Endoscopic resection of ossifying fibroma involving paranasal sinuses and the skull base in a series of 15 cases

Conclusion: The key technical challenges in the resection of OFs are rapid removal of tumors by image-guided navigation, determining the boundary of the resection and the proper control of blood supply through the anterior or posterior ethmoidal arteries.

Objective: This study aimed to analyze the clinical data of adult patients with paranasal ossifying fibromas involving the anterior skull base and orbit. The surgical technique and indications are also discussed.

Methods: This study reviewed the clinical data of 15 patients (age >16 years) who underwent resection of paranasal ossifying fibromas involving the anterior skull base and orbit by endoscopic surgery with an image guidance system between October 2006 and October 2014.

Results: The mean age of the 15 patients was 33.2 years (range?=?16–58 years). All tumors were completely resected via endoscopic surgery. Intra-operative cerebrospinal fluid (CSF) leaks (four cases) were repaired endoscopically. The mean follow-up duration was 43.1 months. One patient lost vision after surgery, recurrence was observed in two patients, one underwent a third excision 8 years after the second surgery, and the other exhibited residual osteoarthritis 3 years after the first surgery and remained under regular observation. One patient was lost to follow-up.     

Endoscopic endonasal technique: treatment of paranasal and anterior skull base malignancies

Technical and technological innovations have spearheaded the expansion of the indications for the use of endoscopic endonasal approaches to extirpate malignancies of the sinonasal tract and adjacent skull base.ObjectiveCritical review of the available literature regarding the use of endoscopic endonasal approaches including indications, limitations, surgical techniques, oncologic outcome, and quality of life.MethodVarious endoscopic endonasal techniques are reviewed according to the origin and local extension of sinonasal and skull base malignancies including anterior cranial base, nasopharynx, clivus, and infratemporal fossa. In addition, the available literature is reviewed to assess outcomes.ConclusionEndoscopic endonasal approaches are an integral part of the armamentarium for the treatment of the sinonasal tract malignancies and skull base. In properly selected cases, it affords similar oncologic outcomes with lower morbidity than traditional open approaches. Nonetheless, these minimal access approaches should be considered a complement to well-established open approaches, which are still necessary in most advanced tumors.     

Endoscopic surgery of the anterior skull base

OBJECTIVES/HYPOTHESIS: Traditional surgical approaches to the anterior skull base often involve craniotomy, facial incisions, disruption of skeletal framework, tracheotomy, and an extended hospital stay. As experience with endoscopic sinus surgery has grown, the techniques and equipment have been found to be adaptable to treatment of lesions of the anterior and central skull base. A minimally invasive endoscopic approach theoretically offers the advantages of avoiding facial incisions, osteotomies, and tracheotomy; surgery should be less painful, recovery quicker, and hospital stays should be shorter. The study attempted to assess endoscopic approaches to the anterior and central skull base for its ability to achieve those goals. STUDY DESIGN: Retrospective review of 72 cases performed at a single institution from November 1996 to July 2003. A subgroup of 15 patients who underwent endoscopic approach to their pituitary tumors was compared with a similar group of 15 patients who underwent traditional open trans-sphenoidal surgery for their pituitary tumors. METHODS: Patient records were analyzed and information tabulated for age, sex, disease, location of lesion, operative time, use of image-guided surgical systems, blood loss, length of intensive care unit stay, duration of operative pain, length of postoperative hospitalization, complications, and completeness of resection. RESULTS: Of the cases, 86.1% were performed exclusively endoscopically, and 13.9% used a combination of endoscopic and open techniques. An image-guided surgical system was used in 83% of cases. Hospital length of stay was 2.3 days for the exclusively endoscopic group as opposed to 8 days for the combined group. With the patients with pituitary tumors, operative times were similar between the two groups (255.13 vs. 245.73 min), blood loss was less in the endoscopic group (125.33 vs. 243.33 mL), pain duration was shorter in the endoscopic group (10 of 15 patients pain free on postoperative day 1 vs. 2 of 15 patients pain free in the open group), and intensive care unit stay and hospital length of stay were both shorter in the endoscopic group. Complication rates and completeness of resection was similar in both groups, although the open group had a higher rate of complications related to the approach to the sella. CONCLUSION: The study demonstrated the safety and efficacy of judicious endoscopic approaches to anterior skull base lesions. An outcomes assessment in pituitary surgery demonstrates advantages of an endoscopic approach in appropriate cases.     

