Middle Turbinate Medialization With Absorbable Packing After Trans-sphenoidal Skull Base Surgery: Outcomes and Significance of a Simple Technique.

Even the most delicate endonasal surgery for skull base lesion causes changes in the nasal cavity, some of them permanent. Morphological changes in the nasal cavity and their consequences (changes in nasal airflow) are often studied by advanced numerical analysis called computational fluid dynamics. This review summarizes current knowledge of endoscopic transsphenoidal skull base surgery effects on nasal airflow. Several studies have shown that endoscopic skull base surgery changes nasal anatomy to the extent that nasal airflow changes significantly postoperatively. Removing any intranasal structure increases the cross-sectional area of the respective nasal meatus, leading to increased nasal airflow in this area while airflow in the narrower periphery decreases. Middle turbinate resection increases airflow in the middle meatus and reduces airflow in the superior and inferior meatus. Small posterior septectomy does not cause a significant change in nasal airflow. Nasal septum deviation is an important factor in airflow changes. Current studies describe nasal changes after rather extensive procedures (e.g., middle turbinectomy, ethmoidectomy) that are unnecessary in routine pituitary adenoma surgery. No studies have compared changes using pre- and postoperative scans of the same patients after actual surgery.

Objectives The frequency of endoscopic skull base surgery in pediatric patients is increasing. This study aims to systematically review the literature for endoscopic skull base surgery outcomes in children/adolescents aged 0 to 18 years. Design A systematic review of the literature was performed in PubMed and SCOPUS databases querying studies from 2000 to 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Final inclusion criteria included: case series with more than 10 patients with pediatric patients aged ≤18 years, endoscopic or endoscopic-assisted skull base surgery, and outcomes reported. Setting This study was conducted at a tertiary care medical center. Participants Children/adolescents aged 0 to 18 years who underwent endoscopic skull base surgery were participated in this study. Main Outcome Measures Patient demographics, pathology, reconstructive technique, intraoperative findings, intraoperative, and postoperative surgical complications were measured through this study. Results Systematic literature search yielded 287 publications. Of these, 12 studies discussing a total of 399 patients aged 0 to 18 years met inclusion criteria for final analysis. Seven of the 12 studies discussed a single pathology. The most common pathology was a skull base defect causing cerebrospinal fluid (CSF) leak. The majority of skull base repairs were made with free tissue grafts. The most common postoperative complication was CSF leak ( n = 40). Twelve cases of meningitis occurred postoperatively with two of these episodes resulting in death. Conclusion Endoscopic skull base surgery has been performed recently in the pediatric population in a variety of disease states. Inconsistent individual-level data and reporting standards are present in existing studies posing challenges for comparative analysis. Standardized reporting will aid future reviews and meta-analysis for rare skull base pathology.

Here we describe the procedures of endoscopic pituitary and skull base surgery in our institute. We also review the literature to reveal recent advances in this field. Endonasal approach via the sphenoid ostium was carried out for pituitary lesions without the nasal speculum. Postoperative nasal packing was basically not needed in such cases. For meningiomas, craniopharyngiomas, and giant pituitary adenomas, which required intra-dural procedures, nasal procedures such as middle nasal conchotomy and posterior ethmoidectomy, and skull base techniques such as optic canal decompression and removal of the planum sphenoidale were carried out to gain a wider operative field. Navigation and ultrasonic Doppler ultrasonography were essential. Angled endoscopes allowed more successful removal of tumors under direct visualization extending into the cavernous sinus and lower clivus. If cerebrospinal fluid (CSF) leakage occurred during operation, the dural opening was covered with a vascularized mucoseptal flap obtained from the nasal septum. Lumbar drainage system to prevent postoperative CSF rhinorrhea was frequently not required. Angled suction tips, single-shaft coagulation tools, and slim and longer holding forceps, all of which were newly designed for endoscopic surgery, were essential for smoother procedures. Endonasal endoscopic pituitary surgery allows less invasive transsphenoidal surgery since no postoperative nasal packing and less dependence on lumbar drainage are needed. Endoscopic pituitary surgery will be more common and become a standard procedure. Endoscopic skull base surgery has enabled more aggressive removal of extrasellar tumors with the aid of nasal and skull base techniques. Postoperative CSF leakage is now under control due to novel methods which have been proposed to close the dural defect in a water-tight manner. Endoscopic skull base surgery is more highly specialized, so needs special techniques and surgical training. Patient selection is also important, which needs collaboration with ear, nose, and throat specialists. As a safe and successful procedure in skull base surgery, this complex procedure should be carried out only in specialized hospitals, which deal with many patients with skull base lesions.

