Endoscopic Endonasal Approach For Resection Research Articles

Endoscopic endonasal approach for resection of odontoid process, decompression of the cervicomedullary junction spinal cord, and resection of pannus.

Odontoid pannus is an abnormal collection of degenerative or inflammatory tissue on the C1-dens joint that can result in severe spinal cord compression myelopathy. Treatment options vary depending on severity and etiology. In cases of severe cord compression, surgical management could be either through a purely posterior approach or in combination with an anterior decompression via endoscopic endonasal approach (EEA). This case presents a 77-year-old female who underwent posterior cervical fixation for odontoid pannus causing dramatic cervical myelopathy who failed to improve over a 6-month period and required anterior transodontoid pannus resection and decompression via EEA. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23176.

Combined Transcranial and Endoscopic Endonasal Approach for Resection of a Complex Sinonasal Squamous Cell Carcinoma: Two-Dimensional Operative Video.

Sinonasal squamous cell carcinoma (SCC) is a rare head-and-neck neoplasm that has a propensity to locally invade vital structures. Currently, the combination of surgical resection and radiation remains the optimal treatment. 1 However, the extent of disease burden and involvement of surrounding anatomy may make these inoperable. Here, we demonstrate the successful application of multidisciplinary approach for surgical resection of a large, complex SCC lesion centered at the superior nasal cavity with extension into the eye orbits and brain. A two-step approach was performed; transcribiform, endoscopic piecemeal resection with reconstruction of the skull base, followed by a bifrontal craniotomy. Reconstruction was achieved using an inlay of DuraMatrix allograft (Stryker Inc., Kalamzoo, Michigan, United States) followed by an inlay of AlloDerm (Allergan Inc., Irvine, California, United States), anchored anteriorly and posteriorly with wide wings placed over the respective orbital roofs. Major steps include (1) a summary of the patient presentation and preoperative imaging, (2) resection of the tumor endonasally, (3) resection of the tumor intracranially from a bifrontal craniotomy, and (4) a review of the postoperative imaging. The patient tolerated the procedure ( Fig. 1 ) well, returned to his baseline with no new neurologic deficits, and was placed on 6-week antibiotics regimen for osteomyelitis discovered during the operation. Approximately, 2 months after discharge, the patient unfortunately returned with altered mental status, was found to have sepsis, and expired shortly thereafter. This operative video illustrates the technical steps and capabilities of surgical treatment, achieving near-complete gross total resection of a complex SCC lesion using a multidisciplinary approach. The link to the video can be found at: https://youtu.be/8ffckKIuBzM .

Perioperative Tranexamic Acid for ACTH-Secreting Pituitary Adenomas: Implementation Protocol Results and Trial Prospectus

Primary resection of adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma has become a front-line standard-of-care treatment for Cushing disease. However, surgical intervention can be challenging because of elevated blood pressure, as well as direct cortisol impacts on endothelial cells, vascular permeability, and tissue friability-potentially resulting in increased intraoperative bleeding. Tranexamic acid (TXA) is a well-studied, widely used intravenous hemostatic; however, the potential benefit during resection of ACTH-secreting pituitary adenoma is unstudied. The purpose of this study was to define an institutional protocol for perioperative administration of TXA in patients undergoing endoscopic endonasal approach for resection of ACTH-secreting pituitary adenoma, and to study the implementation of our novel protocol in a prospective fashion. Criteria for preoperative TXA were defined by age, medical history, and risk factors. Descriptive statistics were reported for all patients receiving perioperative TXA. Thirty patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus in 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg/hour for the duration of the procedure. No incidence of myocardial infarction or postoperative thromboembolic events were noted. Subjective assessments indicated satisfaction with the patient selection protocol, and meaningful reduction in the extent of intraoperative bleeding. Perioperative TXA represents a potentially efficacious approach for control of intraoperative bleeding during endonasal resection of ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously.