计算机辅助导航技术在鼻窦及鼻颅底手术中的应用

目的:探讨计算机辅助导航技术在鼻窦及鼻颅底手术中的应用价值。方法:49例患者(复发性鼻窦炎、鼻息肉25例,鼻腔鼻窦肿瘤9例,脑脊液鼻漏7例,脑膜脑膨出2例,先天性后鼻孔闭锁4例,垂体瘤1例,中颅窝底异物1例)均在计算机辅助导航下行鼻内镜手术。结果:计算机辅助导航术前准备时间为5～13min,平均7min,靶点误差≤1.5mm。49例患者均顺利完成手术,无并发症出现。结论:计算机辅助导航系统有助于术者正确判断鼻窦、颅底及相邻的解剖标志,可提高手术的精确性和安全性,减少术中及术后并发症的发生。     

Craniofacial resection for malignant tumours involving the anterior skull base

Ethmoid malignant tumours are rare, but nearly all at least approach or involve the lamina cribrosa. An anterior craniofacial resection is almost always mandatory for a radical resection. While almost everything has been written about technical details, few studies reported meaningful analysis about prognostic factors and long-term results, for a series of reasons: the infrequency of these tumours, the variety of histologies, small patients cohorts presented by each author, a medley of untreated and pre-treated patients, the lack of a universally accepted classification. We perform a review of the literature in the light of our experience of 330 anterior craniofacial resections for ethmoid malignant tumours. We present our classification of ethmoid malignant tumours (called INT, Istituto Nazionale Tumori). It turned out to be more prognostic than AJCC–UICC classification.     

Reverse rotation flap for reconstruction of donor site after vascular pedicled nasoseptal flap in skull base surgery

Endonasal skull base surgery is growing exponentially as a subspecialty. In recent years, advances in endoscopic techniques and intraoperative navigation systems have allowed us to expand the indications of endoscopic skull base surgery. Major skull base centers worldwide are addressing larger and more complex lesions using endoscopic techniques. As a consequence, the skull base defects are more challenging to reconstruct. In this report, we present a novel technique to reconstruct the denuded septum remaining after the use of the vascular pedicled nasoseptal flap. Laryngoscope, 2010     

Morbidity in the postoperative follow-up of endoscopic anterior skull base surgery

IntroductionEndoscopic access to the sellar region by videoendoscopy shows a low rate of surgical complications, with findings that indicate risk factors for reducing morbidities during and after the postoperative period.ObjectiveTo evaluate, over a nine-year period, the acquisition of skills by the anterior skull base surgical team, according to the time of elimination of nasal crusts and/or the presence of morbidities in the postoperative follow-up of individuals treated in a tertiary public hospital.MethodsAfter confirming the diagnosis of skull base pathologies, the individuals in this study underwent endoscopic surgery according to the rostrocaudal or coronal axis. For the skull base reconstruction, the nasoseptal flap (associated or not with fascia lata with thigh fat) or free graft was used; clinical follow-up of individuals occurred for a minimum period of 12 months. To assess the impact of the surgical approach on patient clinical evolution, qualitative data related to smoking, post-nasal discharge, nasal flow, smell, taste, clinical symptoms of headache, cranial paresthesia, comorbidities and postoperative morbidities were obtained.ResultsThe most frequent diagnosis was pituitary macroadenoma (84.14%). The mean absence of crusts in this cohort was 124.45 days (confidence interval 95% = 119.50–129.39). There was a low cerebrospinal fluid fistula rate (3%). Reconstruction with the nasoseptal flap with a fat graft was an independent variable that recorded the highest mean time for the elimination of nasal crusts (=145 days, confidence interval 95% = 127.32–162.68). Allergic rhinitis and smoking were shown to be the most important and independent variables that increased the mean time to eliminate nasal crusts.ConclusionThe mean time to eliminate nasal crusts did not change over the years during which the procedures were performed, demonstrating the adequate training of the surgical team. Debridement and nasal irrigation with saline solutions should be performed more frequently and effectively in patients with allergic rhinitis, smokers and those who received the nasoseptal flap and fascia lata graft with autologous fat.     