Written and edited by experts and pioneers in the field, Rhinology and Endoscopic Skull Base Surgery covers anatomic principles, applied physiology, medical principles, and surgical management of diseases affecting the paranasal sinuses and anterior skull base. Using evidence-based medicine and practical pathways, this text brings together the basic and clinical knowledge relevant to rhinology and endoscopic anterior skull base surgery. It is designed to be an accessible and essential text for residents and fellows as well as a key reference for practitioners. Key Features: * Applied anatomy, embryology, and physiology of the paranasal sinuses and anterior skull base* Cutting-edge technical information and surgical techniques for rhinology and endoscopic anterior skull base surgery* Advanced concepts important to endoscopic skull base surgery, including the treatment of malignancies and extended endoscopic approaches* Sections dedicated to comprehensive and multidisciplinary patient care, including open skull base surgery principles and radiation therapy strategies This textbook offers a wealth of valuable information that will enhance the practice of otolaryngologists, residents, and fellows as well as affiliated otolaryngology practitioners.

INTRODUCTION: Minimally invasive endoscopic endonasal skull base surgery offer safer and more effective access to the skull base to remove benign and malignant tumors. However, endoscopic skull base surgery around the visual pathway may increase the risk of injury of the visual pathway. Monitoring of flash visual evoked potentials (FVEPs) during surgery may detect a possible injury to the visual pathway, allowing the surgeon to take corrective measures during surgery to reverse or minimize it. METHODS: We identified patients with chiasmatic or pre-chiasmatic lesions who underwent minimally invasive endoscopic skull base surgery. Patients were subjected to eye exam (color vision, visual acuity, and visual field evaluation) within 3 months before surgery, and within 6-12 weeks and 6-9 months after surgery to explore short- and long-term surgical outcomes on eyesight. During surgery, FVEPs were recorded from electrodes placed in the scalp overlying the visual cortex after flashing red light stimulation (Cadwell LED stimulating goggles), as reported previously. We examined the relationship between FVEPs amplitude change and visual outcome on these patients. RESULTS: 102 patients have been enrolled in this retrospective study. The median age at admission was 57 years (range: 22-86 years) and 68.4% of the patients were female. Most of the patients had either pituitary adenoma (64.7%) or skull base meningioma (23.5%). Preliminary eye evaluations (pre- and post-surgery) showed that the patients did not develop short- or long-term eyesight impairments. CONCLUSIONS: Our study provides a new method for rapidly acquiring reproducible FVEP waves for which allows for timely reporting significant FVEP changes resulting in prompt signal action. Thus, monitoring FVEPs during endoscopic endonasal skull base surgery reduces the risk of visual pathway injury.

