Approach For Skull Base Lesions Research Articles

Endoscopic transorbital approach for skull base lesions: a report of 16 clinical cases.

Due to the deep location, complex anatomy, and adjacent vital neurovascular structures, skull base surgery is challenging and requires specific approaches. The emerging endoscopic transorbital approach (eTOA) technique provides a new approach to the orbital content, spheno-orbital region, lateral cavernous sinus, and Meckel's cave. In this study, the clinical utility and effectiveness of the eTOA are reported. Sixteen cases who underwent the eTOA were included in the current study. The patients were divided into 3 groups according to tumor location: Group A (intraorbital, 6 cases), group B (spheno-orbital, 7 cases), and group C (cavernous sinus, and Meckel's cave, 3 cases). The clinical data and surgical results were analyzed. Eight meningiomas, 2 hemangiomas, 1 low-grade glioma, 1 instance of inflammatory hyperplasia tissue, 1 Langerhans cell histiocytosis, 1 epidermoid cyst, 1 trigeminal schwannoma, and 1 bone fibrosis hyperplasia were observed. The mean tumor diameter was 2.4cm. A single case in Group A and Group C underwent biopsy (12.5%), and 1 case of fibrous dysplasia in Group B underwent sufficient orbit decompression (6.25%). The remaining 13 cases underwent gross total tumor resection (81.25%). No cerebral-spinal fluid leak or infection occurred. And no cosmetic problems or significant complications were observed during the follow-up. As a minimally invasive technique, the eTOA has unique advantages for carefully selected skull base lesions because of its direct route, short working distance, and distinct attack angle.

Neurovascular structures in the lateral recess of the sphenoid sinus. A computed tomography evaluation

Introduction and objectivesAnatomical variations of the lateral recess of the sphenoid sinus and its relations with the adjacent neurovascular structures should be preoperatively evaluated to plan an adequate surgical approach and avoid iatrogenic injuries. This study aims to analyze the patterns of pneumatization of the lateral recess of the sphenoid sinus and their association with the presence of protrusion and dehiscence of the optic canal, carotid canal, vidian canal, and maxillary nerve. Materials and methodsA retrospective evaluation of 320 sphenoid sinuses by computed tomography was performed. Studied variables included type of lateral recess, and protrusion, and dehiscence of the optic and carotid canal, and vidian and maxillary nerve. ResultsThe mean age was 45.67±17.43. A total of 55.6% (n=178) of the evaluated sphenoid sinuses corresponded to male subjects. Protrusion of the carotid canal, maxillary nerve, and vidian canal was associated with a type 3 lateral recess pneumatization, while dehiscence of these structures was most commonly observed in a type 2 lateral recess (p=<0.001). ConclusionsProtrusion or dehiscence of neurovascular structures surrounding the sphenoid sinus has been associated with the extent of pneumatization of the lateral recess, increasing the risk of intraoperative injury. Preoperative identification of anatomical variations is mandatory to select the best approach for skull base lesions and avoid iatrogenic injuries.

Minimally invasive endoscopic approaches to pediatric skull base pathologies.

Endoscopic endonasal approaches to pediatric skull base lesions are rare, challenging, and present distinct considerations from adult pathology. In this study, we describe our endoscopic technical approach to various skull base lesions demonstrating the efficacy and nuances of these approaches in pediatric patients. Pediatric patients underwent endoscopic approach for skull base lesions from January of 2015 to April of 2021 were included in the study. Presenting symptoms, indications for surgery, surgical outcomes, intraoperative and postoperative complications, length of hospital stay, and length of follow-up were documented. A total of 18 patients (median age 12, age-range 1-15, 53% male) underwent 19 endoscopic transsphenoidal procedures. The pathologies included craniopharyngioma (N=5), biopsy for an unknown disease (n=2; orbital meningioma and pituitary lymphocytic hypophysitis), pituitary adenoma (N=2; ACTH-secreting and non-functional), Rathke's cleft cyst (n=2), CSF leak repairs (n=2; post-traumatic and spontaneous meningocele), juvenile nasopharyngeal angiofibroma (n=3, 1 patient had 2 procedures) and rhabdomyosarcoma (n=1). GTR was achieved in 11 out of 15 procedures (73.3%). Out of 10 patients with a sellar lesion, 6 patients had intraoperative CSF leak (60%). No patients experienced post-operative CSF leak. The median follow-up for all patients was 14 months (1-36 months). Anterior and middle skull base pathology in pediatric patients can be effectively operated via an endoscopic approach across a wide variety of patient ages and conditions. Minimally invasive techniques with middle turbinate and nasal septum preservation can be achieved without compromising outcomes. A wide variety of surgical repair strategies can be successfully utilized.

