Endoscopic Endonasal Research Articles

Endoscopic endonasal obliteration of the frontal recess and anterior skull base.

Although endoscopic techniques have become more widespread in repair of frontal sinus (FS) defects, certain pathologies still require open approach (extensive trauma or tumors). Under certain circumstances even multiple complex open reconstructive procedures might fail to resolve persistent pneumocephalus or CSF leak and subsequently surgeons tend to escalate the invasiveness and employ even more complex and aggressive approaches. We present our experience treating persistent pneumocephalus or CSF leak after previously failed transcranial reconstruction utilizing an endoscopic endonasal approach (EEA). We retrospectively reviewed a prospectively maintained database of all patients undergoing an EEA for repair of persistent pneumocephalus or CSF leak following FS cranialization between 2016 and 2020. Six patients who underwent cranialization of the FS with subsequent persistent pneumocephalus or CSF leak were identified; two patients suffered a traumatic fracture of the FS, remaining four patients had undergone previous cranial surgery. Clear violation of the FS was not recognized in one patient. All patients underwent cranialization of the FS either directly following initial craniotomy or during open repair of a FS fracture. Two patients underwent multiple transcranial surgeries including using vascularized free tissue transfer. Complete cessation of pneumocephalus/CSF leak was achieved in 83.3% (5/6) after the first and 100% (6/6) after two endoscopic procedures. No morbidity or mortality resulted from the endoscopic procedure. Skull base defects following a failed cranialization of FS are usually located in or in close proximity to the frontal recess. These defects can be safely and effectively repaired via an EEA.

500 Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus: Initial Experience and Impact on Pituitary Surgery Outcomes

INTRODUCTION: Invasion of the medial wall of the cavernous sinus (CS) by pituitary tumors is a factor associated with persistence of disease and subtotal resection of these tumors. Resection of the medial wall of the CSis therefore an option for maximum resection of such tumors, however, there is concern with potential complications associated with this technique and at this time, limited data is available in the literature. METHODS: Single center retrospective study evaluating patients that underwent endoscopic endonasal resection of pituitary adenomas and resection of the medial wall of the CS, between January 2022 and February 2023. Extent of resection, remission rates, complications and histopathological diagnosis were assessed. RESULTS: Out of a population of 120 pituitary surgeries, sixteen cases were eligible for this study. 5 (31.2%) patients had non-functional adenomas, and 11 (68.7%) had functional adenomas, including 4 adrenocorticotropic hormone, 3 prolactin, 3 growth-hormone, 1 pluri-hormonal (GH and prolactin)—secreting tumors. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. At last follow-up, complete biochemical remission (using current criteria) was seen in 11 cases (100%) of functional adenomas. One case developed pulmonary embolism and another one sino-nasal infection postoperatively. No fatalities, carotid injuries or cranial nerve palsies were reported. CONCLUSIONS: Resection of the medial wall of the cavernous sins, performed when there is potential tumor extension into the medial wall, is associated with high rates of disease control. It is particularly useful in cases of functioning but also has a role in non-functional adenomas adherent to the medial wall of the CS. Long term follow up is necessary to evaluate the durability of these results.

1234 The Transposition Technique of Internal Carotid Artery in Endonasal Endoscopic Surgery: Beyond the Lateral Boundary of Middle Line Approach