Image guidance systems for minimally invasive sinus and skull base surgery in children

Objective

The use of image guidance for sinonasal and skull base surgery has been well-characterized in adults but there is limited information on the use of these systems in the pediatric population, despite their widespread use. The aim of this study is to evaluate the use of image guidance systems to facilitate an endoscopic minimally invasive approach to sinonasal and skull base surgery in a pediatric population.

Methods

A retrospective cohort study was performed at a tertiary pediatric hospital. Thirty-three children presented with complications of sinusitis, tumors, traumatic, or congenital lesions of the skull base and underwent endoscopic surgery using image guidance from March 2000 to April 2007. Patient variables including diagnosis, extent of disease, and complications were extracted from paper and computer charts. Additional surgical variables including set-up time, accuracy, surgeon satisfaction index and number of uses per case were also reviewed.

Results

Twenty-eight patients (85%) underwent sinonasal surgery and five (15%) underwent skull base surgery. Indications included infectious complications of acute sinusitis (N = 15), neoplasms (N = 12), choanal atresia (N = 4), and cerebrospinal fluid leak (N = 2). Thirty-one patients (94%) required only one procedure. No surgical complications were reported. Surgeon satisfaction, mean accuracy and number of uses per procedure increased over time (p < 0.05).

Conclusions

Image guidance systems are safe and effective tools that facilitate a minimally invasive approach to sinonasal and skull base surgery in children. Consistent with adult literature, usage and surgeon comfort increased with experience. The additional anatomical information obtained by image guidance systems facilitates a minimally invasive endoscopic approach for sinonasal and skull base pathologies.     

Digital volume tomography (DVT) as a diagnostic modality of the anterior skull base

Conclusion. Because of high resolution and the relatively lower costs in comparison with modern helical CT scanners, digital volume tomography (DVT) can be recommended in the diagnosis of the nasal cavity and paranasal sinuses. Objectives. DVT is an advancement of panoramic tomography and is based on the principles of rotational tomography. It enables high resolution visualization of osseous structures. The slices can be displayed in three orthogonal planes that can be changed in angle arbitrarily. Data volumes of up to 12×17 cm can be examined with a new generation of the DVT. The aim of this study was to point out the potential of DVT in the anterior skull base. Subjects and methods. DVT scans with a cylindrical size of 10 cm in diameter and 10 cm in height were performed in 23 patients. The identification of surgical key landmarks (uncinate process, middle turbinate, ethmoidal bulla, agger nasi cells, Haller cells, frontal recess, anterior ethmoidal artery in its relationship to the skull base, the cribiform plate of the sphenoidal sinus in relation to the optic nerve, and the internal carotid artery) was evaluated. Results. Display of the essential surgical key landmarks was possible in all patients     

Celebrating the golden anniversary of anterior skull base surgery: Reflections on the Past 50 Years and Its Historical Evolution

With its inception nearly half a century ago through the pioneering work of Dandy, McLean, and Smith, anterior skull base (ASB) surgery is a relatively young discipline. It became a distinct entity in 1963 when Ketcham popularized the combined transcranial transfacial approach for en bloc resection of tumors of the paranasal sinuses extending into the anterior cranial fossa. However, because these procedures resulted in major morbidities and mortalities, alternative modes of treatment were sought. Since the 1970s, the introduction and promotion of the surgical endoscope by Messerklinger, Stammberger, and Kennedy, commenced the era of endoscopic sinus surgery. Thaler and colleagues described the utility of the endoscope for ASB surgery at the turn of the century. This allowed direct visualization and safer, more accurate removal of tumors. In 2001, Casiano reported the first purely endoscopic endonasal ASB resection, a novel technique that has been adopted by major skull base centers. The success of ASB surgery can be attributed to both the development of the skull base team as well as improvements in surgical techniques, instrumentation, and visualization technology. In this article, we review the historical evolution of ASB surgery as we approach the 50th anniversary since its recognition as a distinct entity. Laryngoscope, 2013     