Endoscopic Endonasal Approach for Resection of Suprasellar Hemangioblastoma: Selective Pituitary Sacrifice and Use of Indocyanine Dye: 2-Dimensional Operative Video.

Suprasellar hemangioblastomas are rare lesions occurring sporadically or more commonly with von Hippel Lindau disease (VHLD).1,2 A 27-yr-old female presented with amenorrhea, mildly raised prolactin levels and otherwise normal pituitary function, homonymous hemianopia, and mild cognitive decline. Imaging revealed a large suprasellar lesion arising from the infundibulum, causing compression of optic chiasm with edema in the visual pathways. Lesion appeared hypervascular with prominent feeding vessels from the internal carotid arteries bilaterally. To access these vessels derived from the superior hypophyseal arteries and allow early devascularization, endoscopic endonasal approach was performed.3 Stalk preservation was deemed unlikely. After opening of the suprasellar dura, indocyanine dye allowed early identification of the feeding vessels. They were sequentially sacrificed, allowing early devascularization while preserving the normal blood supply to the optic chiasm from the superior hypophyseal arteries. Pituitary gland and stalk were removed with the latter being completely involved by tumor to provide access to the retroclival region and posterior circulation. After opening of the dura underlying the dorsum sella, inferior pole of the tumor was exposed with blood supply identified from the posterior communicating arteries but not the basilar or posterior cerebral arteries. Devascularized lesion was safely removed from the optic apparatus, hypothalamus, and the third ventricle. Histology was consistent with hemangoblastoma (VHLD negative). Patient's cognitive and visual function normalized with a postoperative magnetic resonance imagingdemonstrating complete resection, no ischemic events on diffusion-weighted imaging, and resolution of the edema in the hypothalamus and visual pathways.1 She was started on desmopressin and replacement therapy for pituitary function. The patient consented to the procedure. Patient provided consent for publication.

Commentary: Endoscopic Endonasal Approach for Resection of Suprasellar Hemangioblastoma: Selective Pituitary Sacrifice and Use of Indocyanine Dye: 2-Dimensional Operative Video.

Commentary: Endoscopic Endonasal Approach for Resection of Suprasellar Hemangioblastoma: Selective Pituitary Sacrifice and Use of Indocyanine Dye: 2-Dimensional Operative Video.

Significance of the simultaneous combined transcranial and endoscopic endonasal approach for prevention of postoperative CSF leak after surgery for lateral skull base meningioma

Lateral skull base meningiomas, particularly sphenoorbital meningiomas, sometimes extend extremely widely into adjacent structures including the paranasal sinuses. For endonasal skull base reconstruction using a vascularized nasoseptal flap for prevention of postoperative cerebrospinal fluid (CSF) leak, the simultaneous combined transcranial and endoscopic endonasal approach was applied for resection of these extensive tumors. We performed a retrospective review of four patients treated with the simultaneous combined transcranial and endoscopic endonasal approach for resection of lateral skull base meningiomas. Preoperative characteristics, tumor extent, extent of resection, complications, and postoperative outcomes were analyzed. The tumor extended into the paranasal sinus, infratemporal fossa, and pterygopalatine fossa in all patients. Extracranial extension into the cavernous sinus or superior orbital fissure was detected in two and three patients, respectively. In one patient without extension into the cavernous sinus and superior orbital fissure, gross total resection was achieved, whereas in the other three patients, subtotal resection was performed, and small residual masses of the tumor remained in the cavernous sinus or superior orbital fissure to minimize the risk of postoperative ocular nerve damage. No patients experienced postoperative CSF leak. The simultaneous combined transcranial and endoscopic endonasal approach is useful for a subgroup of patients with lateral skull base meningiomas for prevention of postoperative CSF leak. Particularly in recurrent cases in which vascularized flaps from the transcranial side are likely unavailable due to prior tumor resection, this combined approach is worth considering depending on tumor extension into the paranasal sinus.