INTRODUCTION: There was no report regarding the transposition technique of ICA in endonasal endoscopic surgery (EES) METHODS: Six cadaveric heads (3 arterial and venous injected, 1 embalmed artery injected, 1 fresh artery injected) were prepared for dissection. The trabecular fiber (parasellar ligaments) in cavernous sinus(CS), small branches of ICA, dura, bony structures along ICA were meticulously dissected and photographed. The endoscopic dissections were performed using 0° (4-mm-diameter, 18-cm-long) rod lens endoscopes (Karl Storz). 36 cases (Jan 2014 to June 2022) underwent EES ICA transposition were reviewed. RESULTS: The trabecular fiber and small branches of ICA formed four sets of limiting structures around ICA: the medial, lateral, anterior, and posterior group. The medial group consisted of carotid clinoid ligaments (12/12), inferior hypophyseal artery (11/12), inferior parasellar ligament (6/12). The lateral groupcomprised inferolateral trunk (12/12), the sympathetic nerve plexus (12/12), the trabecular fibers between ICA and CN3 (6/12),CN4 (5/12), CN6 (12/12). The anterior group consisted of trabecular fibers between the proximal dural ring and the ICA (7/12). The posterior group was made of trabecual fibers (8/12) around the post genu and posterior wall of CS. Proximal and distal dura ring was the main dura structures impeding mobilizing ICA. The anterior clinoid and lingual process obstructed ICA lateral transposition. Grade 1 (inner CS limiting structures), Grade 2 (inner CS + dura ring open), Grade 3 (inner CS + dura ring + bony remove) transposition were used in 24 (66.7%), 9 (25%), 3 (8.3%) cases respectively. CSF leakage (2.7%), ICA injury (2.7%), new transient CN palsy (8.3%), permanent CN palsy (5.4%) were developed postoperatively. CONCLUSIONS: The EES ICA transposition technique is technically feasible and could be graded according to extent of freeing the limiting structures. It is a novel technique worth exploring in suitable cases to enlarge the working zone and surgical freedom in middle line approaches.

Paediatric endoscopic endonasal middle skull base reconstruction: retrospective analysis of 78 patients treated in a single tertiary care paediatric center

Introduction Skull base pathologies in the paediatric population are rare and require treatment by multiple qualified specialists. The endoscopic endonasal approach has revolutionized surgical treatment because it is less invasive than existing treatments.The goal of this study was to retrospectively review our experience with the reconstruction of paediatric skull middle base defects and associated complications. Materials and methods We analysed medical records from patients aged ≤ 18 years who were treated at our centre between 2013 and 2021. Patients treated with an endoscopic skull base approach and reconstruction, and who had complete clinical and radiological documentation and a minimum follow-up of 12 months, were included in the analysis. Personal data, reconstructive techniques, and complications were analysed. Results A total of 78 patients met the inclusion criteria and were enrolled in the study. Of these patients, 32 were male and 46 were female, and the mean age was 11.5 years. The main signs and symptoms were as follows: bitemporal hemianopsia in 53 cases, visual impairment in 23 cases, and headache in 30 cases. The most frequent aetiologies were craniopharyngioma (38 cases), pituitary adenoma (23 cases), and clivus chordoma (4 cases). All patients were treated via a pure endoscopic approach. For reconstruction, a multilayer technique was used in 18 cases, naso-septal flap in 43 cases, Gasket-Seal technique in 12 cases, and heterologous reconstruction in 5 cases. Only six patients presented a major complication: two had a postoperative cerebral spinal fluid leak, one developed a brain abscess, and three had diabetes insipidus.The mean follow-up period was 23.4 months.There were no statistically significant differences in postoperative CSF leak in relation to different reconstructive techniques. Conclusion Endoscopic endonasal skull base surgery is a safe and effective treatment for paediatric middle skull base pathologies. Reconstruction techniques have a high success rate of 96.5–100%, and the rate of associated complications is < 3%.

Endoscopic Endonasal Approach to the Orbit: A Case Series and Clinical Experience Emphasizing the Advantages of the Ipsilateral Mononostril Technique

BackgroundLesions situated within the orbit pose significant challenges in management due to the confined space they occupy and their proximity to critical anatomical structures. The objective of our study is to assess the feasibility of the ipsilateral endoscopic endonasal approach for orbital cavernous hemangiomas and to comprehend the surgical anatomy of the orbital apex and inferomedial orbital structures. MethodsThirteen patients with orbital cavernous hemangioma, who underwent surgery via the ipsilateral mononostril endoscopic endonasal approach between August 2018 and August 2023, were retrospectively evaluated. Demographic characteristics, clinical data, radiographic images, and clinical outcomes of the patients were collected from digital medical records. ResultsIn the study, we included 13 patients (8 female, 5 male) with ages ranging from 25 to 54 years (mean 35.2 ± 8.3). The left orbit was more commonly affected (9 left, 4 right). The average postoperative follow-up duration was 22.2 months (range 6 months – 50 months). Among the 13 cases of orbital cavernous hemangioma, 1 (7.7%) was located in the extraconal compartment, while 12 (92.3%) were situated in the intraconal compartment. Complete surgical resection of the tumor was successfully achieved in all patients. ConclusionsOur study highlights the potential advantages of employing a purely ipsilateral mononostril endoscopic endonasal approach for orbital surgery, particularly for accessing the orbital apex and managing medial and inferomedial orbital lesions. This technique holds promise for reducing morbidity and enhancing outcomes, especially when combined with careful patient selection, preoperative planning, and advanced endoscopic skills.

