Combined Endoscopic Endonasal Research Articles

Combined Endoscopic Transmaxillary Approach for Resection of an Extracranial V3 Schwannoma: 2-Dimensional Operative Video.

Tumours of the pterygopalatine (PPF) and infratemporal fossa (ITF) are rare tumours and are difficult to access. The lateral cervical approach is hampered by the mandibular angle and the vascular nervous elements.1 The classic endonasal endoscopic medial maxillectomy approach has been developed over the past 2 decades but does not allow good control of the most lateral and inferior part of the ITF.2 The surgical video presents a 68-year-old woman with trigeminal neuralgia. The radiologic workup showed a trigeminal V3 schwannoma (TS) into the PPF and ITF. This tumor grew during the follow-up despite fractionated radiosurgery. A 2-dimensional intraoperative video illustrates the gross total removal of the TS through a combined endoscopic endonasal and transgingival transmaxillary approach. The combination of these 2 approaches allows on the one hand, a better view of the lateral and inferior part of the maxillary sinus and ITF and on the other hand, a gain of handling in the operating field and security for our surgical procedure.3 The mini-Caldwell-Luc approach gives good aesthetic results without stomatological complication. Neuralgia disappeared after the surgery, and a gross total resection was achieved, and no recurrence was observed during the follow-up. This combined approach is a good alternative of medial extended maxillectomy, which presents a risk for the lacrimal duct risk and postoperative aesthetic deformity because of the removal of the medial and anterior wall of the maxillary sinus. The patient consented to the procedure and publication of her image.

Combined endoscopic endonasal and sublabial transmaxillary approaches for resection of intracranially extended juvenile nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibromas (JNAs) are rare, benign, and locally invasive nasopharyngeal tumors. Endoscopic endonasal resection is effective, non-invasive, with low complication rates. Until recently, endoscopic resection was not suitable for intracranially invasive tumors. We describe resection steps of an intracranially extending JNA with a combined endoscopic endonasal and endoscopic-assisted sublabial transmaxillary approaches. Indications, advantages, and approach-specific complications are also discussed. The main surgical steps are shown in an operative video. Surgical excision of JNAs by a combined endoscopic endonasal and sublabial transmaxillary approaches represents a safe and effective treatment for selected intracranially invasive JNA.

Combined Endoscopic Endonasal and Transpalatal Repair of Congenital Anterior Cranial Fossa Agenesis.

Congenital basal meningoceles and encephaloceles are rare pathologies that may present in isolation or with characteristic-associated clinical features. Rarely, children with congenital midline defects may present with massive encephaloceles secondary to anterior cranial fossa agenesis. Traditionally, transcranial approaches with frontal craniotomies were used to reduce the herniated contents and repair the skull base defect. However, high rates of morbidity and mortality associated with craniotomies have favored the development and adoption of less-invasive techniques. To present a novel technique for combined endoscopic endonasal and transpalatal repair of a giant basal meningocele through an extensive sphenoethmoidal skull base defect. A representative case of congenital anterior cranial fossa agenesis with a giant meningocele was selected. Clinical and radiological presentations were reviewed, and the intraoperative surgical technique was documented and recorded. A surgical video highlighting each surgical step was included to complement the description of the technique. The surgical outcome from the selected case is also presented. This report describes a combined endoscopic endonasal and transpalatal approach to repair an extensive anterior skull base defect with herniation of intracranial content. This technique capitalizes on the advantages of each approach to address this complex pathology.

Combined endonasal and orbital approach for annulus of Zinn area decompression in dysthyroid optic neuropathy

