Endoscopic Skull Base Surgery Research Articles

PosESS-Study (Positioning in Endoscopic Skull Base Surgery): Semi-Sitting Versus Supine: Interim Analysis of a Randomized Controlled Trial

PosESS-Study (Positioning in Endoscopic Skull Base Surgery): Semi-Sitting Versus Supine: Interim Analysis of a Randomized Controlled Trial

Outcomes of Revision Endoscopic Endonasal Skull Base Surgery for Recurrent or Residual Nonfunctioning Pituitary Adenomas: An Analysis of 100 Consecutive Patients

Outcomes of Revision Endoscopic Endonasal Skull Base Surgery for Recurrent or Residual Nonfunctioning Pituitary Adenomas: An Analysis of 100 Consecutive Patients

Dimensions of the Sphenoid and Ethmoid Sinuses on Computed Tomography: Clinical Implications and Role in Sex Determination

Background: The measurements of the sphenoid and ethmoid sinuses (ESs) are essential in forensic investigations and during endoscopic sinus and skull base surgeries. This study aimed at assessing the dimensions of these sinuses and elucidating their role in sex determination. Materials and Methods: This retrospective assessment was conducted using brain-computed tomographic images stored in the Department of Radiology in a Tertiary hospital in Delta State, Nigeria. After institutional ethical approval, images of 292 patients (115 females and 177 males) aged >20 years, were used to measure the dimensions of the ethmoid and sphenoid sinuses (SSs) bilaterally. These were analyzed and summarized using descriptive statistics. Their association with gender, side, or age was assessed using inferential statistics and considered statistically significant at P < 0.05. Discriminant function analysis of the sinus measurements was conducted to evaluate their accuracy in correct sex prediction. Results: Both sphenoid and ESs showed significant sexual dimorphism. The ESs showed significant asymmetry (P < 0.05). The anterior width of the left ES (79.8%) was the best sex-discriminating variable. The combination of the left sinus dimensions was more accurate (74.3%, 85.3%) than the right sinuses (72.6%, 81.2%) in sex allocation. Using the bilateral ES dimensions yielded a higher accuracy (89.0%) than using bilateral SS parameters (80.1%). Conclusion: The sphenoid and ESs may be used in predicting the sex of an unknown skull bone recovered within the studied population with acceptable accuracy levels.

Long term outcome following endoscopic skull base surgery for craniopharyngioma resection

Long term outcome following endoscopic skull base surgery for craniopharyngioma resection

Limitations Of Endoscopic Ventral Skull Base Surgery: A Series Of Eleven Challenging Cases And Review Of Literature-A Retrospective Study

Background: The surgical outcome in different pathologies of skull base has significantly improved with endoscopic endonasal approaches. As the grass is not always green on all side, there remains some limitations to endoscopic skull base surgery. In our paper we will discuss preoperative imaging of common pathologies amenable to endoscopic treatment, instrumentations, and limitations of skull base surgery. Retrospective analysis of the prospectively maintained records of the patients operated for skull base tumor was done between January 2016-Febuary 2019. Patients having skull base tumors irrespective of age, sex. Tumors found inoperable endoscopically after a panel discussion of Neurosurgeon, Neuro-otologist and Neuro-anesthesiologist. Patients who underwent endonasal endoscopic surgical excision at our centre. Results (Case description) Out of 383 skull base pathology patients operated through endoscopic endonasal approach between January 2016- February 2019, eleven(2.87%) patients of skull base tumours who were found inoperable endoscopically were included in our series. The limitations of endoscopic endonasal approach is shown in Table 1. We hereby discuss the technical nuances and details of each cases, in order to highlight the limitation of endo-nasal corridor Conclusion Although endoscopic trans-nasal surgery is emerging as popular alternative to microscopic surgery and replacing it fast, one should not become tool dependent. A lot of conditions still required microsurgical expertize and demand proper training and anatomical considerations. Every case must be approached on individualized basis. A proper pre-operative evaluation is key to success. Keywords: Limitations, endoscopic, ventral, skull base

Quality of Life Considerations in Endoscopic Endonasal Management of Anterior Cranial Base Tumors.