Clinical application of reserved gastric tube in neuroendoscopic endonasal surgery for pituitary tumor.

The neuroendoscopic approach has the advantages of a clear operative field, convenient tumor removal, and less damage, and is the development direction of modern neurosurgery. At present, transnasal surgery for sphenoidal pituitary tumor is widely used. But it has been found in clinical practice that some patients with this type of surgery may experience post-operative nausea and vomiting and other discomforts. To explore the effect of reserved gastric tube application in the neuroendoscopic endonasal resection of pituitary tumors. A total of 60 patients who underwent pituitary adenoma resection via the endoscopic endonasal approach were selected and randomly divided into the experimental and control groups, with 30 in each group. Experimental group: After anesthesia, a gastric tube was placed through the mouth under direct vision using a visual laryngoscope, and the fluid accumulated in the oropharynx was suctioned intermittently with low negative pressure throughout the whole process after nasal disinfection, during the operation, and when the patient recovered from anesthesia. Control group: Given the routine intraoperative care, no gastric tube was left. The number of cases of nausea/vomiting/aspiration within 24 h post-operation was counted and compared between the two groups; the scores of pharyngalgia after waking up, 6 h post-operation, and 24 h post-operation. The frequency of postoperative cerebrospinal fluid leakage and intracranial infection were compared. The hospitalization days of the two groups were statistically compared. The times of postoperative nausea and vomiting in the experimental group were lower than that in the control group, and the difference in the incidence of nausea was statistically significant (P < 0.05). After the patient woke up, the scores of sore throat 6 h after the operation and 24 h after operation were lower than those in the control group, and the difference was statistically significant (P < 0.05). The number of cases of postoperative cerebrospinal fluid leakage and intracranial infection was higher than that of the control group, but there was no statistically significant difference from the control group (P > 0.05). The hospitalization days of the experimental group was lower than that of the control group, and the difference was statistically significant (P < 0.05). Reserving a gastric tube in the endoscopic endonasal resection of pituitary tumors, combined with intraoperative and postoperative gastrointestinal decompression, can effectively reduce the incidence of nausea, reduce the number of vomiting and aspiration in patients, and reduce the complications of sore throat The incidence rate shortened the hospitalization days of the patients.

Surgical treatment of pituitary neuroendocrine tumors with coexisting intracranial lesions: A case series and review of the literature.

Pituitary neuroendocrine tumors (PitNETs) are a diverse group of benign neoplasms that account for a significant proportion of intracranial tumors (13%). The coexistence of PitNET with other intracranial lesions, such as meningiomas and intracranial aneurysms, has been constantly reported in the literature; yet, the pathophysiological mechanisms remain unknown, and the appropriate management is controversial. This study aims to describe the clinical characteristics, surgical treatment, and outcomes of patients with PitNET with coexisting intracranial lesions in a single healthcare center. A retrospective analysis was conducted on 12 patients who underwent surgical treatment for PitNET and another intracranial lesion at our single tertiary referral center over 15 years from January 2008 to May 2023. Among these coexisting lesions, aneurysms were the most commonly found (41.67%), followed by meningiomas (33.33%). Surgical intervention for both lesions was performed in a single-stage procedure for most cases (75%), employing transcranial, endoscopic endonasal, and combined approaches. We found low preoperative Karnofsky Performance Scale scores in three patients, with significant differences in functional outcomes. These findings contribute to the limited knowledge about PitNET coexisting with other intracranial lesions and emphasize the importance of patient-tailored, multidisciplinary management in these unusual scenarios.