The expanded endoscopic endonasal approach for suprasellar meningiomas: long-term outcomes in a single-center series of 27 patients.

The endoscopic endonasal approach (EEA) has become increasingly employed in the treatment of suprasellar meningiomas. These tumors often cause visual symptoms due to compression of the anterior visual pathway. We aimed to examine long-term visual outcomes after EEA for optic nerve decompression and resection of suprasellar meningioma at our center, and to identify preoperative factors predictive of postoperative visual improvement. We performed a retrospective cohort study on 27 patients who underwent the EEA for resection of meningiomas extending into the suprasellar cistern and decompression of anterior visual pathway between January 1, 2005, and March 1, 2019. We treated 8 male and 19 female patients, with a mean follow-up of 7.6 years. The mean age of our patients at initial presentation was 60.1 years. Eighteen patients (66.7%) presented with visual acuity deficits, and 12 (44.4%) patients presented with visual field deficits. Postoperatively, 11 patients had improved visual acuity, 6 had stable visual acuity, and 1 patient had slow and progressive decline of visual acuity; 5 patients had improved visual field, 6 had stable visual field, and 1 patient had slow and progressive decline in visual field. Patients less likely to have postoperative improvement of visual acuity were those with longer than 6-month duration of visual symptoms (P = 0.024*) as well as patients with the presence of a relative afferent pupillary defect (RAPD) (P = 0.023*). The EEA can achieve good visual outcomes in patients harboring suprasellar meningiomas. Symptom duration of less than 6 months and lack of a RAPD were positive predictors of postoperative visual acuity.

Endoscopic endonasal approach for resection of pediatric chordoma with brainstem invasion.

A 14-year-old boy had undergone an orbitozygomatic craniotomy for a pontine lesion. There was growth on surveillance imaging with involvement of posterior clinoids, clivus, and left pons suggestive of chordoma (Fernandez-Miranda et al., 2014b). An endoscopic endonasal approach was undertaken involving full upper and midclival exposure including bilateral posterior clinoidectomy (Fernandez-Miranda et al., 2014a; Truong et al., 2019a, 2019b). The internal carotid artery was skeletonized to maximize exposure and facilitate safe resection. The tumor was removed from between the dural layers of the midclivus while preserving the interdural abducens nerve (Barges-Coll et al., 2010). The brainstem component was resected while preserving the pontine perforators. Postoperative diagnosis was chordoma with MRI demonstrating complete resection. The patient was intact postoperatively.The video can be found here: https://youtu.be/g6SQ5JVK0Ko.

Expanded Endoscopic Endonasal Approach for Resection of Intradural Chordoma: Surgical and Anatomic Nuances: 2-Dimensional Operative Video.

The expanded endoscopic endonasal approach (EEA) has been growing as a surgical alternative for the treatment of clival chordomas because of their frequent midline location and bone erosion. The endoscopic transclival approach provides with a safer and more direct anatomic route for tumors located predominantly in the midline contributing to minimize postoperative comorbidities. In this video, we demonstrate the step-by-step technique for resection of such challenging clival pathology. This is an operative video of an extended endoscopic resection of a clival chordoma with stepwise description of the surgical technique. We present the case of a 49-yr-old man in whom, incidentally in the context of low testosterone level, a clival lesion with purely midline location with intradural extension into the ventral brainstem and occupation of the left cerebellopontine angle was discovered. The patient was submitted to an expanded endoscopic transclival approach and a macroscopic gross total resection was successfully achieved. The final pathology was compatible with a conventional chordoma. This video details the surgical anatomy of the clival region to facilitate the identification of surgical landmarks and anatomic boundaries with the goal of avoiding injury to the neurovascular structures involved in this approach. Extended endoscopic transclival surgery is a useful and safer option for the management of midline chordomas because it provides with a dissection corridor free of major neurovascular structures. Endoscopic techniques are associated with good outcomes in terms of macroscopic gross total resection and low surgical risks in these selected tumors.