BackgroundDysthyroid optic neuropathy (DON) is a serious complication of thyroid-associated ophthalmopathy (TAO) that can cause permanent vision loss from orbital apex syndrome. Urgent management of high-dose corticosteroid pulse therapy is recommended, and salvage orbital apex decompression surgery may require in refractory patients ineffective with corticosteroid pulse therapy. PurposeTo evaluate the short-term efficacy and safety of combined endoscopic endonasal and orbital approach decompression in the annulus of the Zinn (AZ) area in refractory dysthyroid optic neuropathy (DON). MethodsIn this retrospective study, patients who underwent combined endoscopic endonasal and orbital approach decompression around the AZ area for the treatment of refractory DON from May 2021 to March 2022 were enrolled. A total of 15 orbital apex were decompressed across 9 patients. The demographic, imaging, and surgical data, as well as preoperative and postoperative best corrected visual acuity (BCVA), proptosis degree and Modified-Chinese-TAO-QOL scores, were collected and assessed. The t-test was used to identify differences between preoperative and postoperative parameters: visual acuity, proptosis and QOL scores. ResultsThe mean best corrected visual acuity (BCVA) improved from 0.79 ± 0.77 LogMAR preoperatively to 0.21 ± 0.27 LogMAR (P < 0.001) postoperatively. Additionally, proptosis decreased from 22.25 ± 2.01 mm to 18.42 ± 1.85 mm (P < 0.01), with an average decrease of 3.7 mm. The preoperative scores of the visual, psychological, and comprehensive components of QoL were 14.60 ± 9.08, 37.49 ± 6.26 and 26.75 ± 3.70, respectively, which significantly improved postoperatively to 54.18 ± 7.23, 68.78 ± 12.53 and 61.88 ± 9.37, respectively. The postoperative follow-up time ranged from 2 to 11 months, and the median follow-up time was 7 months. There was 1 case of transient postoperative sinusitis and 1 new case of transient diplopia, which was relieved after 3 months. ConclusionCombined endoscopic endonasal and orbital approach adequate decompression for AZ area significantly improves visual acuity and QOL in patients with DON.

Simultaneous combined endoscopic endonasal and transcranial surgery for giant pituitary adenomas: Tips and traps in operative indication and procedure

ObjectivesThis retrospective analysis of patients treated with endoscopic endonasal transsphenoidal surgery (ETSS) alone or simultaneous combined surgery investigated imaging features suitable for surgical methods and pitfalls in simultaneous combined surgery for giant pituitary adenoma. Patients and methodsTen patients with giant pituitary adenoma treated by ETSS alone or simultaneous combined endoscopic endonasal and transcranial surgery were enrolled. By analyzing tumor imaging features on magnetic resonance imaging (MRI), operative findings and clinical outcomes, we examined types of imaging features suitable for each surgical method. ResultsFour patients received ETSS alone and six patients underwent simultaneous combined endonasal and transcranial surgery. Four patients treated by ETSS alone and three patients treated by combined surgery had high resection rates and good outcomes. The remaining three patients with combined surgery achieved partial resection and visual deterioration in one patient. MRI features suitable for ETSS included an enlarged sella, upward tumor extension, and round surface, whereas those for combined surgery included normal/enlarged sella, anterior and/or unilateral tumor extension, and a multilobulated surface. Tumors extending extensively bilaterally or upward and encasing neurovascular structures could not be effectively resected even under combined surgery. ConclusionBoth ETSS alone and simultaneous combined endonasal and transcranial surgery showed good results for giant pituitary adenoma when the surgical methods matched suitable imaging features. Tumors with unilateral or anterior extension and a multilobulated surface were maximally resected without neurological deficit by combined surgery, but tumors showing extensive multi-directional extension and full encasement of neurovascular structures were not effectively resected even with combined surgery.

Combined endoscopic endonasal and transorbital multiportal approach for complex skull base lesions involving multiple compartments.

This study defines the specific areas that connect the surgical corridors of the endoscopic endonasal (EEA) and transorbital approach (TOA) to identify adequate clinical applications and perspectives of this combined multiportal approach. Consecutive patients who underwent combined EEA and TOA procedures for various pathologies involving multiple compartments of the skull base were enrolled. A total of eight patients (2 chondrosarcomas, 2 meningiomas, 2 schwannomas, 1 glioma, and 1 traumatic optic neuropathy) were included between August 2016 and April 2021. The cavernous sinus (CS) was targeted as the connection area of the combined approach in four patients with tumors infiltrating the middle cranial fossa (MCF) and central skull base through the CS. For two patients with MCF tumors extending into the infratemporal fossa (ITF), the horizontal portion of the greater sphenoid wing and the foramen ovale were utilized as the connection area. In the remaining 2 patients, connection was achieved through the optic canal (OC). Gross total and near total resection was achieved in 5 patients with tumors, and circumferential removal of bone composing the OC was performed in one patient with traumatic compressive optic neuropathy. Postoperative complications included one cardiac arrest due to underlying cardiovascular disease and one case of oculomotor nerve palsy. The combined EEA and TOA procedure is a useful strategy for complex lesions involving multiple compartments of the skull base. Herein, we identified the specific areas connecting the two surgical approaches, allowing a common path for EEA and TOA procedures.