Intravascular papillary endothelial hyperplasia of the maxillary sinus extending into the contralateral nasal cavity

IntroductionIntravascular papillary endothelial hyperplasia (IPEH) predominantly occurs in the subcutaneous and dermal regions and rarely originates from the sinonasal mucosa.Case presentationWe report on the case of a 58-year-old male patient who presented with progressive bilateral nasal obstruction, left-sided epiphora, and intermittent epistaxis. Computed tomography revealed a soft tissue opacity in the left maxillary sinus with intersinusoidal nasal wall demineralization, extending into the surrounding ethmoid cells and the right nasal cavity through a contralateral deviation of the nasal septum. Contrast-enhanced T1-weighted magnetic resonance imaging further confirmed these findings. The IPEH originating from the maxillary sinus extended into the contralateral nasal cavity, and it was successfully removed using an endoscopic endonasal approach, avoiding overly aggressive treatment.ConclusionThis case report highlights the diagnostic challenges of IPEH in the sinonasal region and the importance of considering IPEH as a differential diagnosis in patients presenting with nasal obstruction, epiphora, and intermittent epistaxis.

Endoscopic endonasal approach for olfactory groove meningioma resection: Strategies and outcomes in a retrospective case series

ObjectiveThough the endoscopic endonasal approach (EEA) is a widely accepted treatment for skull base tumors, the specific use of EEA for olfactory groove meningiomas (OGMs) is debated, with variable outcomes reported in the literature. We review the surgical results of OGM resections for one surgeon including the operative approach, surgical nuances, and outcomes, with a focus on factors relating to patient selection which favor EEA over transcranial approaches. MethodsWe retrospectively reviewed thirteen cases of endoscopic endonasal resection of olfactory groove meningiomas. Patient characteristics, clinical characteristics, surgical outcomes, and complications were analyzed. Extent of resection was determined based on volumetric analysis of pre- and postoperative MRI. ResultsAnatomic characteristics that render a tumor difficult to access fully are lateral extension beyond the mid-orbit and anterior extension to the falx. Simpson Grade I resection was achieved in 11/13 (84.6 %) cases. Mean pre-operative tumor volume was 8.99 cm3 (range 2.19–16.79 cm3), and 92 % of tumors were WHO grade I. We demonstrate 2 cases of smell preservation, possible with small unilateral tumors and tumors that are confined to either the anterior or posterior portion of the cribriform plate. The post-operative CSF leak rate was 7.7 %, without prophylactic lumbar CSF drainage. The mortality rate was 7.7 % (n = 1) after infectious complications following CSF leak. ConclusionsEndoscopic endonasal resection of olfactory groove meningiomas is an effective and safe operative method with outcomes and complication rates comparable to transcranial approaches. Key considerations include careful patient selection and familiarity with technical nuances of endoscopic endonasal approach for this specific tumor type.

Endoscopic endonasal decompression of the optic nerve in the setting of compressive lesions: how I do it.

Many lesions in the anterior skull base may compress the optic nerve (ON), leading to vision loss, and even irreversible blindness. Although decompression of the optic nerve has traditionally been achieved transcranially, the endoscopic endonasal approach (EEA) is gaining traction as a minimally invasive approach recently. We describe the key steps of an EEA ON decompression. The relevant surgical anatomy with illustration is described. Additionally, a video detailing our technique and instruments on an illustrative case is provided. Endoscopic endonasal approach ON decompression with a straight feather blade is a feasible, minimally invasive procedure to decompress the ON in the setting of anterior skull base mass lesions.

Anterior endoscopic sublabial transmaxillary access to middle cranial base lesions.

