽  
Joseph Raviv ◽  
Ricky H. Wong
Keyword(s):  
Skull Base ◽  
Tumor Resection ◽  
Spinal Fluid ◽  
Direct Access ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Ventral Skull Base ◽  
Fluid Leak ◽  
The Brain

Background: Endoscopic endonasal transclival approaches provide direct access to the ventral skull base allowing the treating of clival and paraclival pathology without the manipulation of the brain or neurovascular structures. Postoperative spinal fluid leak, however, remains a challenge and various techniques have been described to reconstruct the operative defect. The “gasket seal” has been well-described, but has anatomic challenges when applied to clival defects. We describe a modification of this technique for use in endonasal transclival approaches. Methods: Two patients who underwent an endoscopic endonasal transclival approach for tumor resection with an intraoperative spinal fluid leak underwent a modified “gasket seal” closure technique for skull base reconstruction. Results: A 71-year-old woman with a petroclival meningioma and a 22 year old with a clival chordoma underwent endoscopic endonasal transclival resection with the modified repair. No new postoperative deficits occurred and no postoperative spinal fluid leak was seen with a follow-up of 17 and 23 months, respectively. Conclusion: We describe the successful use of a simple, low risk, and technique modification of the “gasket seal” technique adapted to the clivus that allows for hard reconstruction and facilitates placement of the nasoseptal flap.

Expanded endoscopic endonasal transcribriform approach for resection of anterior skull base olfactory schwannoma

2012 ◽  
Vol 32 (Suppl1) ◽  
pp. E3 ◽  
Author(s):  
James K. Liu ◽  
Jean Anderson Eloy
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Tumor Resection ◽  
Cranial Base ◽  
Anterior Skull Base ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Anterior Cranial Base ◽  
Ventral Skull Base ◽  
Brain Retraction

Anterior skull base (ASB) schwannomas are extremely rare and can often mimic other pathologies involving the ASB such as olfactory groove meningiomas, hemangiopericytomas, esthesioneuroblastomas, and other malignant ASB tumors. The mainstay of treatment for these lesions is gross-total resection. Traditionally, resection for tumors in this location is performed through a bifrontal transbasal approach that can involve some degree of brain retraction or manipulation for tumor exposure. With the recent advances in endoscopic skull base surgery, various ASB tumors can be resected successfully using an expanded endoscopic endonasal transcribriform approach through a “keyhole craniectomy” in the ventral skull base. This approach represents the most direct route to the anterior cranial base without any brain retraction. Tumor involving the paranasal sinuses, medial orbits, and cribriform plate can be readily resected. In this video atlas report, the authors demonstrate their step-by-step techniques for resection of an ASB olfactory schwannoma using a purely endoscopic endonasal transcribriform approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/NLtOGfKWC6U.

scholarly journals Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma

2021 ◽  
Author(s):  
Gianluca Agresta ◽  
Alberto Campione ◽  
Fabio Pozzi ◽  
Pierlorenzo Veiceschi ◽  
Martina Venturini ◽  
...  
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Conformal Radiotherapy ◽  
Residual Tumor ◽  
Complete Recovery ◽  
Tumor Location ◽  
Transsphenoidal Approach ◽  
Low Grade ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction

Abstract Objective We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach. Design Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots (Fig. 1). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy. Setting The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy. Participants Skull base team was participated in the study. Main Outcome Measures A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus (Fig. 2) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap. Results No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus (Fig. 1). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion. Conclusion Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved.The link to the video can be found at: https://youtu.be/TsqXjqpuOws.

Anatomic Considerations of Microvascular Free Tissue Transfer in Endoscopic Endonasal Skull Base Surgery

2021 ◽  
Author(s):  
Leila J. Mady ◽  
Thomas M. Kaffenberger ◽  
Khalil Baddour ◽  
Katie Melder ◽  
Neal R. Godse ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Free Tissue Transfer ◽  
Level Of Evidence ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Recipient Vessel ◽  
Tissue Transfer ◽  
Anterior Cranial Base ◽  
Pedicle Length