Perioperative antibiotics are commonly used in endoscopic skull base surgeries as prophylaxis for infectious complications, e.g., meningitis. The role of perioperative prophylactic antibiotics in endoscopic sinus surgery is unclear, and the routine use of prophylactic antibiotics in endoscopic skull base surgery is also highly debated. Currently, there is no formal recommendation for perioperative antibiotic use in skull base surgery, and regimens vary greatly from one institution to the next. To assess perioperative antibiotics as prophylaxis against infectious complications in patients who underwent endoscopic skull base surgery. PubMed, Ovid EMBASE, and the Cochrane Library. A systematic review that examined perioperative antibiotic use in endoscopic skull base and craniofacial surgeries was conducted. Inclusion criteria were prospective or retrospective study design and clinical trials related to the use of antibiotics within 30 days of skull base surgery. End points included infectious complications such as (1) meningitis and (2) sinusitis. A total of 2543 articles were identified by the initial search, and 5 articles met inclusion criteria. The five eligible trials were all observational and involved different types of skull base surgical procedures and antibiotic regimens. Despite institutional variability in antibiotic regimens, meningitis rarely occurs after skull base procedures and seems to be encountered most frequently in open craniofacial surgeries. A systematic review revealed a limited number of published studies, all observational in study design, which precluded a formal meta-analysis. A novel large-scale randomized-controlled clinical trial is needed to evaluate antibiotic selection and need in endoscopic skull base surgery.

Endoscopic endonasal skull base surgery has gained acceptance worldwide. Comparative analysis has demonstrated that endoscopic skull base surgery may have advantages for many pathologies of the anterior skull base, e. g., sinonasal malignant tumors; pathologies of the central skull base, e. g., pituitary adenomas, craniopharyngiomas; well-selected cases of planum sphenoidale and tuberculum sellae meningiomas; or for clival lesions, e. g., chordomas, chondrosarcomas, or selected meningiomas. Over the past three decades, interdisciplinary surgical teams, consisting of otolaryngologists and neurosurgeons, have provided detailed anatomical knowledge, suggested new approaches or modifications of established surgical techniques, and offered continued surgical education. A review of pertinent literature was conducted with an emphasis on interdisciplinary endoscopic surgery of skull base lesions. Based on the authors̓ surgical experience in two different interdisciplinary endoscopic skull base centers, the authors classify approaches for endoscopic endonasal skull base surgery, describe indications, and key anatomic landmarks for common pathologies, and highlight surgical techniques to avoid complications. Interdisciplinary endonasal endoscopic surgery combines surgical expertise, improves resection rates for many pathologies, and minimizes morbidity by reducing the incidence of surgical complications.

Introduction Endoscopic transnasal approaches have been the main treatment option for most of anterior skull base and sellar diseases. Quality-of-life (QOL) assessment after skull base surgeries are now well appreciated and measured to improve medical and surgical care for those patients. Aim To assess QOL after endoscopic transnasal skull base surgery in its six main domains. Patients and methods This study was conducted on 20 patients who had endoscopic skull base surgery for various skull base lesions. QOL was assessed by modified short form health survey questionnaire 1 and 4 weeks postoperatively. A scoring system was adopted, and cases were divided into two group according to their overall score (worse and better groups). Comparison between the two groups was conducted to determine factors that worsen QOL results after endoscopic skull base surgery. Results The overall QOL showed statistical improvement 1 month postoperatively over after 1 week. One week after operation, QOL was statistically affected by age of patient, duration of nasal pack removal, and duration of ICU admission. Postoperative pain domain is worsened by superior turbinate resection or trimming during first week. Conclusion QOL after endoscopic skull base surgeries has been associated with statistically significant improvement after 4 weeks, with significant decrease in the incidence of postoperative complications.

Background: Endoscopic transnasal skull base surgery had started long time ago in different centers around the world for excision of skull base lesions with good results and more cost effectiveness. The aim of this study is to discuss our early results in endoscopic skull base surgery and the development of the learning curve. Patients and Methods: We analyzed our experience regarding 25 patients presented to us in Neurosurgery Department, Assiut University Hospital, Assiut University, Assiut, Egypt in a period of 3 years (2015, 2016, 2017) and operated by endoscopic transnasal approach. All patients signed an informed consent. Results: With the highest percentage was pituitary adenoma 56%, pituitary apoplexy 12%, craniopharyngioma 12%, CSF rhinorrhea 12%, Planum sphenoidal meningioma 4% and suprasellar granuloma 4%. 88% of patients were operated without complications, 8% mortality rate postoperative, 12% complication rate and 76% complete improvement postoperative. Conclusion: Endoscopic skull base surgery is a safe approach to the skull base that needs a good experience, practice and good anatomical knowledge. Teamwork between a Neurosurgeon and ENT surgeon is a must for patient safety.