Anterior endoscopic access to middle cranial base lesions becomes feasible in the presence of infratemporal fossa (ITF) involvement. Various approaches, including endoscopic endonasal, transoral sublabial, and transorbital methods, have been described for accessing the ITF through a transmaxillary corridor. Among these approaches, endonasal access is the most commonly preferred, while the transorbital approach is a novel technique gaining popularity. The transoral sublabial approach is considered suitable for selected lesions. Patients who underwent the anterior endoscopic transoral/sublabial transmaxillary approach to middle cranial base lesions at a single institute from 2016 to 2023 were included in this retrospective study. Malignant lesions were excluded from the study. The sublabial approach was exclusively performed in all cases, with the exception of one patient who required a combined approach. The anterior endoscopic transoral sublabial transmaxillary approach to the infratemporal fossa, upper parapharyngeal space, and middle cranial fossa was performed on 14 patients. The underlying conditions for these patients were as follows: trigeminal schwannomas (n = 8), meningiomas (n = 2), juvenile nasopharyngeal angiofibroma, osteochondroma, arachnoid cyst and encephalocele (n = 1 each). Gross total resection was achieved in 11 cases. The most common complication was numbness in the territory of the maxillary and mandibular nerves (n = 4). Two patients needed endoscopic maxillary antrostomy for persistent suppuration. No wound problems or CSF rhinorrhea occurred. The average follow-up time was 26.6 months. The endoscopic sublabial transmaxillary approach provides direct access to the infratemporal fossa and middle cranial base, enhancing the surgical range of maneuverability while sparing the sinonasal cavity. This procedure is safe, less invasive, and could be used as an efficient corridor for the resection of selected infratemporal fossa lesions with or without extension to the middle cranial base and parapharyngeal space.

Visual outcomes in tuberculum sellae meningiomas comparing transcranial and endoscopic endonasal approaches

Tuberculum sellae meningiomas (TSM) account for 3-10% of intracranial meningiomas. Visual loss is the presenting symptom in up to 80% of cases. Surgical management poses a great challenge due to tumor proximity to neurovascular structures such as the optic nerve and the internal carotid artery (ICA); hence, there is controversy regarding the optimal approach. The aim of this study is to determine differences in visual outcomes between transcranial (TCA) and endoscopic endonasal (EEA) approaches. A retrospective study including 29 patients with TSM surgically treated by TCA or EEA between 2011 and 2023 in a single referral center was conducted. Pre-and post-operative neuro-ophthalmologic evaluations, focusing on visual acuity and campimetry, were evaluated. Sixteen (55.16%) patients were intervened through a TCA and the remaining 13 (44.84%) via an EEA. The lesions in each group were similar in terms of pre- operative volume (15.12 vs 12.9cm3, p=0.497) and neurovascular invasion (optic canal invasion 48.26 vs 41.37%, p=0.664; ICA 44.81 vs 31.03%, p=0.797). There were no significant differences in visual outcomes between both approaches; TCA presented an improvement of 5.18 points in visual fields (p=0.140), whereas EEA had an improvement of 17.39 points in visual acuity (p=0.114). EEA seems to offer greater improvement in visual acuity than TCA. However, the ideal approach should be individualized; taking into account the tumor's volume and invasiveness, as well as the patient's visual complaints.

Combined simultaneous endoscopic endonasal and transcranial surgery using high-definition three-dimensional exoscope for malignant tumors of the anterior skull base.

Advanced surgical interventions are required to treat malignancies in the anterior skull base (ASB). This study investigates the utility of endoscopic endonasal and transcranial surgery (EETS) using a high-definition three-dimensional exoscope as an alternative to traditional microscopy. Six patients with carcinomas of varying histopathologies underwent surgery employing the EETS maneuver, which synchronized three distinct surgical modalities: harvesting of the anterolateral thigh flap, initiation of the transnasal technique, and initiation of the transcranial procedure. The innovative strategy enabled successful tumor resection and skull base reconstruction without postoperative local neoplastic recurrence, cerebrospinal fluid leakage, or neurological deficits. The integration of the exoscope and EETS is a novel therapeutic approach for ASB malignancies. This strategy demonstrates the potential of the exoscope in augmenting surgical visualization, enhancing ergonomics, and achieving seamless alignment of multiple surgical interventions. This technique represents a progressive shift in the management of these complex oncological challenges.

The role of endoscopic endonasal salvage surgery in recurrent or residual craniopharyngioma after a transcranial approach: a systematic review.