Extended Frontobasal Approach for Skull Base Lesions

Abstract Background Lesions involving the skull base can be approached by a variety of surgical corridors and extended frontobasal approach is one of them. It provides quite a wide exposure to lesions in the midline of anterior skull base, paranasal sinuses, and sphenoclival region. Objective To share our experience, and list the merits and demerits, of this approach for anterior skull base lesions. Methods A total of six cases were operated using extended frontobasal approach. Four of them were skull base tumors with extensive involvement of paranansal sinuses and extension into sellar, parasellar, and clival region. Fronto-orbital and sphenoethmoidal osteotomy provided adequate surgical access, thereby facilitating their excision. Two cases of frontonaso-orbital encephalocele with large bone defect at anterior skull base were also operated upon. Skull base repair was performed using autologous bone graft, pericranium, and fibrin glue. Results Gross total excision was achieved in four cases of skull base tumors with good cosmesis as transfacial access was obviated. Excision, repair, and reconstruction of two patients with frontonaso-orbital encephalocele were also done with acceptable cosmesis. Conclusion The extended frontobasal approach is an excellent alternative for extensive anterior skull base tumors (up to posterior skull base), and also for the repair of large malformative lesions of the anterior skull base.

Effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery: a randomised, controlled study.

Nasal lavage with mupirocin has the potential to reduce sinonasal morbidity in endoscopic endonasal approaches for skull base surgery. To evaluate the effects of nasal lavage with and without mupirocin after endoscopic endonasal skull base surgery. A pilot randomised, controlled trial was conducted on 20 adult patients who had undergone endoscopic endonasal approaches for skull base lesions. These patients were randomly assigned to cohorts using nasal lavages with mupirocin or without mupirocin. Patients were assessed in the out-patient clinic, one week and one month after surgery, using the 22-item Sino-Nasal Outcome Test questionnaire and nasal endoscopy. Patients in the mupirocin nasal lavage group had lower nasal endoscopy scores post-operatively, and a statistically significant larger difference in nasal endoscopy scores at one month compared to one week. The mupirocin nasal lavage group also showed better Sino-Nasal Outcome Test scores at one month compared to the group without mupirocin. Nasal lavage with mupirocin seems to yield better outcomes regarding patients' symptoms and endoscopic findings.

Pediatric Endoscopic Endonasal Approaches for Skull Base Lesions in the Very Young: Is It Safe and Effective?

Introduction The fully endoscopic expanded endonasal approach (EEA) has been shown to be safe and efficacious in pediatric patients. However, in the very young patient (ages six and under), the anatomical challenge of working through a small nasal corridor is problematic. The ability to repair the skull base and use a nasoseptal flap (NSF) has also been called into question. Here, we review skull base resections using EEA in patients aged 6 years and younger. Methods A retrospective chart review was conducted on pediatric patients age 6 years and younger who underwent EEA skull base resections over a 3-year period (June 2014 through June 2017). Results Eight children aged 6 and under with seven tumor pathologies underwent an EEA for the resection of their skull base tumors, with a mean follow-up of 1.45 years. Only chordoma cases required multiple-staged resections. There are no tumor recurrences to date. A high-flow intraoperative cerebrospinal fluid (CSF) leak was encountered in three cases, and there were no postoperative CSF leaks. CSF leaks were effectively repaired with NSFs. One patient suffered from postoperative hypopituitarism, one patient experienced recurrent epistaxis secondary to turbinate destruction by the tumor, and one patient expired 8 months postresection secondary to metastatic disease. Conclusion In our case series, EEA for skull base tumors in children aged 6 and under was a safe and effective surgical approach. Skull base defects are able to be effectively addressed with typical repairs including NSFs. Larger studies are warranted to further investigate this technique in this pediatric population.

Endoscopic transsphenoidal approach to skull base lesions. A clinical prospective study.