In this issue, you find the article ‘‘Endoscopic endonasal skull base surgery: past, present and future’’ by Castelnuovo P, Dallan I, Battaglia P and Bognami M. This is an important and valuable article that is submitted to our journal. Endoscopic skull base surgery is under rapid and expanding development. This article focuses on the tremendous development we have experienced with this technique during the past years. The authors stress the current anatomical knowledge in a combination with computer-assisted surgery as main reasons allowing surgery to be performed beyond the nasal cavity and sinuses themselves. Nowadays, it is well accepted to use endoscopic routes in the management of benign diseases. However, the endoscopic techniques are still debated for nasal and paranasal malignancies. The article gives a nice review of what is going on within this field of skull base surgery. The main chapter headings, include the background history of the techniques, inflammatory pathologies, phlogistic diseases, cerebrospinal fluid leaks, orbital and lacrimal pathway pathologies, pituitary surgery, benign neoplastic lesions, sinonasal malignancies, rhinopharyngeal and infratemporal fossa surgery, extrasellar (supra, retro) lesions and cavernous sinus surgery, surgery concerning clivus and petrous apex, surgery of the craniocervical region, as well as intracranial and skull base pathologies. The future involves the use of robotic surgery giving a three-dimensional visualisation and two-hand surgery through small incisions and openings. There seems to be nearly unlimited possibilities in the future using all techniques available. The authors stress the importance of multidisciplinary collaboration, especially with our neurosurgical colleagues. The authors also stress the need for careful and detailed anatomical knowledge which is true not only for endoscopic endonasal surgery, but for all operative techniques. The mentioned techniques may not only be limited to transnasal, but more routes especially transorally should be exploited. The techniques used and the operations performed need a lot of experience. There is especially a need for establishment of centres of excellence to which we in Europe can refer our patients that are in need of this special surgery. There is also a need for these centres to take a responsibility for education of the present and for the forthcoming generations for this technically fantastically interesting field of our speciality. The endoscopic endonasal skull base surgery has opened up a new field for ORL-HNS in collaboration especially with neurosurgeons using four-hand techniques. From an administrative and medico-legal point of view, this type of sub-, or better super-specialisation, will in the future need some kind of accreditation. The actual article by Paolo Castelnuovo et al. definitely gives an insight into past, present and future for endoscopic endonasal skull base surgery. The article is well worth reading. The references quoted are up-to-date and give us additional possibilities to deepen our knowledge within this progressive field of surgery.

Objective Advancements in endoscopic endonasal approaches have increased the extent and complexity of skull base resections, in turn demanding the development of novel techniques for skull base defect reconstruction. The objective of this pilot study was to investigate the effect of leukocyte-platelet-rich fibrin (L-PRF) on the postoperative healing after endoscopic skull base surgery. Methods Between January and May of 2015, 47 patients underwent endoscopic endonasal resection of sellar, parasellar, and suprasellar lesions with the application of L-PRF membranes during the skull base reconstruction at two surgical centers. Early postoperative records were retrospectively reviewed. Results We found that 21 days following the surgery, 17/41 patients (42%) demonstrated improvement in the crusting score as compared with their 7 day postoperative examination. Ten of these patients (23%) showed no crusting. Fourteen (34%) patients had no change in the crusting score. Six patient records were incomplete. A total of 4/47 cases (8.5%) had postoperative cerebrospinal fluid leak requiring surgical repair. Conclusion This study demonstrates the potential utility of L-PRF membranes for skull base defect reconstruction. Future studies will be conducted to better assess the role of L-PRF in endoscopic skull base surgery.