Endoscopic endonasal surgery for Clival Chordomas – a single institution experience and short term outcomes

Purpose: Clival Chordomas are locally aggressive tumours which pose a significant treatment challenge. Endoscopic endonasal approach for clival chordomas is correlated with higher resection rates and lower morbidity rates in comparison to open approaches. We present our initial single institution experience and short-term patient outcomes following endoscopic endonasal approach for resection of clival chordomas.Materials and methods: This is a retrospective analysis of ten patients undergoing endoscopic endonasal approach for clival chordomas in our neurosurgical unit over a 6 year period between August 2010 and September 2016. The procedures were performed using two surgeons, four hands, binostril endoscopic endonasal approach with a Karl Storz® endoscope and intraoperative BrainLab® image guidance.Results: Overall 15 endoscopic endonasal approach resections of clival chordoma were performed in 10 patients with median follow up period of 39.5 months (range 9–76). Gross total resection was achieved in 4 cases (40%), near total resection in 4 cases (40%) and subtotal resection in 2 cases (20%). 5 cases (50%) required revision resections. Cerebrospinal fluid leak occurred in 2 patients. 1 case of meningitis occurred in a patient with revision surgery. There were no new neurological deficits post operatively with 3 patients demonstrating resolution of diplopia post operatively. No recurrence occurred following gross total resection. 1 out of 4 cases of near total resection showed evidence of progression during the follow up period. Both cases of subtotal resection demonstrated evidence of progression with one dying of unrelated cause during the follow up period.Conclusion: Endoscopic endonasal approach represents a safe technique for debulking and resection of clival chordomas. Due to the rarity of clival chordomas, it is important that patients with this pathology are managed in high volume skull base centres where a multi-disciplinary team approach is available.

Utilization of the Nasoseptal Flap for Repair of Cerebrospinal Fluid Leak after Endoscopic Endonasal Approach for Resection of Pituitary Tumors.

BackgroundOne of the most frequent complications after endoscopic endonasal approach (EEA) for resection of pituitary tumors is cerebrospinal fluid (CSF) leaks. With the introduction of the pedicled nasoseptal flap, the reconstruction of the skull base has improved significantly resulting in a decrease in the occurrence of persistent CSF leaks. We present our experience utilizing the pedicled nasoseptal flap technique after EEA for reconstruction of the skull base in cases where CSF leak was detected.MethodsData for patients undergoing EEA for pituitary tumors was retrospectively reviewed. These included demographic, clinical, operative, radiographic, and pathological information. Incidence of post-operative complications and CSF leaks were recorded. Descriptive statistical analysis was performed.ResultsBetween 2008 and 2015, 67 patients and 69 hospital admissions with pituitary tumors underwent a nasoseptal flap to reconstruct a skull base defect at Johns Hopkins Hospital. The mean age at surgery was 54.5±14.2 years. Fifty-two percent of patients were male. Forty-six percent of patients were white, 33% African-American, and 12% belonged to other racial groups. There was an intraoperative CSF leak in 39% of patients. Seventy percent of patients with an intraoperative CSF leak had a nasoseptal flap reconstruction of the skull base. There were zero postoperative CSF leaks.ConclusionWith the introduction of the pedicled nasoseptal flap for reconstruction of the skull base after EEA for resection of pituitary adenomas, the incidence of postoperative CSF leaks has decreased significantly. In this retrospective analysis, we demonstrate the effectiveness of the use of nasoseptal flap in repairing CSF leak after EEA.