Considering quality of life (QOL) is critical when discussing treatment options for patients undergoing endoscopic endonasal skull base surgery (EESBS) for cancers at the base of the skull. Several questionnaires have been developed and validated in the last 20 years to explore QOL in this patient population, including the Anterior Skull Base Questionnaire, Skull Base Inventory, EESBS Questionnaire, and the Sino-Nasal Outcome Test for Neurosurgery. The Sino-Nasal Outcomes Test-22 and Anterior Skull Base Nasal Inventory-12 are other tools that have been used to measure sinonasal QOL in anterior cranial base surgery. In addition to pathology-related perturbations in QOL endoscopic surgical options (transsellar approaches, anterior cranial base surgery, and various reconstructive techniques) all have unique morbidities and QOL implications that should be considered. Finally, we look ahead to new and emerging techniques and tools aimed to help preserve and improve QOL for patients with anterior cranial base malignancies.

Evaluating Skull base Defect Reconstruction after Endoscopic Transsphenoidal Approach among Iraqi Patients

Background: Endoscopic skull base surgery is a well-established technique for the treatment of skull base pathologies. Once the resection is complete, reconstruction of the sellar floor is performed. Fat and fascia lata are used in an underlay fashion and then the dural sealant is placed over the repair. Aim of the study: The study aims to assess the reconstruction of skull base defects after trans sphenoidal endoscopic surgery. Patients and Methods: A total of 15 patients, 11 females & 4 males, were exposed to a cross-sectional study. The age of the participant ranged between 13 to 73 years old. The present work was carried out at Al-Hayat Private Hospital for the period starting from October 2017 to October 2021. All patients were followed up for at least 6 months' duration to assess the final outcome of the surgical operation. All the patients were informed of the aim of the study and they willingly agreed to participate; written consents were obtained from all of them. Results: No CSF leak happened postoperatively in the patients. In spite of the small group of patients in the study, it can be concluded that the way of reconstructing the skull base has been effective

Leukocyte-Rich and Platelet-Rich Fibrin for Skull Base Reconstruction After Endoscopic Endonasal Skull Base Surgery.

Postoperative cerebrospinal fluid (CSF) leak is one of the most common complications after endoscopic endonasal approach to the skull base. To analyze the effect of leukocyte-rich and platelet-rich fibrin (L-PRF) as part of a standardized endonasal skull base repair protocol on postoperative infection and CSF leak rate. One hundred three patients who underwent an endoscopic endonasal approach and were reconstructed using a standard technique (Group A) were compared with 139 patients using the same protocol with the addition of L-PRF (Group B). Postoperative intracranial infection and CSF leak at 6 months were analyzed. In patients with intraoperative CSF leak, postoperative leak occurred in 10.8% in Group A and 2.6% in Group B ( P .024), and in patients with intraoperative high-flow leaks, the incidences were 11.7% and 3.1%, respectively ( P .048). L-PRF reduced postoperative CSF leak by 76% in cases with intraoperative CSF leak (relative risk 0.24, 95% CI 0.06-0.87) and by 73% of patients with high-flow leak (relative risk 0.27, 95% CI 0.07-0.99). In patients undergoing surgery for diagnoses other than adenomas, there were no cases of postoperative leak in Group B, whereas in Group A occurred in 13.4% of those with intraoperative leaks ( P .047) and 15.8% with high-flow intraoperative leaks ( P .033). No significant differences were found in patients with pituitary adenoma. Meningitis occurred in 0.97% in Group A vs 2.16% in Group B ( P .639), without differences between subgroups. L-PRF reduced the rate of postoperative CSF leaks in patients with intraoperative leaks, without differences on postoperative meningitis.