The management of craniopharyngiomas is challenging due to their high rate of recurrence following resection. Excision of recurrent tumors poses further surgical challenges due to loss of arachnoidal planes and adherence to anatomical structures. The endoscopic endonasal approach (EEA) offers a favorable alternative to transcranial approaches for primary craniopharyngiomas. However, the safety and efficacy of EEA for recurrent tumors, specifically after a prior transcranial approach, needs further investigation. We performed a systematic review using PubMed to develop a database of cases of recurrent craniopharyngiomas previously treated with a transcranial approach. Fifteen articles were included in this review with a total of 75 cases. There were 50 males and 25 females with a mean age of 38years (range 2-80). One prior transcranial surgery was done in 80.0% of cases, while 8.0% had two and 12.0% had more than two prior surgeries. Radiotherapy after transcranial resection was given in 18 cases (24.0%). Following EEA, vision improved in 60.0% of cases, and vision worsened in 8.6% of the cases. Of cases, 64.4% had pre-existing anterior hypopituitarism, and 43.8% had diabetes insipidus prior to EEA. New anterior hypopituitarism and diabetes insipidus developed in 24.6% and 21.9% of cases, respectively following EEA. Gross total resection (GTR) was achieved in 64.0%, subtotal resection in 32.0%, and partial resection in 4.0% revision EEA cases. GTR rate was higher in cases with no prior radiotherapy compared to cases with prior radiotherapy (72.0% vs 39.0%, p = 0.0372). The recurrence rate was 17.5% overall but was significantly lower at 10.0% following GTR (p = 0.0019). The average follow-up length was 41.2months (range, 1-182months). The EEA can be utilized for resection of recurrent or residual craniopharyngiomas previously managed by a transcranial approach.

Analysis of visual impairment score in a series of 48 tuberculum sellae meningiomas operated on via the endoscopic endonasal approach.

Tuberculum sellae meningioma (TSM) represents a complex skull base tumor. The primary goals of surgical treatment are represented by maximal safe resection and visual recovery; therefore, appropriate patient selection is critical to optimize results. In the last 2 decades, the endoscopic endonasal approach (EEA) has appeared as a successful and viable strategy for the management of these tumors. The authors identified preoperative factors associated with extent of resection and visual outcome after EEA for TSM. In this retrospective cohort study, the authors analyzed patients who underwent extended endoscopic endonasal surgery for TSM between January 2005 and April 2022 at the Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy. Tumor size, vessel encasement, and optic canal involvement were classified according to University of California, San Francisco, score. Visual acuity and visual fields were analyzed according to the visual impairment score (VIS), defined as a four-level classification: grade 1 (VIS 0-25), grade 2 (VIS 26-50), grade 3 (VIS 51-75), and grade 4 (VIS 76-100). Ophthalmological functions were tested preoperatively and during the early postoperative period (within 6 months after surgery) and late postoperative period. A total of 48 patients were enrolled. Forty-one (85.4%) patients experienced blurred vision or visual field defect as a presenting sign. Gross-total resection was achieved in 40 (83.3%), near-total resection in 2 (4.2%), and subtotal resection in 6 (12.5%). Visual defect improved in 82.9% (34/41) of cases, 12.2% (5/41) had no significant changes, and 2.4% (1/41) had worsened visual defect. The mean change in VIS was 42% (95% CI 58.77-31.23). Visual outcome was poorer when preoperative VIS (VIS-pre) was greater than 25 (p = 0.02). Six postoperative CSF leaks occurred (12.5%), and 1 patient (2.1%) required revision surgery. The EEA is a safe and effective approach for TSM removal, with the advantage of preserving optic apparatus vascularization, and can promote gross-total resection and visual improvement. The authors have defined four categories based on VIS that relate to postoperative outcome: the lower the VIS-pre, the higher the rate of postoperative VIS improvement. This finding may be useful for predicting a patient's visual outcome at the preoperative stage.

Marsupialization as an alternative to reconstruction in endoscopic skull base surgery. How I do it

BackgroundTo treat extradural solid-cystic lesions of the ventral skull base, a pedicled nasoseptal flap (NSF) maintains patency of the marsupialized cavity and prevents restenosis and cyst recurrence.MethodsThe authors provide a step-by-step description of the surgical technique valid in different lesions of the skull base, all treated via the endoscopic endonasal approach (EEA). The application is demonstrated by an operative video.ConclusionIn selected lesions, endoscopic marsupialization using an NSF ensures drainage and ventilation of the surgical cavity. Re-epithelialization provided by a pedicled flap is a viable alternative to multilayer skull base reconstruction.