Predictors of Cerebrospinal Fluid Leaks in Endoscopic Surgery for Pituitary Tumors

<i>Background</i>: Cerebrospinal fluid (CSF) leak is a serious complication of endoscopic endonasal surgery for pituitary adenoma; leading to a more serious and financial burden of the surgery. Prediction of the occurrence of such sequale and proper plaining for reconstruction can reduce its prevalence and associated morbidities. <i>Purpose</i>: To determine the predictors and risk factors associated with intra/and postoperative cerebrospinal fluid (CSF) leaks in endoscopic endonasal pituitary surgery. Methods: A retrospective study included 150 patients who underwent endoscopic endonasal approach for resection of pituitary adenomas between 2015 and 2018. We analyzed the association between CSF leaks (intra/post-operative) and perioperative variables including patients’ demographic data, medical comorbidities, tumor characteristics and operative data (rates of intraoperative leak, reconstructive techniques). <i>Results</i>: 34 patients (22.6%) out of the 150 patients had an overall, CSF leak: 26 (76.5%) patients had intraoperative leaks; 5 patients out of them continued to have a postoperative leak. 8 patients (23.5%) had postoperative leak. Based on multiple logistic regression model analysis; increased body mass index (BMI), associated hydrocephalus, suprasellar extension and recurrent tumors had a significant association with intraoperative CSF leaks, while only BMI and hydrocephalus predicted postoperative CSF leaks. <i>Conclusion</i>: Elevated BMI, suprasellar extension of the tumor, recurrence or previous radiation are all important risk factors that have been proved in this study to have statistically significant association with the incidence of CSF leak. In high risk patients for CSF leakage: adequate reconstruction planis advised to avoid such morbidity.

Endoscopic endonasal surgery for epidermoid and dermoid cysts: a 10-year experience.

OBJECTIVEEpidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of endoscopic endonasal approaches for resection of these tumors has been rarely reported.METHODSThe authors retrospectively reviewed the medical records of 21 patients who underwent endoscopic endonasal surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.RESULTSTotal resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0.008 and 0.0005, respectively). In the whole series, surgical complications were seen in 6 patients (28.6%). No complications were observed in patients with extradural cysts. Among the 15 patients with intradural cysts, the most common surgical complication was postoperative CSF leak (5 patients, 33.3%), followed by postoperative intracranial infection (4 patients, 26.7%). Larger cysts and postoperative CSF leak were associated with intracranial infection (p = 0.012 and 0.028, respectively). Subtotal resection was marginally associated with intracranial infection when compared with total resection (p = 0.091). All patients with neurological symptoms improved postoperatively with the exception of 1 patient with unchanged abducens nerve palsy.CONCLUSIONSEndoscopic endonasal approaches may be effectively used for resection of epidermoid and dermoid cysts in carefully selected cases. These approaches are recommended for cases in which a total or near-total resection is possible in addition to a multilayer cranial base reconstruction with vascularized tissue to minimize the risk of intracranial infection.

Endoscopic Endonasal Approach for Resection of a Pediatric Craniopharyngioma: Operative Video and Technical Nuances.

We present a pediatric case of a retrochiasmatic craniopharyngioma in the suprasellar region with third ventricular extension that was resected through a purely endoscopic endonasal approach (EEA) via the transplanum transtuberculum corridor. The patient is a 12-year-old boy who presented with progressive visual loss and panhypopituitarism. The EEA allows direct visualization of the undersurface of the optic chiasm and hypothalamus so that safe and meticulous tumor dissection can be performed to preserve these critical neurovascular structures. This video atlas demonstrates the operative technique and surgical nuances of the endoscopic skull base approach, microdissection of the tumor from the critical neurovascular structures, and multilayered reconstruction of the skull base defect with a nasoseptal flap. A gross total resection was achieved, and the patient was neurologically intact with improved visual acuity and visual fields. In summary, the EEA via the transplanum transtuberculum corridor is an important strategy in the armamentarium for surgical management of pediatric craniopharyngiomas. The link to the video can be found at: https://youtu.be/bmgO_PMRHPk .

Clinical outcomes of an endoscopic transclival and transpetrosal approach for primary skull base malignancies involving the clivus.