The 100 Most Cited Articles in Endoscopic Endonasal Skull Base Surgery: A Bibliometric Analysis

The accelerated growth of endoscopic endonasal skull base surgery has led to an abundance of highly cited works that have helped shape the field into its current state. Highlighting these works can serve as a guide for trainees and facilitate evidence-based clinical decision making and operative techniques. Elsevier's Scopus database was used to generate a list of the 100 most cited articles on endoscopic endonasal skull base surgery in September 2022. Results were categorized based on pathology, approach, study design, and study objective. A citation per year analysis was conducted to highlight later publications that may not have had the time to accumulate as many citations as older publications. The average number of citations for the 100 most cited articles was 210 per article (range 104-1285). Publication dates ranged from 1997 to 2019, with the highest number of articles among the 100 most cited being published in 2008 (15 articles). The journal with the greatest number of publications was Neurosurgery (30 articles). Of the 100 most cited articles, 77 were published between 2000 and 2010. Moreover, 40 of the 100 articles reported surgical outcomes and related complications, and the most common pathology was pituitary adenoma (25 articles). This article provides a list of highly influential articles in the field of endoscopic endonasal skull base surgery, highlighting its rapid evolution over the last 3decades and demonstrating its leap from small descriptive series confined to certain pathologies to larger cohorts exploring possible boundaries and other pathologies.

Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review.

The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care.

Current Trends in Endoscopic Ear Surgery.

Current Trends in Endoscopic Ear Surgery.

Comparison of Graft Materials in Multilayer Reconstruction with Nasoseptal Flap for High-Flow CSF Leak during Endoscopic Skull Base Surgery.

Cerebrospinal fluid (CSF) leak is a crucial complication after endoscopic skull base surgery. Therefore, multilayer reconstruction with grafts is as essential as a reconstruction with pedicled flaps. Although widely used, the multilayer technique with autologous fascia lata has drawbacks, such as additional wound and donor site complications. We compared acellular dermal graft and banked homologous fascia lata graft (alternative grafts) with autologous fascia lata graft for high-flow CSF leak repair. We retrospectively enrolled 193 subjects who underwent endoscopic skull base reconstruction with multilayer fascial grafts and nasoseptal flap for high-flow CSF leaks from November 2014 to February 2020 at a single institution. Acellular dermal matrix (ADM), banked homologous fascia lata, and autologous fascia lata were used in 48 (24.9%), 102 (52.8%), and 43 (22.3%) patients, respectively. Postoperative CSF leaks occurred in 23 (11.9%) patients and meningitis in 8 (4.1%). There was no significant difference in postoperative CSF leak (p = 0.36) and meningitis (p = 0.17) across the graft groups. Additionally, we could not find out contributing risk factors for postoperative CSF leak and meningitis. ADM and banked homologous fascia lata are non-inferior to autologous fascia lata for endoscopic skull base reconstruction in water-tight reconstruction or safety without additional donor site morbidities.

Inflammatory endotype of odontogenic sinusitis.

Odontogenic sinusitis (ODS) is distinct from non-odontogenic rhinosinusitis with regard to clinical features as well as diagnostic and therapeutic approaches. While numerous studies have explored immune profiles of chronic rhinosinusitis, very few studies have explored the inflammatory endotype of ODS. Odontogenic sinusitis was diagnosed by confirming infectious sinusitis adjacent to infectious maxillary odontogenic pathology. Maxillary sinus cultures and mucosal biopsies were obtained during endoscopic endonasal surgery in ODS and control patients. Controls were patients undergoing endoscopic skull base surgery with no sinus disease. Specimens were snap frozen in liquid nitrogen and stored at -80°C. Analysis was performed using a multiplex assay to measure Th-1 (TNFα, IFNγ, IL-2,12,18), Th-2 (IL-4,5,9,13), Th-17 (IL-17A,17F,22), and innate (CCL5,CXCL9,CXCL10, IL-6,8,10,12,23,27) immune pathways. Groups were compared via independent sample t-tests; if assumptions were violated, nonparametric Wilcoxon ranked sum tests were performed. Specimens from 22 ODS patients were compared to nine controls. ODS mucosal tissue was sampled in the setting of the following dental pathologies: post-dental extraction (n=15), untreated apical periodontitis (n=2), apical periodontitis after root canal therapy (n=2), and maxillary sinus bone grafting with or without dental implantation (n=3). The following cytokines were significantly elevated in ODS compared to controls: IFNγ, TNFα, IL-6, 8, 10, 27, and CXCL9. IL-17 levels were similar in both ODS and controls. Therefore, ODS demonstrated heightened innate and Th1 immune activity. ODS demonstrated both innate immune and Th1 inflammatory endotypes. Further studies are needed to explore ODS immunopathobiology and its potential impact on ODS management.