Objective: The purpose of this study was to determine whether prior history of sinonasal surgery affects the incidence of long-term radiographic sinus disease after endoscopic skull base surgery. Study Design: A retrospective review was conducted at a university medical center. Methods: All patients that underwent a transnasal transsphenoidal endoscopic approach to the skull base with both preoperative and postoperative imaging greater than 6 months after surgery were identified. Lund-Mackay scores for CT images and an analog scoring system for MRI were used to stage all images. Change in preoperative and postoperative imaging scores were calculated and compared between patients with and without a history of a previous sinonasal intervention (i.e., septoplasty, transnasal transsphenoidal skull base surgery, or endoscopic sinus surgery). Results: Eighty-five patients were included in the study, 37 patients without a history of prior surgery and 20 patients with a history of prior surgery. Patients with a history of prior surgery had worse mean preoperative imaging scores compared with the group undergoing primary surgery in the left maxillary sinus (difference = 0.5 vs. 0.1, P = <0.01), left frontal (difference = 0.1 vs. 0.0, P = 0.05), and left sphenoid (difference = 0.2 vs. 0.0, P = <0.01), and right sphenoid sinuses (difference = 0.3 vs. 0.0, P = <0.01). The mean postoperative changes in radiographic scoring of sinusitis differed between patients with prior surgery and those undergoing primary surgery in the right anterior ethmoids (difference = −0.05 vs., 0.3 P = 0.02), left posterior ethmoids (difference = −0.3 vs. 0.1, P = 0.01), right posterior ethmoids (difference = −0.3 vs. 0.2, P = 0.03), and left sphenoid sinus (difference = −0.05 vs. 0.2, P = 0.04). Patients with a prior sinonasal surgery showed no increase in incidence of radiographic sinusitis in the postoperative MRIs. In contrast, patients with no history of prior sinonasal surgery had worse radiographic scores in the right anterior ethmoids, right posterior ethmoids, left and right maxillary, and left and right sphenoid sinuses (P ≤ 0.01, 0.03, 0.02, <0.01, 0.02, respectively). Conclusion: Patients with a history of sinonasal surgery show no increased incidence of radiographic evidence of sinusitis after endoscopic transnasal transsphenoidal skull base surgery.

Endoscopic skull base surgery (ESBS) is a minimal-access technique that provides an alternative to traditional approaches. Patient-reported outcomes are becoming increasingly important in measuring the success of surgical interventions. Endoscopic skull base surgery may lead to improvements in quality of life (QOL) since natural orifices are used to reach the pathology; however, sinonasal QOL may be negatively affected. The purpose of this study was to assess the impact of ESBS on both site-specific QOL, using the Anterior Skull Base Questionnaire (ASBQ), and sinonasal-related QOL, using the Sino-Nasal Outcome Test (SNOT-22). Consecutive patients from a tertiary referral center who were undergoing ESBS were prospectively enrolled in this study. All patients completed the ASBQ and SNOT-22 preoperatively as well as at regular intervals after ESBS. Sixty-six patients were included in the study, and 57.6% of them had pituitary adenoma. There was no significant decline or improvement in the ASBQ-measured QOL at 3 and 6 weeks after ESBS, but there were significant improvements at 12 weeks and 6 months postoperatively (p < 0.05). Improvements were noted in all but one ASBQ subdomain at 12 weeks and 6 months postsurgery (p < 0.05). Preoperative QOL was significantly worse in patients who had undergone revision surgery and significantly improved postoperatively in patients who underwent gross-total resection (p < 0.05). Scores on the SNOT-22 worsened at 3 weeks postoperatively and returned to baseline thereafter. The presence of a nasoseptal flap or a graft-donor site did not contribute to a decreased QOL. Endoscopic skull base surgery is associated with an improvement in postoperative site-specific QOL as compared with the preoperative QOL. Short-term improvements are greater if gross-total resection is achieved. Sinonasal QOL transiently declines and then returns to preoperative baseline levels. Endoscopic skull base surgery is a valuable tool in the neurosurgical management of anterior skull base pathology, leading to improvements in site-specific QOL.

Editorial introductions.

Editorial introductions.