Abstract Objective Though microvascular free tissue transfer is well established for open skull base reconstruction, normative data regarding flap design and inset after endoscopic endonasal skull base surgery (ESBS) is lacking. We aim to describe anatomical considerations of endoscopic endonasal inset of free tissue transfer of transclival (TC) and anterior cranial base resection (ACBR) defects. Design and Setting Radial forearm free tissue transfer (RFFTT) model. Participants Six cadaveric specimens. Main Outcome Measures Pedicle orientation, pedicle length, and recipient vessel intraluminal diameter. Results TC and ACBR defects averaged 17.2 and 11.7 cm2, respectively. Anterior and lateral maxillotomies and endoscopic medial maxillectomies were prepared as corridors for flap and pedicle passage. Premasseteric space tunnels were created for pedicle tunneling to recipient facial vessels. For TC defects, the RFFTT pedicle was oriented cranially with the flap placed against the clival defect (mean pedicle length 13.1 ± 0.6 cm). For ACBR defects, the RFFTT pedicle was examined in three orientations with respect to anterior–posterior axis of the RFFTT: anteriorly, posteriorly, and laterally. Lateral orientation offered the shortest average pedicle length required for anastomosis in the neck (11.6 ± 1.29 cm), followed by posterior (13.4 ± 0.7cm) and anterior orientations (14.4 ± 1.1cm) (p < 0.00001, analysis of variance). Conclusions In ACBR reconstruction using RFFTT, our data suggests lateral pedicle orientation shortens the length required to safely anastomose facial vessels and protects the frontal sinus outflow anteriorly while limiting pedicle exposure through a maxillary corridor within the nasal cavity. With greater understanding of anatomical factors related to successful preoperative flap planning, free tissue transfer may be added to the ESBS reconstruction ladder. Level of Evidence NA

Combined endoscopy-assisted cranionasal approach for resection of infantile myofibromatosis of the ethmoid and anterior skull base

2008 ◽  
Vol 2 (1) ◽  
pp. 58-62 ◽  
Author(s):  
Ercole Galassi ◽  
Ernesto Pasquini ◽  
Giorgio Frank ◽  
Gianluca Marucci
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Radical Resection ◽  
Permanent Tooth ◽  
Anterior Skull Base ◽  
Facial Growth ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Endoscopic Techniques ◽  
Tooth Roots

The advent and widespread development of endonasal endoscopic techniques have recently expanded the frontiers of skull base surgery. The reduced invasiveness, wider and adjustable visualization of the operative field, and lack of postoperative cosmetic defects are well-known advantages of the endonasal endoscopic approaches compared with traditional surgical exposures both in adults and in children. The need to avoid disruption of facial growth centers and permanent tooth roots represents a further special consideration in favor of these endoscopic techniques in children. The authors report on a case of solitary myofibroma involving the ethmoid, mesial orbits, and anterior skull base with intracranial intradural expansion in a 17-month-old girl. The occurrence of such proliferative disease along the skull base is exceedingly rare. The tumor was successfully excised via an endoscopy-assisted cranionasal approach in which a transcranial microsurgical exposure was combined with endonasal endoscopic access to ensure a radical resection and optimize skull base reconstruction. To the authors' knowledge, the patient in this case is the youngest reported patient in the literature who has undergone treatment with this surgical strategy. The outcome in this patient underscores the feasibility and safety of endoscopic endonasal surgery even in toddlers and early childhood.

Endoscopic endonasal approach for resection of ventral skull base keratinaceous cysts

2011 ◽  
Vol 2 (3) ◽  
pp. 258-263 ◽  
Author(s):  
Edward D. McCoul ◽  
Samuel Chow ◽  
Dennis L.Y. Lee ◽  
Vijay K. Anand ◽  
Theodore H. Schwartz
Keyword(s):  
Skull Base ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Ventral Skull Base

scholarly journals Use of Collagen Matrix for Skull Base Reconstruction following Endoscopic Endonasal Resection of Pituitary Adenoma

2018 ◽  
Vol 79 (S 01) ◽  
pp. S1-S188
Author(s):  
Alaa Montaser ◽  
Mostafa Shahein ◽  
Juan Revuelta Barbero ◽  
Guillermo Malve ◽  
Alexandre Todeschini ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Skull Base ◽  
Collagen Matrix ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction

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.

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