An institutional analysis of the outcomes of endonasal endoscopic anterior skull base surgery

Endoscopic skull base surgery is an emerging surgical technique that recolonized the resection of skull base lesions. The present study analyzed the outcome of the endoscopic endonasal anterior skull base.A retrospective data review ofendoscopic endonasal anterior skull base surgeries performed from 2017 to 2022. Minimum follow-up was done 6 months postoperatively.: 63 cases of anterior skull base pathologies have been operated out of which 2 cases of meningioma, 3 cases of meningoencephalocele, 5 olfactory neuroblastoma, 18 angiofibroma extending till anterior skull base, 8 CSF rhinorrhea repair, 12 pituitary macroadenoma, 8 cerebral Mucormycosis and 7 sino-nasal mass with intracranial extension have been operated. Residual disease was left in 10 cases, the rest all the masses were completely removed. The overall complication rate was 28.6 percent. Three mortalities occur a few months post-operatively of which 2 were cerebral mucormycosis and one was sino-nasal malignancy with intracranial extension.Endoscopic endonasal anterior skull base surgeries are safe surgical procedure that provides a high degree of disease clearance and negligible complications.

A New Technique for the Endoscopic Reconstruction of Skull Base Defects Using Multiple-balloon Catheters.

Cerebrospinal fluid (CSF) leakage is a major complication following endoscopic endonasal skull base surgery. Various skull base reconstruction methods are available, and the use of a vascularized nasoseptal flap (NSF) in skull base reconstruction has greatly contributed to a decrease in the CSF leak rate. A balloon catheter such as a sinus balloon or a Foley catheter is often used to support an NSF; however, in cases wherein nasal and/or paranasal structures supporting the balloon are lacking following the surgery, the NSF is not properly fixed and postoperative CSF leak may occur. Here we introduce a new technique of using multiple-balloon catheters to fix an NSF in such cases and provide the results of our analysis of the new technique's efficacy. Eight patients who underwent endonasal endoscopic surgery for the following cases were included: olfactory neuroblastoma (n = 6), recurrent craniofacial meningioma (n = 1), and recurrent chordoma (n = 1). After tumor resection, multilayered reconstruction with vascularized NSF was performed. Given that the Foley catheter was not stable to fix the flap in each case, we used an additional nasal catheter to support the Foley catheter. No complications such as postoperative CSF leak and necrosis of the vascularized flap were observed. These results suggest that the multiple-balloon catheter technique is a useful method for fixing the NSF to the skull base even when nasal cavity structures are missing due to surgical removal.

Endoscopic Skull Base Surgery in Children

Endoscopic Skull Base Surgery in Children

Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus and Its Impact on Outcomes of Pituitary Surgery: A Systematic Review and Meta-Analysis.