Objectives:To review the patients operated by endoscopic transphenoidal approach for skull base lesions. All the clinical data including age, gender, type of pathology, surgical outcome and surgical complications were studied.Methods:A clinical prospective study was conducted on 94 cases with skull base lesion that were treated in Neuroscience Hospital in Baghdad, Iraq between October 2011 and December 2016. We followed each patient for an average of 2 years after surgery to determine most common lesion involving the skull base, age and gender distribution, surgical outcome, complications and hospital accommodation. Freeze system of Storz all the cases in the study.Result:The majority of our patients were between the ages of 20-29 years. Among the 94 patients, 67% had macro adenomas, followed by craniopharyngioma 11%. The mortality rate was 2.1%, Gross total removal was 57.4%. All patients show improvement of the headache after surgery, visual improvement was noticed in 73.4% and hospital accommodation was 2-5 days. Three patients developed cerebrospinal fluid leak, Infection meningitis developed in 3 patients 3.1%, and 2 patients (2.1%) suffered from hormonal disorders and were referred to endocrinologist for therapy. Diabetes insipidus developed as a temporary complication in 4 cases (4.2%).Conclusion:Trassphenoidal surgery is relatively safe surgery for properly selected patients.

Endoscopic endonasal transclival approaches: case series and outcomes for different clival regions.

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution's experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.

Imaging in Common Anterior and Sellar/Perisellar Skull Base Lesions

ABSTRACTSkull base surgery is an advanced surgical subspeciality. A wide range of pathologies can primarily or secondarily involve the skull base. Due to its complex anatomy, cross-sectional imaging is an important part in the multidisciplinary approach for skull base lesions.

Quality of Life Following Endoscopic Endonasal Approach for Skull Base Lesions

Quality of Life Following Endoscopic Endonasal Approach for Skull Base Lesions

Trans-sylvian transtentorial approach for skull base lesions extending from the middle fossa to the upper petro-clival region

Various transpetrosal approaches have been described for excision of lesions extending into both the midlle fossa and the upper petroclival region. These approaches may be associated with significant morbidity. Six patients with lesions along the medial part of the middle fossa and the upper petroclival region were operated by the trans-sylvian transtentorial approach. The surgical corridor was along the tentorial edge with excision of the tentorium providing adequate access to the tumour without the need for petrosectomy. Three patients had a trigeminal schwanomma, one each had a petroclival meningioma, clival chordoma and an epidermoid tumour. In 5 patients a total/neartotal excision was achieved while in one patient with petroclival meningioma, a subtotal excision was possible. All patients improved clinically after the surgery. There was no procedure related morbidity. The transsylvian transtentorial approach provides adequate acces to upper petroclival lesions allowing the tumours in this region to be removed without the need for a petrosal resection.

Infratemporal approach for skull base lesions

Tumors of the infratemporal fossa constitute a diverse group of pathology with similar surgical considerations. Access to the infratemporal fossa is possible through a variety of surgical approaches including anterior, lateral, and inferior approaches. Fisch has provided excellent descriptions of the lateral approach and his works stress the need for facial nerve and internal carotid identification and preservation. Many technological enhancements have furnished the modern skull base team with sophisticated tools for preoperative assessment and intraoperative assistance, improving the outcome and reducing operative morbidity. These have included the use of preoperative balloon occlusion, magnetic resonance imaging (MRI) three-dimensional computed tomography and MRI reconstructions, intraoperative nerve monitoring and navigational systems, and safe and reliable reconstructive and anesthesia methods. Proper interpretation of preoperative studies and translation to careful selection of technique require surgical experience and maturity. Various aspects of infratemporal surgery, based on the author's experience with 93 patients, are discussed in this article. The lateral approaches are broadly classified into preauricular and postauricular approaches. Indications, advantages, and descriptions of each technique are presented with regard to avoidance of complications. The need for internal carotid artery exposure and/or reconstruction and facial nerve transposition determines preference of preauricular or postauricular exposure. Management of the eustachian tube, middle ear, and temporomandibular joint is an important additional consideration. The management of the temporalis muscle may also vary. Intracranial extensions of infratemporal fossa tumors can be quite varied, and precise calculation is necessary to determine appropriate craniotomy exposure. The need for a dural/mucosal barrier is paramount, and therefore appropriate planning and assiduous attention to closure are important. Injuries to important neurovascular structures are best avoided by careful identification of these structures and appropriate surgical manipulations.