Combined endoscopic endonasal and transorbital approach to skull base tumors: a systematic literature review.

In the last decades, there has been a marked evolution in skull base surgery techniques and more recently a combination of different corridors has been proposed and used in order to improve angles of attack, shorten working distances, and ameliorate visualization of skull base lesions. Recently, the endoscopic endonasal and transorbital routes have been combined as multiportal approach to reach and treat complex skull base neoplasms. The aim of this paper is to examine data extracted from the recent literature about the feasibility and effectiveness of combined endonasal and transorbital endoscopic multiportal surgery. A PubMed comprehensive search of literature published until October 2020 was conducted. Nine studies, regarding 24 patients, were included. The majority of tumors were meningiomas (62.5%), mostly located at the spheno-orbital region (93.3%). GTR was accomplished in 10 patients (41.7%), NTR in two patients (8.3%). Endonasal transpterygoid approach (N.=8) and superior eyelid access (N.=17) were the most used routes used. No case of CSF fistula was observed, and the most common complication was a transient periorbital edema. The average hospitalization time (days) was five days. A combined endoscopic endonasal and transorbital multiportal approach grants an adequate corridor to access several skull base tumors, such as those extending towards the paramedian aspects, providing good outcomes in terms of extent of tumor resection with acceptable rates of complications. These preliminary results might encourage the use of multiportal approaches in selected complex skull base neoplasms.

Combined endoscopic endonasal and sublabial transmaxillary approach for resection of giant infratemporal fossa schwannoma with intracranial extension: operative video and technical nuances.

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker’s approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct “head-on” trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript.The video can be found here: https://youtu.be/gy-pkjLdDgE.

Management of Orbital Masses: Outcomes of Endoscopic and Combined Approaches With No Orbital Reconstruction.

IntroductionThe endoscopic endonasal approach to management of orbital pathology has expanded. Due to the rarity of these conditions, most reports in the literature consist of small case reports. We report a series from a single institution with a focus on outcomes.MethodsA retrospective chart review was carried out between 2010 and 2018.ResultsTwenty-four patients were identified (average age 58 years, 15 males, 9 females). Average follow-up was 14.9 months. Most common etiologies included cavernous hemangioma (7), metastases (6), idiopathic orbital inflammatory syndrome (6), orbital hematoma/clot (2), and schwannoma (1). Most common presenting symptoms were decreased visual acuity (8), proptosis (8), diplopia (7), and incidental findings (2). All patients underwent endoscopic medial wall orbital decompressions. Sixteen involved a combined open approach by an ophthalmologist. Pathology was either biopsied (15), resected (6), or could not be identified (3). No intraoperative complications were noted. No patients underwent orbital reconstruction of the medial wall. Six patients developed postoperative sinusitis successfully managed with antibiotics. One patient developed epistaxis managed conservatively. In 5 patients, Sino-Nasal Outcome Test-22 scores increased immediately postop and then decreased, whereas scores only decreased in 6 patients. Six patients noted reduced proptosis. There were no new cases of diplopia or worsening visual acuity.ConclusionsA combined endoscopic endonasal and external approach can be useful for managing orbital lesions. Patients tolerated the procedure well with improvement in ocular symptoms and minimal sinonasal complications. Reconstruction of the medial wall may not be warranted to prevent postoperative diplopia.