Role of perioperative antibiotics in endoscopic skull base surgery

OBJECTIVES/HYPOTHESIS: Direct connection between the sinonasal and intracranial cavities and passage of multiple instruments and graft materials through a contaminated field occur routinely during endoscopic pituitary and skull base surgery. Despite the theoretical risk of intracranial contamination with sinonasal flora, the incidence of central nervous system (CNS) infection following such procedures is not well documented, and the ideal antibiotic regimen has yet to be determined. STUDY DESIGN: Prospective case series of 24 to 48 hours of single-agent perioperative antibiotics in patients undergoing endoscopic skull base surgery. METHODS: Prospective database of procedures performed between January 2004 and May 2006 was reviewed for antibiotic use and infectious complications. RESULTS: The diagnoses of the 90 patients in this series included pituitary tumor (62%), craniopharyngioma (9%), encephalocele (9%), and meningioma (8%). Fifty-eight (64%) patients experienced intraoperative cerebrospinal fluid (CSF) leak. A variety of autologous, synthetic grafts, hemostatic agents, and tissue sealants were placed through the sinonasal cavity for reconstruction. All patients received 24 to 48 hours of a single antibiotic based on patient sensitivity: cefazolin (87%), vancomycin (10%), or clindamycin (3%). Additional antibiotics were subsequently required during the hospital stay in eight (9%) patients for a variety of indications. There were no cases of intracranial infections or meningitis in patients with or without intraoperative CSF leak. CONCLUSIONS: Despite direct contamination of the intracranial cavity during endoscopic, endonasal skull base surgery, the risk of CNS infections is low. Limited use of a single perioperative antibiotic may be sufficient prophylaxis.     

Community-acquired methicillin-resistant Staphylococcus aureus skull base osteomyelitis with occipital condylar cerebrospinal fluid leak in an immunocompetent patient

Community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is emerging as an important pathogen in paranasal sinus disease. However, sinonasal CA-MRSA has not been reported as a source of central skull base osteomyelitis. We report an unusual case of a previously healthy and immunocompetent adult who developed meningitis, central skull base osteomyelitis, and occipital condylar cerebrospinal fluid rhinorrhea from CA-MRSA sphenoid sinusitis requiring endoscopic surgical repair. This case clearly demonstrates the expanding spectrum of severe infections caused by CA-MRSA, which requires prompt diagnosis, a high level of suspicion, and appropriate medical and/or surgical management.     

侵犯鼻窦的前颅窝底脑膜瘤术中脑脊液漏的预防

目的:介绍侵犯颅底骨质及鼻窦的前颅窝底脑膜瘤的手术方法及颅底重建经验。方法:回顾性分析13例患者的临床资料。大冠状或小冠状皮瓣开颅,骨膜向前完整分离,分块切除肿瘤后,咬除或磨除颅底受侵蚀及增生的骨质,将突入鼻窦内的肿瘤切除。切取患者下腹部合适大小的脂肪组织,修剪后填塞入颅骨缺损处,将额骨骨膜翻下,严密缝合骨膜和颅底缺损处周边正常硬膜,用耳脑胶在缝合处粘合一圈。结果:按照Simpson标准,12例Ⅰ级切除,1例Ⅱ级切除。术后并发症包括无菌性脑膜炎3例,额叶症状包括多语、躁动、欣快及缄默3例,无脑脊液漏及颅内感染,无死亡。病理诊断均为良性脑膜瘤,其中2例为细胞增生活跃。随访9个月～8年,平均3.4年,肿瘤无复发。结论:脂肪填塞颅底缺损处,带蒂骨膜与缺损周边正常硬膜严密缝合,用生物胶加固缝合处能有效防止脑脊液漏。