OBJECTIVE The endoscopic endonasal approach for treating primary skull base malignancies involving the clivus is a formidable task. The authors hypothesized that tumor involvement of nearby critical anatomical structures creates hurdles to endoscopic gross-total resection (GTR). The aim of this study was to retrospectively review the clinical outcomes of patients who underwent an endoscopic endonasal approach to treat primary malignancies involving the clivus and to analyze prognostic factors for GTR. METHODS Between January 2009 and November 2015, 42 patients underwent the endoscopic endonasal approach for resection of primary skull base malignancies involving the clivus at 2 independent institutions. Clinical data; tumor locations within the clivus; and anatomical involvement of the cavernous or paraclival internal carotid artery, cisternal trigeminal nerve, hypoglossal canal, and dura mater were investigated to assess the extent of resection. Possible prognostic factors affecting GTR were also analyzed. RESULTS Of the 42 patients, 37 were diagnosed with chordomas and 5 were diagnosed with chondrosarcomas. The mean (± SD) preoperative tumor volume was 25.2 ± 30.5 cm3 (range 0.8-166.7 cm3). GTR was achieved in 28 patients (66.7%) and subtotal resection in 14 patients (33.3%). All tumors were classified as upper (n = 17), middle (n = 17), or lower (n = 8) clival tumors based on clival involvement, and as central (24 [57.1%]) or paramedian (18 [42.9%]) based on laterality of the tumor. Univariate analysis identified the tumor laterality (OR 6.25, 95% CI 1.51-25.86; p = 0.011) as significantly predictive of GTR. In addition, the laterality of the tumor was found to be a statistically significant predictor in multivariate analysis (OR 41.16, 95% CI 1.12-1512.65; p = 0.043). CONCLUSIONS An endoscopic endonasal approach can provide favorable clinical and surgical outcomes. However, the tumor laterality should be considered as a potential obstacle to total removal.

Clinical analysis of extended endoscopic endonasal approach for craniopharyngioma treatment

Objective To evaluate the efficacy and safety of extended endoscopic endonasal approach for resection of craniopharyngiomas. Methods The clinical data of 32 patients with craniopharyngiomas undergoing extended endoscopic endonasal surgery at Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University between November 2014 and May 2016 were analyzed retrospectively. The visual improvement, extent of resection and surgical complications were evaluated. Results The gross total resection (GTR) rate was 69% (22/32), near-total resection (> 95% of tumor removed) was 25% (8/32), and subtotal resection (≥ 80% of tumor removed) was 6% (2/32). Overall, 28 patients presented with visual impairment. In 86% (24 patients) of them, visions were improved or even recovered to normal following surgery. Worsening of the anterior pituitary function was reported in 53% (17 patients) of all, and there were 12 new cases (48% of 25) of postoperative diabetes insipidus. Thirteen (41%) patients had hyposmia and 3 (9%) patients developed severe hypomnesia after surgery. CSF leakage and secondary meningitis occurred in 1 (3%) patient postoperatively. One (3%) patient had brainstem hemorrhage after surgery. The follow-up lasted 4-22 months. No tumor recurrence was identified by MRI examination, and one patient died. Conclusions The extended endoscopic endonasal approach for craniopharyngiomas seems generally effective and safe with high GTR rate, which however could also cause damage of hypothalamic-pituitary axis. Thus, continuous attention should be paid to preservation of the endocrine function during surgical management of craniopharyngioma. Key words: Craniopharyngioma; Neuroendoscopy; Neurosurgical procedures; Treatment outcome; Extended endonasal approach

Endoscopic Endonasal Approach for Resection of Middle Fossa Encephalocele for Treatment of Refractory Temporal Lobe Epilepsy

Background: Epilepsy is one of the most common neurologic disorders and Temporal Lobe Epilepsy (TLE) is the most common type of focal onset epilepsy. TLE is more commonly associated with tumors, hemorrhage, scarring as a result of trauma history, and mesial temporal sclerosis. Anti-epileptic drugs (AEDs) are the mainstay of treatment in most cases but as many as one-third of patients will have medically refractory disease. Medically refractory epilepsy is an unusual presentation of cranial fossa dehiscence with resultant encephaloceles. Here we report a case series of medically refractory TLE secondary to a middle fossa encephalocele with the associated progression of electroencephalogram (EEG) and magnetic resonance imaging (MRI) findings.