Introduction. Pituitary adenomas have the potential to infiltrate the dura mater, skull, and the venous sinuses. Tumor extension into the cavernous sinus is often observed in pituitary adenomas and techniques and results of surgery in this region are vastly discussed in the literature. Infiltration of parasellar dura and its impact for pituitary surgery outcomes is significantly less studied but recent studies have suggested a role of endoscopic resection of the medial wall of the cavernous sinus, in selected cases. In this study, we discuss the techniques and outcomes of recently proposed techniques for selective resection of the medial wall of the cavernous sinus in endoscopic pituitary surgery. Methods. We performed a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and protocol and a total of 4 studies with 106 patients that underwent an endoscopic approach for resection of pituitary tumors with resection of medial wall from cavernous sinus were included. Clinical and radiological data were extracted (sex, mean age, Knosp, prior surgery, tumor size and type, complication rate, and remission) and a meta-analysis using the RevMan 5.4 software was performed. Results. A total of 5 studies with 208 patients were included in this analysis. The mean age of the study population was 48.87 years (range 25–82) with a female/male ratio of 1:1.36. Majority of the patients had Knosp Grade 1 (n = 77, 37.02%) and Grade 2 (n = 53, 25.48%). The complication rate was 4.81% (n = 33/106) and the most common complication observed was a new transient CN dysfunction and diplopia. Early disease remission was observed in 94.69% of the patients (n = 196/207). The prevalence rate of CS medial wall invasion varied from 10.4 % up to 36.7%. This invasion rate increased in frequency with higher Knosp Grade. The forest plot of persistent disease vs. remission in this surgery approach showed a p < 0.00001 and heterogeneity (I^2 = 0%). Discussion. Techniques to achieve resection of the medial wall of the cavernous sinus via the endoscopic endonasal approach include the “anterior to posterior” technique (opening of the anterior wall of the cavernous sinus) and the “medial to lateral” technique (opening of the inferior intercavernous sinus and). Although potentially related with improved endocrinological outcomes, these are advanced surgical techniques and require extensive anatomical knowledge and extensive surgical experience. Furthermore, to avoid procedure complications, extensive study of the patient’s configuration of cavernous ICA, Doppler-guided intraoperative imaging, surgical navigation system, and blunt tip knives to dissect the ICA’s plane are recommended. Conclusion. Endoscopic resection of the medial wall of the cavernous sinus has been associated with reports of high rates of postoperative hormonal control in functioning pituitary adenomas. However, it represents a more complex approach and requires advanced experience in endoscopic skull base surgery. Additional studies addressing case selection and studies evaluating long term results of this technique are still necessary.

Incidence of Sinus Inflammation After Endoscopic Skull Base Surgery in the Pediatric Population.

The extended endonasal approach has been utilized in the resection of anterior skull base lesions in the pediatric population. There are unique challenges to these patients in the post-operative setting, including patient compliance with medical therapy and post-operative debridements, and a smaller nasal airway that may increase propensity toward scarring. Our objective for this study is to evaluate the incidence of post-operative radiographic inflammation in this patient population using the Lund-Mackay (LM) score. A single-center, retrospective review of pediatric patients undergoing endoscopic approach to the skull base between 2009 and 2021 was performed. Demographic and clinicopathologic data and pre- and post-operative imaging were analyzed. One-way ANOVA followed by Tukey multiple pairwise comparisons statistical tests were used to compare mean LM scores between groups. Seventy-two patients (52 males, 20 females) were identified with a median follow-up of 27 months. All patients underwent an extended endonasal approach for resection of skull base lesions. The mean LM scores were compared between pre-operative MRI, first post-operative MRI > 30 days after surgery, and most recent post-operative MRI. One-way ANOVA was performed with significant differences noted between the groups (p < 0.001). Tukey multiple pairwise comparisons test was then performed and noted significant differences between the pre-operative and first post-operative LM (p < 0.0001) and the first post-operative and most recent LM (p < 0.0001). There was no significant difference noted between the pre-operative LM score and most recent LM score (p=0.14). Despite concerns regarding possible subsequent development of chronic rhinosinusitis following endoscopic skull base surgery in pediatric patients, the current study suggests that transient radiographic evidence of sinus inflammation can be seen up to six months postoperatively, which appears to resolve by approximately two years after surgery. 4 Laryngoscope, 133:2014-2017, 2023.

The Current State of Visualization Techniques in Endoscopic Skull Base Surgery.

Skull base surgery has undergone significant progress following key technological developments. From early candle-lit devices to the modern endoscope, refinements in visualization techniques have made endoscopic skull base surgery (ESBS) a standard practice for treating a variety of conditions. The endoscope has also been integrated with other technologies to enhance visualization, including fluorescence agents, intraoperative neuronavigation with augmented reality, and the exoscope. Endoscopic approaches have allowed neurosurgeons to reevaluate skull base neuroanatomy from new perspectives. These advances now serve as the foundation for future developments in ESBS. In this narrative review, we discuss the history and development of ESBS, current visualization techniques, and future innovations.

Is nasal airflow disrupted after endoscopic skull base surgery? A short review.

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