Clinical and Surgical Outcomes of Endoscopic Endonasal Approach for Giant Pituitary Adenomas: Analysis of Predictive Factors

Giant pituitary adenomas (GPAs) are defined as tumors with ≥40mm in any maximum diameter, and these tend to invade multiple intracranial compartments. Hence, treatment remains a surgical challenge. To describe the clinical and surgical outcomes of the endoscopic endonasal approach (EEA) for GPA in a pituitary referral center in Latin America and to analyze associated predictive factors. 37 patients with histologically-confirmed GPA treated solely through the EEA between a 2-year period were included. Preoperative and postoperative clinical and neuroimaging findings; surgical morbidity and mortality; and binary logistic regression analysis to assess predictive factors were analyzed. Preoperative visual impairment prevalence was 97.3%. Mean tumor volume was 32cc and gross total resection rate was 40.5%. Favorable visual acuity and visual fields outcome rate was 75% and 82.9%, respectively. In the multivariate analysis, bilateral cavernous sinus invasion (P= 0.018) and postoperative cerebrospinal fluid (CSF) leak (P= 0.036) were associated with an unfavorable visual acuity outcome, while radiation therapy (P= 0.035) was for visual fields. Similarly, intraoperative CSF leak was a predictive factor for postoperative CSF leak (10.8%) (P= 0.042) and vascular injury (13.5%) (P= 0.048). In this first Mexican clinical series, we demonstrated that the EEA is a safe and effective technique for GPA, although early diagnosis and prompt intervention may promote further visual function preservation without significant endocrine morbidity.

Endoscopic Endonasal Transsphenoidal Transcavernous Transoculomotor Triangle Approach for Resection of an Invasive Pituitary Adenoma Extending Into the Parapeduncular Space Through the Cavernous Sinus.

A subset of invasive pituitary adenomas invade not only the medial wall of the cavernous sinus but can progress superiorly through the cavernous sinus roof at the oculomotor triangle and reach the subarachnoid parapeduncular space. We describe a series of 2 of 3 cases where an endoscopic endonasal approach was used to reach the parapeduncular space through the oculomotor triangle for tumor decompression. Images of the third case are presented. Case 1: We present a 2-dimensional surgical video of a recurrent corticotroph adenoma post gamma knife radiotherapy which was invading the left cavernous sinus and extending into the left parapeduncular space. Histopathological examination revealed densely granulated corticotrophin adenoma. The patient had reduction in the serum cortisol level postoperatively and was induced into remission medically. Postoperative third nerve palsy recovered partially, and sixth nerve palsy recovered completely at the 3-month follow-up. Case 2 : A case of recurrent silent corticotrophin adenoma invading the right parapeduncular space through the right cavernous sinus was operated through the same approach as case 1. Only a subtotal excision of the tumor in the cisternal space was possible. The patient developed a complete right third cranial palsy in the immediate postoperative period with near total recovery at the 6-month follow-up. Endoscopic endonasal approach to the parapeduncular space through a transcavernous transoculomotor route is reasonably safe and effective, as long as key anatomic landmarks and structures are identified and preserved while using natural tumor corridors to achieve tumor clearance.

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.

Management of frontoethmoidal osteoma causing pneumocephalus and cerebrospinal fluid leakage with minimally invasive techniques: illustrative cases.

Osteoid osteoma is a common benign bone tumor frequently seen in the frontoethmoid region. However, involvement of the skull base is rare, with few cases previously reported. The authors report two cases of spontaneous, symptomatic frontoethmoidal osteoma: one presented with neurological deficit secondary to tension pneumocephalus and the other with cerebrospinal fluid leakage. The first case was managed with a transfrontal sinus craniotomy and pneumocephalus decompression with osteoma resection and skull base reconstruction. The second case was managed with a uninaral endoscopic endonasal approach to the anterior skull base with osteoma resection and reconstruction. Given the paucity of cases with associated tension pneumocephalus described in the literature, it was relevant to describe the authors' experience with surgical decision-making and the expected outcomes among patients with this pathology when using minimally invasive techniques.