Postoperative Management to Safely Discharge Pituitary Adenomas Home on Postoperative Day 1

Introduction: Endoscopic endonasal approach for resection of pituitary tumors is a well described technique. Traditionally patients were monitored for a prolonged period in house to identify postoperative complications and manage endocrinopathies. The objective of this study was to implement a safe algorithm in which patients can be discharged home on postoperative day 1 without increased morbidity or hospital readmission.

Advantages and limitations of endoscopic endonasal odontoidectomy. A series of nine cases

IntroductionTransoral odontoidectomy is the treatment of choice in cases of anterior bulbo-medullary compression. The development of endoscopic procedures has made it possible to perform odontoidectomy via a minimally invasive endoscopic endonasal approach. We discuss the feasibility, advantages, and limitations of this surgical approach. Materials and methodsWe report a two-center retrospective series of patients who underwent endoscopic endonasal odontoidectomy between September 2011 and February 2013. Preoperative characteristics, intraoperative data, clinical course, and postoperative complications were studied. The patients were followed for a minimum of 6 months. Cervico-occipital posterior fusion was performed during the same hospital stay in cases of preoperative instability. ResultsNine patients underwent decompressive odontoidectomy, for rheumatoid pannus in five cases and basilar impression in four cases. All had progressive neurological symptoms. Seven patients also underwent posterior fusion. In six patients, the C1 anterior arch was preserved. Decompression was achieved satisfactorily in all nine cases. The patients were able to resume oral feeding the day after the intervention. No patient required tracheostomy. We observed no dural fistulae or infectious complications. One patient died 2 months after the intervention of a pulmonary embolism. All patients improved in terms of their preoperative neurological status. ConclusionThis short series shows the feasibility of the endoscopic endonasal approach for resection of the dens. This approach allows optimal viewing when using angulated instrumentation and seems to result in low morbidity. In some cases, this approach makes it possible to preserve the C1 anterior arch, thus limiting the risk of cranial settling. LevelIV retrospective study.

The modified hemi-Lothrop procedure: A variation of the endoscopic endonasal approach for resection of a supraorbital psammomatoid ossifying fibroma

Tumors in the supraorbital region are most commonly accessed through transcranial approaches, including fronto-orbital, orbitozygomatic, and eyebrow supraorbital keyhole approaches. Purely endoscopic endonasal approaches (EEA) are more challenging to perform because of limitations in access and visualization for lateral extension beyond the midline corridor. The modified hemi-Lothrop procedure, a variation of an extended EEA, allows for binostril access and visualization of the lateral supraorbital region while preserving the contralateral frontal sinus drainage pathway. The operative technique and nuances are illustrated in a rare case of a supraorbital juvenile psammomatoid ossifying fibroma (JPOF) causing symptomatic orbital compression. The key components of the approach consisted of an endoscopic Draf IIB (left frontal sinusotomy) ipsilateral to the tumor, and a superior septectomy for binostril bimanual instrumentation. Excellent visualization, access, and tumor removal of the supraorbital region was achieved with angled endoscopy and curved instrumentation from the contralateral nasal cavity and through the septectomy window (“cross-court” trajectory). The modified hemi-Lothrop procedure with angled endoscopy is a safe and effective alternative route to traditional transcranial approaches to access the supraorbital region. To our knowledge, this is the first case of a supraorbital JPOF that was successfully resected via a purely EEA.