Endoscopic Endonasal Approach Combined with a Simultaneous Transcranial Approach for Giant Pituitary Tumors

The endoscopic endonasal approach is widely used for treating giant pituitary adenomas. However, a small subset of tumors is still challenging to treat, and the risk of complications increases when an endoscopic endonasal approach alone is used. The simultaneous combined endoscopic endonasal and transcranial approach is a surgical option for such difficult adenomas; however, very few studies have described the technical nuances and benefits of this approach. We treated 3 patients with giant pituitary adenoma and 1 patient with pituicytoma. Radiologic findings and clinical outcomes were retrospectively reviewed. All patients had preoperative visual disturbances. A pterional approach was combined with an endoscopic endonasal approach to treat all the patients. Near-total and subtotal tumor removal was accomplished in 3 patients; however, only partial tumor removal was possible in 1 patient. Postoperative visual function improved in 3 patients, but there were no changes in 1 patient. There were no major complications; however, each patient developed either adrenocorticotropic hormone (ACTH) and thyroid-stimulating hormone deficiency or ACTH deficiency and persistent diabetes. Importantly, no cerebrospinal fluid leakage was observed in the patients. Our simultaneous combined endoscopic and transcranial approach offers safe tumor resection and a low rate of complications. In this procedure, it is important that tumor debulking be performed by the main surgeon via a single surgical route and not by 2 surgeons using the simultaneous endonasal and transcranial approach, to avoid interference in the surgical field. This approach may be considered as a surgical option for carefully selected tumors in the sellar region.

Combined endoscopic endonasal and subciliary approach in revision DCR cases

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Study conducted to know surgical outcome of combined endoscopic endonasal and subciliary approach in revision DCR cases and complications associated with the procedure.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Prospective, single-blinded, randomized, interventional study is carried out in Tertiary level center from August 2009 to April 2016. Totally 18 patients (11 female and 7 male) were involved in the study who has undergone previous DCR (11 external DCR and 7 endoscopic DCR). The results were analyzed at end of the 3&lt;sup&gt;rd&lt;/sup&gt; and 6&lt;sup&gt;th&lt;/sup&gt; month both subjectively and objectively. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; All the 18 patients who underwent combined approach were relived from epiphora. None of the patients developed any complications following surgery.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The combination of endoscopic and external approach gives benefits of the both approaches giving huge advantages in revision cases. It gives excellent visualization of the surgical field, ability to correct internal nasal pathologies, make clear rhinostoma, workprecisely on fibrosed lacrimal sac and nearly no external scar. It provides good team work opportunity between otorhinologist and ophthalmologist.&lt;/p&gt;

Erratum to: Combined endonasal and sublabial endoscopic transmaxillary approach to the pterygopalatine fossa and orbital apex.

Background The pterygopalatine fossa (PPF) and inferomedial orbital apex are difficult regions for open neurosurgical access. The traditional extensive anterior approach (transfacial or transmandibular) and lateral/posterolateral (transcranial) approach were used to access the PPF. The combined endonasal and sublabial transmaxillary approach is a less invasive access route for these lesions. In this study, we present the technical and clinical details of our experience with the combined endoscopic endonasal and transmaxillary approach.

Radiology Quiz Case 3

A 30-YEAR-OLD WOMAN IN HER SECOND TRImester of pregnancy (20 weeks) presented with a severe headache and pain in the right side of her face. Magnetic resonance imaging showed a soft tissue lesion in the right ethmoidal sinus, extending into the right orbit (Figure 1). The patient had a history of very poor vision in her right eye because of a cataract that had been present since childhood. Under anesthesia, she underwent a nasal examination and biopsy of the lesion, which was occupying the superior meatus and extending posteriorly toward the sphenoidal sinus. Wide surgical excision of the lesion by a combined endoscopic endonasal and craniofacial facial approach was planned. Proptosis and swelling of the patient’s right eyelid developed as she was waiting for surgery and workup, with further investigation to rule out a secondary focus in her neck and chest. After a couple of days, she suddenly became unconscious. She was not responding to any stimuli, but all her vital signs were within normal limits. An urgent computed tomographic scan of her brain did not show any signs of hemorrhage or increased intracranial pressure. She underwent intubation and was transferred to an intensive care unit. She suddenly gained consciousness the next day, without any neurologic deficits. She was treated with high-dose steroids, but within the next 48 hours she started to complain of blurred vision in her left eye. An urgent computed tomographic scan of her paranasal sinuses (Figure 2) showed a homogeneous mass involving the right ethmoidal sinuses, right orbit, and cavernous sinuses; invading the cribriform plate, left ethmoidal sinus, and left orbit; eroding the pituitary fossa; and compressing the left optic nerve at the apex of the left orbit. What is your diagnosis?